Journal of Affective Disorders 148 (2013) 440443

Contents lists available at SciVerse ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Brief report

Plasma total cholesterol in psychiatric patients after a suicide attempt

and in follow-up
Athanassia Papadopoulou a,n, Manolis Markianos b, Christos Christodoulou a,
Lefteris Lykouras a
a
b

Department of Psychiatry, Attikon General Hospital, Athens University Medical School, Greece
Clinical Neurochemistry Laboratory, Eginition Hospital, Athens University Medical School, Greece

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 28 August 2012
Received in revised form
18 November 2012
Accepted 19 November 2012
Available online 11 December 2012

Background: Low plasma total cholesterol (TC) levels have been found in subjects after a suicide
attempt in most studies. Other studies question these results because of possible inuences on TC of
somatic effects due to the attempt (drugs, somatic trauma, hospitalization), or nutritional habits and
physical activity before attempt, especially in patients with depression.
Methods: To address this issue, TC levels were estimated in 51 subjects on admission to psychiatric
clinic after a suicide attempt, as well as later in follow-up when patients were back in their normal
activities. Patients were evaluated for suicide intent (SIS), aggression, and severity of depression (BDI).
Results: A small (7% in the mean) but statistically signicant increase in plasma cholesterol levels was
observed in samples taken in follow-up compared to samples after attempt. However, TC levels of
patients were signicantly lower than controls in both assessments. There were no differences in TC
between violent and non-violent attempters, either after attempt or in follow-up. In the subgroup of
patients with major affective disorder, TC levels were lower compared to age-matched controls in both
assessments, although patients showed signicant reductions in BDI score in follow-up. In this
subgroup, TC levels after attempt correlated negatively to SIS score.
Conclusions: TC levels in psychiatric patients after a suicide attempt are lower than healthy controls
and remain low in follow-up, independently from the severity of psychopathology. The results support
the role of plasma total cholesterol as a biological risk factor in suicidal behavior, especially in affective
patients.
& 2012 Elsevier B.V. All rights reserved.

Keywords:
Cholesterol
Suicide attempt
Follow-up
Depression
Aggression

1. Introduction
In 1979, Virkkunen studied a group of men with antisocial
personality disorder who were mainly characterized by autodestructive and heterodestructive tendencies. These individuals had
lower serum cholesterol compared to subjects with other personality disorders (Virkkunen, 1979). Since then a systematic
research was carried out addressing the role of cholesterol in
suicide attempts, in the search of biological predictors of suicidal
behavior (Lee and Kim, 2011).
Total cholesterol levels (TC) were studied in recently suicide
attempters, and compared to healthy controls with controversial
results (Seefried and Gumpel, 1997; Tripodianakis et al., 2002;
Diaz-Sastre et al., 2007; Atmaca et al., 2008, 2002, Jokinen et al.,
2010). Especially in patients with affective disorders, low TC was
n
Correspondence to: Department of Psychiatry, Attikon General Hospital,
Athens University Medical School, 1 Rimini Street, Haidari 12462, Athens, Greece.
Tel.: 30 2105832426; fax: 30 2105326453.
E-mail address: athanpapad@hotmail.gr (A. Papadopoulou).

0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2012.11.032

associated with an increased risk for suicide attempt in some

studies (Sullivan et al., 1994; Kunugi et al., 1997; Kim and Myint,
2004; Olie et al., 2011), but not in other studies (Almeida-Montes
et al., 2000; Deisenhammer et al., 2004; D Ambrosio et al., 2012).
Moreover, high cholesterol levels were found to be an indicator of
increased risk for suicide attempt in depressed patients (Fiedorowicz
and Coryell, 2007).
It has been postulated that one factor that may have inuenced the results of the above mentioned studies is that cholesterol levels measured in subjects after a suicide attempt may be
altered by the somatic effects due to the attempt (drugs and
somatic trauma), the stress due to the recent admission to the
hospital, and the nutritional habits and physical activity in the
time period before attempt and after admission. Cholesterol levels
may also be inuenced by drugs used for treatment the time
before attempt, especially atypical antipsychotics (Lindenmayer
et al., 2003; McIntyre et al., 2003). To address these questions, we
measured TC in subjects hospitalized after a suicide attempt,
underwent psychiatric evaluation, and their previous drug
treatment was registered. A second blood sample for cholesterol

A. Papadopoulou et al. / Journal of Affective Disorders 148 (2013) 440443

estimation was taken at a later time, when patients were back in

their normal activities.

2. Subjects and methods

Fifty-one subjects (16 males, 35 females) in the age range of
2180 years who were admitted to Psychiatric Clinic of Attikon
General Hospital in Athens after a suicide attempt and who were
assessed later in follow-up were included in the study. Every self
directed injurious act with at least some intent to end ones own
life was the denition used to characterize an autodestructive
behavior as suicide attempt (Mann, 2003). Also, suicide attempts
were divided into violent and non-violent following the criteria of

Traskman
et al. (1981). Informed consent was obtained from all
subjects and the study protocol was approved by the Ethics
Committee of the Hospital.
Psychiatric diagnoses were established according to DSM
-IV-TR, all by the same psychiatrist. Suicide intent was evaluated
using the Suicide Intent Scale (Beck et al., 1974). At the time of
blood sampling, the Aggression Questionnaire (Buss and Perry,
1992) was given, and severity of depression was assessed using
the 21-item scale of Beck Depression Inventory (BDI) (Beck et al.,
1961). Patients included in this study had a serious psychopathology for which they had been hospitalized in a psychiatric clinic
after the attempt. The majority of them received psychotropic
drugs the time before the attempt, as well as in follow-up.
The rst blood sample was taken at 08.00 in the morning after
overnight fast within 72 h after suicide attempt, or, if patients
were hospitalized in the Intensive Care Unit, within 48 h following discharge (mean 3.0 71.7 days). The second blood sample was
taken 2.672.7 months later. Samples were taken in EDTA, plasma
was separated by centrifugation and stored at  30 1C until
cholesterol estimation.
For comparison of TC levels, we used a control group of
98 subjects in the age range 2173 years, 32 males and 66 females,
with no history of suicide attempt, psychiatric illness, or administration of cholesterol lowering drugs.
Additionally, data of patients with MAD were analyzed separately because of indications in the literature that TC may predict
suicide attempt in patients with affective disorders. Associations
of TC levels to AQ and BDI were searched for data after attempt, at
follow-up, and their changes between assessments.
Statistical analysis included t-test for dependent samples for
comparison of TC levels after attempt and in follow-up. Analysis
of variance (ANCOVA) with covariates sex, age and BMI was used
for comparisons between attempters and controls, as well as
between subgroups of patients receiving or not atypical antipsychotics the time before attempt or in follow-up, and between
subgroups of patients who used violent or non-violent mode of
attempt. Cholesterol levels at attempt, in follow-up, and the
differences between the two states were related to the corresponding scores of AQ and BDI, using the nonparametric Spearman correlation coefcient test.

3. Results
Thirty-four subjects (12 males, 22 females) were diagnosed as
having major affective disorder (MAD), ten (3 males, 7 females)
schizophrenia, and seven (1 male, 6 females) personality disorder.
Suicide Intent Scale score ranged from 1 to 25 (mean7SD
14.376.1).
Cholesterol levels after suicide attempt and in follow-up are
shown in Table 1. Analysis of variance with age and BMI as
covariates showed signicantly lower TC levels in the samples

441

Table 1
Age, body mass index (BMI), time of sampling (days after attempt), plasma
cholesterol (mg/dl) and score in Aggression Questionnaire (AQ) of 51 (17 males,
34 females) suicide attempters. Cholesterol levels of 98 sex- and age-matched
controls are used for comparison (ANOVA).

ATTEMPT
FOLLOW-UP
t
p
CONTROLS
ATT vs. CNTR
F/p
FUP vs. CNTR
F/p

AGE

BMI

SAMPLING

CHOLESTEROL

AQ

45.2 713.2
45.2 713.2

26.3 7 5.9
26.2 7 5.6

3.07 1.7
797 82

80 722
74 722
2.9171
.005

44.6 712.0

25.3 7 4.0

156 7 30
167 7 35
 2.2034
.032
2087 46
67.81/.0001
48.36/.0001

Table 2
Data of the 34 patients (12 male and 22 female) with Major Affective Disorder.
BMI: Body Mass Index; BDI: Beck Depression Inventory; AQ: Aggression Questionnaire. TC levels in both states are signicantly lower compared to a sex- and
age-matched control group (n70, age 48.2 7 10.7, TC 215 735 mg/dl).

Age
BMI
Sampling, days after attempt
BDI
AQ
Cholesterol (mg/dl)

ATTEMPT

FOLLOW-UP

49.1 712.3
26.3 75.0
3.0 71.6
38 710
80 722
159 731

49.3 7 12.3
26.5 7 5.4
87 7 90
21 7 13
77 7 22
168 7 39

5.2806
0.9836
 1.8508

.0001
.33
.07

taken after attempt compared to control subjects, as well as in the

samples taken at follow-up. A small increase in cholesterol levels
(7% in the mean) was observed in the samples taken at follow-up,
which was signicant at p 0.03 level compared to TC in the
samples taken after attempt. The score in Aggression Questionnaire was signicantly reduced in follow-up (p .005). TC levels
were not related to the score in AQ, either after attempt
(Rs 0.0543, n.s.) or in follow-up (r .1062, n.s.). The differences
in TC levels from attempt to follow-up were not related to the
corresponding differences in AQ score (Rs  .2623, p .06).
The correlation coefcient between TC at attempt and SIS score
for the group of 51 patients was negative, but not signicant
(Rs 0.1837, p .20).
There were no differences in TC between violent (29 cases,
TC 159730) and non-violent (22 cases, TC 151 733) attempters (ANCOVA with age and BMI as covariates, p .17).
Possible inuence of drug therapy before attempt and in
follow-up on plasma TC was assessed conducting multiple regression analyses, with dependent variable TC levels, and independent variables sex, age, BMI, and presence in the drug regime of
antidepressants, neuroleptics, benzodiazepines. Only BMI showed
a signicant (t 2.02, p .049) positive association to TC in the
samples taken after attempt. Twelve patients were drug-free
at attempt (seven with MAD, two with schizophrenia and three
with personality disorder), and ten of them were on drug treatment at follow-up. Their TC levels followed the trend of the total
group, with increases from 139 722 to 158 730 mg/dl. No
differences in TC were found between patients who were on
treatment with atypical antipsychotics before attempt (16 cases,
TC 155730) and patients not taking atypical antipsychotics (35
cases, TC 155 730, p .96).
Data of 34 patients with major affective disorder were analyzed separately (Table 2). In follow-up, BDI score decreased
signicantly from 38710 to 21713 (p.0001), while the
changes in AQ score were not signicant (p.33). Cholesterol

442

A. Papadopoulou et al. / Journal of Affective Disorders 148 (2013) 440443

levels were increased from 159731 to 168 739, the difference

being near signicance (p.07). Compared to an age- and sexmatched subgroup of 70 subjects from our control group (age
48.2710.7 years, cholesterol levels 215 735 mg/dl), analysis of
variance with age and body mass index as covariates showed that
patients TC levels were signicantly lower both after attempt and
in follow-up.
Signicant correlations were found for the subgroup of MAD
attempters: TC levels correlated negatively with SIS score
(Rs  .3902, p .02), and the differences in TC between attempt
and follow-up correlated negatively with the differences in AQ
score (Rs  .3468, p .04).
The small number of patients with other than MAD diagnoses
does not allow reliable evaluation of possible associations of TC
levels to psychometric correlates. For the 17 patients with
diagnosis other than MAD, we calculated an Rs .2676 for the
relation of TC to SIS score, and Rs  .1439, for the relation of the
differences in TC and AQ score between attempt and follow-up,
both non-signicant.

4. Discussion
Suicide attempters had signicantly lower TC levels compared
to a control group of healthy subjects adjusted for sex, age and
BMI, both in samples taken after attempt and later in follow-up.
A small but signicant increase in TC levels was found in the
samples taken at follow-up that can be attributed to a change in
nutritional habits, especially after improvement of patients
psychopathology, as shown for the subgroup of patients with
depression.
Suicide attempters with major affective disorder had lower TC
levels compared to control subjects, in accordance to previous
ndings (Sarchiapone et al., 2001; Kim et al., 2002). They remained
lower than controls in the samples taken in follow-up after an
improvement in depressive symptomatology, indicating that low TC
may be attributed to suicidal behavior rather than to depression itself,
in agreement with previous ndings (Papassotiropoulos et al., 1999).
For the whole group of 51 attempters, cholesterol levels were
not related to suicide intent (SIS), and were not different between
violent and non-violent attempt subgroups, in agreement with
some previous studies. There were also no associations between
TC levels and score in the AQ.
Signicant correlations between TC levels and SIS score as well
as between the differences in TC levels and in AQ score from
attempt to follow-up were found only for the subgroup of
attempters with MAD, indicating that TC levels may serve as a
predictive factor for suicide attempt in affective patients. These
results support previous ndings in patients with affective disorders, where low TC was associated with an increased risk for
suicide attempt (Sullivan et al., 1994; Kunugi et al., 1997; Kim and
Myint, 2004; Olie et al., 2011). The negative correlation of SIS to
TC levels at attempt for patients with MAD suggests that low
cholesterol levels may be used as a biological predictive factor for
future suicide after attempt, as it has been shown for high SIS
scores for non-psychotic patients (Stefansson et al., 2012).
Aggression has been related to suicidal behavior in a number of
studies in psychiatric patients. Perroud et al. (2011) found impulsivity, which correlates to aggressive traits, to be a suicide risk factor
in major depressive disorder but not in bipolar disorder, and Neuner
et al. (2011) found that aggression is not a predictor of attempted
suicide in schizophrenic patients. The work of Gietl et al. (2007) on
gene alleles that are related both to cholesterol homeostasis and to
aggressive traits underlines the need for further studies on the issue.
The connection of the serotonergic system to serum cholesterol in
suicidal patients (Asellus et al., 2010) should be considered in the

study of the mechanisms by which low TC levels may be linked to

suicidal behavior.

5. Conclusion
The results show that cholesterol levels are low in suicide
attempters after a recent suicide attempt, and remain lower than
normal in a later time after the event. The role of cholesterol in
suicidal behavior is supported by the results of the present study.
In patients with MAD, TC levels were not related to severity of
depression but negatively to suicide intent score, supporting
previous ndings in patients with affective disorders, where low
TC levels were associated with an increased risk for suicide
attempt.

Authors contributions
AP took the interviews, administrated the rating scales,
collected data and wrote the protocol and the paper in collaboration with MM. MM carried out the laboratory measurements and
the statistical analysis. CC contributed to the collection of the data
and to the critical revision of the manuscript. LL participated in
the conception of the study, supervised the study process and
critically revised the manuscript. All authors have read and
approved the nal manuscript.

Role of funding source

Nothing declared.

Conict of interest
All authors declare that they have no conict of interest.

Acknowledgments
We thank all participants of this study as well as the staff of the Psychiatric
Clinic of Attikon Hospital for their collaboration.

References
Asellus, P., Nordstrom, P., Jokinen, J., 2010. Cholesterol and CSF 5-HIAA in
attempted suicide. Journal of Affective Disorders 125, 388392.
Atmaca, M., Kuloglu, M., Tezcan, E., Ustundag, B., Gecici, O., Firidin, B., 2002. Serum
leptin and cholesterol values in suicide attempters. Neuropsychobiology 45,
124127.
Atmaca, M., Kuloglu, M., Tezcan, E., Ustundag, B., 2008. Serum leptin and
cholesterol values in violent and non-violent suicide attempters. Psychiatry
Research 158, 8791.
Almeida-Montes, L.G., Valles-Sanchez, V., Moreno-Aguilar, J., Chavez-Balderas,
R.A., Garca-Marn, J.A., Cortes Sotres, J.F., Hheinze-Martin, G., 2000. Relation
of serum cholesterol, lipid, serotonin and tryptophan levels to severity of
depression and to suicide attempts. Journal of Psychiatry and Neuroscience 25,
371377.
Beck, A.T., Schuyler, D., Herman, I., 1974. Development of suicidal intent scales. In:
Beck, A.T., Resnik, H.L.P., Lettieri, D.J. (Eds.), The Prediction of Suicide. Charles
Press, Bowie, MD, pp. 4548.
Beck, A., Ward, C., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for
measuring depression. Archives of General Psychiatry 4, 561571.
Buss, A.H., Perry, M., 1992. The aggression questionnaire. Journal of Personality
and Social Psychology 63, 452459.
DAmbrosio, V., Salvi, V., Bogetto, F., Maina, G., 2012. Serum lipids, metabolic
syndrome and lifetime suicide attempts in patients with bipolar disorder.
Progress in Neuro-Psychopharmacology and Biological Psychiatry 37,
136140.
Deisenhammer, E.A., Kramer-Reinstadler, K., Liensberger, D., Kemmler, G.,
Hinterhuber, H., Fleischhacker, W.W., 2004. No evidence for an association
between serum cholesterol and the course of depression and suicidality.
Psychiatry Research 121, 253261.
Diaz-Sastre, C., Baca-Garcia, E., Perez-Rodriguez, M.M., Garcia-Resa, E., Ceverino, A.,
Saiz-Ruiz, J., Oquendo, M.A., de Leon, J., 2007. Low plasma cholesterol levels in
suicidal males: a gender- and body mass index-matched case-control study of
suicide attempters and no nonattempters. Progress in Neuro-Psychopharmacology
and Biological Psychiatry 31, 901905.

A. Papadopoulou et al. / Journal of Affective Disorders 148 (2013) 440443

Fiedorowicz, J.G., Coryell, W.H., 2007. Cholesterol and suicide attempts: a prospective study of depressed inpatients. Psychiatry Research 15, 1120.

Gietl, A., Giegling, I., Hartmann, A.M., Schneider, B., Schnabel, A., Maurer, K., Moller,
H.J., Rujescu, D., 2007. ABCG1 gene variants in suicidal behavior and
aggression-related traits. European Neuropsychopharmacology 17, 410416.

Jokinen, J., Nordstrom,

A.L., Nordstrom,
P., 2010. Cholesterol, CSF 5-HIAA, violence
and intent in suicidal men. Psychiatry Research 178, 217219.
Kim, Y.K., Myint, A.M., 2004. Clinical application of low serum cholesterol as an
indicator for suicide risk in major depression. Journal of Affective Disorders 81,
161166.
Kim, Y.K., Lee, H.J., Kim, J.Y., Yoon, D.K., Choi, S.H., Lee, M.S., 2002. Low serum
cholesterol is correlated to suicidality in a Korean sample. Acta Psychiatrica
Scandinavica 105, 141148.
Kunugi, H., Takei, N., Aoki, H., Nanko, S., 1997. Low serum cholesterol in suicide
attempters. Biological Psychiatry 41, 196200.
Lee, B.H., Kim, Y.K., 2011. Potential peripheral biological predictors of suicidal
behavior in major depressive disorder. Progress in Neuropsychopharmacology
and Biological Psychiatry 35, 842847.
Lindenmayer, J.P., Czobor, P., Volavka, J., Citrome, L., Sheitman, B., McEvoy, J.P.,
Cooper, T.B., Chakos, M., Lieberman, J.A., 2003. Changes in glucose and
cholesterol levels in patients with schizophrenia treated with typical or
atypical antipsychotics. The American Journal of Psychiatry 160, 290296.
Mann, J.J., 2003. Neurobiology of suicidal behaviour. Nature Reviews Neuroscience
4, 819828.
McIntyre, R.S., Trakas, K., Lin, D., Balshaw, R., Hwang, P., Robinson, K., Eggleston, A.,
2003. Risk of weight gain associated with antipsychotic treatment: results
from the Canadian national outcomes measurements study in schizophrenia.
Canadian Journal of Psychiatry 48, 689694.

443

Neuner, T., Hubner-Liebermann, B., Hausner, H., Hajak, G., Wolfersdorf, M., Spiessl,
H., 2011. Revisiting the association of aggression and suicidal behavior in
schizophrenic inpatients. Suicide and Life-Threatening Behavior 41, 171179.
Olie, E., Picot, M.C., Guillaume, S., Abbar, M., Courtet, P., 2011. Measurement of
total serum cholesterol in the evaluation of suicidal risk. Journal of Affective
Disorders 133, 234238.
Papassotiropoulos, A., Hawellek, B., Frahnert, C., Rao, G.S., Rao, M.L., 1999. The risk
of acute suicidality in psychiatric inpatients increases with low plasma
cholesterol. Pharmacopsychiatry 32, 14.
Perroud, N., Baud, P., Mouthon, D., Courtet, P., Malafosse, A., 2011. Impulsivity,
aggression and suicidal behavior in unipolar and bipolar disorders. Journal of
Affective Disorders 134, 112118.
Sarchiapone, M., Camardese, G., Roy, A., Della Casa, S., Satta, M.A., Gonzalez, B.,
2001. Cholesterol and serotonin indices in depressed and suicidal patients.
Journal of Affective Disorders 62, 217219.
Seefried, G., Gumpel, K., 1997. Low serum cholesterol and triglycerides and risk of
death from suicide. Archives of Gerontology and Geriatrics 25, 111117.

Stefansson, J., Nordstrom,

P., Jokinen, J., 2012. Suicide intent scale in the prediction
of suicide. Journal of Affective Disorders 136, 167171.
Sullivan, P.F., Joyce, P.R., Bulik, C.M., Mulder, R.T., Oakley-Browne, M., 1994. Total
cholesterol and suicidality in depression. Biological Psychiatry 36, 472477.

Traskman,
L., Asberg, M., Bertilsson, L., Sjostrand,
L., 1981. Monoamine metabolites
in CSF and suicidal behavior. Archives of General Psychiatry 38, 631636.
Tripodianakis, J., Markianos, M., Sarantidis, D., Agouridaki, M., 2002. Biogenic
amine turnover and serum cholesterol in suicide attempt. European Archives
of Psychiatry and Clinical Neuroscience 252, 3843.
Virkkunen, M., 1979. Serum cholesterol in antisocial personality. Neuropsychobiology 5, 2730.