Gwen L. Zornberg

Statins and the risk of dementia

BACKGROUND Dementia affects an estimated 10% of the population older than 65 years. Because vascular and lipid-related mechanisms are thought to have a role in the pathogenesis of Alzheimers disease and vascular dementia, we did an epidemiological study of the potential effect of HMGCoA (3 hydroxy-3methylglutaryl-coenzyme A) reductase inhibitors (statins) and other lipid-lowering agents on dementia. METHODS We used a nested case-control design with information derived from 368 practices which contribute to the UK-based General Practice Research Database. The base study population included three groups of patients age 50 years and older: all individuals who had received lipid-lowering agents (LLAs); all individuals with a clinical diagnosis of untreated hyperlipidaemia; and a randomly selected group of other individuals. From this base population, all cases with a computer-recorded clinical diagnosis of dementia were identified. Each case was matched with up to four controls derived from the base population on age, sex, practice, and index date of case. FINDINGS The study encompassed 284 cases with dementia and 1080 controls. Among controls 13% had untreated hyperlipidaemia, 11% were prescribed statins, 7% other LLAs, and 69% had no hyperlipidaemia or LLA exposure. The relative risk estimates of dementia adjusted for age, sex, history of coronary-artery disease, hypertension, coronary-bypass surgery and cerebral ischaemia, smoking and body mass index for individuals with untreated hyperlipidaemia (odds ratio 0.72 [95% CI 0.45-1.14]), or treated with nonstatin LLAs (0.96 [0.47-1.97], was close to 1.0 and not significant compared with people who had no diagnosis of hyperlipidaemia or exposure to other lipid-lowering drugs. The adjusted relative risk for those prescribed statins was 0.29 (0.13-0.63; p=0.002). INTERPRETATION Individuals of 50 years and older who were prescribed statins had a substantially lowered risk of developing dementia, independent of the presence or absence of untreated hyperlipidaemia, or exposure to nonstatin LLAs. The available data do not distinguish between Alzheimers disease and other forms of dementia.

What and How Psychiatry Residents at Ten Training Programs Wish to Learn About Ethics

The study’s objective was to survey what and how psychiatry residents want to learn about ethics during residency. A 4-page questionnaire developed for this study was sent to 305 residents at 10 adult psychiatry programs in the United States. One-hundred and eighty-one (59%) of those surveyed responded. Seventy-six percent reported facing an ethical dilemma in residency for which they felt unprepared. Forty-six percent reported having received no ethics training during residency. More than 50% of the respondents requested that “more” curricular attention be paid to 19 specific ethics topics and more than 40% for 25 topics. Preferences with respect to learning methods are presented. This survey may provide guidance in structuring the content and process of ethics education for psychiatry residents. These findings should stimulate the efforts of faculty to commit time and attention to this important curricular area.

Antipsychotic drugs and venous thromboembolism

Sir—Gwen Zornberg and Hershel Jick (Oct 7, p 1219) report that antipsychotic drugs can significantly increase the risk of idiopathic venous thromboembolism. This finding is potentially important and we appraised the paper in our evidence-basedmedicine journal club. We are concerned that the finding represents an idiosyncratic drug reaction in a small number of patients, and could lead to people who would benefit from taking antipsychotic drugs not receiving them. The cases described typically received less than 99 mg (we presume of chlorpromazine equivalents), generally for less than 4 months. Why patients would be prescribed such small doses and short-term courses is unclear, as is whether the patients actually took the drugs. We wonder whether patients had been prescribed antipsychotics at times of stress, when they might also have been drinking and smoking more than usual. Zornberg and Jicks’ analyses control only for the presence or absence of smoking and hypertension, and did not specifically measure alcohol exposure, and there remains much scope for residual confounding. The lack of a dose response between antipsychotic exposure and thromboembolism does not support the association and strongly argues against the possibility that dose-related sideeffects such as sedation cause an increase in sedentary behaviour and explain the effect. Zornberg and Jick suggest that certain individuals are susceptible but the risk of venous thromboembolism is very low at 42 (0·14%) of 29 952 patients. Even if the odds are increased seven-fold, the rate of venous thromboembolism on antipsychotic drugs is still less than 1%. These figures should be contrasted with the beneficial effects antipsychotics have in patients with schizophrenia, and certainly should not discourage doctors or patients from using antipsychotic drugs to treat the disorders they are licensed for.