The Prevalence of the Metabolic Syndrome in Psychiatric

Inpatients With Primary Psychotic and Mood Disorders

RICHARD A. BERMUDES, M.D.

PAUL E. KECK, JR., M.D.
JEFFREY A. WELGE, PH.D.

Patients with severe mental illness have elevated rates of cardiovascular disease (CVD) and dia-
betes compared with the general population, but little is known about the prevalence of the meta-
bolic syndrome that predisposes patients with severe mental illness to both medical conditions.
The purpose of this study was to assess the prevalence of the metabolic syndrome by surveying
hospital records of psychiatric inpatients with severe mood and psychotic disorders. The study
group was 102 consecutively admitted adult patients with a primary DSM-IV diagnosis of a
mood or psychotic disorder. Criteria for comorbid metabolic syndrome required at least three of
the five factors defined by the National Cholesterol Education Program. The prevalence of the
metabolic syndrome was 38.6% in this cohort, and it was associated with increasing age, body
mass index, and Caucasian ethnicity. The metabolic syndrome was common in this cohort of psy-
chiatric inpatients, and the high rate of the metabolic syndrome likely represents an intermediate
step in the future development of CVD and diabetes, which may provide a point of early interven-
tion to prevent the occurrence of these two medical illnesses in chronically mentally ill patients.
(Psychosomatics 2006; 47:491–497)

M ental and medical illnesses frequently co-occur. In a

series of 78 psychiatric inpatients with chronic men-
tal illness, Knutson found that 72% had unrecognized
medical conditions.1 Medical illness complicates the treat-
ment of mental illness, and patients with severe mental
illness die at an earlier age from physical health problems
than do those without mental illness.2,3 High rates of dia-
betes and cardiovascular disease (CVD) contribute to this
premature mortality in severely mentally ill patients.4
However, the mechanisms leading to elevated rates of di-
abetes and CVD in this population remain uncertain.
In the general adult population, the metabolic syn-
drome is an intermediate step toward the final endpoint of
Type II diabetes and CVD.5,6 Fundamental to this syn-
drome is the accumulation of visceral fat. Visceral fat itself
is more insulin-resistant than lower-body adipose tissue.
Also, visceral fat causes increased free fatty acids in the
systemic circulation, which, in turn elicits decreased glu-
cose tolerance, elevated blood pressure, and dyslipidemia.
In 2001, the Third Report of the National Cholesterol
Education Program Adult Treatment Panel (ATP III) in-
cluded diagnostic guidelines for the metabolic syndrome
and proposed that it be a secondary target of intervention
Received November 30, 2004; revised October 25, 2005; accepted No-
vember 29, 2005. From the Dept. of Psychiatry and Behavioral Sciences,
UC Davis Medical Center, Sacramento, CA (RAB); the Psychopharma-
cology Research Program, Dept. of Psychiatry, Univ. of Cincinnati Col-
lege of Medicine; General Clinical Research Center and Mental Health
Care Line, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio
(PEK), and the Quantitative Methods Program, Dept. of Psychiatry, Univ.
of Cincinnati College of Medicine, Division of Epidemiology and Bio-
statistics, Dept. of Environmental Health, Univ. of Cincinnati College of
Medicine (JAW). Send correspondence and reprint requests to Richard
A. Bermudes, M.D., Dept. of Psychiatry and Behavioral Sciences, UC
Davis Medical Center, 2230 Stockton Blvd., Sacramento, CA 95817-
1419. e-mail: rabermudes@ucdavis.edu
Copyright 䉷 2006 The Academy of Psychosomatic Medicine

Psychosomatics 47:6, November-December 2006 http://psy.psychiatryonline.org 491

Metabolic Syndrome in Psychiatric Inpatients
after reducing low-density lipoprotein (LDL) in at-risk pa-
tients. The ATP III criteria require the presence of more
than three of the following for the diagnosis of the meta-
bolic syndrome: 1) abdominal obesity; 2) elevated triglyc-
eride level; 3) low high-density lipoprotein level (HDL);
4) high blood pressure; and 5) an elevated fasting glucose
level.7
Individuals with the metabolic syndrome have higher
rates of coronary heart disease, myocardial infarction, and
stroke than individuals with any one of the components of
hypertension, insulin-resistance, dyslipidemia, or obesity.8
Lakka et al.9 found that men with the metabolic syndrome
were 2–4 times more likely to die from coronary heart dis-
ease and twice as likely to die of any cause than those
without the metabolic syndrome, even after adjustment for
conventional cardiovascular risk factors.
The prevalence of the metabolic syndrome varies de-
pending on the average body mass index (BMI), age, and
ethnicity of the population.10 In 2002, using data collected
during the Third National Health and Nutrition Examina-
tion Survey (NHANES III, 1988–1994), Ford et al.11 cal-
culated an overall prevalence of the syndrome of 21.8% in
the adults in the United States. The prevalence of the syn-
drome increased with BMI to a rate of 59.6% in obese men
(BMI ⬎30), and was highest in Mexican Americans and
lowest in African Americans.
Two studies examined the prevalence of the metabolic
syndrome in persons with mental illness.12,13 In 35 Finnish
outpatients with schizophrenia, Heiskanen et al.12 found an
overall prevalence rate of 37%. In a large, cross-sectional
study utilizing NHANES III data, younger women with a
history of depression were twice as likely to have the met-
abolic syndrome as were women without a history of major
depression.13
In this study, we retrospectively assessed the rate of
the metabolic syndrome in a cohort of psychiatric inpa-
tients with severe and recurrent mood and psychotic dis-
orders. Second, we assessed whether the prevalence of the
syndrome was associated with demographic, lifestyle, psy-
chiatric illness characteristics, or treatment factors that
were reversible or nonreversible.
METHOD
We retrospectively collected data from consecutive adult
psychiatric inpatients admitted to the University of Cincin-
nati Medical Center with a primary DSM-IV14 diagnosis
of schizophrenia, schizoaffective disorder, psychosis not
otherwise specified, bipolar disorders, and major depres-
492 http://psy.psychiatryonline.org
sive disorders from November 1, 2003 to March 30, 2004.
We included patients at least 18 years old, under the care
of a single attending physician (RAB), with data present
in the medical record regarding at least three of the five
parameters of the metabolic syndrome, to generate a group
of 102 subjects. We excluded patients with incomplete data
(i.e., patients with only two data-points); pregnant patients;
patients with primary anxiety disorders, substance abuse,
or Axis II disorders; and patients whose primary attending
physician was not RAB. The University of Cincinnati in-
stitutional review board (IRB) chair approved a waiver for
this study.
Weight, height, clinical laboratory results, and blood
pressure were obtained from the medical record. For
weight and height measurements, a standiometer (cali-
brated metal ruler attached to the balance scale that mea-
sures height) and basic physician’s adult balance-beam
scale are used by nurses during the admission process.
Waist circumference is obtained by measuring the patient’s
maximal girth between the umbilicus and the top of the
iliac crest.
For the purposes of the study, we defined blood pres-
sure (BP) as the average of the BP recorded during the
patient’s hospital stay. We verified, by reviewing physician
order forms, that fasting triglyceride, HDL cholesterol, and
glucose level were obtained at ⱖ 6 hours of fasting. With
a physician’s order for fasting labs, nurses and staff instruct
patients not to eat after midnight; this is verified and doc-
umented by the phlebotomist at the time of the blood draw,
and the patient’s breakfast tray is held until after 7 A.M.
on the following day.
Subjects met criteria for the metabolic syndrome if
three of the following ATP III-defined criteria were pres-
ent: 1) waist circumference ⬎ 102 cm (40 inches) in men
or ⬎ 88 cm (35 inches) in women; 2) elevated serum tri-
glycerides ⱖ 150 mg/dL (ⱖ 1.69 mmol/L); 3) low serum
HDL cholesterol (⬍ 40 mg/dL [ ⬍ 1.03 mmol/L]) in men
or ⬍ 50 mg/dL (⬍ 1.29 mmol/dL) in women; 4) high sys-
tolic blood pressure (ⱖ 130 mm Hg) or high diastolic blood
pressure (ⱖ 85 mm Hg; 5) high fasting plasma glucose
level (ⱖ 110 mg/dL).7 Also, individuals met the criteria
for high blood pressure or elevated glucose level if they
were taking medicines for diabetes or hypertension.
We assessed each subject’s demographic profile, psy-
chiatric, medical, and medication history by reviewing the
subject’s hospital record. We categorized income, educa-
tion, and smoking status as follows: 1) annual income:
⬍$15,000; $15,000–$25,000; ⬎$25,000; and Unknown;
2) education level: ⬍8 years; 8–12 years; ⬎12 years; and
Psychosomatics 47:6, November-December 2006

Unknown; 3) smoking status: current; past (if smoked
ⱖ100 cigarettes ever); Never.
Patients were considered to be physically active if they
regularly engaged in an aerobic type of activity at least
twice per week for 20 minutes; these included walking,
jogging, swimming, or garden/yard work.10 We catego-
rized patients as having a family history of diabetes or
CVD if the patient had a first-degree relative with either of
these two illnesses.
Medication history was based on information docu-
mented in the medical record and included reports from the
patient, outpatient providers, or previous hospitalizations.
We further reviewed the subjects’ hospital record for meno-
pausal status, history of gestational diabetes or having a
child weighing ⱖ9 lbs, primary Axis I diagnosis, evidence
of substance abuse, number of previous hospitalizations,
age at onset of illness, current Clinical Global Impression
(CGI) and Global Assessment of Functioning (GAF)
scores, and medical history. We defined subjects as having
substance abuse if they had a positive drug screen upon
admission or if there was documentation in the history that
they had ongoing substance abuse or dependence, despite
a negative drug screen.
We performed statistical analysis with the SAS for the
personal computer, Version 8.1 (SAS institute; Cary, NC).
Categorical variables were compared by using a two-tailed
Fisher exact test. Continuous variables were compared by
Welch-Satterthwaite t-test for unequal variances. Results
were considered significant when p was ⱕ0.05.
RESULTS
The anthropometric characteristics of the study sample are
summarized in Table 1. Subjects with the metabolic syn-
drome were older (p ⬍0.001), had larger waist circumfer-
ences (p⳱0.03), and BMIs (p ⬍0.001).
The overall prevalence of the metabolic syndrome in
this group of psychiatric inpatients was 38.6% (N⳱39).
TABLE 1. Anthropometric Characteristics of the Study Sample
Variable Mean (SD) for the Study Sample
Age, years 38.0 (10.8)
Height, meters 1.68 (0.10)
Weight, kilograms 85.3 (23.1)
Body Mass Index 30.0 (7.9)
Waist circumference, centimeters 105.9 (21.7)
Data are mean and 95% confidence interval. SD: standard deviation.
Psychosomatics 47:6, November-December 2006
Bermudes et al.
For subjects ages 18–29, the BMI-adjusted prevalence rate
was 15.5% (Figure 1). Subjects ages 30–39 and 40–49 had
an adjusted rate of 39.6%, whereas subjects older than age
50 had a prevalence rate of 69.9% (Figure 1. The preva-
lence of the metabolic syndrome increased with increasing
BMI (Figure 2). After adjustment for age, normal-weight
subjects (BMI ⱕ25) had a rate of 4%; overweight subjects
(BMI ⬎25 but ⱕ30) had a rate of 39%; and obese subjects
(BMI ⬎30) had a rate of 58%.
Table 2 displays the univariate analysis of the socio-
demographic characteristics of the study sample and their
association with the prevalence of the metabolic syndrome.
Compared with African Americans, Caucasians were more
likely to meet criteria for the metabolic syndrome (52.9%
versus 24.5%; p⳱0.004). The metabolic syndrome was not
associated with gender, income, education, smoking his-
tory, physical activity, menopausal status, history of ges-
tational diabetes, family history of cardiovascular disease,
or family history of diabetes.
Multiple logistic regression, using the variables race,
gender, income, education, tobacco use, physical activity,
family history of diabetes, and family history of CVD
showed similar results. Compared with univariate analysis
(Table 2), income was slightly more significantly associ-
ated with the metabolic syndrome (p⳱0.02) and race,
slightly less (p⳱0.014).
Severity of illness characteristics and the prevalence
of the metabolic syndrome are shown in Table 3. Later
onset of illness was associated with the metabolic syn-
drome (p⳱0.002), and there was a trend toward an asso-
ciation with duration of illness (p⳱0.061). Current GAF,
CGI, or number of hospitalizations were not associated
with the metabolic syndrome. Also, individual disorders,
diagnostic groups, and individual medications, as well as
medication classes, were not found to be associated with
the metabolic syndrome in this sample.
Each component of the metabolic syndrome was sig-
nificantly associated with the full syndrome. Compared
Metabolic Syndrome
Present Absent p
43.4 (40.3–46.7) 34.5 (31.9–37.0) ⬍0.001
1.69 (1.65–1.73) 1.68 (1.66–1.70) 0.90
99.2 (91.9–106.6) 76.4 (71.4–81.3) ⬍0.001
34.9 (32.2–37.6) 27.0 (25.4–28.6) ⬍0.001
118.3 (113.0–123.6) 98.0 (92.5–103.5) ⬍0.001
http://psy.psychiatryonline.org 493
 Metabolic Syndrome in Psychiatric Inpatients

with those having a normal waist circumference, subjects
with a larger waist had a higher rate of the metabolic syn-
drome (8.6% versus 56.3%; p ⬍0.001). Subjects with el-
evated triglyceride levels had a higher prevalence rate
(81.3%) than those with normal triglycerides (17.5%; p
⬍0.001). Lower HDL was associated with the syndrome
(65.1% versus 17.3%; p ⬍0.001), as was high BP (70.7%
versus 14.6%; p ⬍0.001) and elevated fasting glucose
(73.9% versus 28.4%; p ⬍0.001).

DISCUSSION
FIGURE 1. Prevalence of the Metabolic Syndrome by Age

80
In this sample of severely mentally ill patients, 38.6% met
criteria for the metabolic syndrome as defined by ATP III
70 guidelines. This rate is elevated, compared with the rate of
60 21.4% found by Ford and others in the United States gen-
eral population during the Third National Health and Nu-
50 trition Examination Survey (NHANES III, 1988–1994).11
Percent

40 Similar to NHANES III data, increasing age, BMI, and

Caucasian ethnicity increased the risk for the metabolic
30
syndrome. Persons with higher incomes were at increased
20
TABLE 2. Sociodemographic Characteristics of the Study
10
Sample
0 With
18–29 30–39 40–49 ≥50
Total Metabolic
Age, years Variable (N) Syndrome p
All subjects 101 38.6%
Prevalence rates were adjusted for Body Mass Index (BMI; estimated Gender
prevalence for BMI: 30). Women 50 40% 0.8
Men 51 37.3%
Race
FIGURE 2. Prevalence of the Metabolic Syndrome by Body Mass African American 49 24.5% 0.004
Index (BMI) Caucasian 51 52.9%
Income
ⱕ$15,000 84 33.3% 0.068
70 $15,001–$25,000 10 60.0%
⬎$25,000 4 75.0%
60 Education, years
⬍8 3 33.3% 1.00
50 8–12 53 37.7%
⬎12 42 38.1%
Smoking
Percent

40
Current 68 39.7% 0.818
Past 5 20.0%
30 Never 27 37.0%
Physical activity
20 Inactive 81 37.0% 1.00
Active 16 37.5%
10 Menopausal status
Postmenopausal 18 55.6% 0.073
Premenopausal 32 28.1%
0
Normal Weight Overweight Obese History
Subjectsa Subjectsb Subjectsc Gestational diabetes 9 11.1% 0.069
No history of gestational diabetes 37 46.0%
Prevalence rates were adjusted for age (estimated prevalence at age Family history of diabetes 36 36.1% 0.833
38). No family history of diabetes 59 39.0%
a
BMIⱕ25. Family history of cardiovascular disease 40 40.0% 0.833
b
25⬍BMIⱕ30. No family history of cardiovascular
c
BMI⬎30. disease 53 37.7%

494 http://psy.psychiatryonline.org Psychosomatics 47:6, November-December 2006


risk for the metabolic syndrome, which suggests that those
of higher socioeconomic status may be at increased risk.
Our study adds to the mounting evidence that mentally
ill patients are at increased risk for the metabolic syndrome.
In a group of 35 Finnish outpatients with schizophrenia,
37% met criteria for the metabolic syndrome.12 Depression
and depressive symptoms are also associated with the met-
abolic syndrome. In a re-examination of the NHANES III
data, young adult women (ages 17–39) with a history of
depression had an increased risk for the metabolic syn-
drome, as compared with women with no history of de-
pression.13 Furthermore, McCaffery et al.15 found an as-
sociation with depressive symptoms and the metabolic
syndrome in monozygotic and dizygotic male twin pairs
who participated in the National Heart, Lung, and Blood
Institute Twin Study.
There are several reasons why severe mood and psy-
chotic disorders might be associated with higher rates of
the metabolic syndrome. Certain lifestyles, such as sed-
entary habits and high fat and carbohydrate diets, are com-
mon in people with severe mental illness and are associated
with the metabolic syndrome.16,17
Second, atypical antipsychotics are associated with
obesity, dyslipidemia, and hyperglycemia, three features of
the metabolic syndrome. For example, moderate-to-severe
elevations in triglycerides, weight, and leptin have been
closely associated with clozapine, olanzapine, risperidone,
and quetiapine therapy, and there are case reports linking
clozapine, olanzapine, quetiapine, and risperidone to hy-
perglycemia.18,19
Finally, severe mood disorders and psychotic disorders
may predispose individuals to physiological changes that
increase the rate of the metabolic syndrome. Abnormalities
of glucose regulation, with a pattern of insulin resistance,
have been described in schizophrenic patients even before
the development of illness and the use of antipsychotic
agents.20,21 In two recent studies, Thakore et al. found in-
creased central obesity in untreated first-episode patients
TABLE 3. Severity of Illness and Distribution of the Metabolic Syndrome
Variable Mean (SD) for the Study Sample
Age at onset, years 26 (8.9)
Duration of illness, years 12 (10.6)
Total hospitalizations 6.5 (7.1)
Current GAF 25.4 (6.9)
CGI 5.6 (0.8)
SD: standard deviation; GAF: Global Assessment of Functioning; CGI: Clinical Global Impression.
Psychosomatics 47:6, November-December 2006
Bermudes et al.
diagnosed with schizophrenia or major depression.22,23
Both depression and schizophrenia have been associated
with dysregulation of the hypothalamic–pituitary–adrenal
(HPA) axis, which has been implicated in the development
of the metabolic syndrome.24–28
There are limitations to our findings: Foremost was
the cross-sectional nature of the study. Although the met-
abolic syndrome was frequent in this group of inpatients,
causal pathways could not be inferred.
Second, the small sample size and the limited medi-
cation history available limited the power of this investi-
gation to detect significant differences among potentially
important subgroups. For example, it was impossible to
determine whether any particular medications were asso-
ciated with the metabolic syndrome or any specific rate
differences were present between the different diagnoses.
This may also explain why we did not find an association
between the metabolic syndrome and family history of di-
abetes. Also, our data were from a retrospective chart re-
view and were limited by the history-taking of the original
clinicians and reporting by the patients.
Third, not all of the five features of the metabolic syn-
drome were measured in each subject: 14 subjects were
missing at least one component, and 5 subjects were miss-
ing two components. Thus, our measured prevalence rate
was likely an underestimate of the prevalence of the met-
abolic syndrome in this sample.
Finally, there was no reference population without
psychopathology. Although there are national rates avail-
able from the NHANES III, this survey was from 1988 to
1994. If rates for the metabolic syndrome parallel the in-
creasing national rates for diabetes, these data from the
NHANES likely underrepresent the present-day frequency
of the metabolic syndrome.
Despite these limitations, our findings are consistent
with high rates of the metabolic syndrome found in other
psychiatric patient populations. Our study indicated that
more than 1 in 3 chronically mentally ill patients had the
Metabolic Syndrome
Present Absent p
30 (10.2) 23 (7.0) 0.002
15 (11.1) 10 (10.0) 0.061
6.5 (5.8) 6.4 (8.0) 0.935
26.8 (6.1) 24.5 (7.2) 0.103
5.7 (0.5) 5.6 (1.0) 0.584
http://psy.psychiatryonline.org 495
Metabolic Syndrome in Psychiatric Inpatients
metabolic syndrome and therefore harbored what is usually
a clinically silent and unidentified elevated risk for cardio-
vascular disease and Type II diabetes. Furthermore, when
one component of the syndrome was present, the rate in-
creased to 1 in 2 patients meeting criteria for the full syn-
drome.
Psychiatrists should consider measuring BP and waist
circumference, two components of the metabolic syn-
drome, which are easily assessed in the office setting. In
this sample, subjects who had an elevated BP and large
waist circumference met criteria for the full syndrome 86%
of the time (25 of 29 subjects; see Table 4). Screening for
the metabolic syndrome by use of BP and waist measure-
ment was 71% sensitive and 93% specific. Abnormalities
in either BP or waist circumference warrant screening for
the other components of the syndrome, more frequent
monitoring of fasting glucose and lipids, and further inter-
ventions such as diet- and exercise-counseling to reverse
the changes.
All patients taking atypical antipsychotics require
monitoring of weight, fasting glucose, and lipids.29–32 Fail-
ure to monitor metabolic parameters and intervene early
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