Egyptian Journal of Psychiatry

: 2015  |  Volume : 36  |  Issue : 2  |  Page : 101--105

Prevalence and risk factors of metabolic syndrome among drug-naive psychotic patients

Nagy Fawzy, Amany El Shabrawy, Amira Youssef 
 Department of Psychiatry, Zagazig University, Zagazig, Egypt

Correspondence Address:
Nagy Fawzy
Department of Psychiatry, Zagazig University, Zagazig, Sharkia


Objectives The aim of the study was to determine the prevalence and risk factors of metabolic syndrome among drug-naive psychotic patients. Patients and methods The sample consisted of two groups: group I had 65 drug-naive patients recruited from psychiatric outpatient clinics of Zagazig University Hospitals and group II had 65 participants selected randomly from among Zagazig University Hospital visitors. Patients were subjected to a semistructured psychiatric interview, using the DSM-IV criteria for diagnosis. Severity of symptoms was rated using the Positive and Negative Syndrome Scale. Detection of metabolic syndrome was based on the criteria of the International Diabetes Federation. Results The results of the study show that the prevalence of metabolic syndrome among drug-naive psychotic patients was 12% (eight patients). There was also significant correlation between sex and marital status and all metabolic syndrome criteria, between education and triglycerides level, and between age and waist circumference, blood pressure, triglycerides, and high-density lipoprotein levels. Conclusion The current study concluded that prevalence of metabolic syndrome is higher in drug-naive psychotic patients and psychosis is a risk factor for developing metabolic syndrome among drug-naive psychotic patients.

How to cite this article:
Fawzy N, Shabrawy AE, Youssef A. Prevalence and risk factors of metabolic syndrome among drug-naive psychotic patients.Egypt J Psychiatr 2015;36:101-105

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Fawzy N, Shabrawy AE, Youssef A. Prevalence and risk factors of metabolic syndrome among drug-naive psychotic patients. Egypt J Psychiatr [serial online] 2015 [cited 2021 Jan 20 ];36:101-105
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Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over time, but the effect of the illness is always severe and is usually long lasting. The disorder usually begins before the age of 25, persists throughout life, and affects persons of all classes; social ostracism is prevalent because of widespread ignorance about the disorder. Although schizophrenia is discussed as if it is a single disease, it probably comprises a group of disorders with heterogeneous etiologies, and it includes patients whose clinical presentations, treatment response, and courses of illness vary (Sadock et al., 2007). Other psychotic disorders include schizophreniform, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder, and psychotic disorder not otherwise specified. The metabolic syndrome (MetS) is a cluster of the most dangerous heart attack risk factors: diabetes and elevated fasting plasma glucose, abdominal obesity, high cholesterol, and high blood pressure (BP). It is estimated that around 20-25% of the world's adult population has MetS and they are twice as likely to die from it and three times as likely to have a heart attack or stroke compared with people without the syndrome. In addition, people with MetS have a five-fold greater risk of developing type-2 diabetes. They would add to the 230 million people worldwide who already have diabetes, one of the most common chronic diseases worldwide and the fourth or fifth leading cause of death in the developed world. The clustering of cardiovascular disease risk factors that typify the MetS is now considered to be the driving force for a new cardiovascular disease epidemic (International Diabetes Federation, 2006). Schizophrenia is associated with ~20% reduced life expectancy and the mortality rate from coronary heart disease is significantly higher compared with the general population (Hennekens et al., 2005). The main risk factors for this higher rate of mortality are impaired glucose regulation/insulin resistance, obesity, dyslipidemia, and hypertension, which collectively constitute the cluster of inter-related disorders termed 'metabolic syndrome'. The high prevalence of MetS in schizophrenic patients has assumed greater significance since the increase in the use of second-generation antipsychotics in the 1990s. Most of these second-generation antipsychotics have been associated with substantial weight gain (Taylor and McAskill, 2000), which is a major risk factor for diabetes and coronary heart disease. Until recently, most studies reporting an elevated prevalence of metabolic abnormalities were conducted with schizophrenic patients who had been previously treated with antipsychotic medication. Hence, it has been difficult to disentangle the effects of medication from baseline abnormalities. There have been a few reports comparing baseline weight and metabolic parameters in drug-naive psychotic patients and healthy controls. However, discordant results have been obtained (Taylor and McAskill, 2000).

 Patients and methods

This study was carried out in Psychiatry Outpatient Clinics of Zagazig University Hospitals in the period between 1 June 2013 and 1 April 2014. The sample consisted of 65 drug-naive patients (20 patients were diagnosed with schizophrenia, 20 with schizophreniform, 23 with acute psychosis, one with bipolar, and one with schizoaffective disorder) and 65 apparently healthy volunteers recruited from among Zagazig university hospital visitors, who served as the control group. To be included in the study, patients had to fulfill the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV-TR) criteria, for psychotic disorders and had to be aged between 18 and 60 years; both sexes were included from all socioeconomic and educational classes. The exclusive criteria were presence of other psychiatric or physical disorders, mental retardation, metabolic disorders, previous treatment with antipsychotic medication, and substance dependence. Written informed consent was obtained from all participants. Detection of schizophrenia and other psychotic disorders was based on the semistructured psychiatric interview with resultant DSM-IV-TR diagnosis (American Psychiatric Association, 2000). Severity of symptoms was rated using the Positive and Negative Syndrome Scale (PANSS) (First et al., 1998), which is one of the most widely used measures of psychopathology of schizophrenia in clinical research. It is a 30-item scale used to evaluate the presence, absence, and severity of positive, negative, and general psychopathology symptoms of schizophrenia. Each item has a definition and a basis for rating. All 30 items are rated on a seven-point scale (1 = absent; 2 = minimal; 3 = mild; 4 = moderate; 5 = moderately severe; 6 = severe; and 7 = extreme). Therefore, the positive and negative subscales range from 7 to 49, and the general psychopathology subscale from 16 to 112. The mean scores were as follows: positive scale = 18.20; negative scale=21.01; and general psychopathology = 37.74 (Kay et al., 1987). Detection of MetS was based on the criteria of the International Diabetes Federation (2006) - namely, central obesity plus two of the following four factors: elevated triglycerides (TGs), reduced high-density lipoprotein (HDL) cholesterol, elevated BP, and elevated fasting plasma glucose. The data collected were analyzed using the Statistical Program for Social Sciences 16.0.1 software (SPSS Inc., 2007) by a professional statistician. Pearson's correlation coefficient (r) and the c2 -test were applied:


where O is the observed value; E is the expected value.


Of the 65 psychotic patients, eight patients (12.3%) had MetS; alternatively, of the 65 control patients, seven (10.8%) had MetS. There were no significant differences. [Table 1] shows that there was no statistically significant difference between patients and controls with respect to age, sex, employment, marital status, residence, or education. However, there was a highly significant increase in smoking in patients compared with the control group. [Table 2] shows that there was a statistically significant difference between patients with and those without MetS regarding marital status and education and high significance with regard to employment. No statistically significant difference was seen with respect to age, sex, residence, or smoking. MetS was more frequent in unemployed, married, and educated drug-naive psychotic patients. [Table 3] shows that there was a statistically significant difference between patients and controls with respect to waist circumference (WC), diastolic BP, TGs, and fasting blood sugar and high significance in HDL-cholesterol. WC, TGs, and HDL cholesterol were lower in patients than in controls, whereas diastolic BP and fasting blood sugar were higher in patients. [Table 4] shows that there is statistically significant difference between patients with and without metabolic syndrome with respect to triglycerides (TGs) and fasting blood sugar (FBS) and high significance in waist circumference (WC). These parameters are significantly higher in patients with metabolic syndrome. [Table 5] shows that there was significant correlation between sex and marital status and all MetS criteria, between education and TG level, and between age and WC, BP, TG, and HDL levels. [Table 6] shows that all mean values are above reference values. [Table 7] shows that there was a statistically significant difference between patients with and those without MetS with respect to PANSS scores for negative symptoms and highly significant difference in positive and general psychopathology. Patients with MetS had more positive symptoms and fewer negative symptoms and general psychopathology symptoms.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}


The results of this study show that drug-naive psychotic patients did not significantly differ from matched healthy controls in the prevalence of MetS, although the prevalence of MetS was found to be higher (12.3%) in the patient group as compared with 10.8% in the control group. A comparison of other studies showed that the prevalence of MetS in drug-naive schizophrenic patients varies from as low as 3.3% to as high as 26% (Saddichha et al., 2007; Grover et al., 2012; Pallava et al., 2012). Although most study populations were in their 20s or early 30s (the mean age in our study was 24.1 ± 8.05 years), the sample size varied widely (30-400 vs. 65 in our study). Methodological issues like definition of MetS used and inclusion criteria might explain this huge variation. For example, the study that recorded the highest prevalence of MetS (26%) had included subjects who had been previously treated with antipsychotics. Even though the authors argued that previous antipsychotic use was unlikely to affect the prevalence in a substantial manner, as only 20% of the study population had received antipsychotics in the past and had been off medications for a mean period of 24.7 months, the chances of confounding cannot be ruled out (Pallava et al., 2012). Recently, Grover et al. (2012) explored the effect of changing definitions for MetS on its prevalence. By applying the NCEP ATP III and the International Diabetes Federation criteria on the same group of patients, the authors showed a differing prevalence of MetS at 13.0 and 10.0%, respectively. Prevalence of subsyndromal MetS was found to be even higher, with 30% of subjects satisfying two of five International Diabetes Federation criteria and 50% fulfilling one out of five criteria. The study highlights the fact that recognizing the underlying subsyndromal abnormalities in MetS is also important.

Sociodemographic factors

Some studies have reported a higher prevalence of MetS in patients who smoke (Ellingrod et al., 2012; Sweileh et al., 2012), whereas others have reported no association between MetS and smoking. There is no conclusive evidence on the relationship of sex with MetS. Some studies have reported that MetS is more common in females, because of the sex hormones that affect the body's metabolism (Meyer et al., 2005; Boke et al., 2008), whereas others have reported no sex-related differences in the prevalence rates of MetS and only a few studies have reported a higher prevalence in males (Brunero et al., 2009). Some studies have reported an association of MetS with higher education level, because of lower participation in sports and deeper involvement in academics (Kang et al., 2011), urban background, employed status, and marital status. This study found a statistically significant elevation in fasting blood glucose among patients compared with controls, as some atypical antipsychotic drugs increase the blood glucose level (Meyer et al., 2005). Drug-naive schizophrenic patients have been reported to have significantly higher fasting plasma glucose levels, impaired fasting glucose tolerance, elevated insulin and cortisol levels, and insulin resistance in various studies (Verma et al., 2009). In one of the earliest studies, about 15% of drug-naive schizophrenic patients showed impaired fasting glucose tolerance, higher than the age-adjusted population rates (Ryan et al., 2003). Two studies (Ryan et al., 2003; Verma et al., 2009) reported lower mean fasting total cholesterol and low-density lipoprotein levels in drug-naive schizophrenic patients, whereas several studies have failed to show any association (Taylor and McAskill, 2000). Spelman et al., in 2007, comparing 38 drug-naive schizophrenic patients with 44 matched healthy controls, found no differences in total cholesterol, low-density lipoprotein, HDL, or TGs Sengupta, 2008. A study on first-episode psychosis (FEP) patients also did not find any lipid derangements except a slight trend toward lower HDL levels. Further, a study on chronic schizophrenic patients in the community, who were never treated, also failed to find any significant lipid disturbances in patients compared with healthy controls (Padmavati et al., 2010). This study found a strong association between psychosis and elevated BP. Grover et al. (2012) investigating MetS in drug-naive psychotic patients, found elevated BP (>135/85 mm/Hg) in 26% of cases. In another study, Fernandez-Egea et al. (2009) reported significantly higher pulse pressure but no significant difference in systolic or diastolic BP while comparing drug-naive schizophrenic patients with FEP and controls. The observed pulse pressure differences were independent of age, ethnicity, smoking, sex, and BMI, suggesting that antipsychotic-naive patients with FEP may be inherently prone to hypertension. Unlike multiple studies that report antipsychotic-induced obesity, studies on drug-naive schizophrenic patients generally show minimal or no body weight disturbance. In a study comparing 26 drug-naive schizophrenic patients with healthy controls, Ryan et al. (2004) did not find any significant difference in BMI, waist-to-hip ratio, or WC between the two groups, despite the fact that the patient group had higher saturated fat content in their diet. Further, Spelman et al. reported lower BMI in drug-naive schizophrenic patients when compared with healthy controls with similar dietary patterns, including low fiber intake and lower exercise levels. Lower BMI in drug-naive schizophrenic patients has also been reported by Padmavati et al. (2010) in studies from India. In contrast, Sengupta (2008) reported an increase in waist-to-hip ratio in their sample of drug-naive schizophrenic patients. Whereas Zhang et al. (2004) reported no significant difference in intra-abdominal or subcutaneous fat deposition between drug-naive schizophrenic patients and controls, Ryan et al. (2004) reported three-fold less intra-abdominal fat in drug-naive schizophrenic patients compared with controls, although no difference was found in subcutaneous or total body fat between the two groups. Differing ethnicity of the two study populations might explain the different findings (Chadda et al., 2013).


Prevalence of MetS is higher in drug-naive psychotic patients compared with controls. Psychosis is a risk factor for developing hypertension and hypertriglyceridemia in drug-naive psychotic patients.


Furthur research is required to detect the effect of early monitoring and intervention of MetS on psychotic patients to attain the most efficient management with the least adverse effects. Sports programs should be established to decrease the incidence of MetS.


Conflicts of interest

There are no conflicts of interest.[26]


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