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Prevalence of metabolic syndrome in unipolar Munish Aggarwal, Sandeep Grover, Subho Chakrabarti, Alakananda Dutt,
Ajit Avasthi, Parmanand Kulhara
Abstract
Background: Metabolic syndrome is a risk factor for the development of coronary heart
disease and type -2 diabetes mellitus. Depression and diabetes share a two way
relationship. Only a few studies have evaluated the prevalence of metabolic syndrome in
depression and there is none from India. Aim: To study the prevalence of metabolic
syndrome in patients with unipolar depression. Methods: A total of 166 patients diagnosed
with unipolar depression were evaluated for the presence of metabolic syndrome
according to International Diabetes Federation (IDF) and National Cholesterol
Education Program Third Adult Treatment Panel (NCEP-ATP III) criteria. Results: Of
the total sample, 41.6% and 44% of patients had metabolic syndrome according to IDF
and NCEP-ATP III criteria respectively. Increased waist circumference (69%) was the
most common abnormality followed by hypertension (51%). Abnormal fasting blood
glucose was the least common abnormality (28.9%). Metabolic syndrome was found to
be higher in subjects who were older and had higher BMI. No significant association
was found between the prevalence of metabolic syndrome and type of antidepressant
used. On regression analysis, high BMI was found to be strongest predictor of development
of metabolic syndrome. Conclusion: Monitoring of BMI, waist circumference and blood
pressure can be helpful for early detection of metabolic syndrome.

Key words: Metabolic syndrome, depression, prevalence
Introduction
Metabolic syndrome (MetS) is a cluster of development of diabetes and poor glycemic disorders/risk factors which include obesity, controls in those with preexisting diabetes.3 dyslipidaemia, insulin insensitivity, deranged Studies have shown that metabolic syndrome glucose metabolism and hypertension. It is of and its various components, especially central obesity and dyslipidemia are predictors of metabolic risk factors are associated with depressive symptoms.4,5 Similarly studies in cerebrovascular disease, as well as type-2 abnormalities of lipid profile,4,8-11 higher diabetes mellitus.1,2 Depression and metabolic prevalence of obesity and increased waist syndr ome share a two way relationship.
circumference4,6 and hypertension.11,12 It issuggested that presence of obesity and other Journal of Mental Health and Human Behaviour : 2012; 17(1) 15
Aggarwal et al : Prevalence of Metabolic syndrome in Unipolar Depression : An exploratory study markers of metabolic syndrome can promote a chronic, sub acute state of inflammation.13 This To be included in the study, the patients were required to be 18 years or above, of either dysregulation of the hypothalamus-pituitary- gender and diagnosed with a depressive disorder adrenal (HPA) axis which can produce a state (first episode or recurrent depressive disorder similar to that of depression.14,15 It is also according to ICD-10).26 Patients were selected suggested that presence of central obesity (i.e., by purposive random sampling, i.e., a random increased waist circumference) may be the key table was generated using SPPS (3:2 ratios in mediator or pathogenic factor responsible for favour of inclusion into the study) and the higher prevalence of metabolic syndrome in patients were allocated to the inclusion or diagnosed with first episode or recurrent metabolic syndrome in subjects with depression to vary from 30.4% to 48.8%.6,16,17 Studies also sampling, of which 20 declined to participate.
suggest that depression increases the risk of Of the remaining 250 patients, a study sample of 166 patients was selected on the basis of pre- folds.18-20 The prevalence of metabolic syndrome generated randomization number table.
in subjects with depression was not influenced using both International Diabetes Federation episodes, age at first episode and presence of a (IDF) criteria and modified National Cholesterol Education Program Adult Treatment Panel III However, there is lack of data from eastern (NCEP ATP-III) criteria (see box 1). NCEP ATP- countries like India. There are occasional studies III criteria has been modified for Asians and accordingly the waist circumference criteria for depressive disorders in patients of hyper- Asians is restricted to >90 cm for males and > tension23 and diabetes mellitus24. There is one 80 for females (in contrast to NCEP ATP-III study which has evaluated the prevalence of where the cut-off is 102 cm and 88 cm for males various subcomponents of metabolic syndrome and females respectively). IDF also defines in depressed patients. In a small sample study metabolic syndrome by using similar cutoffs for (n=30), Das et al25 reported significant elevation various components and requires presence of 3 of serum total cholesterol in depressed patients components but the waist circumference criteria significance of these findings persisted even after controlling for various confounders. In the abnormalities (i.e. metabolic syndrome, or any same study, authors reported that patients with specific abnormality like hypertension, raised severe depression had higher body mass index.
blood sugar, dyslipidemia) were informed, However, there is lack of data with regard to educated about the need for proper diet and prevalence of metabolic syndrome in depressed regular exercise, and were referred for specialist subjects from India. In this background, the present study aimed at assessing prevalence ofmetabolic syndrome in subjects with depression All the eligible patients were approached 16
Journal of Mental Health and Human Behaviour : 2012; 17(1) Aggarwal et al : Prevalence of Metabolic syndrome in Unipolar Depression : An exploratory study Mean and standard deviation were calculated Box 1: Metabolic syndrome: Modified
for continuous variables. Frequencies with NCEP-ATP-III criteria
percentages were calculated for nominal and A minimum of 3 out of the following 5 criteria: ordinal variables. Chi-Square and t-tests were (a) high waist circumference (> 80 cm for females used for comparisons, and a binary logistic (b) systolic blood pressure e” 130 and/or diastolic influence of independent variables on presence (c) triglyceride levels >150 mg/dl (or on treatment (d) HDL cholesterol < 40 mg/dl for male and <50 mg/dl for females (or on treatment for this The socio-demographic and clinical profile (e) Fasting blood sugar more than 110 mg/dl (or of patients is shown in table 1. Selective on treatment for diabetes mellitus).
Serotonin Reuptake Inhibitors (SSRIs) as a and explained about the purpose of the study.
antidepressants, while venlafaxine was the most details of all the subjects were recorded in structured formats. Body weight was measured antipsychotic agent, olanzapine (n=9) and in kilograms (kg) and height was measured in risperidone (n=7) being the commonest. Only centimeters (cm) by a calibrated scale and the one subject received augmentation with lithium.
Body mass index (BMI) was calculated from the above information. Waist circumference wasmeasured in centimeters (cm), at a point midway between the inferior costal margin and the fulfilled the modified NCEP-ATP III criteria for superior iliac crest, at the end of normal metabolic syndrome and 41.6% (N=69) subjects expiration while standing. Standard mercury fulfilled IDF criteria. Among the metabolic manometer was used to measure blood pressure syndrome criteria, waist circumference was the (BP) in supine position. Two readings at 5- most common criteria (69%) followed by high minute intervals were recorded and if high blood blood pressure or preexisting hypertension pressure (e”130/85) was noted in one of the (51.2%) and low HDL levels (45.8%). Abnormal readings, then a third reading was taken after fasting blood glucose level was the least 30 minutes; the lowest of these readings was common abnormality seen (28.9%). Besides 73 included for analysis. Fasting venous blood patients having metabolic syndrome, another 51 sample was collected under aseptic condition patients (30.7%) fulfilled 2 criteria of metabolic to estimate fasting blood sugar (FBS), serum triglycerides (TGA) and serum high density satisfied at least 1 criterion of metabolic There was no difference in the prevalence of MS between male and female patients.
However, in terms of various subcomponents (Chicago, Illinois, USA) was used for analysis.
Journal of Mental Health and Human Behaviour : 2012; 17(1) 17
Aggarwal et al : Prevalence of Metabolic syndrome in Unipolar Depression : An exploratory study Table 1: Socio-demographic and clinical
profile of patients (N=166)
As shown in table 4, compared to patients Variable
Mean±SD/
Frequency (%)
belonged to urban locality, were less frequently Age (years)
receiving sertraline, more frequently had higher Education (years)
Total duration of illness
groups of medications received were analyzed (in months)
in terms of dose, duration and cumulative medication exposure (dose x duration of intake), as shown in table 5, no significant differences Marital status
was seen for duration, dose or cumulative dose of serteraline, escitalopram and venlafaxine, which were the major medication groups in the Occupation
Working/Household work
Religion
Hindu
Binary logistic regression analysis was used to assess the predictors of metabolic syndrome.
Family type
All variables which had statistically significant difference in the comparison analysis were Locality
considered. As shown in table 6, metabolic syndrome was significantly predicted by marital status, urban locality and higher BMI. Among Antidepressants
Sertraline
the various components of metabolic syndrome, triglyceride levels, raised blood pressure, high fasting glucose levels and low high density lipoproteins levels had the least predictive value.
Antipsychotics
Discussion
Mood stabilizers
To our knowledge, this is the first study from India which has evaluated the prevalence triglyceride levels were more prevalent in males of metabolic syndrome in patients of depressive compared to females, whereas lower HDL levels disorders. It is important to understand the and higher waist circumference levels were relationship between depression and risk for the Table-3 provides details of mean values of depression predicts future risk for heart disease.7 pressure, lipid profile and fasting blood glucose representative of depressed patients seen in our Relationship of Metabolic syndrome to set up25,27 and other parts of India.28 The lipid sociodemographic variables, anthropometry 18
Journal of Mental Health and Human Behaviour : 2012; 17(1) Aggarwal et al : Prevalence of Metabolic syndrome in Unipolar Depression : An exploratory study Table 2: Metabolic parameters
Variable
Total sample
Chi-square
value (p)
Abnormal BP (>130//>85) or diagnosed TG levels > 150 mg or on lipid lowering agents FBG levels >100 mg % or diagnosed as DM (>90 cm for males and >80 cm for females) BP – Blood pressure; DM – Diabetes mellitus; FBG – Fasting blood glucose; HDL – High density lipoprotein; HTN – Hypertension; MetS – Metabolic syndrome; TG – Triglycerides; WC – Waist circumference Table-3: Mean values of various anthropometric measures, blood pressure,
lipid profile and fasting blood glucose levels
Variable
Mean ±SD
High density lipoprotein (HDL) levels (mg/dl) profile of the patients included in the present finding is in the range of prevalence rate reported study is also comparable to the lipid profile in previous studies from the West. 6,16,17 When reported for depressed patients in one of the we compare the findings of the present study with a community-based study in our catchment area, the prevalence rates of metabolic syndrome the present study was found to be 42-44%. This [35.8% (NCEP ATP III), 45.3% (modified NCEP Journal of Mental Health and Human Behaviour : 2012; 17(1) 19
Aggarwal et al : Prevalence of Metabolic syndrome in Unipolar Depression : An exploratory study Table-4: Comparison of patients with and without metabolic syndrome as per modified
NCEP-ATP-III
Variable
Subjects with
Subjects
t-test/ Chi-square
MetS (N=73)
without MetS
Mean ± SD/
(N=93) Mean±SD/
Frequency (%)
Frequency (%)
4 subjects received combination of antidepressants (two in each group); Only one subject not fulfilling the criteria for metabolic syndrome had received lithium (no other subject received any other mood stabilizer) Table-5: Comparison of patients with and without metabolic syndrome
Variable
Subjects with
Subjects without
Mann-Whitney
MetS Mean ± SD/
MetS Mean ± SD
Serteraline
Escitalopram
Venlafaxine
ATP III) and 39.5% (IDF criteria)] is more or less equal to the findings of the general population. 29 However, it must be remembered that in this study patients were not screened for depression and it is possible that some of these Increased waist circumference was the most patients may be having depression and other common abnormality seen in the present study, 20
Journal of Mental Health and Human Behaviour : 2012; 17(1) Aggarwal et al : Prevalence of Metabolic syndrome in Unipolar Depression : An exploratory study Table-6: Simple binary logistic regression analysis showing predictors of metabolic
syndrome as per NCEP-ATP III criteria
Confidence
interval
(> 90 cm for males & >80 cmfor females)Abnormal BP (>130//>85) or diagnosed as having hypertensionTG levels >150 mg or on lipid <50 mg F) or on lipidlowering agentsFBG levels >100 mg % or this was followed by higher blood pressure. This Taken together findings of the present study is in keeping with previous studies which have and literature suggest that it is important to study In the present study, certain differences components of metabolic syndrome, BMI more than 25 was the strongest predictor of metabolic subcomponents of metabolic syndrome among syndrome and similar association has also been reported earlier.31Thus, it is logical to assume significantly higher prevalence of raised blood pressure and raised triglyceride levels, whereas fema le patients had significantly higher prevalence of raised waist circumference and variables, urban locality emerged as a significant lower high density lipoprotein levels. Higher predictor of metabolic syndrome. This finding prevalence of increased waist circumference in is line with that reported by Ravikiran et al, 29 female depressed patients is supported by the which evaluated the prevalence of metabolic findings from the West30. Studies from the West syndrome in Indian setting. This could be due also support the finding of higher prevalence of to the life style and dietary factors. Studies from the West suggest that metabolic syndrome is depressed women,4,6,18 but the findings of higher findings of the present study do not support the triglyceride levels in males is in contradiction Journal of Mental Health and Human Behaviour : 2012; 17(1) 21
Aggarwal et al : Prevalence of Metabolic syndrome in Unipolar Depression : An exploratory study factor for diabetes. Expert Rev Cardiovasc syndrome, it was seen that increased waist circumference had the highest predictive value.
The predictive value of abnormal triglyceride levels and high blood pressure was nearly same.
total and cardiovascular disease mortality antidepressant medications was small, findings of the present study suggest that antidepressants have no influence on the prevalence of various diabetic patients: the relationship between metabolic syndrome per se. This is in agreement present study namely a cross-sectional design and lack of healthy control group. Although we comorbidities, the data were not recorded for comorbidities. Similarly, data for drug abuse were not recorded. The relationship between the severity of illness, residual symptoms, treatment refractoriness and life style and prevalence of MS was also not studied. Future studies should depressive symptoms: a population-based 7- To conclude, the present study reveals that depressive disorder have metabolic syndrome.
6. Dunbar JA, Reddy P, Davis-Lameloise N, Metabolic syndrome in unipolar depression is Philpot B, Laatikainen T, Kilkkinen A, et predicted by urban locality and higher BMI.
Higher body mass index had the highest odds components of MS, higher waist circumference and high blood pressure were present more frequently than other components and high predictive value for full metabolic syndrome.
depression and the metabolic syndrome.
These findings imply that monitoring body mass index, waist circumference and blood pressure 8. Morgan RE, Palinkas LA, Barrett-Connor can be useful in monitoring the development of Reference:
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depression in type 2 diabetes patients in a 17. Heiskanen TH, Niskanen LK, Hintikka JJ, 25. Das PP, Malhotra S, Chakrabarti S, Sharma S. Elevated total cholesterol in severely depressed patients: role in cardiovascular risk? and depression, a cross-sectional analysis.
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29. Ravikiran M, Bhansali A, Ravikumar P, 34. Chokka P, Ta ncer M, Yeragani VK.
Bhansali S, Dutta P, Thakur JS, et al.
community survey. Diabetes Res Clin Pract 35. Pyykkonen AJ, Räikkönen K, Tuomi T, 30. Toker S, Shirom A, Melamed S. Depression and metabolic syndrome is not explained by antidepressant medication: Results from the Source of Funding: Nil
Conflict of interest: None declared
Munish Aggarwal, Senior Resident
Sandeep Grover, Assistant Professor
Subho Chakrabarti, Professor
Alakananda Dutt, Formerly Senior Resident
Ajit Avasthi, Professor
Parmanand Kulhara, Professor
Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh -
160012, India
Correspondence to: Dr Sandeep Grover, Assistant Professor, Department of Psychiatry, Postgraduate
Institute of Medical Education & Research, Chandigarh-160012, India Email: drsandeepg
2002@yahoo.com
24
Journal of Mental Health and Human Behaviour : 2012; 17(1)

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