Mass non-communicable diseases are in the first place in terms of
morality and morbidity within the general population. In this group
of diseases, metabolic diseases such as obesity and diabetes
predominate, which are accompanied by an increased risk of
cardiovascular and cerebro-vascular incidents, and a consequent
fatal outcome. In the population of psychiatric patients, however,
it is known that the rate of premature mortality from all causes is
far higher than in the general population. Studies have shown that
the life expectancy of patients with significant psychiatric
disorders is reduced by 7 to 24 years [1,2,3,4]. On the other hand,
about 60% of premature deaths of psychiatric patients occur due to
somatic illnesses, predominantly due to cardiovascular diseases. The
risk of cardiovascular diseases, increased by comorbidities such as
diabetes, obesity, stroke, is multiplied in patients with several
different psychiatric diseases such as psychotic disorders, mood
disorders and anxiety disorders. [1,2,3,4,5].
MetS is defined as a combination of multiple comorbid conditions
such as abdominal obesity, high arterial blood pressure, low "good",
HDL cholesterol, hypertriglyceridemia and hyperglycemia. MetS is
therefore the first step on the so-called. A "metabolic pathway"
that ultimately ends in premature death. This concept of MetS is in
line with the recommendations of the International Diabetes
Federation. The concept of MetS has proven to be the most
appropriate universal predictive factor that allows to select groups
with increased risk and to prevent the progression of the "metabolic
pathway" by timely medical and nutritional action [6,7].
The prevalence of MetS in the general population is between 10% and
15%, while in the population of psychiatric patients the value is
many times higher and ranges from 30% to as much as 60% [8,9,10].
Most of the world's research points to psychotropic therapy as one
of the main causes of the multiple incidence of MetS within a group
of psychiatric patients [11,12]. Weight gain is often a side effect
of a large number of psychotropic drugs. Today it is clear that some
drugs used in psychiatry as a side effect disrupt fat and sugar
We did not find studies of the prevalence of MetS in a group of
psychiatric patients in Serbia. Therefore, this study was conducted
to assess the prevalence of MetS in a sample of patients
hospitalized at the Clinic for Psychiatry of the Clinical Center of
Vojvodina (KCV) in Novi Sad and linked it to socio-demographic
characteristics, psychiatric diagnosis and psycho-pharmacotherapy
used in psychiatric patients and to single out possible predictor
risk factors for MetS screening.
MATERIAL AND METHODS
The study was designed as a retrospective cohort study. Data of
interest for this research were collected from the medical histories
of hospitalized patients at the Clinic for Psychiatry KCV in the
period from January 2018 to January 2020. Data on 2409 patients were
collected. Patients under the age of 18 were not included in the
study, as well as those who did not have a primary psychiatric
discharge diagnosis according to ICD-10, and those patients for whom
there were no complete data from medical histories. Those patients
who were treated more than once in the study period were counted
only once in the total sample. There were no patients treated for
addiction in the sample. Sociodemographic and clinical data are
taken from the history of the disease. The primary psychiatric
diagnosis was taken from the discharge card according to the code
system ICD-10. All diagnoses are grouped into four categories:
psychosis (F20-29), mood disorders (F30-34), anxiety disorders
(F40), and other mental disorders. The MetS is determined by the
criteria envisaged by the agenda of the International Diabetes
1) Waist circumference values > 102 cm for men and> 88 cm for women,
2) triglyceridemia> > 1,7mmol /L (1.5 mg / ml)
3) HDL cholesterolemia HDL< 1.03 mmol/L (men) or < 1.29 mmol/L
(women) (<0.4 mg/ml for men and <0.5 mg/ml for women),
4) arterial blood pressure> 135/85 mmHg,
5) fasting glycemia> 6.1 mmol / l.
If at least three of the above criteria are met, it is considered
that there is a diagnosis of MetS. Patients with a history of
associated arterial hypertension and diabetes mellitus were also
included in the study.
Data on psycho-pharmaceuticals that patients, included in the study,
drank were also recorded. Medications are divided into five groups -
classic and atypical antipsychotics, antidepressants, mood
stabilizers. A large number of patients were not on
monopsychopharmacotherapy, so another group was formed where
patients who took 2 or more drugs were classified. It is considered
that a patient is on therapy with a certain psychopharmaceutical if
he has been drinking it for the last 30 days in the prescribed
Statistical data processing initially consisted of descriptive
variables. Frequencies and proportions were used for their
processing, while standard deviations, means and medians were used
to represent quantitative variables. The chi square test was used to
assess the difference in the prevalence of MetS between the sexes.
Comparison of the prevalence of MetS in different diagnoses was
performed using the ANOVA (F) test, and in the case of a
statistically significant difference, the t and χ² test was applied.
A binary logical regression model was applied to identify the most
important factors for the dichotomous outcome - the presence or
absence of MetS in the study group. For all applied statistical
tests, the error level was set to an acceptable level of p <0.05.
Statistical data processing was done in the computer program SPSS
The conduct of such a study was approved by the Ethics Committee of
the KCV. The study is conducted according to internationally
recognized ethical standards set in the field of biomedical
A total of 2409 psychiatric patients participated in the study.
The prevalence of MetS among this population is 1327 and 55.1%,
Table 1. Sociodemographic characteristics
Note: AS - arithmetic mean, SD - standard
deviation, χ² - statistical, p - statistical significance
Although there are more female respondents in the sample (55.7%),
there are more male respondents with a diagnosis of MetS (58.1%)
than women. The average age of the patient is about 47 years. About
40% of the sample consists of respondents younger than 30 years, a
third from 30 to 50 years, and a quarter over 50 years of age. In
the population of patients younger than 30, one third record the
criteria for the diagnosis of MetS. It can be observed that among
widows and singles there are more subjects with MetS compared to
patients who are married or divorced. On average, respondents have
less than two children. In terms of education, one third of
respondents have completed secondary school, one fifth do not even
have completed primary school, and one in four respondents has only
primary school, and about 20% of them have a high school diploma.
Among patients with incomplete primary school, almost two thirds of
them are diagnosed with MetS. It can be seen that there is a
statistically significant correlation between the sex of the
subjects and the prevalence of MetS χ² (7.045, p=0.008). Men have a
relatively higher prevalence of MetS χ² (49,157, p=0,000). There is
a statistically significant correlation between the level of
education of the subjects and the prevalence of MetS χ² (52,079,
Approximately half of the patients included in the study are being
treated for psychotic disorders, a third are suffering from mood
disorders, and a fifth are suffering from anxiety disorders. The
study sample shows a statistically significantly higher prevalence
of metabolic syndrome among patients treated for psychotic
disorders, with as much as 67% prevalence. Therapy with atypical
antipsychotics was most associated with metabolic syndrome in 67.5%
of patients, followed by a combination of 2 or more antipsychotics
with 60.7% (χ²=26.99, p <0.0019). The diagnosis of metabolic
syndrome is most common in patients up to 5 years of age and is over
65%. The body mass index averages about 28, but is 10 units higher
among the population of subjects who have MetS. The situation is
similar when it comes to waist circumference. The average waist
circumference among the psychiatric population in the sample was 95
cm, while among subjects with MetS the waist circumference was
higher by almost 20 cm compared to those without MetS.
Table 2. Clinical characteristics
Note: AS - arithmetic mean, SD - standard deviation,
χ² - statistical, p - statistical significance
It has been shown that there is a statistically significant
difference in BMI values between subjects with MetS and those who do
not have this syndrome. In subjects with MetS, a significantly
higher value of the mentioned index is recorded in relation to
subjects without MetS, where the magnitude of the impact is large
and amounts to 0.86. Also, there is a statistically significant
difference in the value of the waist circumference indicator between
subjects with MetS and those who do not have this syndrome. Subjects
with MetS have a significantly larger waist circumference compared
to subjects without MetS, with a large impact size of 0.76.Table 3
also shows that there is a statistically significant difference in
blood sugar, triglyceridemia and HDL cholesterol level between
subjects with MetS and those who do not have this syndrome.
Table 3. Mann-Whitney U test to examine
differences between patients with and without metabolic syndrome in
terms of body mass index (BMI) and waist circumference, arterial
blood pressure values and laboratory measurements
Note: Md - median, N - number of subjects,
Mann-Whitney U - test value, Wilcoxon W - statistician, Z -
standardized statistician, p - statistical significance
As shown in Table 4, two independent variables made a unique
statistically significant contribution to the model (abdominal
obesity and triglyceridemia). The strongest predictor of the answer
that the respondents will suffer from the MetS is the waist
circumference, whose quotient is 1.34. Thus, the probability that
the subject will be diagnosed with metabolic syndrome is 1.34 times
higher with an increase in abdominal obesity (waist circumference),
when all other factors are equal. Another important predictor refers
to triglyceridemia, whose probability quotient is 1.12. Thus, the
probability that the subject will be diagnosed with MetS is 1.12
times higher with an increase in triglyceride values, when all other
factors are equal.
Table 4. Estimation of the influence of predictor
variables on the probability of obtaining metabolic syndrome -
binary logistic regression
Note: B - regression coefficient, S.E. - standard
error, Wald - indicator value, df - number of degrees of freedom,
Sig. - statistical significance, Exp (B) - odds ratio, 95% C.I. for
EXP (B) - 95% confidence interval for the probability quotient
As far as the author knows, this is the first work in the
Autonomous Province of Vojvodina, but also in the entire territory
of the Republic of Serbia, which deals with the examination of the
prevalence of MetS in the population of psychiatric patients. It is
known that patients with serious psychiatric illnesses have a far
higher risk of developing MetS than the general population. In this
study, the prevalence of MetS in the study population was 55.1%.
This percentage is significantly higher than values from similar
studies conducted worldwide where the prevalence ranges between 25
and 35% [8,14,15,16]. Although the study from the United Arab
Emirates records an approximately high value of 48.1% prevalence of
MetS in the group psychiatric patients . Regarding the
prevalence of MetS in the general population of Serbia, which is
quite high and ranges from 38.4 to 42.7%, we see that psychiatric
patients in Serbia are also classified as a vulnerable group in
terms of metabolic status . It is clear that a person with a
mental illness is about 30% more likely to develop MetS. High rates
of MetS in both the general population and the population of
psychiatric patients in Serbia are certainly significantly
associated with a predominantly sedentary lifestyle characterized by
minimal physical activity and predominantly calorie-dense foods
represented in the diet.
The prevalence of MetS increases with the age of psychiatric
patients, but that in the population aged 30 to 50 and over 50 is
approximately the same and amounts to about 55%. Such conclusions
are in agreement with the findings of several different studies on
similar topics worldwide . However, what is worrying is that the
incidence of MetS in the study population under the age of 30 is
about 33%. The prevalence of MetS among older adolescents (16-18
years) in Serbia is 13% . How much psychiatric illness is an
additional aggravating factor in the life of a young person for the
development of comorbid physical diseases is clear from the fact
that in practically 10 years from the end of adolescence to 30 years
of age the incidence rate of MetS almost urtostructs. The high
prevalence of MetS in the general population in general can be
explained by the high prevalence of MetS components in the elderly,
such as hyperglycemia and dyslipidemia . Although some studies
suggest that the high incidence of MetS in the elderly is due to
functional and metabolic changes which are a consequence of aging.
And that would mean that the MetS is a common companion of the aging
process, which practically does not stand.
In relation to the differences in the prevalence of MetS in the
population of psychiatric patients in terms of gender, unlike most
similar world studies, it was found that men with psychiatric
diseases significantly more often meet the criteria for diagnosis of
MetS [22,23]. Male, older age, single life, lower level of education
and higher number of children in this study were selected risk
factors for higher risk for the development of MetSin the
psychiatric population. All these characteristics of the model of a
psychiatric patient at risk for the diagnosis of MetS have been
confirmed by studies from South Korea . This deviation can be
explained precisely by the characteristics of the risk population
itself. Single, middle-aged men, middle and lower level of education
and level of economic power, who have a psychiatric illness and
therefore insufficient and inadequate social support have all the
prerequisites to practice a bad lifestyle, often accompanied by
harmful habits such as smoking and alcohol use leading to metabolic
Psychiatric patients have been shown to have a significantly higher
risk of having some of the components of MetS.  And for the
general population, the overall contribution of MetS diagnosis to
overall mortality is estimated at 6-7%, 12-17% as the prevalence of
arterial hypertension and 30-52% regarding diabetes mellitus
[25,26,27]. This study showed that the duration of psychiatric
illness plays a very important role as a risk factor for the
development of MetS in patients. Over 60% of psychiatric patients
treated for up to 5 years, as well as over 5 to 10 years, have a
MetS. Two meta-analyzes by American authors find that the duration
of psychiatric illness is the greatest risk factor for the
development of MetS [27,28]. The duration of psychiatric illness is
certainly related to the age of such patients, but also to the time
of exposure to psychotropic medication, which both have a positive
impact on the development of MetS.
According to recently published studies, there are no statistically
significant differences between the prevalence of MetS among
patients with different psychiatric diagnoses — studies that
directly compared schizophrenic patients with patients with bipolar
disorder. However, there are review studies that find a much higher
incidence of MetS among the population of schizophrenic and bipolar
disorders . The current study sample shows a significantly
higher prevalence of MetS among patients treated for psychotic
disorders, with as much as 67% prevalence. While in the second place
are patients with a diagnosis of mood disorders. Both samples showed
a statistically significant difference in relation to the occurrence
of MetS. Certainly, patients with these two psychiatric diseases are
most often treated with atypical antipsychotics, mood stabilizers
and antidepressants, as well as a combination of several different
psychopharmaceuticals, which seems to be the strongest contributing
factor to metabolic disorders, in addition to practicing unhealthy
lifestyles and harmful habits. But the use of psychotropic drugs is
the main difference between the population of psychiatric patients
and the general population. It is certainly a mixed constellation of
different risk factors such as the clinical characteristics of the
diagnosis itself with a predominance of negative symptoms, lack of
adequate social support that together condition such a somatic risky
lifestyle of psychiatric patients.
Atypical antipsychotics, but also a combination of several different
psychopharmaceuticals, were the only ones that stood out as
statistically significantly associated with the development of MetS.
Such findings agree with most of the world's findings linking the
use of atypical antipsychotics and the development of metabolic
anchor. The CATIE study showed that after 3 months of olanzapine
exposure, there was a significant increase in the number of patients
who met the criteria for MetS . Metabolic deterioration was also
observed during long-term research of patients treated with
clozapine . As the indication field for atypical antipsychotics
has significantly expanded today - from affective disorders to mood
disorders, the population of patients using these drugs has
increased significantly. Therefore, the risk of metabolic
abnormalities should be considered when choosing an appropriate
psychotropic drug, especially atypical antipsychotics.
Waist circumference and triglyceridemia stand out as the two most
common contributing factors for the development of MetS in
psychiatric patients. The risk that a psychiatric patient is
diagnosed with MetS is 1.34 times higher with an increase in waist
circumference, when all other factors are equal. Another important
predictor refers to triglyceridemia, whose probability quotient is
1.12. These findings agree with the findings of several world
studies, which certainly find a statistically significant
association between visceral obesity, waist circumference and poor
mental health in patients . Although some studies do not find an
increased value of triglycerides in the blood as a statistically
significant predictor for the development of MetS. these are the
levels of cholesterol in the blood . The reasons for this
finding in the current study may lie in the fat metabolism itself.
If it is known that triglycerides are only the initial component in
the formation of cholesterol, it can be concluded that a high value
of triglycerides also significantly contributes to metabolic risk,
albeit indirectly through the consequent increase in cholesterol.
The main reason for the increased blood cholesterol values in the
patients included in this study is the diet rich in fats and refined
simple sugars that dominates in the Autonomous Province of Vojvodina.
The prevalence of MetS in psychiatric patients at the Clinical
Center of Vojvodina in Novi Sad is alarmingly high. in more than
half of patients, especially those treated for psychotic and mood
disorders and using atypical antipsychotics and combinations of
antipsychotics. In a patient with metabolic syndrome there is male
dominance, low educational profile and the prevalence increases
statistically significantly with increasing age of psychiatric
patients. These findings once again emphasize the importance of
continuous, long-term and multisystem monitoring of psychiatric
patients, and the need to provide better organized social and health
support, especially vulnerable from the group of psychiatric
patients - the elderly, singles, singles. especially atypical
antipsychotics, as drugs that have stood out as those most strongly
associated with the development of MetS in a group of psychiatric
patients. Waist circumference and blood triglyceride values are
suggested as the best predictor factors for the development of MetS.
Conflict of interest: None.
Special thanks to Prof. Dr. Mini Cvjetković Bošnjak under whose
expert supervision this study was conducted.
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