**2. Patients and methods**

### **2.1 Subjects**

This study was approved by the local ethical committee and all subjects were of Tunisian origin. Our samples included 130 patients with bipolar I disorder (37.9 ± 12.1 years) from the psychiatry department of the University Hospital of Monastir, Tunisia, 45 women (37.5 ± 13.4 years) and 85 men (38.1 ± 11.4 years). Consensus on the diagnosis, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria (American Psychiatric Association, 2004), was made by psychiatrists. The exclusion criteria were age < 18 years, other psychiatric illnesses, epilepsy or mental retardation. The control group consisted of 175 volunteer subjects without psychiatric pathology. The mean age was 40.1 ± 14.0 years, and there were 73 women (42.0 ± 14.4 years) and 102 men (38.8 ± 13.6

in the general population. This mortality gap, which translates to a 13-30 year shortened life expectancy in severe mental illness patients, has widened in recent decades, even in countries where the quality of the health care system is generally acknowledged to be good. About 60% of this excess mortality is due to physical illness especially cardiovascular disease. Additionally, several studies have found that after suicide and accidents, cardiovascular and all vascular diseases are the main leading causes of death in these

Patients with bipolar disorder, especially type I, are known to suffer a considerable number of associated pathologies that may manifest at earlier ages and with higher frequency than in the general population. The most recent studies have explored cardiovascular risk and the association with metabolic and endocrine disorders fundamentally, obesity and metabolic syndrome which are clearly associated with the development of cardiovascular disease

Cardiovascular disease, i.e. coronary heart disease, stroke, and peripheral vascular disease, are potentially preventable diseases. Thanks to epidemiological, experimental and clinical studies, the primary determinants of cardiovascular disease have been identified, as well as the efficacy of specific interventions. The prevalence of cardiovascular disease is increasing in less urbanized, developed populations across the world, as their lifestyles change to a so called "western style", with increasing consumption of dietary saturated fat, cholesterol and salt, cigarette smoking, decreased physical activity and the rise in cardiovascular risk factors including obesity and diabetes. Other known factors that contribute to cardiovascular disease risk are stress and high alcohol intake. Among all these factors, hypercholesterolemia is the leading cause of death from cardiovascular disease. As a result, public health agencies have attempted to reduce the prevalence of hypercholesterolemia through screening and by increasing public awareness and strategies for reducing it

The exact mechanisms increasing the incidence of cardiovascular risk in bipolar patients remain to be clarified, but they possibly include industrialisation, stress, lack of exercise, dietary lipids (that is, omega-3 fatty acid deficiency) and increasing incidence of smoking

This study aims to investigate the principal factors predisposing to the cardiovascular risk in Tunisian bipolar I patients (cigarette smoking, hypertension, diabetes, obesity, lipid profile, hyperhomocysteinemia and metabolic syndrome) and to determine the association between

This study was approved by the local ethical committee and all subjects were of Tunisian origin. Our samples included 130 patients with bipolar I disorder (37.9 ± 12.1 years) from the psychiatry department of the University Hospital of Monastir, Tunisia, 45 women (37.5 ± 13.4 years) and 85 men (38.1 ± 11.4 years). Consensus on the diagnosis, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria (American Psychiatric Association, 2004), was made by psychiatrists. The exclusion criteria were age < 18 years, other psychiatric illnesses, epilepsy or mental retardation. The control group consisted of 175 volunteer subjects without psychiatric pathology. The mean age was 40.1 ± 14.0 years, and there were 73 women (42.0 ± 14.4 years) and 102 men (38.8 ± 13.6

these factors and the clinical and therapeutic characteristics of bipolar I disorder.

and alcohol consumption and other factors (Ezzaher et al., 2010).

patients (De Hert et al., 2011; Garcia-Portilla et al., 2009).

(Angst et al., 2002; Sicras et al., 2008).

(Muntoni et al., 2009).

**2. Patients and methods** 

**2.1 Subjects** 

years). All subjects were questioned about their age, gender, previous treatments and cigarette and alcohol consumption habits.

The clinical and socio-demographic characteristics are shown in table 1. Differences between patients and controls for body mass index (BMI) (p < 0.001) and smoking status (p =0.025) were noted. Therefore, these variables were considered as potential confounder factors for this analysis.


Antipsychotics: Haloperidol, Risperidone, Chlorpromazine, Olanzapine; BMI: body mass index

Table 1. Sociodemographic and therapeutic characteristics of studied population.
