• Laurie Cyr-Martel

Introduction

Approximately 780,000 sworn police officers are accounted for in the United States, (Bureau of Labor Statistics, U.S. Department of Labor 2014) and one out of eight officers are female. (U.S. Dept. of Labor Bureau of Justice Statistics 2007) The literature also supports that law enforcement is one of the most demanding professions in our country. (Marmar, C., McCaslin, S., Metzler, T., Best, S., Weiss, D., Fagan, Nelan,T. 2006: Gershon, R., Barocas, B., Canton, A., Li, X., Vlahov, D., 2009 : Wang, Z., Inslicht,S., Metzler, T., Henn-Haase, C., McCaslin , S., 2010) The general public’s perception is in direct conflict with the reality of those who wear the badge to protect and serve. The media either sensationalizes the profession or degrades the profession dependent on the situation. Men and woman place themselves in harm’s way for the protection of their communities while compromising their own emotional and physical health. The police academy does not prepare the officer for the misery and sorrow encountered once they graduate, nor are they prepared for how the occupation will effects their mind and body. Exposure to human tragedy, trauma, violence, lack of support both personally and professionally can increase the stress the officer’s experience. The cumulative effect of stress within law enforcement can exacerbate underlying physical and behavioral conditions. Physical presentations appear as high blood pressure, increased glucose levels, chest pains and obesity, a condition liken to Metabolic Syndrome. Behavioral conditions present as anger, rage, irritation, bad moods or resentment. Working with police officers for the past fourteen years, eight of them on the street in uniform, allowed a unique perspective regarding their emotional and physical health. Literatures linking physical (metabolic syndrome) and behavioral (depression) conditions for the law enforcement population, although published, are limited. The following review of the literature will attempt to provide an overview of Metabolic Syndrome and depression and how this might relate to those in law enforcement.

Literature Review

Definition

Metabolic Syndrome (MetSyn) is a condition distinguished by several health issues that when placed together are the major risk factors for cardiovascular disease, diabetes, possible organ damage, and even mortality. (Han & Lean 2011: Suls, J., Bunde J. 2005) These include high blood pressure, high blood sugar, high cholesterol and obesity. To review and determine the correlation more closely, studies throughout the literature use various biometrics. These include; measuring waist circumference, allowing a difference for centimeters for men and women, measuring the individual’s blood pressure, and monitoring fasting blood glucose. MetSyn is also referred to as a “cluster of anthropological and biochemical abnormalities that predispose an individual to coronary artery disease.” (Grundy, Brewer, Cleeman, Smith & Lenfant, 2004) Although various definitions are found throughout the literature, a universal definition that every author, discipline, or diagnostician can agree upon was not found. When a patient presents with at least three out of the five risk factors listed below, a diagnosis of Metabolic Syndrome can be made. (Thayyil, Jayakrishnan, Meharoof, & Cheremanalil, J.2012) Regardless of a the differences among those definitions, the medical community agrees that if identification of MetSyn is diagnosed early, the practitioner can include preventative measures for Type 2 Diabetes and Cardio Vascular disease. (Huang 2009) One of the reasons this Syndrome is important to both the medical and behavioral sciences is that it would allow the medical practitioner to focus on the underlying medical concerns such as Type 2 Diabetes and Cardiovascular disease. Although these are medical diagnosis, the behavioral interventions might alleviate further medical compromise.

Metabolic Syndrome and the Police Officer

Literature supports the link between MetSyn and the law enforcement population. (Hartley, Knox, Fekedulegn, Barbosa-Leiker, Violanti, Andrew & Burchfiel 2010). What is known in the world of medicine and psychology is that various psychological presentations such as anxiety and depression are presumed as associated risk factors to diseases encompassed in Metabolic Syndrome. (Hartley et al., 2010; Toker, Shirom & Melamed. 2008; Skilton, Moulin, Terra, & Bonnet. 2007; Kahl, Greggersen, Schweiger, Cordes, Balijepalli , Lo¨sch, & Moebus,S.

2012 ) MetSyn is considered an important cardiovascular risk factor in the development of cardiovascular disease. However, variations due to socioeconomic status, environmental, professional, spiritual, and cultural and ethnicity must be considered. An evaluation of 900 officers found 16.8% or 138 officers were found to have MetSyn. (Thayyil et al., 2012 ) Although the study was conducted in India, the conclusion and relevance to police work in general provided information relevant to MetSyn. MetSyn has more connections to health for the officer than just running the risk of experiencing a heart attack. Hypertension, dyslipidemia (abnormal amount of lipids in the blood), impaired glucose tolerance and obesity are all key elements of MetSyn. (Austin-Ketch, Violanti, Andrew, Hartley, & Vena, J. 2010).

As previously stated many factors are inherent in police work. Shift work is a contributory factor to the physical and psychological health of the officer and has been linked to MetSyn. Officers at higher risk for MetSyn and had a significant number of the components for MetSyn were officers who obtained six hours of sleep or less and worked shifts referred to as midnight shifts. (Violanti, J.,Burchfiel, C., Hartley, T., Mnatsakanova, A., Fekedulegn, D., Andrew, M., . . . Vila, B., 2009) Sleep deprivation also presents in the literature as increasing an individual’s risk for cardiovascular disease and various metabolic dysfunctions and is a common denominator in shift work. (Rajaratnam, S., Barger, L., Lockley, S., Shea, S., Wang, W., Landrigan, C., . . . Czeisler, C. 2011) It is important to identify officers at risk for MetSyn. Without identification, prevention and intervention would not occur.

Depression and the Police Officer

A 12 month study of 119 from four different departments, New York Police Department, and three departments in California took into account not only demographic variables, but baseline depression symptoms using the, child hood trauma, using the Early Trauma Inventory Self Report—Short Form to assess experience of childhood trauma before 18 years of age, The NEO Five-Factor Inventory used to assess neuroticism. The officers self-worth was also assessed using The World Assumptions Scale to determine the officers understanding and perception of how he relates to the world around him. After twelve months the officers were then given the Beck Depression scale, a self-inventory PTSD check list, a critical incident exposure questionnaire, and Life Experiences Survey to assess the negative effects of life changes in the twelve months, and the Work Environment Inventory to assess work stress. The study proposes that the longer the officer is “on the job” the more likely they are to experience moderately high depressive symptoms and partly sovereign from PTSD. (Wang & Inslicht Wang, Z., Inslicht,S., Metzler, T., Henn-Haase, C., McCaslin , S., 2010)

Metabolic Syndrome and Depression in the Police Officer

Several pieces of literature support the association of MetSyn with depression. (Kahl, , Greggersen, Schweiger, Cordes, Balijepalli, Lo¨sch, & Moebus, 2012; Goldbacher, Bromberger, Matthews, 2009; Toker,S.,Shirom, A., Melamed,S. 2008: Skilton, M., P., Moulin, Terra, J., Bonnet, F. 2007 ). An increased occurrence in cardiovascular risk, Type 2 Diabetes (T2D), and hypertension was also presented in the literature when comparing depression and MetSyn. (Skilton et al.,2007) An emergent body of evidence suggests if an individual is diagnosed with depression, this should be considered an important risk factor for MetSyn. Furth more, if a major depressive disorder was present throughout their life, they were at greater risk to develop MetSyn. (Butnoriene, J., Bunevicius, A., Norkus, A., Bunevicius, R. 2014) Another contributory factor to MetSyn is the hypothalamic-pituitary-adrenal (HPA). The hypothalamic-pituitary-adrenal (HPA) axis might also lead to underlying association for MetSyn and depression. When an officer reacts to a threat, the heart rate increases, pupils dilate to allow our visual perspective to widen, blood pressure rises as adrenaline causes the constriction of blood vessels which in turn increases pressure. We know that cortisol‘s main attribute is to increase energy to the body for survival. When the HPA is activated for survival, prolonged activation of the HPA can be a health risk. Cortisol antagonizes insulin. This might indicate to us that if the cortisol levels remain high, the pancreas –which secretes insulin – would struggle to respond to the bodies demand for the insulin. If the glucose levels do not decrease, the cells in our body would not obtain the sugar they need. Thus, when cortisol patterns are no longer normal, and the HPA axis is constantly challenged and prolonged, individuals risk for hypertension, cardiovascular disease and even depression would be increased. (Violanti, Burchfiel & Dorn, 2009) Literature further reviewed MetSyn and the psychological characteristics that might exacerbate CVD and T2D. When depressed patients present with HPA hyperactivity, there is associations with a multitude of psychological characteristics, such as anxiety and anger. Furthermore, those with high cortisol who were depressed were more likely to have been diagnosed with MetSyn. (Goldbacher & Matthews 2007) The general public has a view that most officers are young and healthy, and cannot comprehend the reason the officer would present with physical or emotional problems. Research is now proving what many of us within the law enforcement world knew for a very long time, the occupation compromises physical and emotional well-being. The literature points to one of the first cohesive studies that correlates physical and emotional health. Several tools used in the study reviewed both physical health and depressive signs and symptoms. The Buffalo Cardio Metabolic Occupational Stress Study or commonly known as BCOPS was provided to assess the physiological and psychological ramifications of the stress the officer encounters. Measuring the depressive symptoms was accomplished by using the Center for Epidemiologic Studies-Depression (CES-D) scale. The MetSyn was based on the guidelines provided by the American Heart Association and the National Heart, Lung and Blood Institute. The latitude given was much higher than listed above in the initial table which is from 2012. The individual MetSyn components included the following: (1) abdominal obesity (gender-specific waist circumference ≥102 cm in males, ≥88 cm in females), (2) hypertension (systolic blood pressure ≥ 130mmHg, diastolic blood pressure ≥ 85mmHg, (3) reduced HDL-C (gender-specific fasting HDL-C <40mg/dL in men, <50mg/dL in women, (4) elevated triglycerides (fasting triglycerides ≥ 150mg/dL, and (5) glucose intolerance (fasting serum glucose ≥ 100mg/dL, or reported treatment for diabetes. MetSyn was considered present in individuals with three or more components.} Although differences in age, education and length of employment were present, similarities were present. MetSyn and depressive symptoms were significantly associated. (Hartley et al., 2010) As indicated earlier in this review, more men than women enter the profession of law enforcement. (Bureau of Justice Statistics 2007) Gender may play an important factor in this comorbidity in police work. The literature indicated that for women, depression might lead to MetSyn, but further study is needed. (Toker et al., 2007)

Intervention

It is important to identify those officers who might be at risk in order to implement prevention strategies. Once the comorbidities are identified, it is paramount to intervene and present the officer with resources that are cost effective, efficient and solution focused. Literature supporting intervention and treatment programs for the comorbidity of Metabolic Syndrome and depression in police officers is limited. The literature does advise that building an effective training protocol within departments, would provide the competencies needed when the officer faces stressors, thereby preventing the officer from detrimental psychological and physiological effects. Aarnetz, B., Arble, E., Backman., Lynch, A., Lublin., A.,(2013) Motivational interviewing is another modality listed in the literature to address and change officers behaviors that will presumably lead to healthier outcomes. (Anshel, M., Kang, M. 2008) The literature supporting treatment programs for this population within the New England area is limited. Treatment programs that are in existence for this population are aimed at psychotherapy rather than treatment for co-morbid presentations. (Berard, 2012) The creation and implementation of a population health management program for law enforcement would impact health care policy.

When a police department has a partnership with a health program which treats a chronic condition, adding another component of the officer’s wellness might be added at a reasonable cost. If the program has a direct impact on the officers health care cost, the Population Health Management program our yield a return on their investment into the program. Grossmeier, J. , Terry, P. , Anderson, D. , Wright, S. 2012)

Conclusion

Metabolic syndrome and depressive presentations could be the precursor to a multitude of health concerns, but especially Type 2 diabetes and cardio vascular disease. Diagnosis of this co-morbid condition would lead to intervention and preventative health and wellness programs within police departments. When one has the opportunity to glimpse into the “thin blue line” as it is referred to – one realizes that not all police departments speak openly about the officers’ health and wellness. There are gyms on premises, EAP (Employee Assistance Programs), and perhaps yearly training on health programs. Many times it is not until an officer “crumbles” psychologically and physically that the department is forced to review their policies and protocols regarding overtime, training, inter-departmental conflicts, and a multitude of other concerns . When administration is unable to recognize the problem, the officer will bear the ramifications.

References

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