Depression Increases The Risk For Uncontrolled Hypertension: Clinical Cardiology: Original Article

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clinical carDiology: original article

Depression increases the risk for uncontrolled


hypertension
Alberto Francisco Rubio-Guerra PhD FACP, Leticia Rodriguez-Lopez MD, German Vargas-Ayala MD,
Saul Huerta-Ramirez MC, David Castro Serna MD, Jose Juan Lozano-Nuevo PhD

AF Rubio-Guerra, L Rodriguez-Lopez, G Vargas-Ayala, Self-rating Depression Scale survey for depression. Associations between
S Huerta-Ramirez, D Castro Serna, JJ Lozano-Nuevo. Depression the results of the blood pressure and depression tests were determined using
increases the risk for uncontrolled hypertension. Exp Clin the Spearman correlation coefficient; RR was also measured.
Cardiol 2013;18(1):10-12. RESuLTS: Of the 40 patients, 23 were depressed, and 21 of these 23 had
poor control of their blood pressure. The RR for uncontrolled hypertension
in depressed patients was 15.5. A significant correlation between systolic
bACkGROuND: Because hypertension and depression share common
(r=0.713) and diastolic (r=0.52) blood pressure values and depression was
pathways, it is possible that each disease has an impact on the natural his-
found.
tory of the other.
CONCLuSION: Depression is common in patients with uncontrolled
ObJECTIVE: To determinate whether depression influences blood pres-
hypertension and may interfere with blood pressure control. Screening for
sure control in hypertensive patients.
depression in hypertensive patients is a simple and cost-effective tool that
METHODS: Forty hypertensive patients undergoing antihypertensive
may improve outcomes.
treatment, excluding beta-blockers and central-acting agents, self-measured
their blood pressure several times a day for three days using a validated,
commercially available device. All patients also completed the Zung key Words: Blood pressure control; Depression; Hypertension

A t a prevalence of 30.1%, hypertension is a common health prob-


lem in Mexico; furthermore, only 19% of hypertensive patients
are able to achieve suggested healthy blood pressure targets (1).
as a Grade B recommendation (clinicians routinely provide the service
to eligible patients, the service improves important health outcomes
and benefits overweight the harms) (10).
Depression is also common in Mexico, with approximately 9% of the The Zung Self-rating Depression Scale is a self-administered
population experiencing this mental health disease (2). Depression screening test for depression that is an easy-to-use, accurate and
has a prevalence of 4.8% to 8.6% in primary care settings, and depres- brief (requires approximately 5 min to complete) instrument for
sive illness is projected to be the second leading cause of disability the detection of depression; furthermore, the test has the added
worldwide in the next 20 years (3). advantage of being able to discriminate mild, moderate and severe
Several studies (4) suggest that individuals experiencing depression depression (3).
are at high risk for developing hypertension, as well as being predis- The aim of the present study was to determinate whether depres-
posed to stroke and ischemic heart disease. In fact, depression may put sion influences blood pressure control in hypertensive patients.
patients at higher risk for heart disease, stroke and death (4,5).
Recent theories regarding the etiology of depression have involved METHODS
the biogenic amine pathway, and suggest that the disease is related to To evaluate hypertension control and to avoid the ‘white coat’ phe-
a deficiency in monoamines (serotonin, dopamine and norepineph- nomenon, 40 hypertensive patients undergoing antihypertensive
rine) in the central nervous system. Indeed, all clinical antidepressant therapy for longer than six months, after being trained on how to
drugs enhance the effects of the monoamine neurotransmitters (6). measure their blood pressure, self-administered a blood pressure test
Both depressive and hypertensive patients experience increased several times a day for three days using a commerically available auto-
sympathetic tone (7) and increased secretion of adrenocorticotropic matic digital blood pressure monitor (OMRON HEM713C, OMRON
hormone and cortisol (4); therefore, it is pathophysiologically plaus- Healthcare Inc, USA) that had been previously validated (11).
ible that depression and hypertension affect one another. Using a cuff appropriate for their arm diameter, patients recorded
Dopamine and other related neurotransmitters have antihyperten- their blood pressure on waking up (after urination), before meals and
sive actions; bromocriptine and fenoldopam, which are dopamine recep- before retiring each evening, for three days. After a 5 min seated rest
tor agonists, have been used in the management of high blood pressure period, measurement was recorded in triplicate at 3 min intervals
(8). Lack of dopamine at key sites in the brain may increase blood between measurements.
pressure and/or trigger depression (6). Furthermore, the cerebrovascular To monitor adherence to antihypertensive therapy, the relatives of
and ischemic changes in the brain promoted by high blood pressure may the patients were asked to perform a count of medications each day start-
predispose individuals with hypertension to depression (9). However, ing one week before the beginning of self-measurement, and to be able
there are currently no studies that correlate the presence of depression to recall the patent’s intake of the drug if required. In addition, count-
with hypertension control. ing of returned tablets was also performed by a member of the team.
Despite its high prevalence and impact, depression is usually not All patients completed the Zung Self-rating Depression Scale
detected by primary care physicians, and patients do not typically survey; depression was diagnosed if the patient scored >50 points (the
receive adequate treatment, which may not only affect their quality of maximum possible score using this scale was 80). The Zung Self-rating
life, but may also interfere with the treatment and prognosis of other Depression Scale is a sensitive measure of clinical severity in depressed
chronic diseases such as ischemic heart disease and stroke (4,5). In patients, which has been previously validated and has clinical evi-
fact, the United States Preventive Services Task Forces recommends dence supporting its use as a research instrument (12).
“screening adult patients for depression in clinical practices that have Patients with any of the following diagnoses were excluded from
systems in place to assure accurate diagnosis, treatment and follow-up” the study: secondary hypertension; hypothyroidism; psychological
Metabolic and Research Clinic, Hospital General de Ticomán SS DF and Mexican Group for Basic and Clinical Research in Internal Medicine, México DF,
México
Correspondence: Dr Alberto Francisco Rubio-Guerra, Plan De San Luis S/N Esq Bandera, CP 07330, México DF, México. Telephone and fax
52-55-5754-3939, e-mail clinhta@hotmail.com

10 ©2013 Pulsus Group Inc. All rights reserved Exp Clin Cardiol Vol 18 No 1 2013
Depression and blood pressure control

Table 1 210
baseline characteristics of patients R = 0.713
p<0.001
200
Depressed Not depressed
190
blood pressure
180
Controlled Uncontrolled Controlled Uncontrolled
Age, years, mean 59 61 59 60 170

mmHg
Sex, male/female, n/n 0/2 7/14 5/11 0/1 160
Blood pressure, 130/68 158/89 125/77 142/91 150
systolic/diastolic, 140
mmHg 130
Depression
120
Mild 2 10 – –
110
Moderate – 7 – –
100
Severe – 4 – –
20 40 60 80
Data presented as n unless otherwise indicated
Zung scale score
Figure 1) Correlation between systolic blood pressure and Zung Self-rating
disorders, patients receiving beta-blockers or central acting agents, Depression Scale score
patients with a history of alcohol and/or psychotropic drug abuse, and
patients receiving antidepressant drugs for any purpose.
The present study was conducted with the approval of the Research
R = 0.52, p<0.001
120

and Medical Ethics Committee of the Hospital General de Ticomán SS 110

DF (Mexico DF, Mexico) in accordance with the Declaration of 100


Helsinki. Participants provided written informed consent before their 90
inclusion in the study protocol. mmHg 80
70

Statistical analysis 60
Associations between the results from the blood pressure and depres- 50
sion tests were determined using the Spearman correlation coefficient; 40
RR was also measured. 20 30 40 50 60 70 80 90
Zung Scale Score

RESuLTS Figure 2) Correlation between diastolic blood pressure and Zung Self-rating
The baseline characteristics of the patients are shown in Table 1. Of Depression Scale score
the 40 patients included in the study, 23 were depressed (57.5%), of
whom two had good blood pressure control and 21 had poor blood We found a high prevalence of depression in hypertensive patients;
pressure control. Of the remaining 17 patients without depression, one this prevalence was approximately nine times greater than what is
patient had poor blood pressure control and 16 patients had good observed in the general population. Although the investigators were
blood pressure control. The average blood pressure in depressed patients not directly involved in the gathering of blood pressure data and
with poor blood pressure control was 158/89 mmHg, and the average depression scores for the patients, we recognize that the present study
blood pressure in patients without depression and good blood pressure was not a blinded study. It is interesting to note that systolic blood
control was 125/77 mmHg (Table 1). pressure control was poor, yet there was good diastolic blood pressure
The RR of experiencing uncontrolled hypertension in patients control in all groups. We do not have an explanation for this finding,
with depression was 15.5. but systolic blood pressure control is typically more difficult to main-
When the blood pressure and self-measured depression test results tain than diastolic blood pressure control (15). Nevertheless, the pres-
were analyzed, a significant correlation between systolic (r=0.713 [95%CI ence of depression in hypertensive patients appears to be a risk factor
0.79 to 0.91]; P<0.001 [Figure 1]) and diastolic (r=0.52 [95% CI 0.56 to for poorly controlled blood pressure.
0.82]; P<0.001 [Figure 2]) blood pressure values was found. In a study involving 452 psychiatric outpatients with a diagnosis
Compliance with treatment (according to the relatives of the of depression, Rabkin et al (16) found that hypertension was three
patients) was >90% before the beginning of blood pressure self- times more prevelant when compared with those without depression,
measurement, and all patients were compliant with their treatment supporting a significant association between depression and hyperten-
regimen as prescribed during the study period. sion. However, this study did not relate the presence of depression
with the level of antihypertensive control. The study by Jokisalo et al
DISCuSSION (17) found that a feeling of hopelessness toward hypertension, frustra-
In the present study, we found that depression was a risk factor for poor tion with treatment and perceived anxiety with blood pressure meas-
blood pressure control in hypertensive patients. urement were associated with poor high blood pressure control.
The study design, which included patients using simple, validated, Finally, a recent meta-analysis demonstrated an approximately 42%
semiautomatic blood pressure monitoring equipment (11) and a self- increased risk for hypertension in depressed patients, especially in
administered, validated and accurate screening test for depression (12) patients for whom the diagnosis of depression was made three years
at home, without the intervention of the investigator, produced reli- before the study (4). The results of these studies further support the
able and acurate information that enabled an unbiased analysis of the correlation between a patient’s psychological status and their level of
results without any influence of the ‘white coat’ phenomenon. It is hypertension control.
important to note, however, that there is not enough evidence to rec- Other studies have failed to find associations between depression
ommend one depression screening test over another (13). and hypertension. Hun et al (18) found no relationship between
We did not include patients who were being treated with beta- depression and the development of hypertension over a four-year time
blockers or central-acting agents because these drugs have been known frame, whereas Licht et al (19) found an association between depres-
to cause depression (14). sion and decreased blood pressure.

Exp Clin Cardiol Vol 18 No 1 2013 11


Rubio-Guerra et al

The coexistence of depression and hypertension may have prognos- compliance with the treatment regimen was >90% before blood pres-
tic implications not related to blood pressure values because patients sure self-measurement, and that all patients had taken their medica-
with depression exhibit increased sympathetic tone and decreased tion as prescribed during the study period.
parasympathetic activity, which not only contributes to an increase It is important to note that the different antihypertensive treat-
(and poor control) of blood pressure, but also may increase the risk of ments used for blood pressure control in our patients have previously
cardiac arrhythmias (4,5). Interestingly, the use of serotonin reuptake been shown to be equally effective when used as monotherapy (14).
inhibitors decreases sympathetic activation (4), although whether Combinations of agents were given to approximately 50% of the
antidepressant treatment improves blood pressure control requires patients in each group.
addtional investigation.
Because depression and hypertension share a common pathway, it CONCLuSION
is reasonable to consider depression in hypertensive patients (and Our results suggest that depression is a common feature in patients
hypertension in depressive patients) (20). experiencing uncontrolled hypertension, which may contribute to
Furthermore, depressed patients may have poor control of their poor control. Screening for depression in hypertensive patients is a
blood pressure because they have lost interest in adhering to their simple and cost-effective tool that may improve outcomes and should
theraputic regimen (21). At the Hospital General de Ticomán SS DF, we be performed in all hypertensive patients.
ask relatives of our patients to perform a count of the medication to
verify adherence to antihypertensive therapy. In the present study, we DISCLOSuRES: The authors have no conflicts of interest to disclose.
No honorarium, grant, or other form of payment was provided to anyone to
also applied this practice starting one week before the beginning of
produce this article.
blood pressure self-measurement, with the relatives reporting that

REFERENCES
1. Rubio-Guerra AF, Castro-Serna D, Elizalde-Barrera CI, 11. Calvo-Vargas CG, Padilla V, Troyo-Sanroman R. Loaned self-
Ramos-Brizuela LM. Current concepts in combination therapy for measurement equipment model compared with ambulatory blood
the treatment of hypertension: Combined calcium channel blockers pressure monitoring. Blood Press Monit 2003;8:63-70.
and RAAS inhibitors. Integr Blood Press Control 2009;2:55-62. 12. Biggs JT, Wylie LT, Ziegler VE. Validity of the Zung Self-rating
2. Juárez R, Lavalle F. Depresión. In: Ramiro M, Lifshitz A, Halabe J, Depression Scale. Br J Psychiatry 1978;132:381-65.
Frati A, eds. El internista, un texto de medicina interna para 13. Williams JW, Noël PH, Cordes JA, Ramírez G, Pignone M.
internistas. Mexico: Nieto Editores, 2008:1065-77. Is this patient clinically depressed? JAMA 2002;287:1160-70.
3. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for 14. Brown A, Captain B. 50 years of thiazides: Should thiazide diuretics
depression in adults: A summary of the evidence for the U.S. be considered third-line hypertension treatment? Am J Ther
Preventive Services Task Force. Ann Intern Med 2002;136:765-76. 2011;18:e244-54.
4. Meng L, Chen D, Yang Y, Zheng Y, Hui R. Depression increases the 15. Rubio AF, Arceo A, Lozano JJ, Vargas G, Rodríguez L, Ramos LM.
risk of hypertension incidence: A meta-analysis of prospective Efficacy of a fixed-dose combination of trandolapril-verapamil in
cohort studies. J Hypertens 2012;30:842-851. patients with stage-2 hypertension inadequately controlled by
5. O’Connor CM, Gurbel PA, Serebruany VL. Depression as a risk monotherapy. Clin Drug Invest 2005;25:445-51.
factor for cardiovascular and cerebrovascular disease: Emerging data 16. Rabkin JG, Charles E, Kass F. Hypertension and DSM-III depression
and clinical perspectives. Am Heart J 2000;140:S63-9. in psychiatric outpatients. Am J Psychiatry 1983;140:1072-4.
6. Mycek MJ, Harvey RA, Champe PC. Antidepressant Drugs. In: 17. Jokisalo E, Enlund H, Halonen P, Takala J, Kumpusalo E. Factors
Mycek MJ, Harvey RA, Champe PC, eds. Pharmacology. related to poor control of blood pressure with antihypertensive drug
Philadelphia: Lippincott Williams & Wilkins, 2000:119-26. therapy. Blood Press 2003;12:49-55.
7. Davison K, Jonas BS, Dixon KE, Markovitz JH. Do depression 18. Hun Shinn E, Carlos WS, Kimball KT, St Jeor ST, Foreyt JP.
symptoms predict early hypertension incidence in young adults in Blood pressure and symptoms of depression and anxiety:
the CARDIA study. Arch Intern Med 2000;160:1495-500. A prospective study. Am J Hypertens 2001;14:660-4.
8. Murphy MB, Murray C, Shorten GD. Fenoldopam – a selective 19. Licht CM, de Geus EJ, Seldenrijk A, et al. Depression is associated
peripheral dopamine-receptor agonist for the treatment of severe with decreased blood pressure, but antidepressant use increases the
hypertension. N Engl J Med 2001;345:1548-57. risk for hypertension. Hypertension 2009;53:631-638.
9. Thomas J, Jones G, Scarinci I, Brantley P. A descriptive and 20. Barton DA, Dawood T, Lambert EA, et al. Sympathetic activity in
comparative study of the prevalence of depressive and anxiety major depressive disorder: identifying those at increased cardiac risk?
disorders in low-income adults with type 2 diabetes and other J Hypertens 2007;25:2117-24.
chronic illnesses. Diabetes Care 2003;26:2311-7. 21. Di Matteo MR, Lepper HS, Croghan TW. Depression is a risk factor
10. US Preventive Services Task Force. Screening for depression: for noncompliance with medical treatment. Arch Intern Med
Recommendations and rationale. Ann Intern Med 2000;160:2101-7.
2002;136;760-4.

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