Med/Psych Update

How to diagnose and manage hypertension in a psychiatric patient

Current Psychiatry. 2017 June;16(6):23-26,28-30

Robert M. McCarron, DO

Craig R. Keenan, MD

Banoo Lashai, MD

John C. Onate, MD

Increased risk of morbidity and mortality; be vigilant in drug–disease, drug–drug interactions

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References

1. Centers for Disease Control and Prevention (CDC). Vital signs: awareness and treatment of uncontrolled hypertension among adults—United States, 2003-2010. MMWR Morb Mortal Wkly Rep. 2012;61:703-709.
2. Mozzafarian D, Benjamin EJ, Go AS, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322.
3. Carroll D, Phillips AC, Gale CR, et al. Generalized anxiety and major depressive disorders, their comorbidity and hypertension in middle-aged men. Psychosom Med. 2010;72(1):16-19.
4. Leboyer M, Soreca I, Scott J, et al. Can bipolar disorder be viewed as a multi-system inflammatory disease? J Affect Disord. 2012;141(1):1-10.
5. Goff DC, Sullivan LM, McEvoy JP, et al. A comparison of ten-year cardiac risk estimates in schizophrenia patients from the CATIE study and matched controls. Schizophr Res. 2005;80(1):45-53.
6. Stein DJ, Aguilar-Gaxiola S, Alonso J, et al. Associations between mental disorders and subsequent onset of hypertension. Gen Hosp Psychiatry. 2014;36(2):142-149.
7. Birkenaes AB, Opjordsmoen S, Brunborg C, et al. The level of cardiovascular risk factors in bipolar disorder equals that of schizophrenia: a comparative study. J Clin Psychiatry. 2007;68(6):917-923.
8. Izzo JL, Black HR, Goodfriend TL. Hypertension primer: the essentials of high blood pressure. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
9. Osby U, Correia N, Brandt L, et al. Mortality and causes of death in schizophrenia in Stockholm County, Sweden. Schizophr Res. 2000;45(1-2):21-28.
10. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry. 2000;177:212-217.
11. Auquier P, Lançon C, Rouillon F, et al. Mortality in schizophrenia. Pharmacoepidemiol Drug Saf. 2007;16(12):1308-1312.
12. Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA. 2007;298(15):1794-1796.
13. Bowis J, Parvanova A, McDaid D, et al. Mental and Physical Health Charter: bridging the gap between mental and physical health. https://www.idf.org/sites/default/files/Mental%2520and%2520Physical%2520Health%2520Charter%2520-%2520FINAL.pdf. Published October 7, 2009. Accessed March 6, 2017.
14. Nasrallah HA, Meyer JM, Goff DC, et al. Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophr Res. 2006;86(1-3):15-22.
15. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2571.
16. Handler J. Lithium and antihypertensive medication: a potentially dangerous interaction. J Clin Hypertens (Greenwich). 2009;11(12):738-742.
17. National Collaborating Centre for Mental Health (UK). Depression in adults with a chronic physical health problem: treatment and Management. Appendix 16: table of drug interactions. http://www.ncbi.nlm.nih.gov/books/NBK82914. Published 2010. Accessed March 6, 2017.
18. Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015:163(10):778-786.
19. Wang PS, Bohn RL, Knight E, et al. Noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors. J Gen Intern Med. 2002;17(7):504-511.
20. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101-2107.
21. Consoli SM, Lemogne C, Levy A, et al. Physicians’ degree of motivation regarding their perception of hypertension, and blood pressure control. J Hypertens. 2010;28(6):1330-1339.
22. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Improving Hypertension Control. Bethesda, MD: U.S. Department of Health and Human Services; 2004:61-64.
23. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.
24. The SPRINT Research Group; Wright JT Jr, Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103-2016.
25. Boulware LE, Daumit GL, Frick KD, et al. An evidence-based review of patient-centered behavioral interventions for hypertension. Am J Prev Med. 2001;21(3):221-232.

Hypertension is a widespread, under-recognized, and undertreated cause of morbidity and mortality in the United States and is associated with several psychiatric illnesses. Left untreated, hypertension can have significant consequences, including increased risk of stroke, coronary heart disease, heart failure, chronic kidney failure, and death. Approximately 70 million adults in the United States have hypertension, but only 60% of them have been diagnosed, and of those only 50% have their blood pressure under control.¹ In 2013, 360,000 deaths in the United States were attributed to hypertension.²

Hypertension is associated with major depressive disorder, generalized anxiety disorder, bipolar disorder, and schizophrenia.^3-5 Additionally, impulsive eating disorders, substance abuse, anxiety, and depression are associated with a hypertension diagnosis, although patients with panic disorder develop hypertension at a younger age.⁶ A 2007 study found a 61% prevalence of hypertension in those with bipolar disorder compared with 41% among the general population.⁷ The strong link between bipolar disorder and hypertension might be because of a common disease mechanism; both are associated with hyperactive cellular calcium signaling and increased platelet intracellular calcium ion concentrations.⁸

Hypertension not only is common among patients with psychiatric illness, it likely contributes to worse clinical outcomes. Studies across different cultures have found higher mortality rates in individuals with mental illness.^9-11 Persons with schizophrenia and other severe mental illnesses may lose ≥25 years of life expectancy, with the primary cause of death being cardiovascular disease, not suicide.¹² Patients with depression have a 50% greater risk of cardiovascular disease, which is equivalent to the risk of smoking.¹³

Schizophrenia is strongly associated with numerous comorbidities and has been linked significantly to an elevated 10-year cardiac risk after controlling for body mass index.⁵ The high rate of non-treatment of hypertension for patients with schizophrenia (62.4%) is especially concerning.¹⁴

Because of the well-documented morbidity and mortality of hypertension and its increased prevalence and undertreatment in the psychiatric population, mental health providers are in an important position to recognize hypertension and evaluate its inherent risks to direct their patients toward proper treatment. This article reviews:

the signs and symptoms of hypertension
the mental health provider’s role in the evaluation and diagnosis
how psychotropic drugs influence blood pressure and drug–drug interactions
the management of hypertension in psychiatric patients, including strategies for counseling and lifestyle management.

How to diagnose and manage hypertension in a psychiatric patient

References

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