How do the Psychosocial Factors Affect Blood Pressure in Patients with Hypertension ? A Cross-Sectional Study

Background: Hypertension leads to complications such as myocardial infarction, stroke, and renal failure if not treated appropriately. Blood pressure is influenced by biopsychosocial factors such as physical, environmental, emotional, cognitive and behavioral. The aim of this study is to find the relationship between blood pressure levels of patients with hypertension and sociodemographic characteristics, traumatic life events and depression status. Method: Our sample was 305 hypertensives visiting a family physician in Rize, a city in the Black Sea (Northern part) Region of Turkey. The study was completed between December 2017 to April 2018. Participants completed a sociodemographic questionnaire including questions for sociodemographic characteristics, lifestyle behaviors, psychiatric complaints traumatic life events, and blood pressure control. Depression status was assessed using The Hospital Anxiety and Depression Scale (HAD). Data as analyzed using the SPSS 21 statistical analysis program. Results: Of the participants, 54.0% (n = 165) had psychiatric complaints, 52.5% (n = 160) had traumatic life events, and 37.7% (n = 115) stated that they had controlled blood pressure. Blood pressure levels were significantly related with psychiatric complaints, life events, HAD-Anxiety (HAD-A) and HAD-Depression (HAD-D) scores (p = 0.001, p = 0.000, p = 0.001, p = 0.002, respectively). There was reverse relationship between blood pressure levels and monthly household income (p = 0.03). Conclusion: It is harder to have controlled blood pressure for hypertensives in the presence of traumatic life events, psychiatric complaints, higher HAD-A and HAD-D scores, compared to hypertensives with none of these. Psychosocial factors should be questioned in hypertensives when especially blood pressure cannot control.


Introduction
Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately [1].Traumatic life events, sociodemographic characteristics, anxiety and depression disorders should be considered on hypertension management.In a study about effects of optimism, pessimism, and trait anxiety (measured by mood scales) on ambulatory blood pressure, pessimistic and anxious adults had higher blood pressure levels and felt more negative and less positive than did optimists or low anxious adults [2].In another study, it has been found that happiness, anger, and anxiety (measured emotional state as happy, angry or anxious by scales from one (low) to ten (high) scores) increase blood pressure to differing degrees and emotional effects may be greater with more labile blood pressure [3].The presence of a mental health disorder with hypertension is associated with higher cardiovascular disease mortality than hypertension alone [4].Although earlier detection of hypertension has been demonstrated in patients with anxiety and depression, the relationship of mental health disorders to hypertension control is unknown.It is yet unknown how the diagnosis of either anxiety or depression affects time to incident hypertension con-economic status, monthly household income, number of households, households (alone, wife/husband, wife/ husband and children etc.), place of living, relationship with family members, relationship with friends, alcohol consumption, smoking, exercise, diet, psychiatric complaints, traumatic life events, blood pressure situations.The questionnaire and HAD scale were completed faceto-face and conducted by the authors.

The hospital anxiety and depression scale
The Scale was designed by Zigmond and Snaith in 1983 to measure anxiety and depression in a general medical population of patients [8].The questionnaire comprises seven questions for anxiety and seven questions for depression, a total of 14 items.The score range is between 0 to 21; 0-7 "normal", 8-10 "mild", 11-14 "moderate", and 15-21 "severe" emotional disorder.Turkish validity and reliability of The Hospital Anxiety and Depression Scale was made by Aydemir, et al. in 1997 [9].

Data analysis
Data was analyzed using the SPSS 21 statistical analysis program.Demographic data, psychiatric complaints, life events, blood pressure levels were analyzed as numbers and percentages.HAD scale numerical scores were analyzed as mean and standard deviation.Also HAD-A and HAD-D scores classified by cut-off points and mentioned in results as 'HAD-A/HAD-D classified trol [4].Patients with depression and/or anxiety represent a particularly vulnerable population as they are at higher risk for developing hypertension [5,6].Byrd, et al. [7] found that hypertension diagnosis rates were higher in patients with depression and anxiety than in patients without mental condition.
Our aim in this study was to find the relationship between hypertension and sociodemographic characteristics, psychiatric complaints, traumatic life events, and The Hospital Anxiety and Depression Scale (HAD) scores.

Research design and setting
Our sample was 305 hypertensives visiting a family practice in Rize, a Northern city in the Black Sea Region of Turkey.Only hypertensive patients receiving medicines for blood pressure control included in the study and patients with other chronic conditions (such as diabetes mellitus, hypothyroidism, hypercholesterolemia, heart disease, chronic heart failure, history of heart or cerebral attacks etc.) were excluded.Research was completed between December 2017 to April 2018.Formal permission was obtained from Directorate of Health in Rize.All participants gave informed verbal consent.Participants completed the main questionnaire and The Hospital Anxiety and Depression Scale.We designed the main questionnaire including 18 items.These items are about age, gender, marital status, educational status, socio- gender and traumatic life events (p = 0.021).The rate of controlled blood pressure was significantly higher in males (p = 0.013).HAD-A classified scores (Cut-off values are indicated in Table 5) were significantly related to gender (p = 0.003) and HAD-A scores were higher in female participants (Table 5).
Blood pressure levels was related to monthly household income (p = 0.03) (Table 5).Patients with higher scores'.Pearson chi-square test, Skewness-Kurtosis values, Shapiro-Wilk and Kolmogorov-Smirnov tests were used.Pearson Correlation and Spearman's rho tests were used for correlation.T-test, Mann-Whitney U and One-Way ANOVA tests were used for analysis of independent samples.The level of significance was set as p < 0.05.

Results
Sociodemographic characteristics and lifestyle behaviors of participants are shown in Table 1.Of the participants, only 3.3% (n = 10) were doing regular exercise more than 150 minutes per week, with 60.7% (n = 185) having healthy nutritional habits (Table 1).The mean number of household individuals was 2.6 ± 1.2 persons (Table 1).
Traumatic life events of participants are shown in Table 3.Of the participants, 47.5% (n = 145) had no traumatic life events, 32.8% (n = 100) described their traumatic life events as 'accident, sickness, disability or death of any individual/s in their families' and 13.1% (n = 40) indicated domestic conflict (Table 3).
Blood pressure control in participants is shown in Table 4.About one-third of patients had controlled blood pressure (Table 4).
There was a significant relationship between gender and psychiatric complaints (p = 0.016) and female participants having more psychiatric complaints than males.There was a significant relationship between    There was a significant relationship between psychiatric complaints and HAD-A and HAD-D classified scores (p = 0.0001, p = 0.0001, respectively) (Table 5).
Psychiatric complaints were related to traumatic life events directly (p = 0.030) (Table 5).
As the number of households increased, HAD-D scores significantly decreased (p = 0.019, correlation coefficient = -0.299)(Table 6).However, there was no correlation with HAD-A scores (p > 0.05).Females had income had better control of blood pressure.
Blood pressure was related with psychiatric complaints, traumatic life events, HAD-A and HAD-D classified scores (p = 0.001, p = 0.000, p = 0.001, p = 0.002, respectively).Participants with psychiatric complaints and traumatic life events stated that they had difficulties on blood pressure control and sometimes their blood pressure levels rise.As HAD-A and HAD-D scores were over cut-off values, success on blood pressure control was less (Table 5).diovascular risk associated with tobacco use [21,22].However, we could not find a significant relationship between smoking and blood pressure.
It was interesting to find that almost one-third of the patients had admission to emergency department sometimes due to high blood pressure and complaints due to it (headache, palpitation, feeling bad etc.).A confounding factor such as a traumatic life event should be kept in mind [10].A meta-analysis supported that depression was probably an independent risk factor for hypertension as a confounding factor [6]. Emotional state (happiness, anger, or anxiety) significantly contributed to the variation of blood pressure in this sample of borderline hypertensive patients.The comparison of the pressures during each reported emotional state show that anger and anxiety increase blood pressure more than happiness [3].
It has been previously established that patients with mental health disorders visit healthcare providers more frequently [23] and have a higher economic burden of healthcare utilization than those without mental health disorder [24].This higher visit frequency likely results in more blood pressure measurements, supporting timely blood pressure follow-up [4].
In our study, male participants had more controlled blood pressure levels than females.It may be explained by significantly higher HAD-A scores in females, and thus by the negative effect of anxiety on blood pressure.Conversely, there are studies indicating that women have better control of blood pressure than men [4,25].
As a result, patients with traumatic life events, psychiatric complaints, higher HAD-A and HAD-D scores demonstrated poor control of blood pressure.Sociodemographic characteristics are correlated with blood pressure level.Female patients with higher HAD-A scores had poor blood pressure control.Participants with higher income had better blood pressure control.Traumatic life events, psychiatric complaints and emotional state (anger, unhappiness, sadness) seem to be the confounding factors causing admission to emergency department due to high blood pressure.In conclusion, sociodemographic factors should be considered on the management of hypertension and should be investigated in hypertensives if blood pressure is not controlled.higher HAD-A scores than males (p = 0.001).Participants with high HAD-A and HAD-D scores had significantly poor control of hypertension (p = 0.000, p = 0.002, respectively).HAD-A scores of participants who described their relationship with friends as 'very good' were significantly lower than those of the 'moderate' situation (p = 0.008; post hoc tests, tukey).HAD-A and HAD-D scores were significantly higher in participants having traumatic life event/s (p = 0.002, p = 0.038, respectively).Furthermore, HAD-A and HAD-D scores were significantly higher in participants with psychiatric complaints (p = 0.000, p = 0.000, respectively) (Table 6).

Discussion
This study suggested that psychosocial factors such as psychological complaints and traumatic life events impair blood pressure control in patients with hypertension.A study in South Africa suggested that self-reported diagnosis of hypertension is more common among those with anxiety disorders, depressive disorders and comorbid anxiety-depression compared to those without a mental disorder [10].Our findings about having controlled blood pressure is harder in the presence of psychological factors and mental disorders such as anxiety and depression were consistent with those of the several studies [11][12][13][14][15]. Rutledge and Hogan reported an overall increased hypertension risk among anxious subjects although the hypertension risk did not reach significance.They also found an increased risk for hypertension for the depressed subjects [16].On the contrary, in a large-scale cohort study, it was found that when compared with healthy controls, subjects with major depressive disorder had a significantly lower mean systolic blood pressure and were less likely to have isolated systolic hypertension.In the same study, anxious subjects had a significantly higher mean diastolic blood pressure (but not systolic blood pressure) compared with controls [17].Despite of conflicting findings, it seems that emotional distress and traumatic life events may impair blood pressure control.We also found that psychological disorders, traumatic life events, and emotional state (anger, unhappiness, and sadness) seem to be the confounding factors for elevated blood pressure.
It has been reported that patients with hypertension on antidepressant medications have lower blood pressures compared to those not on these medications possibly due to decreased baroreflex sensitivity and altered neuro-endocrine pathways [17,18].Fluoxetine and sertraline, but not paroxetine, cause a reduction in heart rate that was nearly parallel to the sympatho-inhibition.In the same research, fluoxetine and sertraline did not increase blood pressure [19,20].
There are studies explaining the negative effect of smoking on blood pressure control.Patients without a history of tobacco use had faster and better blood pressure control than current or former tobacco users.This finding is concerning because of the increased car-

Table 3 :
Traumatic life events of participants.

Table 4 :
Blood pressure control in participants.

Table 5 :
Psychiatric complaints, HAD-A and HAD-D classified scores, life events, blood pressure and related sociodemographic factors.

Table 2 :
Psychiatric complaints of participants.

Table 6 :
HAD-A and HAD-D scores, blood pressure and related sociodemographic factors.