Prevalence of undiagnosed hypertension and its associated factors among psychiatric patients: A cross sectional study at a tertiary healthcare center

Abstract

Introduction

Hypertension is the foremost contributor to cardiovascular disease(s) and premature death worldwide. Mental health disorders have a significant impact on global public health, affecting millions of individuals with disorders including anxiety, depression, bipolar disorder, and schizophrenia. Importantly, all of these conditions are distinctly associated with hypertension. Accordingly, this study aimed to investigate the prevalence of undiagnosed hypertension among individuals diagnosed with mental health disorders in Jordan and its associated risk factors.

Methods

Data from individuals 18–80 years of age, who attended the psychiatry clinic at Jordan University Hospital (Amman, Jordan), were included. The study included participants without a previous diagnosis of hypertension, diabetes, or cardiovascular disease. Systolic and diastolic blood pressure, as well as heart rate, were assessed; in addition, demographic information from each participant was collected. Assessments were performed at the clinic facilities during 2 distinct appointments scheduled at a one-week interval.

Results

In total, data from 484 patients (57.2 % female, 42.8 % male) were analyzed. The prevalence of undiagnosed hypertension among those diagnosed with psychiatric disorders was significantly high (30.8 %), the majority of whom were male. Mean age, body mass index, and a positive family history of cardiovascular disease(s) were significantly higher in patients with undiagnosed hypertension. Moreover, patients undergoing treatment with serotonin and norepinephrine reuptake inhibitors (SNRIs) exhibited a significantly higher prevalence of undiagnosed hypertension than their counterparts.

Conclusion

Results of the present study revealed a significant prevalence of undiagnosed hypertension among patients with psychiatric disorders (30.8 %). Factors significantly associated with a higher prevalence of undiagnosed hypertension included male sex, older age, higher BMI, family history of cardiovascular disease(s), and use of SNRIs.

1. Introduction

Adult hypertension is defined as an age-standardized presence of elevated blood pressure (BP), defined as a systolic BP ≥ 140 mmHg and/or a diastolic BP ≥ 90 mmHg [1]. Globally, approximately 7.5 million deaths are attributed to hypertension annually, accounting for approximately 12.8 % of the total mortality rate [1]. This corresponds to 57 million disability-adjusted life years (DALYs) or 3.7 % of overall DALYs [1]. Hypertension is a significant risk factor for coronary heart disease, as well as ischemic and hemorrhagic stroke [1]. In the clinical context, hypertension is diagnosed in individuals with mean BP ≥ 140/90, based on ≥ 2 measurements recorded during ≥2 separate visits on different days [1].

Hypertension is the leading cause of cardiovascular disease(s) and premature death worldwide [2]. Due to the widespread use of antihypertensive medication(s), the average global BP has either remained stable or has slightly decreased over the past 4 decades [2]. In contrast, the prevalence of hypertension has increased, particularly in low- and middle-income countries [2].

Psychiatric disorders have a substantial impact on global health, affecting millions of individuals with conditions including anxiety, depression, bipolar disorder, and schizophrenia, all of which have been clearly associated with hypertension [3]. Unfortunately, individuals among these groups often have a shorter lifespan and an increased risk for premature death [4].

Amid this complex interplay, hypertension has emerged as a silent―yet perilous―threat that exacerbates cardiovascular risk [5]. Cardiovascular disease(s) is the primary cause of death [5]. In this context, fluctuations in BP have emerged as a potential factor contributing to increased cardiovascular risk and potential harm to vital organs [6]. An intriguing study underscored the increased variability in BP observed among individuals with specific mental disorders, particularly anxiety disorders, highlighting the intricate connection between mental well-being and physical health [7]. Recent studies have reported a correlation between anxiety disorders and a higher prevalence and incidence of hypertension [8].

Depression, known for its subtle effect on emotional wellness, is also associated with hypertension [3]. Prospective studies have suggested that depression may represent a risk factor for the development of hypertension, particularly in individuals with pronounced depressive symptoms [9]. The intricate interplay between depression, autonomic nervous system function, and BP regulation underscores the multifaceted nature of this relationship [10,11]. Among individuals with established psychosis, the prevalence of hypertension was reported to be notably high, affecting 54 % of the population in a previous study [12].

Therefore, we hypothesized that psychiatric outpatients would have a higher prevalence of undiagnosed hypertension than the general population due to the overall reduced level of self-care, follow-up, and awareness of hypertension and its complications. Although many studies have addressed this topic worldwide, there is a scarcity of research from the Middle East. As such, the primary objective of the present investigation was to ascertain the prevalence of undiagnosed hypertension and identify associated risk factors among individuals with mental health disorders who attended psychiatric clinics at a tertiary healthcare facility in Jordan.

2. Methods

This study was approved by the University of Jordan Institutional Review Board (Amman, Jordan; Approval number 7194/2022/67) and conducted in accordance with the latest iteration of the Declaration of Helsinki. The study was conducted from September 2022 to July 2023 at Jordan University Hospital (JUH), a tertiary medical center located in Amman, Jordan. Informed written consent was obtained from all participants.

2.1. Participants

Individuals 18–80 years of age, who attended the psychiatry clinic at JUH, were enrolled. The study included participants without a previous diagnosis of hypertension, diabetes, or cardiovascular disease. This information was gathered based on a comprehensive patient history and a thorough review of medical records. Participants were asked to join the study before entering the clinic.

2.1.1. Sample size

A minimum sample size of 320 was calculated using a single-population proportion sample size equation. This calculation was based on the prevalence of hypertension among Arab and Jordanian adults, which was 29.5 % and 30 %, respectively [13,14]. A 95 % confidence interval (CI) and 5 % margin of error were applied to ensure accuracy.

2.1.2. Assessment

All eligible participants received instructions not to smoke or consume coffee, tea, or any other caffeinated beverage within the hour before their BP measurements. To ensure accurate BP readings, the participants were instructed to sit calmly and relax for a minimum of 5 min before measurements were performed. Any clothing covering the arm was removed, and a BP cuff was placed on the left arm at the level of the heart to ensure accurate measurements. These assessments were performed during 2 distinct appointments scheduled at a one-week interval at the authors’ clinic facilities. BP measurements were performed for each participant each day, taking 2 readings with a 2 min interval between them, using a validated upper arm automated BP device [15]. To estimate BP, the mean value of all readings was calculated.

The height and weight of each participant was also measured, in addition to documentation of exercise habits, categorizing individuals who engaged in ≥150 min of moderate-intensity or 75 min of vigorous aerobic activity per week as fulfilling the criteria for adequate routine exercise. Furthermore, data regarding personal history of smoking and family history of hypertension and cardiovascular disease(s) were collected.

Hypertension was diagnosed based on 2 office BP readings ≥140/90 mmHg, measured 1 week apart, in accordance with the European Society of Hypertension practice guidelines [16]. According to these guidelines, office BP measurements remain the most widely―and, often the only―used method for detecting and managing hypertension, according to these guidelines [16].

Diagnosis of depression in the psychiatric clinic was based on the 9-item Patient Health Questionnaire (i.e., “PHQ-9”) score, a validated screening tool for the general population [17].

2.2. Statistical analysis

Data were analyzed using SPSS version 26 (IBM Corporation, Armonk, NY, USA). Categorical variables are expressed as count and percentage, whereas continuous variables are expressed as mean with standard deviation. Chi-squared and t-tests were used to investigate categorical and continuous factors associated with hypertension, respectively. Differences with p < 0.05 were considered to be statistically significant. Multivariate logistic regression analysis was used to further investigate factors significantly associated with hypertension according to the chi-squared and t-test results.

3. Results

Data from 484 patients (57.2 % female, 42.8 % male), with a mean age and body mass index (BMI) of 33.69 ± 13.65 years and 26.83 ± 6.71 kg/m², respectively, were analyzed. The prevalence of family history of cardiovascular disease(s) was 5.7 %, and 47.3 % of patients were smokers. The most commonly used medication was selective serotonin reuptake inhibitors (SSRIs) (45.7 %), followed by antipsychotics (27.1 %). Characteristics of the included patients are summarized in Table 1. One participant declined to respond to questions about smoking and family history of cardiovascular disease(s), but agreed to participate in the remainder of the study. Additionally, 4 patients were not taking their medications at the time of the study.

Table 1.

The general demographics of the participants.

Variable	Response		Frequency	Percentage (%)
Sex	Male		207	42.8
	Female		277	57.2
Smoking	No		254	52.5
	Yes		229	47.3
History of Exercise	No		378	78.1
	Yes		106	21.9
Family History of Cardiovascular Diseases	No		238	49.3
	Yes		245	50.7
Type of Mental Disorder	Mood		432	89.3
	Psychotic		52	10.7
Medications	Antipsychotics		131	27.1
	SNRIs		14	2.9
	SSRIs		221	45.7
	Cyclic Antidepressants		20	4.1
	Benzodiazepine		94	19.4
Variable	Mean	SD	Range
Age (years)	33.69	13.65	18–83
Body Mass Index	26.83	6.71	18–50
Years of Diagnosis	2.54	1.03	1–60

Abbreviations: SNRIs, Serotonin and Norepinephrine Reuptake Inhibitors; SSRIs, Selective Serotonin Reuptake Inhibitors.

The prevalence of undiagnosed hypertension was high among patients with psychiatric disorders (30.8 %) (Fig. 1). Most patients with undiagnosed hypertension were male (p = 0.008). The mean age and BMI were significantly higher among patients with hypertension (p = 0.000 p = 0.000, respectively). Most patients with undiagnosed hypertension did not exercise regularly (p = 0.040). Moreover, the majority of patients had a family history of cardiovascular disease (p = 0.014). Patients undergoing treatment with serotonin and norepinephrine reuptake inhibitors (SNRIs) exhibited a significantly higher prevalence of hypertension than their counterparts (p = 0.006) (Table 2).

Fig. 1.

The prevalence of undiagnosed hypertension among psychiatric patients.

Table 2.

Differences between individuals with hypertension and those without hypertension.

Variable		With Hypertension (n = 149)	Without hypertension (n = 335)	P-value
Gender	Male	77 (37.2)	130 (62.8)	0.008∗
	Female	72 (26.0)	205 (74.0)
Age		37.96 ± 14.14	31.79 ± 13.00	0.000∗
BMI		29.96 ± 7.76	25.43 ± 5.67	0.000∗
Smoking	No	80 (31.5)	174 (68.5)	0.759
	Yes	69 (30.1)	160 (69.9)
History of Exercise	No	125 (33.1)	253 (66.9)	0.040∗
	Yes	82 (77.4)	24 (22.6)
Family History of Cardiovascular Disease	No	61 (25.6)	177 (74.4)	0.014∗
	Yes	88 (35.9)	157 (64.1)
Type of Mental Disorders	Mood	129 (29.9)	303 (70.1)	0.204
	Psychotic	20 (38.5)	32 (61.5)
Medications	Antipsychotics	43 (32.8)	88 (67.2)	0.554
	SNRIs	9 (64.3)	5 (35.7)	0.006∗
	SSRIs	61 (27.6)	160 (72.4)	0.164
	Cyclic Antidepressants	8 (40.0)	12 (60.0)	0.362
	Benzodiazepine	28 (29.8)	66 (70.2)	0.815

Abbreviations: SNRIs, Serotonin and Norepinephrine Reuptake Inhibitors; SSRIs, Selective Serotonin Reuptake Inhibitors.

Multivariate logistic regression analysis revealed that several factors were significantly associated with hypertension. Older age and BMI were significantly associated with an increased risk for hypertension (odds ratio [OR] 1.021 [95 % confidence interval (CI) 1.005–1.037]; OR 1.110 [95 % CI 1.073–1.149], respectively). Notably, having a family history of cardiovascular disease(s) and SNRI use were both significantly associated with greater risk for developing hypertension (OR 1.562 [95 % CI 1.020–2.392]; OR 3.752 [95 % CI 1.115–12.614], respectively). Conversely, female sex was associated with decreased risk for hypertension (OR 0.489 [95 % CI 0.432–0.752]) (Table 3).

Table 3.

Multivariate Regression Analysis for the factors associated with hypertension.

Variable		HTN OR (95%CI)	P-value
Age		1.021 (1.005–1.037)	0.008∗
BMI		1.110 (1.073–1.149)	0.000∗
Gender	Female	0.489 (0.318–0.752)	0.001∗
History of Exercise	Yes	0.741 (0.432–1.272)	0.277
Family History of Cardiovascular Diseases	Yes	1.562 (1.020–2.392)	0.040∗
SNRIs	Yes	3.752 (1.115–12.614)	0.033∗

Abbreviations: SNRIs, Serotonin and Norepinephrine Reuptake Inhibitors.

4. Discussion

In total, 484 patients (57.2 % female, 42.8 % male) were included in this study. The prevalence of family history of cardiovascular disease was 5.7 %, and 47.3 % of patients were smokers. The most frequently prescribed medications among these patients were SSRIs (45.7 %), followed by antipsychotics (27.1 %). The prevalence of undiagnosed hypertension among patients with psychiatric disorders was notably high (30.8 %), the majority of whom were male.

Patients with hypertension had a significantly higher mean age and BMI than those without hypertension. Most patients with undiagnosed hypertension did not engage in regular exercise, and most had a family history of cardiovascular disease(s). Additionally, patients taking SNRIs exhibited a significantly higher prevalence of hypertension than their counterparts. Several factors were significantly associated with hypertension, including older age, BMI, family history of cardiovascular disease(s), and SNRI use, all of which were associated with increased risks. Conversely, female sex was associated with a reduced risk for hypertension.

A study from The University of Jordan (Amman, Jordan) reported a significant association between moderate to severe depression and higher diastolic BP among medical students [18]. Additionally, another recently published study reported significant increases in BP and heart rate among medical students on the day of their clinical examinations compared with baseline measurements, although these increases were potentially attributed to stress and anxiety [19].

A study conducted by The National Health Research Institute, involving a randomly selected sample of 766,427 individuals ≥18 years of age, revealed that the prevalence of hypertension among those with anxiety disorders was 37.9 %. The risk ratio for hypertension in individuals with anxiety disorders compared with the general population was 1.29 [20]. A study from South Africa reported the prevalences of metabolic disorders among 84 psychiatric inpatients, as follows: metabolic syndrome, 32 %; hypertension, 32 %; diabetes mellitus, 8 %; cholesterol dyslipidemia, 32 %; triglyceride dyslipidemia, 29 %; low-density lipoprotein dyslipidemia, 50 %; overweight, 37 %, and obesity, 24 % [21]. Moreover, in a meta-analysis, individuals with post-traumatic stress disorder were found to have a 1.82-fold increased risk for developing metabolic syndrome, highlighting the intricate relationship between mental health and physical well-being [22]. Consistent with these findings, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study, involving 1460 participants, revealed a concerning prevalence of untreated metabolic conditions, notably hypertension, which was observed in 62.4 % of individuals with schizophrenia [23].

Age is a pivotal determinant of the prevalence of hypertension, consistently following a pattern that remains constant across populations. Susceptibility to hypertension tends to increase with advancing age [24]. This age-related vulnerability may be further influenced by physiological changes caused by conditions such as depression and anxiety [25]. Stress-related hormonal responses observed in those with mental disorders may interact with age-related physiological processes, contributing to the development of hypertension [26].

BMI is a widely recognized measure of obesity that is strongly associated with hypertension in the general population [27]. Among individuals with mental disorders, the connection between BMI, obesity, and hypertension may be heightened due to factors such as a sedentary lifestyle, emotional eating habits, hormonal imbalances, and reduced levels of physical activity [[28], [29], [30]].

In a comprehensive eight-year follow-up study involving 3124 elderly participants, clinically significant depressive symptoms were significantly correlated with a 76 % higher likelihood of hypertension [31]. Importantly, this association remained independent of well-established lifestyle risk factors such as obesity [31]. Additionally, research from the Canadian National Population Health Survey indicated that major depression was significantly associated with a 60 % higher likelihood of developing newly diagnosed high BP [32]. Finally, in The National Health and Nutrition Examination I Epidemiologic Follow-up Study, which included 2992 individuals 7–16 years of age, a notable connection was established between elevated anxiety and depression scores and a heightened risk for developing hypertension [33].

Given the high incidence of undiagnosed hypertension in this group, it is vital for psychiatrists and healthcare providers to remain vigilant regarding the increased risk for hypertension in this particular group. Our recommendation is to screen patients with psychiatric disorders for hypertension and its related factors while facilitating referrals to the appropriate healthcare specialists to ensure that they receive the necessary and appropriate treatment.

Our study had some limitations. While it was conducted at a tertiary referral center, which, to some extent, reflects the diverse geographical regions in Jordan, the findings may be more applicable to patients with more severe mental disorders. We encountered challenges in obtaining home BP measurements from the participants. Therefore, it is possible that some individuals with “white-coat” hypertension were inadvertently included in the group diagnosed with hypertension. We did not evaluate quality of life parameters in our study, which could be a significant factor associated with both psychological disorders and hypertension. Additionally, because the study was conducted in a hospital setting, the sample may differ significantly from that of the general population, which could potentially result in over- or underestimation of the prevalence of undiagnosed hypertension. Longitudinal multicenter studies are essential to assess the morbidity and mortality benefits of screening individuals with psychiatric disorders for undiagnosed hypertension and its associated risk factors.

5. Conclusion

Our study revealed a notably elevated prevalence of undiagnosed hypertension among patients with psychiatric disorders (30.8 %). Several factors were significantly associated with a higher prevalence of hypertension, including male sex, older age, higher BMI, family history of cardiovascular disease(s), and use of SNRIs.

CRediT authorship contribution statement

Hussein Alhawari: Writing – original draft, Supervision, Resources, Project administration, Methodology, Data curation, Conceptualization. Sireen Al-Khatib: Writing – review & editing, Supervision, Resources. Sameeha AlShelleh: Writing – review & editing, Supervision, Resources, Conceptualization. Mohammad Ribie: Writing – review & editing, Resources, Data curation, Conceptualization. Fadi Al Owies: Writing – review & editing, Resources, Data curation, Conceptualization. Mohamad Harb: Writing – review & editing, Supervision, Resources, Conceptualization. Ruba Alhabahbeh: Writing – review & editing, Supervision, Formal analysis, Conceptualization. Ahmad A. Toubasi: Writing – review & editing, Methodology, Formal analysis, Conceptualization.

Ethics statement

Written informed consent was obtained from all participants. This study was approved by the University of Jordan Institutional Review Board committee (approval number 7194/2022/67).

Consent for publication

A consent for publication was obtained from all participants.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author, Hussein Alhawari, MD.

Funding

The authors received no financial support for this study.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.