Med/Psych Update

How to diagnose and manage hypertension in a psychiatric patient

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

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.

Diagnosing hypertension

Hypertension is defined as a blood pressure >140/90 mm Hg, the average of ≥2 properly measured readings at ≥2 visits in a medical setting.¹⁵ The proper equipment, including a well-fitting blood pressure cuff, and technique to measure blood pressure are essential to avoid misdiagnosis. The patient should be at rest for ≥5 minutes, without active pain or emotional distress.

Most cases of hypertension (90% to 95%) are primary, commonly called essential hypertension. However, the differential diagnosis also should consider secondary causes, which may include:

obesity
medications
chronic alcohol use
methamphetamine or cocaine use
primary kidney disease
atherosclerotic renal artery stenosis
obstructive sleep apnea
hypothyroidism
primary hyperaldosteronism
narrowing of the aorta
Cushing syndrome
primary hyperparathyroidism
polycythemia
pheochromocytoma.

Common medications, including several psychiatric drugs, also can contribute to elevated blood pressure (Table 1).

Medical evaluation. Once the diagnosis of hypertension is made, a medical evaluation is indicated to determine if the patient has end-organ damage from the elevated pressures, such as renal disease or heart disease, to identify other modifiable cardiovascular risk factors, such as hyperlipidemia, and to screen for secondary causes of hypertension. This evaluation includes¹⁵:

a physical exam
review of medications
lipid profile
urinalysis to screen for proteinuria
serum electrolytes and creatinine
electrocardiogram to screen for left ventricular hypertrophy or prior infarction
fasting glucose or hemoglobin A1_c to screen for type 2 diabetes mellitus.

Psychotropic drugs. In psychiatric patients, the evaluation must consider the potential impact psychotropic drug effects and drug–drug interactions can have on blood pressure (Table 2). For example, patients taking both diuretics and lithium are at increased risk for dehydration and increased serum lithium levels, which could cause severe neurologic symptoms and renal insufficiency.¹⁶ Several antihypertensives when taken with venlafaxine can increase blood pressure, but antihypertensives with α-1 blocking psychotropics can decrease blood pressure. Monoamine oxidase inhibitors can cause hypotension or hypertension with various classes of antihypertensives. Stimulants, such as methylphenidate, atomoxetine, dextroamphetamine, armodafinil, or modafinil, alone or combined with antihypertensives, can cause hypertension.¹⁷

Substance abuse, particularly alcohol, methamphetamine, and cocaine, can cause difficulty controlling blood pressure. Patients with refractory hypertension should have a reassessment of substance abuse as a potential cause.

References

Seeing a doctor reduces readmission risk in schizophrenia patients

How to diagnose and manage hypertension in a psychiatric patient

References

Diagnosing hypertension

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