Indian Write-Ups

Introduction

Hypertension is one of the originally hypothesised psychosomatic illnesses and 'Stress' has long since been considered both a precipitating factor and a sustaining factor in hypertension.

Anxiety and depression are the most common psychological disorders seen in hypertensive patients. The reasons for this could be an interplay of biological, psychological and social factors.

Hypertension, as we know it, is generally a long-standing illness. Consequently, long-term pharmacotherapy and their resulting side effects have been known to lower the patient's quality of life.

Certain anti-hypertensives are also directly responsible for simulating depression or causing depression.

Understanding depression and anxiety disorders

Most people have a vague notion of what 'depression' means and very often it is confused with a transient 'sadness of mood' or the 'blues' as it is known.

However, the truth is that depression is an illness and the 'disturbance in mood' must last at least 6 weeks for the diagnosis of 'depression' to be made. The disturbance may be in the form of 'sadness' of mood, however irritable mood, frequent anger outbursts, or simply ''n empty mood' could constitute part of the symptoms of depression.

Apart from these, a decreased (or sometimes increased) sleep pattern, so also; a decreased (or sometimes increased) appetite, lack of enthusiasm in any pleasurable activity, usually a decreased sexual drive, suicidal ideas and feelings of hopelessness, and worthlessness and / or guilt are some of the other symptoms of depression.

Anxiety disorders could present as 'generalized anxiety' lasting for 6 weeks or more. More commonly, 'panic attacks' simulating a 'heart attack' are seen in hypertensive patients. The patients may develop a 'phobia' or irrational fear that something will happen to them and hence undergo several investigations like ECG, blood tests, stress tests etc. frequently, out of the fear that something is wrong with them. In the face of all investigations being within normal limits, these patients still do not feel reassured and may continue to undergo a variety of tests or some develop a fear of being alone or travelling alone.

What underlies the aetiology of depression?

Biological factors

Psychological factors

One of the earliest attempts to characterise personality features of persons with essential hypertension is the 'Repressed – hostility theory'. According to this, hypertensives have lower assertiveness and fewer hostile characteristics as compared to non-hypertensives. This 'repression' of feelings could lead to depression or anxiety.

Apart from this, after having been diagnosed as hypertensive, the patients may go through an initial 'shock' phase, followed by helplessness or despair leading to depression.

According to some studies, hypertensives have been found to have higher levels of anger, greater frequency of anger experiences, and an increased tendency to express anger outwardly.

Social factors

Apart from certain racial factors, social support, in the form of family support could be most important in helping patients in long-term treatment or care. It goes without saying that poor family support predisposes to developing depression and / or anxiety disorders.

Role of medications in the aetiology of depression

Anti hypertensive medications may sometimes be directly responsible for causing depression or depression-like symptoms.

• Reserpine

An approximate estimate of 5-20% of patients on reserpine are known to develop depression. This response is usually dose-related and more than 0.5mg / day is known to produce severe depression. Depletion of central catecholamine stores by reserpine is responsible for this effect.

A past history of depression is also considered one of the major risk factors for a patient on reserpine to develop depression.

• β - Blockers

These often cause lethargy and are implicated in anecdotal reports in causing depression. Personal history or family history of depression predisposes the patient on b -blockers to depression.

• Methyldopa

Methyldopa, an anti hypertensive, is also associated with depression. However, there is no conclusive causal relation. Here too, a prior history of depression should be asked for as it may predispose the patient on methyldopa, to develop depression.

• Calcium channel blockers

Calcium channel blockers are also implicated in causing depression.

Treatment of anxiety and depression associated with hypertension

As in the case of hypertension, apart from medications like antidepressants for anxiety and depression, alternative treatment modalities must be included in the treatment plan.

What are the various treatments available and what are the risk-benefit factors?

Antidepressants would definitely form the mainstay in the treatment of severe depression. Cardio-safe antidepressants like SSRI's, mainly fluoxetine, are commonly used. New antidepressants like venlafaxine, though effective, are known to raise the blood pressure by 10mm Hg beyond 150mg/day dose and this must be kept in mind.

Dothiepin is also another safe alternative as it is known to reduce anxiety and helps insomniacs too.

Other tricyclic antidepressants may lead to side effects like orthostatic hypotension, antiarrythmic effects, as also conduction defects and hence these must be used with caution.

Electroconvulsive therapy (ECT)

Some psychiatrists think that ECT is the safest option for severe depression in cardiac patients. However, the increased sympathetic activity that follows seizures induced by ECT may an rare occasions cause hypertension, arrhythmias, or even myocardial infarction.

Alternative treatment modalities

Stress reduction is the basic aim of these techniques and life style changes help not only in treating depression but also has a beneficial effect on blood pressure.

Deep muscle relaxation, biofeedback, cognitive behavior therapy and even yoga have proven to be most effective.

Visualization techniques, positive assertions, prayer and increasing faith in oneself, can go along way in getting rid of anxiety and depressive thoughts.