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Management of Hypertension Complicated by Psychiatric Comorbidity

Vol. 9 no. 9 sEpTEmbEr 2007 708 Diverse psychosocial forces can impact hypertension and its clinical care. Chronic mental stress is possibly a cause of essential hypertension. opinions on this are polarized, no doubt partly because the occupational health litigation dimensions of the subject are so divisive. White coat hypertension has psychologic roots that remain enigmatic; introversion and shyness have been implicated. The apparent blood pressure (bp) surges of labile hypertension can be real, artifactual, or illusory; psychologic factors are operative in some instances via panic attacks and episodic life stress. panic disorder not uncommonly coexists with hypertension, confounding the diagnosis of pheochromocytoma and influencing antihypertensive drug choices; panic attacks can masquerade as hypertensive emergencies. obsessive compulsive disorder can transform home bp measurement into a compulsive, ritualized component of the illness. Depressive illness and schizophrenia may coexist with hypertension through prescribed psychotropic drugs causing weight gain and bp elevation. attitudinal barriers to treatment, beyond explicit psychopathology, do exist; antidrug ideology, psychologic denial, and indifference to life itself are examples. in nearly 40 years of medical practice involving primarily the care of patients with high bp in Canberra, australia; ann arbor, michigan; and melbourne, australia, it has been impressed on one of the authors (mE) that some patients are extraordinarily difficult to help. These are the patients who make the heart sink when their names are seen on the patient list for the day, because of past and ongoing therapeutic failure with them. This failure is usually not a result of them having the most severe hypertension. more often than not, it results from the presence of psychiatric illness coexisting with their hypertension or a personality that impinges adversely, in various ways, on the doctor-patient therapeutic alliance. patients with psychiatric comorbidity are common in hypertension clinics. This can result from medical referral biases, with somatic symptoms or morbid health preoccupations in depression and anxiety disorders leading to the initial medical presentation and subsequent referral. in addition, the prevalence of some psychiatric illness is genuinely increased in patients with essential hypertension; an example is panic disorder.1 further, some drugs used in psychiatric care can cause hypertension secondary to weight gain. in this commentary, we try to formulate the common psychosocial reasons for therapeutic failure with hypertensive patients and describe some of the characteristics of everyone’s “difficult” patient. This could only be possible with the input of both the clinical experience of the hypertensionologist (mE) and the psychiatric expertise of his wife (rs), who tried to make sense of his uncomprehending and psychiatrically naive complaints at the end of the working day. Together, we have prepared this commentary in the hope that in the future, treatment of the problem patient might be a little less daunting.