Increased risk of hypertension in patients with anxiety disorders: A population-based study

doi:10.1016/j.jpsychores.2014.10.006

Journal of Psychosomatic Research

Volume 77, Issue 6, December 2014, Pages 522-527

https://doi.org/10.1016/j.jpsychores.2014.10.006 Get rights and content

Highlights

•
The prevalence of hypertension in anxiety was higher than the general population.
•
The incidence of hypertension in anxiety was higher than the general population.
•
Age, male sex, diabetes, and hyperlipidemia had risk for hypertension in anxiety.

Abstract

Objective

We designed this study to examine the prevalence and incidence of hypertension and risk factors in patients with anxiety disorders.

Methods

The National Health Research Institute provided a database of 1,000,000 random subjects for study. We obtained a random sample of 766,427 subjects aged ≥ 18 years in 2005. The differences in the prevalence of hypertension between patients with anxiety disorders and the general population in 2005 were tested by multiple logistic regression adjusted for other covariates, including age, sex, insurance amount, region, urbanicity and depression. The differences in the incidence of hypertension between patients with anxiety disorders and the general population according to age group and sex from 2006 to 2010 were tested by a Cox regression adjusted for the other covariates.

Results

The prevalence of hypertension in patients with anxiety disorders was higher than that in the general population (37.9% vs. 12.4%, odds ratio, 2.61; 95% confidence interval, 2.52–2.70) in 2005. The average annual incidence of hypertension in patients with anxiety disorders from 2006 to 2010 was also higher than that in the general population (3.63% vs. 1.95%, risk ratio, 1.29; 95% confidence interval, 1.23–1.36). Compared with the general population, patients with anxiety disorders had a higher incidence of hypertension in all age and sex groups.

Conclusions

Patients with anxiety disorders had a higher prevalence and a higher incidence of hypertension than that in the general population. Age, male sex, diabetes, and hyperlipidemia were risk factors for hypertension in patients with anxiety disorders.

Introduction

Hypertension and anxiety disorders both cause substantial morbidity to patients and cost to the health care system [1]. The relationship of anxiety to the development of hypertension has been a subject of controversy with mixed findings in large-scale observational studies [1]. Hypertension is an important risk factor for the development of coronary heart disease. There is increasing evidence that anxiety is associated with coronary artery disease [1], [2], [3], as a 3-fold increased risk for cardiovascular disease has been observed in patients with anxiety disorders compared with the general population over a 10-year period.

Some studies have examined the relationship between anxiety and hypertension [4], [5], [6], [7]. However, no conclusive association between anxiety disorders and hypertension has been shown. Several studies seemly have found an association between anxiety and hypertension [8], [9], [10], [11], [12]. One study showed hypertension in men was statistically related to anxiety but not depression [8]. Another study revealed that anxiety patients from a psychiatric disease registry had higher rates of hypertension compared to the general population [9]. Other earlier prospective investigations have consistently found the anxiety trait (daily stress, emotional lability, tension, anger symptoms, and ambitiousness) predictive of later high blood pressure [10], [11], [12]. A review of 15 prospective studies of psychological traits affecting the development of hypertension found small but significant effects of anger, anxiety, depression, and other variables [6]. Thus, no population-level studies to date have investigated the association between anxiety disorders and hypertension. Literature on mental disorders and hypertension did not look specifically at a variety of anxiety disorders [4].

A population-based 22-year follow-up cohort of 3310 normotensive persons without chronic diseases from the National Health and Nutrition Examination Survey I (NHANES I) found that combined symptoms of depression and anxiety (“negative affect”) were associated with an increased risk for hypertension [13]. Similarly, another study found a significant association of hypertension with the co-occurrence of generalized anxiety disorder and major depressive disorder but not either disorder alone [14]. Conversely, in a Norwegian epidemiological study, high baseline depression and anxiety symptoms predicted lower systolic blood pressure at 11-year follow-up [15]. Similarly, a 15-year prospective study of psychosocial risk factors for hypertension based on a follow-up of more than 3000 young adults found that two components of Type A behavior, “time urgency–impatience” and “hostility”, were each associated with almost double the rate of incident hypertension, while anxiety symptoms, depression symptoms, and “achievement-striving–competitiveness” (another Type A component) did not predict hypertension [16].

In summary, there are many limitations in previous studies. First, they mixed many different types of psychological factors together and did not focus on anxiety alone. Second, most of the measures of anxiety in these studies were not using a clinical diagnosis or a formal diagnosis of anxiety disorders. Third, a majority of the studies are cross-sectional and do not allow us to determine the temporality of any possible associations.

Taiwan implemented a National Health Insurance program in March 1995, offering a comprehensive, unified, and universal health insurance program to all citizens and expatriates in Taiwan. The coverage provides outpatient services, inpatient care, Chinese medicine, dental care, childbirth, physical therapy, preventive health care, home care, and rehabilitation for chronic mental illness.

This study tests the hypothesis of a positive association between anxiety disorders and hypertension. We first compared the prevalence of hypertension in 2005 and factors associated with hypertension between patients with anxiety disorders and the general population. Second, we compared the incidence of hypertension in patients with anxiety disorders and the general population from 2006 to 2010. Finally, we detected the risk factors for hypertension in patients with anxiety disorders during the same period.

Section snippets

Sample

The National Health Insurance database of medical claims includes outpatient care, inpatient care, dental services, and prescription drugs. The National Health Research Institutes provided a database of 1,000,000 random subjects, about 4.5% of the total population (22.6 million), to perform a related health service study. Longitudinal Health Insurance Database 2005 contains the original claim data of 1,000,000 beneficiaries enrolled in 2005 randomly sampled from the year 2005 Registry for

Results

Table 1 shows the demographic characteristics of patients with anxiety disorders and the general population.

Table 2 shows the prevalence of hypertension in patients with anxiety disorders and the general population. The prevalence of hypertension in patients with anxiety disorders was higher than that in the general population (37.9% vs. 12.4%; odds ratio, OR, 2.61; 95% CI, 2.52–2.70) in 2005. Compared with the general population, hypertension was more prevalent in persons with anxiety

Discussion

To the best of our knowledge, this is the first study to use population-based National Health Insurance data to investigate the prevalence and incidence of hypertension in patients with anxiety disorders in Taiwan. Our results revealed that the 1-year prevalence of hypertension in patients with anxiety disorders was higher than that in the general population (37.9% vs. 12.4%, OR, 2.61; 95% CI, 2.52–2.70). Our findings also revealed that the incidence rate of hypertension in patients with

Conclusions

Patients with anxiety disorders had a higher prevalence and incidence of hypertension than those in the general population. The prevalence and incidence of hypertension among patients with anxiety disorders was much higher in the young adult age groups compared with the general population. It is important for clinicians to monitor potentially developing hypertension in patients with anxiety disorders, especially in young age groups, males, and patients with diabetes and hyperlipidemia, to

Conflict of interest

We have no conflict of interest.

Acknowledgments

We thank the National Health Research Institute and the Bureau of National Health Insurance for supplying data.

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The National Health Insurance in Taiwan uses diagnostic coding that follows the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic criteria [19]. We identified study subjects who had at least two service claims during 2005 for either outpatient or inpatient care with a primary or secondary diagnosis of anxiety disorders, which includes anxiety states, panic disorder, generalized anxiety disorder, phobic disorder, obsessive-compulsive disorder, acute stress disorder, and post-traumatic stress disorder (ICD-9-CM: 300.0, 300.2, 300.3, 308.3, and 309.81) [20]. Study subjects who had at least one prescription (oral hypoglycemic agents or insulin) for treatment of diabetes during this year for either outpatient or inpatient care were identified [18,21].
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Increased risk of hypertension in patients with anxiety disorders: A population-based study

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Sample

Results

Discussion

Conclusions

Conflict of interest

Acknowledgments

Gen Hosp Psychiatry

J Affect Disord

J Psychosom Res

Lancet

Mayo Clin Proc

Atherosclerosis

Lancet

The influence of anxiety and depression on outcomes of patients with coronary artery disease

Arch Intern Med

Anxiety and coronary heart disease: a synthesis of epidemiological evidence

Ann Behav Med

Physical illness as an outcome of chronic anxiety disorders

Can J Psychiatry

Are symptoms of anxiety and depression risk factors for hypertension? Longitudinal evidence from the National Health and Nutrition Examination Survey I. Epidemiological follow-up study

Arch Fam Med

A quantitative review of prospective evidence linking psychological factors with hypertension development

Psychosom Med

Major depression as a risk factor for high blood pressure: epidemiologic evidence from a national longitudinal study

Psychosom Med

The relationship between hypertension and anxiety or depression in Hong Kong Chinese

Exp Clin Cardiol

The relationship of psychosocial factors to coronary heart disease in the Framingham study I: methods and risk factors

Am J Epidemiol

Does blood pressure rise with age? Or with stress?

J Human Stress

Psychological health behavior and biological predictors of blood pressure change in middle-aged women

J Hypertens

Negative affect as a prospective risk factor for hypertension

Psychosom Med

Generalized anxiety and major depressive disorders, their comorbidity, and hypertension in middle-aged men

Psychosom Med