Michael Ziegler, M.D.: "Psychiatric patients are more likely to
develop hypertension than diabetes." Ziegler is a professor of medicine
at the University of California, San Diego.
Credit: Aaron Levin
Why should psychiatrists be concerned about high blood pressure or its
treatment in their patients?
After all, high blood pressure doesn't usually produce psychiatric
symptoms, and mental illness doesn't usually raise blood pressure.
"Well, for a start, psychiatrists can't avoid it," said Michael
Ziegler, M.D., a professor of medicine at the University of California, San
Diego. "Hypertension is the most common reason why patients visit the
doctor, and its prevalence increases with age and obesity. By age 65, half of
your patients will have high blood pressure."
Ziegler spoke at an "Advances in Medicine" session at APA's
annual meeting in San Diego in May. If the number of interruptions for
questions from the audience was any indication, the psychiatrists were indeed
In fact they may be faced with the condition as a side effect of treatment,
since atypical antipsychotics often contribute to weight gain and diabetes,
both risk factors for hypertension.
"The U.S. and Canada are doing a better job about high blood pressure
awareness than Europe is, but rates of control are still not good," said
Ziegler. About 70 percent of Americans with high blood pressure are aware that
they have the condition, but only 34 percent meet goals for controlling
The underlying causes for what is still called "essential
hypertension" are poorly understood, but obesity, lack of exercise,
dietary fat and sodium, sleep apnea, heavy alcohol use, hyperaldosteronism,
and neuroleptic use can be contributing factors.
Sleep apnea affects 10 percent to 50 percent of hypertensive individuals,
depending on the diagnostic criteria used, said Ziegler. Nighttime sleep-apnea
episodes induce hypertension by causing a burst of activity in the sympathetic
nervous system, as often as once a minute, producing a stress response and
hormone release that persists during the day. Often patients will present with
daytime drowsiness and a consequent loss of attention.
Some psychiatric drugs can affect blood pressure, Ziegler told
Psychiatric News in a later interview. Doctors have long known that
monoamine oxidase inhibitors lower blood pressure on their own, but when a
patient also eats foods containing tyramine, they can sharply elevate blood
pressure. Some tricyclic antidepressants or norepinephrine blockers may cause
Although SSRIs seem to have little effect on blood pressure, one
norepinephrine/serotonin reuptake inhibitor, venlaflaxine, can raise blood
pressure 4-5 mm Hg and should be avoided in patients with hypertension, said
"However, the world is made up of individuals, not averages,"
he said. "If venlaflaxine is indicated, I suggest monitoring blood
pressure to see if clinically significant changes occur."
Some antihypertensive drugs can produce psychiatric symptoms, as well. Much
research on the biology of depression in the 1950s was stimulated when the
early antihypertensive reserpine caused depressive symptoms in some patients.
Although reserpine is no longer used to control blood pressure, guanfacine and
other clonidine-type drugs are occasionally still prescribed. They can cause
drowsiness and general mental slowing that patients may attribute to
depression, but which are not confirmed by the Hamilton Depression Scale or
other measures, said Ziegler.
Diuretics, the most commonly used antihypertensives, may cause impotence or
lack of energy in high doses, effects that may result in referrals to a
psychiatrist. Beta blockers are not only tools for cardiologists but have been
used by psychiatrists to lessen anxiety in musicians and public speakers.
However, some side effects of these drugs, such as lack of energy and vivid
nightmares, may bring patients to a psychiatrist's office.
Newer categories of antihypertensives, like angiotensin-converting enzyme
inhibitors (ACEIs) or angiotensin receptor blockers appear to produce few, if
any, psychiatric symptoms.
Many of the side effects of antihypertensive drugs arise from dosing levels
that are higher than necessary, said Ziegler.
"Package inserts, the Physician's Desk Reference,
pharmaceutical company literature, and most textbooks are all over the board
and do not agree with expert opinion as laid out in the Seventh Report of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure [JNC 7]," he told listeners.
In general, the JNC 7 recommends starting dosages 50 percent lower than
those other sources do, he said. For instance, the standard dose for thiazide
diuretics is 25 mg, but starting a patient at 12.5 mg lowers blood pressure
almost as much with less chance of adverse effects. Increasing doses ratchets
up side effects but does not increase the antihypertensive effect
"There is no superdrug for high blood pressure," said Ziegler."
The best way to treat it is by adding low doses of different
drugs—the effect is additive."
The mainstays of ant ihypertensive treatment recommended by JNC 7 are the
thiazide diuretics and ACEIs, both of which are available in off-patent
versions alone or in combination. "With combined medications, one pill a
day can control 90 percent of hypertensives," said Ziegler.
Lifestyle changes—losing weight, exercising, eating less salt and
more fish with omega-3 fatty acids, and reducing alcohol consumption—can
help and should be suggested, but are hard to sustain, he said.
Because hypertension is a condition without obvious symptoms, keeping
patients on their medications is never easy, he said. The best way to treat
high blood pressure is by developing and maintaining rapport with patients, an
injunction not unfamiliar to psychiatrists.
"Let the patient know you care," said Ziegler. "Bring
them back frequently and say positive things. Emphasizing adverse outcomes
makes compliance worse."
He monitors medication compliance "excessively," he said, and
has a pharmacy student check pill counts, too. He also asks patients to bring
in their medications to the second office visit, "just to make sure you
got the right medicine," he tells them. In reality, he wants to see if
they've even filled the prescription. "When they bring them in, you know
they have them."
A reference card on diagnosing and treating hypertension based on
the Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC 7) is posted at<www.nhlbi.nih.gov/guidelines/hypertension/jnc7card.htm>.▪