Targeting a potentially dangerous comorbidity in psychiatry
Key Takeaways
Physicians should be aware of the increased risk of cardiovascular death and unmanaged hypertension in psychiatric patients.
Psychiatric patients with severe hypertension often require a thiazide diuretic plus another antihypertensive medication because monotherapy usually fails to attain blood pressure goals.
The management of complex presentations such as those involving decompensation of renal function and secondary causes of hypertension require the input of a cardiologist or nephrologist.
Untreated hypertension results in a bevy of comorbidities, including stroke, heart failure, coronary artery disease, and chronic kidney failure.
Psychotropic medications raise blood pressure in direct and indirect ways.
Physicians should be cognizant of the dangers psychotropic drugs may pose, as patients with severe mental illness often receive insufficient hypertensive care and may be at increased risk for heart disease, according to an article published by Current Hypertension Reports.[]
Hypertension in context
About 70 million people in the US have hypertension, with only 60% diagnosed and 50% adequately treated, according to an article published by Current Psychiatry.[]
Hypertension is linked to major depressive disorder, bipolar disorder, anxiety, and schizophrenia, as well as eating and substance abuse disorders. Additionally, patients with panic disorder typically exhibit hypertension at younger ages.
The Current Psychiatry study found that 61% of patients with bipolar disorder have hypertension vs 41% of the general population. Bipolar disorder and hypertension could share common underpinnings, including hyperactive cellular calcium signaling and higher platelet intracellular calcium ion levels.
In cases of schizophrenia or other severe psychiatric illnesses, individuals may lose 25-plus years of life expectancy due to heart disease. Nontreatment of hypertension is especially concerning in schizophrenia patients, with 62.4% receiving no treatment.
"Because of the well-documented morbidity and mortality of hypertension and its increased prevalence and undertreatment in the psychiatric population, mental health providers are in an important position to recognize hypertension and evaluate its inherent risks to direct their patients toward proper treatment."
— McCarron, Current Psychiatry
Drugs of concern
Psychiatric drugs may not only increase the risk of hypertension but also blunt the efficacy of antihypertensive agents. Common psychiatric drugs that can raise hypertension include tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), antipsychotics, methylphenidate, and amphetamines, according to a study published in Arterial Hypertension.[]
Their risks, however, are variable. Drugs like SNRIs may have a milder effect on blood pressure compared to stimulants, which ought to be utilized with extreme caution—or not at all. However, this level of risk should be evaluated on a case-by-case basis, as some medications may affect patients differently than others.
MAOIs are notorious for the risk of hypertension due to dietary interactions. While mood stabilizers don’t raise blood pressure on their own, lithium can interact with diuretics.
Also of note, many antipsychotics are known to cause metabolic syndrome—weight gain that can lead to increased risk for diabetes, heart disease, and hypertension.
Although the intranasal antidepressant esketamine raises blood pressure shortly after dosing, antihypertensive treatments to counter such effects are usually unnecessary, and this medication is not related to an increased risk of cardiac events.
What to do
Ideally, psychiatrists should work with PCPs to treat hypertension.
On their own, psychiatrists should start a first-line psychotropic with follow-up at 1 month or earlier in patients with severe hypertension (>160/100 mm Hg), as well as chronic kidney disease, congestive heart failure, or coronary artery disease.
Psychiatric patients with severe hypertension are often also prescribed a thiazide diuretic with another medication because monotherapy frequently fails to attain blood-pressure goals.
Patients with chronic kidney disease require close monitoring of potassium, creatinine, and potassium when initiating angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, with levels checked within 1 to 2 days of starting or adjusting regimens.
Complex cases that require the expertise of an internist, cardiologist, or nephrologist include:
Decompensated comorbidities involving hyperkalemia, renal failure, heart failure, or coronary disease
Creatinine > 1.8 mg/dL
Blood pressure > 180/120 mm Hg
Need for three or more antihypertensives to reach blood-pressure goals
Secondary causes of hypertension
Adverse effects secondary to antihypertensive medications
What this means for you
The management of hypertension related to psychiatric medications and illness is an important consideration for psychiatrists and other physicians. Death due to cardiovascular causes can be a major risk in those with severe psychiatric illness. In complex cases, multidisciplinary care is necessary, with cardiologists, nephrologists, or internists on board.