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The coronavirus disease 2019 (COVID-19) pandemic in Indonesia has led to an increase in mental health problems, especially among those with comorbid hypertension. Uncontrolled hypertension is the primary comorbidity of COVID-19. Thus, this study aimed to determine the pattern of uncontrolled hypertension at two time points during the pandemic and to confirm its relationship with common mental disorders (CMDs).
Methods
This longitudinal study was conducted at two time points (2019 and 2021), and the data of individuals with hypertension was sourced from the Bogor of Noncommunicable Diseases Risk Factors Cohort Study. Data of 1,231 respondents who met the inclusion and exclusion criteria were included in the analyses. The Self-Reported Questionnaire-20 was used to measure CMDs (score of >6). This study used a generalized estimating equation to analyze the data.
Results
The percentage of those with uncontrolled hypertension increased from 57.6% to 66.4%, whereas those with CMDs increased from 6.1% to 11.5%, from 2019 to 2021. The risk of uncontrolled hypertension was higher in patients with CMDs than in those without CMDs. The risk of uncontrolled hypertension increased from twice (adjusted odds ratio [aOR], 1.57; 95% confidence interval [CI], 1.071–2.069) in 2019 to 3 times (aOR, 2.765; 95% CI, 2.243–3.287) in 2021.
Conclusion
Since stress increases the risk of developing uncontrolled hypertension, individuals with hypertension must be able to manage their stress. Apropos this, the governments should provide mental health consultation services in treating patients with hypertension, especially during adverse events such as pandemics.
Indonesia is undergoing epidemiological transition as the burden of infectious diseases is slowly decreasing in contrast to noncommunicable diseases which continue to impact the health of the population. Stroke, ischemic heart disease, diabetes, cirrhosis and other chronic liver disorders, and tuberculosis are the leading causes of years of life lost. High blood pressure is the leading risk factor for disability-adjusted life-years in Indonesia and in 85% of the provinces [1]. At the community level, there is evidence of a relationship between uncontrolled hypertension and other noncommunicable diseases [2]. A report from the National Cardiovascular Center Harapan Kita indicated that uncontrolled diseases increase the odds of multivessel diseases and doubles the risk of atherosclerotic cardiovascular disease in Balinese patients [3]. Uncontrolled hypertension is also associated with kidney diseases, as evidenced by 64% of the chronic kidney disease patients in Bali who have uncontrolled hypertension, and 66% of uncontrolled hypertension incidents in patients with chronic kidney failure in Karawang [2].
According to the European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines, antihypertensive drugs should be administered immediately to patients with grade 1 or higher hypertension [4]. However, in reality, many people with hypertension still have not achieved blood pressure control targets despite hypertension treatment being relatively affordable [4]. A study in Lebanon comprising 259 respondents who had hypertension, confirmed that 42.7% still had uncontrolled hypertension [5]. Based on a 4-year noncommunicable disease risk factor monitoring study in Bogor City, Indonesia, 76.2% of the respondents with hypertension were unable to manage their blood pressure after treatment.
Appropriate lifestyle changes contribute to blood pressure control in individuals with hypertension who are already undergoing medical therapy, by reducing the amount and dose of antihypertensives [6]. Avoiding stress is a behavior that must be performed to maintain blood pressure as stress can increase susceptibility to disease through endocrine changes [6]. Individuals with hypertension and a stress risk develop severe hypertension [6]. Research in China also showed that patients with both hypertension and depression were more than twice as likely to develop uncontrolled hypertension than those without depression [7]. Stress can increase the function of the sympathetic nervous system to activate the renin-angiotensin-aldosterone system, resulting in the release of renin, which converts angiotensinogen to angiotensin II, increasing blood viscosity and constriction of blood vessels [8].
Bogor City is one of the cities in the West Java Province that has a high prevalence of noncommunicable diseases, especially hypertension. The prevalence of hypertension in Bogor City in 2018 was higher than the national figure (37.3%), with a compliance rate of 45.7% for antihypertensive drugs [9].
The coronavirus disease 2019 (COVID-19) pandemic experience has left Indonesians concerned about their and their families’ health, especially those with chronic diseases such as hypertension. In May 2020, 6.92% of the people experienced moderate-to-severe anxiety symptoms, whereas 8.57% experienced moderate-to-severe depressive symptoms [10]. Therefore, this study aimed to determine the pattern of uncontrolled hypertension at two time points during the pandemic and confirm its relationship with common mental disorders (CMDs) in patients with hypertension.
Methods
Study design
This longitudinal study sourced data from the Bogor of Non-communicable Diseases Risk Factors Cohort Study (NCDRF Cohort Study), conducted by the Center for Research and Development of Public Health Efforts, Ministry of Health, from 2011 to 2021. The NCDRF Cohort Study conducts annual blood pressure measurements, anthropometry, nutritional examinations, and interviews regarding risk behaviors such as smoking, alcohol consumption, and lack of physical activity. The data of two observation points (2019 and 2021) was included in the study. Data for 2020 were not included as data collection was not carried out by the cohort study proposal in that year as Indonesia implemented social distancing in 2020.
Study participants
The study participants were Cohort Study respondents aged ≥30 years who had suffered from hypertension in 2018. The hypertension criteria in determining participants followed the guidelines of 2018 ESC/ESH, Joint National Committee 8 (JNC 8), and Perhimpunan Dokter Hipertensi Indonesia (PERHI; Indonesian Hypertension Doctors Association). Respondents were classified as having hypertension when the systolic blood pressure was 140 mm Hg or diastolic blood pressure was 90 mm Hg, while resting [11]. In the NCDRF Cohort Study, blood pressure was measured 2–3 times with a 5-minute break between each measurement, using a digital sphygmomanometer on the right arm in a sitting position. Bogor City Health Office healthcare employees were trained to take blood pressure and anthropometric measurements [12]. The inclusion criteria were participation in the study based on two longitudinal observations (2019 and 2021), and attending baseline monitoring (2018). Pregnancy was the exclusion criterion. Of the 1,611 eligible respondents who had hypertension in 2018, 1,231 respondents consistently attended the two measurement time points (2019 and 2021) (Figure 1).
Variables
Uncontrolled hypertension
The outcome measure was uncontrolled hypertension. Patients with uncontrolled hypertension were assessed annually. Blood pressure was measured using a calibrated digital sphygmomanometer. Each measurement was performed by trained healthcare workers at least twice in a sitting position with a 3‒5 minute interval between each measurement. Uncontrolled hypertension was defined based on the JNC 8 report as a blood pressure condition ≥140/90 mm Hg in individuals who have suffered from hypertension, aged <60 years and/or hypertension with diabetes, and blood pressure conditions ≥150/90 mm Hg in individuals who have suffered from hypertension, aged ≥60 years [13]. This outcome variable was coded “0” for controlled hypertension and “1” for uncontrolled hypertension.
Common mental disorders
The main independent factor in this study was CMDs. In the NCDRF Cohort Study, the CMDs data were collected annually via the Self-Reported Questionnaire-20 (SRQ-20), developed by the World Health Organization [14]. Respondents were asked 20 questions by trained enumerators regarding how they felt in the last 30 days, with response options of “yes” or “no” to each item. Respondents who answered six or more “yes” were categorized as having CMDs [15]. This instrument has been tested and translated in many languages, and based on the works of Chipimo and Fylkesnes, the area under the curve (AUC) of 0.95 confirms SRQ- 20 as a valid instrument. In Indonesia, a study using national data identified two factors on the SRQ-20: depression and somatic anxiety symptoms [16]. The SRQ-20 was implemented by the Indonesian Ministry of Health from the inaugural Riskesdas in 2007 and has been domestically validated for use with individuals aged 15 years and older, with a positive predictive value of 60% and a negative predictive value of 92% [17]. The results of testing the one-factor model using confirmatory factor analysis and the AUC-receiver operating characteristic curve values of the two-factor model exceeded 0.7, indicating that the SRQ-20 is a reliable tool for measuring CMDs [16]. Furthermore, Cronbach’s α coefficient of the SRQ-20 was higher than 0.84.
Covariates
Other independent variables included in the model to control for the association between CMDs and uncontrolled hypertension were age, sex, marital status, sodium intake, body mass index (BMI), and antihypertensive medication use. These variables are believed to be related to CMDs and are also risk factors for uncontrolled hypertension.
All covariates were time-dependent, and the variables can change over time. Age was measured on a numerical ratio scale, and gender was categorized as “0” for women and “1” for men. Marital status was coded as “0” for married, “1” for unmarried, and “2” for divorced or separated. Sodium intake refers to a person’s total sodium consumption in 1 day, and was categorized as normal (coded as 0) if sodium consumption was <2,000 mg and high (coded as 1) if it was ≥2,000 mg [18]. Variable BMI was categorized as normal weight (coded as 0) if BMI was 18.5‒22.9 kg/ m2, underweight (coded as 1) if BMI was <18.5 kg/m2, overweight (coded as 2) if BMI was 23.0‒24.9 kg/m2, and obese (coded as 3) if BMI was ≥25 kg/m2 [19]. The hypertension medication variable was the respondent’s compliance in taking antihypertension medication in the past week, coded as “0” for yes and “1” for no.
Statistical analysis
The data were analyzed using generalized estimation equation (GEE). Initially, the data were analyzed univariately to determine the percentage of each variable and trends in the incidence of uncontrolled hypertension and CMDs at the two time points (Figure 2). Bivariate analysis was used to obtain the relationship between independent variables and the incidence of uncontrolled hypertension in the same year (2019 or 2021). Chi-square analysis was used for categorical independent variables, while the independent t-test was used for numeric independent variables. Bivariate analysis was also performed to determine the pairwise relationship between each variable and the observation time (2019 and 2021). McNemar’s analysis was used for categorical variables, whereas numeric variables were analyzed using paired t-tests (Table 1). The bivariate GEE yielded crude odds ratios and quasi-likelihood under the independence model criterion-corrected (QICC) value for each correlation type (Table 2). Multivariate analysis was performed using the GEE to determine the magnitude of the association between CMDs and uncontrolled hypertension after controlling for other covariates. The results of the multivariate analysis are presented with adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P-value of <0.05 for statistical significance (Table 3). Statistical analysis was performed using IBM SPSS ver. 22.0 (IBM Corp.) with statistical estimation using generalized linear models.
Ethical approval
All study processes complied with the applicable ethical norms to respect respondents’ information and privacy. This study was approved by the Health Research Ethics Committee of the National Institute of Health Research and Development, Indonesian Ministry of Health (KEPK-BPPK) (no., LB.02.01/2/KE.259/2021).
Results
Figure 2 shows that the percentage of CMDs increased from 6.1% in 2019 to 11.5% in 2021. Likewise, the percentage of patients with uncontrolled hypertension increased from 57.6% to 66.4% among those diagnosed with hypertension.
The study participants had an average age of 54–56 years, and the majority were female (77.1%), married (75%–76%), had a sodium intake of <2,000 mg per day (86%), and were obese (approximately 70%). Most participants had taken hypertension drugs in the week before monitoring was carried out (60%). Table 1 shows that the percentage of participants with both uncontrolled hypertension and CMDs (65.3% in 2019; 83% in 2021) was higher than that of those without CMDs (57.1% in 2019; 64.2% in 2021). It can be seen that the percentage of participants with CMDs and uncontrolled hypertension in 2021 increased by 17.7% from 2019. Table 1 also shows that with the increase in observation time (2019 to 2021), there was an increase in the proportion of uncontrolled hypertension (57.6% to 66.4%; P<0.000), CMDs cases (6.1% to 11.5%; P<0.000), and the proportion of those divorced (21% to 22.3%; P=0.002).
Before multivariate analysis, it was necessary to select the most appropriate working correlation structure (WCS) by selecting the smallest QICC in each crude model. Table 2 shows that the WCS autoregressive (1), exchangeable, 1-dependent, and unstructured models have the same QICC values, which are smaller than the QICC value of the independent WCS. For multivariate analysis, the researchers used the unstructured WCS to determine whether the prevalence of uncontrolled hypertension in the two monitored time points had different correlations in each participant.
Table 3 presents the multivariate results. The risk of uncontrolled hypertension with CMDs was higher in patients with CMDs than in those without CMDs. The risk of uncontrolled hypertension increased from 2 times (aOR, 1.57; 95% CI, 1,071‒2.069) in 2019 to 3 times (aOR, 2,765; 95% CI, 2,243‒3,287) in 2021.
Discussion
The incidence of uncontrolled hypertension increased from 57.6% in 2019 to 66.4% in 2021in Indonesia. This is in line with the trend of CMDs, which also increased from 6.1% in 2019 to 11.5% in 2021. This may be because the first case of COVID-19 in Indonesia was discovered in March 2020, meaning that in 2019, Indonesians were not worried about COVID-19. Meanwhile, from 2020–2021, people had started to worry about their health, especially those with comorbid hypertension [20].
The results of an online survey conducted from March 31 to April 23, 2020, proved that 80% of the participants with chronic diseases (heart diseases, diabetes, and hypertension) reported that their mental health deteriorated during COVID-19 [21]. A study conducted in the United Kingdom revealed that among 45,418 patients with hypertension, 33,468 (73.7%) exhibited uncontrolled blood pressure during the COVID-19 pandemic [22].
Uncontrolled hypertension is often suspected to be the result of daily or past exposure to life events, trauma, anger, and anxiety [8]. This study showed that people with both hypertension and CMDs had a higher risk of uncontrolled hypertension than those without CMDs. This risk increased almost three-fold at the peak of the pandemic (2021), whereas psychological problems increased two-fold. In other words, mental disorders were positively correlated with uncontrolled hypertension.
Women with uncontrolled hypertension had considerably higher psychological distress scores, whereas those with less psychological distress had higher self-care scores [23]. Additionally, individuals who carried self-care items, had decreased stress, exercised regularly, or stopped or cut down smoking were less likely to develop uncontrolled hypertension [24].
There are several explanations for the relationship between CMDs and uncontrolled hypertension. Previous research has concluded that lower psychological distress scores can lead to higher self-care, thereby improving the possibility of better hypertension control and raising the probability that the patient will have better blood pressure control [23]. Additionally, individuals with depression were more likely to not take their blood pressure medicine as prescribed [25], which could lead to uncontrolled hypertension. Another study observed that individuals with mental disorders may have poor blood pressure control because they lose the motivation to adhere to their therapeutic regimen [26].
The psychological effects of uncontrolled hypertension are associated with inflammation and negative behaviors that arise because of psychological problems [27]. Chronic stress activates the sympathetic nervous system and hypothalamus-pituitary-adrenal axis, resulting in hypertension. Stress stimulates the sympathetic nervous system and the circulation of catechol amines, thus triggering negative behaviors such as smoking, alcohol consumption, substance abuse, poor diet, obesity, and reduced physical activity, which are risk factors for uncontrolled hypertension [28].
Psychological problems also affect nonadherence to hypertension medication, leading to uncontrolled blood pressure [25]. Hypertension can cause pathological disorders in the brain with symptoms of depression, such that patients do not adhere to medication, and hypertension becomes uncontrolled. This increases blood vessel disorders in the brain and worsens the symptoms of depression [29].
Individuals with both hypertension and depressive symptoms have an increased brachial-ankle pulse wave velocity, which can lead to uncontrolled hypertension. Antidepressant use in individuals with hypertension was independently associated with increased blood pressure, with antidepressant use causing a 1.6 mmHg increase in diastolic blood pressure [30].
This study has several limitations. First, although the number of study participants was quite large, 25% were excluded from the analysis because of incomplete or invalid data, leading to a possibility of bias. However, we confirmed minimal bias as that the distribution of the excluded participants was random. This research was also strengthened by data collectors who underwent a structured training and were blinded to the research hypotheses. Second, this survey was conducted online, which raises concerns about whether the respondents understood the questions. However, despite being conducted online, this was a cohort study with respondents who had been health-tracked for several years, raising confidence in their familiarity with answering questions about their health. Third, the independent and dependent variables in this study were measured simultaneously at two time points; this may have impacted the causality of the findings.
In conclusion, individuals with both hypertension and CMDs were at higher risk of developing uncontrolled hypertension than those with hypertension but not CMDs. Thus, psychological support must be integrated into hypertension prevention and maintenance programs to control hypertension.
Notes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
We thank the Health Policy and Development Agency of the Ministry of Health for providing the data used in this study.
Funding
None.
Data availability
Contact the corresponding author for data availability.
Author contribution
Conceptualization: TW, RM, IYS, WPN. Data curation: TW. Formal analysis: TW. Methodology: TW, RM, IYS, WPN. Project administration: TW, RM, IYS. Visualization: TW, RM, IYS. Writing–original draft: TW, RM, IYS. Writing–review & editing: TW, RM, IYS, WPN. Final approval of the manuscript: all authors.
Figure. 1.
Selection of the study participants.
Figure. 2.
Trends of uncontrolled hypertension and common mental disorders (CMDs) in 2019 and 2021 in Indonesia.
Table 1.
Percentage of uncontrolled hypertension in individuals with hypertension in 2019 and 2021 in Indonesia
a)Test of model effects type III generalized estimating equation with unstructured correlation.
b)Adjusted age, sex, marital status, sodium intake, body mass index, and hypertension medication.
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