Med/Psych Update

How to diagnose and manage hypertension in a psychiatric patient

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Increased risk of morbidity and mortality; be vigilant in drug–disease, drug–drug interactions



Hypertension is a widespread, under-recognized, and undertreated cause of morbidity and mortality in the United States and is associated with several psychiatric illnesses. Left untreated, hypertension can have significant consequences, including increased risk of stroke, coronary heart disease, heart failure, chronic kidney failure, and death. Approximately 70 million adults in the United States have hypertension, but only 60% of them have been diagnosed, and of those only 50% have their blood pressure under control.1 In 2013, 360,000 deaths in the United States were attributed to hypertension.2

Hypertension is associated with major depressive disorder, generalized anxiety disorder, bipolar disorder, and schizophrenia.3-5 Additionally, impulsive eating disorders, substance abuse, anxiety, and depression are associated with a hypertension diagnosis, although patients with panic disorder develop hypertension at a younger age.6 A 2007 study found a 61% prevalence of hypertension in those with bipolar disorder compared with 41% among the general population.7 The strong link between bipolar disorder and hypertension might be because of a common disease mechanism; both are associated with hyperactive cellular calcium signaling and increased platelet intracellular calcium ion concentrations.8

Hypertension not only is common among patients with psychiatric illness, it likely contributes to worse clinical outcomes. Studies across different cultures have found higher mortality rates in individuals with mental illness.9-11 Persons with schizophrenia and other severe mental illnesses may lose ≥25 years of life expectancy, with the primary cause of death being cardiovascular disease, not suicide.12 Patients with depression have a 50% greater risk of cardiovascular disease, which is equivalent to the risk of smoking.13

Schizophrenia is strongly associated with numerous comorbidities and has been linked significantly to an elevated 10-year cardiac risk after controlling for body mass index.5 The high rate of non-treatment of hypertension for patients with schizophrenia (62.4%) is especially concerning.14

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. This article reviews:

  • the signs and symptoms of hypertension
  • the mental health provider’s role in the evaluation and diagnosis
  • how psychotropic drugs influence blood pressure and drug–drug interactions
  • the management of hypertension in psychiatric patients, including strategies for counseling and lifestyle management.


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