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POSSIBILITY OF THE COMBINATION OF ANXIETY-DEPRESSIVE SYNDROME AТВARTERIAL HYPERTENSION IN THE POPULATION OF THE NORTHWEST OF RUSSIA
Fishman Boris Borisovich, Doctor of Medicine, Professor
Chapman M.E., Candidate of Medical Sciences, doctoral candidate
Bober M.A., Candidate of Medical Sciences, doctoral candidate
Fomenko L.A., Candidate of Psychological Sciences
NovgorodStateuniversity named after Yaroslav Mudryi
Kuprin P.Е., Candidate of Medical Sciences, doctoral candidate
St.-Petersburg State Medical university named after I.P.Pavlova
ChorochevskajaA.I., Candidate of Medical Sciences, doctoral candidate
Novgorod region medical centre
Prevalence of arterial hypertension, anxiety and depression was investigated in course of the selective study performed in thepopulation of 2 areas of the Northwest of Russia. Calculation of the relation of chances of possibility of combination of clinical forms of anxiety and depression in patients with arterial hypertension of different degree was done. High risk and strong correlation between obesity of the 2-3 degrees, subclinical and clinical forms of anxiety and depression in patients with arterial hypertension was shown.
Keywords: Selective study, prevalence of arterial hypertension, anxiety and depression. The relation of chances, correlation dependence.
Social-and-psychological situation, which had developed in Russia during the Post-Soviet period, has led to the destruction of public consciousness and vital orientation of tens million people. Psychoemotional overstrain and psychic disadaptation developing as a result are in essence a collective trauma (Aleksandrovsky J.A., 1992).
The majority of epidemiological studies in patients with depression showed the increased risk of arterial hypertension development during the next 5-16 years (JonasB.S.etal, 1997; CARDIA, 2000; MeyerC.M. etal, 2004; ScalcoA.Z. etal, 2005). For example, in 10 yearlong study of 12270 persons who initially had no increased BP, in persons with depression the risk of arterial hypertension was 60 % higher (Patten S.B. et al, 2009). Among patients with marked depression frequency of arterial hypertension was almost 3 times as high (Rabkin J.G. et al, 1983).
Association of depression and hypertension seems to be indirect and is mediated by the general risk factors and hyperactivity of the sympathetic nervous system (Scalco A.Z. et al, 2005; KabirA.A. etal, 2006).
In patients with arterial hypertension depression was associated with the risk of stroke (2.3-2.7 times) and cardiovascular mortality (Simonsick E.M. et al, 1995). In SHEP study increase of depression manifestation due to CES-D scale by 5 points in old patients was associated with mortality rate increase by 25 %, risk of stroke or infarct by 18 %. Probably increased BP has no significant influence on the frequency of psychiatric disturbance. There were no significant differences of psychological factors - anxiety, depression, anger, personal features - in groups of patients with normal BP and mild hypertension (FriedmanR. etal, 1996). The awareness of patients on the presence of arterial hypertension did not influence frequency of affective, anxious disorders (Schmitz N. et al, 2006).
In NHANES I study anxiety, as well as depressions, was associated with 1.8 times increased risk of hypertension within 7-16 years of observation (Jonas B.S. et al, 1997). Unlike women, in men of middle age with anxiety risk of arterial hypertension was 2.2 times increased according to the data of 20 yearlong observation in Fremingemsky research (MarkovitzJ.H. etal, 1993). Later in Finnish 9 yearlong observation in women of middle age high level of anxiety, anger and low social support were associated with increased risk of hypertension (Raikkonen K. et al, 2001). At the same time in two epidemiological studies no association between anxiety and risk of arterial hypertension was found (Shinn E.H. et al, 2001).
Thereforethe aim of the present researchwas studying of prevalence of anxiety and depression in the population of the Northwest Russian Federation and patients with arterial hypertension, and also determination of expression of combination of chances of anxiety and depression in patients with arterial hypertension of different degree considering age-sex features.
Materials and methods
Characteristic of selective research
Selective, epidemiological study (cross-sectional study) for revealing arterial hypertension (AH) and its separate risk factors (RF) among adult population of the Novgorod and Pskov areas was carried out. Single random sample based on the number of a general totality was used in the study.
AH evaluation was done according to classification JNC VII «the Seventh report of Incorporated national committee of the USA on prevention, revealing, evaluation and hypertension treatment» and ESH-ESC, 2003 «References of the European Society on hypertension and the European society of cardiologists on AH treatment» (Britov A.N., Bystrova M. M, 2003).
For psychometric screening hospital anxiety and depression scale HADS - A and HADS-D (Zigmond A., 1983) was used. Criteria for reference to various forms of anxiety and depression included:
Subclinical levels of anxiety/depression - 8-10 points;
Clinical levels of anxiety/depression - 11 points and more.
Sex-age characteristic of respondents
70 and over
Group of patients with AH
Group of patients with AH
Considering that the data obtained are characterized by asymptomatic normal distribution the Mantel-Henzel factor of disagreement or the relation of chances (Odds ratio) was used.
Results of the study
The studies showed that among the population of the Northwest Russian Federation prevalence of the subclinical form of anxiety is 31.1 % in women and - 23.9 % in men; the clinical form – 26.4 % and 16.8 %, respectively (fig. 1). Thus it becomes clear that unlike men in women anxiety, irrespective of its clinical form is dominant. Evaluation of age aspects of prevalence of the subclinical form of anxiety showed that in men the subclinical form of anxiety is characteristic both for younger and senior age groups, except for the age group of 40-49 in which the lowest indices of subclinical anxiety 17.6 % were noted. Stable high indices of subclinical anxiety were registered in women except for an insignificant negative trend in the age group of 20-29. The range of variation considering age is insignificant and is in the zone of one statistical corridor at P>0.05.
The clinical form of anxiety has significant both sex-and-age and numerical differences. Increase of an index of clinical anxiety in the process of transition in more senior age group is characteristic for both gender groups. In men the most significant increase was noted beginning from the age of 50-59 and reached its maximum at the age of 70 and over (from 11.9 % to 37.5 %, accordingly).
In women index increase was of less prompt character rising from 24.9 % in the age group of 50-59 and reaching its maximum (35.4 %) in the age group of 60 and over. Relative density of the index both on subclinical and clinical form of anxiety in women was found.
Evaluation of depression prevalence in the Northwest Russian Federation population (fig. 2) showed that the subclinical form of depression within 21.3 % and clinical form of depression within 13.3 % is characteristic for the population.
Age-sex features show that in men the subclinical and clinical form of depression has the general patterns of increase beginning from the age group of 30-39 (the subclinical form) and 40-49 (the clinical form) and reaching its maximum of 28-29 % in the age group of 50-59 (the subclinical form) and 60-69 (the clinical form). Thus, it becomes obvious that the subclinical form precedes clinical form with aging of the population by one decade.
Somewhat different picture was observed in evaluation of women subpopulation. Thus, if the subclinical form of depression has two peaks (at the age of 40-49 – 27.6 % and 60-69 - 28 %) the clinical form of depression at the initial indices of 3.8 % in the age group of 20-29 increases up to 46.5 % in the age group of 70 and over. The most intensive growth is in the older age groups.
Thus, the presented data characterize the Northwest Russian Federation population as the population for which anxiety-depressive syndrome dominant is characteristic, especially in the older age groups irrespective of sex.
As it was stated above prebackground in prevalence of anxiety and depression among the population proves necessity of introduction in the analysis of demonstrative medicine criterion - the relation of chances giving accurate gradation in possibility of influence of a risk factor on the immediate disease under the scheme “case – control”.
The study (3) showed that in women the index of the relation of chances stresses significant interrelation of anxiety and arterial hypertension. Thus, the subclinical anxiety at 1 degrees AH was according to Rc = 2.19 (CI 95 % 1.44?3.32), р=0,000. At AH 2 degrees Rc = 0.6 (CI 95 % 0.34 ? 1.04), р=0,000. This shows possible association of anxiety and AH at the upper border of the confidential interval.
At AH 3 degrees Rc is 3.26 (CI of 95 % 1.78?5,92), р=0,000. At ISAP Rc is 1.39 (CI 95 % 0.72?2.8), р=0,233. Thereby, it was shown, that subclinical anxiety has the highest chances to be associated with AH 3 degrees.Clinical anxiety is associated with AH degree due to the index of the relation of chances in the form of linear dependence, “р” is of high degree of reliability.
Maximum size of the upper border of a confidential interval is 4.62 at AH 3 degrees, the lower border – 1.09. So it is obvious that the clinical form of anxiety is comorbid with AH.
A Fig. 3. Characteristic of the value of the relation of chances (Rc) taking into account a confidential interval of manifestation of anxiety in women with arterial hypertension
Numerical data to fig. 3
Relation of chances
In men subclinical and clinical anxiety is also associated with arterial hypertension, however “р” value shows reliability only in an estimation of clinical anxiety and AH 3 degrees at Rc = 3.45 (CI of 95 % 1.33 ? 9.57), р= 0,033. The most significant association, both subclinical and clinical anxiety, was noticed at ISAН(fig. 4). So, Rc in subclinical anxiety was 9.81 (CI 95 % 3.77 ? 24.93), р= 0,000 and for clinical anxiety Rc = 3.27 (CI 95 % 0.81?2.49), р= 0,047.
Thus, it was proved, that in men the highest association of anxiety and ISAP is possible. At AH 3 degrees the same pattern is noted by the index of clinical anxiety.
Fig. 4. Characteristic of value of the relation of chances (Rc) considering a confidential interval of manifestation of anxiety in men with arterial hypertension
Numerical data to fig. 4
Relation of chances
AH 1 degree
AH 2 degree
Estimating the value of the relation of chances by association of depression and degree of arterial hypertension in women (fig. 5), it is possible to notice complete comorbidity of depression and arterial hypertension irrespective of their forms and degree at statistically reliable “р” value. The highest Rc values are noted at estimation of the clinical form of depressions within Rc values from 2.54 at AH 1 degrees to 6.19 at AH of 3 degree. The maximum value of the upper border of a confidential interval in clinical depression in patients with AH 3 degree was 11.4.
Thereby, it was proved, that possibility of depression in women with AH is very high, providing high comorbidity clinical picture.
Fig. 5. Characteristic of the relation of chances (Rc) considering confidential interval of manifestation of depression in women with arterial hypertension
In men (fig. 6) association of depression and various clinical degrees of arterial hypertension has its own features. Thus, at high value of the relation of chances reaching maximum at the clinical form of depression in patients with AH 3 degrees equaling 5.34 (CI 95 % 2.05 ? 14.34), р= 0,002, subclinical form at Rc = 3.23 (CI 95 % 1.17 ? 9.69) is doubtful, as р= 0.056. Indices for subclinical form of depression are also doubtful at AH 1 and 2 degrees.
Numerical data to fig. 5
Relation of chances
So it was proved that in men with AH there are strong chances of association of clinical form of depression and AH irrespective of its clinical degree. Also like at estimation of the clinical form of anxiety in men with ISAP, its combination with clinical form of depression is quite common.
Fig. 6. Characteristic of value of the relation of chances (Rc) considering confidential interval of manifestation of depression in men with arterial hypertension
Thus, the analysis performed proved the primary importance of subclinical and clinical forms of anxiety and especially depression on the background of high anxiety in women with AH 3 degrees, requiring interdisciplinary approach (cardiologist, psychiatrist, medical psychologist) in therapy of the given group of patients. In patients with ISAP high degree of association with anxiety-depressive syndrome was found.
Numerical data to fig. 6
Relation of chances
AH 1 degree
AH 2 degree
AH 3 degree
In complex estimation of manifestation of risk factors in patients with arterial hypertension comparing manifestation of relative risks in patients with AH irrespective of sex (fig. 8) the highest risks correspond with the indices of obesity, abdominal type of obesity and a complex of anxiety-depressive syndrome.
Manifestation of clinical anxiety and depression is comparable with indices of obesity and IMB, suggesting possibility of association of the given symptoms as links of one pathogenic chain.
The above facts stress the direct interrelation of development of abdominal type of obesity and anxiety-depressive syndrome in which may be underlain by hormonal changes occurring in women in early or late postmenopause period. This hypothesis can be proved only by target studies of hormonal background in women considering the presence of biochemical markers of anxiety and depression.
Thus, it was proved, that in the Northwest Russian Federation in a quartet of the metabolic syndrome it is necessary to introduce the parameter of the presence of anxiety-depressive syndrome in patients with AH in subclinical and clinical forms, accordingly tactics of treating patients with AH 2-3 degrees and ISAG must regard the presence of antidepressants combined with hypotensive preparations in the managing report.
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