ACE inhibitors or angiotensin receptor blockers are preferred for initial treatment of hypertension in diabetes, especially if proteinuria is present. Some authorities feel the level of blood pressure control in diabetes is more important than the agent(s) chosen to achieve that control. Most patients with hypertension and diabetes are not controlled on a single antihypertensive drug, and a diuretic is often added.
Psychological aspects of hypertension management
The diagnosis of hypertension and a resulting perception of loss of health or longevity may trigger a grief reaction in some patients.
Several psychological aspects to hypertension treatment make it difficult to achieve long-term control. Patients may become discouraged as dosages are increased and more medications are added. Asymptomatic patients may have no incentive to control their blood pressure. Many report, “I don’t feel any better” when their blood pressure comes down.
Because the goal of hypertension therapy is control rather than cure, the patient must commit to long-term treatment. Lifestyle changes such as dietary sodium restriction, smoking cessation, and weight loss may be difficult to achieve, especially for patients already dealing with a psychiatric disorder.
Also, the cost of treatment—the price of medications and initial and follow-up laboratory studies, plus the expense of follow-up office visits (possibly requiring time off work)—may be high.
Psychiatrists can help by offering moral support and encouraging patients to manage their medical problems, risk factors, and overall health. Psychiatrists can also educate patients on the importance of blood pressure control in preventing cardiovascular morbidity and mortality.
Brief cognitive-behaviorial therapy can identify the individual’s state of change (precontemplation, contemplation, preparation, action, or maintenance). Process techniques (such as consciousness-raising, commitment, or self-reevaluation) appropriate to the stage of change may then be employed.
For example, a patient in the precontemplation stage may resist returning to his or her primary care doctor to begin treatment for high blood pressure, employing such reasoning as, “I can’t afford those expensive office visits, and the medications would cost too much anyway.”
The psychiatrist might then apply consciousness-raising to motivate the patient: “How serious do you think it is to have high blood pressure that isn’t controlled? Are you aware that many people with high blood pressure are treated by means other than medications, or that many blood pressure medications are inexpensive?”
Providing relaxation techniques or a 12-week course of buproprion also can enhance the efficacy of smoking cessation efforts.
Related resources
- Drugs for hypertension. The Medical Letter 2001;43(1099):17-22.
- Some drugs that cause psychiatric symptoms. The Medical Letter 1998;40(1020):21-4.
- Hypertension—Journal of the American Heart Association. http://hyper.ahajournals.org/
- National Heart, Lung, and Blood institute’s Cardiovascular information site. http://www.nhlbi.nih.gov/health/public/heart/index.htm#hbp
Drug brand names
- Bupropion • Wellbutrin
- Guanadrel • Hylorel
- Lisinopril • Prinivil, Zestril
- Losartan • Hyzaar
- Ramipril • Altace
- Reserpine • Diutensen-R
- Valsartan • Diovan
- Venlafaxine • Effexor
- (Numerous other drugs mentioned in this article are available generically)
Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.