麻豆传媒

Among patients with uncontrolled hypertension, those who are depressed are less likely to have their treatment intensified to achieve blood pressure goals, researchers found.

At two hospital-based primary care clinics, clinical inertia -- a lack of medication intensification, referral to a hypertension specialist, or work-up for identifiable hypertension -- occurred in 70% of patients with depression and 51% of those without depression (P=0.02), according to , of Columbia University Medical Center in New York City, and colleagues.

That difference remained significant after accounting for potential confounders (relative risk 1.49, 95% CI 1.06-2.10), they reported in a research letter in .

"Hence, clinical inertia may be one mechanism by which depressed patients have worse cardiovascular outcomes," they wrote. "Research has shown that patients with mental illness receive less intensive medical care, such as coronary revascularization; our study extends this literature by demonstrating differences in clinician behavior with respect to cardiovascular risk factor management in this population."

"Future studies should explore the underlying processes that affect clinician treatment practices when managing a patient with depression," they continued. "In the meantime, primary care providers should be cautious about undertreating cardiovascular risk factors among patients identified as having depression."

To explore the relationship between depression and clinical inertia, Moise and colleagues examined data from 158 adult patients (average age 65) with uncontrolled hypertension who were treated at two inner-city, academic hospital-based primary care clinics by 27 primary care physicians and one nurse practitioner.

All of the patients were taking at least one blood pressure medication (an average of 2.5) but had a blood pressure above goal -- at least 140/90 mm Hg for most patients, but at least 130/80 mm Hg for patients with diabetes or chronic kidney disease. The average systolic reading was 159 mm Hg at a first visit and 155 mm Hg at a second visit.

Depression was noted in the electronic medical record for 45% of the patients. This group was more likely to experience clinical inertia in response to uncontrolled blood pressure, even after excluding those who had at least one documented home or clinic systolic reading below goal and after adjustment for medication adherence counseling.

The study "is novel because it clearly demonstrates that co-occurrence of depression has a significant impact on the treatment of hypertension," , of the University of California San Francisco, wrote in an accompanying editor's note.

But it's not clear that clinical inertia is always a bad thing, added Covinsky, who is an associate editor of the journal.

"In some cases, clinicians may have thought that their patients' depression was more pressing than their hypertension," he wrote. "Especially if the blood pressure elevation was modest, over the long term, management of the hypertension may be best optimized by first managing depression."

"The study ... demonstrates that we need to think hard about the best management strategies for patients with multiple medical problems," he wrote.

From the American Heart Association:

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