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Doctors less likely to adjust depressed patients' blood pressure drugs

By Shereen Jegtvig

NEW YORK (Reuters Health) - Doctors may be less likely to make medication changes for patients with uncontrolled high blood pressure who are also depressed, according to a new study.

So-called clinical inertia is when doctors don't intensify treatment - upping the dose of current drugs or adding new drugs, for instance - for patients who are not at their goals, in this case for ideal blood pressure.

"I'm not saying that physicians are making the wrong decisions, I'm just saying doctors may be less likely to make changes to your blood pressure medications if you're depressed as opposed to if you're not depressed," Dr. Nathalie Moise told Reuters Health.

Moise led the new study at Columbia University Medical Center in New York City.

She explained that doctors are often overwhelmed by other medical problems these patients face and optimizing their blood pressure control may drop lower on the list of issues to address during any given visit.

Still, the authors caution that doctors should be careful about under-treating high blood pressure and other heart-related problems among patients with depression.

"Physicians and patients alike may not be aware that depression places you at an increased risk for cardiovascular disease," Moise said.

She noted that the American Heart Association recently called for depression to be considered a risk factor for heart disease and other poor outcomes among patients who have had acute coronary syndrome, which includes a heart attack or feeling chest pain without exercising, a condition called unstable angina. That's based on evidence that depression is linked to higher rates of death among those patients.

For their study, Moise and her colleagues examined the medical records of 158 people with uncontrolled high blood pressure seen at one of two inner-city primary care clinics in New York City.

Most patients were women, Hispanic and in their 60s or older. About 45 percent had been diagnosed with depression.

The researchers defined clinical inertia as a lack of changes in medication, referral to a hypertension specialist or intensive evaluation despite high blood pressure that wasn't kept in check by a patient's current drugs.

They reported in JAMA Internal Medicine that people with depression had a 49 percent higher risk of clinical inertia than those who weren't depressed.

Moise said doctors could be assuming that depressed people aren't as good about taking their medication, but that wasn't the case among patients in her study.

It's also possible that depressed patients have a lot of other medical conditions that need to be addressed during any given visit.

"I think awareness is very important and I also think that because depression is associated with worse outcomes and other chronic illnesses such as diabetes, for instance, it would really be interesting to see whether or not we would be able to replicate these findings (among people with other chronic diseases)," Moise said.

"I think that the fact that research like this is being done is very important because it focuses on making sure we can optimize healthcare delivery to people, particularly those at greatest risk for heart disease," Dr. Nieca Goldberg told Reuters Health.

Goldberg is medical director of the Women's Heart Program at NYU Langone Medical Center in New York City. She was not involved in the new study.

She said sometimes patients with high blood pressure stop taking their medication because they don't feel well when they take it, but they don't talk to their doctors about that.

"Another mistake that patients make with hypertension is when they find out their blood pressure is normal they stop taking the medication," she said. "So it's really important to communicate to the patient that taking the medication is the connection with the improvement in blood pressure."

Goldberg said it can be more difficult to reach patients who are depressed. In that case, it's important to engage friends and family members so they can help the doctor help the patient.

She noted that the new study involved mostly Hispanic patients and said it's important to communicate in the language the patient is most comfortable using.

"Most hospitals have translation services to help," she said.

SOURCE: http://bit.ly/1bjKKa8 JAMA Internal Medicine, online March 10, 2014.

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