Now we are sick: labeling and hypertension

Hypertension in the first blood pressure reading and the risk of cardiovascular disease mortality in the general population: findings from the prospective KORA study

BACKGROUND

The risk of cardiovascular disease (CVD) mortality in individuals with an alerting reaction, assessed by hypertension in the first blood pressure (BP) reading but normal BP in further readings, remains unknown in the general population.

METHODS AND RESULTS

In a sample of 11 146 adults (51.5% men and 48.5% women) with a mean age of 47.1 years (SD ± 12.3) from a German population-based cohort, we analyzed risk factors and CVD mortality risk associated with an alerting reaction. An alerting reaction was prevalent in 10.2% of the population and associated with sociodemographic, lifestyle, and somatic CVD risk factors. Within a mean follow-up period of 22.7 years (SD ± 7.05 years; max: 32 years; 253 201 person years), 1420 (12.7%) CVD mortality cases were observed. The CVD mortality rate associated with an alerting reaction was significantly higher than in normotension (64 vs. 32 cases/10 000 person-years), but lower than hypertension (118 cases/10 000 person-years). Correspondingly, the alerting reaction was associated with a 23% higher hazard ratio of CVD mortality than normal blood pressure [hazard ratio 1.23 (95% confidence interval 1.02-1.49), P  = 0.04]. However, adjustment for antihypertensive medication use attenuated this association [1.19 (0.99-1.44), P  = 0.06].

CONCLUSION

The results may warrant monitoring of an alerting reaction as a preventive measure of CVD mortality in untreated individuals with elevated first BP readings, as well as optimized treatment in treated individuals.

Associations between mental health, blood pressure and the development of hypertension

Multiple studies have reported a link between mental health and high blood pressure with mixed or even contradictory findings. Here, we resolve those contradictions and further dissect the cross-sectional and longitudinal relationship between mental health, systolic blood pressure, and hypertension using extensive psychological, medical and neuroimaging data from the UK Biobank. We show that higher systolic blood pressure is associated with fewer depressive symptoms, greater well-being, and lower emotion-related brain activity. Interestingly, impending hypertension is associated with poorer mental health years before HTN is diagnosed. In addition, a stronger baseline association between systolic blood pressure and better mental health was observed in individuals who develop hypertension until follow-up. Overall, our findings offer insights on the complex relationship between mental health, blood pressure, and hypertension, suggesting that-via baroreceptor mechanisms and reinforcement learning-the association of higher blood pressure with better mental health may ultimately contribute to the development of hypertension.

Experience of suffering in patients with hypertension: a qualitative analysis of in-depth interview of patients in a university hospital in Seoul, Republic of Korea

OBJECTIVE

To describe the suffering experienced by patients with hypertension, not only regarding symptoms, but also suffering in a social context.

DESIGN

A qualitative analysis of semi-structured interview data. Interviews were audio-recorded and transcribed verbatim. A descriptive approach was taken by exploring patient accounts and presenting their experiences and perspectives.

SETTING

Cardiology clinic in a university hospital (Samsung Medical Center, Seoul, Republic of Korea).

PARTICIPANTS

Patients with hypertension and without serious comorbidities who had been followed-up at a cardiology clinic of a training university hospital.

RESULTS

Nineteen men and women (male:female=12:7) were interviewed. The mean age was 44 years, and the average hypertension duration was 4 years. All 19 patients reported symptoms allegedly to be associated with hypertension. Anxiety about blood pressure fluctuation and hypertension complications, dislike of antihypertensive medication and associated labelling effect, family stress and refusal to be enrolled in life insurance were commonly found among patients' interviews. Relatively younger (≤50 years of age), actively working patients experienced stigmatisation and discrimination in the workplace.

CONCLUSION

The illness experience of patients with hypertension consists of suffering associated with threatened or damaged self-identity at the individual and social level. Medical professionals should have more awareness of the suffering of these patients to improve the quality of care. An education programme with proper focus on the elements of patients' suffering may help to alleviate it.

Investigating the feasibility and ethical implications of phenotypic screening using stem cell-derived tissue models to detect and manage disease

Stem-cell-derived tissue models generated from sick people are being used to understand human development and disease, drug development, and drug screening. However, it is possible to detect disease phenotypes before a patient displays symptoms, allowing for their use as a disease screening tool. This raises numerous issues, some of which can be addressed using similar approaches from genetic screenings, while others are unique. One issue is the relationship between disease disposition, biomarker detection, and patient symptoms and how tissue models could be used to define disease. Other issues include decisions of when to screen, what diseases to screen for, and what treatment options should be offered.

Comparability of a Blood-Pressure-Monitoring Smartphone Application with Conventional Measurements-A Pilot Study

(1) Background: New cuffless technologies attempting blood-pressure measurements (BPM) offer possibilities to improve hypertension awareness and control. The aim of this study was to compare a smartphone application (app)-based algorithm with office BPM (OBPM). (2) Methods: We included consecutive patients with an indication for ambulatory BPM. The smartphone app (RIVA digital) acquired the pulse wave in the fingers’ arterial bed using the phone’s camera and estimated BP based on photoplethysmographic (PPG) waveforms. Measurements were alternatingly taken with an oscillometric cuff-based device and smartphone BPM (AppBP) on two consecutive days. AppBP were calibrated to the first OBPM. Each AppBP was compared to its CuffBP (mean of the previous/following OBPM). (3) Results: 50 participants were included, resulting in 50 AppBP values on Day 1 and 33 on Day 2 after exclusion of 225 AppBP due to insufficient quality. The mean ± SD of the differences between AppBP and CuffBP was 0.7 ± 9.4/1.0 ± 4.5 mmHg (p-value 0.739/0.201) on Day 1 and 2.6 ± 8.2/1.3 ± 4.1 mmHg (p-value 0.106/0.091) on Day 2 for systolic/diastolic values, respectively. There were no significant differences between the deviations on Day 1 and Day 2 (p-value 0.297/0.533 for systolic/diastolic values). Overall, there were 10 (12%) systolic measurement pairs differing by >15 mmHg. (4) Conclusions: In this pilot evaluation, the RIVA Digital app shows promising results when compared to oscillometric cuff-based measurements, especially regarding diastolic values. Its differences between AppBP−CuffBP have a good stability one day after calibration. Before clinical use, signal acquisition needs improvement and the algorithm needs to undergo formal validation against a gold-standard BPM method.

Individuals' Experiences of Being Screened for Hypertension in Dental Health Care - "No Big Deal"

BACKGROUND

Hypertension is a common disease globally that accounts for the highest number of lost healthy life years and strongly associated with sequelae such as stroke and myocardial infarction. Early detection of individuals with high blood pressure can be ensured by screening also those who consider themselves "healthy". Screening has both positive and negative effects where a diagnosis of hypertension can lead to worry about the future. These effects need to be elucidated in order to balance between benefit and harm before screening is introduced. The aim of the study was to describe individuals' experiences of being screened for hypertension in dental health care.

METHODS

Data from individual semi-structured interviews, with twenty participants screened for cardiovascular risk factors in connection with dental examination and aged 55-80 years, were analysed by means of qualitative content analysis.

RESULTS

The results describe individuals' experiences of blood pressure screening in dental health care by means of the following theme: "No big deal" based on two categories: "Convenient way of measuring blood pressure" and "Increased awareness of health".

CONCLUSION

The overall message from the interviews was that having one's blood pressure measured when visiting the dentist was convenient, easy and "No big deal". Blood pressure screening did not create any major concerns and contributed to an increased awareness of health.

The impact of antihypertensive treatment initiation on health-related quality of life and cardiovascular risk factor levels: a prospective, interventional study

Background

Effective prevention and treatment of hypertension is one of the most potential interventions in terms of preventing cardiovascular deaths and disabilities. However, the treatment control is often poor. This may be partly explained by the impact of hypertension diagnoses and treatment on health-related quality of life. Quality of life is also an important outcome for a hypertensive patient. Most of the previous studies on health-related quality of life in hypertension have concentrated on patients with treated hypertension and less is known about the initiation of medication and the first treatment year.

Methods

In this interventional study, we followed 111 primary care patients with newly diagnosed hypertension in real world primary care setting in Finland for 12 months.

Results

We found significant decrease in both systolic and diastolic blood pressure levels, as well as modest decrease in cholesterol levels and alcohol consumption. However, the health-related quality of life also slightly deteriorated during the first treatment year.

Conclusions

Our study shows that the initiation of hypertension treatment results in cardiovascular risk decrease among newly diagnosed Finnish hypertensive patients, but it is accompanied by small negative impact on health-related quality of life. However, the deterioration in health-related quality of life is of small magnitude and earlier research demonstrates several measures to enhance treatment and avoid impairment in health-related quality of life.

Trial registration ClinicalTrials NCT02377960 (Date of registration: 04/03/2015).

What is in a Name? It is Time to Retire the Term "Asian Blepharoplasty"

PURPOSE

This perspective explores the term "Asian blepharoplasty" and its socioemotional meaning to some patients.

METHODS

N/A.

RESULTS

Words have power. The term "Asian blepharoplasty" makes some patients uncomfortable. To our knowledge, it is the only medical descriptor that uses race.

CONCLUSIONS

The use of the term "Asian Blepharoplasty" may unwittingly make patients uncomfortable and pathologize Asian features. Therefore, we suggest replacing the term "Asian Blepharoplasty" with "Double Eyelid Surgery." For the subset of procedures which do not include the creation of an eyelid crease, "Blepharoplasty" is appropriate.

Benefits and Harms of Hypertension and High-Normal Labels: A Randomized Experiment

BACKGROUND

Recent US guidelines lowered the threshold for diagnosing hypertension while other international guidelines use alternative/no labels for the same group (blood pressure [BP], <140/90 mm Hg). We investigated potential benefits and harms of hypertension and high-normal BP labels, compared with control, among people at lower risk of cardiovascular disease.

METHODS

We conducted a randomized experiment using a national sample of Australians (n=1318) 40 to 50 years of age recruited from an online panel. Participants were randomized to 1 of 3 hypothetical scenarios where a general practitioner told them they had a BP reading of 135/85 mm Hg, using either hypertension/high-normal BP/control (general BP description) labels. Participants were then randomized to receive an additional absolute risk description or nothing. Primary outcomes were willingness to change diet and worry. Secondary outcomes included exercise/medication intentions, risk perceptions, and other psychosocial outcomes.

RESULTS

There was no difference in willingness to change diet across label groups (P=0.22). The hypertension label (mean difference [MD], 0.74 [95% CI, 0.41-1.06]; P<0.001) and high-normal BP label (MD, 0.45 [95% CI, 0.12-0.78]; P=0.008) had increased worry about cardiovascular disease risk compared with control. There was no evidence that either label increased willingness to exercise (P=0.80). However, the hypertension (MD, 0.20 [95% CI, 0.04-0.36]; P=0.014), but not high-normal label (MD, 0.06 [95% CI, -0.10 to 0.21]; P=0.49), increased willingness to accept BP-lowering medication compared with control. Psychosocial differences including lower control, higher risk perceptions, and more negative affect were found for the hypertension and high-normal labels compared with control. Providing absolute risk information decreased willingness to change diet (MD, 0.25 [95% CI, 0.10-0.41]; P=0.001) and increase exercise (MD, 0.28 [95% CI, 0.11-0.45]; P=0.001) in the hypertension group.

CONCLUSIONS

Neither hypertension nor high-normal labels motivated participants to change their diet or exercise more than control, but both labels had adverse psychosocial outcomes. Labeling people with systolic BP of 130 to 140 mm Hg, who are otherwise at low risk of cardiovascular disease, may cause harms that outweigh benefit. Registration: URL: http://www.anzctr.org.au/; Unique identifier: ACTRN12618001700224.

How Should We Measure and Deal with Office Blood Pressure in 2021?

Arterial hypertension is a major risk factor for cardiovascular disease worldwide. Office blood pressure measurements (OBPMs) are still recommended for diagnosis and follow-up by all major guidelines; however, the recommended procedures differ significantly. In analogy, major outcome studies usually apply OBPMs, again, with a variety of procedures. This variety of OBPM procedures complicates the comparability between studies and challenges daily clinical practice. In this narrative review, we compile the most recent recommendations for office blood pressure measurement together with the major limitations and strategies and how these could be overcome.

Association of hypertension cut-off values with 10-year cardiovascular mortality and clinical consequences: a real-world perspective from the prospective MONICA/KORA study

AIMS

To investigate the clinical value of a lower blood pressure (BP) cut-off for Stage 1 (S1) hypertension (130-139 mmHg systolic or 80-89 mmHg diastolic) in comparison to the currently established Stage 2 (S2) cut-off (≥140/90 mmHg) in a population-based cohort.

METHODS AND RESULTS

We assessed the hypertension prevalence and associated cardiovascular disease (CVD) events in a sample of 11 603 participants (52% men, 48% women; mean 47.6 years) from the MONICA/KORA prospective study. The implementation of the new S1 cut-off increased the prevalence of hypertension from 34% to 63%. Only 24% of S2 hypertension patients were under treatment. Within a follow-up period of 10 years (70 148 person-years), 370 fatal CVD events were observed. The adjusted CVD-specific mortality rate per 1000 persons was 1.61 [95% confidence interval (CI) 1.10-2.25] cases in S2 and 1.07 (95% CI 0.71-1.64) cases in S1 hypertension in comparison to normal BP. Cox proportional regression models were significant for the association of S2 and CVD mortality (1.54, 95% CI 1.04-2.28, P = 0.03), also in the presence of competing risks (1.47, P = 0.05). However, statistical significance for S1 hypertension was not reached (0.93, 95% CI 0.61-1.44, P = 0.76). Among S2 participants, there was a significantly higher prevalence of depressed-mood in treated patients (47%) in comparison to non-treated patients (33%) (P < 0.0001).

CONCLUSION

The lower BP cut-off substantially increased hypertension prevalence, while capturing a population with lower CVD mortality. Additionally, participants under treatment were more likely to have depressed-mood in comparison to non-treated participants, which might reflect a negative labelling effect.

The clinical significance of isolated diastolic hypertension

The prevalence of isolated diastolic hypertension (IDH) has been increased in hypertensive subjects with the new 2017 ACC/AHA blood pressure treatment guidelines to 6.5% from 1.3% by the JNC-7 guidelines. However, its clinical significance as a cause of adverse cardiovascular (CV) events especially in older subjects has been debated by several investigators, who have demonstrated no adverse CV effects of untreated IDH, but not by others. It is also more common in the young subjects who are at low CV risk and quite rare in the older subjects, who are at increased CV risk. Treatment of IDH in the older subjects could increase the CV complications due to a J-curve effect and, in addition, could increase the incidence of stroke from further lowering the normal systolic blood pressure (SBP). Very low SBP and DBP cannot be sustained by the cerebral blood flow autoregulation and could lead to cerebral ischemia. In order to get a better perspective of the current status of the treatment of IDH, a review of the English language literature of the available studies was conducted and 12 papers with pertinent information were retrieved. The analysis of results from these studies suggests that IDH is associated with adverse CV events in younger persons and it should be treated. In contrast, the prevalence of IDH is low in older subjects and is not associated with adverse CV events in the majority of cases. Thus, its further lowering should be avoided to prevent further decrease in normal SBP and prevent the onset of adverse CV events. However, the decision to treat IDH in older subjects should be individualized.

Hypertension, socioeconomic status and depressive symptoms in Chinese middle-aged and older adults: Findings from the China health and retirement longitudinal study

BACKGROUND

This study aimed to examine the effect of diagnosed hypertension on depressive symptoms and socioeconomic status (SES) as moderator in the effect in middle-aged and older adults in China.

METHODS

We used data from the nationally representative survey of China Health and Retirement Longitudinal Study, including 6273 participants free from depressive symptoms at baseline in 2011-12. We assessed the depressive symptoms based on the 10-item Center for Epidemiological Studies Depression scale. We conducted Cox proportional hazards regression models to examine the effect of baseline diagnosed hypertension status on the subsequent depressive symptoms in 2011-15 with the report of Hazards ratios (HRs).

RESULTS

The diagnosed hypertensive participants were more likely to have depressive symptoms than non-hypertensive peers (HR = 1.12, 95% CI: 1.02-1.23) after adjusted for controlled variables. The effect only occurred in the group of low SES, with rural residency (HR = 1.13, 95% CI: 1.02-1.26), below-average household income (HR = 1.14, 95% CI: 1.02-1.26) and primary school or below educational attainment (HR = 1.12, 95% CI: 1.00-1.25).

LIMITATIONS

Measures of the onset or duration of hypertension were not included, which may modify the estimated effects on depressive symptoms.

CONCLUSIONS

Diagnosed hypertension is a chronic stressor leading to depressive disorders, and the responses to this stressor merely occurred among the low socioeconomic individuals. Our findings underscored the importance of examining the connection between mental and physical health in the context of aging and shed lights on the action to developing strategies for detection and management of hypertension that could cause psychological stress, which may contribute to fighting against depressive symptoms, especially in the low SES population.

The new US and European guidelines in hypertension: A multi-dimensional analysis

The Systolic Blood Pressure Intervention Trial (SPRINT) compared the clinical outcomes between target systolic blood pressure (SBP) levels between 140 and 120 mmHg or lower. Both,the 2017 ACC/AHA and the 2018 ESC/ESH guidelines in hypertension are derived from the SPRINT trial and advise initiation and/or intensification of treatment at lower blood pressure thresholds. The ACC/AHA guidance supersedes the 2014 Eight Joint National Committee guideline (JNC-8) which advised initiation of treatment when the BP was 140/90 mmHg or higher; in adults 60 years or over, the target was 150/90 mmHg. Compared to JNC-8, the new guidelines lower the SBP target by 10 mmHg in patients under age of 60 years, and by 20 mmHg in the elderly. We performed a qualitative multi-dimensional analysis in order to answer two key questions: will the new guidelines deliver the stated benefits? and, will translation to the clinic be simple, risk-free, and affordable? A major investment by national healthcare administrations will be necessary for the initiation and support of this program but this decision can only be justified by a valid expectation of clinical benefit. At this time, a definitive answer is not available and a "wait and see" attitude appears appropriate and reasonable. In the interim, efforts are best directed to the immediate problem of untreated hypertension worldwide.

Acceptability and psychological impact of out-of-office monitoring to diagnose hypertension: an evaluation of survey data from primary care patients

BACKGROUND

Out-of-office blood pressure (BP) is recommended for diagnosing hypertension in primary care due to its increased accuracy compared to office BP. Moreover, being diagnosed as hypertensive has previously been linked to lower wellbeing. There is limited evidence regarding the acceptability of out-of-office BP and its impact on wellbeing.

AIM

To assess the acceptability and psychological impact of out-of-office monitoring in people with suspected hypertension.

DESIGN AND SETTING

A pre- and post-evaluation of participants with elevated (≥130 mmHg) systolic BP, assessing the psychological impact of 28 days of self-monitoring followed by ambulatory BP monitoring for 24 hours.

METHOD

Participants completed standardised psychological measures pre- and post-monitoring, and a validated acceptability scale post-monitoring. Descriptive data were compared using χ² tests and binary logistic regression. Pre- and post-monitoring comparisons were made using the paired t-test and Wilcoxon signed rank test.

RESULTS

Out-of-office BP monitoring had no impact on depression and anxiety status in 93% and 85% of participants, respectively. Self-monitoring was more acceptable than ambulatory monitoring (n = 183, median 2.4, interquartile range [IQR] 1.9-3.1 versus median 3.2, IQR 2.7-3.7, P<0.01). When asked directly, 48/183 participants (26%, 95% confidence interval [CI] = 20 to 33%) reported that self-monitoring made them anxious, and 55/183 (30%, 95% CI = 24 to 37%) reported that ambulatory monitoring made them anxious.

CONCLUSION

Out-of-office monitoring for hypertension diagnosis does not appear to be harmful. However, health professionals should be aware that in some patients it induces feelings of anxiety, and self-monitoring may be preferable to ambulatory monitoring.

Potential Cardiovascular Disease Events Prevented with Adoption of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline

BACKGROUND

Over 10 years, achieving and maintaining 2017 ACC/AHA guideline goals could prevent 3.0 million (UR, 1.1-5.1 million), 0.5 million (UR, 0.2-0.7 million), and 1.4 million (UR, 0.6-2.0 million) cardiovascular disease (CVD) events compared with maintaining current blood pressure (BP) levels, achieving 2003 Seventh Joint National Committee Report goals, and achieving 2014 Eighth Joint National Committee goals, respectively. We estimated the number of cardiovascular disease events prevented and treatment-related serious adverse events incurred over 10 years among US adults with hypertension by achieving 2017 ACC/AHA guideline-recommended BP goals compared with (1) current BP levels, (2) achieving 2003 Seventh Joint National Committee Report BP goals, and (3) achieving 2014 Eighth Joint National Committee panel member report BP goals.

METHODS

US adults aged ≥45 years with an indication for BP treatment were grouped according to recommendations for antihypertensive drug therapy in the 2017 ACC/AHA guideline, 2003 Seventh Joint National Committee Report, and 2014 Eighth Joint National Committee. Population sizes were estimated from the 2011 to 2014 National Health and Nutrition Examination Surveys. Rates for fatal and nonfatal CVD events (stroke, coronary heart disease, or heart failure) were estimated from the REGARDS (REasons for Geographic And Racial Differences in Stroke) study, weighted to the US population. CVD risk reductions with treatment to BP goals and risk for serious adverse events were obtained from meta-analyses of BP-lowering trials. CVD events prevented and treatment-related nonfatal serious adverse events over 10 years were calculated. Uncertainty surrounding main data inputs was expressed in uncertainty ranges (UR).

RESULTS

Over ten years, achieving and maintaining 2017 ACC/AHA guideline goals compared with current BP levels, achieving 2003 Seventh Joint National Committee Report goals, or achieving 2014 Eighth Joint National Committee goals could prevent 3.0 million (UR, 1.1-5.1 million), 0.5 million (UR, 0.2-0.7 million), or 1.4 million (UR, 0.6-2.0 million) CVD events, respectively. Compared with current BP levels, achieving and maintaining 2017 goals could prevent 71.9 (UR, 26.6-122.3) CVD events per 1000 treated. Achieving 2017 guideline BP goals compared with current BP levels could also lead to nearly 3.3 million more serious adverse events over 10 years (UR, 2.2-4.4 million).

CONCLUSIONS

Achieving and maintaining 2017 ACC/AHA BP goals could prevent a greater number of CVD events than achieving 2003 Seventh Joint National Committee Report or 2014 Eighth Joint National Committee BP goals but could also lead to more serious adverse events.

Arterial stiffness and subclinical aortic damage of reclassified subjects as stage 1 hypertension according to the new 2017 ACC/AHA blood pressure guidelines

Background: The 2017 ACC/AHA blood pressure (BP) guidelines generated controversies due to the new proposed BP cut-off values defining hypertension. We aimed to assess aortic stiffness of subjects who are reclassified as stage 1 hypertensive according to the new guidelines and compare them with the subjects of "elevated BP" category. Patients and methods. Data from the "Corinthia" study, an observational, cross-sectional survey of 2,043 participants were analyzed. Subjects were classified into 4 groups: group A: systolic pressure (SBP) 120-129 and diastolic pressure (DBP) < 80 mmHg, group B: SBP 130-139 or DBP 80-89 mmHg, group B1: SBP 130-139 and DBP < 80 mmHg and group B2: SBP 130-139 and DBP 80-89 mmHg. Aortic stiffness was assessed by carotid-to-femoral pulse wave velocity (PWV). A value of PWV > 10m/s was consider indicative of asymptomatic organ damage while values of PWV exceeded the 90 % percentile for each age group were consider as abnormal. Results: Groups B, B1 and B2 have significantly increased PWV compared to group A, independently from age and other risk factors (PWV: 9.2 ± 2.8 vs 9.4 ± 2.7 vs 8.6 ± 2.5 vs 8.1 ± 2.3 m/s, p < 0.01, respectively). The prevalence of PWV > 10 m/s and abnormal PWV values in group A was significantly lower than the corresponding prevalence in randomly selected, age-matched subjects from group B (13.5 % vs 24.4 %, p = 0.027 and 5.6 % vs 14.2 %, p = 0.022, respectively). Conclusions: The reclassified subjects as stage 1 hypertensive by the new guidelines have a significantly increased aortic stiffness and greater prevalence in asymptomatic aortic damage compared to subjects with elevated BP. This finding may indirectly explain the increased cardiovascular risk of this group.

Hypertension

Systemic arterial hypertension is the most important modifiable risk factor for all-cause morbidity and mortality worldwide and is associated with an increased risk of cardiovascular disease (CVD). Fewer than half of those with hypertension are aware of their condition, and many others are aware but not treated or inadequately treated, although successful treatment of hypertension reduces the global burden of disease and mortality. The aetiology of hypertension involves the complex interplay of environmental and pathophysiological factors that affect multiple systems, as well as genetic predisposition. The evaluation of patients with hypertension includes accurate standardized blood pressure (BP) measurement, assessment of the patients' predicted risk of atherosclerotic CVD and evidence of target-organ damage, and detection of secondary causes of hypertension and presence of comorbidities (such as CVD and kidney disease). Lifestyle changes, including dietary modifications and increased physical activity, are effective in lowering BP and preventing hypertension and its CVD sequelae. Pharmacological therapy is very effective in lowering BP and in preventing CVD outcomes in most patients; first-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, dihydropyridine calcium-channel blockers and thiazide diuretics.

How medical technologies shape the experience of illness

In this article we explore how diagnostic and therapeutic technologies shape the lived experiences of illness for patients. By analysing a wide range of examples, we identify six ways that technology can (trans)form the experience of illness (and health). First, technology may create awareness of disease by revealing asymptomatic signs or markers (imaging techniques, blood tests). Second, the technology can reveal risk factors for developing diseases (e.g., high blood pressure or genetic tests that reveal risks of falling ill in the future). Third, the technology can affect and change an already present illness experience (e.g., the way blood sugar measurement affects the perceived symptoms of diabetes). Fourth, therapeutic technologies may redefine our experiences of a certain condition as diseased rather than unfortunate (e.g. assisted reproductive technologies or symptom based diagnoses in psychiatry). Fifth, technology influences illness experiences through altering social-cultural norms and values regarding various diagnoses. Sixth, technology influences and changes our experiences of being healthy in contrast and relation to being diseased and ill. This typology of how technology forms illness and related conditions calls for reflection regarding the phenomenology of technology and health. How are medical technologies and their outcomes perceived and understood by patients? The phenomenological way of approaching illness as a lived, bodily being-in-the-world is an important approach for better understanding and evaluating the effects that medical technologies may have on our health, not only in defining, diagnosing, or treating diseases, but also in making us feel more vulnerable and less healthy in different regards.

Influence of the disease label 'polycystic ovary syndrome' on intention to have an ultrasound and psychosocial outcomes: a randomised online study in young women

Study question

Does the disease label 'polycystic ovary syndrome' (PCOS) have an impact on desire for medical testing and psychosocial outcomes?

Summary answer

When given the disease label PCOS in a hypothetical scenario, participants had higher intention to have an ultrasound, perceived the condition to be more severe and had lower self-esteem than those not given the disease label.

What is known already

Widening diagnostic criteria and improved imaging sensitivity have increased the number of reproductive-aged women diagnosed with PCOS from 4% to 8% to up to 21%. The uncertain clinical benefit of knowing this diagnosis needs to be weighed against the potential for poor psychological outcomes in women labelled with PCOS.

Study design, size, duration

This experimental online study randomised 181 young women to receive one of four hypothetical scenarios of a doctor's visit in a 2 (PCOS disease label versus no disease label) x 2 (information about unreliability of ultrasounds in clarifying diagnosis versus no information) design.

Participants/materials, setting, methods

Participants were university students (mean age: 19.4). After presenting the scenario, intention to have an ultrasound, negative affect, self-esteem, perceived severity of condition, credibility of the doctor and interest in a second opinion were measured. Participants were then presented with a second scenario, where the possibility of PCOS overdiagnosis was mentioned. Change in intention and perceived severity were then measured.

Main results and the role of chance

Participants given the PCOS label had significantly higher intention to have an ultrasound (mean = 6.62 versus mean = 5.76, P = 0.033, 95% CI(difference) = 0.069-1.599), perceived the condition to be more severe (17.17 versus 15.82, P = 0.019, 95% CI(difference) = 0.229-2.479) and had lower self-esteem (25.86 versus 27.56, P = 0.031, 95% CI(difference) = -3.187 to -0.157). After receiving overdiagnosis information, both intention and perceived severity decreased, regardless of condition (both P < 0.001).

Limitations, reasons for caution

This study used hypothetical scenarios; it is likely that for women facing a real diagnosis of PCOS, outcomes would be more affected than in the current study. The hypothetical design, however, allowed the symptoms and risks of PCOS to be held constant across conditions, the impact on intention and psychosocial outcomes directly attributable to the effect of the disease label.

Wider implications of the findings

These findings demonstrate the potential negative consequences of PCOS labelling. It is crucial we consider the impact of the label before diagnosing more women with PCOS when clinical benefit of this diagnosis is uncertain.

Study funding/competing interest(s)

This paper was written with support from a NHMRC grant awarded to the Screening and Test Evaluation Program. J.J. is supported by an NHMRC Early Career Fellowship. K.M. is supported by an NHMRC Career Development Fellowship. The authors declare that no competing interests exist.

Trial registration number

ACTRN12617000111370.

Trial registration date

20/01/2017.

Date of first patient's enrolment

01/06/2015.

Diagnosis, narrative identity, and asymptomatic disease

An increasing number of patients receive diagnoses of disease without having any symptoms. These include diseases detected through screening programs, as incidental findings from unrelated investigations, or via routine checks of various biological variables like blood pressure or cholesterol. In this article, we draw on narrative identity theory to examine how the process of making sense of being diagnosed with asymptomatic disease can trigger certain overlooked forms of harm for patients. We show that the experience of asymptomatic disease can involve 'mismatches' between one's beliefs about one's health status on the one hand, and bodily sensations or past experience on the other. Patients' attempts to integrate these diagnoses into their self-narratives often involve either forming inaccurate beliefs about bodily sensations and/or past experience, or coming to believe that feelings and experience do not necessarily track or predict health status, leading to an ongoing sense of vulnerability to ill health. These resulting alterations in self-understanding can sometimes be considered harmful, in view of their implications for ascriptions of responsibility and ongoing anxiety.

Words do matter: a systematic review on how different terminology for the same condition influences management preferences

OBJECTIVES

Changing terminology for low-risk, screen-detected conditions has now been recommended by several expert groups in order to prevent overdiagnosis and reduce the associated harms of overtreatment. However, the effect of terminology on patients' preferences for management is not well understood. This review aims to synthesise existing studies on terminology and its impact on management decision making.

DESIGN

Systematic review.

METHODS

Studies were included that compared two or more terminologies to describe the same condition and measured the effect on treatment or management preferences and/or choices. Studies were identified via database searches from inception to April 2017, and from reference lists. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias of included studies.

RESULTS

Of the 1399 titles identified, seven studies, all of which included hypothetical scenarios, met the inclusion criteria. Six studies were quantitative and one was qualitative. Six of the studies were of high quality. Studies covered a diverse range of conditions: ductal carcinoma in situ (3), gastro-oesophageal reflux disease (1), conjunctivitis (1), polycystic ovary syndrome (1) and a bony fracture (1). The terminologies compared in each study varied based on the condition assessed. Based on a narrative synthesis of the data, when a more medicalised or precise term was used to describe the condition, it generally resulted in a shift in preference towards more invasive managements, and/or higher ratings of anxiety and perceived severity of the condition.

CONCLUSIONS

Different terminology given for the same condition influenced management preferences and psychological outcomes in a consistent pattern in these studies. Changing the terminology may be one strategy to reduce patient preferences for aggressive management responses to low-risk conditions.

TRIAL REGISTRATION NUMBER

PROSPERO: CRD42016035643.

Defining disease in the context of overdiagnosis

Recently, concerns have been raised about the phenomenon of 'overdiagnosis', the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises questions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue that 'disease' should be considered a vague concept with a non-classical structure. On this view, overdiagnosed cases are 'borderline' cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a précising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient.

Getting clearer on overdiagnosis

Overdiagnosis refers to diagnosis that does not benefit patients because the diagnosed condition is not a harmful disease in those individuals. Overdiagnosis has been identified as a problem in cancer screening, diseases such as chronic kidney disease and diabetes, and a range of mental illnesses including depression and attention deficit hyperactivity disorder. In this paper, we describe overdiagnosis, investigate reasons why it occurs, and propose two different types. Misclassification overdiagnosis arises because the diagnostic threshold for the disease in question has been set at a level where many people without harmful disease are nonetheless diagnosed. We illustrate misclassification overdiagnosis using the example of chronic kidney disease. Misclassification occurs in diseases diagnosed using biomarkers or based on patient reported phenomena. Maldetection overdiagnosis arises because, at the time the diagnosis is made and despite the presence of a 'gold standard' diagnostic test, it is not possible to discriminate between harmful and non-harmful cases of the index disease. We illustrate maldetection overdiagnosis using the example of thyroid cancer. While there is some overlap between misclassification and maldetection overdiagnosis, this conceptual analysis helps to clarify the phenomenon of overdiagnosis and is a necessary first step in developing strategies to address the problem.

The relationship between affective symptoms and hypertension-role of the labelling effect: the 1946 British birth cohort

OBJECTIVES

To investigate the association between repeated measures of affective symptoms collected over 2 decades and hypertension (clinically ascertained or self-report); to test whether, among people with hypertension, affective symptoms are associated with awareness of hypertension, and to evaluate the longitudinal effects of the label of hypertension on affective symptoms.

METHODS

Multivariable logistic regression, accounting for confounders and mediators, were used to test the aforementioned associations in 1683 participants from a national British cohort.

RESULTS

Weak evidence of a cumulative impact of affective symptoms across adulthood on self-reported hypertension at age 60-64 years was observed (OR 1.40 (95% CI 1.10 to 1.78) and 1.19 (0.79 to 1.80) for symptoms at 1-2 time points and at 3-4 time points vs no symptoms, respectively). Study members with affective symptoms in recent times were more likely to have self-reported hypertension at age 60-64 years than those without symptoms (OR 1.47 (1.10 to 1.96)). Similar results were observed for awareness of hypertension (OR 2.00 (1.30 to 3.06)). Conversely, no associations were found with clinically ascertained hypertension. The act of labelling someone as hypertensive at age 53 years was associated with affective symptoms at age 60-64 years, independently of antihypertensive treatment and affective symptoms at the time of the diagnosis (OR 2.40 (1.32 to 4.36)).

CONCLUSIONS

Our findings suggest that elevated risk of hypertension in participants with affective symptoms might be explained by awareness of hypertension and by exposure to medical attention, though not by a direct effect of affective symptoms on blood pressure. Conversely, long-term psychological consequences of the label of hypertension are observed.

Psychological consequences of screening for cardiovascular risk factors in an un-selected general population: Results from the Inter99 randomised intervention study

Background: Concerns that general health checks, including screening for risk factors to ischemic heart disease (IHD), have negative psychological consequences seem widely unfounded; however, previous studies are only based on self-reports from participants. Aim: To investigate if risk factor screening in healthy adults leads to mental distress in the study population, independent of participation. Methods: The Inter99 study (1999 – 2006) was a randomised intervention in the general population, aiming to prevent IHD by a healthier lifestyle. We included the whole study population, independent of participation ( n = 60,915). We merged data with information on the use of psychotropic medication and/or hospitalisation due to psychiatric diagnoses, as retrieved from national registers in Denmark, 4 years before and 5 years after the study began. We conducted analyses using generalised estimating equations. Results: There was no significant difference between the intervention and control groups in their use of antipsychotics, hypnotics/sedatives, antidepressants or anxiolytics. As regards admission to the hospital with mental disorders, no significant difference was seen. These findings were true based on a yearly basis, and when investigating both short-term and a long-term effects of the intervention. There was no interaction with socioeconomic status. Of the 918 persons with a psychiatric diagnosis before the study start, 303 (33%) were re-admitted in the intervention period. Pre-screening of psychological status did not influence the psychological impact of screening. Conclusions: This large, randomised intervention study supports that screening for risk factors to IHD does not increase mental distress, not even in the mentally or socioeconomically most vulnerable persons. This study included the whole Inter99 study population (not only study participants).

Prevalence and costs of treating uncomplicated stage 1 hypertension in primary care: a cross-sectional analysis

BACKGROUND

Treatment for uncomplicated stage 1 hypertension is recommended in most international guidelines but there is little evidence to indicate that therapy is beneficial.

AIM

To estimate the prevalence of this condition in an untreated population and the potential costs of initiating therapy in such patients.

DESIGN AND SETTING

Cross-sectional study of anonymised patient records in 19 general practices in the West Midlands, UK.

METHOD

Data relating to patient demographics, existing cardiovascular disease (CVD), and risk factors (blood pressure and cholesterol) were extracted from patient records. Patients with a blood pressure of 140/90-159/99 mmHg, no CVD, and <20% 10-year cardiovascular risk were classified as having uncomplicated stage 1 hypertension. Missing data were imputed. The prevalence of untreated, uncomplicated stage 1 hypertension was estimated using descriptive statistics and extrapolated using national data. The cost of achieving blood pressure control in this population was examined in a cost-impact analysis using published costs from previous studies.

RESULTS

Of the 34 975 patients (aged 40-74 years) in this study, untreated, uncomplicated stage 1 hypertension was present in 2867 individuals (8.2%, 95% confidence interval [CI] = 7.9 to 8.5). This is equivalent to 1 892 519 patients in England and Wales, for whom the additional cost of controlling blood pressure, according to guidelines, was estimated at £106-229 million per annum, depending on the health professional delivering care.

CONCLUSION

Untreated, uncomplicated stage 1 hypertension is relatively common, affecting 1 in 12 patients aged 40-74 years in primary care. Current international guidelines and pay-for-performance targets, if followed, will incur significant costs for a patient benefit that is debatable.

Race and Ethnic Differences in the Associations between Cardiovascular Diseases, Anxiety, and Depression in the United States

INTRODUCTION

Although cardiovascular diseases and psychiatric disorders are linked, it is not yet known if such links are independent of comorbid medical diseases and if these associations depend on race and ethnicity. This study aimed to determine if the associations between cardiovascular diseases with general anxiety disorder (GAD) and major depressive episode (MDE) are independent of comorbid medical diseases and if these links differ among African Americans, Caribbean Blacks, and Non-Hispanic Whites.

METHODS

This cross-sectional study enrolled African American, Caribbean Black, and Non-Hispanic White adults who had participated in the National Survey of American Life (NSAL), 2001 - 2003. Data on socioeconomics (age, sex, and education level) were collected. Self-reported physician diagnosed cardiovascular diseases (heart disease, atherosclerosis, hypertension, and stroke) and chronic medical conditions (peptic ulcer, cancer, diabetes, liver disease, kidney disease, asthma, other chronic respiratory diseases, sickle cell anemia, and glaucoma) were measured. The 12month GAD and MDE were measured using the Composite International Diagnostic Interview (CIDI). Logistic regressions were fitted to data to determine if the associations between cardiovascular diseases and 12-month GAD and 12-month MDE are independent of socio-economic status and comorbid chronic medical diseases across race and ethnic groups.

RESULTS

Above and beyond other medical conditions, heart disease and atherosclerosis were associated with 12-month GAD among Caribbean Blacks, but not African Americans or non-Hispanic Whites. Hypertension was associated with 12-month MDE among African Americans, and heart disease was associated with 12-month MDE among Caribbean Blacks. None of the cardiovascular diseases were associated with 12-month MDE among non-Hispanic Whites, while all the other medical conditions were controlled.

CONCLUSION

Our study showed race and ethnicity may be associated with specific patterns of comorbidity between cardiovascular diseases and 12month MDE and GAD. By other words, the link between psychiatric disorders and cardiovascular diseases may depend on race and ethnicity. More research is needed to explore the behavioral and mental health profile of individuals with heart disease based on race and ethnicity. Race and ethnicity should inform mental health evaluation of patients with cardiovascular diseases.

Chronic Kidney Disease, Anxiety and Depression among American Blacks; Does Ethnicity Matter?

INTRODUCTION

Chronic kidney disease (CKD) is known to be associated with deterioration of mental health. However, it is clear that this link is over and beyond the effects of socio-economic factors and other medical conditions. This study had two aims: 1) to compare the association between CKD and general anxiety disorder (GAD) among the two major ethnic groups of American Blacks (e.g. African Americans and Caribbean Blacks), and 2) to compare the association between CKD and major depressive episode (MDE) between African Americans and Caribbean Blacks.

METHODS

We analyzed data from African Americans and Caribbean Blacks who participated in the National Survey of American Life (NSAL). Self-reported physician diagnosis of CKD was the independent variable. Outcomes were 12- month GAD and MDE measured by the World Mental Health Composite International Diagnostic Interview (CIDI), a fully structured diagnostic interview. Ethnic-specific logistic regressions were used to determine the associations between CKD and 12- month GAD and MDE, after controlling for the effects of age, sex, educational level, and 13 other medical conditions.

RESULTS

Although CKD was positively associated with GAD and MDE in bivariate analysis, this association did not remain statistically significant in the multivariate analysis which controlled for socio-economic factors and other medical conditions. The study suggested that the main confounders for the association between CKD, GAD, and MDE vary based on ethnicity. For instance, the chronic medical condition that may play the role of confounder for the association between CKD and 12-month GAD among African Americans and Caribbean Blacks might be hypertension and heart disease, respectively.

CONCLUSION

Possible confounders of the associations between CKD and GAD and MDE among American Blacks vary by ethnicity. Further research is needed to determine the links between different types of CKD and poor mental health among American Blacks. Consideration of ethnicity might be important in evaluation and treatment of mental health problems among Black patients with CKD.

The comorbidity of hypertension and psychological distress: a study of nine countries in the former Soviet Union

BACKGROUND

Mental health problems in those with physical ailments are often overlooked, especially in the former Soviet Union (fSU) where this comorbidity has received little attention. Our study examines the comorbidity of psychological distress and hypertension in the fSU.

METHODS

Nationally representative household survey data from Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2001 and 2010 were analysed to compare the levels of psychological distress in people with and without self-reported hypertension. Multivariate regression analysed determinants of psychological distress in hypertensive respondents, and prevalence rate ratios were calculated to compare the change in distress between the two groups.

RESULTS

There were significantly higher levels of psychological distress among hypertensive respondents (9.9%) than in the general population (4.9%), and a significant association between the two conditions [odds ratio (OR) = 2.27 (1.91; 2.70)]. Characteristics associated with distress among hypertensive respondents included residing in Armenia or Kyrgyzstan, being female, over age 50, with a poor economic situation, lower education, poor emotional support and limited access to medical drugs. Levels of distress declined between 2001 and 2010, but at a lesser rate in hypertensive respondents [rate ratio (RR) = 0.85 (0.75; 0.95)] than non-hypertensive respondents [RR = 0.65 (0.56; 0.75)].

CONCLUSIONS

There is a significant association between psychological distress and hypertension in the region.

Do you think it's a disease? a survey of medical students

BACKGROUND

The management of medical conditions is influenced by whether clinicians regard them as "disease" or "not a disease". The aim of the survey was to determine how medical students classify a range of conditions they might encounter in their professional lives and whether a different name for a condition would influence their decision in the categorisation of the condition as a 'disease' or 'not a disease'.

METHODS

We surveyed 3 concurrent years of medical students to classify 36 candidate conditions into "disease" and "non-disease". The conditions were given a 'medical' label and a (lay) label and positioned where possible in alternate columns of the survey.

RESULTS

The response rate was 96% (183 of 190 students attending a lecture): 80% of students concurred on 16 conditions as "disease" (eg diabetes, tuberculosis), and 4 as "non-disease" (eg baldness, menopause, fractured skull and heat stroke). The remaining 16 conditions (with 21-79% agreement) were more contentious (especially obesity, infertility, hay fever, alcoholism, and restless leg syndrome). Three pairs of conditions had both a more, and a less, medical label: the more medical labels (myalgic encephalomyelitis, hypertension, and erectile dysfunction) were more frequently classified as 'disease' than the less medical (chronic fatigue syndrome, high blood pressure, and impotence), respectively, significantly different for the first two pairs.

CONCLUSIONS

Some conditions excluded from the classification of "disease" were unexpected (eg fractured skull and heat stroke). Students were mostly concordant on what conditions should be classified as "disease". They were more likely to classify synonyms as 'disease' if the label was medical. The findings indicate there is still a problem 30 years on in the concept of 'what is a disease'. Our findings suggest that we should be addressing such concepts to medical students.

Race differences in the physical and psychological impact of hypertension labeling

BACKGROUND

Blood pressure screening is an important component of cardiovascular disease prevention, but a hypertension diagnosis (i.e., label) can have unintended negative effects on patients' well-being. Despite persistent disparities in hypertension prevalence and outcomes, whether the impact of labeling differs by race is unknown. The purpose of this study was to evaluate possible race differences in the relationship between hypertension labeling and health-related quality of life and depression.

METHODS

The sample included 308 normotensive and unmedicated hypertensive subjects from the Neighborhood Study of Blood Pressure and Sleep, a cross-sectional study conducted between 1999 and 2003. Labeled hypertension was defined (by self-report) as having been diagnosed with high blood pressure or prescribed antihypertensive medications. Effects of labeling and race on self-reported physical and mental health and depressive symptoms were tested using multivariate analysis of covariance, controlling for age, sex, body mass index (BMI), previous medication use, and "true" hypertension status, defined by average daytime ambulatory blood pressure (ABP).

RESULTS

Both black and white subjects who had been labeled as hypertensive reported similarly poorer physical health than unlabeled subjects (P = 0.001). However, labeling was associated with poorer mental health and greater depressive symptoms only among blacks (Ps < 0.05 for the interactions). These findings were not explained by differences in socioeconomic status.

CONCLUSIONS

These results are consistent with previous studies showing negative effects of hypertension labeling, and demonstrate important race differences in these effects. Clinical approaches to communicating diagnostic information that avoid negative effects on well-being are needed, and may require tailoring to patient characteristics such as race.

The combined influence of hypertension and common mental disorder on all-cause and cardiovascular disease mortality

BACKGROUND

Common mental disorders, such as anxiety and depression, are risk factors for mortality among cardiac patients, although this topic has gained little attention in individuals with hypertension. We examined the combined effects of hypertension and common mental disorder on mortality in participants with both treated and untreated hypertension.

METHODS

In a representative, prospective study of 31 495 adults (aged 52.5 ± 12.5 years, 45.7% men) we measured baseline levels of common mental disorder using the 12-item General Health Questionnaire (GHQ-12) and collected data on blood pressure, history of hypertension diagnosis, and medication use. High blood pressure (systolic/diastolic >140/90 mmHg) in study members with an existing diagnosis of hypertension indicated uncontrolled hypertension and, in undiagnosed individuals, untreated hypertension.

RESULTS

There were 3200 deaths from all causes [943 cardiovascular disease (CVD)] over 8.4 years follow-up. As expected, the risk of CVD was elevated in participants with controlled [multivariate hazard ratio = 1.63, 95% confidence interval (CI) 1.26-2.12] and uncontrolled (multivariate hazard ratio = 1.57, 95% CI 1.08-2.27) hypertension compared with normotensive participants. Common mental disorder (GHQ-12 score of ≥4) was also associated with CVD death (multivariate hazard ratio = 1.60, 95% CI 1.35-1.90). The risk of CVD death was highest in participants with both diagnosed hypertension and common mental disorder, especially in study members with controlled (multivariate hazard ratio = 2.32, 95% CI 1.70-3.17) hypertension but also in uncontrolled hypertension (multivariate hazard ratio = 1.90, 95% CI 1.18-3.05). The combined effect of common mental disorder was also apparent in participants with undiagnosed (untreated) hypertension, especially for all-cause mortality.

CONCLUSIONS

These findings suggest that the association of hypertension with total and CVD mortality is stronger when combined with common mental disorder.

Hypertension awareness and psychological distress

There is conflicting evidence regarding the association of hypertension with psychological distress, such as anxiety and depressive symptoms. The association may be because of a direct effect of the raised blood pressure, adverse effects of treatment, or the consequences of labeling. In a representative study of 33 105 adults (aged 51.7+/-12.1 years; 45.8% men), we measured levels of psychological distress using the 12-item General Health Questionnaire and collected blood pressure, data on history of hypertension diagnosis, and medication usage. Awareness of hypertension was confirmed through a physician diagnosis or the use of antihypertensive medication, and unaware hypertension was defined by elevated clinic blood pressure (systolic/diastolic > or =140/90 mm Hg) without previous treatment or diagnosis. In comparison with normotensive participants, an elevated risk of distress (General Health Questionnaire score > or =4) was observed in aware hypertensive participants (multivariable adjusted odds ratio: 1.57 [95% CI: 1.41 to 1.74]) but not in unaware hypertensives (odds ratio: 0.91 [95% CI: 0.78 to 1.07]). Antihypertensive medication and comorbidity were also associated with psychological distress, although this did not explain the greater risk of distress in aware hypertensives. We observed a weak curvilinear association between systolic blood pressure and distress, which suggested that distressed participants were more likely to have low or highly elevated blood pressure. These findings suggest that labeling individuals as hypertensive, rather than having elevated blood pressure, per se, may partially explain the greater levels of distress in patients treated for hypertension.