Relationship between anxiety and treatment compliance in patients with hypertension.
Anxiety represents one of the most common human emotions, while pathological anxiety is one of the most frequent psychiatric disorders. It has been reported that 25 % of the general population have met--at least once in their life--the criteria for an anxiety disorder. Anxiety includes several mental, vegetative, and motor manifestations (1, 2). Anxiety mood is perceived as a threat, as an undefined imminent danger, which the danger cannot escape. It is accompanied by a feeling of helplessness, of annoyance without reason and without object, and of irritability. This unpleasant and painful experience is accompanied by increased alertness and involuntary over-attention. Cognitive functions are interfered. Anxiety distorts perception: patients unconsciously tend to select information related to dangers or to personal issues (1, 3, 4).
Chronic diseases are a pregnant reality of our days. They require multidisciplinary management, drug therapy, a healthy lifestyle, and a fundamental, but often minimized or even ignored element: adjusting to the idea of chronic disease and controlling the potential anxiety or depression fund of the patient (5, 6, 7).
Hypertension is a chronic pathology, which represents the consequence of vascular anomaly or systemic vascular resistance; its emergence is determined by a series of specific and unspecific factors (gender, age, obesity, atherosclerosis, stress, etc.), manifested by an increase in blood pressure values over the normal threshold and the borderline hypertension level. Considering the severe consequences entailed by lack of blood pressure control, hypertension drugs must be taken permanently and continuously. Even if blood pressure is stabilized again, the treatment must not be interrupted (5, 7).
Compliance is a patient's behaviour that plays a fundamental role in the final success or failure of any treatment. It represents the extent to which a patient's behaviour matches the prescriber's advice. Adherence is a term that tends to replace compliance. Aspects of non-compliance include non-fulfilment, skipping doses, non-persistence, or taking more than prescribed; all of them lead to therapeutic inefficiency and they entail major risks (7, 8).
Factors that influence non-compliance are related to the patient, the physician, to features of the disease, to characteristics of treatment regimen, and to various contextual factors. Tolerability, early improvement, and simple instructions are important factors in patient's compliance. Increase in compliance has a great potential of reducing healthcare costs and patient's pain (5, 6).
Compliance is related mostly to perceived disease, to patient's attitude toward treatment and disease awareness, medication costs, adverse effects of drugs, and inadequate treatment for disease symptoms (7). Therapeutic adherence failure is determined by two great categories of factors--unintentional (problems remembering doses, misunderstanding the regimen, language barriers, dementia, other disorders involving cognitive impairment, changes in schedule, impossibility of accessing prescriptions) and intentional (patients feel better and believe that medication is no longer necessary; they are afraid of adverse effects; drugs as perceived as ineffective; the regimen is considered too complicated; patients are afraid of becoming addicted) (8).
This study assesses the relationship between anxiety level, gender, and compliance with chronic disease treatment. More precisely, we wonder whether an individual with high anxiety level has lower treatment compliance and whether gender influences the attitude toward medication in close connection with anxiety.
Hence, the study proposes the following: determining the relationship between anxiety level and compliance with chronic disease treatment; establishing the relationship between subjects' gender and the level of compliance with chronic disease treatment (with hypertension treatment, in this case); determining the existence of a potential interaction between gender and anxiety level in terms of degree of compliance with chronic disease treatment.
Taking into account the research objectives and its central issue, three research hypotheses were issued: concerning the influence of gender upon treatment compliance; the relationship between the anxiety level and the treatment compliance; treatment compliance and anxiety in terms of degree of compliance to hypertension treatment as a representative of chronic diseases.
MATERIALS AND METHODS
Study series--The study series comprised 172 subjects (same number of males and females), aged between 50 and 60 (considering the age correspondent between males and females). All these subjects are registered to a family medicine practice and diagnosed with hypertension; they all receive permanent treatment for this disease. Initially, 180 patients were considered for the study, but eight of them were taken out to eliminate the influence of a parasite variable: adverse effects of medication (patients were asked before applying the instruments whether they suffered from concrete adverse effects of the medication received from hypertension).
We applied two instruments to all 172 subjects: one for measuring anxiety and another one for quantifying the level of compliance with hypertension treatment. These instruments were applied in similar conditions for all 172 subjects, in the family medicine practice to which they belong. We also obtained the informed consent from them and their GP. We agreed to keep the anonymity of subjects. For measuring the anxiety variable (named anxiety_g), we used The Hamilton Anxiety Rating Scale, with 14 items, each of them evaluated from 0 to 4 by their degree of severity (their total score ranges from 0 to 56).
For measuring compliance, we used The 6-item Modified Morisky Scale comprising "yes" or "no" questions. Questions 1, 2, and 6 (that measure forgetfulness or negligence in treatment adherence) are considered indicative of motivation (or lack of it, thereof). Questions 3, 4, and 5 assess the way in which the patient understands the long-term benefits of medication and the way in which this cognitive aspect influences treatment compliance. As for scoring, in terms of motivation, each negative answer to questions 1, 2, or 6 gets a point, while each affirmative answer gets 0 points. Hence, a subject may score 0-3 points for motivation; if the patient scores 0-1 point, the motivational compliance is low; if the patient scores more than 1 point, compliance is high (normal). For the cognitive field, negative answers to questions 3, 4 and affirmative answer to question 5 score 1 point; for the others, 0 points are scored (9). The scoring from 0 to 3 for the knowledge field comprises: score between 0-1--low cognitive compliance and score over 1 point, high (normal) compliance. Global compliance with treatment is calculated as follows: 0-3 points--low compliance; 4-6 points--high (normal) compliance (Table 1).
For the statistical analysis (of the main effect of independent variables gender and anxiety_g, and of the interaction effect upon the dependent variable general_compliance, then upon motivational_compliance, and cognitive_compliance), we applied ONE WAY three times (for each case). Levene's Test for Homogeneity was insignificant in all three cases, thus allowing us to use the aforementioned method.
General compliance with chronic disease treatment is different in female subjects compared to male subjects: men record higher compliance with chronic disease treatment. General compliance with chronic disease treatment varies by the level of subjects' anxiety, while low general anxiety is associated to increased general compliance compared to the one scored by subjects with moderate anxiety, while high general anxiety is associated to significantly low general compliance compared to the one scored by subjects with moderate anxiety. No interaction effect was found between gender and the level of subjects' anxiety concerning their compliance with chronic disease treatment (Figure 1).
[FIGURE 1 OMITTED]
Motivational compliance with chronic disease treatment is slightly different in female subjects compared to male subjects. Motivational compliance with chronic disease treatment varies by the level of subjects' anxiety, while low general anxiety is associated to high motivational compliance compared to the one scored by the subjects with moderate anxiety, while high general anxiety is associated to a significantly lower motivational compliance compared to the one scored by the subjects with moderate general anxiety. No interaction effect was found between gender and the level of subjects' anxiety concerning their motivational compliance with chronic disease treatment (Figure 2).
[FIGURE 2 OMITTED]
Cognitive compliance with chronic disease treatment is not different in female subjects compared to male subjects. Cognitive compliance with chronic disease treatment varies by the level of subjects' anxiety, while low general anxiety is associated to higher cognitive compliance compared to the one scored by subjects with moderate anxiety, while high general anxiety is associated to a significantly lower cognitive compliance compared to the one scored by subjects with moderate general anxiety. No interaction effect was found between gender and the level of subjects' anxiety concerning their cognitive compliance with chronic disease treatment (Figure 3).
[FIGURE 3 OMITTED]
Compliance with chronic disease treatment is influenced by patients' anxiety level in an inversely proportional manner: patients with high anxiety usually report low compliance compared to those with moderate anxiety. In their turn, the latter report lower compliance than those with low anxiety. At the same time, no interaction effect was found between gender and subjects' anxiety level concerning their compliance to treatment. It can be reiterated that men are equally influenced by anxiety. In extreme situations (such as high anxiety levels and normal anxiety levels), compliance is the same for both genders only concerning moderate anxiety: compliance mean--though not significantly lower--is a couple of hundredths shy from pathological limits in women, while in men it remains at the lower limit of normal parameters. By becoming aware of this relational pattern (anxiety --therapeutic compliance in hypertension), it is possible to anticipate prevention and management methods of anxiety phenomena.
Ilinca UNTU--M. D., Ph. D. Student, "Socola" Institute of Psychiatry, Iasi, Romania
Vasile CHIRITA--Prof., M. D., Ph. D., "Socola" Institute of Psychiatry, Iasi, Romania
Dania Andreea RADU--M. D., Ph. D. Student, "Socola" Institute of Psychiatry, Iasi, Romania
Anamaria CIUBARA--Lecturer, M. D., Ph. D., "Socola" Institute of Psychiatry, Iasi, Romania
Roxana CHIRITA--Prof., M. D., Ph. D., "Socola" Institute of Psychiatry, Iasi, Romania
ACKNOWLEDGMENTS AND DISCLOSURE
The authors declare that they have no potential conflicts of interest to disclose.
(1.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM 5), Washington, D. C., 2013.
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(3.) Fontaine, O. Ghidul clinic de terapie comportamentala pi cognitiva, 2006, Retz, Paris (2008, Polirom, pp. 374-382).
(4.) Holdevici, I. Psihoterapia tulburarilor anxioase, Editura Ceres, Bucuresti, 2000.
(6.) Dosse, C., Bernardi, C. (2009). Factors associated to patient's noncompliance with hypertension treatment. Rev. Lationo-am Enfermagem, 03-04, 17 (2): 201-206.
(7.) Marinescu, V. (2007). Non-aderenta--un obstacol major in calea eficacitapii tratamentulului. Revista Romana de Psihiatrie, series III, Vol. IX, issues 2-3.
(8.) Mann, D., Poniemon, D. (2009). Predictors of adherence to diabetes medication: the role of disease and medications beliefs, Medical Behaviour Journal, 32:278-284.
(9.) Bosworth, H., Oddone, Z., Weinberge, M. (2008). Techniques of questioning that promote medication adherence (Patient treatment adherence: concepts, interventions and measurement), Taylor and Francis e-library.
"SOCOLA" INSTITUTE OF PSYCHIATRY
No. 36 str. Bucium, Iasi, Romania
Submission: September, 30th, 2015
Acceptance: October, 29th, 2015
Table 1. Modified Morisky Scale (9) Questions YES NO Do you ever forget to take 0 1 your medicine? Are you careless at times about 0 1 taking your medicine? When you feel better do you 0 1 sometimes stop taking your medicine? Sometimes if you feel worse 0 1 when you take your medicine, do you stop taking it? Do you know the long-term 1 0 benefit of taking your medicine as told to you by your doctor or pharmacist? Sometimes do you forget to 0 1 refill your prescription medicine on time?
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|Author:||Untu, Ilinca; Chirita, Vasile; Radu, Dania Andreea; Ciubara, Anamaria; Chirita, Roxana|
|Publication:||Bulletin of Integrative Psychiatry|
|Date:||Dec 1, 2015|
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