Received Date: April 16, 2016; Accepted Date: July 10, 2016; Published Date: July 17, 2016
Citation: Aberha M, Gebeyehu A, Ayano G (2016) Prevalence and Factors Associated with Anxiety among Patients with Hypertension on Follow Up at Menelik- II Referral Hospital, Addis Ababa Ethiopia. J Psychiatry 19:378. doi:10.4172/2378- 5756.1000378
Copyright: © 2016 Aberha M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Anxiety disorders are common among people living hypertension. The co-existence of these disorders are associated with barriers to treatment and worsening medical outcomes, including treatment resistance, increased risk for suicide, greater chance for recurrence and utilization of medical resources and/or increase morbidity and mortality. Therefore, assessing depression and anxiety among hypertensive patients has a pivotal role for further interventions.
Methods: Institution based cross sectional study was used by face to face interview using standardized questioner, Amharic Version of Hospital Anxiety & Depression Scale (HADS), which has scores for classifying the participants having anxiety symptoms, was applied in systematic random sampling of 417 adult participants. Data entry was performed by using EPI info 3.5.3 and SPPSS version 20. Binary logistic regression analysis (multivariate analysis) was used to identify associated factors.
Result: The study revealed that the prevalence of anxiety was 28.5%. Stressful life events (AOR 1.69, 95%CI (1.03, 2.79), being female (AOR 2.57, 95% CI (1.42, 4.56), co-morbid diabetes illness (AOR 2.98, 95%CI (1.61, 5.53), unable to read and write (AOR 2.72, 95% CI (1.33, 5.58) and poor social support (AOR 6.98, 95% CI (3.48, 13.96) had statistically significant association with anxiety with p-value <0.05.
Conclusion and Recommendation: Prevalence of anxiety was high. Co-morbid diabetes mellitus, low social support, being female sex, having stressful life events and unable to read and write educational status were associated with anxiety. Clinicians who provide service for patients with hypertension should focus on patients who have co-morbid of other illness such as, diabetes mellitus, and who have stressful life events in the last six months to assess the presence of anxiety. In additions ministry of health should give training on how to screen anxiety hypertensive patients and should develop guidelines to screen and treat among hypertensive patients.
Anxiety is a vague feeling of apprehension, worry, uneasiness, or dread, the source of which is often non-specific or unknown to the individual . However its emotion prepares the individual to the environmental changes or helps to create a response to those changes. Anxiety disorder is amongst the most common psychiatric disorders in all over the world . Emerging evidence suggests that anxiety and the anxiety disorders, which have received relatively less attention and many patients have co morbid anxiety symptoms, which are associated with increased severity of psychiatric illness, additive functional impairment and medical costs and also amplify symptoms of some medical illnesses and appear to worsen clinical outcomes. However, there is a remarkable lack of data from rigorously designed clinical trials to guide treatment decisions in patients with common medical illness .
Anxiety disorders are common and costly in older adults and the detection and diagnosis of anxiety disorders in late life is complicated by medical co morbidity, cognitive decline, and changes in life circumstances that do not face younger age groups. Furthermore, the expression and report of anxiety symptoms may differ with age. For these reasons, anxiety disorders in late life may be even more likely to be under diagnosed than in younger age groups . Patients with anxiety exhibit a higher likelihood of medication non-adherence on hypertension treatment and they may limit the feature of treatment option, worsen the prognosis of patients, increase death rate from the disease or the ability to enjoy .
Patients with chronic conditions like hypertension may experience many negative emotions which increase their risk for the development of mental health disorders particularly anxiety. Hypertension seems to be more strongly related to anxiety . Patients with hypertension manifested symptoms of anxiety, depression and stress.
This implies that the patient’s hypertensive state and perhaps the need for adherence to the anti-hypertensive medications placed psychological demands on their health . Antihypertensive drugs have been suggested to modulate symptoms of anxiety .
Even though a global hypertension prevalence of 26% is projected to ascend to 29% by the year 2025  and anxiety is present in about 20% to 25% of patients diagnosed with a cardiovascular disease, even in the absence of an adverse events or invasive interventions . Despite the high magnitude and known effect of anxiety on hypertensive patients, there is very little data available in the study area. Therefore, this study was planned to determine the prevalence and correlates of anxiety among patients with hypertension at Menelik-II referral hospital Ababa, Ethiopia.
Study setting and design
Institution based cross-sectional study was conducted at Menelik- II referral hospital May, 2015, Addis Ababa, Ethiopia.
The study population consisted of all adult hypertensive patients who were on follow up at Menelik-II referral hospital that was included in the sample. Those hypertensive patients who were critically ill were excluded from the study.
Sample size was determined based on single population proportion formula using Epi-info version 7 with a 95% CI, 5% margin of error and taking prevalence of anxiety 56% . Assuming a 10% nonresponse rate a total sample size of 417 hypertensive cases was required. Systematic sampling technique was used to select the study participants. Sampling interval was determined by dividing the total study population who had follow-up during four weeks data collection period by total sample size then the starting point was randomly selected.
Data were collected using pretested interviewer administered questionnaire, which contains socio-demographic characteristics (age, education, occupation, marital status and others), Social support (individuals who were scored greater than or equal to 9 (moderate and strong) on Oslo 3- item social support scale), HADS Anxiety (anxiety was measured by using seven items of (anxiety sub scale) HADS with cut-off points of greater than or equal to 8 scores) , Wealth index:- was classified as poor, medium and rich based on the wealth index score . Stressful life events; when subjects experienced one or more stressful life events (like health risk death of spouse, financial crisis) from the listed twelve items in the last 6 months.
Data processing and analyses
Data were analysed using SPSS version 20. Description of means, frequencies, proportions and rates of the given data for each variable was calculated. Bivariate analysis was done to see the association of each independent variable with the outcome variable. Those variables having p-value less than 0.2 were entered into the multivariate logistic regression model to identify the effect of each independent variable with the outcome variables. A p-value of less than 0.05 was considered statistically significant, and adjusted odds ratio with 95% CI was calculated to determine association.
Ethical clearance was obtained from the Institutional Review Board of the University of Gondar and Amanuel Mental Specialized hospital. Supportive letter was obtained from Addis Ababa health office. Written informed consent was obtained from each study participant after they were introduced to the purpose of the study and informed about their rights to interrupt the interview at any time. Participants were informed that the information collected for this research project were kept confidential and information about collected by this study will be stored in a file, without their name, but code number assigned to it. It will not be revealed to anyone except the principal investigator and during final dissemination of aggregate results on workshops, publications and the like. Any individual level clinical data will not be disseminated for any one and it will be kept locked with key. Hypertensive patients who were found to have depression and anxiety were referred for further investigations.
Socio-economic and demographic characteristics
A total of 417 participants were included in the study which makes the response rate 100%. The mean age of the respondents was 55.63 (SD=13.29) years. Among the respondents, the majority 129 (30.9%) were in age range of 48 – 57 years, around half 213 (51.1%) were male, about 186 (44.6%) were Amhara, most 299 (71.7%) were married, around half 225 (54%) were attended secondary education and above, more than two third 292 (70%) were orthodox religion members and almost all participants were in equal proportion in terms of wealth index (Table 1).
|68 and above years||84||20.1|
|Education status||Unable to read and write||80||19.2|
|Secondary education and above||225||54|
|Occupation status||Government employee||130||31.2|
Table 1: Descriptions of Socio demographic factors among patients with hypertension on follow up at Menelik- II referral hospital, Addis Ababa, Ethiopia, 2015.
Clinical psychosocial and substance use characteristics of the respondents
Regarding to clinical characteristics, the majority 328 (78.7%) had less than or equal to 10 years duration of illness, 218 (52.3) were stage two, most 343 (82.3%) were started anti hypertension medication, more than two third 307 (73.6%) had no other co morbid chronic illness, about 72 (17.3%) had diabetes (DM), less than half 183 (43.9%) had medium social support and about 241 (57.8%) had no stressful life events. From all study participants none of them had any history of substance (khat, cigarette and alcohol) use currently and in the last three month (Table 2).
|Duration of illness||< 10 years||328||78.7|
|Stage of hypertension||Normal||218||52.3|
|Treatment condition||Started medication(Yes)||343||82.3|
|Not-started medication (No)||74||17.7|
|Co-morbid chronic illness||No co-morbid illness||307||73.6|
|Social support||Low social support||73||17.5|
|Medium social support||183||43.9|
|Good social support||161||38.6|
|Stressful life events||Yes||176||42.2|
|CurrentSubstance (khat, cigarette & alcohol) use||Yes||0||0|
Table 2: Description of clinical, psychosocial & substance use factors among hypertensive patients on follow at Menelik- II referral hospital, Addis Ababa, Ethiopia, 2015.
Prevalence of anxiety among hypertensive patients
This study revealed that the prevalence of anxiety was 28.5% (CI 23.9, 33.0) among hypertensive patients.
Factors associated with anxiety among patients with hypertension
Multivariate logistic regression analysis revealed that patients who had stressful life events, unable to read and write co-morbid diabetes (DM) illness, poor social support and Being female were significantly associated with anxiety.
By using multivariate logistic regression, patients who had stressful life events (AOR 1.69, 95% CI (1.03, 2.79), being female (AOR 2.57, 95% CI (1.42, 4.65), co-morbid diabetes (DM) illness (AOR 2.29, 95% CI (1.61, 5.53), unable to read and write (AOR 2.72, 95% CI (1.33, 5.56) and poor social support (AOR 6.98, 95% CI (3.48, 13.96) had statistically significant association with anxiety (Table 3).
|Explanatory Variables||Anxiety||COR, 95% (CI)||AOR, 95% (CI)|
|Unable to write and read||35||45||2.65,(1.55, 4.56)||2.72, (1.33, 5.58)**|
|Primary education||33||79||1.43, (0.85, 2.34)||1.44,(0.75,2.78)|
|Secondary education and above||51||174||1|
|Unemployed||41||134||0.86, (0.51,1.46)||0.55, (0.28, 1.09)|
|House wives||32||56||1.61,(0.90, 2.90)||0.66, (0.29, 1.49)|
|Others||12||12||2.82, (1.16, 6.88)*||1.19,(0.42, 3.42)|
|Stressful life events|
|Yes||66||110||2.13, (1.38,3.28)||1.69,(1.03, 2.79)**|
|Co-morbid chronic illness|
|No chronic illness||70||237||1||1|
|Diabetes (DM)||34||38||3.03, (1.78,5.17)||2.98,(1.61, 5.53)**|
|Renal disease||8||14||1.94, (0.78,4.80)||1.31,(0.47,3.67)|
|Other chronic illness||7||9||2.63, (0.95,7.33)||2.00,(0.62,6.41)|
|Poor||54||84||2.21, (1.31, 3.72)*||1.30, (0.69, 2.45)|
|Medium||33||104||1.09,(0 .63, 1.90)||0.81,(0.43,1.53)|
Table 3: Factors associated with anxiety among patients with hypertension on-follow at, Menelik- II referral hospital, Addis Ababa, Ethiopia, 2015; n=417.
Prevalence and factors associated with anxiety among patients with hypertension
The study revealed that the prevalence of anxiety was (28.5%). The finding was similar with other studies carried out in Iran 28.5% . On the other hand, the current study finding is higher than the studies done in Egypt 4.75% , South African adult population 8.1% , in primary care in Qatar 18.7% , in Germany 22.8%  and in Primary Care Centre of the University Kebangsaan Malaysia Medical Centre 8.56% , and lower than the study done in two hospitals in Ghana 56%  and 40%  respectively. The variation might be due to the difference in sample size, study design and data collection tool which was a door-to-door household survey and MINI-Plus diagnostic interview with14640 participant in Egypt , prospective study design with 158 participant and PHQ 9 in Germany , difference in tool and sample size which was 4351 and the Composite International Diagnostic Interview to measure DSM-IV mental disorders in South Africa adult population , the difference in a data collection tool by using DASS in Ghana , using Zung Self-Rating Anxiety Scale test (SAS) in Ghana  and a self-administered questionnaire comprising three sections: (1) Socio- demographic data, (2) Illness perception score, measured using the Malay version of Brief Illness Perception Questionnaire (BIPQ) and (3) Malay version of depression and anxiety, assessed by the Hospital Anxiety and Depression Scale (HADS) at the Primary Care Centre of the University Kebangsaan Malaysia Medical Centre .
The multivariate logistic regression analysis in indicated that being females were 2.57 times more likely to have anxiety than males. The possible reason might be increased exposure to acute life events, gender specific roles, chronic social stresses, lower income, and smaller social networks . The current result is similar with the study conducted in South African Adults .
Patients with Co-morbid diabetes mellitus (DM) were 2.98 times more likely to have anxiety than patients had no other co-morbid illness; this is relatively higher than the study conducted previously in Karachi (Pakistan)  and in Egypt . This might be due to the difference in change life style modification. Metabolic components like systolic blood pressure and fasting blood glucose found to be independently associated with anxiety . The co-morbidity between medical illness and anxiety disorders poses difficulties for differential diagnosis and detection of anxiety .
With respect to stressful life events, Patients who had one or more stressful life events in the last six months were 1.69times more likely to have anxiety than patients who had no stressful life events in the last six months, this is similar with study conducted in South Africa adults that concluded participant with 1-2 stressful life events 1.15 times, 3-4 stressful life events 1.44 times and those had 5 or more stressful life events 2.62 times to have anxiety . Significant stressful events independently have been reported to be responsible for hypertension.
Although hypertension could be viewed in itself as a biomedical problem, patients’ experiences with the demands of living as hypertensive have resulted in mental health problems .
With respect to educational status, those who are unable to read and write were 2.72 times more likely to have anxiety than patients with secondary and above education status; this is in contrast to the study conducted previously in Egypt . This might be due to difference in socio cultural status, individuals coping mechanism to ward stress and difference in socioeconomic status.
Regarding to social support, Patients who had poor social support were 6.98 times more likely to have anxiety than patients who had good social support, this might be due to feeling isolated or loneliness, lack of social support and somatic illness (like hypertension) may lead to increased psychological distress (mental disorders); on the other hand, good social support is vital for those with good health in reducing the risk of having anxiety .
The prevalence of anxiety among hypertensive patients (28.5%) was high. Anxiety had statistically significant association with co-morbid diabetes mellitus, low social support, being female sex, having one or more stressful life events in the last six months and unable to read and write educational status. Ministry of Health should develop guidelines to screen and treat depression and anxiety among hypertensive patients. Further research on risk factors of anxiety should be conducted to strengthen and broaden these findings.
The authors acknowledge Amanuel Mental Specialized Hospital, Ethiopia for funding the study. The authors appreciate the respective study institutions and the study participants for their cooperation in providing the necessary information.
MA conceived the study and was involved in the study design, reviewed the article, analysis, report writing and drafted the manuscript AG & GA were involved in the study design, analysis and drafted the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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