Anxiety sensitivity and medication nonadherence in patients with uncontrolled hypertension

https://doi.org/10.1016/j.jpsychores.2014.07.009Get rights and content

Highlights

  • We examined the association of anxiety sensitivity with medication nonadherence.

  • Medication nonadherence was measured objectively in patients with hypertension.

  • High anxiety sensitivity was strongly associated with BP medication nonadherence.

  • Those with high vs. low anxiety sensitivity had a 76% increased risk of nonadherence.

Abstract

Objective

Anxiety sensitivity—fear of the negative social, physical, or cognitive consequences of anxiety related sensations—has been linked to cardiovascular disease and adverse cardiovascular health behaviors. Medication nonadherence may account for this association. We examined whether anxiety sensitivity was independently associated with objectively measured medication nonadherence in a multi-ethnic primary care sample.

Methods

Eighty-eight patients with uncontrolled hypertension completed the Anxiety Sensitivity Index and had their adherence to blood pressure (BP) medications measured during the interval between two primary care visits using an electronic pillbox (MedSignals®). Multivariable Poisson regressions were conducted to determine the relative risks of medication nonadherence associated with anxiety sensitivity after adjustment for age, gender, Hispanic/Latino ethnicity, education, total number of prescribed medications, and depressive and posttraumatic stress disorder (PTSD) symptoms.

Results

Nearly twice as many patients with high anxiety sensitivity were nonadherent to BP medications compared to patients with low anxiety sensitivity (65.0% vs. 36.8%; p = 0.03). Patients with high anxiety sensitivity had higher relative risks of medication nonadherence than their low anxiety sensitivity counterparts (adjusted relative risk [RR] = 1.76; 95% CI: 1.03–3.03).

Conclusions

In this first study of the association between anxiety sensitivity and medication adherence, we found that high anxiety sensitivity was strongly associated with BP medication nonadherence, even after adjustment for known confounders. Our results suggest that teaching patients who have uncontrolled hypertension adaptive strategies to manage their anxiety sensitivity may help improve their medication adherence, and thereby lower their cardiovascular risk.

Introduction

Anxiety sensitivity—fear of the negative social, physical, or cognitive consequences of anxiety-related sensations [1], [2], [3]—has been linked to cardiovascular disease [4], [5] and adverse cardiovascular health behaviors [5], [6], [7], [8], [9], [10], [11]. Anxiety sensitivity is considered a multi-dimensional and trait-like cognitive vulnerability that exacerbates antecedent levels of anxiety. It is composed of three lower-order and interrelated factors pertaining to fear of anxiety: social concerns (e.g., belief that observable anxiety symptoms will lead to social rejection), physical concerns (e.g., belief that palpitations result in cardiac arrest/heart attack), and cognitive concerns (e.g., belief that concentration difficulties result in mental incapacitation) [12], [13]. For example, individuals with high anxiety sensitivity are more likely to make catastrophic interpretations of arousal-related sensations of anxiety and in turn experience increased anxiety, which creates a positive feedback loop and escalating cycle [3]. This tendency to fear and catastrophize anxiety-related or arousal-related sensations is thought to lead to avoidance behaviors that limit or remove altogether exposures to anxiety-provoking triggers, situations, and contexts [2].

While anxiety sensitivity has been linked to certain cardiovascular health risk behaviors including smoking, drinking alcohol, using ilicit drugs, and being less likely to exercise [7], [8], [9], to our knowledge, no prior studies have examined the association between anxiety sensitivity and adherence to cardiovascular medications. Medication nonadherence is an established risk factor for cardiovascular disease [14], and may account for the association between anxiety sensitivity with cardiovascular disease. Anxiety sensitivity may influence medication adherence as it is possible that patients with high anxiety sensitivity experience increased anxiety in the context of perceived medication side-effects or as a response to their hypertension symptoms that mimic anxiety-related sensations; this may lead to avoidance of medications and worse overall medication adherence. Indeed, common side-effects to BP medications and common symptoms of hypertension include dizziness, headaches, and palpitations [15], [16], which are also common symptoms of anxiety or arousal [17]. We examined whether anxiety sensitivity was independently associated with objectively measured medication nonadherence in a multi-ethnic sample of primary care patients with uncontrolled hypertension. We also explored whether or not specific subscales of anxiety sensitivity predicted medication nonadherence. We were particularly interested in the association of anxiety sensitivity to medication nonadherence independent of depressive symptoms and posttraumatic stress disorder symptoms, two well-established and consistent predictors of medication nonadherence [18], [19], [20]. We also tested whether anxiety sensitivity was associated with increased self-reported side-effects to BP medications. We hypothesized that individuals with high anxiety sensitivity would be more likely to exhibit poor medication adherence and to report medication side-effects.

Section snippets

Methods

We enrolled a convenience sample of patients with uncontrolled hypertension from a hospital-based primary care clinic in New York City. Patients were eligible if they had elevated blood pressure [BP] on two consecutive clinic visits prior to enrollment (BP  140/90 mm Hg or ≥ 130/80 if they had diabetes mellitus or chronic kidney disease) and if they were prescribed at least one BP medication. Patients were ineligible if they were unable to self-manage their BP medications due to dementia,

Results

Between October 2011 and November 2013, 113 patients enrolled in the study; 88 had usable pillbox data and complete covariate information. Overall, patients had a mean age of 64.65 (SD = 8.06) years, 68 were women (77.3%), 72 were Hispanic/Latino (81.8%), and patients had a mean of 8.52 (SD = 4.42) years of education. The mean ASI score was 23.55 (SD = 14.93), and 22.7% had high anxiety sensitivity. Patients with high compared to low anxiety sensitivity did not significantly differ from each other on

Conclusions

In this first study on the association of anxiety sensitivity with medication adherence, we found that high anxiety sensitivity was associated with nearly double the risk of nonadherence to BP medications, even after adjustment for potential confounders. In this sample, the relative risk of medication nonadherence associated with high anxiety sensitivity (RR = 1.76) was of the same magnitude as that reported for depression in a meta-analysis of the association between depression and medication

Acknowledgments

This work was supported by funds from the National Heart, Lung, and Blood Institute at the National Institutes of Health (R01 HL115941-01S1 to CA, R01 HL117832 to D.E., K23 HL-098359 to I.M.K.), the American Heart Association (SDG 10SDG2600321 to I.M.K.) and the Health Resources and Services Administration (T32HP10260 to N.M.).

References (30)

  • MJ Zvolensky et al.

    Anxiety, substance use, and their co-occurrence: advances in clinical science

    J Cogn Psychother

    (2011)
  • M. Wong et al.

    Anxiety sensitivity as a predictor of acute subjective effects of smoking

    Nicotine Tob Res

    (Jun 2013)
  • JA Smits et al.

    The interplay between physical activity and anxiety sensitivity in fearful responding to carbon dioxide challenge

    Psychosom Med

    (Jul-Aug 2011)
  • L. Ong et al.

    Psychological correlates of quality of life in atrial fibrillation

    Qual Life Res

    (Oct 2006)
  • S. Taylor et al.

    Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3

    Psychol Assess

    (Jun 2007)
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