Anxiety sensitivity and medication nonadherence in patients with uncontrolled hypertension
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.).
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