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Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 84-88

Psychiatric morbidity in hypertensives attending a cardiology outpatient clinic in West Africa

1 Department of Psychiatry, Lagos University Teaching Hospital and College of Medicine University of Lagos, Nigeria
2 Department of Internal Medicine, Lagos University Teaching Hospital and College of Medicine University of Lagos, Nigeria
3 Department of Psychiatry, University of Stellenbosch, Cape Town, South Africa

Date of Acceptance26-Apr-2011
Date of Web Publication20-Mar-2012

Correspondence Address:
Y O Oshodi
Department of Psychiatry, Lagos University Teaching Hospital and College of Medicine University of Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.94105

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Objectives: To determine kinds of psychiatric morbidity among a sample of stable hypertensive outpatients in a teaching hospital.
Materials and Methods: A cross-sectional study of 260 enrolled outpatients. Psychiatric morbidity was assessed using a 2-stage evaluation method with the General Health Questionnaire Version 12 (GHQ-12) and Structured Clinical Interview for DSM-IV (SCID) to assess for psychiatric diagnosis.
Results: 28 (10.8%) of the 260 patients endorsed some psychological distress, with a mean GHQ-12 score of ≥2. At the second stage, 16.1% (N=13 of 81) interviewed had one or more psychiatric disorder on the SCID. The commonest psychiatric diagnosis made were mood disorders, with current major depressive disorder occurring at a rate of 6.2%. Other disorders found were past major depressive episode (2.5%), organic mood syndrome (3.7%), and somatoform disorder (3.7%).
Conclusion: The relationship between hypertension and mood disorders should inform a higher index of suspicion among physicians and general practitioners in order to give patients appropriate treatments or referrals where necessary. It is recommended that collaboration with mental health service providers be encouraged.

Keywords: African, cardiology, hypertensive, psychiatric morbidity

How to cite this article:
Oshodi Y O, Adeyemi J D, Oke D A, Seedat S. Psychiatric morbidity in hypertensives attending a cardiology outpatient clinic in West Africa. Niger J Clin Pract 2012;15:84-8

How to cite this URL:
Oshodi Y O, Adeyemi J D, Oke D A, Seedat S. Psychiatric morbidity in hypertensives attending a cardiology outpatient clinic in West Africa. Niger J Clin Pract [serial online] 2012 [cited 2020 Feb 29];15:84-8. Available from:

   Introduction Top

Under-recognition and under-treatment of psychiatric illness constitute a major problem in outpatient medical setting. Patients with cardiac conditions are at a high risk of medical and psychiatric comorbidities, [1],[2],[3] with the estimated prevalence of psychiatric disorders in primary care patients put at between 20% and 30%. [4]

Worldwide, there is an increased interest in the relationship between hypertension and depression, myocardial infarction, and heart failure. [5],[6],[7]

In Nigeria, existing studies have investigated psychiatric morbidity in general hospitals and primary care settings; [8] however, few have looked specifically at the relationship of disorders such as depression among cardiac patients. [9]

The obvious risks of these comorbidities often complicate the course of the hypertension and may further lead to increased morbidity and mortality [10],[11],[12] among sufferers, it is therefore imperative to examine the patterns of psychiatric morbidity.

In the setting of hypertension, knowledge about associated psychopathology may aid in improving early detection and paving way for more optimal patient care.

The aim of this study was to determine the nature of psychiatric morbidity among hypertensive patients attending the cardiology outpatient clinic of a Lagos teaching hospital.

   Materials and Methods Top

Study procedure

The study was descriptive and cross-sectional in nature. It was conducted in a Multispecialty Teaching Hospital in Lagos, which is a mega city and the economic nerve center of Nigeria. The hospital is a referral center for many primary and secondary care providers within the state as it provides specialist care services in all areas of medicine, including cardiology. The hospital cardiology clinic runs once a week attending to approximately 70 patients per clinic. Patients present with various cardiac conditions, including hypertension, and a diagnosis of hypertension is usually confirmed based on history, physical examination, and laboratory investigations after the first few visits.


Eligibility criteria were an age range of 20-60 years, a known diagnosis of systemic hypertension, current/past use of antihypertensive agents, absence of any complication from the hypertension, and no known past history of psychiatric illness.

Eligible patients were recruited to the study every week and between 10 and 25 people were enrolled per clinic session over a period of 6 months, and a sample size of 260 was achieved at the end of this time frame.

Ethical approval to conduct the study was obtained from the hospital Ethical and Research Committee and written informed consent was obtained from all participants prior to commencement of study procedures.


A sociodemographic questionnaire devised by the authors was administered and psychiatric morbidity was assessed using a 2-stage evaluation method. First, the General Health Questionnaire Version 12 (GHQ-12) was administered and this was followed up with a semistructured diagnostic interview (Structured Clinical Interview for DSM IV diagnosis or SCID). [13] The SCID was administered to patients with scores suggestive of psychiatric morbidity on the GHQ, namely all those with GHQ≥2 (positive scores) were interviewed. A third of the GHQ negatives were randomly selected and also interviewed with the SCID in the second stage, this was in order to correct for possible missed cases, thus improving the yield of identifying cases.

Data analysis

Data were analyzed using SPSS - version 17 statistical package. Descriptive statistics (means and frequencies) were calculated for continuous and categorical variables, respectively. While parametric and nonparametric tests, such as Pearsons Product Moment and Spearman Ranks, were used in determining correlation. Comparison of means of categorical variables was also done using the independent samples t test. A 95% level of confidence was used in the statistical interpretation, thus allowing for 5% sampling error.

   Results Top

Demographic characteristics

Of the two hundred and sixty patients (260), 92 (35.4%) were males and 168 (64.6%) were females [Table 1]. The mean age of respondents was 50 ± 7.87 years, median of 52.0 years, range 27-60 years. The majority were married and in monogamous relationships. The predominant ethnic groups were the Yorubas, 145 (55.8%). Most were fairly educated, with the minimum educational level being secondary school (67.3%) [Table 1].
Table 1: Sociodemographic variables of hypertensives

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10.8% (N=28) had GHQ scores ≥2, which is suggestive of psychological distress. These 28 patients along with additional randomly selected 53 patients out of those with GHQ scores of 0-1 were further evaluated with the SCID (total N=81).

A total of four types of psychiatric disorders were found in the sample based on the SCID and most of them were the mood disorders. Elicited disorders were namely current major depressive disorder (6.2%), past major depressive episode (2.5%), organic mood syndrome (3.7%), and somatoform disorder (3.7%) [Table 2].
Table 2: GHQ ratings and SCID psychiatric diagnoses psychological morbidity ON GHQ 12

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A comparison of sociodemographic variables of subjects with and without psychiatric morbidity shows that a psychiatric diagnosis was prevalent among females (69.2%, P<0.05), those aged above 50 years (61.5%), with some degree of education (69.3%), having a diagnosis of hypertension for over 2 years (62.5%), and was on at least 2 or more drugs (61.4%, P<0.05).

Though at the time of interview, most of them were stable, with normal systolic and diastolic blood pressure readings at 69.2% and 46.2%, respectively [Table 3].
Table 3: Psychiatric diagnosis, sociodemographics and blood pressure

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Using Spearmans rank tests, significant correlates of psychiatric morbidity (using SCID) were; ethnicity (P<0.05) and GHQ score (P<0.05). Both of these variables had negative correlations with having a comorbid psychiatry diagnosis on the SCID.

   Discussion Top

Hypertensive heart disease is common in Nigeria with a prevalence of 20% in a population of 130 million people, with Kano having the highest rates. [14] Erhum et al.[15] also reported a low prevalence rate of 21% in a workplace study of hypertension amongst Nigerians.

The main findings of this study among hypertensive outpatients reflected that most of the patients were middle aged with a median age score of 52 years. The gender distribution pattern had 92 (35.4%) males and 168 (64.6%) females and was similar to that by Bensenor [16] in Brazil. However that study had a smaller study sample size of 41 and subjects were all severe hypertensives. This may support reports that females use hospital services for follow-up care more than their male counterparts. [17]

The Yoruba (55.8%) and Igbo (32.3%) ethnic groups were in the majority. This can be explained by the location of the study being in Lagos, a Yoruba speaking city and economic capital of Nigeria.

Among these hypertensive the mean GHQ score was 0.45 (SD±1.09) with a median score of 0.45 and the overall prevalence of psychological distress on the GHQ 12 was 10.8%.

This was lower than figures gotten by Eze [8] in a general hospital setting in Benin, Nigeria, with 64.1% using GHQ 30 which is a more detailed enquiry. It was also lower than that study by WHO [4] in primary care centers which found prevalence of 27.8% of probable psychiatric morbidity. The higher figures in these studies may be attributed to the wide variety of medical disorders that may exist with psychiatric morbidity in general hospital and primary care settings; this would reflect an overall higher prevalence of psychological distress than in this index study which was specific only to cardiology patients. Among the gender groups, the presence of psychological distress was similar with 10.9% of men and 10.7% of women with GHQ +ve scores. The remaining 232 (89.2%) had no psychological distress.

At the second stage of screening, 81 of the patients progressed to being administered with the SCID, 16 (19.75%) of the 81 subjects met the criteria for a threshold SCID diagnosis, while 65 (80.25%) did not meet any diagnostic criteria.

The younger hypertensives seemed more likely to have psychiatric diagnosis and the age distribution was statistically significant (χ2 =33.511, DF=1, P=0.000). A larger study should clarify this further.

The diagnosis made were mostly mood disorders (4.3%). The other disorders were current depressive illness, uncomplicated bereavement, past major depressive episode, organic mood syndrome, and somatisation disorder. The fact that majority of the diagnosis made were mood disorders is similar to the study by Benensor et al.[16] in Brazil; however, it is note worthy that though Benensor studied only patients with severe hypertension, this study recruited known hypertensive subjects whose blood pressure happened to be either within normal range or at stage I hypertension at the time of the study. Overall, these 16 made up 6.15% psychiatric morbidity among the 260 subjects. Other epidemiological studies on psychiatric morbidity among primary care patients in Nigeria found 21.3% [18] and 27.8%, [19] both studies also had a 2-stage study design using GHQ 12 along with PSE and CIDI, respectively. This comparatively low percentage here is explained by the fact that the exclusion criteria in the study removed all known psychiatric patients and those with positive family history of mental illness. Thus, already reducing the number of subjects that will be eventually picked. In addition, the population of interest here, i.e., hypertensives, is only a subset of the primary care subjects in these other studies hence the lower prevalence of psychiatric morbidity.

A sensitivity of 69.2% and a specificity of 69.1% were found for the GHQ as a screening instrument of psychiatric morbidity in this population group. This finding is similar to that of Gureje [19] and Abiodun. [18]

Most of the subjects with psychiatric morbidity were on at least 2-3 different medications, this is often the pattern of prescription in many cardiology clinics. [14] Diuretics were the most prescribed as found also in the study by Adigun et al.[20] among hypertensives in tertiary hospitals in Nigeria. A few studies have shown that sodium retention plays a central role in the development of obesity-related hypertension, which is also common among the black race. [21] Therefore, treatment with an ACE-inhibitor or a diuretic is usually considered as first-line antihypertensive drug therapy in obesity - hypertension.

The presence of psychiatric diagnosis correlated significantly with ethnicity (P<0.05) among all the sociodemographic variables, this finding is expected as most of the respondents were from the Yoruba tribe which is the predominant tribe in the study location. The presence of a psychiatric diagnosis showed no significant correlations with the blood pressure severity, type of drug used nor any of the drugs in use, but there was a significant negative correlation with GHQ scores (at P<0.05).

All these differ from the general notion that drugs and blood pressure may be causative to psychiatric morbidity, which is still hard to establish especially without a longitudinal case control study in place.

The findings were also similar to that of Bensenor, [16] who found other factors such as systolic and diastolic blood pressure, not to show any association with the psychiatric disturbance. This is also corroborated by the meta analytic study on by Dennis et al., [22] which reported that the conventional assumption that beta blocker therapy is associated with depression is not supported by data and that there is no significant risk of depressive symptoms.

A cause effect relationship of psychiatric morbidity and hypertension is not established from this study, a larger case control study will be put in place in order to explore this in more detail.

Limitations of the study include the finding that most patients had commenced use of antihypertensive medication and were mostly on polytherapy before recruitment to the study, and so the role of specific drug groups or that of hypertension in the onset of psychiatric morbidity cannot be clearly defined. Future longitudinal studies will be useful in clarifying this for these groups of patients.

   Conclusion Top

This study will serve usefully in the understanding the possible comorbidity states between hypertension and emotional disorders in this environment. The study finds that younger hypertensives and those on multiple antihypertensive agents are more at risk of psychiatric morbidity. Monotherapy and the use consultation-liason psychiatry services in cardiology clinics are encouraged. Larger and locally based case control studies are recommended.

   Acknowledgment Top

The authors are grateful to all the patients that participated in the study, for their patience and cooperation during the period of data collection.

   References Top

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6.Bankier B, Januzzi JL, Littman AB. The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease. Psychosom Med 2004;66:645-50.  Back to cited text no. 6
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8.Eze GO. Pattern of Sexual dysfunction in a general hospital setting in Benin City, Nigeria. Part II dissertation for FWACP. 1994.  Back to cited text no. 8
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11.Frasure-Smith N, Lesperance F, Talajic M. Drepression and 18-month prognosis after myocardial infarction. Circulation 1995;91:999-1005.  Back to cited text no. 11
12.Barefoot JC, Helms MJ, Mark DB, Blumenthal JA, Califf RM, Haney TL, et al. Depression and long-term mortality risk in patients with coronary artery disease. Am J Cardiol 1996;78:613-7.  Back to cited text no. 12
13.First, MB., Spitzer, RL, Gibbon M, Williams, JB. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition. (SCID-I/NP) New York: Biometrics Research, New York State Psychiatric Institute, November 2002.  Back to cited text no. 13
14.Kabir MZ, lliyasu IS, Abubakar, Jibril M. Compliance to medication among hypertensive patients in Murtala Mohammed Specialist Hospital, Kano, Nigeria. J Commun Med Pri Health Care 2004;16:16-20.  Back to cited text no. 14
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16.Bensenor IM. Systemic arterial hypertension and psychiatric morbidity in the outpatient care setting of a tertiary hospital. Arq Neuropsiquiatr 1998;56:406-11.  Back to cited text no. 16
17.Hill L, Hofstetter CR, Hovell M, Lee J, Irvin V, Zakarian J. Koreans' use of medical services in Seoul, Korea and California. J Immigr Minor Health 2006;8:273-80.  Back to cited text no. 17
18.Abiodun OA. A study of mental morbidity among primary care patients in Nigeria. Journal of Comprehensive Psychiatry 1993;34:10-5.  Back to cited text no. 18
19.Gureje O, Obikoya B. The GHQ as a screening tool in a Primary care setting. Soc Psychiatry Psychiatr Epidemiol 1990;5:276-80.  Back to cited text no. 19
20.Adigun AQ, Ishola DA, Akintomide AO, Ajayi AA. Shifting trends in the pharmacologic treatment of hypertension in a Nigerian tertiary hospital: A real-world evaluation of the efficacy, safety, rationality and pharmaco-economics of old and newer antihypertensive drugs. J Hum Hypertens 2003;17:277-85.  Back to cited text no. 20
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  [Table 1], [Table 2], [Table 3]

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