Untreated hypertension results in a bevy of comorbidities, including stroke, heart failure, coronary artery disease, and chronic kidney failure. Psychotropic medications raise blood pressure in direct and indirect ways.

Physicians should be cognizant of the dangers psychotropic drugs may pose, as patients with severe mental illness often receive insufficient hypertensive care and may be at increased risk for heart disease, according to an article published by Current Hypertension Reports.

Hypertension in context

Hypertension is linked to major depressive disorder, bipolar disorder, anxiety, and schizophrenia, as well as eating and substance abuse disorders. Additionally, patients with panic disorder typically exhibit hypertension at younger ages.

The Current Psychiatry study found that 61% of patients with bipolar disorder have hypertension vs 41% of the general population. Bipolar disorder and hypertension could share common underpinnings, including hyperactive cellular calcium signalling and higher platelet intracellular calcium ion levels.

In cases of schizophrenia or other severe psychiatric illnesses, individuals may lose 25-plus years of life expectancy due to heart disease. Nontreatment of hypertension is especially concerning in schizophrenia patients, with 62.4% receiving no treatment.

“Because of the well-documented morbidity and mortality of hypertension and its increased prevalence and undertreatment in the psychiatric population, mental health providers are in an important position to recognise hypertension and evaluate its inherent risks to direct their patients toward proper treatment.”

— McCarron, Current Psychiatry

Drugs of concern

Psychiatric drugs may not only increase the risk of hypertension but also blunt the efficacy of antihypertensive agents. Common psychiatric drugs that can raise hypertension include tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), antipsychotics, methylphenidate, and amphetamines, according to a study published in Arterial Hypertension.

Their risks, however, are variable. Drugs like SNRIs may have a milder effect on blood pressure compared to stimulants, which ought to be utilised with extreme caution—or not at all.  However, this level of risk should be evaluated on a case-by-case basis, as some medications may affect patients differently than others.

MAOIs are notorious for the risk of hypertension due to dietary interactions. While mood stabilisers don’t raise blood pressure on their own, lithium can interact with diuretics.

Also of note, many antipsychotics are known to cause metabolic syndrome—weight gain that can lead to increased risk for diabetes, heart disease, and hypertension.

Although the intranasal antidepressant esketamine raises blood pressure shortly after dosing, antihypertensive treatments to counter such effects are usually unnecessary, and this medication is not related to an increased risk of cardiac events.

What to do

On their own, psychiatrists should start the first-line psychotropic with follow-up at 1 month or earlier in patients with severe hypertension (>160/100 mm Hg), as well as chronic kidney disease, congestive heart failure, or coronary artery disease.

Psychiatric patients with severe hypertension are often also prescribed a thiazide diuretic with another medication because monotherapy frequently fails to attain blood-pressure goals.

Patients with chronic kidney disease require close monitoring of potassium, creatinine, and potassium when initiating angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, with levels checked within 1 to 2 days of starting or adjusting regimens.

Complex cases that require the expertise of an internist, cardiologist, or nephrologist include:

• Decompensated comorbidities involving hyperkalemia, renal failure, heart failure, or coronary disease
• Creatinine > 1.8 mg/dL
• Blood pressure > 180/120 mm Hg
• Need for three or more antihypertensives to reach blood-pressure goals
• Secondary causes of hypertension
• Adverse effects secondary to antihypertensive medications

This story is contributed by Naveed Saleh and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.