Journal of General Internal Medicine

, Volume 17, Issue 7, pp 504–511 | Cite as

Noncompliance with antihypertensive medications

The impact of depressive symptoms and psychosocial factors
  • Philip S. Wang
  • Rhonda L. Bohn
  • Eric Knight
  • Robert J. Glynn
  • Helen Mogun
  • Jerry Avorn
Original Articles


OBJECTIVE: Addressing the epidemic of poor compliance with antihypertensive medications will require identifying factors associated with poor adherence, including modifiable psychosocial and behavioral characteristics of patients.

DESIGN: Cross-sectional study, comparing measured utilization of antihypertensive prescriptions with patients’ responses to a structured interview.

STUDY POPULATION: Four hundred ninety-six treated hypertensive patients drawn from a large HMO and a VA medical center.

DATA COLLECTION: We developed a survey instrument to assess patients’ psychosocial and behavioral characteristics, including health beliefs, knowledge, and social support regarding blood pressure medications, satisfaction with health care, depression symptom severity, alcohol consumption, tobacco use, and internal versus external locus of control. Other information collected included demographic and clinical characteristics and features of antihypertensive medication regimens. All prescriptions filled for antihypertensive medications were used to calculate actual adherence to prescribed regimens in a 365-day study period.

MAIN OUTCOME OF INTEREST: Adjusted odds ratios (ORs) of antihypertensive compliance, based on ordinal logistic regression models.

RESULTS: After adjusting for the potential confounding effects of demographic, clinical, and other psychosocial variables, we found that depression was significantly associated with noncompliance (adjusted OR per each point increase on a 14-point scale, 0.93; 95% confidence interval [95% CI], 0.87 to 0.99); in unadjusted analyses, the relationship did not reach statistical significance. There was also a trend toward improved compliance for patients perceiving that their health is controlled by external factors (adjusted OR per point increase, 1.14; 95% CI, 0.99 to 1.33). There was no association between compliance and knowledge of hypertension, health beliefs and behaviors, social supports, or satisfaction with care.

CONCLUSIONS: Depressive symptoms may be an under-recognized but modifiable risk factor for poor compliance with antihypertensive medications. Surprisingly, patient knowledge of hypertension, health beliefs, satisfaction with care, and other psychosocial variables did not appear to consistently affect adherence to prescribed regimens.

Key words

antihypertensive medication adherence depressive symptoms psychosocial factors 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Burt V, Whelton P, Roccells E, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension. 1995;25:305–13.PubMedGoogle Scholar
  2. 2.
    Sharkness CM, Snow DA. The patient’s view of hypertension and compliance. Am J Prev Med. 1992;8:141–6.PubMedGoogle Scholar
  3. 3.
    Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am J Public Health. 1996;86:1805–8.PubMedGoogle Scholar
  4. 4.
    Clark T. Improving compliance and increasing control of hypertension: needs of special hypertensive populations. Am Heart J. 1991;121:664–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Oparil S, Calhoun DA. Managing the patient with hard-to-control hypertension. Am Fam Physician. 1998;57:1007–14.PubMedGoogle Scholar
  6. 6.
    Setaro J, Black H. Refractory hypertension. N Engl J Med. 1992;327:543–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Sackett D, Haynes R, Gibson E, et al. Randomised clinical trial of strategies for improving medication compliance in primary hypertension. Lancet. 1975;7918:1205–7.CrossRefGoogle Scholar
  8. 8.
    The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:2413–44.CrossRefGoogle Scholar
  9. 9.
    Haynes RB. Determinants of compliance: the disease and the mechanics of treatment. In: Haynes RB, Taylor D, Sackett D, eds. Compliance in Health Care. Baltimore: Johns Hopkins University Press; 1979.Google Scholar
  10. 10.
    Klein LE. Compliance and blood pressure control. Hypertension. 1988;11:II61–4.PubMedGoogle Scholar
  11. 11.
    Costa FV. Compliance with anthihypertensive treatment. Clin Exp Hypertens. 1996;18:463–72.PubMedGoogle Scholar
  12. 12.
    Bailey JE, Lee MD, Somes GW, Graham RL. Risk factors for antihypertensive medication refill failure by patients under Medicaid managed care. Clin Ther. 1996;18:1252–62.PubMedCrossRefGoogle Scholar
  13. 13.
    McClellan W, Hall W, Brogan D, Miles C, Wilber J. Continuity of care in hypertension. Arch Intern Med. 1988;148:525–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Balazovjech I, Hnilica P Jr. Compliance with antihypertensive treatment in consultation rooms for hypertensive patients. J Hum Hypertens. 1993;7:581–3.PubMedGoogle Scholar
  15. 15.
    Shaw E, Anderson J, Maloney M, Jay S, Fagan D. Factors associated with noncompliance of patients taking antihypertensive medications. Hosp Pharm. 1995;30:201–7.PubMedGoogle Scholar
  16. 16.
    Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. The effects of initial drug choice and comorbidity on antihypertensive therapy compliance. Am J Hypertens. 1997;10:697–704.PubMedCrossRefGoogle Scholar
  17. 17.
    Haynes RB, Mattson M, Chobanian A, et al. Management of patient compliance in the treatment of hypertension. Report of the NHLBI Working Group. Hypertension. 1982;4:415–23.Google Scholar
  18. 18.
    Haynes RB. A critical review of the “determinants” of patient compliance with therapeutic regimens. In: Sackett DL, Haynes RB, eds. Compliance with Therapeutic Regimens, Johns Hopkins University Press; 1976.Google Scholar
  19. 19.
    Norman SA, Marconi KM, Schezel GW, Schechter CF, Stolley PD. Beliefs, social normative influences, and compliance with antihypertensive medication. Am J Prev Med. 1985;1:10–7.PubMedGoogle Scholar
  20. 20.
    Haines C, Ward G. Recent trends in public knowledge, attitudes, and reported behavior with respect to high blood pressure. Public Health Rep. 1981;96:515–22.Google Scholar
  21. 21.
    Earp J, Ory M. The effects of social support and health professional home visits on patient adherence to hypertension regimens. Prev Med. 1979;8:155–62.Google Scholar
  22. 22.
    Nelson E, Stason W, Neutra R, Solomon H. Identification of the noncompliant hypertensive patient. Prev Med. 1980;9:504–17.PubMedCrossRefGoogle Scholar
  23. 23.
    Bittar N. Maintaining long-term control of blood pressure: the role of improved compliance. Clin Cardiol. 1995;18:(6 suppl 3)12–6.Google Scholar
  24. 24.
    Baksaas I, Helgeland A. Patient reaction to information and motivation factors in long-term treatment with antihypertensive drugs. Acta Med Scand. 1980;207:407–12.PubMedCrossRefGoogle Scholar
  25. 25.
    Hershey JC, Morton BG, Braithwaite Davis J, Reichgott MJ. Patient compliance with antihypertensive medication. Am J Public Health. 1980;70:1081–9.PubMedGoogle Scholar
  26. 26.
    Volicer B, Volicer L. Randomized response technique for estimating alcohol use and noncompliance in hypertensives. J Stud Alcohol. 1982;43:739–50.PubMedGoogle Scholar
  27. 27.
    Carney RM, Freedland KE, Eisen SA, Rich MW, Jaffe AS. Major depression and medication adherence in elderly patients with coronary artery disease. Health Psychol. 1995;14:88–90.PubMedCrossRefGoogle Scholar
  28. 28.
    Derogatis L, Melisaratos N. The brief symptom inventory: an introductory report. Psychol Med. 1983;13:595–605.PubMedCrossRefGoogle Scholar
  29. 29.
    Rudnick K, Sackett D, Hirst S, Holmes C. Hypertension in a family practice. Can Med Assoc J. 1977;117:492–7.PubMedGoogle Scholar
  30. 30.
    Levine D, Gren L, Deeds S, Chwalow J, Russell P, Finlay J. Health education for hypertensive patients. JAMA. 1979;241:1700–3.PubMedCrossRefGoogle Scholar
  31. 31.
    Rotter J. Some problems and misconceptions related to the construct of internal versus external control of reinforcement. J Consult Clin Psychol. 1975;43:56–67.CrossRefGoogle Scholar
  32. 32.
    Marlowe D, Crowne DP. Social desirability and response to perceived situation demands. J Consult Psychol. 1961;25:109–15.PubMedCrossRefGoogle Scholar
  33. 33.
    Gurwitz JH, Glynn RJ, Monane M, et al. Treatment for glaucoma: adherence by the elderly. Am J Public Health. 1993; 83:711–6.PubMedGoogle Scholar
  34. 34.
    Avorn J, Monette J, Lacour A, et al. Persistance of use of lipid-lowering medications. JAMA. 1998;279:1458–62.PubMedCrossRefGoogle Scholar
  35. 35.
    Haynes RB, Sackett DL, Gibson ES, et al. Improvement of medication compliance in uncontrolled hypertension. Lancet. 1976;1:1265–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Hypertension Detection and Follow-Up Program Cooperative Group. Five-year findings of the hypertension detection follow-up program. JAMA. 1979;242:2562–77.CrossRefGoogle Scholar
  37. 37.
    SAS User’s Guide. Version 6.12. SAS Institute, Cary, N.C., 1998.Google Scholar
  38. 38.
    Avorn J, Everitt D, Weiss S. Increased antidepressant use in patients prescribed beta-blockers. JAMA. 1986;225:357–60.CrossRefGoogle Scholar
  39. 39.
    Morgado A, Raoux N, Smith M, Allilaire J, Widlocher D. Subjective bias in reports of poor work adjustment in depressed patients. Acta Psychiatr Scand. 1989;80:541–7.PubMedGoogle Scholar
  40. 40.
    Singh N, Squier C, Sivek C, Wagener M, Nguyen MH, Yu VL. Determinants of compliance with antiretroviral therapy in patients with human immunodeficiency virus: prospective assessment with implications for enhancing compliance. AIDS Care. 1996;8:261–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Kiley D, Lam C, Pollak R. A study of treatment compliance following kidney transplantation. Transplantation. 1993;55:51–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Bosley C, Fosbury J, Cochrane G. The psychological factors associated with poor adherence with treatment for asthma. Eur Respir J. 1995;8:899–904.PubMedGoogle Scholar
  43. 43.
    Meichenbaum D, Turk D. Facilitating Treatment Adherence. New York: Plenum; 1987.Google Scholar
  44. 44.
    Col N, Fanale J, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med. 1990;150:841–5.PubMedCrossRefGoogle Scholar
  45. 45.
    Conn V, Taylor S, Abele P. Myocardial infarction survivors: age and gender differences in physical health, psychosocial state, and regimen adherence. J Adv Nurs. 1991;16:1026–34.PubMedCrossRefGoogle Scholar
  46. 46.
    Waxman HM, McCreary G, Weinrit RM, Carner EA. A comparison of somatic complaints among depressed and nondepressed older patients. Gerontologist. 1987;85:501–7.Google Scholar
  47. 47.
    Marks G, Richardson J, Graham J, Levine A. Role of health locus of control beliefs and expectations of treatment efficacy in adjustment to cancer. J Pers Soc Psychol. 1986;51:443–50.PubMedCrossRefGoogle Scholar
  48. 48.
    Bursten B. Medication nonadherence due to feelings of loss of control in “biological depression.” Am J Psychiatry. 1985;142:244–6.PubMedGoogle Scholar
  49. 49.
    Ley P. Doctor-patient communication: some quantitative estimates of the role of cognitive factors in non-compliance. J Hypertens. 1985;3(suppl 1):51–5.Google Scholar
  50. 50.
    Carney R, Rich M, Freedland K, et al. Major depressive disorder predicts cardiac events in patients with coronary artery disease. Psychosom Med. 1988;50:627–33.PubMedGoogle Scholar
  51. 51.
    Carney R, Rich M, teVelde A, Saini J, Clark K, Jaffe A. Major depressive disorder in coronary artery disease. Am J Cardiol. 1987;60:1273–5.PubMedCrossRefGoogle Scholar
  52. 52.
    Wassertheil-Smoller S, Applegate W, Berge K, et al. Change in depression as a precursor of cardiovascular events. Arch Intern Med. 1996;156:553–61.PubMedCrossRefGoogle Scholar
  53. 53.
    Bruce M, Leaf P. Psychiatric disorders and 15-month mortality in a community sample of older adults. Am J Public Health. 1989;79:727–30.PubMedCrossRefGoogle Scholar
  54. 54.
    Rabins P, Harvis K, Koven S. High fatality rates of late life depression associated with cardiovascular disease. J Affect Disord. 1985;9:165–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Hirschfeld R, Keller M, Panico S, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277:333–40.PubMedCrossRefGoogle Scholar
  56. 56.
    Katz SJ, Kessler RC, Lin E, Wells KB. Medication management of depression in the United States and Ontario. J Gen Intern Med. 1998;13:77–85.PubMedCrossRefGoogle Scholar
  57. 57.
    Wang PS, Berglund P, Kessler RC. Recent care of common mental disorders in the United States: prevalence and conformance with evidence-based recommendations. J Gen Intern Med. 2000;15:284–92.PubMedCrossRefGoogle Scholar
  58. 58.
    Mohr D, Goodkin D, Likosky W, Gatto N, Baumann K, Rudick R. Treatment of depression improves adherence to interferon beta-1b therapy for multiple sclerosis. Arch Neurol. 1997;54:531–3.PubMedGoogle Scholar
  59. 59.
    Lustman P, Griffith L, Freedland K, Kissel S, Clouse R. Cognitive behavior therapy for depression in type 2 diabetes mellitus. Ann Intern Med. 1998;129:613–21.PubMedGoogle Scholar
  60. 60.
    Eastaugh S, Hatcher M. Improving compliance among hypertensives: a triage criterion with cost-benefit implications. Med Care. 1982;20:1001–17.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2002

Authors and Affiliations

  • Philip S. Wang
    • 1
  • Rhonda L. Bohn
  • Eric Knight
  • Robert J. Glynn
  • Helen Mogun
  • Jerry Avorn
  1. 1.Division of Pharmacoepidemiology and PharmacoeconomicsBrigham and Women’s HospitalBoston

Personalised recommendations