Introduction

Hypertension (HTN) (140/90 mmHg), now and then called vascular hypertension, is a ceaseless clinical condition in which the strain due to circulation in the veins is raised. At rest, normally, systolic blood pressure (BP) is within the range of 100–140 mm Hg and 60–90mmHg diastolic (Nandhini, 2014). HTN is one of the most common prevailing diseases in adult aged groups of people (Muammar et al., 2019). The burden of various sorts of chronic diseases in India is found to be associated with HTN, the prevalence of HTN in India is increasing day by day and less awareness and control are identified reasons from various studies done across India (Gupta, Gaur, Ram, & Venkata, 2019).

The significant prevalence in HTN patients is found to be associated with an increase in psychological distress and raised the level of systolic BP, more commonly in females than males (Hu et al., 2015; Ojike et al., 2004). A substantial body of evidence supports the role of psychosocial factors, and psychological distress are primary risk factors for HTN (Awuah et al., 2019; Cuffee, Ogedegbe, Williams, Ogedegbe, & Schoenthaler, 2014). Psychological distress and hypertension share a significant association (Ugwu, Onyedibe, & Chukwuorji, 2021). Obesity, high alcohol intakes, physical inactivity, tobacco use and emotional stress are some of the other factors which are said to be associated with HTN (Go et al., 2014). A survey conducted among 396 HTN-Pt which were on follow-up at Jimma University, Teaching Hospital, located in Ethiopia (2017) reported the 31.6% prevalence of psychological distress among single patients more likely as compared to the married and in participants, who were illiterate than who were capable of reading and writing. Also, 7.8% of them had disorders firmly associated with consumption of alcohol, and 19.9% were consuming khat or indulge in substance abuse on a daily basis (Soboka, Gudina, & Tesfaye, 2017). However, another study on herbal extracts by Wong et al. 2016, included grape seed, green tea, and ginkgo and ingredients in Brain, suggested a significant association with psychological distress. In that study, 46.47% out of 85% of patients who were consuming grapes were suffering from psychological distress. (Wong, Darvishzadeh, Maler, & Bota, 2016).

So, as Psychological status in HTN-Pt was found to be affected by various socio-demographic, clinical and lifestyle factors in previous studies done at other locations, there is a need to explore this association in the North-India region, too as there is a paucity on related literature. To address the lacuna, this study was designed to explore the association of various factors (socio-demographic factors, perception about disease, lifestyle, clinical background and usage of herbal supplements) affecting psychological status in HTN-Pt in Ludhiana, Punjab, India.

Materials and Methods

Study Design

The retrospective cohort study was conducted at SPS Hospital, Ludhiana, comprising of 213 patients satisfying the selection criteria:

• Patients with primary and secondary hypertension

• Age more than 18 years

• Both the gender

• Patient suffering from a disease (not less than 1 year)

• Both IPD and OPD patients who appeared for treatment of hypertension except the pregnant women and patients having genotype-specific hypertension.

The study was carried out over a period of a 1-month period from June 2017 to July 2017. All participants provided written informed consent. Ethics approval under protocol number (SPS 01/2017) was obtained from the SPS Hospitals review committee.

Measures

The background information was collected using authentic sciences article search engines, like Google Scholar, Medline Plus, Google, PubMed and other journal sources covering the recent information on the topic till 2019. Patients' data was collected using a hard copy version questionnaire by face-to-face interview.

Socio-Statistic Qualities

A qualitative questionnaire was utilized to estimating socio-statistic qualities of members (age, sexual orientation, married status, educational status, occupation, religion, place of living arrangement), utilization of liquor or cigarette, patient's clinical information on and about hypertension, and self practices, i.e. a way of life factors (work out, salt use and utilization of herbal options).

Psychological distress using Kessler 10-Scale

A quantitative questionnaire, i.e. the Kessler Psychological Distress Scale (K10), is a basic tool to measure mental or psychological distress (Soboka et al., 2017; Wong et al., 2016). It comprises ten questions for which response is recorded at five different levels, i.e. the frequency of experiencing symptoms that a common person has encountered in the latest 4-week time frame.

The total score ranges from 10 to 50. The total score was interpreted as follow: well (10 to 19), mild (20 to 24), moderate (25 to 29) and severe psychological distress (30 to 50).

Data collection procedures

Information gathering was done after the surveys were pretested on a small sample (5% of the aggregate sample) of the patients with HTN going to the cardiac OPD at SPS Hospital.

The patients included in the pre-test were excluded from the fundamental examination. Self-collection of data in the form of questionnaires and software Akhil Systems Pvt. ltd (health care IT partner), 1mg, MedPlus mart, Mims was done.

Data analysis

Information was interpreted utilizing the Statistical Package for Social Sciences (SPSS) form 22 using bivariate logistic regression analysis, keeping in mind the end goal to appraise the quality of affiliation utilizing odds ratios (COR). All factors related with mental distress with a p value<0.05 were considered as altogether relate. All factors related with psychological distress with a p value<0.05 under 0.25 were analysed using multivariable logistic regression for adjusting potential confounders. Ages, hypersensitivity, utilization of grapes and patients’ perception were investigated as constant factors.

Ethical considerations

Ethical approval was received from the Human Ethic board of trustees of SPS Hospitals, Ludhiana, Punjab. Informed consent was also retrieved from every participant before information accumulation. Confidentiality was maintained at all phase of information preparing and examination.

Results and Discussion

Socio-demographic characteristics of Hypertensive patient:

A total of 275 patients were taken into this study and 213 patients agreed to participate with a response rate of 77.45%. The mean age of patients was 50.97±1.051 years and ranged from 18 to 86 years. Table 1 shows that out of total participants, female HTN-Pt were in the majority, majorly belonging to Sikh religion, followed by Hindus residing in an urban area, and were retired from occupation. Most of HTN-Pt were married and educationally sounded, i.e. graduate or undergraduates.

Table 2 shows the percentage responses of an unstructured questionnaire, which was framed to assess the perception and awareness of the patients regarding hypertension and its maintenance.

The prevalence of alcohol use in this study, 15.3%, was higher than the similar study performed in Southwest Ethiopia (7.8%) but lower than the findings from a community-based study done in Jimma town (62.4%), Gurage Zone (21%) (Bissa, Mossie, & Gobena, 2014).

Clinical status

During the filling up of questionnaires, the vital of the patients were also measured to assess their current clinical status. The mean BMI of patients was 25.274±0.339 (Overweight) and ranged from 20 to 50. An analysis of mean systolic and diastolic pressures among the Urban Indian population in the age range between 40-49 years showed an increase of mean systolic pressure 120.4 mmHg and mean diastolic pressure 73.2 mm of Hg in 1942 to 128.7/84.2 mm of Hg in 1985, 128.8/83.2 mm of Hg in 1995 and 141/85 mm of Hg in 2005. A higher prevalence of hypertension is often indicated by a rise in mean systolic and diastolic pressure (Hamer, Batty, Stamatakis, & Kivimaki, 2010).

In this study, the mean pulse rate of patients was 91.04/min (ranged from 70-100 beats/min), and the mean Blood Pressure of HTN-Pt was 93.74±7.4 mm of Hg (Diastolic)/137.05±7.14 mm of Hg (Systolic).

Prevalence of Psychological distress

The Kessler – 10 ten items questionnaire was administered to patients to record the rate of psychological morbidity. As per the collected data, the commonness of psychological distress was found to be 46.9 %. As per the indications, 53 % of the patients were well, 26 % were suffering from mild distress, 17% from moderate psychological distress and 4% were severely affected (Figure 1).

The present study findings revealed that the prevalence of psychological distress (46.9%) was higher than the findings of community-based studies done among HTN-Pt in England (15.7%) and former the Soviet Union (9.9%) (Footman, Roberts, Tumanov, & McKee, 2013). Psychological distress was found to be highly prevalent among HTN-Pt on follow-up at Jimma University Hospital.

Similarly, the prevalence of psychological morbidity found in this study was higher than the finding of a similar study done in Southwest Ethiopia (36.6%) (Soboka et al., 2017). The discrepancy between the four studies might be due to the difference in the tools used to assess psychological morbidity (Kessler-10, Kessler-6 and GHQ-12).

Association of socio-demographic and several other factors governing awareness, patients' perception, lifestyle and clinical background with psychological distress

Data obtained using the questionnaire was entered stepwise and analyzed using the Statistical Package for Social Sciences (SPSS). The outcome and explanatory variables were entered into a bivariate logistic regression analysis, one by one, in order to estimate the strength of association using odds ratios (OR). The data with a p-value<0.05 were considered significant.

Highest percentage (33.80%) of patients with psychological distress were associated with the age group 31-60 years of age (p value=0.003, COR= 0.240, 95% CI 0.072, 0.584). Table 3 shows the response received from the patients regarding the use of herbal formulations and supplements, significant association was found with the use of grapes and the occurrence of psychological distress. Table 3 shows that patients having diet enriched with grapes has 0.380 times (62%) more likely to have psychological distress compared to the patients not consuming grapes (p value=0.034, COR= 0.380, 95% CI 0.155, 0.930) or patients not eating grapes are 2.63 times more likely not to have psychological morbidity. However, there was no association between substance use and psychological morbidity.

Most of the herbal therapies used by the participants of this study are similar to those reported from other studies in the literature. Garlic, grapes, green tea, olives and some of the vitamins are natural foods recommended for healthy nutrition. However, they may be harmful when consumed in higher amounts and they may interact with drugs used for hypertension treatment (Edwards, Colquist, & Maradiegue, 2005).

In this study, most of the hypertensive subjects perceived herbal therapies or formulations containing garlic, grapes, green tea and vitamins. It has been suggested in the literature that minerals and vitamins present in garlic, grape juice, green tea, etc., play a role in reducing blood pressure (Bahar et al., 2013).

However, another study on herbal extracts included grape seed, green tea, and ginkgo, ingredients in Brain Awake and Brain Support. These and several other herbs were found to inhibit sulfotransferase 1A3, a phase II detoxifying enzyme in the intestinal epithelium that modulates dopamine sulfation, thus increasing the bioavailability of dopaminergic drugs. With the effect of elevated dopamine levels in psychosis, the ability of these herbal interactions to modulate dopamine metabolism and reuptake may have contributed to Mr A's psychotic symptoms. In this study, 85% of patients using herbal formulations were using grapes and out of which 50.50% patients were suffering from psychological distress (Wong et al., 2016).

Conclusion

The prevalence of psychological distress among HTN-Pt was 46.9% of the total participants, incorporating those who had alcohol use disorders and were addicted to smoking habits. Patients with age (31-60 years) and those who were using herbal alternatives containing grapes were more likely to have psychological distress. However, no association with substance abuse, clinical background, and patient’s perception and awareness was found. The effects of alternative herbal substances on blood pressure needs further investigation.