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\begin{document}


\def\RunningAuthor{Arshvir Kaur et al.}
\firstPage{2132}
\articleType{Original Article}
\receivedDate{02 Jun 2021}
\acceptedDate{12 Jul 2021}
\revisedDate{08 Jul 2021}
\journalVolume{2021, 12}
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\journalDoi{ijrps.v12i3.4823}
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\title{\textbf{Psychological distress and its associated factors in the hypertensive patient (HTN-Pt) in Ludhiana, Punjab: A questionnaire-based retrospective study }}
\author{Maninder~Singh\textsuperscript{1},  
            Bikram~Singh\textsuperscript{1}, 
            Arshvir~Kaur\textsuperscript{*}\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Lovely School of Pharmaceutical Sciences, Lovely Professional University, Jalandhar-Delhi GT Road, Phagwara-144001, Punjab, India}~\\{\textsuperscript{2}Department of Pharmacology, Delhi Institute of Pharmaceutical Sciences and Research, Sector 3, MB Road, Pushp Vihar-110017, New Delhi, India}}

\begin{abstract}
An elevation in blood pressure is an important risk factor of cardiovascular disease and several factors that can contribute to hypertension induce psychological distress. This study was aimed at estimating the prevalence of psychological distress and to assess general awareness regarding disease, concomitant substance abuse, and use of herbal drugs among hypertensive patients (HTN-Pt) at Satguru Pratap Singh (SPS) Hospitals, Ludhiana. The psychological distress was assessed using the standard Kessler-10 scale along with face-to-face interview among 275 outpatient department (OPD) HTN-Pt on follow-up. 15.30\% (n=33) of total participants (n=213) had alcohol use disorders and 8.80\% (n=19) of them were addicted to smoking habits. K10 scale results in patients, showed 46.9\% (100) patients were suffering from psychological distress out of which 26\% (n=56) were having mild, 17\% (n=36) moderate and 4\% (n=8) patients were having severe psychological distress. Highest percentage (33.80\%) of patients with psychological distress were from age group 31-60 years of age (p value=0.003, COR= 0.240, 95\% CI 0.072, 0.584). Many HTN-Pt were consuming the herbal supplements out of which 92 \% of patients consuming grapes were found to have psychological distress (p value=0.034, COR= 0.380, 95\% CI 0.155, 0.930). The results of the study indicated that there was a high prevalence of psychological distress in HTN-Pt belonging to age group of 31-60 years of age and patients involved in the consumption of grapes. This study asks for supervision on the concomitant administration of herbal supplements with allopathic medicines in HTN-Pt to avoid psychological distress. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Hypertension,\newline herbal formulations,\newline Psychological distress,\newline Kessler-10,\newline grapes
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Arshvir~Kaur~\\ Phone:\ +91-9855518759~\\  Email:\ archie.dhwal@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{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{\textendash}140 mm Hg and 60{\textendash}90mmHg diastolic \unskip~\citep{1156208:22694541}. HTN is one of the most common prevailing diseases in adult aged groups of people \unskip~\citep{1156208:22694545}. 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 \unskip~\citep{1156208:22694542}. 

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 \unskip~\citep{1156208:22694544,1156208:22694539}. A substantial body of evidence supports the role of psychosocial factors, and psychological distress are primary risk factors for HTN \unskip~\citep{1156208:22694553,1156208:22694549}. Psychological distress and hypertension share a significant association \unskip~\citep{1156208:22694543}. 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 \unskip~\citep{1156208:22694552}. 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 \unskip~\citep{1156208:22694538}. However, another study on herbal extracts by Wong \textit{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. \unskip~\citep{1156208:22694540}. 

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. 
    
\section{Materials and Methods}
\textbf{Study Design}

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


  
  \begin{enumerate}
  \item \relax Patients with primary and secondary hypertension 
  \item \relax Age more than 18 years 
  \item \relax Both the gender
  \item \relax Patient suffering from a disease (not less than 1 year)
  \item \relax Both IPD and OPD patients who appeared for treatment of hypertension except the pregnant women and patients having genotype-specific hypertension. 
  \end{enumerate}
  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.

\textbf{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. 

\textbf{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).

\textbf{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 \unskip~\citep{1156208:22694538,1156208:22694540}. 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). 


\bgroup
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\caption{\boldmath {Prevalence of psychological distress in HTN-Pt}}
\label{f-2e36f64866ce}
\end{figure}
\egroup

\begin{table*}[!htbp]
\caption{\boldmath {Socio-Demographic Characteristics } }
\label{tw-58985ed33cc1}
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\ignorespaces 
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Variable & \cAlignHack Frequency & \cAlignHack Percent (\%)\\
\tblmidrule 
\cAlignHack \textbf{Gender} &
   &
  \\
\cAlignHack Male &
  \cAlignHack 105 &
  \cAlignHack 48.8\\
\cAlignHack Female &
  \cAlignHack 109 &
  \cAlignHack 50.7\\
 &
   &
  \\
\cAlignHack \textbf{Residence} &
   &
  \\
\cAlignHack Rural &
  \cAlignHack 74 &
  \cAlignHack 34.4\\
\cAlignHack Urban &
  \cAlignHack 140 &
  \cAlignHack 65.1\\
 &
   &
  \\
\cAlignHack \textbf{Occupation} &
   &
  \\
\cAlignHack Daily Labor &
  \cAlignHack 22 &
  \cAlignHack 10.2\\
\cAlignHack Farmer &
  \cAlignHack 13 &
  \cAlignHack 6.0\\
\cAlignHack Housewife &
  \cAlignHack 74 &
  \cAlignHack 34.4\\
\cAlignHack Merchant &
  \cAlignHack 68 &
  \cAlignHack 7.0\\
\cAlignHack Teacher &
  \cAlignHack 15 &
  \cAlignHack 99.5\\
\cAlignHack Retired &
  \cAlignHack 7 &
  \cAlignHack 3.3\\
\cAlignHack Other &
  \cAlignHack 68 &
  \cAlignHack 31.6\\
 &
   &
  \\
\cAlignHack \textbf{Marital Status} &
   &
  \\
\cAlignHack Single &
  \cAlignHack 14 &
  \cAlignHack 6.5\\
\cAlignHack Married &
  \cAlignHack 165 &
  \cAlignHack 76.7\\
\cAlignHack Divorced &
  \cAlignHack 5 &
  \cAlignHack 2.3\\
\cAlignHack Widowed &
  \cAlignHack 30 &
  \cAlignHack 14.0\\
 &
   &
  \\
\cAlignHack \textbf{Education Status} &
   &
  \\
\cAlignHack Illiterate &
  \cAlignHack 13 &
  \cAlignHack 6.0\\
\cAlignHack Read \& Write &
  \cAlignHack 22 &
  \cAlignHack 10.6\\
\cAlignHack Undergraduate &
  \cAlignHack 98 &
  \cAlignHack 45.6\\
\cAlignHack Graduate &
  \cAlignHack 81 &
  \cAlignHack 37.7\\
 &
   &
  \\
\cAlignHack \textbf{Religion} &
   &
  \\
\cAlignHack Hindu &
  \cAlignHack 90 &
  \cAlignHack 41.9\\
\cAlignHack Muslim &
  \cAlignHack 11 &
  \cAlignHack 5.1\\
\cAlignHack Sikh &
  \cAlignHack 109 &
  \cAlignHack 50.7\\
\cAlignHack Orthodox &
  \cAlignHack 4 &
  \cAlignHack 1.9\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Awareness and perception of patients regarding hypertension} }
\label{tw-7fcddd77877e}
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Variable & \cAlignHack Frequency & \cAlignHack Percent (\%)\\
\tblmidrule 
\cAlignHack \textbf{Is HTN Curable? } &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 13.5 &
  \cAlignHack 62.8\\
\cAlignHack  No &
  \cAlignHack 79 &
  \cAlignHack 36.7\\
\cAlignHack \textbf{Is HTN Deadly?} &
   &
  \\
\cAlignHack Yes &
  \cAlignHack 92 &
  \cAlignHack 42.8\\
\cAlignHack  No &
  \cAlignHack 122 &
  \cAlignHack 56.7\\
\cAlignHack \textbf{Do you smoke?} &
   &
  \\
\cAlignHack Yes &
  \cAlignHack 19 &
  \cAlignHack 8.8\\
\cAlignHack  No &
  \cAlignHack 195 &
  \cAlignHack 90.7\\
\cAlignHack \textbf{Do you exercise?} &
   &
  \\
\cAlignHack Yes &
  \cAlignHack 95 &
  \cAlignHack 44.2\\
\cAlignHack  No &
  \cAlignHack 119 &
  \cAlignHack 55.3\\
\cAlignHack \textbf{Do you have junk food?} &
   &
  \\
\cAlignHack Yes &
  \cAlignHack 53 &
  \cAlignHack 24.7\\
\cAlignHack  No &
  \cAlignHack 161 &
  \cAlignHack 74.9\\
\cAlignHack \textbf{Do you follow salt restrictions?} &
   &
  \\
\cAlignHack Yes &
  \cAlignHack 24 &
  \cAlignHack 11.2\\
\cAlignHack  No &
  \cAlignHack 190 &
  \cAlignHack 88.4\\
\cAlignHack \textbf{Do you practice yoga?} &
   &
  \\
\cAlignHack Yes &
  \cAlignHack 45 &
  \cAlignHack 20.9\\
\cAlignHack  No &
  \cAlignHack 169 &
  \cAlignHack 78.6\\
\cAlignHack \textbf{Do you consume alcohol?} &
   &
  \\
\cAlignHack Yes &
  \cAlignHack 33 &
  \cAlignHack 15.3\\
\cAlignHack  No &
  \cAlignHack 181 &
  \cAlignHack 84.2\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Association of use of herbal alternatives with the prevalence of psychological distress } }
\label{tw-df60dbadceaf}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.16595714285714283\linewidth-2\tabcolsep}p{\dimexpr.14645714285714286\linewidth-2\tabcolsep}p{\dimexpr.1540571428571429\linewidth-2\tabcolsep}p{\dimexpr.1381571428571429\linewidth-2\tabcolsep}p{\dimexpr.13051428571428573\linewidth-2\tabcolsep}p{\dimexpr.13654285714285718\linewidth-2\tabcolsep}p{\dimexpr.1283142857142858\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Variables & \multicolumn{2}{p{\dimexpr(.30051428571428573\linewidth-2\tabcolsep)}}{\cAlignHack Psychological Distress} & \cAlignHack p-value & \cAlignHack OR & \multicolumn{2}{p{\dimexpr(.26485714285714298\linewidth-2\tabcolsep)}}{\cAlignHack 95 \% CI}\\
\rowcolor{kwdboxcolor}\cAlignHack  & \cAlignHack Yes & \cAlignHack No & \cAlignHack  & \cAlignHack  & \cAlignHack Lower & \cAlignHack Upper\\
\rowcolor{kwdboxcolor}\cAlignHack  & \cAlignHack N (\%) & \cAlignHack N (\%) & \cAlignHack  & \cAlignHack  & \cAlignHack  & \cAlignHack \\
\tblmidrule 
\cAlignHack \textbf{L-arginine} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 40(44.9) &
  \cAlignHack 49(55.1) &
  \cAlignHack .889 &
  \cAlignHack 1.043 &
  \cAlignHack .578 &
  \cAlignHack 1.884\\
\cAlignHack No &
  \cAlignHack 60(48.4) &
  \cAlignHack 64(51.6) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\cAlignHack \textbf{Garlic} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 88(48.4) &
  \cAlignHack 94(51.6) &
  \cAlignHack .615 &
  \cAlignHack .809 &
  \cAlignHack .353 &
  \cAlignHack 1.851\\
\cAlignHack No &
  \cAlignHack 12(38.7) &
  \cAlignHack 19(61.3) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\cAlignHack \textbf{Grapes} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 92(50.5) &
  \cAlignHack 90(49.5) &
  \cAlignHack .034 &
  \cAlignHack .380 &
  \cAlignHack .155 &
  \cAlignHack .930\\
\cAlignHack No &
  \cAlignHack 8(25.8) &
  \cAlignHack 23(74.2) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\cAlignHack \textbf{Olive} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 29(41.4) &
  \cAlignHack 41(58.6) &
  \cAlignHack 0.75 &
  \cAlignHack 1.856 &
  \cAlignHack .939 &
  \cAlignHack 3.669\\
\cAlignHack No &
  \cAlignHack 71(49.7) &
  \cAlignHack 72(50.3) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\cAlignHack \textbf{Green Tea} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 50(53.2) &
  \cAlignHack 44(46.8) &
  \cAlignHack 0.91 &
  \cAlignHack .583 &
  \cAlignHack .311 &
  \cAlignHack 1.091\\
\cAlignHack No &
  \cAlignHack 50(42.0) &
  \cAlignHack 69(58.0) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\cAlignHack \textbf{Vitamins} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 79(47.9) &
  \cAlignHack 86(52.1) &
  \cAlignHack .566 &
  \cAlignHack .816 &
  \cAlignHack .408 &
  \cAlignHack 1.634\\
\cAlignHack No &
  \cAlignHack 21(43.8) &
  \cAlignHack 27(56.3) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\multicolumn{3}{p{\dimexpr(.4664714285714286\linewidth-2\tabcolsep)}}{\textbf{Do you use Herbal medicines?}} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 18(46.2) &
  \cAlignHack 21(53.8) &
  \cAlignHack .893 &
  \cAlignHack 1.123 &
  \cAlignHack .205 &
  \cAlignHack 6.168\\
\cAlignHack No &
  \cAlignHack 82(47.1) &
  \cAlignHack 92(52.9) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\multicolumn{3}{p{\dimexpr(.4664714285714286\linewidth-2\tabcolsep)}}{\textbf{Because they are Cheap?}} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Do not use &
  \cAlignHack 84(47.2) &
  \cAlignHack 94(52.8) &
  \cAlignHack .314 &
  \cAlignHack 5.982 &
  \cAlignHack .184 &
  \cAlignHack 194.644\\
\cAlignHack Yes &
  \cAlignHack 8(34.8) &
  \cAlignHack 15(65.2) &
  \cAlignHack .098 &
  \cAlignHack 4.867 &
  \cAlignHack .749 &
  \cAlignHack 31.630\\
\cAlignHack No &
  \cAlignHack 8(66.7) &
  \cAlignHack 4(33.3) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\multicolumn{3}{p{\dimexpr(.4664714285714286\linewidth-2\tabcolsep)}}{\textbf{Because they are effective?}} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Do not use &
  \cAlignHack 84(47.2) &
  \cAlignHack 94(52.8) &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 10(43.5) &
  \cAlignHack 13(56.5) &
  \cAlignHack .921 &
  \cAlignHack .914 &
  \cAlignHack .153 &
  \cAlignHack 5.459\\
\cAlignHack No &
  \cAlignHack 6(50.0) &
  \cAlignHack 6(50.0) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\multicolumn{3}{p{\dimexpr(.4664714285714286\linewidth-2\tabcolsep)}}{\textbf{Because they have lesser side effects?}} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Do not use &
  \cAlignHack 84(47.2) &
  \cAlignHack 94(52.8) &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 10(41.7) &
  \cAlignHack 14(58.3) &
  \cAlignHack .551 &
  \cAlignHack 1.732 &
  \cAlignHack .285 &
  \cAlignHack 10.531\\
\cAlignHack No &
  \cAlignHack 6(54.5) &
  \cAlignHack 5(45.5) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
 &
   &
   &
   &
   &
   &
  \\
\multicolumn{3}{p{\dimexpr(.4664714285714286\linewidth-2\tabcolsep)}}{\textbf{Because they are popular?}} &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Do not use &
  \cAlignHack 84(47.2) &
  \cAlignHack 94(52.8) &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack  &
  \cAlignHack \\
\cAlignHack Yes &
  \cAlignHack 10(47.6) &
  \cAlignHack 11(52.4) &
  \cAlignHack .861 &
  \cAlignHack .851 &
  \cAlignHack .141 &
  \cAlignHack 5.140\\
\cAlignHack No &
  \cAlignHack 6(42.9) &
  \cAlignHack 8(57.1) &
  \cAlignHack  &
  \multicolumn{2}{p{\dimexpr(.26705714285714294\linewidth-2\tabcolsep)}}{\cAlignHack Reference} &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{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 \textit{Akhil Systems Pvt. ltd (health care IT partner), 1mg, MedPlus mart, Mims }was done.

\textbf{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 \textit{p value}{\textless}0.05 were considered as altogether relate. All factors related with psychological distress with a \textit{p value}{\textless}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. 

\textbf{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.
    
\section{Results and Discussion}
\textbf{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\ensuremath{\pm}1.051 years and ranged from 18 to 86 years. Table~\ref{tw-58985ed33cc1} 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~\ref{tw-7fcddd77877e} 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\%) \unskip~\citep{1156208:22694548}.

\textbf{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\ensuremath{\pm}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 \unskip~\citep{1156208:22694551}. 

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\ensuremath{\pm}7.4 mm of Hg (Diastolic)\textbf{/}137.05\ensuremath{\pm}7.14 mm of Hg (Systolic).

\textbf{Prevalence of Psychological distress}

The Kessler {\textendash} 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~\ref{f-2e36f64866ce}). 

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\%) \unskip~\citep{1156208:22694547}. 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\%) \unskip~\citep{1156208:22694538}. 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).

\textbf{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{\textless}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 \textit{(p value=0.003, COR= 0.240, 95\% CI 0.072, 0.584)}. Table~\ref{tw-df60dbadceaf} 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~\ref{tw-df60dbadceaf} 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 \textit{(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 \unskip~\citep{1156208:22694546}. 

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 \unskip~\citep{1156208:22694550}. 

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 \unskip~\citep{1156208:22694540}. 
    
\section{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.  
\section*{Acknowledgement}The authors greatly acknowledge the support and guidance provided by Dr. Shivani Tandon (Head, Pharmacology Department) and Shalloo Devi (Supervisor, Clinical Pharmacology Unit), Satguru Pratap Singh (SPS) Hospitals, Ludhiana for the successful completion of the project work.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.
    

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