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 Table of Contents  
SYSTEMATIC REVIEW ARTICLE
Year : 2020  |  Volume : 27  |  Issue : 2  |  Page : 76-82

Effectiveness of behavioural therapy on the blood pressure of adults with hypertension: A systematic review in non-african populations


1 Department of Psychology, Covenant University, Ota, Ogun State, Nigeria
2 Tuberculosis Control Unit, Communicable and Non-Communicable Diseases Cluster, World Health Organization Country Office, Lagos State, Nigeria

Date of Submission20-Dec-2019
Date of Decision13-Feb-2020
Date of Acceptance25-Feb-2020
Date of Web Publication11-Apr-2020

Correspondence Address:
Ms. Sophie Omanogo Ogiri
Department of Psychology, Covenant University, Ota, Ogun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_199_19

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  Abstract 


Hypertension or high blood pressure is the foremost risk factor of cardiovascular diseases which in turn are the leading cause of death globally. Despite the widespread use of antihypertensive medication, the condition remains a global health concern. In a bid to ascertain that other therapies such as psychological treatment may be adopted as complementary treatments for hypertension, this paper therefore examines literature on the effectiveness of behavioural therapy in the treatment of hypertension, identify the technique which seems most effective though blood pressure reductions, highlight other hypertension-related domains and report sustainability of blood pressure control post-intervention. A systematic literature review of randomised control trials reporting the effectiveness of behaviour therapy on blood pressure among hypertensive adults, published between the years 2014 and 2018, was conducted. A total of 79 articles were identified from the database search after which 11 met the inclusion criteria, with 10 of the 11 studies reporting behavioural therapy to be effective in blood pressure control. Relaxation therapy and meditation training appeared to be most effective as they brought about the most significant decrements in blood pressure. The mean blood pressure reduction ranged from 2.88–36.33 mmHg (systolic) to 0.04–21.48 mmHg (diastolic). Blood pressure control was found to have been sustained from between 0.7 and 24 months post-intervention. From this current paper, behaviour intervention is a viable, albeit complementary treatment method for hypertension; however, there is the need for more research to be conducted in various parts of the world, specifically in Nigeria and in Africa at large to allow for more relatable report on this topic.

Keywords: Behavioural therapy, blood pressure control, diastolic blood pressure, hypertension, non-African populations, systolic blood pressure


How to cite this article:
Agoha BC, Ogiri SO, Akindele ZA, Ogiri SO. Effectiveness of behavioural therapy on the blood pressure of adults with hypertension: A systematic review in non-african populations. Niger Postgrad Med J 2020;27:76-82

How to cite this URL:
Agoha BC, Ogiri SO, Akindele ZA, Ogiri SO. Effectiveness of behavioural therapy on the blood pressure of adults with hypertension: A systematic review in non-african populations. Niger Postgrad Med J [serial online] 2020 [cited 2020 Aug 15];27:76-82. Available from: http://www.npmj.org/text.asp?2020/27/2/76/282319




  Introduction Top


Hypertension is one of the leading global risks for mortality accounting for 13% of deaths globally.[1] It is also the foremost risk factor for cardiovascular diseases.[2] Global statistics show that about 1.13 billion adults are living with hypertension.[3] Also known as high blood pressure, hypertension is a pathophysiological condition characterised by blood pressure higher than 130 over 80 mm of mercury (mmHg),[4] sustained overtime; a single elevated reading is insufficient for a diagnosis of hypertension to be made. Blood pressure is the force of blood against the arterial walls as the heart beats and also as it rests in between beats. Blood is pumped into the arteries when the heart contract; and the blood pressure, known as the systolic blood pressure (SBP), is highest at this point. Blood pressure lowers when the heart rests between beats, and this is known as the diastolic blood pressure (DBP). Based on aetiology hypertension is classified as either primary (also known as essential) or secondary. In primary hypertension, the blood pressure elevation is not traceable to any medical condition, while secondary hypertension is corollary to premorbid conditions such as diabetes mellitus or kidney disease.[5] Primary hypertension constitutes as high as 90%–95% of hypertension cases[6],[7] and may be associated with psychological state.

Psychological variables such as anxiety, depression, stress and personality may predicate blood pressure elevation, which, sustained over time, could lead to hypertension.[8] These variables may contribute to blood pressure via increased sympathetic activity and increased secretion of cortisol[9] and norepinephrine which triggers vasoconstriction and thus increases blood pressure.[10] Moreover, each of these three conditions, depression, anxiety and hypertension, in themselves may be precipitous of the other.[11]

Given that blood pressure control has a physiological basis, antihypertensive drugs are the most widely used form of treatment for hypertension.[12] Nevertheless, the prevalence of high blood pressure has continued to increase despite the common employment of this method of treatment.[13] There is thence the need for other forms of treatment to be administered or paired with antihypertensive drugs to suppress the increasing global prevalence of hypertension. Psychological approaches come in handy at this point, considering the established links between hypertension and psychological factors.

Behavioural therapy is one variety of psychological treatment employed as full or complementary treatment of hypertension. It consists of a wide range of proficiencies whose primary task is to identify and replace unhelpful or maladaptive patterns of ideas, emotions and behaviour with more helpful patterns.[14] The techniques of behavioural therapy include, but are not restricted to, cognitive behavioural therapy (CBT), relaxation therapy and systematic desensitisation. It is important to note that behavioural therapy is not synonymous with behavioural intervention which typically consists of lifestyle modification programs adopted as part of the first line treatment given in the management of hypertension and also as preventive measures against the development of hypertension. Behavioural therapy specifically covers techniques of psychological treatment.

Techniques of behavioural therapy are useful for treating psychological disorders such as depression and anxiety, which increase the risk of high blood pressure. For instance, Beiman et al.[15] found that progressive relaxation training resulted in clinically important reductions in blood force per unit area of a patient in the household context. They observed that the clinical setting caused this patient to elicit a conditioned response of anxiety, a condition known as white coat hypertension, which resulted in more elevated blood pressure. Application of systematic desensitisation to this anxiety resulted in reduced blood pressure. Similarly, Dillon et al.[16] found that hypertensive patients had high levels of anxiety in the hospital and this had adverse effects on the accuracy of their blood pressure measurements. Psychological treatment, including CBT and systematic desensitisation, and anxiety medication were reported to be of aid to these patients. It is therefore not far-fetched to explore the effectiveness of psychological treatment methods on high blood pressure in both clinical and natural scenes.

Research objective

The purpose of this review is to evaluate through reported changes in systolic and DBP readings, the effectiveness of behavioural therapy in high blood pressure of human adults; identify the most effective behavioural therapy technique(s) for hypertension across all studies; highlight other domains which may contribute to blood pressure control post behavioural therapy and further investigate the effectiveness of behavioural therapy through follow-up reports on blood pressure readings, post-intervention.

Research question

The questions this paper seeks to address are:

  1. Can behavioural therapy techniques bring about clinically significant changes in blood pressure of hypertensive adults?
  2. What behavioural therapy technique(s) is/are apparently most effective in manipulating the blood pressure of hypertensive adults?
  3. What other hypertension-related domains does behavioural therapy have an effect on?
  4. Is blood pressure control sustained over time after post behavioural therapy?



  Methods Top


Study design

This work is a systematic review of randomised control trials demonstrating the effectiveness of behavioural therapy for high blood pressure.

Search strategy

Articles that fit the selection criteria were searched for from 5 databases (PubMed/Medline, PsycInfo, Cochrane and Science direct). The search produced a total of 614 articles with the keywords 'blood pressure, behavioural therapy, therapy, effect of and hypertension' after which eliminations were made based on selection criteria.


  Screening and Selection Top


Inclusion criteria

The articles were first screened based on their title, abstract and then full text availability. Other eligibility criteria included study design (randomised control trials), age of participants (≥18 years), population (individuals with systolic and DBP ≥130/90 mmHg), intervention (psychological treatment programs directed towards producing positive hypertension-related behaviour), pre-intervention and post-intervention measurement of blood pressure and period (2014–2018).

Participants included in all the studies reviewed had blood pressure readings within the ranges of 130–160 mmHg for SBP and 80–110 mmHg for DBP. Screening protocols varied across studies; however, a blood pressure monitor (sphygmomanometer) was used to measure BP in all studies at baseline, during behavioural therapy and post-intervention. Two studies excluded people who were on any antihypertensive medication and two other studies included participants with a comorbid physical condition.

Exclusion criteria

Articles with no full text access as well as articles that did not meet all other inclusion criteria were excluded from the review.

Data extraction

The online search for articles produced 614 articles (PubMed = 501, PsycInfo = 14, Cochrane = 69 and Science Direct = 30), of which 11 met the inclusion criteria and were retained for review.[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27] The details of the selection and screening process are illustrated in [Figure 1] above.
Figure 1: Flow chart of screening and selection of articles

Click here to view


Process of synthesis

Research design

The study design used in all 11 studies reviewed was the randomised control trial.

Regional representation

A total of 7 countries were represented in this review: U. S. A,[18],[24],[26] Canada,[19] China,[17],[20] Korea,[27] Brazil,[21] Greece[23] and Iran.[22],[25] Studies from Asian countries had the highest representation, 45.5% (n = 5), followed by studies from North America (n = 4), which had a 36.4% representation and then a 9.1% representation for each of the studies from South America (n = 1) and Europe (n = 1).

Sample distribution

In total, 2465 (male = 40.2%, female = 59.8%) participated in the studies with a total of 1,520 people in the intervention groups. The mean age of participants across the studies reviewed was 52.1 years. Women had a higher representation majorly attributable to two studies which were single-gendered.

Materials

For the measurement of blood pressure, one study[17] reported the use of a standard mercury sphygmomanometer. Automated blood pressure machines were used in 8 studies,[18],[19],[20],[21],[23],[24],[26],[27] and 2 studies[22],[26] were unclear about the type of sphygmomanometer used to obtain BP readings. Automated home BP monitors were also provided in one study.[26]

Intervention and control groups

Seeing as all studies reviewed adopted the randomised control trial design, each included an intervention group and a control group. Participants in the intervention groups across all studies were administered behavioural therapy; 9 of these studies reported that behavioural therapy was combined with the use of antihypertensive medication,[17],[18],[20],[21],[22],[23],[24],[25],[26] while 2 studies specifically recruited participants who were naïve to pharmacological treatment.[19],[27] The control groups in 9 studies were reported to receive usual care which included medication and routine medical consultation, but without any behavioural therapy, while the control group in one study received foot massage performed and taught by a trained foot reflexologist, without any antihypertensive medication.[27] Also, one study recruited the control group as a 'wait-list' group;[19] behavioural therapy was administered after the immediate intervention group had completed the intervention program as no pharmacological treatment was used at all for either group.


  Results Top


Research question 1: Can behavioural therapy techniques bring about clinically significant changes in blood pressure of hypertensive adults?

The studies included in this review showed mixed results with 90.9% (n = 10) of the studies[17],[18],[20],[21],[22],[23],[24],[25],[26],[27] reporting significant changes in systolic and DBP of hypertensive patients and 9.1% (n = 1) of the studies[19] reporting no significant decrease in blood pressure after behavioural therapy. Given that all studies included in this review are randomised control trials, each involving an intervention group and a control group, it is important to report that within group and between group analyses was conducted. Of the 10 studies that found behavioural therapy to be effective, only one study[26] found significant changes in blood pressure from the within groups analysis of the intervention group, but no significant changes were found between the intervention and control groups.

Research question 2: What behavioural therapy technique is seemingly most effective in controlling the blood pressure of hypertensive adults?

The techniques of behavioural therapy applied in the studies include CBT,[17],[27] mindfulness training (MT),[20],[22],[23],[26] relaxation therapy (RT),[18],[23],[24] motivational interviewing (MI),[21] telephone counselling (TC)[19],[25],[27] and group counselling (GC)[27] depicted in [Figure 2].
Figure 2: Behavioural therapy techniques used across studies

Click here to view


The highest mean reductions in systolic and DBP was obtained from the study by Ahmadpanah et al.,[22] in which the techniques of mindfulness training and relaxation therapy were respectively used within two intervention groups The mean systolic and diastolic BP reductions for the mindfulness group were reported to be 36.33/16.03 mmHg, while that of the relaxation group were 43.56/21.48 mmHg. The lowest mean reductions for systolic and diastolic BP reported were 0.4 mmHg[20] and 0.04 mmHg, respectively.[27] It is worthy to note that this study with the lowest mean SBP and DBP reductions specifically recruited participants with unmedicated hypertension.

Using the absolute difference in means of blood pressure reported from pre-intervention to post-intervention, reductions in SBP ranged from 0.4 to 46.56 mmHg, while reductions in DBP ranged from 0.04 to 21.48 mmHg. These reductions are illustrated in [Figure 3]. However, the mean reductions of SBP and DBP were not reported in two studies.[21],[26]
Figure 3: Mean systolic and diastolic blood pressure reductions

Click here to view


Research question 3: What other hypertension-related domains does behavioural therapy have an effect on?

Other hypertension-related domains were assessed in some studies in addition to blood pressure, which was the primary domain of assessment in all 11 studies. These domains include depression, which was reported to have significantly reduced in all studies where it was assessed;[18],[22],[27] anxiety for which there was no report of improvement;[17],[23],[27] stress management which was reported to have improved significantly in all studies which assessed for it;[23],[25],[27] nutrition/diet which was also shown to have improved significantly[24],[25] and medication adherence for which no significant improvement was reported[18],[24],[26] [Figure 4]. These improvements or non-improvements in each of the above-mentioned domains were observed post-intervention and compared with the baseline characteristics of the participants.
Figure 4: Representation of studies which assessed other hypertension-related domains (in %)

Click here to view


Research question 4: Is blood pressure control sustained over time after behavioural therapy

Six of the ten studies that reported effectiveness of behavioural therapy[17],[20],[22],[24],[25],[27] provided post-intervention follow-up reports on blood pressure control. All 6 studies found blood pressure control to still be significantly sustained by patients who received behavioural therapy. The follow-up points ranged from 3 weeks to 2 years [Figure 5].
Figure 5: Postintervention follow-up points

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Summary of findings

Findings from this study revealed that behavioural therapy can bring about clinically significant changes in blood pressure in hypertensive adults; 90.9% (n = 10) of the studies reported this:

  1. The behavioural therapy techniques which may be more effective in achieving blood pressure control were mindfulness training and relaxation therapy as they brought about the highest decrements in systolic and DBP
  2. Other hypertension-related domains including depression, anxiety, stress management, medication adherence and diet were assessed in some studies at baseline and post-intervention. And, significant improvements were observed in some of these domains
  3. Gains in blood pressure control were reported in 6 studies to have been sustained over time through follow-up.



  Discussion Top


The aim of this systematic review was to determine the effectiveness of behavioural therapy in the treatment of hypertension in adults as well as to highlight other domains which when assessed and addressed during behavioural therapy, may have positive effects on blood pressure control of individuals with hypertension. The studies reviewed were conducted in different parts of the world, with Asia having the highest representation, while no studies conducted in any region in Africa were found. A total of 11 studies were included, all of which were published between the years 2014 and 2018.

From the articles reviewed, it was mostly found that the reductions in the systolic and DBP within the intervention groups were significant, as contrasted with the reductions found within the control groups which were non-significant. This finding positively addresses the first research question and is also consistent with findings of earlier studies.[28],[29]

To answer the second research question, it was found that the behavioural therapy techniques which appeared most effective were mindfulness training and relaxation therapy used in the study by Ahmadpanah et al.[22] They brought about the highest mean blood pressure reductions recorded in this review. Other studies[28],[30] found these techniques to be effective in treating hypertension. These two techniques are effective for the management of stress[31] which is also a risk factor for hypertension.

Stamler[32] reported that for every 2 mmHg in SBP, coronary and stroke mortality of the individual is estimated to decrease by 4% and 3%, respectively, and for every 5 mmHg decrease, there is a respective difference of 9% and 14%; Hardy et al.[33] found that every population wide 1 mmHg decrease in SBP can prevent a significant number of cardiovascular disease events. Also, Liu et al.[17] found that the stroke prevalence among hypertensive members of the Chinese workforce who received psychological intervention lowered significantly. Therefore, working by the range of the mean reductions in SBP across studies as illustrated in [Figure 3] above, it can be further established that behavioural therapy is an effective method in achieving blood pressure control in hypertension, with emphasis on relaxation and mindfulness training.

The third research question sought to highlight other hypertension-related domains, which, if controlled, may contribute positively to blood pressure control. These domains include depression, anxiety, stress, medication adherence and diet. The results from the pre- and post-intervention assessment of the hypertension-related domains secondary to blood pressure showed that depression significantly reduced after intervention. A link between hypertension and depression is that people suffering from depression are less likely than non-depressed people to engage in adequate self-care,[34] which includes medication adherence. Furthermore, depression is associated with other risk factors for hypertension such as poor dieting, low physical activity, smoking and excessive use of alcohol.[35]

Participants who scored high on anxiety assessments were found to have higher blood pressure readings than their non-anxiety counterparts within the same study; and previous studies have also shown that anxiety is associated with increased risk of hypertension.[36],[37],[38] However, no study in which anxiety was assessed in this review reported a significant mean decrease in anxiety levels even after behavioural therapy, albeit these studies reported significant decrements in blood pressure regardless. This therefore suggests that anxiety as a single factor is not sufficient to lead to a diagnosis of hypertension, hence may not bring about a significant decrease in blood pressure if made the sole target of behavioural therapy.

Stress plays a major role in the development of hypertension.[37] From the reports of the studies reviewed, stress management as well as blood pressure control significantly improved after behavioural therapy. Medication adherence was shown to have not improved significantly throughout the studies despite the reductions in blood pressure, however in the studies by Ahmadpanah et al.[22] and Liu et al.,[17] though medication adherence did not significantly improve, it was reported that behavioural therapy was more effective when combined with pharmacotherapy. This is inversely supported by the outcome of the study of Blom et al.[19] in which people who were on antihypertensive medications were specifically excluded from the study and mindfulness training was used to treat the eligible participants. The results showed that behavioural therapy alone (mindfulness training) did not bring about a significant decrease in either SBP or DBP, however this same technique was found to be effective in reducing blood pressure significantly in other studies in which people who were on antihypertensive medication were eligible.[21],[22],[25] Also, although the study by Lee and Yeun[27] included participants with untreated hypertension showed that there were significant reductions in SBP and DBP, it reported the lowest BP reductions when compared with all other studies in which blood pressure significantly decreased post-intervention, as previously displayed in [Figure 3]. This further suggests that behavioural therapy is more effective when combined with pharmacological treatment.

Dietary habits were found to have improved after intervention across the studies and improved blood pressure control was recorded in these studies also. Similarly, Olowofela and Isah[39] in a study in Southern Nigeria found that hypertensive patients who met the recommendations of eating healthy (reduction in salt intake and food quantity, carbohydrate restriction and increased intake of fruits and vegetables at least three times a week) achieved better blood pressure control than their counterparts who failed to meet these recommendations.

Finally, the fourth research question addressed the issue of follow-up and sustainability of the effects of behavioural therapy on blood pressure control. Follow-up was conducted and reported in 6 studies and each of them found that participants who were exposed to behavioural therapy still had good BP control. The different points in time in which follow-up was conducted include 3 weeks/0.7 months,[27] 2 months,[22],[25] 6 months,[17],[18],[24] 12 months[17] and 24 months.[17] The effect of this sustained blood pressure control is that the receptor cells in the body, which are responsible for sensing and regulating pressure in the body, known as the baroreceptors, 'learn' and recognise this new range of pressure as normal and adjust accordingly overtime. These receptors are constantly adjusting to the behavioural state of an organism based on peripheral command and feedback it receives from other receptors regarding change in somatic activities including metabolic and sympathetic activities.[40] If risk factors such as depression, stress and anxiety, which affect sympathetic activities especially, can be treated during behavioural therapy and the behavioural state of the individual which the baroreceptors are answerable to is conditioned to be more adaptive, blood pressure control will be achieved and if sustained overtime, then the risk of hypertension is reduced maximally.

Limitations of the study

The findings of this review should be interpreted within its context in view of limitations which include the small number of studies, inaccessibility to full texts of some articles (n = 14) and poor representation of studies from the African region. There were also some methodological limitations such as studies which included only one gender and the assessment of anxiety in the study by Liu et al.[17] which was self-reported by participants rather than assessed with a standardised psychological test tool.


  Identified Gaps and Recommendations Top


Hypertension is ubiquitous; hence, the major limitation of this review was the non-representation of studies from the African context due to their scarceness on the internet. Furthermore, it was identified that most of the studies (n = 7) were published in 2014, which is the start year for the range of years of publication given in the inclusion criteria. No studies for the year 2016 and 2018 were found. This makes the distribution across the years uneven and suggests that not enough research has been conducted in this subject from 2014 till date.

This study therefore recommends to medical practitioners that more holistic approaches be adopted in the diagnosis and treatment of hypertension; assessing more domains than just blood pressure. However, for this to happen, a collaboration with mental health practitioners such as psychologists may be needed. Health-care institutions and the respective departments of which they consist are advised therefore to be more inclusive of each other. More so, going by the regional representation of this review, it is suggested that further research be conducted in healthcare institutions in Nigeria and in Africa at large to allow for more relatable reports on this subject. This will help the people become more aware of behavioural therapy and may also encourage them to seek behavioural therapy in combination with pharmacotherapy, especially if the studies find behavioural therapy to be effective.


  Conclusion Top


This study has been an attempt to review literature reporting the effectiveness of behavioural therapy on hypertension among adults. The findings reveal that behavioural therapy is an effective treatment method as it is able to address other hypertension-related behaviours that antihypertensive medication is unable to address; albeit it is more effective when used as a complementary treatment with pharmacotherapy. The outcome of this review is instructive to healthcare practitioners and also to psychologists regarding the factors to address when treating hypertension.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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