Consequences of worksite hypertension screening. Differential changes in psychosocial function

National Hypertension Guidelines: A Review of the India Hypertension Control Initiative (IHCI) and Future Prospects

Hypertension is a silent killer; however, the treatment of hypertension is simple, effective, readily available, and needs to be continued lifelong. It is a significant health problem that is included under the umbrella of non-communicable disease conditions and has a strong alliance with cardiovascular morbidity and mortality. The India Hypertension Control Initiative (IHCI) is an extensive program in India that involves the Indian Council of Medical Research, the Ministry of Health and Family Welfare (Government of India), the state governments of India, and World Health Organization Country Office for India (WHO-India). The IHCI is a multi-partner initiative carried forward systemically across various states. The states are categorized into Grade I and Grade II. There is the involvement of specialized teams of cardiovascular experts and health officials to insure precise execution and seamless healthcare service. 

The implementation of the free and easy-to-use mobile application and software, Simple (Resolve to Save Lives, New York City, United States), in the analysis and storage of data, is a novel step taken to insure safe record keeping and follow-ups. Emphasis is on the adoption of demography-specific interventional methods and drugs, and proper acquisition and storage of these drugs is the key step. Treatment modalities involve the adoption of medicines and lifestyle modifications as a combined recipe. Advancements have been made in the area of drug development like gene therapies but they seem to show low success rates at the given moment. Adoption of lifestyle modifications along with medications is the gold standard treatment option. This review article aims to shed light on the current status of IHCI, its milestones, and the future of the initiative in India.

‘People say it is dangerous’

Introduction: Mild hypertension is a common asymptomatic condition present in people at low risk of future cardiovascular events. These people represent approximately two-thirds of those diagnosed with hypertension. The best available evidence does not support pharmacological treatment for mild hypertension to reduce cardiovascular mortality. Additionally, overdetection of hypertension also occurs, and this practice is supported by public awareness campaigns, screening, easy access to testing, and poor clinical practice, enhancing the overdiagnosis potential. Moreover, sparse qualitative patient-oriented evidence that diagnosing hypertension has harmful consequences is observed. Therefore, evidence regarding the potential for unintended psychosocial effects of diagnosing mild hypertension is required. Objective: The aim of this study was to investigate if diagnosing low-risk people with mild hypertension has unintended psychosocial consequences. Methods: Eleven semi-structured single interviews and four focus groups were conducted in São Paulo, Brazil, among people diagnosed with mild hypertension without comorbidities. Informants were selected among the general population from a list of patients, a primary healthcare clinic, or a social network. The informants had a broad range of characteristics, including sex, age, education level, race/skin colour, and time from diagnosis. Data were subjected to qualitative thematic content analysis by three of the authors independently, followed by discussions, to generate categories and themes. Results: The informants confirmed that the hypertension diagnosis was a label for psychosomatic reactions to stress, medicalised illness experiences, and set a biographical milestone. We observed unintended consequences of the diagnosis in a broad range of psychosocial dimensions, for example, fear of death, disabilities, or ageing; pressure and control from significant others; and guilt, shame, and anxiety regarding work and leisure. Although informants had a broad range of characteristics, they shared similar stories, understandings, and labelling effects of the diagnosis. Conclusion: The diagnosis of hypertension is a significant event and affects daily life. Most of the impact is regarded as negative psychosocial consequences or harm; however, sometimes the impact might be ambiguous. Patients’ explanatory models are key elements in understanding and changing the psychosocial consequences of the diagnosis, and healthcare providers must be aware of explanatory models and psychosocial consequences when evaluating blood pressure elevations.

Combination of Echocardiography and Pulse Wave Velocity Provides Clues for the Differentiation between White Coat Hypertension and Hypertension in Postmenopausal Women

OBJECTIVE

To determine whether or not noninvasive assessment of the cardiovascular system can discriminate white coat hypertension and hypertension in postmenopausal women. The major reason is the high prevalence of white coat hypertension in these subjects and the uncertain associations of white coat hypertension with cardiovascular risk.

PATIENTS AND METHODS

Selected women were required to be naturally or surgically menopausal for at least 1 year but not more than 5 years past their menstrual period. White coat hypertension patients were defined as subjects who had office blood pressures >150/90 mm Hg but who had both systolic and diastolic ambulatory pressures <120/80 mm Hg. In total, 44 subjects with a mean age of 52 years were recruited from the outpatient clinic and examined. Office and home blood pressures were measured using the HEM 401C (Omron Life Science Co. Ltd., Tokyo, Japan), a semi-automatic device that operates on the cuff-oscillometric principle and generates a digital display of the systolic (SBP) and diastolic blood pressure as well as the pulse rate. The pulse wave velocity (PWV) was recorded, and the left ventricular (LV) diameter, septal wall thickness, and left posterior wall thickness were assessed by M-mode echocardiography after selecting the measurement section by B-mode echocardiography.

RESULTS

Twenty patients were diagnosed as having white coat hypertension based on the criteria in the trial. Pulse wave patterns were different between subjects with white coat hypertension and those with hypertension. PWV of subjects with white coat hypertension was 1.32 ± 0.33 m/s and that of patients with hypertension was 1.46 ± 0.37 m/s (p < 0.01). In addition to these findings, there was a significant association between the values of home SBP and PWV and the LV mass index. However, this association was not seen for office SBP. When the data of the LV mass index and PWV were combined, white coat hypertension could be easily differentiated from hypertension.

CONCLUSIONS

The combination of blood pressure self-monitoring, echocardiographic data, and PWV can be a powerful indicator for the treatment of hypertension in postmenopausal women.

Pulse Wave Velocity in Postmenopausal Women

Cardiovascular disease (CVD) and osteoporosis are major causes of morbidity and mortality in postmenopausal women. The relationship between atherosclerosis and osteoporosis has been established by studies of the underlying pathophysiological mechanisms and biochemical pathways that seem to overlap in many places. Pulse wave velocity (PWV) is one of the known predictors of cardiovascular and all-cause mortality. Studies indicate that PWV in hypertensive postmenopausal women is increased, and hormone replacement therapy (HRT) attenuates this increase. In addition, recently, many studies have suggested a role for arterial stiffness in the association between CVD and osteoporosis. From these findings, it appears that estrogen deficiency combined with production of inflammatory cytokines plays a role in increased PWV closely associated with CVD and osteoporosis, although the mechanisms of arterial stiffness in postmenopausal women may be more complex. Accordingly, a possible role for PWV as a surrogate marker of CVD as well as osteoporosis in postmenopausal women is discussed in this review. First, menopause leads to increased arterial stiffness with aging in females. Further, epidemiological data evaluating arterial stiffness assessed by PWV provided evidence that most of the established CVD risk factors are determinants of PWV, and these risk factors are increased in patients with CVD. In turn, contrary to expectation, HRT did not always contribute to a lower incidence of CVD in postmenopausal women. By reviewing the current data available, it becomes clear that, at present, the effects of menopause including HRT on PWV remain controversial, and further studies are needed to clarify these associations.

Effects of a mail‐based intervention to improve knowledge of blood pressure and cholesterol values

Purpose

The purpose of this paper is to evaluate a mail‐based educational intervention to improve knowledge of blood pressure and cholesterol values among members of a large insurance population.

Design/methodology/approach

As part of the 2004 health risk appraisal (HRA) follow‐up program, 48,429 members of WEA Trust received at least two mailings for the mail‐based blood pressure and cholesterol intervention. These members then completed a follow‐up HRA in 2006. Change in the knowledge and risks of blood pressure and cholesterol values were analyzed among two‐time participants. A survey was also completed six to nine months after the first mailing to study participants' awareness and perception of the program.

Findings

The 2004 and 2006 two‐time HRA participants showed a 13.9 percentage point gain (p<0.05) and 12.2 percentage point gain (p<0.05) in people who knew their blood pressure and cholesterol values, respectively, as well as a significant increase in the percent of people taking medication or under medical care for their blood pressure (+2.9 for overall and +11.3 for BP≥140/90 population; p<0.05) or cholesterol conditions (+3.8 for overall and +11.4 for cholesterol≥240 population; p<0.05). Among those who knew their values (BP or cholesterol) in both 2004 and 2006, there was a 3.9 percentage point increase (p<0.05) in the number of people with normal BP (BP<120/80 mmHg) and a 4.8 percentage point increase (p<0.05) in the number of people with normal cholesterol (cholesterol <200 mg/dL) in 2006. The majority (83 percent) of survey respondents found the materials useful for improving health and 22 percent contacted a physician because of the information they received.

Practical implications

This relatively low‐cost and easily implemented educational intervention was successful in increasing knowledge of blood pressure and cholesterol values, taking control of blood pressure and cholesterol risks and in encouraging appropriate follow‐up with a physician.

Originality/value

Knowledge of blood pressure and cholesterol numbers are an important first step in raising awareness of a person's health risks and disease status.

The influence of long-term awareness of hyperlipidemia and of 3 years of dietary counseling on depression, anxiety, and quality of life

OBJECTIVE

The purpose of this study is to investigate the long-term effects of participation in a cardiovascular screening program and of dietary counseling on self-reported psychosocial outcomes and health concerns.

METHODS

High-risk subjects (n=563) with hyperlipidemia from the Oslo Diet and Antismoking Study (1972-1977) were reexamined after 25 years and randomly assigned to a new 3-year prospective 2x2 factorial placebo-controlled study in 1997 of n-3 polyunsaturated fatty acids and/or dietary counseling. Hospital Anxiety and Depression Scale (HADS), Life Satisfaction Index (LSI), and a new questionnaire on health concerns and behavior in response to risk information were collected at the 25-year follow-up. Hospital Anxiety and Depression Scale and LSI were evaluated at the end of the 3-year Diet and Omega-3 Intervention Trial on atherosclerosis (DOIT) in 505 subjects.

RESULTS

Twenty-five years after the screening program, HADS-anxiety was similar to the Norwegian norms (3.3 vs. 3.5), while HADS-depression was significantly lower (3.6 vs. 4.1, P<.01). Patients reported that 25 years of awareness of hyperlipidemia had influenced health concerns through a moderate change in diet habits, some restriction in life conduct, but an improvement of the total life situation. After a novel 3-year intervention in DOIT, there was no difference between the dietary counseling and control group with regard to anxiety, depression, or life satisfaction, but HADS-anxiety increased significantly (4.0 vs. 3.3, P<.001) in both groups.

CONCLUSION

Compared to the general population, screening-positive subjects did not have increased mental distress 25 years after screening, and beneficial health behavior persisted. Dietary counseling did not affect psychosocial outcomes.

Screening for risk of cardiovascular disease is not associated with mental distress: the Inter99 study

OBJECTIVE

To analyze mental distress in relation to participation in lifestyle intervention.

METHODS

In 2000-2001 a total of 1948 consecutive participants, living in the suburbs of Copenhagen, were asked to complete a short version of SCL-90-R (anxiety, depression, and somatization) before screening, immediately after screening, and one and 10 months after screening. The screening classified participants into high or low risk individuals. High risk individuals received personal lifestyle counselling and were randomized to either group-based counselling (A) or referred care (B). Multilevel regression models taking into account repeated measurements and missing data at follow-up were performed.

RESULTS

Before screening, high risk individuals had higher scores on anxiety, depression, and somatization than low risk individuals. All categories of participants decreased in scores after screening. The scores increased after 1 month, but were still significantly lower than before screening. After 10 months, low risk individuals and high risk individuals in group A still had significantly lower scores (except for depression) compared with pre-screening levels, whereas high risk individuals in group B reached the pre-screening level (except for anxiety).

CONCLUSION

Screening for risk of cardiovascular disease followed by health counselling does not give rise to mental distress, but has a temporary beneficial effect.

Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature

BACKGROUND

Guidelines now recommend routine assessment of global coronary heart disease (CHD) risk scores. We performed a systematic review to assess whether global CHD risk scores result in clinical benefits or harms.

METHODS

We searched MEDLINE (1966 through June 13, 2007) for articles relevant to our review. Using predefined inclusion and exclusion criteria, we included studies of any design that provided physicians with global risk scores or allowed them to calculate scores themselves, and then measured clinical benefits and/or harms. Two reviewers reviewed potentially relevant studies for inclusion and resolved disagreement by consensus. Data from each article was then abstracted into an evidence table by one reviewer and the quality of evidence was assessed independently by two reviewers.

RESULTS

11 studies met criteria for inclusion in our review. Six studies addressed clinical benefits and 5 addressed clinical harms. Six studies were rated as "fair" quality and the others were deemed "methodologically limited". Two fair quality studies showed that physician knowledge of global CHD risk is associated with increased prescription of cardiovascular drugs in high risk (but not all) patients. Two additional fair quality studies showed no effect on their primary outcomes, but one was underpowered and the other focused on prescribing of lifestyle changes, rather than drugs whose prescribing might be expected to be targeted by risk level. One of these aforementioned studies showed improved blood pressure in high-risk patients, but no improvement in the proportion of patients at high risk, perhaps due to the high proportion of participants with baseline risks significantly exceeding the risk threshold. Two fair quality studies found no evidence of harm from patient knowledge of global risk scores when they were accompanied by counseling, and optional or scheduled follow-up. Other studies were too methodologically limited to draw conclusions.

CONCLUSION

Our review provides preliminary evidence that physicians' knowledge of global CHD risk scores may translate into modestly increased prescribing of cardiovascular drugs and modest short-term reductions in CHD risk factors without clinical harm. Whether these results are replicable, and translate across other practice settings or into improved long-term CHD outcomes remains to be seen.

Functional status before and after diagnosis of Type 2 diabetes

AIMS

We examined functional health status prior to the diagnosis of Type 2 diabetes, and measured the effect on functional health status of receiving the diagnosis.

METHODS

After the ADA reduced its fasting plasma glucose level for diagnosing diabetes from > 7.8 to > 7.0 mmol/l, we identified 1014 members of a large HMO who met the new criteria, and an age- and gender-matched comparison group who did not. We mailed questionnaires to these subjects in 1998, and again in 1999 to 623 who met the new criteria, after some had been notified of their diabetes, while others had not. We used the SF-12(R) Health Survey to measure physical and mental subjective health status.

RESULTS

Mean age of respondents meeting new diagnostic criteria (n = 498) was 67.3 + 10.4 years, 43.6% were women. Comparison group respondents (n = 589) were 66.7 + 10.6 years, 45.2% women. The groups were not statistically different on either characteristic. Prior to the diagnosis of Type 2 diabetes, physical functioning was already lower in subjects who met the new criteria than in the comparison group (39.5 vs. 42.1, P < 0.001), mental functioning was similar (51.4 vs. 51.9, P = 0.406). Among those who newly met diagnostic criteria for diabetes, there was no difference in the change in health status (mental or physical) in those who reported receiving a diagnosis (n = 105) compared with those who did not (n = 168).

CONCLUSIONS

Physical health status is already reduced prior to diabetes diagnosis, perhaps because of obesity or other aspects of the insulin resistance syndrome. Receiving a diabetes diagnosis after adjusting the diagnostic criteria does not adversely affect either mental or physical health status.

Screening for high blood pressure: a review of the evidence for the U.S. Preventive Services Task Force

CONTEXT

In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended screening adults for hypertension. Since that time, the published literature on hypertension has expanded rapidly, necessitating a new examination of the evidence supporting screening.

OBJECTIVE

Update the 1996 evidence review on screening for hypertension.

DATA SOURCES

The 1996 Guide to Clinical Preventive Services, recent systematic reviews, and focused searches of MEDLINE were used to identify new evidence relevant to detecting and treating hypertension.

STUDY SELECTION

When a good quality, recent systematic review was available, it was used to summarize previous research; MEDLINE was searched only for more recent articles. Two authors reviewed abstracts (and full texts, if necessary) of potentially relevant articles to determine if they should be included.

DATA EXTRACTION

One author extracted data from included studies into evidence tables.

DATA SYNTHESIS

Hypertension can be effectively detected through office measurement of blood pressure. Treatment of elevated blood pressure in adults can reduce cardiovascular events. The magnitude of risk reduction depends on the degree of hypertension and the presence of other cardiovascular risk factors. Available studies have found no important adverse effects on psychological well-being and mixed effects on the absenteeism rates of adults who are screened and labeled as being hypertensive.

CONCLUSIONS

Substantial indirect evidence supports the effectiveness of screening adults to detect hypertension and treating them to reduce cardiovascular disease.

Impact of diabetes screening on quality of life

OBJECTIVE

Diagnosis of a chronic illness can have a negative impact on patients' perception of their well-being ("labeling" effect). We sought to determine the effects of a new diagnosis of diabetes, discovered by systematic screening, on patients' health-related quality of life (HRQoL) 1 year after diagnosis.

RESEARCH DESIGN AND METHODS

We performed diabetes screening at the Durham Veterans Affairs Medical Center of 1,253 outpatients, aged 45-64 years, who did not report having diabetes. Our initial screen was a serum HbA(1c) measurement. All subjects with HbA(1c) > or = 6.0% were invited for follow-up measurement of blood pressure and fasting plasma glucose. A case of unrecognized diabetes was defined as HbA(1c) > or = 7.0% or fasting plasma glucose > or = 7 mmol/dl. HRQoL was measured by Medical Outcomes Study Short Form 36 (SF-36) for all patients at baseline and 1 year after enrollment. Linear multivariable models were used to determine the independent effect of the new diagnosis of diabetes on HRQoL.

RESULTS

Mean SF-36 Physical Component Score (PCS) for all patients was 36.2, and mean Mental Component Score (MCS) was 49.6. A total of 56 patients (4.5%) were found to have diabetes at screening. Patients found to have diabetes at screening had mean PCS of 35.6, which was not different from a mean PCS of 36.3 for those patients found not to have diabetes (P = 0.67). After adjusting for baseline PCS values, PCS 1 year after screening was similar for patients with and without diabetes found at screening (P = 0.95). Similarly, patients found to have diabetes at screening had mean MCS of 48.8; those found not to have diabetes had MCS of 49.6 (P = 0.70). After adjusting for baseline MCS values, MCS 1 year after screening was also similar between the two groups (P = 0.77).

CONCLUSIONS

For patients with a new diagnosis of diabetes discovered through systematic screening, HRQoL is similar to patients found not to have diabetes. Furthermore, HRQoL scores remain stable over the year after screening. This suggests that screening for diabetes has minimal, if any, "labeling" effect with respect to HRQoL.

Changes in health beliefs after labelling with hypercholesterolaemia

Background: Patients' health beliefs infl uence their willingness to comply with medical advice. In an earlier study, it was found that men with a previous history of information on risk factors for ischaemic heart disease expressed more feelings of threat to their health than did men without this experience. As anxiety may have adverse effects, such as making patients avoid the desired action, this could complicate adequate patient treatment. Aims: To investigate the impact on health beliefs caused by participation in a screening programme for risk factors for ischaemic heart disease, including individualized information to patients with hypercholesterolaemia. Methods: A random sample of middle-aged, urban men participating in a health screening completed a questionnaire on socioeconomic factors, medical history, lifestyle, and health beliefs. Blood pressures and plasma cholesterol values were measured. Four months after the initial screening, hypercholesterolaemic men and controls completed the questionnaire again. Results: In a univariate analysis, no differences in health belief indices were found between cases and controls at the baseline screening. Controls achieved lower values of the indices "perceived control over illness'' and "medical motivation'' at follow-up. In a matched case-control design, the differences in "medical motivation'' increased between cases and controls because controls reported lower values. "Perceived threat to health'' did not change, and it is suggested that this is due to the supportive information to the patients. Conclusion: Individualized and supportive patient information on risk factors for cardiovascular disease does not increase patients' perceptions of threat.

Psychological impact of predicting individuals' risks of illness: a systematic review

The aim of this review is to determine the frequency and circumstances under which predicting individuals' risk of illness has adverse psychological effects. Using systematic review methodology, the literature was searched for studies that had assessed the adverse psychological outcomes of risk assessment programmes. The outcomes investigated are emotional (anxiety, depression, distress) cognitive (intrusive thoughts, perceptions of health) and behaviour (work absenteeism). The impact of both positive and negative test results are summarised in terms of the number of studies showing significant effects between and within groups in the short (one month or less) and longer term (more than one month). Where sufficient data were available, a meta-analysis was conducted to assess effect size. Fifty-four studies met the criteria for inclusion. The studies assessed the impact of informing individuals about cardiovascular risk (21), risk of AIDS (eight), risk of cancer (10), risk of Huntington's disease (10), risk of diabetes (two), risk of spinocerebellar ataxia (one) and risk of osteoporosis (two). Overall, the quality of studies assessed was limited, with only two using a randomised design to determine the psychological impact of risk assessment. Receiving a positive test result was associated in the short term in the great majority of studies with depression, anxiety, poorer perceptions of health and psychological distress. Data were available for a quantitative synthesis of results on three outcomes, anxiety, depression and distress. Anxiety and depression were significantly higher in those tested positive compared with those tested negative in the short term but not the longer term. Distress could only be assessed in the longer term: there was no evidence of an increase for those receiving positive test results. The five experimental studies that reported interventions aimed at preventing some of these adverse effects all reported favourable results. There was little evidence of any adverse psychological effects of receiving an unfavourable test result. Adverse psychological effects are a common immediate consequence of positive test results following risk assessment. Results from the few experimental studies reviewed suggest that these adverse outcomes should not be seen as inevitable.

Anxiety and cardiovascular reactivity in the Tecumseh population

OBJECTIVE

Increased cardiovascular reactivity has been proposed to be a critical mediator in the development of hypertension and cardiovascular disease. The personality factors associated with cardiovascular reactivity are still subject to debate. The studies reported here were undertaken to examine the relationship between trait anxiety and cardiovascular stress reactivity in a community-based sample (Tecumseh).

DESIGN AND METHODS

All studies were carried out in an outpatient setting. Cardiovascular reactivity to isometric handgrip and mental arithmetic was assessed and recorded by automatic blood pressure monitoring in 832 subjects aged 19-41 years. Spielberger trait and state anxiety measures were collected immediately before the stressors were applied.

RESULTS

No differences in baseline heart rate, systolic or diastolic blood pressure were observed across anxiety categories. There was a clear negative correlation between trait anxiety and cardiovascular reactivity to mental arithmetic. The pattern was less clear in response to isometric handgrip.

CONCLUSIONS

These results suggest that individuals with high trait anxiety demonstrate reduced cardiovascular reactivity while those with low trait anxiety demonstrate increased reactivity, whereas the opposite might have been expected.

Effects of a health examination programme on quality of life and subjective well-being

The effects on quality of life and psychological well-being of a health examination programme in a branch of Swedish industry were studied by means of questionnaires in 124 white-collar workers. They were asked to answer two questionnaires, one before and the other one month after the examination (the Nottingham Health Profile (NHP) and the Psychological General Well-being Schedule (PGWB)). Both are well-known and well-documented standard questionnaires used for estimating quality of life and degree of subjective well-being. The answers were compared with those of a control group comprising other white-collar workers in the same industry, of the same sex and age but who did not participate in the health examination and who were asked to complete the same questionnaires twice. The group that had participated in the health examination did not differ generally from the control group with respect to intra-individual differences as studied in the questionnaires on the two occasions. This indicates that no deterioration of quality of life or of psychological well-being was experienced by the participants in the health examination.

Someone who cares--patients' experiences concerning health examinations

The aim of this inquiry was to gain an understanding of laymen's experiences and opinions about general health check-ups. Medical experts often draw attention to unwanted effects, especially the risk of creating worry and of recommending and even giving unnecessary medical treatment. By using a qualitative research method with unstructured interviews we wanted to explore the participants' conceptions of health, their expectations before and their perceived benefits after health checks and whether the check-up gave rise to negative feelings. The participants held broad views on health and, possibly as a consequence, also great expectations of health check-ups. Consequences of the check-ups were that examinees felt encouraged to change their life style, had learnt to handle risk factors for disease, and after some time, reported feeling better. The individual attention and care, which in general did not differ from other caring situations described in the literature, was highlighted as an important factor for a positive result. Worries afterwards either did not exist or could be rationalized by knowing the causes of abnormalities and receiving guidance from the medical staff.

Hypertensive labeling: does it have therapeutic implications

Screening for hypertension within the proper setting potentially leads to the detection of numerous (mild) hypertensives, some of whom in due time may well qualify for treatment. One disadvantage of the procedure appears to be that hitherto unwitting hypertensives may develop some adverse psychological and physiological phenomena. Behavioral effects seem to be particularly obvious after screening on the worksite, where newly identified hypertensive employees tend to respond with increased absenteeism and allied symptoms of labeling. In the clinical setting, physiological studies in recently informed hypertensives have demonstrated a series of signs of increased sympathetic activity: heart rate, cardiac index, circulating catecholamines, and renin, and even blood pressure itself, tend to be higher in aware vs. unaware young hypertensives. Although some correlations between psychological and physiological sequelae have been observed, the true nature of such links is far from clear. Simple anxiety does not seem to be the main mechanism. Pending further research, the question is discussed as to whether these phenomena are harmful enough to warrant a need for counseling or treatment.

Does anxiety or cardiovascular reactivity have a causal role in hypertension?

Anxiety, stress, and cardiovascular reactivity (CVR) are variously believed to play a role in sustained hypertension. Although acute anxiety or stress elicits acute pressor responses, there is little support for their significant role in sustained hypertension. Anxiety correlates poorly with CVR, and blood pressure levels and anxiolytics do not sustain blood pressure lowering in subjects with hypertension-associated anxiety. Chronic anxiety disorders tend to be characterized by relatively low blood pressure and prevalence of sustained hypertension. Blood Pressure Regulation in hypertension is normal, and normo- and hypertensives have similar ambulatory blood pressure variability. Laboratory CVR fails to predict variability in natural environments, hyperreactors do not exhibit increased variability in natural environments, and the increased variability and ambulatory reactivity that is "accounted for" by laboratory responses is small. These findings do not support the belief that hypertension is related to a summation of heightened pressor responses over time. Antihypertensives normalize elevated blood pressures but do not alter CVR in the laboratory or variability in natural environments, probably because of a dual central regulation of resting and reactive blood pressures. Psychological stress responses result from selective neuronal activation rather than from generalized sympathetic neural responses or dysregulation. Differences in blood pressure responses during various emotions are only quantitative, with no specificity of sympathoadrenal or emotional responses to stressors. It may be time to regard reactive cardiovascular responses as physiological, rather than as psychological, and to require much stronger evidence to confirm causal roles of anxiety, stress, and reactivity in sustained hypertension.

Hypertension labelling, life events and psychological well-being

Almost all previous studies of the psychological sequelae of hypertension labelling have lacked a prospective, longitudinal design which could allow for causal interpretations. The present study relies on questionnaire data from a hypertension screening carried out on the entire adult population of a medium-sized, Norwegian county (total number of participants = 74977). 'Labelled' individuals, i.e. previously unaware hypertensives (N = 173), false positives (N = 233), and patients in need of continued BP control (N = 474) have been followed up after 1-3 years, and comparisons are made with aware hypertensives (N = 206), patients previously treated for hypertension (N = 118), and a random sample of normotensives (N = 2326). 'Pre-labelling', baseline measures of subjective well-being had been carried out on all comparison groups in connection with the screening. Changes in psychological well-being are not significantly related to labelling or BP-status. However, there is a deterioration in psychological well-being among participants who have been subjected to one or more negative life events/stresses (other than labelling) in the preceding 12 months.

Consequences of worksite hypertension screening. Changes in absenteeism

To confirm reports of increased absenteeism after worksite hypertension screening, we performed a three-stage blood pressure screening among 5888 self-selected heterogeneous workers at 11 electronics plants using standardized screening and labeling procedures. A total of 296 subjects with mean systolic blood pressure of 140 mm Hg or greater or diastolic blood pressure of 90 mm Hg or greater on all three occasions were considered to have sustained hypertension. From the untreated normotensive subjects matched for eight sociodemographic and occupational variables, we prospectively selected one to three controls for each sustained hypertensive subject. Uncorrected absenteeism rates for sustained hypertensive subjects increased 22% from baseline in the postscreening year. Correction by logarithmic transformation for skewed distributions and by rates for matched controls for temporal trends reduced these changes to statistical insignificance with high statistical power. Several subgroups exhibited trends to increased absenteeism. At 12-month follow-up, the blood pressure of the sustained hypertensive subjects showed mean decreases of 12.6/6.7 mm Hg (p less than 0.0001) after the majority had received pharmacological antihypertensive treatment. These results suggest that worksite hypertension screening and labeling produce insignificant absenteeism change overall among self-selected heterogeneous work force populations.