Depression Incidence in Patients with Hypertension in a Single Outpatient Center
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Abstract Introduction: Hypertension and depression are both highly prevalent in the United States and each condition is commonly managed in the outpatient setting. This study aims to investigate the incidence of depression in patients who are diagnosed with hypertension. Methods A retrospective cohort study was conducted analyzing 9,240 adult patients at a single center outpatient clinic between 2019 and 2022. Blood pressure and PHQ-9 from the latest outpatient visit were recorded. Demographic data associated with hypertension were also obtained. Bivariate statistical analysis was performed. Multivariate linear and logistic regression models were adjusted for co-morbid conditions. Results Out of the 9,240 patients studied, 3,694 (40%) had a diagnosis of hypertension. Patients with hypertension were more likely to be older (61.96 ± 14.95 vs 39.85 ± 15.61, p = 0.000), male (37% vs 33%, p = 0.002) and black (45.2% vs 23.3%, p < 0.001) compared with those without a diagnosis of hypertension. The mean PHQ-9 score was higher in patients with hypertension than in those without (2.97 ± 4.66 vs 2.70 ± 4.93, p = 0.000). Patients with hypertension were more likely to have uncontrolled depression defined as PHQ-9 score > 4 (22.55% vs 19.4%, p < 0.001) even when adjusted for co-morbid conditions (adj OR 1.216 95% CI 1.06–1.34 p = 0.005). Conclusions In this cohort of patients, a diagnosis of hypertension was associated with an increased rate of uncontrolled depressive symptoms. Hence patients with hypertension should be screened using validated PHQ-9 tools in the outpatient setting and offered appropriate treatment for depression.
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This study aims to investigate the incidence of depression in patients who are diagnosed with hypertension. Methods A retrospective cohort study was conducted analyzing 9,240 adult patients at a single center outpatient clinic between 2019 and 2022. Blood pressure and PHQ-9 from the latest outpatient visit were recorded. Demographic data associated with hypertension were also obtained. Bivariate statistical analysis was performed. Multivariate linear and logistic regression models were adjusted for co-morbid conditions. Results Out of the 9,240 patients studied, 3,694 (40%) had a diagnosis of hypertension. Patients with hypertension were more likely to be older (61.96 ± 14.95 vs 39.85 ± 15.61, p = 0.000), male (37% vs 33%, p = 0.002) and black (45.2% vs 23.3%, p < 0.001) compared with those without a diagnosis of hypertension. The mean PHQ-9 score was higher in patients with hypertension than in those without (2.97 ± 4.66 vs 2.70 ± 4.93, p = 0.000). Patients with hypertension were more likely to have uncontrolled depression defined as PHQ-9 score > 4 (22.55% vs 19.4%, p < 0.001) even when adjusted for co-morbid conditions (adj OR 1.216 95% CI 1.06–1.34 p = 0.005). Conclusions In this cohort of patients, a diagnosis of hypertension was associated with an increased rate of uncontrolled depressive symptoms. Hence patients with hypertension should be screened using validated PHQ-9 tools in the outpatient setting and offered appropriate treatment for depression. Depression hypertension PHQ-9 Introduction Hypertension (HTN) is a significant public health problem and patients are routinely screened for this condition in the outpatient setting. Over 116 million patients, representing 47% of all adults in the U.S., suffer from hypertension[ 1 ]. Patients with hypertension face increased risks of stroke, cardiovascular disease, premature disability, and even death [ 2 , 3 ]. These negative outcomes related to hypertension are associated with significant psychosocial stress to patients, making them more susceptible to developing psychological disorders. Depression is a common psychological disorder associated with poor health outcomes and comorbid conditions. According to the 2020 National Survey of Drug Use and Health (NSDUH), an estimated 21.0 million U.S. adults aged 18 or older had at least one major depressive episode [ 4 ]. It is well established that depression is a common risk factor for multiple conditions such as cardiovascular disease [ 5 , 6 ], but depression most often goes undiagnosed which contributes to ineffective control of the primary disease. Hypertension and depression are both highly prevalent in the United States. Several clinical trials have highlighted the prevalence of depression in patients with hypertension [ 7 – 10 ]; however, most of these studies were conducted in China. Further studies are needed to better define the relationships between these conditions. Accordingly, this study aims to investigate the incidence of depression in patients who are diagnosed with uncontrolled hypertension in the outpatient setting. Methods All patients at single outpatient primary care center were retrospectively reviewed. This study was reviewed and approved by the Institutional Review Board at Allegheny Health Network. Given the retrospective design and use of de-identified data, the requirement for informed consent was waived. Patient demographics were obtained from electronic medical records. Records of patients with prior diagnosis of hypertension, and comorbidities were obtained. Blood pressure measurements were obtained at each visit. HTN was defined according to the 2017 AHA/ACC hypertension guidelines. Stage I HTN was defined as a systolic blood pressure > 130 mmHg or a diastolic blood pressure > 80 mmHg. Stage II HTN was defined as a systolic blood pressure > 140 mmHg or diastolic blood pressure > 90mm Hg. [ 3 ] For the purposes of this study, all Stage II HTN was defined as uncontrolled hypertension. Patients were screened for depression using the nine-item patient health questionnaire-9 (PHQ-9) tool. The PHQ-9 screening tool contains items derived from the DSM-IV classification for major depression disorder and pertains to: (1) anhedonia, (2) depressed mood, (3) insomnia, (4) fatigue, (5) appetite change, (6) guilty feeling, (7) concentration difficulties, (8) restless feeling or feeling down and lastly (9) suicidal ideations. Patients answered each question on a 4-point scale with a response of 0–3 based on frequency of their symptoms: (0) no symptoms; (1) several days; (2) more than half the days; or (3) nearly every day. Statistical Analysis All data were analyzed using Statistical Package for the Social Sciences (SPSS) version 28 for Mac. Bivariate analyses were performed. Student’s t-test was used for quantitative variables such as age. Chi-square and Fischer-Exact test were used for categorial variables, hypertension diagnosis, PHQ-9 score, and absence or presence of comorbidities. A multivariate regression analysis was performed. Adjusted Odds ratio and corresponding 95% confidence intervals were obtained. A p-value < 0.05 was considered statistically significant. Data are expressed as mean ± standard deviation. Results Baseline characteristics Demographic characteristics of 9,240 patients are outlined in Table 1 . A total of 3694 (40%) patients carried a diagnosis of hypertension. Most of the study population were female; however, a diagnosis of hypertension was most strongly associated with male sex (42% of males had hypertension compared to 39% of females, p < 0.002). The study population was predominantly White (n = 5566, 60%). A total of 1898 (34%) White patients had a chart diagnosis of hypertension compared to 1671 (56%) of 2960 Black patients (p < 0.001). Table 1 Baseline characteristics Characteristic Hypertension n = 3694 (n%) Without Hypertension n = 5546 (n%) Total N = 9240 P-value Age (years) 61.96+/- 14.95 39.85+/- 15.61 48.69+/-18.8 0.000 Sex 0.002 Female 2329 (63) 3673 (66.3) 6002 Male 1365 (37) 1871(33) 3236 Race/Ethnicity < 0.001 Caucasian 1898 (51.4) 3668 (66.1) 5566 Black 1671 (45.2) 1289 (23.2) 2960 Asian 29 (0.8) 174 (3.1) 203 Hispanic/Latino 41 (1.1) 128 (2.3) 169 Mean PHQ-9 score 2.97 +/- 4.66 2.70 +/- 4.93 2.81+/- 4.82 0.000 Uncontrolled Depression (PHQ 9 > 4) 830 (22.5) 1078 (19.4) 1908 < 0.001 Co-morbidities Alcohol use 2272 (61.5) 4030 (72.7) 6302 < 0.001 Other Substance use 433 (11.7) 962 (17.3) 557 < 0.001 Tobacco Use < 0.001 Current smoker 503 (13.6) 587 (10.6) Former smoker 882 (23.9) 775 (14) Uncontrolled HTN (BP ≥ 140/90) 1324 (36.9) 521 (9.7) < 0.001 Diabetes 1417 (38.4) 426 (7.7) 1843 < 0.001 COPD 450 (11) 110 (2) 515 < 0.001 Asthma 387 (10.5) 546 (9.8) 933 0.324 CHF 433 (11.7) 56 (1) 489 < 0.001 CKD 540 (14.6) 66 (1.2) 606 < 0.001 CLD 196 (5.3) 140 (2.5) 336 < 0.001 PHQ, patient health questionnaire; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; CKD, chronic kidney disease; CLD, chronic liver disease Depression and Hypertension In the entire cohort, 7296 (79%) had controlled depression or were not depressed as defined by PHQ-9 < 5. The mean PHQ-9 score for patients with hypertension was higher than for patients without hypertension (2.97± 4.66 vs 2.70 ± 4.93, p = 0.000). Of all patients with hypertension, 842 (23%)) had uncontrolled depression and PHQ-9 scores > 4, as compared to 1097 (20%) in the non-hypertensive group. Mild depressive symptoms (PHQ-9 5–9) were most strongly associated with hypertensive diagnosis (17.5% vs 12.8%, p < 0.001). In addition, 245 patients had severe depression, 95 (2.5%) of whom were in the hypertensive group (Table 2 ) Table 2 Depression severity by PHQ-9 in hypertensive patients Depression severity by PHQ-9 Hypertension n = 3694 (n%) Without Hypertension n = 5546 (n%) Total N = 9240 0–4 (Not depressed) 2848 (77.2) 4448 (80.2) 7296 5–9 (mild depression) 646 (17.5) 711 (12.8) 1357 10–14 (moderate depression) 61 (0.7) 130 (1.4) 191 15–19 (moderately severe depression) 44 (1.2) 103 (1.9) 147 > 19 (severe depression) 91 (2.5) 153 (2.8) 245 PHQ, patient health questionnaire Comorbidities Traditional cardiovascular risk factors were common in the population studied (Table 1 ). In the hypertensive group, 1324 (37%) patients had ACC/AHA stage II hypertension which was classified as uncontrolled hypertension in this study. Diabetes, chronic kidney disease (CKD), tobacco use, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) correlated most strongly with hypertension (P-values < 0.001). Interestingly, alcohol use and other illicit substance use showed a lesser association in the hypertensive group compared to patients without hypertension (62% vs 73% and 12% vs 17% respectively, p-value < 0.001). Multivariate regression analysis ( Table 3 ) Table 3 Multivariate regression analysis of all variables on hypertension diagnosis Variable OR 95% Confidence Interval Lower Upper P-value Uncontrolled Depression: PHQ-9 > 4 1.216 1.059 1.395 0.005 Age 1.076 1.071 1.080 < 0.001 Black Race 2.379 2.105 2.687 < 0.001 Asian Race 0.534 0.329 0.867 0.011 Female Sex 0.668 0.594 0.752 < 0.001 Tobacco Use 1.081 0.911 1.281 0.372 Alcohol Use 1.295 1.142 1.468 < 0.001 Other illicit drug use 0.929 0.714 1.187 0.522 CHF 2.912 2.102 4.034 < 0.001 Diabetes 3.414 2.964 3.931 < 0.001 COPD 1.357 1.051 1.753 0.019 Asthma 1.106 0.924 1.323 0.273 CKD 2.633 1.954 3.549 < 0.001 CLD 1.1 0.831 1.456 0.505 PHQ, patient health questionnaire; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; CKD, chronic kidney disease; CLD, chronic liver disease Using a multivariate regression analysis, uncontrolled depression (PHQ-9 > 4) was independently associated with hypertension diagnosis. Hypertensive patients were 1.2 times more likely to have uncontrolled depression than patients without the condition (1.216 OR 95% CI 1.06–1.40, p < 0.05). Among other comorbidities, diabetes was most strongly associated with hypertension, followed by congestive heart failure, chronic kidney disease (3.414 OR 95% CI 2.96–3.93, p < 0.001; 2.912 OR 95% CI 2.10–4.03, P < 0.001; 2.633 OR 95% CI 1.95–3.55, p < 0.001; 2.379 OR 95% CI 2.11–2.69, respectively). Black race was also associated with hypertension in the population studied (p < 0.001). Discussion In our single-center outpatient setting, nearly 40% (n = 3,694) of 9,240 patients had a diagnosis of hypertension, and of those, more than one third (1,324) were classified as having uncontrolled hypertension with blood pressure ≥ 140/90. These individuals scored higher on PHQ-9 screening with a greater likelihood of uncontrolled depression compared to those in the non-hypertensive group. This was even true after adjusting for other comorbid conditions. Other factors that placed individuals at risk for uncontrolled depression in both groups included increased age, male sex, and Black race. These findings support existing evidence that patients with hypertension are more likely to experience depressive symptoms and should be routinely screened in the outpatient setting. Our analysis also confirmed that patients with multiple comorbid conditions were more likely to have hypertension, consistent with prior literature describing the burden of cardiovascular risk factors and adverse outcomes in hypertensive individuals [ 11 ]. Black race was associated with higher odds of hypertension in this cohort, while Asian race had the lowest odds. Black patients in our population were more likely to experience health disparities and disproportionate health inequities, which may contribute to higher rates of both uncontrolled hypertension and uncontrolled depression [ 12 , 13 ]. The lower observed odds of hypertension among Asian patients in this study warrant further investigation in larger and more diverse cohorts. Several prior studies have examined the relationship between hypertension and depression. A systematic review and meta-analysis by Li et al. including 41 observational studies with 30,796 individuals found that approximately one-third of hypertensive patients had depressive symptoms when assessed by clinical interview [ 9 , 14 ]. However, a cohort study by Obas et al. found that in normotensive people, the age-related increase in systolic BP was lower by about 2 mmHg among patients with depression compared to participants without depression over a 10-year time frame [ 15 ]. It was also concluded that the presence of depression at baseline increased the odds of hypertension diagnosis. Similarly, a study of ethnic minority groups in the Netherlands showed no associations between significant depressed mood and hypertension management [ 16 ]. Despite these mixed results in the literature on the relationship between hypertension with depression, there is a growing consensus that the two conditions share an association. Screening for depression in individuals with hypertension (and other chronic comorbidities) should be performed during outpatient visits, as addressing mental illness among chronically ill individuals is necessary to improve quality of life [ 17 ]. Our results successfully demonstrated the usefulness of the validated PHQ-9 screening tool, which should be widely incorporated in most patient encounters in the clinical setting. Screening for depression is conducted routinely in primary care clinics via patient-reported questionnaires. The most widely used tool is the Patient Health Questinnaire-9 (PHQ-9), which has a sensitivity of 74% and a specificity of 91%. [ 17 ] The tool consists of 9 items, each of which is scored on a scale of 0–3. The questionnaire is therefore scored between 0–27, with scores above 10 indicating a likely depressive disorder. As part of a two-step approach, a short preliminary questionnaire called the Patient Health Questionnaire-2 (PHQ-2) may be used before PHQ-9 as pre-screening, with positive screening warranting the more detailed PHQ-9. The use of PHQ-2 has been shown to decrease the need for PHQ-9 screening, but sensitivity and specificity are almost the same whether the tools are used alone or together [ 18 ]. Strengths and Limitations This study has several strengths, including a relatively large sample size and a racially diverse outpatient population. The use of standardized, validated tools for both blood pressure classification (2017 AHA/ACC guidelines) and depression screening (PHQ-9) enhances the reliability of our findings. However, several limitations should be noted. The cross-sectional, retrospective design limits our ability to infer causality or temporal relationships between hypertension control and depression. We analyzed data from a single outpatient center, which may limit generalizability to other settings or regions. Additionally, information on medication therapy (both antihypertensive and antidepressant medications) was not collected, which could have influenced both blood pressure control and depressive symptom burden. Conclusion In this single-center outpatient cohort, a diagnosis of hypertension was associated with a higher prevalence of uncontrolled depressive symptoms. Black race and comorbid conditions such as diabetes and congestive heart failure were also significantly associated with hypertension. Hypertensive patients should be routinely screened for depression using validated tools such as the PHQ-9 in the outpatient setting and provided appropriate treatment or referral when indicated. Abbreviations CHF, congestive heart failure CLD, chronic liver disease CKD, chronic kidney disease COPD, chronic obstructive pulmonary disease HTN, hypertension PHQ, patient health questionnaire Declarations Disclosures/ Conflicts of Interest The authors have no conflicts of interest or disclosures to declare. Human Ethics This study was approved by the Institutional Review Board at Allegheny Health Network. The requirement for informed consent was waived due to the retrospective nature of the study and use of de-identified data. Consent to Participate declarations Not applicable. This manuscript does not contain any individual person’s identifiable data. Funding: Not applicable Author Contribution RA and EO performed the statistical analysis and wrote and edited portions of the manuscript. NA wrote the bulk of the discussion. XT wrote the introduction. AJ and MG edited and reviewed the manuscript. Data Availability The study was reviewed and approved by the Allegheny Health Network Institutional Review Board, and all data were obtained from the electronic medical record in accordance with institutional ethical standards. There was no external funding for this work. The authors report no conflicts of interest. References (CDC). C.f.D.C.a.P., Hypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association’s 2017 Hypertension Guideline—NHANES 2015–2018. Atlanta, GA . US Department of Health and Human Services; 2021. Benenson I, Waldron FA, Bradshaw MJ. Treating hypertension in older adults: Beyond the guidelines. J Am Assoc Nurse Pract. 2020;32(3):193–9. Whelton PK et al. 2017 ACC /AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/ PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2018. 71(19): pp. e127-e248. SAMHSA.gov, 2020 National Survey of Drug Use and Health (NSDUH) releases. . Chávez-Castillo M, et al. Depression as an Immunometabolic Disorder: Exploring Shared Pharmacotherapeutics with Cardiovascular Disease. Curr Neuropharmacol. 2020;18(11):1138–53. Arroll B, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348–53. Xue J, et al. The prevalence of depressive symptoms among older patients with hypertension in rural China. Int J Geriatr Psychiatry. 2017;32(12):1411–7. Chen S, et al. Protocol of an ongoing randomized controlled trial of care management for comorbid depression and hypertension: the Chinese Older Adult Collaborations in Health (COACH) study. BMC Geriatr. 2018;18(1):124. Li Z, et al. Prevalence of Depression in Patients With Hypertension: A Systematic Review and Meta-Analysis. Med (Baltim). 2015;94(31):e1317. Lobo-Escolar A, et al. Association of hypertension with depression in community-dwelling elderly persons: results from the ZARADEMP Project. Psychother Psychosom. 2008;77(5):323–5. Perumareddi P. Prevention of Hypertension Related to Cardiovascular Disease. Prim Care. 2019;46(1):27–39. Bailey ZD, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453–63. McClendon J, et al. Black-White racial health disparities in inflammation and physical health: Cumulative stress, social isolation, and health behaviors. Psychoneuroendocrinology. 2021;131:105251. Herrera PA et al. Understanding the Relationship between Depression and Chronic Diseases Such as Diabetes and Hypertension: A Grounded Theory Study. Int J Environ Res Public Health, 2021. 18(22). Obas KA, et al. Depression and cardiovascular disease are not linked by high blood pressure: findings from the SAPALDIA cohort. Sci Rep. 2022;12(1):5516. Fernald F, et al. Depression and hypertension awareness, treatment, and control in a multiethnic population in the Netherlands: HELIUS study. Intern Emerg Med. 2021;16(7):1895–903. Shah S et al. Anxiety and Depression among Hypertensive Adults in Tertiary Care Hospitals of Nepal. Psychiatry J, 2022. 2022: p. 1098625. Lai FTT, et al. Sociodemographic moderation of the association between depression and stroke incidence in a retrospective cohort of 0.4 million primary care recipients with hypertension. Psychol Med. 2022;52(2):283–91. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Apr, 2026 Read the published version in SN Comprehensive Clinical Medicine → Version 1 posted Editorial decision: Revision requested 14 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Submission checks completed at journal 13 Jan, 2026 First submitted to journal 24 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8446198","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":574607720,"identity":"05b29032-49d5-420a-b34a-da8c5c2d6a22","order_by":0,"name":"Emmanuel Olumuyide","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYFAC5gYQycNwgIFB4gOQxcZOUAsjQovkDJAWZiK1MIC0SPOArSWggZ+9sU3qZtthGb7j3Ym3bX5tk+djZmD88DEHtxbJnoNt0rlth3kkz5zdbJ3bd9uwjZmBWXLmNtxaDG4kQrQY3MjdJp3bc5sRqIWNmRePFnu4lvtvt0lb9ty2J6jFQAJuC+82aYYftxMJapE4c7DZOudcOtAvuZstextuJ7cxMzbj9Qt/e/PB2zll1vZ8x89uvPHjz23b+UCRDx/xaIGCZgjF2AYmGwiqB4I6KP2HGMWjYBSMglEw0gAAj15TpQf/2NkAAAAASUVORK5CYII=","orcid":"","institution":"Advocate Illinois Masonic Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Olumuyide","suffix":""},{"id":574607721,"identity":"b82e8e27-2175-4f61-943d-91562e138773","order_by":1,"name":"Richard Amoateng","email":"","orcid":"","institution":"University of Illinois at Chicago","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Amoateng","suffix":""},{"id":574607722,"identity":"b410d21e-5022-47f3-aca0-bbbc4c3c254a","order_by":2,"name":"Natthew Arunthamakun","email":"","orcid":"","institution":"Allegheny General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Natthew","middleName":"","lastName":"Arunthamakun","suffix":""},{"id":574607723,"identity":"6221a03f-51fc-4110-b607-7a51866ceed3","order_by":3,"name":"Xiarepati Tierliwaerdi","email":"","orcid":"","institution":"Allegheny General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiarepati","middleName":"","lastName":"Tierliwaerdi","suffix":""},{"id":574607724,"identity":"4dc83a32-7bb8-451a-9c48-7255113bdb3d","order_by":4,"name":"Alexandra Johnston","email":"","orcid":"","institution":"Allegheny General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Johnston","suffix":""},{"id":574607725,"identity":"24a264d4-a986-460f-a755-658363171357","order_by":5,"name":"Mrudula Gadani","email":"","orcid":"","institution":"Allegheny General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mrudula","middleName":"","lastName":"Gadani","suffix":""}],"badges":[],"createdAt":"2025-12-25 04:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8446198/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8446198/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s42399-026-02343-6","type":"published","date":"2026-04-10T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":106808752,"identity":"a1629482-e9ac-4f15-b642-d0e4585ea631","added_by":"auto","created_at":"2026-04-13 16:00:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":705160,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8446198/v1/9f50e35e-9730-4311-bf53-b3ab329ff61a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Depression Incidence in Patients with Hypertension in a Single Outpatient Center","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHypertension (HTN) is a significant public health problem and patients are routinely screened for this condition in the outpatient setting. Over 116\u0026nbsp;million patients, representing 47% of all adults in the U.S., suffer from hypertension[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients with hypertension face increased risks of stroke, cardiovascular disease, premature disability, and even death [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These negative outcomes related to hypertension are associated with significant psychosocial stress to patients, making them more susceptible to developing psychological disorders.\u003c/p\u003e \u003cp\u003eDepression is a common psychological disorder associated with poor health outcomes and comorbid conditions. According to the 2020 National Survey of Drug Use and Health (NSDUH), an estimated 21.0\u0026nbsp;million U.S. adults aged 18 or older had at least one major depressive episode [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is well established that depression is a common risk factor for multiple conditions such as cardiovascular disease [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], but depression most often goes undiagnosed which contributes to ineffective control of the primary disease.\u003c/p\u003e \u003cp\u003eHypertension and depression are both highly prevalent in the United States. Several clinical trials have highlighted the prevalence of depression in patients with hypertension [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; however, most of these studies were conducted in China. Further studies are needed to better define the relationships between these conditions. Accordingly, this study aims to investigate the incidence of depression in patients who are diagnosed with uncontrolled hypertension in the outpatient setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAll patients at single outpatient primary care center were retrospectively reviewed. This study was reviewed and approved by the Institutional Review Board at Allegheny Health Network. Given the retrospective design and use of de-identified data, the requirement for informed consent was waived. Patient demographics were obtained from electronic medical records. Records of patients with prior diagnosis of hypertension, and comorbidities were obtained. Blood pressure measurements were obtained at each visit. HTN was defined according to the 2017 AHA/ACC hypertension guidelines. Stage I HTN was defined as a systolic blood pressure\u0026thinsp;\u0026gt;\u0026thinsp;130 mmHg or a diastolic blood pressure\u0026thinsp;\u0026gt;\u0026thinsp;80 mmHg. Stage II HTN was defined as a systolic blood pressure\u0026thinsp;\u0026gt;\u0026thinsp;140 mmHg or diastolic blood pressure \u0026gt;\u0026thinsp;90mm Hg. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] For the purposes of this study, all Stage II HTN was defined as uncontrolled hypertension.\u003c/p\u003e \u003cp\u003ePatients were screened for depression using the nine-item patient health questionnaire-9 (PHQ-9) tool. The PHQ-9 screening tool contains items derived from the DSM-IV classification for major depression disorder and pertains to: (1) anhedonia, (2) depressed mood, (3) insomnia, (4) fatigue, (5) appetite change, (6) guilty feeling, (7) concentration difficulties, (8) restless feeling or feeling down and lastly (9) suicidal ideations. Patients answered each question on a 4-point scale with a response of 0\u0026ndash;3 based on frequency of their symptoms: (0) no symptoms; (1) several days; (2) more than half the days; or (3) nearly every day.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll data were analyzed using Statistical Package for the Social Sciences (SPSS) version 28 for Mac. Bivariate analyses were performed. Student\u0026rsquo;s t-test was used for quantitative variables such as age. Chi-square and Fischer-Exact test were used for categorial variables, hypertension diagnosis, PHQ-9 score, and absence or presence of comorbidities. A multivariate regression analysis was performed. Adjusted Odds ratio and corresponding 95% confidence intervals were obtained. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Data are expressed as mean \u0026plusmn; standard deviation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eDemographic characteristics of 9,240 patients are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 3694 (40%) patients carried a diagnosis of hypertension. Most of the study population were female; however, a diagnosis of hypertension was most strongly associated with male sex (42% of males had hypertension compared to 39% of females, p\u0026thinsp;\u0026lt;\u0026thinsp;0.002). The study population was predominantly White (n\u0026thinsp;=\u0026thinsp;5566, 60%). A total of 1898 (34%) White patients had a chart diagnosis of hypertension compared to 1671 (56%) of 2960 Black patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;3694 (n%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout Hypertension\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;5546 (n%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;9240\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.96+/- 14.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.85+/- 15.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.69+/-18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2329 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3673 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1365 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1871(33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace/Ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1898 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3668 (66.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5566\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1671 (45.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1289 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e174 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic/Latino\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean PHQ-9 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.97 +/- 4.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.70 +/- 4.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.81+/- 4.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncontrolled Depression (PHQ 9\u0026thinsp;\u0026gt;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e830 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1078 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1908\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCo-morbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2272 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4030 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Substance use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e433 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e962 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobacco Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e503 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e587 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e882 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e775 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncontrolled HTN (BP\u0026thinsp;\u0026ge;\u0026thinsp;140/90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1324 (36.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e521 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1417 (38.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e426 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1843\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e450 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e387 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e546 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e433 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e540 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePHQ, patient health questionnaire; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; CKD, chronic kidney disease; CLD, chronic liver disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDepression and Hypertension\u003c/h3\u003e\n\u003cp\u003eIn the entire cohort, 7296 (79%) had controlled depression or were not depressed as defined by PHQ-9\u0026thinsp;\u0026lt;\u0026thinsp;5. The mean PHQ-9 score for patients with hypertension was higher than for patients without hypertension (2.97\u0026plusmn; 4.66 vs 2.70 \u0026plusmn; 4.93, p\u0026thinsp;=\u0026thinsp;0.000). Of all patients with hypertension, 842 (23%)) had uncontrolled depression and PHQ-9 scores\u0026thinsp;\u0026gt;\u0026thinsp;4, as compared to 1097 (20%) in the non-hypertensive group. Mild depressive symptoms (PHQ-9 5\u0026ndash;9) were most strongly associated with hypertensive diagnosis (17.5% vs 12.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition, 245 patients had severe depression, 95 (2.5%) of whom were in the hypertensive group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDepression severity by PHQ-9 in hypertensive patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression severity by PHQ-9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypertension n\u0026thinsp;=\u0026thinsp;3694 (n%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout Hypertension\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;5546 (n%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;9240\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;4 (Not depressed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2848 (77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4448 (80.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;9 (mild depression)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e646 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e711 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1357\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;14 (moderate depression)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;19 (moderately severe depression)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;19 (severe depression)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e153 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e245\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePHQ, patient health questionnaire\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eComorbidities\u003c/h3\u003e\n\u003cp\u003eTraditional cardiovascular risk factors were common in the population studied (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the hypertensive group, 1324 (37%) patients had ACC/AHA stage II hypertension which was classified as uncontrolled hypertension in this study. Diabetes, chronic kidney disease (CKD), tobacco use, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) correlated most strongly with hypertension (P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Interestingly, alcohol use and other illicit substance use showed a lesser association in the hypertensive group compared to patients without hypertension (62% vs 73% and 12% vs 17% respectively, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cem\u003eMultivariate regression analysis (\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate regression analysis of all variables on hypertension diagnosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e95% Confidence Interval\u003c/p\u003e \u003cp\u003eLower Upper\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncontrolled Depression: PHQ-9\u0026thinsp;\u0026gt;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.395\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack Race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian Race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.752\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobacco Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.911\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther illicit drug use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.929\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.912\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.964\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.924\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.633\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.549\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.831\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.456\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.505\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePHQ, patient health questionnaire; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; CKD, chronic kidney disease; CLD, chronic liver disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUsing a multivariate regression analysis, uncontrolled depression (PHQ-9\u0026thinsp;\u0026gt;\u0026thinsp;4) was independently associated with hypertension diagnosis. Hypertensive patients were 1.2 times more likely to have uncontrolled depression than patients without the condition (1.216 OR 95% CI 1.06\u0026ndash;1.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Among other comorbidities, diabetes was most strongly associated with hypertension, followed by congestive heart failure, chronic kidney disease (3.414 OR 95% CI 2.96\u0026ndash;3.93, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 2.912 OR 95% CI 2.10\u0026ndash;4.03, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 2.633 OR 95% CI 1.95\u0026ndash;3.55, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 2.379 OR 95% CI 2.11\u0026ndash;2.69, respectively). Black race was also associated with hypertension in the population studied (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our single-center outpatient setting, nearly 40% (n\u0026thinsp;=\u0026thinsp;3,694) of 9,240 patients had a diagnosis of hypertension, and of those, more than one third (1,324) were classified as having uncontrolled hypertension with blood pressure\u0026thinsp;\u0026ge;\u0026thinsp;140/90. These individuals scored higher on PHQ-9 screening with a greater likelihood of uncontrolled depression compared to those in the non-hypertensive group. This was even true after adjusting for other comorbid conditions. Other factors that placed individuals at risk for uncontrolled depression in both groups included increased age, male sex, and Black race. These findings support existing evidence that patients with hypertension are more likely to experience depressive symptoms and should be routinely screened in the outpatient setting.\u003c/p\u003e \u003cp\u003eOur analysis also confirmed that patients with multiple comorbid conditions were more likely to have hypertension, consistent with prior literature describing the burden of cardiovascular risk factors and adverse outcomes in hypertensive individuals [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Black race was associated with higher odds of hypertension in this cohort, while Asian race had the lowest odds. Black patients in our population were more likely to experience health disparities and disproportionate health inequities, which may contribute to higher rates of both uncontrolled hypertension and uncontrolled depression [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The lower observed odds of hypertension among Asian patients in this study warrant further investigation in larger and more diverse cohorts.\u003c/p\u003e \u003cp\u003eSeveral prior studies have examined the relationship between hypertension and depression. A systematic review and meta-analysis by Li et al. including 41 observational studies with 30,796 individuals found that approximately one-third of hypertensive patients had depressive symptoms when assessed by clinical interview [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, a cohort study by Obas et al. found that in normotensive people, the age-related increase in systolic BP was lower by about 2 mmHg among patients with depression compared to participants without depression over a 10-year time frame [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It was also concluded that the presence of depression at baseline increased the odds of hypertension diagnosis. Similarly, a study of ethnic minority groups in the Netherlands showed no associations between significant depressed mood and hypertension management [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Despite these mixed results in the literature on the relationship between hypertension with depression, there is a growing consensus that the two conditions share an association. Screening for depression in individuals with hypertension (and other chronic comorbidities) should be performed during outpatient visits, as addressing mental illness among chronically ill individuals is necessary to improve quality of life [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur results successfully demonstrated the usefulness of the validated PHQ-9 screening tool, which should be widely incorporated in most patient encounters in the clinical setting. Screening for depression is conducted routinely in primary care clinics via patient-reported questionnaires. The most widely used tool is the Patient Health Questinnaire-9 (PHQ-9), which has a sensitivity of 74% and a specificity of 91%. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] The tool consists of 9 items, each of which is scored on a scale of 0\u0026ndash;3. The questionnaire is therefore scored between 0\u0026ndash;27, with scores above 10 indicating a likely depressive disorder. As part of a two-step approach, a short preliminary questionnaire called the Patient Health Questionnaire-2 (PHQ-2) may be used before PHQ-9 as pre-screening, with positive screening warranting the more detailed PHQ-9. The use of PHQ-2 has been shown to decrease the need for PHQ-9 screening, but sensitivity and specificity are almost the same whether the tools are used alone or together [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eStrengths and Limitations\u003c/h3\u003e\n\u003cp\u003eThis study has several strengths, including a relatively large sample size and a racially diverse outpatient population. The use of standardized, validated tools for both blood pressure classification (2017 AHA/ACC guidelines) and depression screening (PHQ-9) enhances the reliability of our findings.\u003c/p\u003e \u003cp\u003eHowever, several limitations should be noted. The cross-sectional, retrospective design limits our ability to infer causality or temporal relationships between hypertension control and depression. We analyzed data from a single outpatient center, which may limit generalizability to other settings or regions. Additionally, information on medication therapy (both antihypertensive and antidepressant medications) was not collected, which could have influenced both blood pressure control and depressive symptom burden.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this single-center outpatient cohort, a diagnosis of hypertension was associated with a higher prevalence of uncontrolled depressive symptoms. Black race and comorbid conditions such as diabetes and congestive heart failure were also significantly associated with hypertension. Hypertensive patients should be routinely screened for depression using validated tools such as the PHQ-9 in the outpatient setting and provided appropriate treatment or referral when indicated.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHF, congestive heart failure \u0026nbsp; \u0026nbsp;CLD, chronic liver disease\u003c/p\u003e\n\u003cp\u003eCKD, chronic kidney disease \u0026nbsp; COPD, chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003eHTN, hypertension \u0026nbsp; \u0026nbsp; PHQ, patient health questionnaire\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDisclosures/ Conflicts of Interest\u003c/h2\u003e \u003cp\u003e \u003cb\u003e\u003c/b\u003eThe authors have no conflicts of interest or disclosures to declare.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHuman Ethics\u003c/strong\u003e \u003cp\u003e This study was approved by the Institutional Review Board at Allegheny Health Network. The requirement for informed consent was waived due to the retrospective nature of the study and use of de-identified data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Participate declarations\u003c/strong\u003e \u003cp\u003e \u003cb\u003e\u003c/b\u003eNot applicable. This manuscript does not contain any individual person\u0026rsquo;s identifiable data.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRA and EO performed the statistical analysis and wrote and edited portions of the manuscript. NA wrote the bulk of the discussion. XT wrote the introduction. AJ and MG edited and reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe study was reviewed and approved by the Allegheny Health Network Institutional Review Board, and all data were obtained from the electronic medical record in accordance with institutional ethical standards. There was no external funding for this work. The authors report no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e(CDC). C.f.D.C.a.P., \u003cem\u003eHypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association\u0026rsquo;s 2017 Hypertension Guideline\u0026mdash;NHANES 2015\u0026ndash;2018. Atlanta, GA\u003c/em\u003e. US Department of Health and Human Services; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenenson I, Waldron FA, Bradshaw MJ. Treating hypertension in older adults: Beyond the guidelines. J Am Assoc Nurse Pract. 2020;32(3):193\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhelton PK et al. 2017 ACC\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/\u003c/span\u003e\u003cspan address=\"http:///AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cem\u003ePCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.\u003c/em\u003e J Am Coll Cardiol, 2018. 71(19): pp. e127-e248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSAMHSA.gov, \u003cem\u003e2020 National Survey of Drug Use and Health (NSDUH) releases.\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCh\u0026aacute;vez-Castillo M, et al. Depression as an Immunometabolic Disorder: Exploring Shared Pharmacotherapeutics with Cardiovascular Disease. Curr Neuropharmacol. 2020;18(11):1138\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArroll B, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXue J, et al. The prevalence of depressive symptoms among older patients with hypertension in rural China. Int J Geriatr Psychiatry. 2017;32(12):1411\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen S, et al. Protocol of an ongoing randomized controlled trial of care management for comorbid depression and hypertension: the Chinese Older Adult Collaborations in Health (COACH) study. BMC Geriatr. 2018;18(1):124.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Z, et al. Prevalence of Depression in Patients With Hypertension: A Systematic Review and Meta-Analysis. Med (Baltim). 2015;94(31):e1317.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLobo-Escolar A, et al. Association of hypertension with depression in community-dwelling elderly persons: results from the ZARADEMP Project. Psychother Psychosom. 2008;77(5):323\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerumareddi P. Prevention of Hypertension Related to Cardiovascular Disease. Prim Care. 2019;46(1):27\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBailey ZD, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcClendon J, et al. Black-White racial health disparities in inflammation and physical health: Cumulative stress, social isolation, and health behaviors. Psychoneuroendocrinology. 2021;131:105251.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerrera PA et al. Understanding the Relationship between Depression and Chronic Diseases Such as Diabetes and Hypertension: A Grounded Theory Study. Int J Environ Res Public Health, 2021. 18(22).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObas KA, et al. Depression and cardiovascular disease are not linked by high blood pressure: findings from the SAPALDIA cohort. Sci Rep. 2022;12(1):5516.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernald F, et al. Depression and hypertension awareness, treatment, and control in a multiethnic population in the Netherlands: HELIUS study. Intern Emerg Med. 2021;16(7):1895\u0026ndash;903.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah S et al. \u003cem\u003eAnxiety and Depression among Hypertensive Adults in Tertiary Care Hospitals of Nepal.\u003c/em\u003e Psychiatry J, 2022. 2022: p. 1098625.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLai FTT, et al. Sociodemographic moderation of the association between depression and stroke incidence in a retrospective cohort of 0.4 million primary care recipients with hypertension. Psychol Med. 2022;52(2):283\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Depression, hypertension, PHQ-9","lastPublishedDoi":"10.21203/rs.3.rs-8446198/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8446198/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eHypertension and depression are both highly prevalent in the United States and each condition is commonly managed in the outpatient setting. This study aims to investigate the incidence of depression in patients who are diagnosed with hypertension.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted analyzing 9,240 adult patients at a single center outpatient clinic between 2019 and 2022. Blood pressure and PHQ-9 from the latest outpatient visit were recorded. Demographic data associated with hypertension were also obtained. Bivariate statistical analysis was performed. Multivariate linear and logistic regression models were adjusted for co-morbid conditions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of the 9,240 patients studied, 3,694 (40%) had a diagnosis of hypertension. Patients with hypertension were more likely to be older (61.96\u0026thinsp;\u0026plusmn;\u0026thinsp;14.95 vs 39.85\u0026thinsp;\u0026plusmn;\u0026thinsp;15.61, p\u0026thinsp;=\u0026thinsp;0.000), male (37% vs 33%, p\u0026thinsp;=\u0026thinsp;0.002) and black (45.2% vs 23.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared with those without a diagnosis of hypertension. The mean PHQ-9 score was higher in patients with hypertension than in those without (2.97\u0026thinsp;\u0026plusmn;\u0026thinsp;4.66 vs 2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93, p\u0026thinsp;=\u0026thinsp;0.000). Patients with hypertension were more likely to have uncontrolled depression defined as PHQ-9 score\u0026thinsp;\u0026gt;\u0026thinsp;4 (22.55% vs 19.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) even when adjusted for co-morbid conditions (adj OR 1.216 95% CI 1.06\u0026ndash;1.34 p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn this cohort of patients, a diagnosis of hypertension was associated with an increased rate of uncontrolled depressive symptoms. Hence patients with hypertension should be screened using validated PHQ-9 tools in the outpatient setting and offered appropriate treatment for depression.\u003c/p\u003e","manuscriptTitle":"Depression Incidence in Patients with Hypertension in a Single Outpatient Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 13:52:29","doi":"10.21203/rs.3.rs-8446198/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-14T14:09:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T15:44:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-13T08:00:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2025-12-25T04:00:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"671d9e4c-160c-4d64-a530-b5f1f6f055de","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T15:59:55+00:00","versionOfRecord":{"articleIdentity":"rs-8446198","link":"https://doi.org/10.1007/s42399-026-02343-6","journal":{"identity":"sn-comprehensive-clinical-medicine","isVorOnly":false,"title":"SN Comprehensive Clinical Medicine"},"publishedOn":"2026-04-10 15:57:06","publishedOnDateReadable":"April 10th, 2026"},"versionCreatedAt":"2026-02-09 13:52:29","video":"","vorDoi":"10.1007/s42399-026-02343-6","vorDoiUrl":"https://doi.org/10.1007/s42399-026-02343-6","workflowStages":[]},"version":"v1","identity":"rs-8446198","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8446198","identity":"rs-8446198","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}
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