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Stress management interventions and blood pressure

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Bandolier has been told that it may have a 'type A' personality, whatever that means. Worse than being branded something you can't understand is the punch line, that 'type A' personalities will have raised blood pressure. Even worse again is the accusation that if we have hypertension it's our fault, and worse of all is the exhortation to relax and manage our stress, because then everything will be all right.

So Bandolier thought a look at the evidence that stress management helps would be fun. Can stress management interventions help reduce blood pressure in people who are mildly hypertensive? Current published trials suggest not.

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PubMed was searched for randomised controlled trials published from 1990 to mid-2002 using the terms 'stress', 'hypertension' and 'blood pressure'. Studies included compared a stress management intervention comprised of several components with a control intervention. Excluded were studies that assessed a single component alone, such as transcendental meditation or progressive muscle relaxation.

Results


Duplicate publications and subset analyses were excluded, leaving four trials for inclusion [1-4], and details of these will be found in this Table . There were 762 patients in the four studies. Before study entry patients in all the trials had diastolic blood pressure greater than 80 mmHg, and in two systolic blood pressure was greater than 125 or 140 mmHg. Trials were diverse in terms of duration, which varied between eight weeks and 18 months, and stress management intervention, though all incorporated a relaxation component. Quality was not high, all four trials scoring 2 out of 5 on a much-used system.

Other components of the stress management interventions included education about blood pressure and stress, psychological or behavioural components (anger and anxiety response), and problem solving. Controls received no intervention in three studies, and undertook mild non-aerobic exercise in another. Compliance with the interventions was reported in one trial only and relied on self-reports by patients, but was good.

Absolute changes in systolic and diastolic blood pressure were small. Figure 1 shows the results for the change in systolic blood pressure over the period of the study for each trial, with larger symbols indicating larger trials. The two largest trials were on the line of equality, and intervention made no difference over six and 18 months.

Figure 1: Changes (start-end) in systolic blood pressure for stress management interventions



Changes reached statistical significance compared with control in the two smaller trials over eight and twelve weeks. In one of these post-treatment reduction in diastolic blood pressure was maintained at six months follow-up, but systolic blood pressure had increased to baseline levels.

The weighted mean systolic blood pressure reduction was 4 mmHg with stress management interventions and 3 mmHg with control. Weighted mean diastolic reductions were 5 mmHg and 4 mmHg respectively.

Comment


There is no evidence for using stress management interventions alone since the studies showed no long-term reduction in blood pressure of clinical significance. There may be a place for using these interventions, to help individuals relax, in addition to advising the usual lifestyle changes such as reduction in salt intake, increased aerobic exercise, and weight reduction.

What is interesting is that small, short trials had the capacity to mislead, showing bigger reductions for treatment over control over short periods. Larger, longer studies demonstrated no difference between treatment and control, and there was no difference overall.

References:

  1. DM Batey et al. Stress management intervention for primary prevention of hypertension: detailed results from Phase I of Trials of Hypertension Prevention (TOHP-I). Ann Epidemiol 2000 10:45-58.
  2. P Bennett et al. Treating Type A behaviours and mild hypertension in middle-aged men. J Psychosom Res 1991 35:209-223.
  3. DW Johnston et al. Effect of stress management on blood pressure in mild primary hypertension. BMJ 1993 306:963-966.
  4. W Linden et al. Individualized stress management for primary hypertension: a randomized trial. Arch Intern Med 2001 161:1071-1080.
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