The Associations Between Mental Health Status, Hypertension, and Hospital Inpatient Visits in Women in the United States

The Associations Between Mental Health Status, Hypertension, and Hospital Inpatient Visits in... Abstract BACKGROUND Poor mental health status is more prevalent in women and may be related to poor hypertension outcomes and increased hospital inpatient visits. This study aims to find the association between mental health status and hypertension in women and the combined effect of mental health status and hypertension on hospital inpatient visits in women in the United States. METHODS The household component of 2014 Medical Expenditure Panel Surveys (MEPS) was analyzed (N = 9,137). Kessler (K6) scale for mental health status (poor, good/excellent), hypertension (yes, no), and hospital inpatient visits (yes, no) were examined. A combined effect variable for mental health status and hypertension was created. Multiple logistic regression analysis was conducted and adjusted odds ratios (AORs) with corresponding 95% confidence intervals (CIs) were calculated. RESULTS After adjusting for confounders, women who reported poor mental health had significantly higher odds of hypertension compared to women who reported good/excellent mental health (AOR = 1.39, 95% CI = 1.16, 1.68). Further, women who reported hypertension coupled with poor mental health had higher odds of having hospital inpatient visits compared to women who reported no hypertension coupled with good/excellent mental health in the adjusted analysis (AOR = 3.03, 95% CI = 1.96, 4.69). CONCLUSIONS There is a significant association between mental health status and hypertension in women. Further, poor mental health status coupled with hypertension leads to increase hospital inpatient visits for women. It is important that health professionals focus on utilizing available screening tools to assess mental health status of women for early detection and to manage the disorder. cardiovascular diseases, hypertension, hospital inpatient visits, Kessler (K6) scale, mental health status Hypertension is a major public health problem in the United States. It is the leading risk factor for chronic cardiovascular disease occurrence, ischemic heart diseases, and stroke. In addition, hypertension has significant economic implication.1 Even though the prevalence of hypertension is similar for men and women,2 the mortality rate associated with cardiovascular diseases is higher in women compared to men.3,4 Cardiovascular disease is still the major cause of death in women over the age of 65 years.4 However, there were more studies examining hypertension and cardiovascular disorder in men than in women.5–7 Mental health disorders are more prevalent in women and may affect cardiovascular outcomes. For example, lifetime major depression have been reported to be significantly greater in women (11.7%) than men (5.6%) in the United States.8 According to the Global Burden of Disease Study 2010, mental health disorders contribute to a significant proportion of disease burden and are the leading cause of years lived with disability worldwide.9 Mental health disorders increase risk for communicable and non-communicable diseases.10 A systematic review of evidence from population-based research reported strong associations between depression and coronary heart disease from prospective studies.11 Poor mental health status may be related to chronic stress in women12 and chronic stress is a known risk factor for hypertension.13,14 Hypertension-related complications and comorbidities increase the probability of hospitalization,15 and hospitalization costs associated with hypertension are substantial.16,17 Additionally, mental illness often co-occurs with somatic conditions and thus might increase the likelihood of hospitalization.18 Hypertension coupled with mental health condition in women may increase the probability of hospitalization further; thereby may increase the medical costs significantly. A previous study examined the independent associations between mental illness and hospitalization and between hypertension and hospitalization.19 However, the combined effect of mental health status and hypertension on hospital inpatient visits has not been well investigated. Understanding the combined effect will be beneficial in designing intervention to improve quality of life, morbidity, and mortality for the women. Therefore, the current study aims to investigate the association between mental health status and hypertension in women in the United States using a nationally representative survey. Additionally, the study will explore the combined effect of mental health status and hypertension on hospital inpatient visits in women in the United States. METHODS Study design and data source Data from the household component (HC) of the 2014 Medical Expenditure Panel Surveys (MEPS) was analyzed. The MEPS-HC is conducted by the Agency for Healthcare Research and Quality (AHRQ).20 The objective of the MEPS-HC is to provide nationally representative estimates of health care use, expenditures, sources of payment, and health insurance coverage for the US civilian noninstitutionalized population. In addition, the MEPS-HC provides estimates of respondents’ health status, demographic and socioeconomic characteristics, employment, access to care, and satisfaction with health care. The MEPS-HC is a complex national probability survey. The MEPS sample includes an oversample of Blacks, Hispanics, Asians, and persons with a predicted low income. More detailed information on the methodology are available elsewhere.20 Study population The MEPS sample for 2014 included 34,875 US persons. The current study included only females who were 18 years or older (N = 9,137) for analysis (Figure 1). The analysis was restricted to female 18 years or older because the questions about high blood pressure was only asked if the respondent was 18 years or older. Figure 1. View largeDownload slide A flow diagram displaying distribution of study population in relation to exclusion criteria, mental health status, hypertension, and hospital inpatient visits among women in the United States. Figure 1. View largeDownload slide A flow diagram displaying distribution of study population in relation to exclusion criteria, mental health status, hypertension, and hospital inpatient visits among women in the United States. Outcome variables The outcome variables examined in this study were hypertension and hospital inpatient visits. Hypertension was defined based on the following question in the survey: “Has the person ever been told by a health professional that the person has hypertension (except during pregnancy)” (yes = 1, no = 0). Self-report of hypertension usually have high sensitivity and good overall accuracy and therefore, should be considered valid.21 Hospital inpatient visits was based on the data for hospital discharges for each sample person. Data for hospital discharges were collected from the respondents at the event level and summed to produce the annual utilization data for 2014. A binary variable was created for hospital inpatient visits (yes/no) for the current study based on the total number of hospital discharges for each sample person in the dataset (≥1 discharge = yes, 0 discharge = no). The self-report of hospital inpatient visit should be considered valid because of relatively short reference periods (3–4 months) for each round of the survey used for MEPS data collection.21 Furthermore, self-reported hospital inpatient visits has been validated in other studies.22,23 Exposure variables The main exposure variable, mental health status, was defined based on the mental health status measure, Kessler (K6) scale, available in the MEPS dataset. The Kessler (K6) score is a summary measure of overall rating of feeling by the respondent in past 30 days. The score was pre-calculated in the dataset based on the respondents’ answers to 6 mental health-related questions assessing nonspecific psychological distress of that person.20 The higher the score, the greater the person’s tendency towards mental disability. The main independent variable, poor mental health status, was constructed as a binary variable based on the Kessler score (yes = 1, if ≥5; no = 0, if 0–4). An optimal lower threshold cut point was indicative of moderate mental distress. The item nonresponse rate for this variable was only 1.16%. Kessler (K6) scale is a widely used validated measure of nonspecific psychological distresses.20 The optimal lower threshold cut point used in the current study to indicate moderate mental distress has been validated in other studies.24 Potential confounders Potential confounders considered in this analysis included age (18–24, 25–44, 45–64, 65+ years), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, others), marital status (married, never married, widowed/divorced/separated), education (less than high school graduate, high school graduate, less than bachelor’s degree, college graduate or greater), insurance status (private health insurance, public health insurance, uninsured), and body mass index (BMI; underweight = BMI <18.5; normal weight = BMI ≥18.5 and <25.0; overweight = BMI ≥25.0 and <30.0; obesity = BMI ≥30.0). The age at diagnosis of high blood pressure (continuous in years) and current smoking status (smoker/non-smoker) were also examined. History of coronary heart disease (yes, no), high cholesterol (yes, no), and diabetes (yes = 1, no = 0) were also considered as potential control variables. These comorbidities were identified at person-level based on questions that asked if the person had ever been diagnosed by a health care professional as having these conditions. These measures, therefore, should be considered valid. Statistical analysis Data analyses were conducted using survey procedures in SAS 9.4 (SAS Institute, Cary, NC) utilizing appropriate analysis weights to account for the complex survey design and to produce estimates that are nationally representative of the adult female population. Descriptive analysis was conducted to examine the distribution of overall study population and by hypertension and hospital inpatient visits. The association between mental health status and hypertension in women was determined using logistic regression analysis, which generated crude odds ratios (CORs) and adjusted odds ratios (AORs) and corresponding 95% confidence intervals (CIs). The association between mental health status and hospital inpatient visits was also determined using logistic regression analysis. To assess the combined effect of mental status and hypertension in women on hospital inpatient visits, a combined effect variable with 4 categories was created (hypertension and poor mental health, hypertension but no poor mental health, no hypertension but poor mental health, and no hypertension and no poor mental health). The combined effect of mental status and hypertension in women on hospital inpatient visits was determined using logistic regression analysis. Possible effect modifiers were assessed using interaction terms between the main exposure and the covariates. No covariates were identified as potential effect modifiers. Parsimonious logistic models were created using the 10% change-in-estimates procedure to identify and control for the confounders. Bonferroni correction method for multiple comparison tests was performed and overall adjusted level of significance for all tests was set to P <0.01. The study was exempt from Institutional Review Board (IRB) approval as secondary data were utilized for analyses and the study did not require access to any existing identifiable private information. RESULTS Overall, nearly 35% of women reported being diagnosed with hypertension, 20% reported poor mental health, and 6% had hospital inpatient visits (Table 1). Table 1 displays the summary characteristics of the study population. The majority of the women was 45 years or older (52.2%), non-Hispanic White (64.5%), married (54.1%), had education higher than high school (57.8%), and had private insurance (69.0%). Furthermore, majority of the respondent women were overweight or obese (70.3%), nonsmokers (82.6%), had normal or low cholesterol (67%), and did not have coronary heart disease (93.4%) or diabetes (90.1%). There was a statistically significant association between age, race, marital status, educational status, insurance, BMI, coronary heart disease, high cholesterol, diabetes, perceived mental health status, and inpatient visits and hypertension in women. Inpatient visit was prevalent among women age 65 years or older, divorced/separated/widowed, and with public insurance, poor mental health status, coronary artery disease, high cholesterol, and diabetes. There was a statistically significant association between age, race, marital status, insurance status, coronary heart disease, high cholesterol, diabetes, and perceived mental health status, and inpatient visit in women. Table 1. Characteristics of study population by hypertension and hospital inpatient visits Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Abbreviations: N, total sample size; n, subsample size; SD, standard deviation. aP values are calculated from t-test or chi-square tests to find differences between hypertension and no hypertension. bP values are calculated from t-test or chi-square tests to find differences between hospital and no hospital inpatient visits. View Large Table 1. Characteristics of study population by hypertension and hospital inpatient visits Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Abbreviations: N, total sample size; n, subsample size; SD, standard deviation. aP values are calculated from t-test or chi-square tests to find differences between hypertension and no hypertension. bP values are calculated from t-test or chi-square tests to find differences between hospital and no hospital inpatient visits. View Large The prevalence of hypertension was higher among women with poor mental health status (44.8%, 95% CI = 42.0%, 47.7%) compared to those with good or excellent mental health status (33.7%, 95% CI = 32.1%, 35.4%). Similarly, the rate of hospital inpatient visits was higher among women with poor mental health status (11.3%, 95% CI = 9.3%, 13.3%) compared to those who reported good or excellent mental health status (4.6%, 95% CI = 4.0%, 5.3%; Table 1). The unadjusted analysis showed that the odds of hypertension was 60% higher among women with poor mental health status compared to women with good or excellent mental health status (COR = 1.60, 95% CI = 1.38, 1.84; Table 2). Furthermore, women with poor mental health status were 2.62 times as likely to have inpatient visits as women with good or excellent mental health status (COR = 2.62, 95% CI = 2.03, 3.39). After adjusting for age, race/ethnicity, marital status, insurance status, congestive heart disease, cholesterol, and diabetes, the odds of hypertension was 39% higher for women with poor mental health status (AOR = 1.39, 95% CI = 1.16, 1.68) compared to women with good or excellent mental health status. Similarly, compared to women with good or excellent mental health status, women with poor mental health status had a 129% higher odds of having inpatient visits (AOR = 2.29, 95% CI = 1.73, 3.03). Table 2. Logistic regression analysis of mental health status and hypertension and hospital inpatient visits in women Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Abbreviations: CI, confidence interval; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large Table 2. Logistic regression analysis of mental health status and hypertension and hospital inpatient visits in women Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Abbreviations: CI, confidence interval; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large Table 3 reports the unadjusted ORs and AORs of combined mental health status and hypertension, and hospital inpatient visits. In the unadjusted analysis, compared to women with no hypertension coupled with good or excellent mental health, women with hypertension and poor mental health were 7.64 times as likely (COR = 7.64, 95% CI = 5.38, 10.85), women with hypertension but good or excellent mental health were 3.75 times as likely (COR = 3.75, 95% CI = 2.73, 5.13), and women with no hypertension but poor mental health were 3.01 times as likely (COR = 3.01, 95% CI = 1.98, 4.58) to have hospital inpatient visits. After controlling for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes, women who reported having hypertension coupled with poor mental health had 203% higher odds (AOR = 3.03, 95% CI = 1.96, 4.69), women with hypertension but good or excellent mental health had 58% higher odds (AOR = 1.58, 95% CI = 1.10, 2.27), and women with no hypertension but poor mental health had 197% higher odds (AOR = 2.97, 95% CI = 1.96, 4.48) of having hospital inpatient visits compared to women with good or excellent mental health and no hypertension. Table 3. Logistic regression analysis of combined effect of mental health status and hypertension on inpatient visits Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Abbreviations: CI, confidence interval; HTN, hypertension; MH, mental health; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large Table 3. Logistic regression analysis of combined effect of mental health status and hypertension on inpatient visits Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Abbreviations: CI, confidence interval; HTN, hypertension; MH, mental health; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large DISCUSSION This study revealed that poor mental health status was independently associated with both hypertension and increased hospital inpatient visits in women. Additionally, the study showed that the odds of hospital inpatient visits was significantly higher among women who reported poor mental health status coupled with hypertension when compared to women with good or excellent mental health status without hypertension. To the authors’ knowledge, there were no studies that examined the association between mental health status and hypertension in women. However, the observed relationships between mental health status and hypertension could be explained by chronic stress being a potential mediator on the causal pathway between mental health status and hypertension. Prior studies have reported significant association between poor mental health status and chronic stress in women.12,25 Previous studies have also implicated that chronic stress is associated with poor lifestyle behaviors, such as drinking alcohol, smoking, and consuming high fat and high sugar food.26,27 These negative health behaviors may be an indicators of poor mental health status among individuals,28,29 that are also known risk factors for hypertension. Previous studies have revealed higher prevalence of hypertension among individuals with chronic stress.13,14 Research has shown that chronic stress is associated with reduced participation in positive health behaviors, such as maintaining a healthy diet and engaging in regular physical activity.30 Chronic stress has been demonstrated to increase susceptibility to disease through changes in endocrine functioning in women.31 Additionally, a growing body of literature suggests that certain psychosocial factors, such as depression, anxiety disorders, anger suppression, and stress are associated with relationships or family responsibilities (e.g., stress associated with responsibilities at home or multiple roles), which may contribute to the pathogenesis of cardiovascular disease in women.32–34 Data from the Women’s Ischemia Syndrome Evaluation (WISE) suggests that stress-induced disruptions in ovulatory cycling may be associated with cardiovascular diseases in premenopausal women.35 To the authors’ knowledge, no previous studies were found that examined the combined effect of mental health status and hypertension on hospital inpatient visits. However, the observed association between hypertension coupled with poor mental health and hospital inpatient visits in the current study can be compared to previous studies that found independent associations between mental illness and hospitalization and between hypertension and hospitalization.18,19,36 Merrill and Elixhauser reported that mental illnesses, especially depression and substance abuse, are among the top 10 conditions for hospitalization in the United States across all age groups. The same study reported that hypertension was the most common comorbid condition associated with hospitalization seen in about 30% of all hospital records. Hypertension could be an important predictor or correlate of poor mental health status in women and therefore, can play a major role in early detection of and intervention for women with mental health disorders. Early detection of and intervention for mental health disorders will substantially reduce the mental health-related morbidities and hospitalization, and thereby will substantially reduce the associated health care cost and other adverse impacts on patients and their families. Furthermore, poor mental health status in combination with hypertension could be a strong predictor of hospital inpatient visits in women and therefore, can play a major role in early detection of women who are at risk for hospital inpatient visit. Also, hospital inpatient women with hypertension as comorbidity should be particularly screened for mental health status and managed accordingly to prevent further detrimental physical and financial consequences. This study has several strengths. The current analysis was performed using a nationally representative sample of the US civilian noninstitutionalized women which allows for inference to the general US women population. The measures used for independent and dependent variables in the current study were valid and reliable.20–24 The relatively short reference period (3–4 months) for each round of the survey used for MEPS data collection24 might have reduced the potential for recall biases.27 Despite its strengths, this study is not without limitations. First, MEPS-HC is a cross-sectional survey and therefore, causal inferences cannot be made. Second, the Kessler (K6) scale that was used to assess mental health status of the respondent used overall rating of feelings of the respondent during the past 30 days only; therefore, the temporality of the association between mental health status and hypertension cannot be inferred. Third, the analysis for the study is limited to data from a single year, and a longitudinal study would be preferable to examine the directionality of the association between mental health status and hypertension and to assess the combined effect of mental health status and hypertension on hospital inpatient visits. Fourth, the MEPS-HC is a household survey based on self-report and has the potential for recall bias.37 However, recall bias is significantly influenced by the time between an event and its assessment37 and the relatively short reference period for each round of the survey used for MEPS data collection should reduce the potential for recall bias in the current study. Fifth, all data in our study were collected through face-to-face interviews and research suggests that participants are likely to underreport sensitive experiences, such as mental health status, during face-to-face interviews. Sixth, the current study evaluates hospital inpatient visits and does not capture hypertension cases treated in the emergency departments, and then discharged. We suggest future study to evaluate the relationship between hypertension, mental health, and urgent care/emergency room visits in women population. Finally, uncontrolled confounding factors, such as antihypertension treatment, physical activities, and dieting, which were not available in the dataset, might have affected the results. Specifically in regard to antihypertension treatment– the type of treatment, degree of blood pressure control, and adherence to the treatment are tightly connected to a poor mental status, either as a cause or as a consequence.38–40 Inability to adjust for these conditions might have caused overestimation or underestimation of the true association between mental health status and hypertension in the current study. This study provides insight into the relationship between mental health status, hypertension, and hospital inpatient visits in women in the United States. Findings from this study suggest that poor mental health status was associated with hypertension in women. Further, it suggests that poor mental health status coupled with hypertension may lead to increased hospital inpatient visits and thereby may increase the associated medical costs for individuals and the nation. Future research with longitudinal data is necessary to understand the temporality in these associations and to infer causality. DISCLOSURE The authors declared no conflict of interest, funding, or grant. REFERENCES 1. Uddin MDJ , Alam N , Sarma H , Chowdhury MAH , Alam DS , Niessen L . Consequences of hypertension and chronic obstructive pulmonary disease, healthcare-seeking behaviors of patients, and responses of the health system: a population-based cross-sectional study in Bangladesh . BMC Public Health 2014 ; 14 : 547 . Google Scholar CrossRef Search ADS PubMed 2. Yoon SS , Fryar CD , Carroll MD . Hypertension prevalence and control among adults: United States, 2011–2014 . NCHS Data Brief 2015 ; 220 : 1 – 8 . 3. Mosca L , Barrett-Connor E , Wenger NK . Sex/gender differences in cardiovascular disease prevention what a difference a decade makes . Circulation 2011 ; 124 : 2145 – 2154 . Google Scholar CrossRef Search ADS PubMed 4. Maas AH , Appelman YE . Gender differences in coronary heart disease . Neth Heart J 2010 ; 18 : 598 – 602 . Google Scholar CrossRef Search ADS PubMed 5. Ridker PM , Cushman M , Stampfer MJ , Tracy RP , Hennekens CH . Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men . N Engl J Med 1997 ; 336 : 973 – 979 . Google Scholar CrossRef Search ADS PubMed 6. Heo SG , Hwang JY , Uhmn S , Go MJ , Oh B , Lee JY , Park JW . Male-specific genetic effect on hypertension and metabolic disorders . Hum Genet 2014 ; 133 : 311 – 319 . Google Scholar CrossRef Search ADS PubMed 7. Lakka HM , Laaksonen DE , Lakka TA , Niskanen LK , Kumpusalo E , Tuomilehto J , et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men . JAMA 2002 ; 288 : 2709 – 2716 . Google Scholar CrossRef Search ADS PubMed 8. Ford DE , Erlinger TP . Depression and C-reactive protein in US adults: data from the Third National Health and Nutrition Examination Survey . Arch Intern Med 2004 ; 164 : 1010 – 1014 . Google Scholar CrossRef Search ADS PubMed 9. Whiteford HA , Ferrari AJ , Degenhardt L , Feigin V , Vos T . The global burden of mental, neurological and substance use disorders: an analysis from the Global Burden of Disease Study 2010 . PLoS One 2015 ; 10 : e0116820 . Google Scholar CrossRef Search ADS PubMed 10. Prince M , Patel V , Saxena S , Maj M , Maselko J , Phillips MR , et al. No health without mental health . Lancet 2007 ; 370 : 859 – 877 . Google Scholar CrossRef Search ADS PubMed 11. Hemingway H , Marmot M . Evidence based cardiology: psychosocial factors in the etiology and prognosis of coronary heart disease. Systematic review of prospective cohort studies . BMJ 1999 ; 318 : 1460 – 1467 . Google Scholar CrossRef Search ADS PubMed 12. Hange D , Mehlig K , Lissner L , Guo X , Bengtsson C , Skoog I , Björkelund C . Perceived mental stress in women associated with psychosomatic symptoms, but not mortality: observations from the Population Study of Women in Gothenburg, Sweden . Int J Gen Med 2013 ; 6 : 307 – 315 . Google Scholar CrossRef Search ADS PubMed 13. Richardson S , Shaffer JA , Falzon L , Krupka D , Davidson KW , Edmondson D . Meta-analysis of perceived stress and its association with incident coronary heart disease . Am J Cardiol 2012 ; 110 : 1711 – 1716 . Google Scholar CrossRef Search ADS PubMed 14. Agyei B , Nicolaou M , Boateng L , Dijkshoorn H , van den Born BJ , Agyemang C . Relationship between psychosocial stress and hypertension among Ghanaians in Amsterdam, the Netherlands—the GHAIA study . BMC Public Health 2014 ; 14 : 692 . Google Scholar CrossRef Search ADS PubMed 15. Wang G , Fang J , Ayala C . Hypertension-associated hospitalizations and costs in the United States, 1979–2006 . Blood Press 2014 ; 23 : 126 – 133 . Google Scholar CrossRef Search ADS PubMed 16. Arredondo A . Hospitalization costs associated with hypertension as a secondary diagnosis . Am J Hypertens 2010 ; 23 : 224 . Google Scholar CrossRef Search ADS PubMed 17. Wang G , Fang J , Ayala C . Hospitalization costs associated with hypertension as a secondary diagnosis among insured patients aged 18–64 years . Am J Hypertens 2010 ; 23 : 275 – 281 . Google Scholar CrossRef Search ADS PubMed 18. Saba DK , Levit KR , Elixhauser A. Hospital Stays Related to Mental Health, 2006: Statistical Brief #62. 2008 October. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] . Agency for Healthcare Research and Quality (US) : Rockville, MD , 2006 . https://www.ncbi.nlm.nih.gov/books/NBK54564/pdf/Bookshelf_NBK54564.pdf. Accessed 12 December 2017. 19. Merrill CT , Elixhauser A. Hospitalization in the United States, 2002 . Agency for Healthcare Research and Quality : Rockville, MD , 2005 . 20. Agency for Healthcare Research and Quality . MEPS HC-171 2014 Full Year Consolidated Data File, September 2016 . https://meps.ahrq.gov/data_stats/download_data/pufs/h171/h171doc.pdf. Accessed 10 December 2017. 21. Thawornchaisit P , Looze FD , Reid CM , Seubsman S , Sleigh A ; the Thai Cohort Study Team . Validity of self-reported hypertension: findings from the Thai Cohort Study compared to physician telephone interview . Glob J Health Sci 2014 ; 6 : 1 – 11 . 22. Mirel LB , Simon AE , Golden C , Duran CR , Schoendorf KC . Concordance between survey report of Medicaid enrollment and linked Medicaid administrative records in two national studies . Natl Health Stat Report 2014 ; 72 : 1 – 9 . 23. Zuvekas SH , Olin GL . Validating household reports of health care use in the Medical Expenditure Panel Survey . Health Serv Res 2009 ; 44 : 1679 – 1700 . Google Scholar CrossRef Search ADS PubMed 24. Prochaska JJ , Sung HY , Max W , Shi Y , Ong M . Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization . Int J Methods Psychiatr Res 2012 ; 21 : 88 – 97 . Google Scholar CrossRef Search ADS PubMed 25. Forsyth JM , Schoenthaler A , Ogedegbe G , Ravenell J . Perceived racial discrimination and adoption of health behaviors in hypertensive Black Americans: the CAATCH trial . J Health Care Poor Underserved 2014 ; 25 : 276 – 291 . Google Scholar CrossRef Search ADS PubMed 26. Oliver G , Wardle J , Gibson EL . Stress and food choice: a laboratory study . Psychosom Med 2000 ; 62 : 853 – 865 . Google Scholar CrossRef Search ADS PubMed 27. Ng DM , Jeffery RW . Relationships between perceived stress and health behaviors in a sample of working adults . Health Psychol 2003 ; 22 : 638 – 642 . Google Scholar CrossRef Search ADS PubMed 28. Jackson JS , Knight KM , Rafferty JA . Race and unhealthy behaviors: chronic stress, the HPA axis, and physical and mental health disparities over the life course . Am J Public Health 2010 ; 100 : 933 – 939 . Google Scholar CrossRef Search ADS PubMed 29. Mezuk B , Rafferty JA , Kershaw KN , Hudson D , Abdou CM , Lee H , et al. Reconsidering the role of social disadvantage in physical and mental health: stressful life events, health behaviors, race, and depression . Am J Epidemiol 2010 ; 172 : 1238 – 1249 . Google Scholar CrossRef Search ADS PubMed 30. Dallman MF . Stress-induced obesity and the emotional nervous system . Trends Endocrinol Metab 2010 ; 21 : 159 – 165 . Google Scholar CrossRef Search ADS PubMed 31. Mason SM , Wright RJ , Hibert EN , Spiegelman D , Forman JP , Rich-Edwards JW . Intimate partner violence and incidence of hypertension in women . Ann Epidemiol 2012 ; 22 : 562 – 567 . Google Scholar CrossRef Search ADS PubMed 32. Allan R , Scheidt S . Stress, anger, and psychosocial factors for coronary heart disease . In Manson JE , Ridker PM , Gaziano JM , Hennekens CH (eds), Prevention of Myocardial Infarction . Oxford University Press : New York , 1996 , pp. 274 – 299 . 33. Rosengren A , Hawken S , Ounpuu S , Sliwa K , Zubaid M , Almahmeed WA , Blackett KN , Sitthi-amorn C , Sato H , Yusuf S ; INTERHEART Investigators . Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study . Lancet 2004 ; 364 : 953 – 962 . Google Scholar CrossRef Search ADS PubMed 34. Low CA , Thurston RC , Matthews KA . Psychosocial factors in the development of heart disease in women: current research and future directions . Psychosom Med 2010 ; 72 : 842 – 854 . Google Scholar CrossRef Search ADS PubMed 35. Bairey Merz CN , Johnson BD , Sharaf BL , Bittner V , Berga SL , Braunstein GD , Hodgson TK , Matthews KA , Pepine CJ , Reis SE , Reichek N , Rogers WJ , Pohost GM , Kelsey SF , Sopko G ; WISE Study Group . Hypoestrogenemia of hypothalamic origin and coronary artery disease in premenopausal women: a report from the NHLBI-sponsored WISE study . J Am Coll Cardiol 2003 ; 41 : 413 – 419 . Google Scholar CrossRef Search ADS PubMed 36. Burley M. The Costs and Frequency of Mental Health‐Related Hospitalizations in Washington State Are Increasing . Washington State Institute for Public Policy : Olympia, WA , 2009 , Document No. 09‐04‐3401. 37. Hassan E . Recall bias can be a threat to retrospective and prospective research designs . Internet J Epidemiol 2005 ; 3 : 2 . 38. Muller M , Jochemsen HM , Visseren FL , Grool AM , Launer LJ , van der Graaf Y , Geerlings MI ; SMART-Study Group . Low blood pressure and antihypertensive treatment are independently associated with physical and mental health status in patients with arterial disease: the SMART study . J Intern Med 2013 ; 274 : 241 – 251 . Google Scholar CrossRef Search ADS PubMed 39. Kretchy IA , Owusu-Daaku FT , Danquah SA . Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence . IJMHS 2014 ; 8 : 25 . 40. Boal AH , Smith DJ , McCallum L , Muir S , Touyz RM , Dominiczak AF , Padmanabhan S . Monotherapy with major antihypertensive drug classes and risk of hospital admissions for mood disorders . Hypertension 2016 ; 68 : 1132 – 1138 . Google Scholar CrossRef Search ADS PubMed © American Journal of Hypertension, Ltd 2018. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Hypertension Oxford University Press

The Associations Between Mental Health Status, Hypertension, and Hospital Inpatient Visits in Women in the United States

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Oxford University Press
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© American Journal of Hypertension, Ltd 2018. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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0895-7061
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1941-7225
D.O.I.
10.1093/ajh/hpy065
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Abstract

Abstract BACKGROUND Poor mental health status is more prevalent in women and may be related to poor hypertension outcomes and increased hospital inpatient visits. This study aims to find the association between mental health status and hypertension in women and the combined effect of mental health status and hypertension on hospital inpatient visits in women in the United States. METHODS The household component of 2014 Medical Expenditure Panel Surveys (MEPS) was analyzed (N = 9,137). Kessler (K6) scale for mental health status (poor, good/excellent), hypertension (yes, no), and hospital inpatient visits (yes, no) were examined. A combined effect variable for mental health status and hypertension was created. Multiple logistic regression analysis was conducted and adjusted odds ratios (AORs) with corresponding 95% confidence intervals (CIs) were calculated. RESULTS After adjusting for confounders, women who reported poor mental health had significantly higher odds of hypertension compared to women who reported good/excellent mental health (AOR = 1.39, 95% CI = 1.16, 1.68). Further, women who reported hypertension coupled with poor mental health had higher odds of having hospital inpatient visits compared to women who reported no hypertension coupled with good/excellent mental health in the adjusted analysis (AOR = 3.03, 95% CI = 1.96, 4.69). CONCLUSIONS There is a significant association between mental health status and hypertension in women. Further, poor mental health status coupled with hypertension leads to increase hospital inpatient visits for women. It is important that health professionals focus on utilizing available screening tools to assess mental health status of women for early detection and to manage the disorder. cardiovascular diseases, hypertension, hospital inpatient visits, Kessler (K6) scale, mental health status Hypertension is a major public health problem in the United States. It is the leading risk factor for chronic cardiovascular disease occurrence, ischemic heart diseases, and stroke. In addition, hypertension has significant economic implication.1 Even though the prevalence of hypertension is similar for men and women,2 the mortality rate associated with cardiovascular diseases is higher in women compared to men.3,4 Cardiovascular disease is still the major cause of death in women over the age of 65 years.4 However, there were more studies examining hypertension and cardiovascular disorder in men than in women.5–7 Mental health disorders are more prevalent in women and may affect cardiovascular outcomes. For example, lifetime major depression have been reported to be significantly greater in women (11.7%) than men (5.6%) in the United States.8 According to the Global Burden of Disease Study 2010, mental health disorders contribute to a significant proportion of disease burden and are the leading cause of years lived with disability worldwide.9 Mental health disorders increase risk for communicable and non-communicable diseases.10 A systematic review of evidence from population-based research reported strong associations between depression and coronary heart disease from prospective studies.11 Poor mental health status may be related to chronic stress in women12 and chronic stress is a known risk factor for hypertension.13,14 Hypertension-related complications and comorbidities increase the probability of hospitalization,15 and hospitalization costs associated with hypertension are substantial.16,17 Additionally, mental illness often co-occurs with somatic conditions and thus might increase the likelihood of hospitalization.18 Hypertension coupled with mental health condition in women may increase the probability of hospitalization further; thereby may increase the medical costs significantly. A previous study examined the independent associations between mental illness and hospitalization and between hypertension and hospitalization.19 However, the combined effect of mental health status and hypertension on hospital inpatient visits has not been well investigated. Understanding the combined effect will be beneficial in designing intervention to improve quality of life, morbidity, and mortality for the women. Therefore, the current study aims to investigate the association between mental health status and hypertension in women in the United States using a nationally representative survey. Additionally, the study will explore the combined effect of mental health status and hypertension on hospital inpatient visits in women in the United States. METHODS Study design and data source Data from the household component (HC) of the 2014 Medical Expenditure Panel Surveys (MEPS) was analyzed. The MEPS-HC is conducted by the Agency for Healthcare Research and Quality (AHRQ).20 The objective of the MEPS-HC is to provide nationally representative estimates of health care use, expenditures, sources of payment, and health insurance coverage for the US civilian noninstitutionalized population. In addition, the MEPS-HC provides estimates of respondents’ health status, demographic and socioeconomic characteristics, employment, access to care, and satisfaction with health care. The MEPS-HC is a complex national probability survey. The MEPS sample includes an oversample of Blacks, Hispanics, Asians, and persons with a predicted low income. More detailed information on the methodology are available elsewhere.20 Study population The MEPS sample for 2014 included 34,875 US persons. The current study included only females who were 18 years or older (N = 9,137) for analysis (Figure 1). The analysis was restricted to female 18 years or older because the questions about high blood pressure was only asked if the respondent was 18 years or older. Figure 1. View largeDownload slide A flow diagram displaying distribution of study population in relation to exclusion criteria, mental health status, hypertension, and hospital inpatient visits among women in the United States. Figure 1. View largeDownload slide A flow diagram displaying distribution of study population in relation to exclusion criteria, mental health status, hypertension, and hospital inpatient visits among women in the United States. Outcome variables The outcome variables examined in this study were hypertension and hospital inpatient visits. Hypertension was defined based on the following question in the survey: “Has the person ever been told by a health professional that the person has hypertension (except during pregnancy)” (yes = 1, no = 0). Self-report of hypertension usually have high sensitivity and good overall accuracy and therefore, should be considered valid.21 Hospital inpatient visits was based on the data for hospital discharges for each sample person. Data for hospital discharges were collected from the respondents at the event level and summed to produce the annual utilization data for 2014. A binary variable was created for hospital inpatient visits (yes/no) for the current study based on the total number of hospital discharges for each sample person in the dataset (≥1 discharge = yes, 0 discharge = no). The self-report of hospital inpatient visit should be considered valid because of relatively short reference periods (3–4 months) for each round of the survey used for MEPS data collection.21 Furthermore, self-reported hospital inpatient visits has been validated in other studies.22,23 Exposure variables The main exposure variable, mental health status, was defined based on the mental health status measure, Kessler (K6) scale, available in the MEPS dataset. The Kessler (K6) score is a summary measure of overall rating of feeling by the respondent in past 30 days. The score was pre-calculated in the dataset based on the respondents’ answers to 6 mental health-related questions assessing nonspecific psychological distress of that person.20 The higher the score, the greater the person’s tendency towards mental disability. The main independent variable, poor mental health status, was constructed as a binary variable based on the Kessler score (yes = 1, if ≥5; no = 0, if 0–4). An optimal lower threshold cut point was indicative of moderate mental distress. The item nonresponse rate for this variable was only 1.16%. Kessler (K6) scale is a widely used validated measure of nonspecific psychological distresses.20 The optimal lower threshold cut point used in the current study to indicate moderate mental distress has been validated in other studies.24 Potential confounders Potential confounders considered in this analysis included age (18–24, 25–44, 45–64, 65+ years), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, others), marital status (married, never married, widowed/divorced/separated), education (less than high school graduate, high school graduate, less than bachelor’s degree, college graduate or greater), insurance status (private health insurance, public health insurance, uninsured), and body mass index (BMI; underweight = BMI <18.5; normal weight = BMI ≥18.5 and <25.0; overweight = BMI ≥25.0 and <30.0; obesity = BMI ≥30.0). The age at diagnosis of high blood pressure (continuous in years) and current smoking status (smoker/non-smoker) were also examined. History of coronary heart disease (yes, no), high cholesterol (yes, no), and diabetes (yes = 1, no = 0) were also considered as potential control variables. These comorbidities were identified at person-level based on questions that asked if the person had ever been diagnosed by a health care professional as having these conditions. These measures, therefore, should be considered valid. Statistical analysis Data analyses were conducted using survey procedures in SAS 9.4 (SAS Institute, Cary, NC) utilizing appropriate analysis weights to account for the complex survey design and to produce estimates that are nationally representative of the adult female population. Descriptive analysis was conducted to examine the distribution of overall study population and by hypertension and hospital inpatient visits. The association between mental health status and hypertension in women was determined using logistic regression analysis, which generated crude odds ratios (CORs) and adjusted odds ratios (AORs) and corresponding 95% confidence intervals (CIs). The association between mental health status and hospital inpatient visits was also determined using logistic regression analysis. To assess the combined effect of mental status and hypertension in women on hospital inpatient visits, a combined effect variable with 4 categories was created (hypertension and poor mental health, hypertension but no poor mental health, no hypertension but poor mental health, and no hypertension and no poor mental health). The combined effect of mental status and hypertension in women on hospital inpatient visits was determined using logistic regression analysis. Possible effect modifiers were assessed using interaction terms between the main exposure and the covariates. No covariates were identified as potential effect modifiers. Parsimonious logistic models were created using the 10% change-in-estimates procedure to identify and control for the confounders. Bonferroni correction method for multiple comparison tests was performed and overall adjusted level of significance for all tests was set to P <0.01. The study was exempt from Institutional Review Board (IRB) approval as secondary data were utilized for analyses and the study did not require access to any existing identifiable private information. RESULTS Overall, nearly 35% of women reported being diagnosed with hypertension, 20% reported poor mental health, and 6% had hospital inpatient visits (Table 1). Table 1 displays the summary characteristics of the study population. The majority of the women was 45 years or older (52.2%), non-Hispanic White (64.5%), married (54.1%), had education higher than high school (57.8%), and had private insurance (69.0%). Furthermore, majority of the respondent women were overweight or obese (70.3%), nonsmokers (82.6%), had normal or low cholesterol (67%), and did not have coronary heart disease (93.4%) or diabetes (90.1%). There was a statistically significant association between age, race, marital status, educational status, insurance, BMI, coronary heart disease, high cholesterol, diabetes, perceived mental health status, and inpatient visits and hypertension in women. Inpatient visit was prevalent among women age 65 years or older, divorced/separated/widowed, and with public insurance, poor mental health status, coronary artery disease, high cholesterol, and diabetes. There was a statistically significant association between age, race, marital status, insurance status, coronary heart disease, high cholesterol, diabetes, and perceived mental health status, and inpatient visit in women. Table 1. Characteristics of study population by hypertension and hospital inpatient visits Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Abbreviations: N, total sample size; n, subsample size; SD, standard deviation. aP values are calculated from t-test or chi-square tests to find differences between hypertension and no hypertension. bP values are calculated from t-test or chi-square tests to find differences between hospital and no hospital inpatient visits. View Large Table 1. Characteristics of study population by hypertension and hospital inpatient visits Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Characteristics Total (N = 9,137) Hypertension (n = 3,115) With hospital inpatient visits (n = 501) Without hospital inpatient visits (n = 8,636) Unweighted N (weighted %) Unweighted n (weighted row %) P valuea Unweighted n (weighted row %) Unweighted n (weighted row %) P valueb Age (in years) <0.0001 <0.0001  18–24 1,304 (13.3) 64 (4.9) 24 (1.6) 1,395 (98.4)  25–44 3,020 (34.5) 634 (18.7) 70 (2.2) 3,280 (97.8)  45–64 3,334 (34.6) 1,443 (46.2) 198 (6.4) 2,671 (93.6)  65+ 1,479 (17.6) 974 (70.1) 209 (15.8) 1,290 (84.2) Race/ethnicity <0.0001 <0.0001  Hispanic 2,652 (16.0) 671 (25.0) 77 (2.6) 2,626 (97.4)  Non-Hispanic White 3,731 (64.5) 1,434 (38.4) 264 (6.9) 3,538 (93.1)  Non-Hispanic Black 1,731 (11.1) 715 (38.7) 119 (6.9) 1,597 (93.1)  Non-Hispanic Other 1,023 (8.4) 295 (28.2) 41 (3.8) 875 (96.2) Marital status <0.0001 <0.0001  Married 4,529 (54.1) 1,893 (42.6) 278 (7.0) 4,275 (93.0)  Never married 3,305 (31.4) 528 (16.0) 89 (2.7) 3,135 (97.3)  Divorced/separated/widow 1,303 (14.5) 694 (51.0) 134 (9.3) 1,226 (90.7) Education 0.006 0.95  Less than high school 2,030 (14.6) 518 (32.7) 110 (6.1) 1,913 (93.9)  High school 2,625 (27.6) 1,522 (39.7) 151 (6.2) 2,477 (93.8)  Less than bachelor degree 2,450 (29.5) 556 (34.3) 128 (5.7) 2,334 (94.3)  Bachelor degree or more 2,022 (28.3) 490 (34.7) 112 (5.9) 1,912 (98.1) Insurance status <0.0001 <0.0001  Private 5,378 (69.0) 1,802 (34.2) 284 (5.7) 5,112 (94.3)  Public 1,940 (17.2) 1,001 (51.7) 186 (10.8) 1,720 (89.2)  Uninsured 1,819 (13.8) 312 (21.4) 31 (1.5) 1,804 (98.5) Mental health status <0.0001 <0.0001  Poor 1,897 (20.2) 865 (44.8) 215 (11.3) 1,682 (88.7)  Good/excellent 7,240 (79.8) 2,250 (33.7) 286 (4.6) 6,954 (95.4) BMI (kg/m2) <0.0001 0.04  Underweight (<18.5) 118 (1.0) 17 (14.3) 7 (7.8) 102 (92.2)  Normal weight (18.5–24.9) 2,607 (28.8) 506 (21.8) 112 (4.6) 2,514 (95.4)  Overweight (25.0–29.9) 3,439 (40.7) 1,215 (34.5) 201 (5.8) 3,500 (94.2)  Obese (30.0+) 2,803 (29.6) 1,337 (51.2) 180 (6.9) 2,504 (93.1) Current smoker 1,746 (17.4) 640 (37.0) 0.54 99 (5.6) 1647 (94.4) 0.45 Coronary heart disease 660 (6.6) 544 (82.2) <0.0001 155 (23.6) 504 (76.4) <0.0001 High cholesterol 3,326 (33.0) 2,196 (65.0) <0.0001 334 (10.4) 2991(89.6) <0.0001 Diabetes 1,153 (9.9) 906 (78.6) <0.0001 175 (14.8) 977 (85.2) <0.0001 Variable Mean (SD) Mean (SD) P valuea Mean (SD) Mean (SD) P valueb Average age (in years) 46.4 (17.4) 56.5 (15.2) <0.0001 59.2 (17.0) 43.7 (17.1) <0.0001 Age at diagnosis of high blood pressure (in years) – 46.0 (14.4) – 48.8 (14.1) 44.8 (14.4) <0.0001 Duration of hypertension (in years) – 11.5 (10.0) – 14.7 (11.6) 10.6 (9.7) 0.03 BMI (kg/m2) 27.3 (8.3) 29.5 (8.1) <0.0001 26.9 (9.9) 26.8 (8.3) 0.84 Abbreviations: N, total sample size; n, subsample size; SD, standard deviation. aP values are calculated from t-test or chi-square tests to find differences between hypertension and no hypertension. bP values are calculated from t-test or chi-square tests to find differences between hospital and no hospital inpatient visits. View Large The prevalence of hypertension was higher among women with poor mental health status (44.8%, 95% CI = 42.0%, 47.7%) compared to those with good or excellent mental health status (33.7%, 95% CI = 32.1%, 35.4%). Similarly, the rate of hospital inpatient visits was higher among women with poor mental health status (11.3%, 95% CI = 9.3%, 13.3%) compared to those who reported good or excellent mental health status (4.6%, 95% CI = 4.0%, 5.3%; Table 1). The unadjusted analysis showed that the odds of hypertension was 60% higher among women with poor mental health status compared to women with good or excellent mental health status (COR = 1.60, 95% CI = 1.38, 1.84; Table 2). Furthermore, women with poor mental health status were 2.62 times as likely to have inpatient visits as women with good or excellent mental health status (COR = 2.62, 95% CI = 2.03, 3.39). After adjusting for age, race/ethnicity, marital status, insurance status, congestive heart disease, cholesterol, and diabetes, the odds of hypertension was 39% higher for women with poor mental health status (AOR = 1.39, 95% CI = 1.16, 1.68) compared to women with good or excellent mental health status. Similarly, compared to women with good or excellent mental health status, women with poor mental health status had a 129% higher odds of having inpatient visits (AOR = 2.29, 95% CI = 1.73, 3.03). Table 2. Logistic regression analysis of mental health status and hypertension and hospital inpatient visits in women Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Abbreviations: CI, confidence interval; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large Table 2. Logistic regression analysis of mental health status and hypertension and hospital inpatient visits in women Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Mental health status Crudea OR (95% CI) Adjustedb OR (95% CI) Hypertension Good or excellent 1.00 1.00 Poor 1.60 (1.38, 1.84)* 1.39 (1.16, 1.68)* Hospital inpatient visits Good or excellent 1.00 1.00 Poor 2.62 (2.03, 3.39)* 2.29 (1.73, 3.03)* Abbreviations: CI, confidence interval; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large Table 3 reports the unadjusted ORs and AORs of combined mental health status and hypertension, and hospital inpatient visits. In the unadjusted analysis, compared to women with no hypertension coupled with good or excellent mental health, women with hypertension and poor mental health were 7.64 times as likely (COR = 7.64, 95% CI = 5.38, 10.85), women with hypertension but good or excellent mental health were 3.75 times as likely (COR = 3.75, 95% CI = 2.73, 5.13), and women with no hypertension but poor mental health were 3.01 times as likely (COR = 3.01, 95% CI = 1.98, 4.58) to have hospital inpatient visits. After controlling for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes, women who reported having hypertension coupled with poor mental health had 203% higher odds (AOR = 3.03, 95% CI = 1.96, 4.69), women with hypertension but good or excellent mental health had 58% higher odds (AOR = 1.58, 95% CI = 1.10, 2.27), and women with no hypertension but poor mental health had 197% higher odds (AOR = 2.97, 95% CI = 1.96, 4.48) of having hospital inpatient visits compared to women with good or excellent mental health and no hypertension. Table 3. Logistic regression analysis of combined effect of mental health status and hypertension on inpatient visits Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Abbreviations: CI, confidence interval; HTN, hypertension; MH, mental health; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large Table 3. Logistic regression analysis of combined effect of mental health status and hypertension on inpatient visits Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Combined effect of MH status and HTN Hospital inpatient visits Crudea OR (95% CI) Adjustedb OR (95% CI) No HTN and good or excellent MH status 1.00 1.00 HTN but good or excellent MH status 3.75 (2.73, 5.13)* 1.58 (1.10, 2.27)* No HTN but poor MH status 3.01 (1.98, 4.58)* 2.97 (1.96, 4.48)* HTN and poor MH status 7.64 (5.38, 10.85)* 3.03 (1.96, 4.69)* Abbreviations: CI, confidence interval; HTN, hypertension; MH, mental health; OR, odds ratio. aUnadjusted. bAdjusted for age, race/ethnicity, marital status, insurance, congestive heart disease, cholesterol, and diabetes. *Associations are statistically significant at P <0.01 level. View Large DISCUSSION This study revealed that poor mental health status was independently associated with both hypertension and increased hospital inpatient visits in women. Additionally, the study showed that the odds of hospital inpatient visits was significantly higher among women who reported poor mental health status coupled with hypertension when compared to women with good or excellent mental health status without hypertension. To the authors’ knowledge, there were no studies that examined the association between mental health status and hypertension in women. However, the observed relationships between mental health status and hypertension could be explained by chronic stress being a potential mediator on the causal pathway between mental health status and hypertension. Prior studies have reported significant association between poor mental health status and chronic stress in women.12,25 Previous studies have also implicated that chronic stress is associated with poor lifestyle behaviors, such as drinking alcohol, smoking, and consuming high fat and high sugar food.26,27 These negative health behaviors may be an indicators of poor mental health status among individuals,28,29 that are also known risk factors for hypertension. Previous studies have revealed higher prevalence of hypertension among individuals with chronic stress.13,14 Research has shown that chronic stress is associated with reduced participation in positive health behaviors, such as maintaining a healthy diet and engaging in regular physical activity.30 Chronic stress has been demonstrated to increase susceptibility to disease through changes in endocrine functioning in women.31 Additionally, a growing body of literature suggests that certain psychosocial factors, such as depression, anxiety disorders, anger suppression, and stress are associated with relationships or family responsibilities (e.g., stress associated with responsibilities at home or multiple roles), which may contribute to the pathogenesis of cardiovascular disease in women.32–34 Data from the Women’s Ischemia Syndrome Evaluation (WISE) suggests that stress-induced disruptions in ovulatory cycling may be associated with cardiovascular diseases in premenopausal women.35 To the authors’ knowledge, no previous studies were found that examined the combined effect of mental health status and hypertension on hospital inpatient visits. However, the observed association between hypertension coupled with poor mental health and hospital inpatient visits in the current study can be compared to previous studies that found independent associations between mental illness and hospitalization and between hypertension and hospitalization.18,19,36 Merrill and Elixhauser reported that mental illnesses, especially depression and substance abuse, are among the top 10 conditions for hospitalization in the United States across all age groups. The same study reported that hypertension was the most common comorbid condition associated with hospitalization seen in about 30% of all hospital records. Hypertension could be an important predictor or correlate of poor mental health status in women and therefore, can play a major role in early detection of and intervention for women with mental health disorders. Early detection of and intervention for mental health disorders will substantially reduce the mental health-related morbidities and hospitalization, and thereby will substantially reduce the associated health care cost and other adverse impacts on patients and their families. Furthermore, poor mental health status in combination with hypertension could be a strong predictor of hospital inpatient visits in women and therefore, can play a major role in early detection of women who are at risk for hospital inpatient visit. Also, hospital inpatient women with hypertension as comorbidity should be particularly screened for mental health status and managed accordingly to prevent further detrimental physical and financial consequences. This study has several strengths. The current analysis was performed using a nationally representative sample of the US civilian noninstitutionalized women which allows for inference to the general US women population. The measures used for independent and dependent variables in the current study were valid and reliable.20–24 The relatively short reference period (3–4 months) for each round of the survey used for MEPS data collection24 might have reduced the potential for recall biases.27 Despite its strengths, this study is not without limitations. First, MEPS-HC is a cross-sectional survey and therefore, causal inferences cannot be made. Second, the Kessler (K6) scale that was used to assess mental health status of the respondent used overall rating of feelings of the respondent during the past 30 days only; therefore, the temporality of the association between mental health status and hypertension cannot be inferred. Third, the analysis for the study is limited to data from a single year, and a longitudinal study would be preferable to examine the directionality of the association between mental health status and hypertension and to assess the combined effect of mental health status and hypertension on hospital inpatient visits. Fourth, the MEPS-HC is a household survey based on self-report and has the potential for recall bias.37 However, recall bias is significantly influenced by the time between an event and its assessment37 and the relatively short reference period for each round of the survey used for MEPS data collection should reduce the potential for recall bias in the current study. Fifth, all data in our study were collected through face-to-face interviews and research suggests that participants are likely to underreport sensitive experiences, such as mental health status, during face-to-face interviews. Sixth, the current study evaluates hospital inpatient visits and does not capture hypertension cases treated in the emergency departments, and then discharged. We suggest future study to evaluate the relationship between hypertension, mental health, and urgent care/emergency room visits in women population. Finally, uncontrolled confounding factors, such as antihypertension treatment, physical activities, and dieting, which were not available in the dataset, might have affected the results. Specifically in regard to antihypertension treatment– the type of treatment, degree of blood pressure control, and adherence to the treatment are tightly connected to a poor mental status, either as a cause or as a consequence.38–40 Inability to adjust for these conditions might have caused overestimation or underestimation of the true association between mental health status and hypertension in the current study. This study provides insight into the relationship between mental health status, hypertension, and hospital inpatient visits in women in the United States. Findings from this study suggest that poor mental health status was associated with hypertension in women. Further, it suggests that poor mental health status coupled with hypertension may lead to increased hospital inpatient visits and thereby may increase the associated medical costs for individuals and the nation. Future research with longitudinal data is necessary to understand the temporality in these associations and to infer causality. DISCLOSURE The authors declared no conflict of interest, funding, or grant. REFERENCES 1. Uddin MDJ , Alam N , Sarma H , Chowdhury MAH , Alam DS , Niessen L . Consequences of hypertension and chronic obstructive pulmonary disease, healthcare-seeking behaviors of patients, and responses of the health system: a population-based cross-sectional study in Bangladesh . 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For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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American Journal of HypertensionOxford University Press

Published: Apr 20, 2018

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