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http://hpq.sagepub.com/ Journal of Health Psychology http://hpq.sagepub.com/content/early/2014/10/01/1359105314550350 The online version of this article can be found at: DOI: 10.1177/1359105314550350 published online 7 October 2014 J Health Psychol Aghaei, Marzieh Nazaribadie, Edith Holsboer-Trachsler and Serge Brand Mohammad Ahmadpanah, Somaye Jamali Paghale, Azadeh Bakhtyari, Sattar Kaikhavani, Elham patients with hypertension pharmacotherapy only on blood pressure, depression, and anxiety in female Effects of psychotherapy in combination with pharmacotherapy, when compared to Published by: http://www.sagepublications.com can be found at: Journal of Health Psychology Additional services and information for http://hpq.sagepub.com/cgi/alerts Email Alerts: http://hpq.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: What is This? - Oct 7, 2014 OnlineFirst Version of Record >> at TEXAS SOUTHERN UNIVERSITY on October 26, 2014 hpq.sagepub.com Downloaded from at TEXAS SOUTHERN UNIVERSITY on October 26, 2014 hpq.sagepub.com Downloaded from

Effects of psychotherapy in combination with pharmacotherapy, when compared to pharmacotherapy only on blood pressure, depression, and anxiety in female patients with hypertension

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http://hpq.sagepub.com/Journal of Health Psychology

http://hpq.sagepub.com/content/early/2014/10/01/1359105314550350The online version of this article can be found at:

 DOI: 10.1177/1359105314550350

published online 7 October 2014J Health PsycholAghaei, Marzieh Nazaribadie, Edith Holsboer-Trachsler and Serge Brand

Mohammad Ahmadpanah, Somaye Jamali Paghale, Azadeh Bakhtyari, Sattar Kaikhavani, Elhampatients with hypertension

pharmacotherapy only on blood pressure, depression, and anxiety in female Effects of psychotherapy in combination with pharmacotherapy, when compared to

  

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can be found at:Journal of Health PsychologyAdditional services and information for    

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http://www.sagepub.com/journalsReprints.navReprints:  

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- Oct 7, 2014OnlineFirst Version of Record >>

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Journal of Health Psychology 1 –12© The Author(s) 2014Reprints and permissions: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1359105314550350hpq.sagepub.com

Effects of psychotherapy in combination with pharmacotherapy, when compared to pharmacotherapy only on blood pressure, depression, and anxiety in female patients with hypertension

Mohammad Ahmadpanah1, Somaye Jamali Paghale2, Azadeh Bakhtyari3,4, Sattar Kaikhavani5, Elham Aghaei6, Marzieh Nazaribadie3,4, Edith Holsboer-Trachsler7 and Serge Brand7,8

AbstractWe investigated effects of metacognitive detached mindfulness therapy and stress management training on hypertension and symptoms of depression and anxiety, as compared to a control condition. A total of 45 female patients (mean age: M = 36.49 years) were randomly assigned to one of three conditions: metacognitive detached mindfulness therapy, stress management training, and the control condition. Blood pressure and symptoms of depression and anxiety decreased from baseline to post-test, to follow-up. Group comparisons showed that blood pressure and symptoms of depression and anxiety decreased more in psychotherapeutic groups than in the control group. Psychotherapeutic treatment of hypertension reduced blood pressure and symptoms of depression and anxiety. Positive effects were observable at follow-up 8 weeks later.

Keywordshypertension, metacognitive detached mindfulness, stress management, symptoms of depression and anxiety

1 Research Center for Behavioral Disorders and Substances Abuse, Hamadan University of Medical Sciences, Hamadan, Iran

2 Department of Psychology, School of Psychology and Educational Sciences, University of Alzahra, Tehran, Iran

3 Department of Clinical Psychology, School of Psychology and Educational Sciences, University of Isfahan, Iran

4 Seddigheh Tahereh Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

5 Department of Clinical Psychology, Ilam University of Medical Sciences, Ilam, Iran

550350 HPQ0010.1177/1359105314550350Journal of Health PsychologyAhmadpanah et al.research-article2014

Article

6 Department of Psychology, School of Human Sciences, Shahed University, Tehran, Iran

7Psychiatric Clinics of the University of Basel, Switzerland8 Department of Sport and Health Science, Division of Sport Science, University of Basel, Basel, Switzerland

Corresponding author:Serge Brand, Center for Affective, Stress and Sleep Disorders, Psychiatric Hospital of the University of Basel, Wilhelm Klein-Strasse 27, 4012 Basel, Switzerland. Email: [email protected]

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2 Journal of Health Psychology

Introduction

Hypertension (HT) is not only an important fac-tor in chronic disability but is estimated world-wide to be the third most important cause of premature death (World Health Organization (WHO), 2006). By virtue of its slowly emerging symptoms and unpleasant complications, HT as a cardiovascular disease has been described as the “silent murderer” (Davison et al., 2004). Results showed that 25–33 percent of adults suf-fer from HT (Denni et al., 2005). A survey con-ducted in 19 different countries (N = 52,095) showed that HT was associated with psychiatric conditions such as impulsive eating, substance abuse, anxiety, and depression (Stein et al., 2014). Additionally, there is evidence that blood pressure (BP) may vary as a function of emo-tional state (Davison et al., 2004). More specifi-cally, research lends support to the notion that symptoms of depression and anxiety, perceived stress, sleep disturbances (Genta-Pereira et al., 2014), job strain (Babu et al., 2014; Netterstrøm, 2014; Trudel et al., 2010), or negative emotions (Symonides et al., 2014) are causally linked to the development and maintenance of HT (Abbott et al., 2014; Petermann and Vaitl, 2009). In this regard, Meng et al. (2012) observed that the occurrence of symptoms of depression increased the risk of HT incidence. Kagee et al. (2007) observed symptoms of depression in about 20 percent of patients suffering from HT, a pat-tern of results also observed elsewhere (Cukrowicz et al., 2012; Stein et al., 2014; but see Ringoir et al. (2014) for opposite results). In these respects, also increased rates of anxiety (Bacon et al., 2014; Bhattacharya et al., 2014), lower quality of life (Rueda and Pérez-García, 2006; Trevisol et al., 2011), and decreased psy-chological well-being (Trudel-Fitzgerald et al., 2014) were observed in patients suffering from HT. Specifically, suffering from an anxiety dis-order was associated with the four-fold risk of developing HT (Bacon et al., 2014). Interestingly, Khatib et al. (2014) observed that stress, anxiety, and depression were most commonly reported as factors hindering or delaying the adoption of a healthier life style in patients suffering from

HT, in that medication intake was often forgot-ten. In this regard, forgetting medication intake might be considered as a sign of cognitive impairments often observed with symptoms of depression (Trivedi and Greer, 2014).

To treat HT, both non-pharmacological and pharmacological treatments (see below) are applied. Besides the advantages of a pharmaco-logical treatment, several studies showed that low medication compliance is a major treatment concern (Botha et al., 2002; Cohn et al., 2012; Taylor et al., 2006; Van Wijk et al., 2008), whereas, for instance, Dusek et al. (2008) showed that relaxation treatment led to a noteworthy decrease of antihypertensive medication.

As regards underlying psychophysiological mechanisms to explain HT, it has been observed that states of anxiety and depression lead to increased secretion of cortisol (Holsboer and Ising, 2010) and norepinephrine (Petermann and Vaitl, 2009), which in turn increase the arousal of the sympathetic system, and thus peripheral vasoconstriction, increased heart rate, and increased BP.

Both pharmacological and non-pharmacological interventions are employed in the treatment of HT. Pharmacological treatments usually involve administration of diuretics, beta-blockers, and angiotensin-converting enzyme (ACE) inhibi-tors.1 However, even though the most common treatment is pharmacological, treatment compli-ance (see above) and side effects as described in Note 1 limit patients’ total compliance and recov-ery. In contrast, although non-pharmacological or psychotherapeutic treatments such as relaxation techniques (autogenic training, meditation, imagination, progressive muscle relaxation; cf. Abbott et al., 2014; Petermann and Vaitl, 2009) need instructions and time to learn, adverse side effects are virtually unknown (Davison et al., 2004). More specifically, Abbott et al. (2014) observed a reduction of stress, depression, and anxiety after a mindfulness-based intervention to treat HT, whereas the authors also summarized that results on physiological outcomes were mixed.

The underlying rationale to explain the influ-ence of psychotherapeutic interventions to treat

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Ahmadpanah et al. 3

HT is that if HT is caused and maintained by cognitive-emotional processes such as symp-toms of depression and anxiety and perceived stress, then HT should be treatable with psycho-therapeutic (i.e. non-pharmacological) inter-ventions aimed at reducing the symptoms of depression and anxiety (Beevers et al., 2001). In this regard, methods such as cognitive-behavioral therapy, stress management, relaxa-tion, biological feedback, anger management, cognitive change, and life style change have already been used successfully (Albright et al., 1991; Davydov et al., 2012; Yung and Keller, 1996). For example, Tacon et al. (2003) assessed the effectiveness of Kabat-Zinn’s mindfulness-based stress-reduction program and reported significant reductions in anxiety and negative affect and improvements in emotional control and coping among a group of women with heart disease. Mindfulness-based stress reduction has also induced positive physiological changes in BP, heart rate, and cardiac respiratory sinus arrhythmia (Abbott et al., 2014; Barnes et al., 2004; Ditto et al., 2006). This approach has also been integrated into a psycho-educational inter-vention for patients with chronic heart failure (Sullivan et al., 2009). Following a combination of mindfulness techniques, health education/coping skills, and a support group, participants reported improvements in quality of life, physi-cal symptoms, and psychological functioning. Given the encouraging results of these studies, and the evidence for the reduction of symptoms of depression and anxiety (Baer, 2003), stress management programs have been used effec-tively across a range of medical conditions including cardiovascular disease, diabetes, and cancer (Snoek et al., 2001).

In contrast, Dickinson et al. (2008) were less enthusiastic about the impact of relaxation ther-apies for the management of primary HT in adults. They concluded that given the poor quality of trials and unexplained variation between trials, the evidence in favor of a causal association between relaxation and BP reduc-tion was weak. Furthermore, some of the appar-ent benefit of relaxation was probably due to aspects of treatment unrelated to relaxation.

Taken together, however, there is reason to explore if non-pharmacological, that is, psycho-therapeutic treatments of HT, may lead to a decrease in both HT and symptoms of depres-sion and anxiety.

However, to our knowledge, no study has thus far investigated the effect of a brief (8-week) group therapy program on HT and symptoms of depression and anxiety in the short and longer term. More specifically, ++this study aimed to shed more light on the effect of two new psycho-therapeutic interventions, namely, metacogni-tive detached mindfulness therapy (MDM) and stress management training (SMT). MDM is a recent theoretical and therapeutic advance in mental health research, which offers a poten-tially effective approach to the treatment of emotional distress (Wells, 2006). MDM has been used with a range of problems including stress, symptoms of depression, and anxiety (Chambers et al., 2009). Moreover, mindful-ness-based psychological interventions are effective in alleviating distress and in enhancing well-being (cf. Abbott et al., 2014).

SMT is a broad term, and programs typi-cally incorporate a number of techniques including relaxation training, biofeedback, cognitive restructuring, problem-solving, and time management skills training (McGinnis et al., 2005). In the context of a physical ill-ness, individuals can be resistant to the idea of psychological intervention, whereas stress management, with perceived benefits for well-being more generally, is often well received (Soo and Lam, 2009). Accordingly, the aim of this study was to investigate the effectiveness of both MDM and SMT on BP among patients suffering from HT and symptoms of depression and anxiety, and to compare these data with those from a control group (CG) without psy-chotherapeutic intervention.

The following three hypotheses were formu-lated. First, and following Tacon et al. (2003), and Petermann and Vaitl (2009), we expected that MDM would, compared to a CG, reduce HT over time. Second, again following Tacon et al. (2003) and Petermann and Vaitl (2009), we hypothesized that SMT would reduce HT

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4 Journal of Health Psychology

over time. Third, we expected that both MDM and SMT would have a positive impact on symptoms of depression and anxiety. Last, we anticipated that both MDM and SMT would have a positive impact in the longer term, namely, at a follow-up 8 weeks after completion of the study.

Methods

Sample

A total of 45 female patients (mean age in years (M) = 46.49; standard deviation (SD) = 2.33 years) suffering from HT took part in the study. They were all recruited in 2013 from the Hazrate Sedigheh Tahereh Medical Research Center in Hamadan (Islamic Republic of Iran). Patients reported to suffer from at least 5–8 years of HT. There were no differences in age between con-ditions (see below; MDM: M = 46.33 years (2.97); SMT: M = 46.47 years (3.78); CG: M = 46.49 years (3.53); F(2, 42) = 0.04, p = .96). The entire study was approved by the local eth-ics committee, and conducted in accordance with the Declaration of Helsinki.

Female patients2 were included in the study if the following criteria were met: (1) diagnosis of HT (diastolic (90–110) and systolic (140–160) BP, (2) age between 30 and 55 years, (3) upper diploma, (4) depressive symptoms (10–17 points according to the Beck Depression Inventory (BDI), see below) and symptoms of anxiety (8–15 according to the Beck Anxiety Inventory (BAI), see below), and (5) written informed consent.

Exclusion criteria were (1) not meeting inclusion criteria; (2) known physical or psy-chological illness discouraging participation; (3) lack of compliance (medication; group sessions); (4) after routing electrocardiogram (ECG), possible cardiac diseases; (5) sus-pected psychiatric disorders after a brief psy-chiatric screening interview (M.I.N.I.: Mini International Neuropsychiatric Interview; Sheehan et al., 1998); (6) intake of psychoac-tive or mood-altering substances (medication, drugs).

Procedure

After a thorough medical examination and assessment of the inclusion and exclusion crite-ria, patients were randomly assigned to one of the following conditions: MDM, SMT, or con-trol condition. To achieve randomization and to assign 15 patients at every study condition, a total of 45 chips in three different colors were put in a ballot box and stirred. Each color repre-sented a different condition. At the start of the study, patients drew a chip and were assigned to the corresponding condition. At baseline, patients provided background information (including age). Next, they completed two questionnaires related to symptoms of anxiety and depression. Thereafter, a study nurse meas-ured BP. The procedure was repeated at the end of the study, that is, 8 weeks later, as well as at follow-up 8 weeks after completion of the study.

During the entire study through to the fol-low-up, the individual HT medication was kept constant for all patients.

Interventions

MDM. Mindfulness meditation practice is a form of cognitive training aimed at learning how and where to guide one’s attention (see Table 1 for more details; see also Marks, 2010). This involves maintaining awareness of attention from one moment to the next, and gently but firmly escort-ing it back to the initial target object when the mind becomes distracted (Kang et al., 2013). Most discussions of mindfulness include the fol-lowing four elements: (1) awareness, (2) sus-tained attention, (3) focus on the present moment, and (4) nonjudgmental acceptance (Wells, 2006).

This intervention is based on and consists of the elements set out in Table 1, and the sessions were organized and scheduled as reported in Table 1.

SMT. Relaxation training and biofeedback are considered particularly beneficial in reducing physiological and related hormonal influences on HT. Initially, all techniques were taught in group sessions with patients doing follow-up

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Ahmadpanah et al. 5

work at home. The program consists of eight 1-hour sessions, each session involving 10–15 participants. The sessions consist of didactic presentations, group discussions, completion of questionnaires and forms, progressive muscle relaxation, systematic desensitization, and prac-tical retraining. For the systematic desensitiza-tion sessions, the leader drew upon the method developed by Wolpe (1958). The program is usually evaluated when all eight sessions have been completed. The evaluation consists of both subjective and objective reports, including oral feedback, a written program evaluation, and pre-and post-administrations of the State-Trait Anxiety and depression Inventory.

The technique needs a proactive approach that raises awareness of the symptoms of stress and enables individuals to develop coping skills. Training in SMT allows people to recog-nize the nature of stress, to identify areas that need improvement, and to ensure that risks are properly controlled. This section contains a stress management awareness training presen-tation and background notes.

This intervention is based on and consists of the elements set out in Table 2, and the sessions were organized and scheduled as described in Table 2.

Control condition. Patients assigned to the control condition came once a week to the ward. As for

the intervention group, a brief medical check was performed and BP was assessed. This ensured that all patients had comparable frequencies of social contact with the study staff, and thus, any possible bias due to variations in social contact with study staff was kept to a minimum.

Instruments

Depressive symptoms. To assess depressive symptoms, participants completed the BDI (Beck et al., 1961). Answers are given on 4-point rating scales with the anchor points 0 (=never) and 3 (=always), with higher sum/mean scores reflecting greater depressive symp-toms. The following cut-off ranges are pro-posed: 0–9 sum scores—no symptoms of depression; 10–18 sum scores—mild symp-toms of depression; 19–29 sum scores—moder-ate to severe symptoms of depression; >30 sum scores—severe symptoms of depression.

Anxiety. Symptoms of anxiety were assessed with the BAI (Beck et al., 1961). Answers are given on 4-point rating scales with the anchor points 1 (=never) and 5 (=always), with higher sum/mean scores reflecting greater symptoms of anxiety. The following cut-off ranges are proposed: 0–7—minimal level of anxiety; 8–15—mild anxiety; 16–25—moderate anxi-ety; 26–63—severe anxiety.

Table 1. Metacognitive detached mindfulness therapy: sessions and description.

Sessions Session description

1. Orientation, motivation, goal of session, fill in BDI and BAI, blood pressure measurement

2. Explanation treatment plan, metacognitive detached mindfulness therapy, attention training techniques (ATT)

3. Talk about home assessment, training and metacognitive leading exercise, assessment against prevented inhibition

4. Talk about home assessment, training and association technique exercise5. Talk about home assessment, training and wandering mind and task oriented exercise6. Talk about home assessment, training and circle words and unruly child exercise7. Talk about home assessment, training and imagery clouds and train station exercise8. Review of techniques and fill in BDI and BAI, blood pressure measurement

BDI: Beck Depression Inventory; BAI: Beck Anxiety Inventory.

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6 Journal of Health Psychology

Statistical analysis. A series of four analyses of variance (ANOVAs) for repeated measures was performed with the factors Time (three condi-tions: baseline, post, and follow-up) and Group (three conditions: MDM, SMT, and Controls), and as dependent variables, anxiety, depression, and systolic and diastolic BP. Post hoc analyses were performed after Bonferroni–Holm correc-tion for p values. Statistical tests were performed using Greenhouse–Geisser corrected degrees of freedom, although throughout the article, the original degrees of freedom are reported with the relevant Greenhouse–Geisser epsilon value (ε). For ANOVAs, effect sizes are indicated with the partial eta squared (η2), with 0.059 ≥ η2 ≥ 0.01 indicating small (S), 0.139 ≥ η2 ≥ 0.06 indicating medium (M), and η2 ≥ 0.14 indicating large (L) effect sizes. The level of significance was set at p ≤ .05, and all statistics were processed using SPSS® 20.0 (IBM Corporation, Armonk NY, USA) for Apple McIntosh®.

Results

Tables 3 and 4 report the descriptive and infer-ential statistics for the dependent variables symptoms of anxiety and depression, and

systolic and diastolic BP, separately for Time (baseline, post-test, follow-up), Group (MDM, SMT, and Controls), and for the Time × Group interaction.

For all dependent variables, the pattern of results was as follows. Symptoms of depression (Figure 1) and anxiety, and systolic and dias-tolic BP (Figure 2) decreased significantly over time from baseline to post-assessment to fol-low-up. Compared to those in the control condi-tion, participants in both intervention conditions had significantly lower scores. There were also significant Time × Group interactions. Post hoc tests after Bonferroni–Holm corrections for p values showed that mean values did not differ between groups at baseline, but did so at post-assessment and at follow-up, with significantly higher scores in the control condition than in either intervention condition. No significant mean differences were found between the two intervention conditions.

Discussion

The key results of this study are that among female patients suffering from HT and symptoms of depression and anxiety, compared to a control

Table 2. Stress management training: sessions and description.

Sessions Session description

1. About the program, stressful factors and responses, increasing relaxation of 16 muscle groups

2. Stress effect, stress and awareness, exercise in awareness of physical signs of stress, increasing relaxation of 8 muscle groups

3. Diaphragm breath, increasing relaxation of 4 muscle groups, imagery and relaxation, thought and emotion relation, exercise in the power of thought

4. Diaphragm breath and imagery, passive increasing relaxation along with special image imagery, negative thought and distort cognition, negative thought and behavior, identify negative thoughts

5. Integration relaxation, introduce self-creation training and self-creation exercise for heaviness and warmth, difference between rational and irrational self-utterance, displacement of rational thoughts

6. Self-creation training for heart-beat, breath, stomach and front head, definition of encounter, different functional and mal-functional encounter, talk about encounter strategies

7. Logic of self-creation training, with imagery and self-induction, sun meditation, encounter with effective steps, functional encounter exercise, soften techniques

8. Physical conditions of meditation, exercise in mantra meditation, breath counting meditation, personal stress management schedule, measuring

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Ahmadpanah et al. 7

condition, two non-pharmacological treatments of HT, MDM and SMT, produced improvements in symptoms of anxiety and depression and reduced HT after an 8-week treatment and at a follow-up 8 weeks later. Results showed therefore that both MDM and SMT had effects on level of BP, and symptoms of depression and anxiety in patients suffering from HT.

Three hypotheses were formulated and each of these is considered now in turn.

Our first hypothesis was that compared to a control condition, MDM would reduce HT over time. This hypothesis was fully supported.

Thus, the present results are consistent with numerous other studies indicating that psycho-therapeutic interventions have positive effects on HT (cf. Albright et al., 1991; Petermann and Vaitl, 2009; Yung and Keller, 1996). We thus conclude that MDM is a further psychothera-peutic intervention that can be used success-fully to treat HT.

Our second hypothesis was that SMT would show an identical pattern, and our data did fully support this. Accordingly, we conclude that SMT is also an effective psychotherapeutic treatment for HT.

Table 3. Descriptive overview of symptoms of depression and anxiety, and blood pressure, separately for time (baseline, on completion of the study (post-test), and 8 weeks later at follow-up), and separately for the three groups (MDM, SMT, CG).

Groups

MDM SMT CG

BL Post-test FU BL Post-test FU BL Post-test FU

Depression 24.26 (5.12)

16.26 (3.83)

16.80 (3.26)

20.20 (5.12)

14.93 (4.29)

14.60 (3.50)

22.00 (5.53)

23.33 (4.88)

25.20 (4.95)

Anxiety 22.33 (5.23)

16.13 (3.79)

15.46 (3.93)

22.66 (3.83)

17.00 (4.29)

16.13 (3.50)

19.46 (4.65)

24.00 (5.38)

23.46 (5.89)

Blood pressure (systolic; mm Hg)

156.54 (16.88)

120.21 (14.18)

109.23 (9.49)

163.02 (15.12)

119.46 (11.63)

117.46 (10.74)

162.07 (18.66)

171.60 (16.17)

170.97 (13.45)

Blood pressure (diastolic; mm Hg)

109.05 (12.41)

87.57 (8.55)

88.21 (8.66)

110.52 (11.68)

94.46 (10.74)

88.93 (6.67)

105.61 (9.17)

115.30 (9.17)

115.25 (7.29)

BL: baseline; FU: follow-up; MDM: metacognitive detached mindfulness therapy; SMT: stress management training; CG: control group.Values are means and, in parentheses, standard deviations.

Table 4. Inferential statistical overview of symptoms of depression and anxiety, and blood pressure, separately for Time (baseline, post-test 8 weeks later, and follow-up again 8 weeks later), and Group (MDM, SMT, CG).

Factors

Time Group Time × Group interaction

Greenhouse–Geisser epsilon

Post hoc tests

F, partial eta2 F, partial eta2 F, partial eta2 BL Post Follow-up

Depression 59.39***, .59 10.39***, .33 41.40***, .66 .83 – Is < CG Is < CGAnxiety 50.95***, .55 4.26*, .17 78.06***, .79 .91 – Is < CG Is < CGBlood pressure 1 129.65***, .76 28.57***, .78 48.32***, .70 .90 – Is < CG Is < CGBlood pressure 2 31.43***, .43 19.62***, .48 30.40***, .59 .94 – Is < CG Is < CG

MDM: metacognitive detached mindfulness therapy; SMT: stress management training; CG: control group; BL: baseline; IS: intervention groups; CG: control group.Degrees of freedom for Group: (1, 42); degrees of freedom for Time and Time × Group interaction: (2, 84).*p < .05; *** p < .001.

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8 Journal of Health Psychology

Our third hypothesis was that both MDM and SMT would have positive impacts on symptoms of depression and anxiety, and data did again fully support this hypothesis. Therefore, the pre-sent findings accord with previous studies, but add to the current literature in an important way in that we showed that both MDM and SMT also had a positive influence in the longer term, namely, in a follow-up 8 weeks after completion of the study.

We offer the following explanations for the favorable effects of these two psychothera-peutic

interventions on HT, and on symptoms of depres-sion and anxiety.

Metacognitive detached mindfulness exer-cises increase awareness of current effects on the cognitive system and information process-ing by focusing on breath and attention to the body and to the present (“here and now”). The effectiveness of group therapy MDM on stress can be explained as follows. Patients with high BP are more sensitive to concerns and anxieties and are more inclined to misinterpret physio-logical symptoms of anxiety. In fact, individu-als pay great attention to physiological symptom of anxiety and interpret these as sudden increases in symptoms of BP. They are also more sensitive to their physical performance, and it is possible that BP causes changes in per-sonal perceptions (Abbott et al., 2014; Valk, 1975).

On the other hand, both MDM and SMT cause changes in the attitude and cognition of patients, such that they accept their disease and engage with its mental consequences. Research has shown that stress management based on cognitive-behavioral therapy reduces BP, anxiety, and depression. Therefore, this method can be employed as a treatment for BP.

As regards SMT, the effectiveness of stress management on the systolic and diastolic BP of patients with HT might be explained in terms of stress and anxiety as the most significant factors in intensity of BP symptoms. Stress and anxiety are always accompanied by physical tension, and individuals often experience physical responses. Responses to anxiety activate the hypothalamic–pituitary–adrenocortical (HPA) axis with its primary marker of cortisol release; cortisol plays an important role both in the pathology and intensity of BP and in depressive and anxiety disorders (Holsboer and Ising, 2010). Given that anxiety causes a broad vari-ety of physiological changes, we believe that reducing anxiety and thus physiological changes contributes to increased psychological and physiological well-being. However, in these respects, the evidence available from this study does not provide any clarification of the

Figure 1. Symptoms of depression decreased significantly over time, but only in the intervention groups, not in the control group. Points are means.MDM: metacognitive detached mindfulness therapy; SMT: stress management training; CG: control group.

Figure 2. Systolic blood pressure decreased significantly over time, but only in the intervention groups, not in the control group. Points are means.MDM: metacognitive detached mindfulness therapy; SMT: stress management training; CG: control group.

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Ahmadpanah et al. 9

underlying physiological processes. Nonetheless, the physiological responses asso-ciated with anxiety can be observed in a wide range of physical indicators. By applying dif-ferent treatment techniques, we believe it is possible to reduce BP to a significant degree by reducing anxiety, stress, and physical tension along with physiological symptoms and decreasing level of cortisol, epinephrine, and norepinephrine hormones. This study does not, however, shed any light on the psychophysio-logical processes underlying the techniques. Additionally, there is a relation between anxiety and activation of the sympathetic system, which produces increases in BP and arteriosclerosis (Wells, 2006). As a result, treatment for anxiety should improve BP.

This study cannot tell us why MDM and SMT led to significant improvements in both the short and longer term. More specifically, it remains unclear why the significant improve-ments in BP and symptoms of anxiety and depression persisted 8 weeks after study com-pletion. Petermann and Vaitl (2009) identified various advantages of psychothera-peutic interventions. Thus, in general, patients under-going psychotherapeutic treatments show improvements in self-competence, self-con-trol, and self-management (cf. Kanfer et al., 2012); they also have improved concentration (Lazar et al., 2000; Ott, 2009), relaxation (Ott, 2001), and psychological well-being (Lohaus et al., 2001; Löwe et al., 2002). We believe that these factors could similarly have contrib-uted to the significant improvements described above. On the other hand, the present study cannot exclude the possibility raised by Dickinson et al. (2008) that method-specific and method-unspecific factors might lead to improvements.

Despite the clarity of the results, several limitations warrant against their overgener-alization. First, participants were highly selected and recruited from one study center. Therefore, a systematic selection bias cannot be excluded. This holds particularly true, as exclusively female patients with higher edu-cational degrees were selected for study

participation. Second, it remains unclear whether a similar pattern of results would have been obtained with male patients. Third, psychoendocrinological markers such as cor-tisol and neuronal markers such as brain-derived neurotrophic factor (BDNF) were not assessed; future studies might usefully include these biological markers to gain fur-ther insight into the influence of psychother-apeutic interventions on psychophysiological processes. Fourth, from a purely scientific point of view, it would be interesting to com-pare the influence of further psychotherapeu-tic techniques such as mindfulness-based stress reduction with that of psychoanalytical techniques on symptoms of depression and anxiety and HT. Fifth, other limitations of this study are the lack of detailed information on the treatment, HT-related and demo-graphic characteristics of patients, and lack of more accurate control over home assess-ment. It is worth noting finally that, notwith-standing the current research findings, matters such as group size, length of treat-ment, and patients’ social and economic cir-cumstances should be considered in future studies. Sixth, it is questionable to what extent the results between the treatment and control conditions might be comparable, given that in the intervention conditions, a qualitatively and quantitatively more intense social interaction between patients and the study staff took place, compared to the con-dition of mere weekly checks of BP. Therefore, a result bias due to different con-ditions of social interactions cannot be ruled out. Further studies might apply sham inter-ventions while keeping the condition of social interactions identical between the study conditions. Seventh, physical activity was not assessed, whereas Arredondo et al. (2012) showed that the degree of physical activity mediated the relation between depression and medical conditions such as HT. Last, the present pattern of results might have emerged due to a latent third variable causing the measured variables to change in the same direction.

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10 Journal of Health Psychology

Conclusion

Non-pharmacological treatments, such as MDM and SMT, have a positive effect on HT but also reduce symptoms of depression and anxiety.

Acknowledgements

The authors express their appreciation to the patients and administrators of the Hazrate Sedigheh Tahereh Medical Research Center in Hamadan (Islamic Republic of Iran). The authors also thank N. Emler (University of Surrey, UK) for proofreading the man-uscript. The trial registration is IRCT138812123480N1; http://www.irct.ir

Funding

The entire study was conducted without external funding.

Notes

1. Following Katzung et al. (2009), diuretics, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors are the most frequently employed medications: Diuretics are hyperten-sion medications flush extra water and sodium (salt) from the body. Diuretics may have side effects such as hypokalemia and related heart conductance problems, along with extra urina-tion, erectile problems in some men, weakness, leg cramps, and fatigue. Beta-blockers reduce heart rate and blood pressure. Beta-blockers may have side effects such as asthmatic symp-toms, erectile problems, sleep problems includ-ing insomnia, and symptoms of depression. ACE inhibitors block the formation of vasocon-strictive hormones; the following side effects have been observed: dry, hacking cough; skin rash; and a loss of taste.

2. In the Islamic Republic of Iran, both female and male patients are treated in the same hospitals, although wards are gender-separated. Please note that there are absolutely no gender differ-ences as regards the treatment standards and treatment quality.

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