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Psychosomatics 46:135-141, April 2005
© 2005 The Academy of Psychosomatic Medicine

Antihypertensive Medication Adherence and Blood Pressure Control in Patients With Psychotic Disorders Compared to Persons Without Psychiatric Illness

Christian R. Dolder, Pharm.D., Kari Furtek, Pharm.D., Jonathan P. Lacro, Pharm.D., and Dilip V. Jeste, M.D.

Received Dec. 9, 2003; revision received April 13, 2004; accepted May 12, 2004. From the Department of Psychiatry, University of California, San Diego, San Diego; the Pharmacy Service and the Psychiatry Service, VA San Diego Healthcare System; and the Wingate University School of Pharmacy, Wingate, N.C. Address correspondence and reprint requests to Dr. Jeste, Geriatric Psychiatry Advanced Center for Interventions and Services Research, VA San Diego Healthcare System, 116A-1, 3350 La Jolla Village Dr., San Diego, CA 92161; djeste{at}ucsd.edu (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The authors compared antihypertensive medication adherence and blood pressure control among middle-aged and older outpatients with schizophrenia and related those with psychotic disorders versus persons without any psychiatric illness. A total of 178 subjects were included in the investigation (89 patients with a psychotic disorder and 89 randomly selected, age-matched comparison subjects). Although the two groups had similar antihypertensive medication adherence, the patients with a psychotic disorder were significantly less likely to have had controlled blood pressure during the 1-year study period. The results highlight the need for clinicians to monitor closely the management of medical comorbidity in patients with schizophrenia and related disorders.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Fifty million individuals in the United States have been estimated to have hypertension.1 In a national survey of adults with known blood pressures, older adults comprised the greatest proportion of individuals with uncontrolled hypertension.2 Several large clinical trials have shown the ability of blood pressure control to reduce cardiovascular morbidity and mortality.3–5 Despite the known benefits of controlling blood pressure, the percentage of those with hypertension having controlled blood pressure is relatively low (i.e., approximately 30%) in most industrialized countries.1,6,7 Nonadherence with antihypertensive therapy has been reported to be one of the most common causes of uncontrolled hypertension in primary care settings.8 In a meta-analysis of medication adherence and medical treatment outcomes, hypertension was identified as a disease in which the level of medication adherence significantly affected treatment outcomes.9

Hypertension is a common medical comorbidity among patients with psychiatric illness.10–12 Cardiovascular morbidity has been identified as one of the most common causes of schizophrenia patients’ increased mortality.13–16 The degree to which mental illness increases the risk of developing a medical disorder such as hypertension is unclear. Nonetheless, in a sample of Medicaid beneficiaries, patients treated for a severe mental illness had a significantly higher risk of physical disorders, including hypertension, after adjustment for age and gender.10

Aging can complicate both hypertension17,18 and medication adherence. Whereas the relationship between aging and adherence is unclear, medication adherence presents special issues in older persons because elderly individuals are more likely to take multiple medications, to have side effects, and to experience greater cognitive and sensory deficits compared to their younger counterparts.19–21 Adherence may be further complicated in older adults with schizophrenia. Many patients with schizophrenia have neurocognitive deficits in attention, memory, and executive function, domains that are also associated with age-related declines in functioning.22–25 In patients with psychotic disorders, medication nonadherence is likely not limited to antipsychotics. In a study of middle-aged and older psychotic patients given prescriptions for antipsychotics and antihypertensive, antihyperlipidemic, and/or antidiabetic agents, nonadherence was found to be problematic for all four classes of medications.26 We did not find any published studies comparing rates of nonpsychiatric medication adherence between persons with versus without psychotic disorders.

The purpose of our study was to compare antihypertensive medication adherence and blood pressure control between middle-aged and older outpatients with schizophrenia and related psychotic disorders and age-matched individuals without any psychiatric illness. We sought to test the hypotheses that patients with a psychotic illness would have 1) significantly higher rates of nonadherence to their antihypertensive medication and 2) significantly lower rates of blood pressure control compared to persons without psychiatric illness.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Patient Selection
This protocol was approved by the University of California, San Diego, Human Subjects Research Protection Program. Using the Veteran’s Administration (VA) San Diego Healthcare System computer database, we identified 6,098 individuals who had been given a prescription for hydrochlorothiazide, metoprolol, or fosinopril during the first quarter of 2001. These particular medications were chosen because at the VA San Diego Healthcare System, they are three of the most commonly prescribed antihypertensives and represent first-line hypertension pharmacotherapy. The two study groups were then drawn from this original sample of 6,098 individuals. Of these 6,098 persons, we selected those who 1) were at least 45 years of age, 2) had a minimum of two antihypertensive prescriptions filled during the 12-month study period, accounting for at least 60 days’ worth of medication, and 3) had been diagnosed with hypertension. Those patients who, according to chart review, appeared to be receiving part of their general medical care outside of the VA system were excluded.

The two study groups were then identified: 1) those with a psychotic disorder and 2) persons without a diagnosed psychiatric disorder. To identify these two groups, ICD-9 diagnostic codes and electronic chart notes were employed. Eighty-nine patients with schizophrenia, schizoaffective disorder, or psychosis not otherwise specified met selection criteria and were included. Eighty-nine age-matched individuals (within 4 years of age) without a psychiatric illness were then randomly selected from the original sample pool. In order to identify patients without psychiatric disorders, ICD-9 diagnostic codes and electronic chart notes were used. Chart notes were used for a number of activities but especially to verify the presence, or lack of, a DSM-IV-based chart diagnosis of schizophrenia, schizoaffective disorder, psychosis not otherwise specified, or other mental disorders.

Data Collection
Electronic chart review was used to gather demographic and relevant clinical information, including age, gender, ethnicity, psychiatric and nonpsychiatric diagnoses, body mass index, and medications. All measurements of blood pressure made in the general medicine clinic were recorded. The general medicine clinic represents the clinic where a majority of outpatients receive primary care within the VA San Diego Healthcare System. Nearly 80% of the study subjects had blood pressure readings from the general medicine clinic in 2001. Numbers of general medicine clinic visits, urgent care encounters, and hospitalizations during 2001 were also obtained. Service use was examined to assess whether potential differences in adherence or blood pressure control were related to differences in the use of services between the two groups.

Adherence to prescribed antihypertensive regimens was determined by examinations of computerized medication records during the 2001 calendar year. For each patient meeting selection criteria, rates of adherence were calculated for hydrochlorothiazide, metoprolol, and/or fosinopril. If a patient was given a prescription for more than one of these three medications, the medication with the greatest nonadherence was used for the adherence assessment.

Adherence was computed by calculating the cumulative mean gap ratio.27,28 This method was chosen because direct measurement of medication consumption was not feasible. All of the methods commonly used to evaluate antipsychotic medication adherence in outpatients have limitations.29 Nonetheless, the use of refill records is objective, and the rates of adherence based on pharmacy refill records have been reported to correlate with other adherence behaviors (e.g., appointment keeping) and serum drug levels (e.g., phenytoin). Of note, refill record adherence has correlated with the pharmacological effects of medications, such as blood pressure control30 with antihypertensive medications.31–33 This technique was used by the authors in previous examinations of antipsychotic and nonpsychiatric medication adherence.26,34 Cumulative mean gap ratios were calculated by dividing the number of days of medication that were unavailable for consumption (due to delayed refills) by the total number of days during the same interval. Thus, cumulative mean gap ratios provided a continuous assessment of gaps in therapy for each patient’s antihypertensive medication.

In addition to calculating antihypertensive medication adherence rates, blood pressure readings were collected to compare blood pressure control between the groups. Blood pressure readings were limited to the general medicine clinic in order to compare the two groups. These readings were then evaluated in relation to the blood pressure goals established by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.5 Adequate blood pressure control was determined by comparing each subject’s blood pressure measurements with the treatment guidelines set up by the Sixth Report of the Joint National Committee. For each patient, blood pressure control was assessed by examining systolic and diastolic blood pressure readings recorded in 2001. Each reading was compared to the goals of the Sixth Report of the Joint National Committee and the percentage of measurements that met the goals of the Sixth Report of the Joint National Committee was computed for each subject. The mean percentage of measurements that met the goal was then compared between the groups.

The chronic disease score was calculated for each patient in order to compare comorbidity between the groups. The chronic disease score uses pharmacy data (i.e., the prescription of certain medication types) to measure an individual’s comorbidity. This instrument, and subsequent modifications, has been shown to predict hospitalization and mortality during the following year, as well as association with physician-rated disease severity.35,36 Briefly, pharmacy data were used to calculate chronic disease scores for each patient based on medications prescribed in 2001.

Statistical Analysis
One-way analysis of variance (ANOVA) and Pearson’s chi-square tests were used to compare demographic, adherence, blood pressure, and service use data, as appropriate. Fisher’s exact test was employed with nominal data when expected frequencies were small. All of the statistical tests were two-tailed, and significance was defined as {alpha}≤0.05. We did not use analysis of covariance because there were no significant differences between the two groups on medical comorbidity (i.e., chronic disease score) and service use (i.e., nonpsychiatric hospitalizations or general medicine clinic visits).


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Patient and Treatment Characteristics
Table 1 compares baseline demographic and clinical data for the psychotic and nonpsychiatric comparison groups. Overall, both of the groups tended to be obese (based on National Institute of Health guidelines) and had a number of medical disorders in addition to hypertension. No significant differences between the two age-matched groups were found in terms of gender, ethnicity, medical comorbidity (i.e., chronic disease score), body mass index, or percent diagnosed with diabetes mellitus. Patients in the psychotic group had a significantly greater mean number of hospitalizations in the VA San Diego Healthcare System in 2001 than the nonpsychiatric comparison group. This difference in hospitalization was driven by psychiatric hospitalizations since there was no significant difference between the groups in nonpsychiatric hospitalizations.


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TABLE 1. Baseline Demographic and Clinical Characteristics of Subjects With Psychosis and Nonpsychiatric Comparison Subjects



With respect to antihypertensive medications, individuals in the two groups were given prescriptions for similar agents. No significant differences existed in the mean number of antihypertensive medication classes (e.g., diuretics, beta-blockers, calcium channel blockers) prescribed in 2001 or in the antihypertensive agents used in the adherence assessment for individual subjects (see Table 1). Additionally, the percentages of use for the types of antihypertensives (i.e., thiazide diuretics, beta-blockers, calcium channel blockers, angiotensin receptor blockers, and other agents) between the two groups did not differ (Pearson’s chi-square value: range=0.091 to 1.45, p value: range=0.28 to 0.76). The mean daily doses of hydrochlorothiazide, metoprolol, and fosinopril prescribed during 2001 were compared between the groups, and no significant differences were found (F value: range=0.39 to 2.06, p value: range=0.15 to 0.54).

Adherence Rates
Each patient’s cumulative mean gap ratio for hydrochlorothiazide, metoprolol, or fosinopril was calculated by using pharmacy refill records to assess medication adherence. No significant difference in the cumulative gap ratio was found between the psychotic (mean=11.7%, SD= 22.2) and nonpsychiatric (mean=10.6%, SD=18.3) comparison groups (F=0.14, df=1, 176, p=0.71). Although a wide range of adherence rates was found among different individuals (see Figure 1), the mean adherence rates indicated approximately 40 days without antihypertensive therapy during the 1-year period. For each patient’s antihypertensive adherence calculation, the total number of days of therapy assessed during 2001 was computed. No difference between the two groups was found (F=0.09, df=1, 176, p=0.76), and the mean duration of assessment for the overall sample was 322 days (SD=74).



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FIGURE 1.  Antihypertensive Adherence in Subjects With Psychosis and Nonpsychiatric Comparison Subjects


Blood Pressure Control
Blood pressure measurements taken in general medicine outpatient clinics were examined, based on the technique described in the Methods section, to assess blood pressure control by using established hypertension treatment goals.5 In terms of blood pressure assessment, the psychiatric group had a significantly lower frequency of blood pressure control than the nonpsychiatric group (Figure 2).



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FIGURE 2.  Blood Pressure Control in Subjects With Psychosis and Nonpsychiatric Comparison Subjects



  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This investigation found differences in blood pressure control but not in antihypertensive medication adherence between middle-aged and older psychotic patients and an age-matched nonpsychiatric comparison group. Even though no significant differences in antihypertensive medication adherence were found, the calculated adherence rates demonstrated that a number of individuals, regardless of diagnosis, had low rates of adherence (i.e., 34 of the 178 patients had gap ratios of at least 25%). Nearly one-third of the persons in both groups appeared to be excess fillers of medications (i.e., days’ supply of medication that exceeded the study period). Additional prospective studies are needed to examine the relationships between possessing excess medications, adherence, and outcomes. Individuals that appeared to possess extra medication, from a refill record perspective, may have poor adherence or outcomes for a variety of reasons.

We did not find any published studies that had specifically compared nonpsychiatric medication adherence rates and medical outcomes between psychotic individuals and a control group. We have previously reported that medication adherence to both antipsychotic and nonpsychiatric medications was problematic in middle-aged and older veteran outpatients with schizophrenia.26 Not finding a significant difference in antihypertensive medication adherence between the psychotic and nonpsychiatric groups was surprising, especially when factoring in a previously published report that found antihypertensive medication adherence to be negatively influenced by depression.37 Although there are many differences between depressive disorders and schizophrenia, we had hypothesized that the psychiatric disorder in question would negatively impact medication adherence. The antihypertensive adherence finding must be considered in the context of our study. Specifically, the sample size and wide distribution of adherence resulted in statistical power that was inadequate to detect at least a 30% difference between the groups (i.e., our a priori clinically relevant difference).

The difference in blood pressure control between the two groups lends itself to several interpretations. It is not clear whether the finding is due to differences in treatment, differences in treatment response, or a combination of the two. In general, we did not find differences between the two age-matched groups in terms of subject demographics, service use, or antihypertensive therapy (i.e., gender, ethnicity, chronic disease score, body mass index, presence of diabetes, or antihypertensive medication) except that the psychiatric group had significantly more total hospitalizations. We were not able to compare the groups on certain lifestyle factors (e.g., exercise, diet, drug and alcohol use) that can affect blood pressure. The high rates of smoking in patients with schizophrenia38,39 and lower rates of health-promoting behaviors in patients with schizophrenia than in the general population40 may have decreased blood pressure control. In addition, antihypertensive tolerability might have affected blood pressure control. In a study by Davies et al.,41 persons with anxiety or depressive disorders had high rates of nonspecific medication intolerability that was related to blood pressure control. It is likely that a combination of factors, including lifestyle, health status, potential differences in the quality of medical care provided to older patients with mental disorders,42 and schizophrenia itself may affect blood pressure control.

There are several limitations to our study that merit discussion. First, the investigation was retrospective, allowing only for associations to be implicated. Second, we examined a narrowly defined sample (i.e., middle-aged and older veteran outpatients seen in a general medicine clinic). Although our selection criteria might have limited generalizability, we felt that it was important to make the psychotic and nonpsychiatric groups comparable on demographic and treatment-related variables. With all subjects seen in the same clinic and treated using VA hypertension guidelines, variance between the two groups was reduced. In addition, only blood pressure readings measured as a part of each patient’s general medicine clinic appointment were used when we evaluated blood pressure control, once again reducing possible confounding factors. Third, more extensive measures could have improved our study. For example, using multiple measures of adherence, obtaining information regarding lifestyle, and examining subjects to measure medical comorbidity would have been useful; however, the retrospective nature of the study did not allow for this. Fourth, we did not compare the two groups on the total number of prescribed medications during the study period. Nevertheless, no difference between the groups on a measure of medical comorbidity, derived from the prescription of various medications, was found. Despite these limitations, the strengths of our study included its 1-year duration, the use of refill records as an objective measure of medication adherence, application of widely accepted hypertension treatment goals (i.e., Sixth Report of the Joint National Committee guidelines), and comparison of groups using variables such as body mass index, presence of diabetes, and a measure of medical comorbidity.

In summary, we found antihypertensive medication adherence rates to be similar between persons with psychotic disorders and individuals without a psychiatric diagnosis. Adherence was, however, problematic in a number of subjects, regardless of diagnosis. Rates of blood pressure control were significantly lower in persons with a psychotic disorder than in the comparison subjects, highlighting a need for clinicians to monitor closely the management of medical comorbidity in patients with schizophrenia and other psychotic disorders. Future studies should be conducted to validate the current findings, especially investigations with larger sample sizes, trials with different treatment sites, and studies using multiple measures of adherence.


  ACKNOWLEDGMENTS

 
Supported in part by NIMH grants MH-19934, MH-49671, MH-43693, and MH-59101 and by the Department of Veterans Affairs.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Burt VL, Whelton P, Roccella EJ: Prevalence of hypertension in the adult population: results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension 1995; 25:305–313[Abstract/Free Full Text]
  2. Hyman DJ, Pavlik VN: The unhealthy lifestyle of people with schizophrenia. N Engl J Med 2001; 345:479–486[Abstract/Free Full Text]
  3. MacMahon S, Peto R, Cutler J: Blood pressure, stroke, and coronary heart disease. Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 1990; 335:765–774[CrossRef][Medline]
  4. Kannel WB, Castelli WP, McNamara PM: Role of blood pressure in the development of congestive heart failure: The Framingham Study. N Engl J Med 1972; 287:781–787
  5. Joint National Commission: The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997; 157:2413–2446[Abstract]
  6. Colhoun HM, Dong W, Poulter NR: Blood pressure screening, management and control in England: results from the health survey for England 1994. J Hypertens 1998; 16:747–752[CrossRef][Medline]
  7. Marques-Vidal P, Tuomilehto J: Hypertension awareness, treatment and control in the community: Is the ‘rule of halves’ still valid? J Hum Hypertens 1997; 11:213–220[CrossRef][Medline]
  8. Cramer JA: Consequences of intermittent treatment of hypertension: the case for medication compliance and persistence. Am J Managed Care 1998; 4:1563–1568[Medline]
  9. DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW: Patient adherence and medical treatment outcomes. Med Care 2002; 40:794–811[CrossRef][Medline]
  10. Dickey B, Normand SLT, Weiss RD, Drake RE, Azeni H: Medical morbidity, mental illness, and substance abuse disorders. Psychiatr Serv 2002; 53:861–867[Abstract/Free Full Text]
  11. Koran LM, Sox HC, Marton KI, Moltzen S, Sox CH, Kraemer HC, Imai K, Kelsey TG, Rose TG Jr, Levin LC, et al: Medical evaluation of psychiatric patients: results in a state mental health system. Arch Gen Psychiatry 1989; 46:733–740[Abstract]
  12. Dixon L, Postrado L, Delahanty J, Fischer PJ, Lehman A: The association of medical comorbidity in schizophrenia with poor physical and mental health. J Nerv Ment Dis 1999; 187:496–502[CrossRef][Medline]
  13. Davidson M: Risk of cardiovascular disease and sudden death in schizophrenia. J Clin Psychiatry 2002; 63:5–11
  14. Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP: Medical comorbidity in schizophrenia. Schizophr Bull 1996; 22:413–430
  15. Allebeck P: Schizophrenia: a life-shortening disease. Schizophr Bull 1989; 15:81–89
  16. Tabbane K, Joober R, Spadone C, Poirier MF, Olie JP: Mortality and cause of death in schizophrenia: review of the literature. Encephale 1993; 19:23–28[Medline]
  17. Weber MA: Hypertension in the aging patient: new imperatives, new options. Am J Geriatr Cardiol 2000; 9:12–15[Medline]
  18. Varagic J, Susic D, Frohlich E: Heart, aging, and hypertension. Curr Opin Cardiol 2001; 16:336–341[CrossRef][Medline]
  19. Salzman C: Medication compliance in the elderly. J Clin Psychiatry 1995; 56:18–22
  20. Sharma T, Antonova L: Cognitive function in schizophrenia: deficits, functional consequences, and future treatment. Psychiatr Clin North Am 2003; 26:25–40[CrossRef][Medline]
  21. Palmer BW, Heaton SC, Jeste DV: Older patients with schizophrenia: challenges in the coming decades. Psychiatr Serv 1999; 50:1178–1183[Abstract/Free Full Text]
  22. Green MF, Neuchterlein KH: Should schizophrenia be treated as a neurocognitive disorder? Schizophr Bull 1999; 25:309–318
  23. Keefover RW: Aging and cognition. Neurol Clin 1998; 16:635–648[CrossRef][Medline]
  24. Heaton R, Paulsen J, McAdams LA, Kuck J, Zisook S, Braff D, Harris J, Jeste DV: Neuropsychological deficits in schizophrenia: relationship to age, chronicity and dementia. Arch Gen Psychiatry 1994; 51:469–476[Abstract]
  25. Heinrichs RW, Zakzanis KK: Neurocognitive deficit in schizophrenia: a quantitative review of the evidence. Neuropsychology 1998; 12:426–445[CrossRef][Medline]
  26. Dolder CR, Lacro JP, Jeste DV: Adherence to antipsychotic and nonpsychiatric medications in older patients with psychotic disorders. Psychosom Med 2003; 65:156–162[Abstract/Free Full Text]
  27. Steiner JF, Prochazka AV: The assessment of refill compliance using pharmacy records: methods validity, and applications. J Clin Epidemiology 1997; 50:105–116[CrossRef][Medline]
  28. Hamilton RA, Briceland LL: Use of prescription-refill records to assess patient compliance. Am J Hosp Pharm 1992; 49:1691–1696[Abstract]
  29. Vitolins MZ, Rand CS, Rapp SR, Ribisl PM, Sevick MA: Measuring adherence to behavioral and medical interventions. Control Clin Trials 2000; 21:188S-194S
  30. Deyo RA, Inui TS, Sullivan B: Noncompliance with arthritis drugs: magnitude, correlates, and clinical implications. J Rheumatol 1981; 8:931–936[Medline]
  31. Peterson GM, McLean S, Millingen KS: Determinants of patient compliance with anticonvulsant therapy. Epilepsia 1982; 23:607–613[Medline]
  32. Steiner JF, Koepsell TD, Fihn SD, Inui TS: A general method of compliance assessment using centralized pharmacy records. Med Care 1988; 26:814–823[Medline]
  33. Steiner JF, Fihn SD, Blair B, Inut TS: Appropriate reductions in compliance among well-controlled hypertensive patients. J Clin Epidemiol 1991; 44:1361–1371[CrossRef][Medline]
  34. Dolder CR, Lacro JP, Dunn LB, Jeste DV: Medication adherence: is there a difference between typical and atypical agents? Am J Psychiatry 2002; 159:103–108[Abstract/Free Full Text]
  35. Von Korff M, Wagner EH, Saunders K: A chronic disease score from automated pharmacy data. J Clin Epidemiol 1992; 45:197–203[CrossRef][Medline]
  36. Putnam KG, Buist DS, Fishman P, Andrade SE, Boles M, Chase GA, Goodman MJ, Gurwitz JH, Platt R, Raebel MA, Arnold Chan K: Chronic disease score as a predictor of hospitalization. Epidemiology 2002; 13:340–346[CrossRef][Medline]
  37. Wang PS, Bohn RL, Knight E, Glynn RJ, Mogun H, Avorn J: Noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors. J Gen Intern Med 2002; 17:504–511[CrossRef][Medline]
  38. Behavioral Risk Factor Surveillance System: Atlanta, Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion 1999
  39. Ziedonis DM, Kosten TR, Glazer WM, Frances RJ: Nicotine dependence and schizophrenia. Hosp Community Psychiatry 1994; 45:204–206[Abstract/Free Full Text]
  40. Holmberg SK, Kane C: Health and self-care practices of persons with schizophrenia. Psychiatr Serv 1999; 50:827–829[Abstract/Free Full Text]
  41. Davies SJ, Jackson PR, Ramsay LE, Ghahramani P: Drug intolerance due to nonspecific adverse effects related to psychiatric morbidity in hypertensive patients. Arch Intern Med 2003; 163:592–600[Abstract/Free Full Text]
  42. Druss BG, Bradford WB, Rosenheck RA, Radford MJ, Krumholz HM: Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001; 58:565–572[Abstract/Free Full Text]



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