Prevalence of major depressive disorders in a reference center for the treatment of hypertension

Abstracts

OBJETIVO: Investigar a prevalência de transtorno depressivo maior em pacientes hipertensos matriculados em um centro de referência universitário para tratamento de hipertensão arterial e fatores de risco cardiovascular. MÉTODOS: Estudo transversal, descritivo, em amostra aleatória representativa, obtida de forma sistemática, de pacientes em atendimento contínuo na Liga de Hipertensão Arterial da Universidade Federal de Goiás. Aplicou-se o Inventário de Depressão de Beck para rastreamento de sintomas depressivos e a Entrevista Estruturada para o Manual de Diagnóstico e Estatística das Perturbações Mentais - Transtornos do Eixo I para avaliação diagnóstica de transtorno depressivo maior. Foram constituídos um grupo com pacientes portadores de depressão maior, denominado grupo-estudo, e um grupo com pacientes não-portadores de depressão maior, denominado grupo-controle. Avaliou-se variáveis sociodemográficas, pressão arterial e bioquímica sangüínea no momento da coleta de dados. RESULTADOS: Foram entrevistados 285 pacientes, tendo sido encontrada prevalência de 20% de depressão maior na população investigada. A idade média foi significativamente menor para o grupo-estudo, com predomínio do sexo feminino. A prática de atividade física regular foi também significativamente menor entre os pacientes do grupo-estudo, que também apresentaram valores mais elevados de pressão arterial diastólica e de colesterolemia. CONCLUSÕES: Foi encontrada uma prevalência de transtorno depressivo maior em pacientes hipertensos superior àquela encontrada na população geral. Isso aponta para uma necessidade de maior atenção ao diagnóstico dos transtornos depressivos em pacientes hipertensos em atendimento primário e ambulatorial.

Prevalência; sintomas depressivos; depressão maior; hipertensão arterial; comorbidade

ORIGINAL ARTICLE

Prevalence of major depressive disorders in a reference center for the treatment of hypertension

Geraldo Francisco do Amaral^I; Paulo César Brandão Veiga Jardim^II; Marco Antonio Alves Brasil^III; Ana Luiza Lima Souza^IV; Helberte Fernandes Freitas^V; Larissa Mayumi Taniguchi^V; Aline Ferreira Bandeira de Melo^V;Carolina Nazeozeno Ribeiro^V

^IPhD in Health Sciences, Universidade de Brasília (UnB), Brasília, DF, Brazil, and Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil. Associate professor, Department of Mental Health and Forensic Medicine, Faculdade de Medicina, UFG. Coordinator, Psychiatric Consultation-liaison Service at Hospital das Clínicas, UFG

^IIPhD in Cardiology, Universidade de São Paulo (USP), São Paulo, SP, Brazil. Associate professor, Department of Medical Clinic, Faculdade de Medicina, UFG. Coordinator, Hypertension Study Group, UFG

^IIIPhD in Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. Associate professor, Department of Psychiatry and Forensic Medicine, UFRJ. Head, Psychiatry Service, Hospital Universitário, UFRJ

^IVPhD in Public Health/Epidemiology, USP. Associate professor, Faculdade de Enfermagem, UFG. Vice-coordinator, Hypertension Study Group, UFG.

^VResident

^{Correspondence}

ABSTRACT

OBJECTIVE: To investigate the prevalence of major depression disorders in hypertensive patients enrolled in a university reference center for treatment of hypertension and other cardiovascular risk factors.

METHODS: Cross-sectional, descriptive study of a representative randomized sample of patients, obtained according to a systematic protocol, among individuals enrolled for continuous treatment at the Hypertension League of Universidade Federal de Goiás. The Beck Depression Inventory was administered to detect depressive symptoms, and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders for diagnostic classification of major depressive disorders. Two groups were formed, one with patients with major depressive disorder, called study group, and another with patients without major depression, called control group. Sociodemographic variables, blood pressure and plasma biochemistry were evaluated at the time of data collection.

RESULTS: A total of 285 patients were evaluated and results indicated a 20% prevalence of major depression in the population included in the study. Mean age was significantly lower for the study group, in which female patients were predominant. Regular physical activity was significantly lower among patients in the study group, and higher diastolic blood pressure values as well as cholesterolemia were also found in this group.

CONCLUSIONS: These results show a higher prevalence of major depressive disorder among these hypertensive patients, compared with the general population. More attention should be paid to establishing an adequate diagnosis for depressive disorders in hypertensive patients, both in primary care facilities and in outpatient clinics.

Keywords: Prevalence, depressive symptoms, major depression, hypertension, comorbidity.

Introduction

Over the past decades, clinical investigations and reviews have suggested an association between depressive disorders (DD) and hypertension. Some studies have shown consistency as to interactions between those diseases, both concerning psychosocial and genetic aspects, and especially as to the fact that depression can be an independent risk factor for hypertension in men and women.^1-12

Major depressive disorder (MDD) is considered one of the most prevalent and severe disease among all medical diseases. Such statement is justified because MDD is manifested with long-duration episodes and high rates of chronicity and recurrence, leading to professional losses, physical and psychic impairment, besides considerable morbidity and mortality due to suicide or association with other diseases.¹³ Prevalence described for all MDD lifespan is 16%, and incidence for the last year was 6.6%.¹⁴ In primary care, studies indicate prevalence of 4.8-13% of patients with depressive symptoms,^15,16 only half of them are identified and less than 25% receive proper care.^14,17

MDD is described as an independent risk factor for hypertension, especially if there are recurrent episodes or even a long period of disease development.¹⁸ However, other variables may be present, such as those related to lifestyle (use of alcohol, smoking, obesity and being sedentary).¹⁹ Sociodemographic variables and permanent stress situations are also important to trigger both hypertension and MDD, which can be seen in communities with low schooling level and occupational status and with high rates of family maladjustment or criminality.⁷

Hypertension is the most common chronic disease in outpatient care and the leading cause of morbidity and mortality in adults. Its prevalence ranges according to region, and values from 4% in China to more than 30% in the USA can be found. In Brazil, rates vary between 22-43%, dependent on country region.^20,21 A considerable part of hypertensive patients have comorbid diabetes, obesity and dyslipidemia, besides other risk factors, such as sedentary lifestyle and smoking.^20,21

Sociocultural and environmental issues, low schooling level and family income, as well as sodium intake influence increase in pressure values.^22,23 Primary hypertension is found in 95% of patients with hypertension, and only 5% of individuals are diagnosed with secondary hypertension.²⁴

The V Brazilian Guidelines on Hypertension²⁴ and The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure²⁵ define hypertension as blood pressure ≥ 140 x 90 mm/Hg.

Prevalence of DD in a population of hypertensive individuals has been reported between 18-37%, but there are few studies reporting these rates.^10-12

In a study performed by Fuller,¹² there was a 28% prevalence of hypertension among depressed patients undergoing outpatient care. According to that author, etiologic hypotheses for this association could be summarized as follows: 1 - a common physiological factor to both diseases; 2 - depression as a result of adverse effect of antihypertensive drugs; 3 - depression secondary to a chronic disease (in this case, hypertension); 4 - depression as a result of treatment for hypertension, in which there is reduced blood pressure, could be a cause of brain failure in the elderly; and 5 - association between these diseases is only coincidental.

Simonsick et al.¹⁰ suggest that in hypertensive patients depression is associated with decline in health, without, however, being able to determine whether depressive symptoms are a potential cause or consequence of complications. Likewise, Cohen et al.²⁵ found depressive hypertensive patients having a higher rate of acute myocardial infarction when compared with nondepressed patients.

Authors have suggested that comorbidities between DD and hypertension should be investigated in the fist visit, considering that this attitude can be of great benefit for the patient.^6,7

Objectives

To investigate prevalence of MDD in hypertensive patients at a reference center for hypertension treatment, its correlation with gender and age, besides possible differences in blood and biochemical pressure control in relation to a group of nondepressed patients of the studied sample.

Methods

This study was developed in a partnership with the Hypertension League of Universidade Federal de Goiás (LHA-UFG), Department of Mental Health and Forensic Medicine of Faculdade de Medicina at UFG and Department of Psychiatry and Forensic Medicine at Universidade Federal do Rio de Janeiro.

Design

Cross-sectional, descriptive study with a representative sample of patients, between 18 and 70 years, enrolled at a reference center for treatment of hypertension and other cardiovascular risk factors.

Study site

LHA-UFG is a multiprofessional service located at Hospital das Clínicas at UFG (HC-UFG), which diagnoses and treats patients with hypertension and cardiovascular risk factors. Besides care provided to hypertensive individuals, it also develops teaching and research activities, being used as an internship site for undergraduate and graduate students in the health area.

It has an active record of 1,400 patients. The population at LHA is comprised of 1/3 of men and 2/3 of women. Referrals are performed by community health services and from other clinics of HC-UFG, and this service is a reference for municipal and state public network.

Sample characterization

The sample was performed among patients enrolled at LHA-UFG located in the active file. To calculate the sample, 302 individuals aged more than 70 years and 47 who were taking part in other studies were excluded, considering a total of 1,051 patients for the final calculation of the population to be studied.

Estimating a prevalence of depression in hypertensive patients between 18-37%,^10-12 a sample of 251 patients was calculated as representative of this population, for a 5% standard error (calculation for finite population). In a systematic random sample, 285 individuals were selected, which corresponded to 13.5% more than necessary for this study.

Patients who refused to participate and/or those who had difficulty cooperating with the interview for any reason were excluded.

Data collection

The patients were selected from November 2003 to June 2005, between 8 and 9 in the morning on Mondays, Tuesdays and Fridays, through patients' medical records scheduled for that day. In the daily routine, medical records are organized by secretaries at LHA-UFG reception, in groups, according to type of care and order of patient arrival: first group - medical visit (up to 10 patients); second group - nursing visit (up to 10 patients); third group - nutrition visit (up to 10 patients).

Patients were selected based on the last medical record in each group, corresponding to the last patient in the daily schedule, always starting by the group to be given care by physicians, then by nursing and finally by nutrition.

Choice of last medical chart in each group aimed at not interfering with the service routine. Each selected patient was approached before their scheduled visit, returning to reception and waiting for their visit normally.

For operational convenience, three patients/day in average were selected. Patients were invited for an interview with the researcher before routine care, when they were explained about the objective of the study. After agreeing and signing a consent term, instruments for diagnosing depression were applied, and later, data were collected from medical records according to visit performed in the same day.

Assessment instruments used for creating groups

Beck Depression Inventory (BDI), which is a symptomatic scale for depression screening, was applied to all selected patients.^26-28 Those who reached a score of 16 or more (moderate, moderate to severe and severe depression) were given the Structured Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) - Axis I Disorders (SCID-I/P, version 2.0)^29-31 for diagnostic confirmation and classification.

Based on the application of the BDI, patients who had depressive symptoms with cut-off point ≥ 16 were selected to be given SCID-I/P 2.0.

Those classified by SCID-I/P 2.0 as having MDD were included in the study group (SG). The control group (CG) was then formed by individuals who did not reach the cut-off point (BDI < 16) and by those who, even reaching the specified cut-off point (BDI ≥ 16), were considered as not having MDD by SCID-I/P 2.0 (Table 1).

Cut-off point

Regarding this cut-off point, Gorenstein & Andrade²⁷ and Cunha²⁸ showed studies with small variations between scores, usually differing in scores for absence of symptoms (0-9) and mild depression (10-17). In a sample of 127 adult patients, Spitzer et al.²⁹ applied the BDI and Structured Clinical Interview for DSM-III-R (SCID-III-R), and managed to define a cut-off point of 17 to classify what is considered major depression. Splinkle et al.³⁰ and Beck & Steer²⁶ considered that a cut-off point between 16 and 14 for mild depression can be significant. Beck & Steer²⁶ suggest that decision for a cut-off point to be used can be based only on sample characteristics.

Sprinkle et al.,³⁰ in a comparative study with that by Beck & Steel,²⁶ applied the BDI in test and retest and, next, the depression module of SCID-I/P 2.0, identifying a cut-off point of 17 in the BDI for correlation with major depression.

In this study, the interest is the identification of depressive comorbidity that might influence the evolution of antihypertensive treatment and, for that, scores within an average established by mentioned studies were chosen. That is why we chose to exclude, in this study, patients with scores between 10 and 15 (mild depression), since the object of interest was to identify patients with MDD according to DSM-IV.³²

Scores used for BDI were as follows: 0 to 9 - absence of symptoms; 10 to 15 - mild depression; 16 to 19 - moderate depression; 20 to 29 - moderate to severe depression; 30 to 63 - severe depression.

All individuals who reached a score ≥ 16 for BDI were analyzed based on SCID-I/P 2.0.

Ethical aspects

The protocol was reviewed and approved by the Ethics and Human Medical and Animal Research Committee at HC-UFG.

Along the interviews using BDI and SCID-I/P 2.0, patients identified as depressed were referred for treatment and follow-up at the Psychiatric Outpatient Clinic of the Department of Mental Health and Forensic Medicine at Faculdade de Medicina/ HC-UFG. Patients who had BDI scores for mild depression (between 10 and 15 points) and those with BDI ≤ 16, but not identified as MDD by SCID-I/P 2.0, were referred for psychiatric assessment at the Psychiatric Outpatient Clinic of HC-UFG.

Parameters

Individuals were assessed as to:

- Blood pressure: systolic and diastolic pressures, considering the second value registered in the last visit at LHA-UFG;

- Body mass index (BMI): as registered in the medical record;³³

- Smoking: presence/absence;

- Alcoholism: presence/absence and its quantification according to a table used at LHA;

- Physical activity: regular, irregular or absent, according to the classification used at LHA (absent - no physical activity; irregular - less than three times a week; regular - three or more times a week);

- Cholesterol levels, triglycerides and blood glucose: according to registered results.

All data were collected from medical records according to a visit performed during selection.

Statistical analysis

Excel 2000 was used to create the database, and SPSS 13.5 for statistical tests.Variance analysis was used to verify difference between SG and CG as to age; chi-square test was used for sociodemographic characterization of the sample, and Mann-Whitney³⁴ test was used for assessment between groups.

Results

Of the 285 patients initially selected for BDI application, 206 (72.3%) had scores lower than the cut-off point (BDI < 16) (Table 2). Application of SCID-I/P 2.0 to 79 (27.7%) patients who reached minimal cut-off point (BDI ≥ 16) confirmed diagnosis of MDD in 57 (20.0%) patients, representing the SG. The 22 (7.7%) patients with BDI ≥ 16, but not confirmed as having MDD by SCID-I/P 2.0 were added to the 206 patients previously selected by the BDI, representing the CG (Table 3).

Clique here to enlarge

Clique here to enlarge

Therefore, there were 57 patients who met the criteria for MDD according to SCID-I/P 2.0, accounting for a 20% prevalence of patients with MDD among those enrolled at LHA.

Mean age in SG was 52.5±8.3 years, whereas in CG it was 55.8±9.5 years, with a significant difference between groups (p = 0.013)

There was also a significant difference in gender between SG and CG (p = 0.001), and hazard ratio for major depression was 2.39 for women in relation to men (Table 3).

Sociodemographic data concerning marital status, schooling level, smoking and alcoholism did not show significant difference between SG and CG. As to physical activity, CG members practiced regular physical activity with a higher frequency than SG, with statistically significant difference (p = 0.013), as can be seen in Table 3.

When SG and CG were compared as to blood and biochemical pressure, there was significant difference as to diastolic blood pressure (DBP) (p = 0.040) and total cholesterol (p = 0.045) (Table 4).

Considering only male patients, this difference was maintained as to DBP (p = 0.019).

SCID-I/P 2.0 classified the following diagnoses in the 57 (20%) patients with MDD: 16 (28.1%) patients with single melancholic MDD; 24 (42.1%) patients with recurrent melancholic MDD; six (10.5%) patients with single atypical MDD; and 11 (19.3%) patients with recurrent atypical MDD. There were no diagnoses of postpartum depression neither catatonic symptoms.

Among assessed patients, none was undergoing previous treatment with antidepressants.

Discussion

There are few studies^10-12 on prevalence of depression among individuals with hypertension, which vary and are dependent on sample and scale.

Dilsaver & Coffman,¹¹ in a comment of research studies carried out between 1959 and 1983 using scales and questionnaires (unspecified), reported major depressive symptoms in around 37% of hypertensive patients, drawing attention to the fact that any study was performed before antihypertensive treatment onset and that those with atypical depression, adjustment disorders with depressive symptoms, dysthymia and MDD were all considered as having DD.

Fuller¹² reports rates found by other authors ranging between 30 and 67% of depressive symptoms among hypertensive patients. He highlights in those studies the use of different methodologies and different definitions of depression and hypertension. In his study, he found a 28% rate of depressive hypertensive patients, using DSM-II constant criteria as diagnostic method.

Simonsick et al.,¹⁰ in a multi-centered sample of hypertensive individuals followed for 10 years, using the Center for Epidemiologic Studies Depression Scale (CES-D), found prevalence of depression between 9.4 and 13.5% for men and 20.6 and 27.1% for women, establishing mean prevalence of 18%, which he classified as high depressive symptoms, which could indicate possibility of being patients characterized as having MDD.

MDD prevalence of 20% found after application of SCID-I/P 2.0 is closer to Simonsick et al.'s study¹⁰ and seems to reflect the reality of our population. Although the prevalence found in this study may seem underestimated in relation to prevalence observed in other studies, it should be considered that those authors worked with scales that defined only depressive symptoms and not specifically MDD diagnosis, which allow us to infer that variations in these results found in the literature can be due to different forms of assessment.^10-12

A limitation of this investigation can be the fact that SCID-I/P 2.0 was not applied to patients who had BDI scores between 10 and 15. However, Sprinkle et al.,³⁰ by setting a cut-off point of 17 in the BDI for association with major depression, allowed use of that cut-off point in our study.

Using BDI to identify depressed patients, excluding those classified as mild depression and confirming major depression through a structured interview made diagnosis more accurate, avoiding overestimation of the prevalence in our sample.

For example, by taking only BDI results for a cut-off point of 15, without applying SCID-I/P 2.0, there would have been a 27.7% prevalence of depressive symptoms, close to the results found by Fuller.¹²

Even more, considering a sample with lower scores (between 10 and 15 in BDI - "mild depression") for the statistical calculation, 48 patients would be added with diagnosis of DD without specification, which would increase prevalence to 44.6%, much closer, in average, to the results obtained by Dilsaver & Conffman¹¹ and by other authors cited by Fuller.¹²

Mean age in our study was significantly lower (p = 0.013) for SG patients, compared with CG patients, which is in contrast with some authors,^35,36 but is in agreement with the studies by Scherrer et al.¹ and Karpansalo et al.³⁷ assessing a middle-aged male population.

As to gender, after correction of male/female ratio present at LHA (1/3 of male and 2/3 of female), there was MDD prevalence 2.39 times higher for women than for men, a number that is slightly higher than that reported in the literature.

The findings also indicate that CG patients perform systematic physical activity more frequently than SG patients (p = 0.013). It is important to stress that physical activity is a mandatory component for the treatment of hypertension and MDD,^7,9,21 and this fact may contribute to major differences in therapeutic outcome.

The data concerning BP levels showed significantly higher values in SG for DBP (p = 0.040), and this tendency was also present for SBP. Even with a significant difference only for DBP, this fact may represent an additional risk for the cardiovascular system.

Regarding biochemical parameters (cholesterol, triglycerides and blood glucose), Shizuka & Yambe³⁸ found relevant data for increased total cholesterol among women, although they also reported a similar tendency in men. We also found a significant difference concerning total cholesterol (p = 0.045), when compared with SG and CG (Table 4). Although there is statistical significance when dividing groups according to gender, there was a tendency for higher cholesterolemia levels among women.

Conclusion

There was prevalence of MDD in hypertensive patients higher than that found in the general population, besides consistent data as to higher DBP and cholesterolemia level and lower frequency of physical activity among SG individuals.

This significant presence of MDD and even of depressive symptoms not assessed in this group of patient is a matter of concern, especially when taking into account that both diseases are among the most frequent noncommunicable chronic diseases.

More attention should be paid by health professionals to complaints presented by hypertensive patients concerning depressive symptoms in primary care, specific outpatient clinic and general hospital, with the aim of having a more accurate and earlier diagnosis and a more efficacious therapy.

More prospective studies should be carried out in the sense of assessing the impact of MDD treatment to improve diagnosis and quality of life of hypertensive patients.

References

Received June 3, 2007

Accepted June 27, 2007

This study was carried out at the Hypertension Study Group and at Department of Mental Health and Forensic Medicine, UFG, and at Department of Psychiatry and Forensic Medicine, UFRJ.

• 1. Scherrer JF, Xian H, Bucholz KK, Eisen SA, Lyons MJ, Goldberg J, et al. A twin study of depression symptoms, hypertension, and heart disease in middle-aged men. Psychosom Med. 2003;65(4):548-57.
• 2. Frasure-Smith N, Lespérance F. Depression and other psychological risks following myocardial infarction. Arch Gen Psychiatry. 2003;60(6):627-36.
• 3. Scalco AZ, Scalco MZ, Azul JB, Lotufo Neto F. Hypertension and depression. Clinics. 2005;60(3):241-50.
• 4. Carney RM, Freedland KE, Stein PK, Watkins LL, Catellier D, Jaffe AS, et al. Effects of depression on QT interval variability after myocardial infarction. Psychosom Med. 2003:65(2):177-80.
• 5. Wassertheil-Smoller S, Shumaker S, Ockene J, Talavera GA, Greenland P, Cochrane B, et al. Depression and cardiovascular sequelae in postmenopausal women. The Women's Health Initiative (WHI). Arch Intern Med. 2004;164(3):289-98.
• 6. Yan LL, Liu K, Matthews KA, Daviglus ML, Ferguson TF, Kiefe CI. Psychosocial factors and risk of hypertension; the coronary artery risk development in young adults. JAMA. 2003;290(16):2138-48.
• 7. Reiff M, Schwartz S, Northridge M. Relationship of depressive symptoms to hypertension in a Household //survey in Harlem. Psychosom Med. 2001;63(5):711-21.
• 8. Amaral GF, Porto CC, Brasil MAA, Jardim PCBV. Depressão e doenças cardiovasculares: importância para o clínico. Rev Soc Bra Clin Med. 2005;3(4):102-12.
• 9. Shinn EH, Poston WS, Kimball KT, St. Jeor ST, Foreyt JP. Blood pressure and symptoms of depression and anxiety: a prospective study. AJH. 2001;14(7 Pt 1):660-4.
• 10. Simonsick EM, Wallace RB, Blazer DG, Berkman LF. Depressive symptomatology and hypertension-associated morbidity and mortality in older adults. Psychosom Med. 1995;57(5):427-35.
• 11. Dilsaver SC, Coffman JA. Hypertension and depression: question of a causal relationship persist. Psychiatry Res. 1988; 26(1):115-7.
• 12. Fuller BF. DSM-III depression and hypertension in two psychiatric outpatient populations. Psychossomatics. 1988;29(4):417-23.
• 13. Abas M, Hotopf M, Prince M. Depression and mortality in a high-risk population. 11-Year follow-up of the Medical Research Council Elderly Hypertension Trial. Br J Psychiatry. 2002;181:123-8.
• 14. Glass R. Awareness about depression: important for all physicians. JAMA. 2003;289(23):3169-70.
• 15. Meredith LS. Depression: 20 years of progress. Med Care. 2004;42(6):499-501.
• 16. Mann JJ. The medical management of depression. N Engl J Méd. 2005;353(17):1819-34.
• 17. Lima MS. Epidemiologia e impacto social. Rev Bras Psiquiatr. 1999;21(SI):1-5.
• 18. Meyer CM, Armenian HK, Eaton WW, Ford DE. Incident hypertension associated with depression in the Baltimore Epidemiologic Catchment area follow-up study. J Affect Dis. 2004;83(2-3):127-33.
• 19. Markovitz J, Matthews KA, Kannel WB, D'Agostino RB. Psychological predictors of hypertension in the Framingham Study. JAMA. 1993;270(20):2439-43.
• 20. Jardim PCBV, Gondim MRP, Monego ET, Moreira HG, Vitorino PVO, Souza WKSB, et al. Hipertensão arterial e alguns fatores de risco em uma capital brasileira. Arq Bras Cardiol. 2007;88(4):452-7.
• ²¹
  Brasil, Ministério da Saúde. Controle da hipertensão arterial: uma proposta de integração ensino-serviço. Rio de Janeiro: CDCV/NUTES; 1993. p. 232.
• 22. Jardim PCBV, Souza ALL, Monego ET, Barroso WKSS. Pressão arterial: semiotécnica e avaliação clínica do paciente. In: Porto CC. Doenças do coração: prevenção e tratamento. 2Ş ed. Rio de Janeiro: Guanabara Koogan; 2005. p. 504-9.
• 23. Sociedade Brasileira de Hipertensão, Sociedade Brasileira de Cardiologia, Sociedade Brasileira de Nefrologia. Diretrizes brasileiras de hipertensão arterial - IV DBHA. Rev Soc Bras Hipertensão. 2002;5:123-63.
• 24. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al. The seventh report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure (VII JOINT). JAMA. 2003;289:2560-72.
• 25. Cohen HW, Madhavan S, Alderman MH. History of treatment for depression: risk factor for myocardial infarction in Hypertensive patients. Psychosom Med. 2001;63(2):203-9.
• 26. Beck AT, Steer R. Beck depression inventory manual - II. San Antonio (TX): Psychological; 1993.
• 27. Gorenstein C, Andrade LHSG. Inventário de depressão de Beck: propriedades psicométricas da versão em português. In: Gorenstein C, Andrade LHSG, Zuardi AW, orgs. Escalas de avaliação clínica em psiquiatria e psicofarmacologia. São Paulo: Lemos; 2000. p. 89-95.
• 28. Cunha JA. Manual da versão em português das escalas Beck. São Paulo: Martins Fontes; 2001.
• 29. Spitzer RL, Williams JBW, Gibbon M, First MB. Users guide for the structured clinical interview for DSM-III-R. Washington, DC: American Psychiatric; 1990.
• 30. Sprinkle SD, Lurie D, Insko SL, Atkinson G, Jones GL, Logan AR, et al. Criterion validity, severity cut scores, and test-retest reliability of the beck depression inventory-II in a university counseling center sample. J Couns Psychol. 2002:49(3):381-5.
• 31. Tavares M. Entrevista clínica estruturada para o DSM-IV. Transtornos do eixo I: edição para pacientes - SCID - I/P (versão 2.0). Brasília DF; Universidade de Brasília; 1999.
• 32. American Psychiatric Association. Manual diagnóstico e estatístico de transtornos mentais (DSM-IV). 4a ed. Porto Alegre; Artmed; 1995.
• ³³
  World Health Organization. Physical status: the use and interpretation of anthropometry. (Technical Report Series, 854). Geneva: WHO Report; 1995.
• 34. Monteiro Filho G. Segredos da estatística: pesquisa científica. Goiânia: Vieira; 2004.
• 35. Cervilla JA, Prince M, Joels S, Mann A. Does depression predict cognitive outcome 9 to 12 years late? Evidence from a prospective study of elderly hypertensives. Psychol Med. 2000;30(5):1017-23.
• 36. Bosworth HB, Bartash RM, Olsen MK, Steffens DC. The association of psychosocial factors and depression with hypertension among older adults. Int J Geriatr Psychiatry. 2003;18(12):1142-8.
• 37. Karpansalo M, Kauhanen J, Lakka TA, Manninen P, Kaplan G, Salonen JT. Depression and early retirement: prospective population based study in middle aged men. J Epidemiol Community Health. 2005:59(1):70-74.
• 38. Shizuka K, Yambe T. Relationship between depression and lipid metabolism in the elderly with hypertension. Jap J Geriat. 2001;38(6):785-90.

Publication Dates

• Publication in this collection
  13 Dec 2007
• Date of issue
  Aug 2007

History

• Accepted
  27 June 2007
• Received
  03 June 2007