Patients' decisions about whether or not to take antihypertensive drugs: qualitative study
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7369.873 (Published 19 October 2002) Cite this as: BMJ 2002;325:873
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
It would be helpful to learn from the authors how much time elapsed
between the study patients' first receipt of advice to start
antihypertensive drug treatment, and when they arrived at a decision to
accept or not the advice. It would also be helpful to learn the
proportion of patients who initiated treatment and then shortly changed
their decision and stopped treatment.
Competing interests: No competing interests
Editor- It is well known that patient factors contribute a lot
towards the treatment in chronic conditions like asthma,diabetes, heart
disease and HIV(Human immunodeficieny disease).Their beliefs about health
and illness, in particular about medication and the impact it has on the
illness are crucial.Horne R and Fisher et al have discussed "The
perception of HIV and HAART"(Highly active antiretroviral treatment) as
barrier to adherence, 5th AIDS impact,Brighton,2001,abstract 105.
In a chronic disease like HIV where a life long commitment to taking
drugs is important and especially where 100% adherence is
preferred,understanding patients perceptions to the disease and treatment
plays a major role in their adherence and indirectly to the success of the
therapy. Failure to appreciate this important fact has resulted in the
development of drug resistance and eventual failure.Many of these
situations can be avoided if the clinicians explore the patient's views
and beliefs and then start the treatment.The time spent on counselling is
well invested.There are a lot of adherence support clinics run by the
pharmacists and nurses which help in understanding, educating and
influencing their knowledge.Maybe similar clinics for patients with
hypertension can contribute to some improvement in the current situation.
Competing interests: No competing interests
If I were a young adult being asked to take a beta blocker to prevent
the cardiac and cerebral complications of hypertension I would be most
concerned that the drug would increase the likelihood of my developing
Alzheimer’s, Parkinson’s and/or an unknown neurodegenerative disorder in
years to come.
The Gibbs-Ng model for memory, derived from data generated from the
avoidance model in one-day-old chicks, implicates glycogenolysis and
oxidative phosphorylation (1,2). One way of preventing the development of
memories in the avoidance model in the one-day-old chick is to administer
an inhibitor of glyocogenolysis, such as a beta blocker. The effect is
apparent in humans. In one study participants treated with propranolol had
slightly fewer correct responses to questions at 3 months (33 +/- 3 [mean
+/- SD] relative to 34 +/- 2 with placebo, P = 0.02) and slightly more
errors of commission at 3 months (4 +/-5 versus 3 +/- 3, P = 0.04) and at
12 months (4 +/- 4 versus 3 +/- 3, P = 0.05) (3). There is, furthermore,
a case report from the department of neurology at the Massachusetts
General Hospital of a patient who developed an amnestic syndrome, similar
to Alzheimer’s, with propranolol toxicity (4). These findings raise the
possibility that the long term administration of propranolol might cause
an Alzheimer’s-like state.
The possibly of developing a neurodegenerative disorder might be
increased by being asked to take a statin to lower the blood cholesterol,
for statins reduce mitochondrial coenzyme Q (5). Any other factor that
compromises the adequacy of mitochondrial oxidative phosphorylation might
increase the likelihood of these medications causing a neurodegenerative
disorder. The uncoupler dinitropheol, for example, prevents the
development of memories in the one-day-old chick model. Other uncouplers
include most halogenated and nitrophenols such as those found in
insecticides, ascaricides, molluscicides, herbicides, common medications
such as dicoumarol, and even inhalation anaesthetic agents such as
halothane. Energy transfer inhibitors include oligomycin. Inhibitory
uncouplers include DDT, ditnitrophenol again, clorodiene and some
insecticides. Cytokines putatively released by viral infections,
lipopolysaccharide, sepsis, devitalised tissues and blood transfusions,
may also uncouple oxidative phosphorylation (6).
The real danger is likely to lie in the mixing of agents capable of
impairing mitochondrial oxidative phosphorylation (7). If patients choose
to take beta blockers and statins to reduce the likelihood of them
developing cardiac and cerebral complications perhaps they should consider
also taking coenzyme Q and other micronutients that are likely to enhance
mitochondrial function (8).
1. Ng KT, Regan C, O'Dowd B. Astrocyte involvement in learning. In
Glial cells: their role in behavior. Laming PR, Sykova T, Reichenbach A,
Hatton GI, Bauer H eds. Cambridge Univeristy Press 1998, pp 315-38.
2. Daisley JN, Rose SP. Amino Acid Release from the Intermediate Medial
Hyperstriatum Ventrale (IMHV) of Day-Old Chicks Following a One-Trial
Passive Avoidance Task. Neurobiol Learn Mem. 2002 Mar;77(2):185-201.
3. Perez-Stable EJ, Halliday R, Gardiner PS, Baron RB, Hauck WW, Acree M,
Coates TJ. The effects of propranolol on cognitive function and quality of
life: a randomized trial among patients with diastolic hypertension. Am J
Med. 2000 Apr 1;108(5):359-65.
4. Fisher CM. Amnestic syndrome associated with propranolol toxicity: a
case report.
Clin Neuropharmacol. 1992 Oct;15(5):397-403.
5. Fiddian-Green RG. Might statins cause Parkinsons? bmj.com, 18 Oct 2002
6. Fiddian-Green RG Mitochondrial considerations
bmj.com/cgi/eletters/325/7367/735/a#26019, 4 Oct 2002
7. Fiddian-Green RG The real danger is in the mixing?
bmj.com/cgi/eletters/325/7367/736/c#26113, 7 Oct 2002
8. Misner BD. Coenzyme Q-10 Repletion bmj.com, 18 Oct 2002
Competing interests: No competing interests
this article may open a pandora's box.
is it really practical to let patients make decision choices regarding
their treatment?. a patient may refuse to take anti-hypertensives for any
of the reasons cited. thereafter, there are several visits to ER for
hypertensive crisis, cva, angina, mi and all attendant complications, the
cost could run into millions. it is fair for the patient to opine about
the treatment of hypertension, but would he be responsible for the
escalated costs his decision may entail?
what if a group of people refuse vaccinations, this will bring to nought
the entire country's preventive medicine.
in my practice too, i have informed patients who opt for alternative
medicine for such condition as IDDM. it is not long before they present
with diabetic coma. at this juncture, everyone including relatives, want
allopathic treatment which would include infusion of insulin, iv fluids
and repeated investigations of blood sugar u&e and name it.of course
the patient have to pay for it as in india nothing comes free!
Competing interests: No competing interests
Tipping the balance in hypertension follow-uo
Editor,
Benson and Britten’s article (1) examining why patients choose to
take medication for hypertension exposes the ambivalence some people feel
about pharmaceutical intervention for chronic disease.
We have recently
completed a study looking at the reasons a significant proportion of
diagnosed hypertensives fail to return for follow-up appointments. We
identified 35 such non-returners in three general practice populations in
Worcester, Droitwich and Exmouth (approximately 5% of the hypertension
registers). Eleven of these patients (age 30-75, median age 62, 6 male, 5
female) were interviewed in their homes and asked their views on their
diagnosis, follow-up and treatment options. Transcripts were analysed
using standard qualitative techniques.
Many of the themes we identified
fit well with those described, notably the dislike of medication and fear
of being labelled as sick. We also noted that many of the patients had
wider concerns about how regular follow-up would affect their perception
by others. This includes worries that they would be seen as a
hypochondriac not only by other patients (“Well the other people in the
waiting room might think that silly old fool sitting there, there’s
nothing wrong with them.”), but also by the GP (“It may not be recorded
that someone’s told you to come in. They might think, ‘He comes down here
every 3 months and its always normal, why does he do it. You know, he just
likes to come in.’ ”). There were concerns that this might influence
future treatment for other, more ‘serious’ conditions (“If I was down
there every week then she’d start thinking you know, let’s give him some
placebo.”)
Nonetheless, all patients understood their diagnosis, although this
was countered by varying degrees of denial, and agreed that medical
intervention was appropriate given the severity of the possible
consequences of untreated hypertension. This study, along with that of
Benson and Britten, highlights some of the dilemmas patients face when
attempting to resolve conflicting ideas regarding medical advice. Rather
than considering such patients as non-compliant, it might be more
constructive to think of them as sitting on a decision seesaw. The use of
alternative consultation options and the adoption of more patient centered
approaches, in particular having a greater understanding of health
beliefs, may then be a way of tipping the balance towards regular follow-
up and effective treatment.
1. John Benson and Nicky Britten BMJ 2002; 325: 873
Tom Lewis
Foulkes Foundation Fellow
Richard Woof
Lecturer in General Practice
Department of General Practice,
University of Birmingham
B15 2TT
Competing interests:
None declared
Competing interests: No competing interests