This presentation is an overview of the collaborative care model of hypertension management for behavioral health providers, primary care doctors and health care teams. It explored social determinants of health, complex interaction of adverse childhood experiences and treatment and provides a map for integrated care.

1. Hypertension Treatment
Integrated Behavioral Health
and Primary Care
Michael Changaris, PsyD

8. Social Determinants of Health

10. Team Based Care
OUTCOMES: Review and Meta-analysis of 100 randomized trials determined that team-
based care is highly effective compared with other strategies for BP control.
TEAM PLAYERS: Team-based care includes the patient, the primary care clinician, and
other professionals such as nurses, pharmacists, physician assistants, dieticians, social
workers, and community health workers, each with pre-defined responsibilities in care.
TEAM BASED CARE: Team-based care incorporates a multidisciplinary team,
centered on the patient, to optimize the quality of hypertension care.

13. Health Psychologist Role in CVD and HTN Tx
Medication
Adherence
& Health
Literacy
Change in Health
Behaviors
Substance Use,
Salt Intake, DASH
Diet, Exercise,
Weight Loss
Mental
Health Tx.,
ACEs, SDOH
and Toxic
Stress
1 2 3

14. Adverse Childhood
Experiences
Hypertension, ACEs and Toxic Stress

20. ACEs and Toxic Stress = Increased HTN and Risk
• ACEs and HTN Risk: According to a recent study, even one adverse childhood
experience is strongly and independently associated with cardiovascular risk
factors, with implications for primordial prevention.
• Younger and Faster: In this novel longitudinal study, we observed that
participants who were exposed to multiple ACEs displayed a greater increase of
BP levels in young adulthood compared to their counterparts without ACEs.
• Food Insecurity: Those who were food insecure were significantly less likely to
have good cardiovascular health compared to participants who were food secure

21. ACEs and Toxic Stress = Increased HTN and Risk
• ACEs Not Just Behaviors: As expected, a graded association of ACEs with
childhood SES and negative health behaviors was observed (p<0.001). The ACE-
SBP relation was not explained by these factors, while the ACE-DBP partially
mediated by illicit drug use.
• Women and SES: Women raised in lower socioeconomic status (SES) families
were found elevated markers of inflammation & hemostasis, > risk for CVD in
adulthood.
• Anti-Poverty Predicts Health: Receipt of anti-poverty public assistance during
childhood was found to decrease risk for hypertension by mid-life among women
in another study.

23. Complex Medication Reactions
Neuroendocrine changes from trauma increase risk of complex
reactions to medications.
Treatment Adherence
Trauma dramatically impacts treatment adherence through
increased anxiety, gaps in care or
crisis only appointments.
Patient Provider Relationship
The patient provider relationship has a
large impact on health outcomes.
1. Trust, 2. Emotional Reactivity, 3. Follow Through

24. Mental Health and
Hypertension

26. Mental Health and HTN/CVD
• Prevention: Up to 80% of premature deaths from heart disease
and stroke are preventable.
• CVD and Depression: Up to 20% of people with CVD suffer
from depression.
• Worse Outcomes: The presence of depression and/or anxiety
at least doubles the risk for a poor outcome after a cardiac
event.
• High Costs: The cost of treating patients with depression and
heart failure is double that of treating people with heart failure
who are not depressed.

27. Mental Health and HTN/CVD
• MH and Risk Factors: Identifying and managing modifiable risk factors for CVD in
people with a severe mental disorder will reduce their risk for premature mortality.
• Discrimination: Discrimination against people with severe mental disorder prevents
them from accessing services and increases their risk for premature death and
disability from CVD. Addressing discrimination should therefore be a priority.
• Annual Assessment of Risk: The risk of every person with a severe mental disorder for
a cardiovascular event should be measured annually with a recognized risk algorithm.
• Integration Needed: The combination of as diabetes, hypertension and CVD, and the
presence of a severe mental disorder requires integrated by specialists in mental and
physical health.
• High Prevalence in Bipolar: 61% prevalence of hypertension in those with bipolar
disorder compared with 41% among the general population.

28. Mental Health and HTN/CVD
• Contributes to Mental Health Outcomes: Hypertension not only is
common among patients with psychiatric illness, it likely contributes to
worse clinical outcomes.
• Early Death: People with severe mental disorder die 15–20 years earlier
than the general population, most commonly from CVD.
• Risk of Stroke: The risk of a person with a severe mental disorder for a
heart attack or a stroke is at least double that of the general population,
and the risk of a long stay as an inpatient is tripled
• PTSD: 17.3% of PTSD versus 6% in the normal population in a cohort of 35
consecutive patients with refractory hypertension.

29. Psychosis Early Death, HTN and CVD
• Antipsychotic Medication:
• Influences the electrical current that coordinates each contraction of the heart, placing the
heart at greater risk for a fatal irregular rhythm.
• This so-called “torsades de pointes” can be recognized in the electrocardiogram (> time
between QRS complex and the T wave, the QT interval) )fatal arrhythmia).
• Antipsychotic medication is an increase in the incidence of venous thromboembolism this is
increased by smoking.
• Severe mental disorders CVD Death:
• The commonest cause of death among people with severe mental disorders such as
schizophrenia and bipolar disorder is CVD.
• Identifying and managing modifiable risk factors for CVD in people with a severe mental
disorder (such as alcohol and tobacco use) will reduce their risk for premature mortality.
• Bigotry and Discrimination: Against people with severe mental disorders prevents them from
accessing services and increases their risks for premature death and disability from CVD.

30. • Patients with increased depressive symptoms are less likely to
comply with antihypertensive medication.
• Patients with confirmed depression are 3 times more likely to
not adhere to medical treatment recommendations than non-
depressed patients.
• Motivation improves when patients have positive experiences
with, and trust in, the clinician. Empathy builds trust and is a
potent motivator.
Adherence and Depression – Motivation and Empathy

31. Hypertension
Integrated Health
An Integrated Model of Care

33. How Health Psychologist Plays a Role on the Team
Medication
Adherence
& Health
Literacy
Change in Health
Behaviors
Substance Use,
Salt Intake, DASH
Diet, Exercise,
Weight Loss
Mental
Health Tx.,
ACEs, SDOH
and Toxic
Stress
1 2 3

34. Causes of Failure to Normalize BP
Screening and Access to Care
Lack of health
insurance
Lack of access
to health care
Absence of a
usual source
of care
Failure to
diagnose HT
Failure to
screen for
high BP
Inaccurate BP
measurement
Failure to
recognize
masked HT

35. Causes of
Failure
to Normalize
BP
Provider and
BH Factors
Clinician
therapeutic inertia
Failure to treat
masked HT
Failure to initiate
treatment when HT
is present
Failure to intensify
therapy in a treated
patient when BP is
above goal
Inadequate patient
education
Absence of shared
decision-making
Inadequate lifestyle
recommendations
and counseling
Low adherence to
lifestyle modification
and/or prescribed
antihypertensive
medication
Absence of home or
ambulatory BP
monitoring and
reporting
Low patient and/or
provider awareness
of BP target
Absence of
systematic
follow-up
H H
H
H
H
H
H = Health Psych
Support

36. HTN Lifestyle Changes and Genetics
Genetic loading and
heritability of HTN is
about 30% to 50%.
Randomized trials
indicated that aerobic
exercise
(5-7 mm Hg reduction)
Dynamic and isometric
resistance are effective
as well.
(4-5 mm Hg reduction)
Clinical studies have
repeatedly shown that
weight loss reduces the
risk for hypertension.
The combination of low
sodium intake and
DASH diet = greater BP
red. than > sodium or
the DASH diet alone.
Increased potassium
adults especially among
African Americans,
older adults, or high
dietary sodium
Moderate physical
activity can reduce HTN
incidence
H = Health Psych
Support
H
H
H
H
H
H
H

37. ISOMETRIC EXERCISE EXAMPLES

38. Key Lifestyle Change Targets for HTN Treatment
The greatest impact can be achieved by targeting lifestyle areas of
highest deficiency & combining >1 of these lifestyle modifications
Nevertheless, only a minority of adults change their lifestyle after a
diagnosis of hypertension, and sustainability is difficult.
Changing HTN is a Change of Heart
Weight and Obesity Unhealthy Diet
High Sodium
Intake
Inadequate
Potassium
EtOH Intake or BP
Elevating Substance
Physical Activity
1 2 3
4 5 6

39. Treatment Adherence: Poor Adherence is Common
• Low adherence to antihypertensive medication is common
• 21.3% of 6,627 older adults initiating antihypertensive dc’d tx. within 1 year
• 31.7% of patients who continued antihypertensive medication had low
adherence (< 80% of days having medications available).
• Barriers to adherence are multifactorial
• Complex medication regimens (e.g., multipill regimens),
• Convenience factors (e.g., dosing frequency), Limited access to care,
• Behavioral factors, Depressive symptoms
• Tx of asymptomatic disease (e.g., treatment side effects)
• Younger age (ACEs lead to younger age in HTN)
• Lack of lifestyle modification

40. Factors to Improve Treatment Adherence
Educate patients,
their families, and
caregivers about
hypertension
Address patient
health literacy
Collaborate with
patients to establish
goals of therapy and
the plan of care
Use antihypertensive
agents dosed once
daily and fixed-dose
combinations
Use low-cost and
generic medications
whenever possible
Consolidate refill
schedule to obtain all
prescribed medication
at a single pharmacy
visit
Use motivation
adherence scales to
identify barriers
Assess for medication
nonadherence
regularly and
systematically
Use team-based care
Maintain contact with
patient via telehealth
technology
H
H
H
H H
H
H = Health Psych
Support

41. Provider Team
Member
Health Psychology
Team Member
6 Sessions
“The WHY”
Joan’s Value – Joan’s Why
“I want to Live to See My
Grandchildren Married”
Current BP = 162/94
Depression (PHQ-9 = 18), ACEs = 3,
Smoker, Hx of IPV, BMI 42
HTN
Meds
Reduce
NaCl
Exercise
150 Min
Per Week
BP Target
> 140/90
Aware
of BP
Target
Depression &
Toxic Stress
Management
Home
Monitoring
Med.
Adherence
Plan
Shared Team Tx. Plan
CBT Tx of
Depression
Motivational
Interviewing for
Health Behaviors