Journal of Preventive Medicine

Introduction
Hypertension is one of the most important causes of cardiovascular diseases. The prevalence of this disease is increasing. In 2016, the prevalence of hypertension in Iran in adults over 18 years old was 27% (25.7% in males and 28.2% in females). Patients with hypertension may have many negative feelings that increase the risk of developing psychological disorders, especially anxiety, stress, and depression. The presence of clinical symptoms of depression and anxiety as well as perceived stress are associated with high blood pressure. Despite effective medical treatment, the prevalence of uncontrolled hypertension is still high. In order to control blood pressure, it is necessary to use non-pharmacological methods such as lifestyle modification and stress reduction interventions. One of the psychological interventions to reduce stress is mindfulness. Mindfulness means the human ability to be aware moment by moment and accept thoughts and feelings without judgment. Considering that hypertension is a chronic disease and can affect the mental health of affected patients due to the need for long-term treatment, and given that mental health problems of the affected person have a negative effect on the effective control of blood pressure, in this study, we aim to investigate the effect of mindfulness-based stress reduction (MBSR) compared to routine health care on the psychological health of middle-aged women with hypertension in Iran.

Methods
This is a randomized controlled clinical trial that was conducted in 2019. The study population consists of all women with hypertension referred to Imam Ali Comprehensive Health Service Center in Isfahan, Iran. The inclusion criteria were primary hypertension with a doctor's confirmation, blood pressure control with medication, age 30-65 years, ability to participate in intervention sessions, and consent to participate in the study. Patients were not included in the study if they abused alcohol and drugs, received psychological treatments in the past year, were pregnant or breastfeeding, or had chronic diseases such as cancer or any other serious medical disease. Eighty people entered the study using a convenience sampling method and were randomly assigned to two intervention and control groups. Before the intervention, a demographic form and DASS-21 questionnaire were completed for both groups to measure their anxiety, depression, and stress. The intervention group received 82-hour sessions of MBSR and then performed the exercises at home for 4 weeks. The control group was under routine system care. One week after the end of the interventions, the mental health examination was done in the same way as before the intervention. The control group received routine care. One week after the end of the interventions, the psychological health examination was done again using DASS-21. The data were analyzed in SPSS software, version 24 using descriptive statistics, independent t-test, paired t-test, and MANCOVA. The significance level was set at 0.05.

Results
From 80 middle-aged women with high blood pressure included in the study, finally, 37 people in the intervention group and 40 people in the control group were analyzed. In the intervention and control groups, the average age was 53.78±6.05 and 54.91±7.34 years, respectively (P=0.48) and the mean duration of hypertension was 7.5±4.34, and 7.88±4.68 years respectively (P=0.79). The distribution of demographic characteristics and underlying diseases did not show significant differences between the two groups. In the intervention group, the mean scores of depression, anxiety and stress after the intervention were 11.64±3.4, 10.78±2.72, and 11.75±2.94 respectively. All of them were significantly lower compared to the control group (11.97±2.85, 11.62±2.37, and 12.75±2.86 respectively, P<0.05).The Cohen's d effect size for depression, anxiety and stress was -0.12, -0.35, and -0.35 respectively (P<0.01).

Conclusion
This study showed that the level of depression, anxiety and stress in the group using the mindfulness method has significantly decreased compared to the control group. Therefore, mindfulness as an inexpensive therapeutic method with no complications can be effective in improving the mental health of patients with hypertension. 

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Isfahan University of Medical Sciences (Code: IR.MUI.MED.REC.1397.015) and was registered by  the Clinical Trial Registration Center (IRCT) (Code: RCT20190410043230N1). All participants signed a written informed consent.

Funding
This study was extracted from the PhD ddissaertation of Shabnam Pournemati, approved by the Department of Community and Family Medicine, School of Medicine, Isfahan University of Medical Sciences, and was funded by Isfahan University of Medical Sciences.

Authors' contributions
Conceptualization & methodology: Anahita Babak and Zahra Dana Siadat; Investigation: Anahita Babak, Shabnam Pournemati and Shabnam Pournemati; Writing: All authors; Supervision: Anahita Babak.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to thank the esteemed staff of the Imam Ali Urban Health Services Center in Isfahan, as well as the Vice Chancellors for Research and Health at Isfahan University of Medical Sciences for their financial and executive support.  


References

1. Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al. Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. Plos Med. 2017; 14(9):e1002389. [DOI:10.1371/journal.pmed.1002389] [PMID] [PMCID]
2. Mirzaei M, Moayedallaie S, Jabbari L, Mohammadi M. Prevalence of hypertension in Iran 1980-2012: A systematic review. J Tehran Heart Cent. 2016; 11(4):159-67. [PMID] [PMCID]
3. Djalalinia S, Modirian M, Sheidaei A, Yoosefi M, Zokaiee H, Damirchilu B, et al. Protocol design for large-scale cross-sectional studies of surveillance of risk factors of non-communicable diseases in Iran: STEPs 2016. Arch Iran Med. 2017; 20(9):608-16. [PMID]
4. Bolarinwa OA, Ameen HA, Sanya EO, Kolo PM, Durowade KA, Uthman MB, et al. Pattern and predictive factors of health-related quality of life of patients with hypertension, diabetes and concomitant hypertension with diabetes in Ilorin, Nigeria. Niger Postgrad Med J. 2016; 23(4):182-90. [DOI:10.4103/1117-1936.196252] [PMID]
5. Reckelhoff JF. Gender differences in hypertension. Curr Opin Nephrol Hypertens. 2018; 27(3):176-81. [DOI:10.1097/MNH.0000000000000404] [PMID]
6. Kretchy IA, Owusu-Daaku FT, Danquah SA. Mental health in hypertension: Assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence. Int J Ment Health Syst. 2014; 8:25. [DOI:10.1186/1752-4458-8-25] [PMID] [PMCID]
7. Conversano C, Orrù G, Pozza A, Miccoli M, Ciacchini R, Marchi L, et al. Is mindfulness-based stress reduction effective for people with hypertension? A systematic review and meta-analysis of 30 years of evidence. Int J Environ Res Public Health. 2021; 18(6):2882. [DOI:10.3390/ijerph18062882] [PMID] [PMCID]
8. Moceri J, Cox PH. Mindfulness-based practice to reduce blood pressure and stress in priests. J Nurse Pract. 2019; 15(6):e115-7. [DOI:10.1016/j.nurpra.2019.01.001]
9. Song Y, Lindquist R. Effects of mindfulness-based stress reduction on depression, anxiety, stress and mindfulness in Korean nursing students. Nurse Educ Today. 2015; 35(1):86-90. [DOI:10.1016/j.nedt.2014.06.010] [PMID]
10. Takahashi T, Sugiyama F, Kikai T, Kawashima I, Guan S, Oguchi M, et al. Changes in depression and anxiety through mindfulness group therapy in Japan: The role of mindfulness and self-compassion as possible mediators. Biopsychosoc Med. 2019; 13:4. [DOI:10.1186/s13030-019-0145-4] [PMID] [PMCID]
11. Sharma M, Rush SE. Mindfulness-based stress reduction as a stress management intervention for healthy individuals: A systematic review. J Evid Based Complementary Altern Med. 2014; 19(4):271-86.[DOI:10.1177/2156587214543143] [PMID]
12. Nejati S, Zahiroddin A, Afrookhteh G, Rahmani S, Hoveida S. Effect of group mindfulness-based stress-reduction program and conscious yoga on lifestyle, coping strategies, and systolic and diastolic blood pressures in patients with hypertension. J Tehran Heart Cent. 2015; 10(3):140-8. [PMID] [PMCID]
13. Ahmadpanah M, Paghale SJ, Bakhtyari A, Kaikhavani S, Aghaei E, Nazaribadie M, et al. Effects of psychotherapy in combination with pharmacotherapy, when compared to pharmacotherapy only on blood pressure, depression, and anxiety in female patients with hypertension. J Health Psychol. 2016; 21(7):1216-27.[DOI:10.1177/1359105314550350] [PMID]
14. Sahebi A, Asghari MJ, Salari RS. [Validation of depression anxiety and stress scale (DASS-21) for an Iranian population (Persian)]. Dec Psychol. 2005; 1(4): 36-54. [Link]
15. Santorelli SF, Meleo-Meyer F, Koerbel L. Mindfulness-based stress reduction (MBSR): Authorized curriculum guide. Worcester: UMass Memorial Center for Mindfulness; 2017. [Link]
16. Hasanzade S, Khalatbari J. The effectiveness of mindfulness-based cognitive therapy (MBCT) on quality of life (QL) and dysfunctional attitudes (DA) in patients with high blood pressure. J Appl Psychol Behav Sci. 2017; 2(3):155-62. [Link]
17. Momeni J, Omidi A, Raygan F, Akbari H. The effects of mindfulness-based stress reduction on cardiac patients' blood pressure, perceived stress, and anger: A single-blind randomized controlled trial. J Am Soc Hypertens. 2016; 10(10):763-71. [DOI:10.1016/j.jash.2016.07.007] [PMID]
18. Hofmann SG, Gómez AF. Mindfulness-based interventions for anxiety and depression. Psychiatr Clin North Am. 2017; 40(4):739-49.[DOI:10.1016/j.psc.2017.08.008] [PMID] [PMCID]
19. Ponte Márquez PH, Feliu-Soler A, Solé-Villa MJ, Matas-Pericas L, Filella-Agullo D, Ruiz-Herrerias M, et al. Benefits of mindfulness meditation in reducing blood pressure and stress in patients with arterial hypertension. J Hum Hypertens. 2019; 33(3):237-47. [DOI:10.1038/s41371-018-0130-6] [PMID]
20. Sangprasert P, Palangrit S, Tiyoa N, Pattaraarchachai J. Effects of mindfulness-based health education practice on health behaviors and quality of life among hypertensive patients: A quasi-experimental research. J Health Res. 2019; 33(3):186-96. [DOI:10.1108/JHR-07-2018-0059]
21. Ahn H, Zhong C, Miao H, Chaoul A, Park L, Yen IH, et al. Efficacy of combining home-based transcranial direct current stimulation with mindfulness-based meditation for pain in older adults with knee osteoarthritis: A randomized controlled pilot study. J Clin Neurosci. 2019; 70:140-5. [DOI:10.1016/j.jocn.2019.08.047] [PMID]