Neil Chesanow has written an excellent review of hypertension treatment. He reports that in the United States, 3.8 billion prescriptions are written every year but over 50% of them are taken incorrectly or not at all. It is very clear that successful hypertension treatment requires changing patient thinking, not making a new revolutionary breakthrough in medical care. We have the tools but they are not being used.
New guidelines have recently been written by the American Heart Association that lower the goal for blood pressure treatment to 130/80 for most patients. The first step is an honest assessment of diet and exercise with the goal of preventing overweight or obesity. If blood pressure remains high in spite of these measures then medication is ordered as well as lab tests to look for other associated conditions. A step by step guideline is available for doctors to follow, generally they first prescribe diuretics then lisinopril, an ARB or a calcium channel blocker like amlodipine. Eventually three or even four drugs may be necessary. It is all cut and dry and works very well. So why is there a problem?
The first barrier to successful treatment is distrust of physicians. I have read that most patients do not trust and even may hate their doctor. They continue to make office visits but have no intention of doing what they are told. They come because their spouse insists or because their mother goes there or because”the last doctor was even worse”. Sometimes this distrust is a family or even community issue. Sometimes it is triggered by a cold attitude from the doctor or a sense of disinterest. The doctor may be very caring or compassionate, but rushed and harried by an impossible schedule.
Another barrier is fear of side effects. Men talk about the impact of blood pressure drugs “on their sex”. They share tales of friends who “lost their manhood”. Older women may fear dizziness and a disastrous fall without access to help. Younger women may have “heard those make you fat or make your hair fall out”. The internet whispers that “those pills will grow hair on your pancreas”. “You should throw them away and take turmeric or at least see a naturopath.” Sadly that alternative health care guy is probably smoother and more superficially convincing than your doctor.
The “sick role” is also important. High Blood Pressure is generally a disease without symptoms. It is the long-term consequences: stroke, congestive heart failure and kidney failure that are disastrous. By agreeing to take a long-term medication you must accept that you are “sick”. This is a lot different from taking an antibiotic for ten days for an ear infection. It is natural to ask:”I feel well why do I need this pill”.
I have concluded after four decades of doctoring that generally the decision not to take a medication is made very deliberately, not because of forgetting or “just being stupid”. A contract between doctor and patient is essential to correct this situation because the dollar costs and health consequences of untreated hypertension are staggering.