Anxiety and depression in primary aldosteronism: Overlooked and neglected

To the Editor

Primary aldosteronism (PA) is a curable cause of hypertension. Aldosterone excess is inappropriate for sodium status and relatively autonomous of regulation, resulting in adverse cardiovascular, central nervous and psychological effects, partly independent of hypertension. Compared with age-, sex- and blood pressure–matched individuals with essential hypertension (EH), patients with PA have an increased risk of cardiovascular and renal comorbidities. The prevalence of depression and anxiety disorders was reportedly as high as 30% and 70%, respectively, and should not be ignored (Reincke, 2018).

In a controlled study comparing patients with PA (n = 23), EH (n = 23) and matched normotensive controls (n = 23), generalised anxiety disorder was more frequent in PA (30.4%) compared to EH (8.7%) and controls (0%) (Sonino et al., 2011). Using the Psychosocial Index, individuals with PA had higher level of psychological distress (p < 0.01) and lower level of well-being (p < 0.05) than controls. Compared with patients with EH, higher scores in stress subscale were reported for those with PA (p < 0.05). Based on the Symptom Questionnaire, higher levels of depression (p < 0.01) and anxiety (p < 0.01) and lower physical well-being (p < 0.05) were found in subjects with PA than controls (Sonino et al., 2011).

In a cross-sectional study of 132 patients with PA (27 studied before treatment, 56 studied 5.4 years after medical therapy, 49 studied 4.3 years after adrenalectomy), the prevalence rates for depressive disorder (⩾5) were 50% for untreated PA, 42% for mineralocorticoid (MR) antagonist-treated patients and 38% for patients who had undergone adrenalectomy (Apostolopoulou et al., 2014). Compared to the German reference population, the mean values of brief patient health questionnaire (PHQD) were significantly higher in untreated PA and MR antagonist-treated group (p < 0.01). Using the general anxiety disorder questionnaire (GAD-7), the prevalence rates for anxiety disorder (⩾5) were 50% for untreated PA, 42% for MR antagonist-treated patients and 38% for patients who had undergone adrenalectomy (Apostolopoulou et al., 2014).

The MR function in the central nervous system has been implicated in the response to anti-depressants (Reincke, 2018). The receptor is thought to influence emotional memory processes and aldosterone acts selectively in the mood-regulating brain areas. In resistant hypertension (common in PA), the use of multiple antihypertensives and difficult-to-control hypertension might affect an individual’s quality of life (Reincke, 2018). Resistant hypertension could lead to cerebrovascular impairment and white matter lesions (‘vascular hypothesis’ of depression) (Reincke, 2018). With the increasing clinical recognition of PA as a public health issue, the associated psychiatric comorbidities require urgent attention.