https://orcid.org/0000-0001-8747-8717
Figures
Abstract
Introduction
A critical component in the hypertension management and the prevention of its life-threatening complications, is self-care. Psychological factors such as stress, anxiety and depression may significantly influence self-care behaviors in people with hypertension. Therefore, this study aimed to investigate the prevalence of anxiety, depression and stress and their association with self-care levels among hypertensive patients.
Methods
This analytical cross-sectional study was conducted in 2024−2025 in Gonabad, Iran, among a population of 509 hypertensive patients. Participants were selected through cluster random sampling, with inclusion criteria consisting of: A confirmed diagnosis of hypertension by a physician, Willingness to provide informed consent, Absence of cognitive impairment, and At least one year of residency in Gonabad. Data were gathered by three self-administered questionnaires: a demographic questionnaire, the DASS-21 (Depression, Anxiety, and Stress Scale), and the Self-Care of Hypertension Inventory (SC-HI V3). The collected data were analyzed using SPSS v25, with statistical tests including independent t-tests, ANOVA, Multiple Linear Regression and Pearson’s correlation.
Results
The majority of participants in this study were female and older persons (age > 60 years). Marital status showed a significant association with levels of depression, anxiety, and stress. Additionally, variables such as age group, marital status, education level, and occupation were significantly correlated with hypertension self-care levels and all three of its subscales. Furthermore, 62.5%, 75.2%, and 59.3% of hypertensive patients exhibited depression, anxiety, and stress, respectively. Pearson’s correlation analysis revealed a significant negative association between: Depression and self-care (r = −0.314, p < 0.001), Anxiety and self-care (r = −0.330, p < 0.001). A significant negative correlation was also observed between depression/anxiety and the age at hypertension onset. Variables of Depression, Anxiety, Stress, Age, Education and Income could predict 15% of self-care of hypertension variance.
Conclusion
The prevalence of psychological disorders—particularly stress, depression, and anxiety—among hypertensive patients is alarmingly high. Moreover, significant negative correlations exist between these mental health conditions and hypertension self-care levels. These findings underscore the critical need for: Preventive interventions and Mental health promotion programs tailored to this population. Policymakers, healthcare providers, and researchers must prioritize integrating psychological support into hypertension management strategies to mitigate these adverse effects and improve patient outcomes.
Citation: Naddafi F, Jafari A, Nejatian M, Tehrani H (2026) Psychological distress in hypertension: Prevalence and links to self-care in Gonabad, Iran. PLoS One 21(7): e0352892. https://doi.org/10.1371/journal.pone.0352892
Editor: Mukhtiar Baig, King Abdulaziz University Faculty of Medicine, SAUDI ARABIA
Received: January 7, 2026; Accepted: June 16, 2026; Published: July 10, 2026
Copyright: © 2026 Naddafi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: DASS-21, Depression, Anxiety, and Stress Scale-21; SC-HI V3, Self-Care of Hypertension Inventory version 3
Introduction
Hypertension affects approximately 1.28 billion people worldwide and 25% of Iranians – equating to 1 in 4 adults [1–3]. Hypertension described as sustained diastolic pressure ≥90 mmHg or systolic blood pressure ≥140 mmHg [4,5], this “silent killer” represents a major risk factor for cardiovascular disease, stroke, and renal disorders [6,7]. Uncontrolled hypertension may lead to severe complications including cerebrovascular accidents, myocardial infarction, renal failure, vascular rupture, vision loss, and cognitive impairment [8].
Poor adherence to self-care practices constitutes the primary barrier to effective hypertension control [8]. Self-care is the first and most effective step to control and improve high blood pressure, and successful management of hypertension requires continued self-care behaviors [9,10]. As the cornerstone of hypertension management, self-care encompasses voluntary, adaptive behaviors to restore, maintain, or enhance health [11]. For hypertensive patients, this includes: Medication adherence, Blood pressure monitoring, Low-sodium/low-fat dietary compliance, Smoking cessation, Alcohol moderation, Weight management, Regular physical activity, Stress reduction, Routine health screenings [8,12]. Inadequate self-care correlates with elevated risk of cardiovascular and cerebrovascular events and increased hospitalization rates [13], underscoring the imperative for enhanced self-care to improve blood pressure control and reduce complications [14].
Psychological distress significantly undermines self-care behaviors, contributing to poor long-term hypertension control and reduced treatment adherence [15]. Depression, stress, and anxiety are most prevalent in chronic diseases such as hypertension [16]. Patients with hypertension demonstrate significant vulnerability to anxiety and depression. Abdisa et al.’s Ethiopian study revealed that over 25% of hypertensive patients reported clinically significant depressive and anxiety symptoms [17]. Similarly, Kretchy et al.’s Ghanaian research found notable prevalence rates of 56% for anxiety, 20% for stress, and 4% for depression among this population [18]. Also results of a study by Ranjbar kouchaksaraei et al. in Iran among hypertensive patients indicated that 54% and 38% of them have type A and type B personality, respectively [19]. Also according to a 10-year longitudinal study, there was relationship between hostility and diastolic blood pressure [20]. Results of another study suggested that there is significant difference between hypertensive and healthy people in psychosis and neurosis traits and Emotion-oriented coping style. Also hypertensive people with essential hypertension are anxious, worried, aggressive and susceptible to depression [21].
These mental health comorbidities (depression, anxiety, stress) exert particularly detrimental effects on treatment adherence behaviors [18,22].Among the various factors influencing hypertension self-care, psychological disturbances appear to play a disproportionately prominent role [16]. This relationship was quantitatively demonstrated in Iran by Eghbali et al., who documented significantly higher self-care among patients with lower psychological distress levels [16].
The crucial importance of self-care in hypertension management, coupled with the high prevalence and substantial impact of depression, anxiety, and stress on self-care behaviors, underscores the necessity of this investigation. Our comprehensive literature review reveals two significant research gaps in the Iranian context: No prior study has systematically examined both the prevalence of these psychological factors and their interrelationships with self-care in hypertensive patients and Existing research, including Eghbali et al.’s study [16], has not employed condition-specific instruments for assessing hypertension self-care and psychological distress. To address these limitations, this study was carried out in 2024 to: Determine the prevalence of depression, anxiety, and stress and Evaluate their association with self-care levels among hypertensive patients in Gonabad, Iran, using validated, disease-specific measurement tools.
Methods
This cross-sectional analytical study was performed to assess the prevalence of stress, depression and anxiety and their association with self-care levels among hypertensive patients in Northeast Iran (Gonabad) in 2025.
Sampling method
Participants were selected through population-proportionate cluster sampling in Gonabad (February 2, 2025 to May 9 2025). The sampling process involved: Identification of all comprehensive health service centers, Determination of the hypertensive people number at each center, Treatment of each center as a cluster, with sample size allocation proportional to cluster population and Random selection of eligible participants meeting inclusion criteria from each cluster. Trained researchers visited the health centers to: Distribute questionnaires in person, collect self-reported data from literate participants and Assist illiterate participants through interviewer-administered questionnaires Inclusion Criteria include: Physician-confirmed hypertension diagnosis, Willingness to provide written informed consent, Absence of cognitive impairment and Minimum one-year residency in Gonabad. Exclusion Criteria include: Incomplete questionnaires (participants with excessive missing data were excluded during analysis).
Sample size calculation
Due to the absence of prior studies directly measuring hypertension self-care prevalence in Iran, we calculated the maximum required sample size using: Prevalence proportion (p) = 0.5, 95% confidence level, 80% statistical power, 0.066 precision and 10% nonresponse rate. The final calculated sample size was 495 participants, settled using the following formula:
Data collection tools
The data collection tools in this study comprised a demographic variables questionnaire, the DASS-21, and the SC-HI V3.
Demographic variables questionnaire
This section examined variables such as marital status, education level, gender, age, occupational status, hypertension treatment modalities, and participants’ comorbidities.
Depression, Anxiety, and Stress Scale-21 (DASS-21)
This study employed the DASS-21, consisting of three subscales (7 items per subscale) and 21 items. This tool assesses the prevalence of depressive, anxious, and stress-related symptoms over the preceding weeks. Data were obtained using a Likert-type scale with four response options, ranging from 0 (“Not at all”) to 3 (“Most of the time”). Subscale scores were calculated by summing item scores, with a maximum possible score of 21 per subscale. Higher scores indicate greater psychological distress. High reliability for the DASS-21 was established in the original validation study, with Cronbach’s alpha coefficients of 0.84 (anxiety), 0.90 (stress), and 0.91 (depression) [23,24]. In this study the Cronbach’s alpha of DASS-21 was 0.942.
Self-care of hypertension inventory version3 (SC-HI V3)
The development of this questionnaire was carried out by Dickson et al. in 2021. SC-HI V3 has 23 items and 3 subscales including maintenance (9 items), monitoring (7 items), and management (7 items). Each item is rated on a 5-point Likert scale. The responses to this questionnaire are also rated on a 5-point Likert scale from never and rarely (1), sometimes (2,3,4), and daily and always (5) in the maintenance and monitoring subscales, as well as not unlikely (1), somewhat likely (2,3,4), and very likely (5) in the management subscale. This inventory includes 12 recommended behaviors in hypertension self-care and is based on the recommendations of the American Heart Association, studies, and clinical guidelines. A higher score indicates a higher level of self-care, and a lower score indicates a lower level of self-care for the patient [25,26]. The score of each subscale was calculated according to the tool developers’ instructions using the formula (Actual raw score-lowest possible raw score)/(possible raw score range) [27]. For this research, the overall score was calculated by aggregating the subscale scores. Previous validation in an Iranian sample reported a Cronbach’s alpha of 0.879 for the tool [28]. In this study the Cronbach’s alpha of SC-HI V3 was 0.904.
Statistical analysis
Prior to analysis, the distribution of the data was evaluated for normality using kurtosis and skewness indices. Given the normality of the data, parametric statistical tests (one way ANOVA, independent samples t-test and Pearson correlation) were used. Data analysis was conducted using SPSS version 25, adopting a significance level of p < 0.05. Also Multiple Linear Regression model was employed to determine self-care predicting factors and control for confounding variables such as age, income, and education.
Ethics approval and consent to participate
This study is based on a research project approved by Ethics Committee of Mashhad University of Medical Sciences with the code of ethics IR.MUMS.REC.1403.363. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable. Written Informed Consent was obtained from all subjects
Results
In this study, Participants had an average age of 60.40 years and a standard deviation of 13.09 Most of the participants were the age of 60 (n = 266), the woman (n = 348), married (n = 390), with the elementary education (n = 158), housewife (n = 286), resident in urban areas (n = 349), and with medium income (n = 354). The age onset of hypertension in most participants was between 30–60 (n = 327) and 43.4% (n = 204) reported that their duration period of hypertension was more than 10 years (Table 1).
Most people reported that the most treatment modalities that the used for hypertension management were used the medicine/ drug, physical exercise, and diet (Fig 1).
Among the various comorbidities reported, dyslipidemia was the most prevalent (n = 185), and cerebrovascular disease (n = 6) and hyperthyroidism (n = 7) were the least prevalent (Fig 2).
The associations between the states of depression, anxiety, stress and demographic variables are displayed in Table 2. Based on the results, marital status had a significant relationship with depression, anxiety, and stress (p < 0.001). A significant association was observed between the Inhabitant and depression (p = 0.002) and anxiety (p = 0.003). A significant association was observed between Income status and depression, anxiety, and stress (p < 0.001). A significant association was observed between the age at hypertension onset and anxiety (p = 0.026) and stress (p = 0.047). Duration period of hypertension had only significant relationship with anxiety (p = 0.012).
Table 3 showed the relationship between demographic variables and self-care of hypertension and its domains (Maintenance, Monitoring and Management). Based on the results, age group had a significant relationship with self-care (p < 0.001) and domains of maintenance (p < 0.001), monitoring (p = 0.002), and management (p = 0.001). The age at hypertension onset was significantly associated with overall self-care (p < 0.001) and its maintenance (p < 0.001), monitoring (p = 0.001), and management (p < 0.001) domains. Marital status had a significant relationship with self-care (p < 0.001) and subscales of maintenance (p < 0.001), monitoring (p = 0.030), and management (p = 0.002). A significant association was found between education level and self-care (p < 0.001), including its monitoring (p = 0.004), maintenance (p < 0.001) and management (p = 0.013) domains. Occupation had a significant relationship with self-care (p = 0.007) and subscales of maintenance (p = 0.021), monitoring (p = 0.017), and management (p = 0.019). The maintenance (p = 0.034) and management (p = 0.003) aspects of self-care, along with the overall score (p = 0.025), demonstrated significant relationships with the inhabitants’ residential area. BMI had a significant relationship only with domain of monitoring (p = 0.016).
Table 4 showed the frequency of psychological disorders and based on the results 62.5% (n = 318) had depression and only 14.3% (n = 73) had extremely severe depression. Among participants, 75.2% (n = 383) had the anxiety and only 32.2% had extremely severe anxiety. Also, 59.3% (n = 302) had the stress and only 6.7% (n = 34) had extremely severe stress. Other information was mentioned in the Table 4. Also the psychological disorders Frequencies were presented separately in Fig 3, Fig 4, and Fig 5.
Table 5 showed Pearson correlation between variables. Based on the results, depression had a positive and significant bidirectional correlation with anxiety (r = 0.797), stress (r = 0.836), and HTN duration (r = 0.108). Also, depression had a negative and significant bidirectional correlation with self-care (r = −0.314) and subscales of maintenance (r = −0.289), monitoring (r = −0.247), management (r = −0.273), and age of onset of HTN (r = −0.098). Anxiety had a positive and significant bidirectional correlation with stress (r = 0.767) and HTN duration (r = 0.190). Also, anxiety had a negative and significant bidirectional correlation with self-care (r = −0.330) and subscales of maintenance (r = −0.323), monitoring (r = −0.209), management (r = −0.319), and age of onset of HTN (r = −0.099) (Table 5).
Table 6 presented the Linear regression in prediction the Hypertension Self-care. According to the table the variables of Depression, Anxiety, Stress, Age, Education and Income could predict 15% of self-care of hypertension variance (Table 6).
Discussion
This study investigated the prevalence of anxiety, stress and depression, and their association with self-care levels in individuals with hypertension. The results generally indicate a substantial burden of psychological distress, notably stress, anxiety and depression among hypertensive patients. Specifically, 62.5% of patients had depression, with 14.3% experiencing severe depression; 75.2% had anxiety, with 32.2% experiencing severe anxiety; and 59.3% had stress, with 6.7% experiencing severe stress. Similarly, Mamoona Mushtaq et al. demonstrated that mental health issues such as depression, anxiety, and stress are frequently observed as comorbidities in hypertensive individuals and contribute to worsened outcomes and quality of life [27]. This finding underscores the importance of screening for and addressing psychological disorders in hypertensive populations as part of clinical care. The psychological disorders prevalence especially anxiety was exceptionally high in this study. The possible reasons for this issue could be the vigilance” effect (anxiety specifically related to medical monitoring or the special Persian translation of DASS-21that the 4-point Likert Persian translation was relatively different by original version.
Beyond the demographic correlates identified in our sample, the present findings may also reflect broader psychological mechanisms described in the international literature. Recent evidence suggests that personality-related factors such as vigilance and Type D traits are associated with greater anxiety and somatization in hypertensive patients, supporting the idea that an enduring tendency toward threat monitoring and negative affectivity may increase psychological distress and reduce effective self-care. In addition, poor emotional regulation, particularly anger suppression and avoidant coping, has been linked to higher levels of anxiety and depressive symptoms, indicating that maladaptive coping styles may further compromise disease management. Finally, the decline in vitality observed in hypertensive populations has been shown to relate to mental distress partly through impaired social functioning, underscoring the protective role of social support and social participation in buffering distress and promoting self-care behaviors. Together, these findings provide a broader framework for interpreting the significant associations observed in our study between marital status, social isolation, psychological distress, and low self-care [29].
A significant negative correlation was observed between the age at which hypertension developed and the severity of anxiety and stress symptoms. The association implies that the developmental timing of hypertension may influence mental health, with younger age at onset correlating with a heavier burden of stress and anxiety. Younger hypertensive patients may face more challenges related to the chronic nature of the disease and its implications for life expectancy and quality of life. The stress of managing a long-term condition, coupled with concerns about potential complications, can contribute to increased anxiety [30]. A meta-analysis by Yu Pan et al. on the association between hypertension and anxiety also indicated that individuals diagnosed at a younger age experience higher psychological pressure [31]. Another study by Nicola Mucci et al., investigating the impact of anxiety and stress on blood pressure, found that younger adults with hypertension often experience greater psychological stress and anxiety compared to older adults [32]. This finding highlights the necessity of addressing mental health challenges in younger hypertensive patients as part of comprehensive disease management.
Regarding the age of hypertension onset and self-care, our study found a significant positive correlation. This implies that a later onset of hypertension is associated with more appropriate self-care practices. Older individuals may have had more time to acquire knowledge, establish consistent routines, and integrate self-management practices—such as medication adherence, dietary control, physical activity, and regular blood pressure monitoring—into their daily lives. Sari et al. reported that older hypertensive patients demonstrate better self-care behaviors, potentially due to greater awareness and longer experience in managing their condition [33]. Kazemi Shishavan et al. also found that self-care adherence tends to be higher among older patients [34].
The analysis revealed a significant positive association between marital status and self-care, indicating that married individuals with hypertension tended to maintain better self-care practices. This aligns with existing literature emphasizing the vital role of social support, particularly spousal support, in boosting adherence to self-care behaviors. Married individuals may benefit from the emotional and practical assistance provided by their partners, such as reminders for medication, encouragement to maintain lifestyle modifications, and shared responsibility in health management, all of which contribute to better hypertension control. Ranak B Trivedi et al. also demonstrated that marital status, as an indicator of social network, is associated with improved hypertension control, primarily through better medication adherence and lower smoking rates [35]. The presence of a supportive spouse can enhance patients’ self-efficacy and motivation, which are crucial for consistent self-care [36]. Furthermore, Azmiardi et al., showed a significant positive correlation between self-care behaviors and family support and in hypertension management [37].
Based on the results, depression had a significant positive correlation with anxiety, stress, and the duration of hypertension. This means that individuals with a longer history of hypertension exhibited higher levels of depression, stress, and anxiety. This finding suggests that the persistent burden of managing a chronic condition like hypertension can increase psychological distress and further exacerbate mental health outcomes. Mushtaq and Najma, in their study on demographic factors affecting blood pressure, also found significant positive relationships between depression, anxiety, stress, and hypertension [27]. Another longitudinal study by Geetha Kandasamy et al. confirmed that long-term hypertension is significantly associated with anxiety and depression [38].
Furthermore, the analysis showed a significant negative correlation between self-care adherence and the severity of both depressive and anxiety symptoms. In other words, individuals with higher levels of depression and anxiety had lower levels of self-care. Psychological distress, particularly in the form of depressive and anxiety symptoms, often impairs an individual’s motivation and capacity to participate in effective self-care activities. Studies across various patient populations consistently indicate that depression and anxiety disrupt self-care routines, likely due to reduced energy, concentration, and self-efficacy necessary for maintaining health practices [39–41].
Finally, the results of linear regression indicated that 15% of self-care variance was predicted by depression, anxiety, stress, age, education and income. Two variables of anxiety and age could significantly predict self-care of hypertension. Anxiety not only could interfere with normal self-care routines, also it could exacerbate hypertension on its own, therefore anxiety screening then providing mental health services by psychologists among hypertensive people seems necessary.
The substantial sample size employed in this study enhances the statistical power and generalizability of our findings. Additionally, the inclusion of diverse predictive factors, encompassing psychological, social, and demographic variables, increased the comprehensiveness and accuracy of the predictions. The dependence on self-report measures constitutes a study limitation, as responses may have been influenced by factors such as social desirability bias or memory inaccuracies.
Conclusion
This study revealed a high prevalence of anxiety, depression, and stress among patients with hypertension and found significant associations between these psychological disorders and the patients’ self-care levels. The findings indicate that hypertensive individuals with higher levels of depression and anxiety exhibit lower self-care, which can undermine disease management and clinical prognosis. Our results indicate that an earlier diagnosis of hypertension correlates with a heavier psychological burden, characterized by elevated levels of anxiety and stress. These findings call for targeted mental health screening and interventions for this vulnerable patient subgroup. Conversely, older hypertensive patients demonstrated better self-care for various reasons, and married individuals showed higher levels of self-care compared to singles, underscoring the key role of social support. Consequently, a multifaceted strategy incorporating psychological assessment, therapeutic support, and robust social backing is crucial to mitigate the multifaceted burden of hypertension and promote better life quality among affected individuals. In summary, the comprehensive management of chronic diseases should integrally address mental health and social factors to achieve optimal treatment outcomes.
Clinical implications
From a clinical perspective, the findings of this study suggest that routine screening for psychological distress should be integrated into hypertension care. In addition, combined interventions such as cognitive-behavioral counseling and psychoeducation may be beneficial for improving patients’ psychological well-being and self-management behaviors. Previous evidence indicates that such integrated programs can also contribute to improvements in physical indicators, including BMI, highlighting their potential value in a multidisciplinary approach to hypertension management.
Acknowledgments
The authors of the study express their sincere gratitude of Mashhad University of Medical Sciences. We would also like to thank all the people who assisted us in conducting this research project. We would like to express our gratitude to DeepSeek Chat for its valuable assistance in translating and paraphrasing parts of this manuscript.
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