At least one half of patients who are prescribed antihypertensive medications do not take them as recommended. The reasons for this poor adherence are unclear but include active decisions by patients based on medical and nonmedical sources of information. Benson and Britten interviewed patients in two urban British general practices to explore patient perceptions of antihypertensive therapy.

They identified 576 patients who received repeat prescriptions for antihypertensive medications. A representative sample of 38 patients (nine groups of three to six patients) was selected for home interviews. The interviews followed a qualitative research guideline based on the relevant literature and three pilot interviews. Transcripts of the interviews were analyzed to generate the major themes in the patients' responses. The results were validated by sending a summary of the findings to the participants and inviting their feedback.

All but seven of the patients interviewed were older than 50 years and most (24) had been taking antihypertensive medication for more than four years. One half of the 20 men and 18 women took only one medication for hypertension, but 25 of the patients took other medications regularly (range: one to more than five additional drugs). The most commonly prescribed antihypertensive medications were diuretics (17), followed by beta blockers (15), angiotensin-converting enzyme inhibitors (12), calcium antagonists (12), and alpha blockers (2).

Reservations about taking medications in general were expressed by 28 of the patients (see the accompanying table). Eleven patients expressed reservations as general unwillingness to take medications, and 16 specified concerns that medicines were unnatural or unsafe. In 13 patients, concerns arose from adverse experiences, either their own or those of others. Three patients expressed the belief that physicians prescribed medications too readily. Sixteen of the 28 patients who had general concerns about drugs also had specific concerns about antihypertensive medications.

Patients asked about being able to discontinue therapy, possible alternatives, and potential adverse effects. Nevertheless, all of the patients who had reservations about anti-hypertensive therapy also had positive perceptions about their therapy. Many of these perceptions related to positive interactions with physicians and perceived benefits of the medications, both in avoiding serious complications of hypertension and in the positive side effects of the medications. Patients expressed their internal process of balancing the perceived risks and benefits of antihypertensive medication.

The authors conclude that patients' ideas may derive from considerations unrelated to the drugs' pharmacology. The authors emphasize the powerful effect of discussing the decision to use medication for hypertension with each patient in a way that reinforces the decision to accept and persist with therapy.

editor's note: Even the “compliant” patients studied reported having significant concerns about the management of their condition. The striking features of this study are the reports of feeling better on therapy and the strong influence of the physician in the complex process of remaining adherent to therapy. As physicians, we frequently “shoot ourselves in the foot” in prescribing long-term therapy for patients. The decision to start medication frequently is presented as a failure, and we focus on the potentially problematic side effects and episodes when blood pressure readings are high rather than the positive (and potentially life-saving) effects of therapy. Why do we make it so difficult for patients to do the right thing? This study tells us to ask our patients how they perceive long-term medical therapy and to adjust our support of each patient accordingly. Nevertheless, all patients who start therapy for hypertension should be congratulated for taking control and reducing their risk of serious consequences, and encouraged by positive feedback about successes rather than burdened with all the negatives we currently use, consciously or subliminally. Even stoic patients respond better to praise, encouragement, and positive outcomes than to nagging and vague threats of impending stroke.—A.D.W.