Beyond the beats: exploring the link between blood pressure fluctuations with anxiety, depression, and sleep

Abstract

Introduction: Blood pressure variability (BPV) is a marker of vascular and autonomic regulation, and emerging evidence links BPV with anxiety and depression. Limited research has explored central BPV, and secondly whether sleep modulates the association between BPV with anxiety and depression.

Study design: Eighty-eight adults from clinical and community settings underwent 24-hour ambulatory blood pressure monitoring to assess central and brachial BPV, including augmentation index (AIx), mean arterial pressure (MAP), and pulse pressure (PP). Psychological symptoms were evaluated using the Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire (PHQ-9), and Sleep Condition Indicator (SCI). Correlation and regression analyses were conducted, adjusting for age and gender. Mediation analyses explored the role of sleep disturbances in BPV-mood relationships.

Results: Higher central BPV was associated with lower anxiety symptom severity, for somatic and cognitive symptoms (e.g., trouble relaxing: rs = -0.28, p < 0.01), whereas brachial BPV showed minimal associations. No significant relationships emerged between BPV and depressive symptoms after adjustment. AIx demonstrated significant negative associations with sleep-related issues, with stronger effects seen when adjusting for age and gender (β = -0.04, p < 0.01). Mediation analysis revealed sleep-related issues partially mediated the BPV-anxiety relationship.

Discussion: Findings suggest that central BPV is more strongly associated with cognitive and somatic anxiety symptoms than depressive symptoms, with sleep disturbances potentially mediating this relationship. These results support BPV's role in autonomic dysfunction, emphasizing the need for longitudinal research to clarify its role in mental health.

Keywords: ambulatory blood pressure monitoring; anxiety; arterial pressure; cardiovascular disease; cerebrovascular disease; depression; sleep.

Figure 1

Study Procedure. Figure showing the flow of participants through the study, the study procedural timeline and reasons for exclusion. ABPM Ambulatory blood pressure monitor, PhQ-9 Patient Health Questionnaire- 9, GAD-7 Generalised Anxiety Disorder Assessment-7, SCI Sleep Quality Assessment, DSM-5 Diagnostic Statistical Manual of Mental Disorders – fifth edition.

Figure 2

Spearman’s correlations of BPV and anxiety scores. Heatmap of the pairwise Spearman’s rho correlations between blood pressure variability (BPV) phenotypes and individual items from the Generalized Anxiety Disorder scale (GAD-7), stratified by 24-hour period (Overall, Awake, Asleep). Darker shades of red indicate strong positive correlations, while darker shades of blue indicate strong negative correlations. The color scale ranges from -1 (perfect negative correlation) to 1 (perfect positive correlation), with 0 indicating no correlation. GAD – 7 Item 1: Nervousness, Item 2: Uncontrollable worry, Item 3: Excessive worry, Item 4: Difficulty relaxing, Item 5: Restlessness, Item 6: Irritability, Item 7: Feeling afraid. Alx Augmentation Index of Arterial Stiffness, Augmentation Pressure, DBP Diastolic Pressure, MAP Mean Arterial Pressure, PP Pulse Pressure, rs Spearman’s rho correlation coefficient, SBP Systolic Pressure. *P < 0.05 ** P< 0.01.

Figure 3

Spearman’s correlations of BPV and depression scores. Heatmap of the pairwise Spearman’s rho correlations between blood pressure variability (BPV) phenotypes and individual items from the Patient Health Questionnaire (PHQ-9), stratified by time period (Overall, Awake, Asleep). Darker shades of red indicate strong positive correlations, while darker shades of blue indicate strong negative correlations. The color scale ranges from -1 (perfect negative correlation) to 1 (perfect positive correlation), with 0 indicating no correlation. PHQ-9 Item 1: Diminished interest, Item 2: Hopelessness, Item 3: Sleep difficulties, Item 4: Fatigue, Item 5: Changes in appetite or weight, Item 6: Feeling like a failure, Item 7: Concentration difficulties, Item 8: Psychomotor agitation, Item 9: Suicidal ideations. Alx Augmentation Index of Arterial Stiffness, AP Augmentation Pressure, DBP Diastolic Pressure, MAP Mean Arterial Pressure, PP Pulse Pressure, r_s Spearman’s rho correlation coefficient, SBP Systolic Pressure. *P < 0.05.

Figure 4

Spearman’s correlations of BPV and reversed scored sleep quality. Heatmap of the pairwise Spearman’s rho correlations between blood pressure variability (BPV) phenotypes and items from the Sleep Condition Indicator (SCI), stratified by time period (Overall, Awake, Asleep). Darker shades of red indicate strong positive correlations, while darker shades of blue indicate strong negative correlations. The color scale ranges from -1 (perfect negative correlation) to 1 (perfect positive correlation), with 0 indicating no correlation. SCI Item 1: Initiating sleep, Item 2: Length of sleep interruptions. Item 3: Frequency of difficulties. Item 4: Self-rated quality. Item 5: Impact on mood, energy or relationships. Item 6: Impact on concentration or productivity. Item 7: Distress. Item 8: Length of sleep problems. Alx Augmentation Index of Arterial Stiffness, AP Augmentation Pressure, DBP Diastolic Pressure, MAP Mean Arterial Pressure, PP Pulse Pressure, rs Spearman’s rho correlation coefficient, SBP Systolic Pressure. *P < 0.05.

Figure 5

Mediation model of sleep difficulties on the relationship between BPV and GAD-7 symptoms. Mediation model illustrating the proposed role of sleep difficulties in the relationship between blood pressure variability (BPV) and anxiety symptoms (GAD-7). Path A reflects the association between BPV and sleep; Path B reflects the link between sleep and anxiety symptoms; Path C is the total effect, and Path C′ the indirect effect. Analyses are adjusted for age and gender.