Psychological Determinants of Pre-Hypertension Among First Year Undergraduate Students in a Public University in Malaysia

Background and Context

Pre-hypertension—defined as systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg—represents a clinically important risk category that substantially increases the likelihood of progression to established hypertension and its associated cardiovascular complications. While the role of traditional physiological risk factors such as obesity, physical inactivity, and dietary sodium intake in the development of elevated blood pressure has been well established, the contribution of psychological factors has received comparatively less attention, particularly among young adult populations.

University students represent a population at a critical life stage where health behaviours and risk factor profiles are being established. The transition to university life brings significant psychological stressors including academic pressure, financial concerns, social adjustment challenges, and separation from family support structures. Depression, anxiety, and stress have each been associated with elevated blood pressure through various physiological pathways, including activation of the hypothalamic-pituitary-adrenal axis, sympathetic nervous system hyperactivity, and pro-inflammatory processes. However, most previous research had focused on the relationship between psychological factors and established hypertension rather than pre-hypertension. This study aimed to fill this gap by examining the association between depression, anxiety, and stress with pre-hypertension among first-year undergraduate students at a public Malaysian university.

Study Design and Methods

A cross-sectional study was conducted in 2012 among first-year students at a public Malaysian university. A random cluster sampling technique was used: five of fifteen faculties were randomly selected, and all eligible first-year students within those faculties were invited to participate. A total of 495 students aged 18 to 26 years were included in the final analysis.

Blood pressure measurements were obtained using standardised protocols, with participants classified according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) criteria. Psychological status was assessed using the Malay version of the Depression, Anxiety and Stress Scale-21 (DASS-21), a well-validated self-report instrument that provides separate subscale scores for depression, anxiety, and stress, each categorised into five severity levels: normal, mild, moderate, severe, and extremely severe. Sociodemographic data, family history of hypertension, anthropometric measurements, and lifestyle factors were also collected. Multivariate logistic regression was employed to identify independent predictors of pre-hypertension.

Key Results

The prevalence of pre-hypertension among first-year university students was 30.1 per cent—a notably high figure for a young adult population. This finding was consistent with other Malaysian studies that reported pre-hypertension prevalence ranging from 11.5 to 34.2 per cent among comparable university populations, and it aligned with the broader concern about the rising burden of cardiovascular risk factors among young Malaysians.

Regarding psychological factors, the study found that the percentage of students with severe depression was 3.8 per cent and extremely severe depression was 1.2 per cent. The key finding was that students with severe or extremely severe depression were significantly more likely to have pre-hypertension compared to those without depression, with an adjusted odds ratio exceeding three after controlling for sociodemographic and anthropometric confounders. This association was specific to higher severity levels of depression; mild or moderate depression did not show statistically significant independent associations with pre-hypertension.

While anxiety and stress were both prevalent in the student population, neither showed statistically significant independent associations with pre-hypertension after adjusting for depression and other covariates in the multivariate model. This suggests that among the three psychological dimensions assessed, depression at severe levels carries the strongest and most specific association with early blood pressure elevation.

Mechanisms and Interpretation

The observed association between severe depression and pre-hypertension is biologically plausible through several established physiological pathways. Severe depression is associated with chronic activation of the sympathetic nervous system, leading to sustained elevations in heart rate and peripheral vascular resistance. The hypothalamic-pituitary-adrenal axis dysregulation commonly observed in depression results in elevated cortisol levels, which promote sodium retention, increase vascular reactivity, and contribute to endothelial dysfunction. Additionally, depression is associated with increased production of pro-inflammatory cytokines, which can accelerate atherosclerotic processes and impair vascular function. Behavioural correlates of depression—including physical inactivity, poor dietary choices, disordered sleep, and increased use of alcohol or tobacco—may further compound these direct physiological effects.

The finding that only severe and extremely severe depression (but not milder forms) was associated with pre-hypertension suggests that a threshold level of depressive severity may be necessary to produce measurable haemodynamic effects. This has implications for clinical screening and intervention priorities.

Implications for University Health Services

The high prevalence of pre-hypertension (30.1 per cent) among first-year students underscores the need for routine blood pressure screening during university health assessments. The significant association with severe depression supports integrated screening approaches that assess both cardiovascular risk factors and mental health status simultaneously. University health services should consider implementing routine mental health screening for incoming students, with pathways for referral and treatment for those identified with severe depression. Given the bidirectional relationship between depression and cardiovascular risk, effective treatment of severe depression may have secondary benefits for blood pressure control, while identification of pre-hypertension may prompt assessment for underlying psychological distress.

Limitations

The cross-sectional design precludes determination of the temporal sequence between depression and pre-hypertension, and it remains possible that early awareness of elevated blood pressure or its consequences contributed to psychological distress rather than the reverse. The DASS-21, while validated, is a self-report instrument and may be subject to reporting bias. A single blood pressure measurement session, while following standardised protocols, may not capture the full picture of an individual’s blood pressure profile, and white-coat effects may have contributed to some pre-hypertension classifications. The study population was drawn from a single university and may not be fully representative of Malaysian university students in general. Finally, the relatively small numbers of students with severe and extremely severe depression limit the statistical precision of the effect estimates for these categories.