BACKGROUND:
In hypertension care, common mental disorder (CMD) symptoms such as depression and anxiety shape adherence, self-management, and outcomes. Evidence from low- and middle-income-settings on what drives symptom severity and how patients experience these symptoms remains limited.

METHODS:
We conducted a community-based, explanatory sequential mixed-methods study in Budhanilkantha Municipality (Kathmandu, Nepal). Quantitatively, 327 adults with hypertension were selected via systematic-random-sampling. Depressive and anxiety symptom severity were measured with PHQ-9 and GAD-7 and modeled as continuous outcomes using linear-regression in prespecified blocks (socio-demographic; health/medication; lifestyle) and a fully adjusted model. Qualitatively, we conducted in-depth interviews with 16 purposively selected participants (with and without CMD symptoms). Transcripts were thematically analyzed and interpreted using a Biopsychosocial-framework. We integrated findings through triangulation to identify convergent, complementary, and divergent patterns.

RESULTS:
In fully adjusted models, sleep ≥6hours was the strongest moderator, associated with lower symptom severity (PHQ-9 β:−3.20, 95% CI −4.40-−2.10; GAD-7 β:−2.60, 95% CI −3.70 - −1.60). Non-High caste-status independently predicted higher depressive symptoms (β:1.80, 95% CI 0.59-3.10), while older age related to lower anxiety (β:−0.05 per year, 95% CI −0.07- −0.02). Diet >2 servings/day was modestly protective for depression; income ≥50K and controlled blood pressure showed borderline inverse-associations with anxiety. Qualitatively, patients with CMD symptoms reported persistent insomnia, bothersome medication side-effects, activity restriction, loneliness/stigma, anger/fear, low confidence, and financial strain, whereas those without symptoms described adaptation to medicines, stronger family-support, and greater self-efficacy. Triangulation demonstrated strong convergence on sleep as a core, modifiable-driver; complementarity linked social position and finances to symptom burden; and divergence highlighted perceived BP-related distress despite weak quantitative-links.

CONCLUSIONS:
Among hypertensive adults in Nepal, sleep duration, social position (ethnicity), age, diet, and socioeconomic context are key-moderators of CMD symptom severity. Embedding brief sleep interventions, family/support-oriented strategies, and equity-aware care within hypertension-services may reduce depressive and anxiety symptoms& improve overall management.