Journal of General Internal Medicine

, Volume 29, Issue 6, pp 855–861 | Cite as

Outcomes of Anticoagulation Therapy in Patients with Mental Health Conditions

  • Helen T. Paradise
  • Dan R. Berlowitz
  • Al Ozonoff
  • Donald R. Miller
  • Elaine M. Hylek
  • Arlene S. Ash
  • Guneet K. Jasuja
  • Shibei Zhao
  • Joel I. Reisman
  • Adam J. Rose
Original Research



Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes.


To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy.


Retrospective cohort analysis.


We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007–2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders.

Main Measures

Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations.

Key Results

Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively (p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates.


Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin.


anticoagulation mental health veterans warfarin therapy psychiatric conditions 



This project was supported by VA grant VA-HSRD-IIR-10-374. The opinions expressed here are those of the authors and do not necessarily represent the official views or policies of the US Department of Veterans Affairs.

Conflict of Interest

Dr. Hylek has served on advisory boards for Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Johnson and Johnson, Merck, and Pfizer. None of the other authors report any potential conflicts of interest.

Supplementary material

11606_2014_2784_MOESM1_ESM.pdf (366 kb)
ESM 1 (PDF 365 kb)


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Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Helen T. Paradise
    • 2
    • 3
  • Dan R. Berlowitz
    • 1
    • 3
    • 4
  • Al Ozonoff
    • 1
    • 5
  • Donald R. Miller
    • 1
    • 4
  • Elaine M. Hylek
    • 1
    • 3
  • Arlene S. Ash
    • 1
    • 3
    • 6
  • Guneet K. Jasuja
    • 1
    • 4
  • Shibei Zhao
    • 1
  • Joel I. Reisman
    • 1
  • Adam J. Rose
    • 1
    • 3
  1. 1.Center for Healthcare Organization and Implementation ResearchBedford VA Medical CenterBedfordUSA
  2. 2.Department of Community Based ClinicsUniversity of Texas Medical Branch (UTMB)League CityUSA
  3. 3.Department of Medicine, Section of General Internal MedicineBoston University School of MedicineBostonUSA
  4. 4.Department of Health Policy and ManagementBoston University School of Public HealthBostonUSA
  5. 5.Biostatistics Section, Boston Children’s HospitalBostonUSA
  6. 6.Department of Quantitative Health Sciences, Division of Biostatistics and Health Services ResearchUniversity of Massachusetts School of MedicineWorcesterUSA

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