Outcomes of Anticoagulation Therapy in Patients with Mental Health Conditions
- 311 Downloads
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.
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.
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.
KEY WORDSanticoagulation 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.
- 12.Connolly SJ, Pogue J, Eikelboom J, Flaker G, Commerford P, Franzosi MG, Healey JS, Yusuf S. Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range. Circulation. 2008;118(20):2029–37.PubMedCrossRefGoogle Scholar
- 14.Jones M, McEwan P, Morgan CL, Peters JR, Goodfellow J, Currie CJ. Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvular atrial fibrillation: a record linkage study in a large British population. Heart. 2005;91(4):472–7.PubMedCentralPubMedCrossRefGoogle Scholar
- 19.Rose AJ, Hylek EM, Ozonoff A, Ash AS, Reisman JI, Berlowitz DR. Risk-adjusted percent time in therapeutic range as a quality indicator for outpatient oral anticoagulation: results of the Veterans Affairs Study to Improve Anticoagulation (VARIA). Circ Cardiovasc Qual Outcomes. 2011;4(1):22–9.PubMedCrossRefGoogle Scholar
- 20.Perlin J, Kazis LE, Skinner KM, Ren XS, Lee A, Rogers W, Spiro A III, Selim A, Miller D. (Veterans Health Administration: Office of Quality and Performance). 1999 Large Health Survey of Veteran Enrollees: Executive Report. 2000.Google Scholar
- 21.American Psychiatric Association. “Multiaxial Assessment.” DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington: American Psychiatric Association; 2000.Google Scholar
- 26.Aas IHM. Guidelines for rating Global Assessment of Functioning (GAF). Ann Gen Psychiatry. 2011;10(2):1–11.Google Scholar
- 27.Aas IHM. Global Assessment of Functioning (GAF): properties and frontier of current knowledge. Ann Gen Psychiatry. 2010;9(20):1–11.Google Scholar
- 28.Lip GY, Frison L, Halperin JL, Lane DA. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol. 2011;57(2):173–80.PubMedCrossRefGoogle Scholar