Outcomes of Anticoagulation Therapy in Patients with Mental Health Conditions

Journal of General Internal Medicine (Impact Factor: 3.42). 02/2014; 29(6). DOI: 10.1007/s11606-014-2784-2
Source: PubMed


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.

1 Follower
14 Reads
  • Source
    Journal of General Internal Medicine 03/2014; 29(6). DOI:10.1007/s11606-014-2798-9 · 3.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Although warfarin is often recommended for pulmonary arterial hypertension (PAH) management to mitigate thrombotic risk and improve survival, limited information exists to guide anticoagulation therapy. The purpose of this study was to compare and contrast warfarin therapy monitoring requirements and outcomes in patients with PAH and atrial fibrillation (AF) receiving long-term anticoagulation. Materials and Methods Patients initiated on warfarin for PAH between January 1, 2000 and December 31, 2008 were matched by warfarin initiation date (± 90 days), age (± 5 years), chronic disease score (± 1 points), and sex to patients initiated for AF. The primary study endpoint was frequency of INR monitoring per 30 days of observation. Secondary endpoints included indicators of INR control and warfarin-related adverse events. Results and Conclusion A total of 84 patients were included - 18 and 66 in the PAH and AF groups, respectively. Patients with PAH had a higher median rate of INR measurements per 30 days compared to patients with AF (median = 2.0, interquartile range [IQR] = 1.5 – 2.3 vs. median = 1.6, IQR = 1.3 – 2.0, p = 0.046). There were no differences between groups with respect to percent of INR measurements in range, overall time in therapeutic range (TTR), or warfarin-related adverse events (all p>0.05). Study results suggest that patients with PAH may be more difficult to manage as seen through more frequent INR monitoring. Potential management difficulties did not translate to a lower performance on indicators of INR control or increased risk of warfarin-related adverse events.
    Thrombosis Research 05/2014; 133(5). DOI:10.1016/j.thromres.2014.02.029 · 2.45 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Depressive symptoms have detrimental effects on quality of life and mortality. Poor adherence to treatment regimen is a potential mechanism for the increased risk for adverse medical events associated with depression. Regarding oral anticoagulation with vitamin K antagonists, adherence is crucial for the outcome. Little is known about the clinical relevance of current depressiveness for anticoagulation treatment.Objectives To examine the impact of current depressiveness on anticoagulation treatment in regular medical care.Patients/Methods We examined the association between clinically significant depressiveness as assessed by the Patient Health Questionnaire-2 ≥ 2 (PHQ-2 ≥ 2) with the percentage of time in the therapeutic range (TTR), self-rated compliance, several aspects of health literacy, anticoagulation side-effects and treatment satisfaction in a cross-sectional study of 1,790 oral anticoagulation outpatients.Results716 participants (40.0%) had clinically significant depressive symptoms. Depressed persons reported lower compliance with intake of prescribed medication and regular visits for control of anticoagulation, more unspecific side-effects (e.g. pruritus) and lower satisfaction with the anticoagulation treatment and their doctors’ expertise and empathy. Depressed as compared with non-depressed individuals had a lower TTR (-4.67, 95%CI -8.39 to -0.95). Increasing severity of depressiveness was related with decreasing TTR. However, depressiveness lost its significant impact on TTR after multivariable adjustment (-3.11, 95%CI -6.88 to 0.66).Conclusions Clinically significant depressiveness was highly prevalent and impaired several aspects of anticoagulation treatment. Depressiveness should be regarded as a clinically significant condition that needs to be addressed in the management of anticoagulation patients.This article is protected by copyright. All rights reserved.
    Journal of Thrombosis and Haemostasis 10/2014; 12(12). DOI:10.1111/jth.12743 · 5.72 Impact Factor