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Outcomes of Anticoagulation Therapy in Patients with Mental Health Conditions

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A Capsule Commentary to this article was published on 05 March 2014

Abstract

Background

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.

Objective

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

Design

Retrospective cohort analysis.

Participants

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.

Conclusion

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.

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Acknowledgments

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.

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Authors and Affiliations

  1. Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA

    Dan R. Berlowitz MD, MPH, Al Ozonoff PhD, Donald R. Miller ScD, Elaine M. Hylek MD, MPH, Arlene S. Ash PhD, Guneet K. Jasuja PhD, Shibei Zhao MPH, Joel I. Reisman AB & Adam J. Rose MD, MSc, FACP

  2. Department of Community Based Clinics, University of Texas Medical Branch (UTMB), 6465 South Shore Blvd. Suite 500, League City, TX, 77573, USA

    Helen T. Paradise MD, MPH

  3. Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA

    Helen T. Paradise MD, MPH, Dan R. Berlowitz MD, MPH, Elaine M. Hylek MD, MPH, Arlene S. Ash PhD & Adam J. Rose MD, MSc, FACP

  4. Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA

    Dan R. Berlowitz MD, MPH, Donald R. Miller ScD & Guneet K. Jasuja PhD

  5. Biostatistics Section, Boston Children’s Hospital, Boston, MA, USA

    Al Ozonoff PhD

  6. Department of Quantitative Health Sciences, Division of Biostatistics and Health Services Research, University of Massachusetts School of Medicine, Worcester, MA, USA

    Arlene S. Ash PhD

Authors
  1. Helen T. Paradise MD, MPH
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  2. Dan R. Berlowitz MD, MPH
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  5. Elaine M. Hylek MD, MPH
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  8. Shibei Zhao MPH
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  9. Joel I. Reisman AB
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  10. Adam J. Rose MD, MSc, FACP
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Corresponding author

Correspondence to Helen T. Paradise MD, MPH.

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Paradise, H.T., Berlowitz, D.R., Ozonoff, A. et al. Outcomes of Anticoagulation Therapy in Patients with Mental Health Conditions. J GEN INTERN MED 29, 855–861 (2014). https://doi.org/10.1007/s11606-014-2784-2

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  • DOI: https://doi.org/10.1007/s11606-014-2784-2

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