Factors Associated With Oral Anticoagulant Use in Patients With Atrial Fibrillation and Mental Disorders

Dina Farran, MSc, MPH; Matthew Broadbent, MA (hons); Aikaterini Dima, MD, MSc; Mark Ashworth, DM; Fiona Gaughran, MD

J Clin Psychiatry 2024;85(1):23m14824

ABSTRACT

Objective: This study aims to identify how mental illness severity interacts with oral anticoagulant (OAC) patterns among people with atrial fibrillation (AF).

Methods: AF patients with comorbid mental illness (classified using ICD-10) were identified from the South London and Maudsley Biomedical Research Centre Case Register. CHA₂DS₂-VASc and ORBIT scales were used to calculate stroke and bleeding risks, respectively, whereas Health of the Nation Outcome Scales (HoNOS) assessment was used for functional impairment.

Results: Overall, 2,105 AF patients were identified between 2011 and 2019. Serious mental illness (SMI) was associated with lower prescription of any OAC (adjusted risk ratio [aRR]: 0.94; 95% CI, 0.90–0.99). A total of 62% of SMI patients at risk of stroke were not prescribed an OAC. In the AF cohort, alcohol or substance dependence and activities of daily living (ADL) impairment were associated with lower prescription of warfarin (aRR: 0.92; 95% CI, 0.86–0.98 and aRR: 0.96; 95% CI, 0.93–0.99, respectively). Among people with AF and SMI, warfarin was less likely to be prescribed to people with self-injury (aRR: 0.84; 95% CI, 0.77–0.91), hallucinations or delusions (aRR: 0.92; 95% CI, 0.85–0.99), ADL impairment (aRR: 0.91; 95% CI, 0.84–0.99), or alcohol or substance dependence (aRR: 0.92; 95% CI, 0.87–0.98). Among people with AF and comorbid substance use disorder, self-injury (aRR: 0.78; 95% CI, 0.64–0.96), cognitive problems (aRR: 0.84; 95% CI, 0.70–0.99), and other mental illnesses (aRR: 0.83; 95% CI, 0.70–0.99) were associated with lower prescription of warfarin.

Conclusions: An OAC treatment gap for AF patients with comorbid SMI relative to other mental illnesses was identified. The gap was wider in those with dependence comorbidities, positive symptoms, self-injury, or functional impairment.

J Clin Psychiatry 2024;85(1):23m14824

Author affiliations are listed at the end of this article.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

References (27)

Hindricks G, Potpara T, Dagres N, et al; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373–498. PubMed CrossRef
Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857–867. PubMed CrossRef
Odum L, Cochran K, Aistrope D, et al. The CHADS2 versus the new CHA2DS2-VASc scoring systems for guiding antithrombotic treatment of patients with atrial fibrillation: review of the literature and recommendations for use. Pharmacotherapy. 2012;32(3):285–296. PubMed CrossRef
Jones C, Pollit V, Fitzmaurice D, et al; Guideline Development Group. The management of atrial fibrillation: summary of updated NICE guidance. BMJ. 2014;348(jun19 1):g3655. PubMed CrossRef
Højen AA, Nielsen PB, Riahi S, et al. Disparities in oral anticoagulation initiation in patients with schizophrenia and atrial fibrillation: a nationwide cohort study. Br J Clin Pharmacol. 2022;88(8):3847–3855. PubMed CrossRef
Fenger-Grøn M, Vestergaard CH, Ribe AR, et al. Association between bipolar disorder or schizophrenia and oral anticoagulation use in Danish adults with incident or prevalent atrial fibrillation. JAMA Netw Open. 2021;4(5):e2110096. PubMed CrossRef
Jaakkola J, Teppo K, Biancari F, et al. The effect of mental health conditions on the use of oral anticoagulation therapy in patients with atrial fibrillation: the FinACAF study. Eur Heart J Qual Care Clin Outcomes. 2022;8(3):269–276. PubMed CrossRef
Fanning L, Ryan-Atwood TE, Bell JS, et al. Prevalence, safety, and effectiveness of oral anticoagulant use in people with and without dementia or cognitive impairment: a systematic review and meta-analysis. J Alzheimers Dis. 2018;65(2):489–517. PubMed CrossRef
Mongkhon P, Alwafi H, Fanning L, et al. Patterns and factors influencing oral anticoagulant prescription in people with atrial fibrillation and dementia: Results from UK primary care. Br J Clin Pharmacol. 2021;87(3):1056–1068. PubMed CrossRef
Levin JB, Aebi ME, Tatsuoka C, et al. Adherence to psychotropic and nonpsychotropic medication among patients with bipolar disorder and general medical conditions. Psychiatr Serv. 2016;67(3):342–345. PubMed CrossRef
Blixen CE, Kanuch S, Perzynski AT, et al. Barriers to self-management of serious mental illness and diabetes. Am J Health Behav. 2016;40(2):194–204. PubMed CrossRef
Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955–962. PubMed CrossRef
Schauer DP, Moomaw CJ, Wess M, et al. Psychosocial risk factors for adverse outcomes in patients with nonvalvular atrial fibrillation receiving warfarin. J Gen Intern Med. 2005;20(12):1114–1119. PubMed CrossRef
Lawrence D, Kisely S. Inequalities in healthcare provision for people with severe mental illness. J Psychopharmacol. 2010;24(suppl):61–68. PubMed CrossRef
HONOS ASSESSMENT (Health of the Nation Outcome Scales). Peardonville House. Accessed January 18, 2023. https://peardonvillehouse.ca/wp-content/uploads/2018/12/Assessments.pdf
Hayes RD, Chang CK, Fernandes AC, et al. Functional status and all-cause mortality in serious mental illness. PLoS One. 2012;7(9):e44613. PubMed CrossRef
Hayes RD, Chang CK, Fernandes A, et al. Associations between symptoms and all-cause mortality in individuals with serious mental illness. J Psychosom Res. 2012;72(2):114–119. PubMed CrossRef
Wu CY, Chang CK, Hayes RD, et al. Clinical risk assessment rating and all-cause mortality in secondary mental healthcare: the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) Case Register. Psychol Med. 2012;42(8):1581–1590. PubMed CrossRef
Su YP, Chang CK, Hayes RD, et al. Mini-mental state examination as a predictor of mortality among older people referred to secondary mental healthcare. PLoS One. 2014;9(9):e105312. PubMed CrossRef
Stewart R, Soremekun M, Perera G, et al. The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register: development and descriptive data. BMC Psychiatry. 2009;9(1):51. PubMed CrossRef
CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk. MDCalc. Accessed January 18, 2023.https://www.mdcalc.com/calc/801/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk
ORBIT Bleeding Risk Score for Atrial Fibrillation. MDCalc. Accessed January 18, 2023.https://www.mdcalc.com/calc/10227/orbit-bleeding-risk-score-atrial-fibrillation
CRIS NLP Service. Library of production-ready applications. 2021. Vol 6. https://www.maudsleybrc.nihr.ac.uk/media/463740/applications-library-v21.pdf. Accessed January 18, 2023.
Kadra G, Stewart R, Shetty H, et al. Extracting antipsychotic polypharmacy data from electronic health records: developing and evaluating a novel process. BMC Psychiatry. 2015;15(1):166. PubMed CrossRef
Farran D, Bean D, Wang T, et al. Anticoagulation for atrial fibrillation in people with serious mental illness in the general hospital setting. J Psychiatr Res. 2022;153:167–173. PubMed CrossRef
Correll CU, Solmi M, Veronese N, et al. Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry. 2017;16(2):163–180. PubMed CrossRef
Roth JA, Bradley K, Thummel KE, et al. Alcohol misuse, genetics, and major bleeding among warfarin therapy patients in a community setting. Pharmacoepidemiol Drug Saf. 2015;24(6):619–627. PubMed CrossRef