warfarin and Mental-Disorders

Warfarin significantly reduces thromboembolic risk, but perceptions of associated bleeding risk limit its use. The evidence supporting the association between bleeding and individual patient risks factors is unclear. This systematic review aims to determine the strength of evidence supporting an accentuated bleeding risk when patients with risk factors listed in the warfarin prescribing information are prescribed the drug. A systematic literature search of MEDLINE and Cochrane CENTRAL was conducted to identify studies reporting multivariate relationships between prespecified covariates and the risk of bleeding in patients receiving warfarin. The prespecified covariates were identified based on patient characteristics for bleeding listed in the warfarin package insert. Each covariate was evaluated for its association with specific types of bleeding. The quality of individual evaluations was rated as 'good', 'fair' or 'poor' using methods consistent with those recommended by the Agency for Healthcare Research and Quality (AHRQ). Overall strength of evidence was determined using the Grading of Recommendations Assessment, Development (GRADE) criteria and categorised as 'insufficient', 'very low', 'low', 'moderate' or 'high'. Thirty-four studies, reporting 134 multivariate evaluations of the association between a covariate and bleeding risk were identified. The majority of evaluations had a low strength of evidence for the association between covariates and bleeding and none had a high strength of evidence. Malignancy and renal insufficiency were the only two covariates that had a moderate strength of evidence for their association with major and minor bleeding respectively. The associations between covariates listed in the warfarin prescribing information and increased bleeding risk are not well supported by the medical literature.

Topics: Alcohol Drinking; Anemia; Anticoagulants; Drug Labeling; Heart Diseases; Hemorrhage; Humans; Liver Diseases; Medication Adherence; Mental Disorders; Neoplasms; Prescription Drugs; Renal Insufficiency; Risk Factors; Warfarin

The differential diagnosis for altered mental status (AMS) is broad and aetiological pathologies can arise from nearly all organs and body systems. Further complicating the matter, the altered patient is poorly suited to provide a comprehensive and accurate historical account. Thus, the physician must rely on collateral information, laboratories and imaging, and their own clinical suspicion. We present the case of a 75-year-old woman, found prone in her home with AMS, who was unable to provide a history. As her hospital stay evolved, we were forced to consider the entire breadth of possible causes of AMS. Eventually, the patient was found to have cerebral venous thrombosis, the significant extent of which is rarely reported. During the course of caring for the patient, we were reminded of the importance of remaining unbiased and unanchored while attempting to identify the source of the patient's ailment.

Topics: Aged; Diagnosis, Differential; Emergency Service, Hospital; Enoxaparin; Female; Humans; Intracranial Thrombosis; Mental Disorders; Mental Status Schedule; Warfarin

To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs).. Retrospective cohort study.. This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics).. Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions.. Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.

Topics: Aged; Alcoholism; Anticoagulants; Anxiety Disorders; Atrial Fibrillation; Depressive Disorder; Female; Humans; Male; Mental Disorders; Middle Aged; Psychotic Disorders; Retrospective Studies; Stress Disorders, Post-Traumatic; Warfarin

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.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation; Cohort Studies; Comorbidity; Drug Monitoring; Female; Hemorrhage; Humans; Male; Mental Disorders; Middle Aged; Proportional Hazards Models; Psychiatric Status Rating Scales; Retrospective Studies; Risk Adjustment; Risk Factors; Thromboembolism; United States; Warfarin

Topics: Atrial Fibrillation; Female; Hemorrhage; Humans; Male; Mental Disorders; Thromboembolism; Warfarin

Topics: Depression; Drug Evaluation, Preclinical; Drug Repositioning; Humans; Mental Disorders; Minocycline; Molecular Targeted Therapy; Psychiatry; Schizophrenia; Warfarin

To determine whether atrial fibrillation (AF) patients with mental health conditions (MHCs) were less likely than AF patients without MHCs to be prescribed warfarin and, if receiving warfarin, to maintain an International Normalized Ratio (INR) within the therapeutic range.. Detailed chart review of AF patients using a Veterans Health Administration (VHA) facility in 2003.. For a random sample of 296 AF patients, records identified clinician-diagnosed MHCs (independent variable) and AF-related care in 2003 (dependent variables), receipt of warfarin, INR values below/above key thresholds, and time spent within the therapeutic range (2.0-3.0) or highly out of range. Differences between the MHC and comparison groups were examined using X2 tests and logistic regression controlling for age and comorbidity.. Among warfarin-eligible AF patients (n = 246), 48.5% of those with MHCs versus 28.9% of those without MHCs were not treated with warfarin (P = .004). Among those receiving warfarin and monitored in VHA, highly supratherapeutic INRs were more common in the MHC group; for example, 27.3% versus 1.6% had any INR >5.0 (P <.001). Differences persisted after adjusting for age and comorbidity.. MHC patients with AF were less likely than those without MHC to have adequate management of their AF care. Interventions directed at AF patients with MHC may help to optimize their outcomes.

Topics: Anticoagulants; Atrial Fibrillation; Chi-Square Distribution; Drug Interactions; Drug Monitoring; Health Status Indicators; Humans; International Normalized Ratio; Mental Disorders; Practice Patterns, Physicians'; United States; United States Department of Veterans Affairs; Warfarin

The 2009 Golden Helix Symposium on Pharmacogenomics and Personalized medicine was held in Athens, Greece, where approximately 150 participants from 21 countries were updated on recent developments in the fields of pharmacogenetics and pharmacogenomics. The meeting was supported by ten corporate entities, of which three were major pharmaceutical and two were technology companies. It was endorsed by the University of Chicago and partly funded by the University of Patras. Here, we report some highlights of this meeting.

Topics: Anticoagulants; Drug-Related Side Effects and Adverse Reactions; Genetic Variation; Humans; Mental Disorders; Nervous System Diseases; Pharmacogenetics; Polymorphism, Single Nucleotide; Precision Medicine; Warfarin

Our goal was to establish whether psychosocial risk factors for nonadherence, previously identified as negative predictors of warfarin prescribing, are predictors of adverse events for patients with nonvalvular atrial fibrillation receiving warfarin.. Retrospective cohort analysis.. Ohio Medicaid administrative database.. We studied Ohio Medicaid recipients with nonvalvular atrial fibrillation receiving warfarin to determine whether a history of substance abuse, psychiatric illness, or social factors (identified as conditions perceived to be barriers to adherence) are predictors of adverse events, including stroke, intracranial hemorrhage, and gastrointestinal bleeding. Multivariable risk ratios were calculated for each risk factor using Cox proportional hazards models.. 9,345 patients were identified as having nonvalvular atrial fibrillation and receiving 2 or more warfarin prescriptions between 1997 and 2002. The event rates for the sample as a whole were 1.5 strokes, 0.7 intracranial hemorrhages, and 4.3 gastrointestinal bleeds per 100 person-years of follow-up. Subjects with substance abuse had the highest adjusted risk ratio, 2.4 (95% confidence interval [CI]: 1.4, 4.0) for an intracranial hemorrhage while receiving warfarin, followed by subjects with psychiatric illness, adjusted risk ratio of 1.5 (95% CI: 1.04, 2.1). Subjects with psychiatric illness also had an adjusted risk ratio of 1.4 (95% CI: 1.1, 1.7) for stroke. Patients in all 3 identified risk groups were at a significantly increased risk of gastrointestinal bleeding.. Patients with nonvalvular atrial fibrillation treated with warfarin who have psychosocial risk factors for nonadherence have an increased risk of adverse events.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Cohort Studies; Female; Gastrointestinal Hemorrhage; Humans; Intracranial Hemorrhages; Male; Mental Disorders; Middle Aged; Retrospective Studies; Risk Factors; Socioeconomic Factors; Stroke; Substance-Related Disorders; Treatment Outcome; Treatment Refusal; Warfarin

Topics: Adult; Angiography; Arterial Occlusive Diseases; Carotid Artery Diseases; Carotid Artery Injuries; Carotid Artery, Internal; Electroencephalography; Hematoma; Humans; Male; Mental Disorders; Physical Therapy Modalities; Rupture; Ultrasonography; Vasa Vasorum; Warfarin