Mental health conditions and adherence to direct oral anticoagulants in patients with incident atrial fibrillation: A nationwide cohort study

Konsta Teppo,Jussi Jaakkola,K.E Juhani Airaksinen,Fausto Biancari,Olli Halminen,Jukka Putaala,Pirjo Mustonen,Jari Haukka,Juha Hartikainen,Alex Luojus,Mikko Niemi,Miika Linna,Mika Lehto

doi:10.1016/j.genhosppsych.2021.12.012

Abstract

ObjectiveMedication adherence is essential for effective stroke prevention in patients with atrial fibrillation (AF). We aimed to assess whether adherence to direct oral anticoagulants (DOACs) in AF patients is affected by the presence of mental health conditions (MHCs). MethodsThe nationwide FinACAF cohort covered 74,222 AF patients from all levels of care receiving DOACs during 2011–2018 in Finland. Medication possession ratio (MPR) was used to quantify adherence. Patients with MPR ≥0.90 were defined adherent. MHCs of interest were depression, bipolar disorder, anxiety disorder and schizophrenia. ResultsThe patients' (mean age 75.4 ± 9.5 years, 50.8% female) mean MPR was 0.84 (SD 0.22), and 59.5% had MPR ≥0.90. Compared to patients without MHC, the adjusted ORs (95% CI) for adherent DOAC use emerged slightly lower in patients with depression (0.92 (0.84–0.99)) and bipolar disorder (0.77 (0.61–0.97)) and unsignificant in patients with anxiety disorder (1.08 (0.96–1.21)) and schizophrenia (1.13 (0.90–1.43)). However, when only persistent DOAC therapy was analyzed, no MHC was associated with poor adherence, and instead anxiety disorder was associated with adherent DOAC use (1.18 (1.04–1.34)). ConclusionAdherence to DOACs in AF patients in Finland was relatively high, and no meaningful differences between patients with and without MHCs were observed.

Highlights

Atrial fibrillation (AF) is the most common sustained arrhythmia affecting up to 4.1% of the adult population and is a major risk factor of ischemic stroke [1,2,3]
When each diagnostic mental health condition (MHC) category was analyzed separately, we found that Medication possession ratio (MPR) in patients with depression or bipolar disorder did not differ from the non-MCH patients, whereas MPR was significantly higher in patients with anxiety disorder or schizophrenia compared to patients without MHCs
After adjusting for confounding factors, a lower likelihood of adherent direct oral anticoagulants (DOACs) use was observed in patients with depression or bipolar disorder as well as in patients receiving psychiatric medications when compared to pa tients without MHC, while anxiety disorder and schizophrenia had no effect on DOAC adherence (Table 2)

Summary

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia affecting up to 4.1% of the adult population and is a major risk factor of ischemic stroke [1,2,3]. Life-long oral anti coagulation (OAC) therapy can effectively decrease the risk of stroke, and current guidelines recommend direct oral anticoagulants (DOACs) as the first line anticoagulant over the older vitamin K antagonists in non-valvular AF (VKAs) [4,5]. In Finland, DOACs are increasingly common accounting for over 90% of OAC initiations during 2018, and while being more expensive than VKAs, 42–65% of their costs have been reimbursed to AF patients with at least intermediate stroke risk since. Medication adherence is essential for effective stroke prevention with DOACs, and poor DOAC adherence has been associated with higher mortality and stroke risk in patients with AF [7,8,9]. Medication adherence can be divided in three phases: initiation, implementation, and persistence, with implementation referring to how a patient’s actual dosing corre sponds to the prescribed dosing from treatment initiation until the last dose [10]

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Conclusion