The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

Comorbidity, Treatment, and Service Utilization Patterns in Difficult-to-Treat Depression Patients: A Retrospective Study in a Portuguese Community Mental Health Team

Background and Objectives: Observational studies with data from real-world clinical practice with patients with difficult-to-treat depression (DTD) are rare. This study aims to collect observational data from the real-world clinical practice of a Portuguese community mental health team (CMHT) on the prevalence of DTD and to explore differences between DTD and non-DTD groups. Materials and Methods: We conducted a retrospective chart review study using data from Electronic Health Records (EHRs) of adult patients with psychiatric disorders followed by a CMHT from the Department of Psychiatry of the Coimbra Local Health Unit (between 1 December 2020-31 December 2022). The Dutch Measure for quantification of Treatment Resistance in Depression (DM-TRD) was used to assess the degree of treatment resistance and the Charlson Comorbidity Index (CCI) to measure medical comorbidity. Results: A quantity of 473 patients were referred to Cantanhede CMHT for a first assessment. Of these, 219 patients met the criteria for a primary diagnosis of any depressive disorder. Assistant psychiatrists identified 57 patients with DTD during follow-up (approximately 26%). The DTD group had higher rates of depressive episodes, greater depression severity, increased service use, higher DM-TRD scores, and a higher prevalence of comorbid anxiety symptoms, personality disorders, and severe medical comorbidities. The DTD group also had a higher prescription rate of antidepressants. Differences were observed in the use of antidepressant augmentation strategies and in the prescription of anticoagulant/antiplatelet drugs and analgesics, with higher prescription rates in the DTD group. We found correlations between DM-TRD and CCI scores, and between DM-TRD scores and all service use variables. Conclusions: Our results are consistent with a similar study in the United Kingdom, highlighting the need for a different approach to the management of DTD patients, who continue to live with a significant burden despite usual pharmacological and non-pharmacological treatments.

Temporal trends of gender disparities in oral anticoagulant use in patients with atrial fibrillation

AIMS

To investigate sex-specific temporal trends in the initiation of oral anticoagulant (OAC) therapy among patients diagnosed with atrial fibrillation (AF) in Finland between 2007 and 2018.

METHODS

The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) Study included all patients with incident AF in Finland from 2007 to 2018. The primary outcome was the initiation of any OAC therapy.

RESULTS

We identified 229,565 patients with new-onset AF (50.0% women; mean age 72.7 years). The initiation of OAC therapy increased continuously during the observation period. While women were more likely to receive OAC therapy overall, after adjusting for age, stroke risk factors and other confounding factors, female sex was associated with a marginally lower initiation of OACs (unadjusted and adjusted hazard ratios comparing women to men: 1.08 (1.07-1.10) and 0.97 (0.96-0.98), respectively). Importantly, the gender disparities in OAC use attenuated and reached parity by the end of the observation period. Furthermore, when only patients eligible for OAC therapy according to the contemporary guidelines were included in the analyses, the gender inequalities in OAC initiation appeared minimal. Implementation of direct OACs for stroke prevention was slightly slower among women.

CONCLUSION

This nationwide retrospective cohort study covering all patients with incident AF in Finland from 2007 to 2018 observed that although female sex was initially associated with a lower initiation of OAC therapy, the sex-related disparities resolved over the course of the study period.

The importance, consequences and treatment of psychosocial risk factors in heart disease: less conversation, more action!

Psychosocial factors play a significant role in the incidence and prognosis of cardiovascular disease with a rapidly increasing body of knowledge, as acknowledged by their inclusion in the European Society of Cardiology cardiovascular prevention guideline since 2012. Nevertheless, psychosocial risk is not consistently assessed, acknowledged and treated in daily clinical practice. Therefore, adopting a multidimensional approach that encompasses biological, psychological, and social factors is crucial for understanding the dynamic nature of cardiovascular health and disease, delivering patient-centred care, and developing effective interventions to ultimately enhance health and satisfaction with contemporary medicine and care. The current review summarises the state-of-the-art evidence for screening and treating psychological risk factors in coronary heart disease, heart failure, and atrial fibrillation in the context of cardiac rehabilitation, along with accompanying recommendations. The limited adoption of routine screening, despite longstanding recommendations, highlights the importance of prioritising the implementation and expansion of routine screening in primary and secondary prevention. To advance psychosocial treatment, a standardised and personalised approach including comprehensive education, physical exercise, and psychosocial support with a focus on patient-reported outcomes is crucial. Treating heart and mind together has the potential to decrease psychosocial risk while enhancing the prognosis and quality of life, therefore delivering true patient-centred care.

Depression and atrial fibrillation in a reciprocal liaison: a neuro-cardiac link

OBJECTIVE

To explore the reciprocal relationship of depression and atrial fibrillation (AF).

METHODS

A literature search was conducted in Pub Med, Scopus, and Google Scholar using relevant terms for depression and AF and respective therapies.

RESULTS

There is evidence that depression is involved in the aetiology and prognosis of AF. AF, independently of its type, incurs a risk of depression in 20-40% of patients. Also, depression significantly increases cumulative incidence of AF (from 1.92% to 4.44% at 10 years); 25% increased risk of new-onset AF is reported in patients with depression, reaching 32% in recurrent depression. Hence, emphasis is put on the importance of assessing depression in the evaluation of AF and vice versa. Persistent vs paroxysmal AF patients may suffer from more severe depression. Furthermore, depression can impact the effectiveness of AF treatments, including pharmacotherapy, anticoagulation, cardioversion and catheter ablation.

CONCLUSIONS

A reciprocal association of depression and AF, a neurocardiac link, has been suggested. Thus, strategies which can reduce depression may improve AF patients' course and treatment outcomes. Also, AF has a significant impact on risk of depression and quality of life. Hence, effective antiarrhythmic therapies may alleviate patients' depressive symptoms. KEY POINTSAF, independently of its type of paroxysmal, permanent or chronic, appears to have mental besides physical consequences, including depression and anxietyA reciprocal influence or bidirectional association of depression and AF, a neurocardiac link, has been suggestedAF has considerable impact on the risk of depression occurrence with 20-40% of patients with AF found to have high levels of depressionAlso, depression significantly increases 10-year cumulative incidence and risk of AF from 1.92% to 4.44% in people without depression, and the risk of new-onset AF by 25-32%Emphasis should be placed on the importance of assessing depression in the evaluation of AF and vice versaPersistent/chronic AF patients may suffer from more severe depressed mood than paroxysmal AF patients with similar symptom burdenDepression and anxiety can impact the effectiveness of certain AF treatments, including pharmacotherapy, anticoagulation treatment, cardioversion and catheter ablationThus, strategies which can reduce anxiety and depression may improve AF patients' course and treatment outcomesAlso, effective antiarrhythmic therapies to control AF may alleviate patients' depressive mood.

Exploring the Association between Schizophrenia and Cardiovascular Diseases: Insights into the Role of Sigma 1 Receptor

Contemporary society is characterized by rapid changes. Various epidemiological, political and economic crises represent a burden to mental health of nowadays population, which may at least partially explain the increasing incidence of mental disorders, including schizophrenia. Schizophrenia is associated with premature mortality by at least 13-15 years. The leading cause of premature mortality in schizophrenia patients is high incidence of cardiovascular diseases. The specific-cause mortality risk for cardiovascular diseases in schizophrenia patients is more than twice higher as compared to the general population. Several factors are discussed as the factor of cardiovascular diseases development. Intensive efforts to identify possible link between schizophrenia and cardiovascular diseases are made. It seems that sigma 1 receptor may represent such link. By modulation of the activity of several neurotransmitter systems, including dopamine, glutamate, and GABA, sigma 1 receptor might play a role in pathophysiology of schizophrenia. Moreover, significant roles of sigma 1 receptor in cardiovascular system have been repeatedly reported. The detailed role of sigma 1 receptor in both schizophrenia and cardiovascular disorders development however remains unclear. The article presents an overview of current knowledge about the association between schizophrenia and cardiovascular diseases and proposes possible explanations with special emphasis on the role of the sigma 1 receptor.

Association of income and educational levels on initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study

AIMS

Socioeconomic disparities have been reported in the outcomes of patients with atrial fibrillation (AF). We assessed the hypothesis that AF patients with higher income or educational level are more frequently initiated with oral anticoagulant (OAC) therapy for stroke prevention.

METHODS

The nationwide registry-based Finnish AntiCoagulation in Atrial Fibrillation cohort covers all patients with AF from all levels of care in Finland. Patients were divided into income quartiles according to their highest annual income during 2004-2018 and into three categories based on educational attainment. The outcome was the first redeemed OAC prescription.

RESULTS

We identified 239 222 patients (mean age 72.7 ± 13.2 years, 49.8% female) with incident AF during 2007-2018. Higher income was associated with higher OAC initiation rate: compared to the lowest income quartile the adjusted SHRs (95% CI) for OAC initiation were 1.09 (1.07-1.10), 1.13 (1.11-1.14) and 1.13 (1.12-1.15) in the second, third and fourth income quartiles, respectively. Patients in the highest educational category had a slightly lower OAC initiation rate than patients in the lowest educational category (adjusted SHR 0.92 [95% CI 0.90-0.93]). Income-related disparities were larger and education-related disparities only marginal among patients at high risk of ischemic stroke. The socioeconomic disparities in OAC initiation within 1-year follow-up decreased from 2007 to 2018. The adoption of direct OACs as the initial anticoagulant was faster among patients with higher income or educational levels.

CONCLUSION

These findings highlight potential missed opportunities in stroke prevention, especially among AF patients with low income, whereas the education-related disparities in OAC initiation appear controversial.

Socioeconomic factors and bleeding events in patients with incident atrial fibrillation: A Finnish nationwide cohort study

Background

Low socioeconomic status has been associated with higher risk of ischemic stroke and death in patients with atrial fibrillation (AF). However, whether socioeconomic status affects risk of bleeding events is unknown. We assessed the hypothesis that low income and educational attainment are associated with higher risk of bleeding in patients with AF.

Methods

The registry-based FinACAF study covers all patients with AF in Finland during 2007-2018. Patients were divided into income quartiles and three categories based on their educational attainment. Outcomes of interest were the first-ever gastrointestinal (GI), intracranial (IC) and any bleeding.

Results

We identified 205 019 patients (50.9 % female; mean age 72.3 (SD 13.4) years) with incident AF without prior bleeding. Mean follow-up time was 4.0 (SD 3.2) years, during which 25 013 (12.2 %) patients experienced first-ever any bleeding (incidence rate 3.07 (95 % CI 3.03-3.10) /100 patient-years). Low income was independently associated with hazard of any bleeding as well as GI and IC bleeding (adjusted hazard ratios (HRs) comparing lowest vs highest income quartile: 1.13 (1.08-1.17), 1.32 (1.23-1.41) and 1.15 (1.06-1.24), respectively). Income-related bleeding disparities were larger among younger patients under 65 years and among men. Education-related bleeding disparities were smaller than income related-disparities (adjusted HRs comparing lowest vs highest educational category: any bleeding 1.06 (1.02-1.11), GI bleeding 1.16 (1.08-1.24), IC bleeding 1.10 (0.93-1.09)).

Conclusions

Patients with AF and low income are at higher risk of bleeding, especially GI bleeding.

Impact of mental disorders on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study

BACKGROUND

It is unclear whether mental disorders are an independent risk factor for atrial fibrillation (AF) in patients with diabetes. We aimed to investigate whether patients with diabetes who have mental disorders have an increased risk for AF.

METHODS

Using the Korea National Health Insurance Service database, we enrolled 2,512,690 patients diagnosed with diabetes without AF between 2009 and 2012. We assessed five mental disorders: depression, insomnia, anxiety, bipolar disorder, and schizophrenia. Newly diagnosed AF was identified during the follow-up period, and multivariate Cox regression analysis was performed.

RESULTS

Among the 2,512,690 patients (mean age 57.2 ± 12.3 years; 60.1% men), 828,929 (33.0%) had mental disorders. Among the five mental disorders, anxiety (68.1%) was the most common, followed by insomnia (40.0%). During a median follow-up duration of 7.1 years, new-onset AF was diagnosed in 79,525 patients (4.66 per 1,000 person-years). Patients with diabetes who had mental disorders showed a higher risk for AF (adjusted hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.17-1.21; p-value < 0.001). Depression, insomnia, and anxiety were significantly associated with higher risk for AF (adjusted HR [95% CI]: 1.15 [1.12-1.17], 1.15 [1.13-1.18], and 1.19 [1.67-1.21], respectively; all p-values < 0.001), whereas bipolar disorder and schizophrenia were not.

CONCLUSIONS

Mental disorders, especially depression, insomnia, and anxiety, were associated with an increased risk for AF in patients with diabetes. Greater awareness with a prompt diagnosis of AF should be considered for patients with both DM and mental disorders.

Rural-urban differences in the initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study

AIMS

Little is known about rural-urban differences in the treatment and outcomes in patients with atrial fibrillation (AF). We aimed to assess whether the initiation of oral anticoagulant (OAC) therapy in patients with AF differs between those with rural and urban residence.

METHODS

The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The outcome was the first redeemed OAC prescription.

RESULTS

We identified 222 419 patients (50.1% female; mean age 72.8 (SD 13.2) years) with incident AF during 2007-2018. Urban residence was associated with a lower rate of OAC therapy initiation (adjusted subdistribution hazard ratio (SHR) (95% CI) 0.96 (0.95-0.97)). Correspondingly, an inverse graded dose-response relationship was observed between higher urbanization degree tertile and OAC initiation rate (highest tertile compared to lowest: adjusted SHR (95% CI) 0.94 (0.93-0.95)). The adoption of direct oral anticoagulants for stroke prevention was faster among patients with urban residence.

CONCLUSION

This nationwide cohort study documented that urban residence is associated with a slightly lower rate of OAC therapy initiation in patients with incident AF, but faster adoption of direct oral anticoagulant use.

Mental health conditions and bleeding events in patients with incident atrial fibrillation: A Finnish nationwide cohort study

OBJECTIVE

We assessed the hypothesis that mental health conditions (MHCs) are associated with higher risk of bleeding in patients with atrial fibrillation (AF).

METHODS

The registry-based FinACAF study covers all patients with AF diagnosed during 2007-2018 in Finland. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and any MHC. The outcomes were first-ever gastrointestinal, intracranial, and any bleeding event.

RESULTS

We identified 205,019 patients (50.9% female; mean age 72.3 [standard deviation 13.4] years) with incident AF without prior bleeding, and the prevalence of any MHC was 6.1%. Any MHC, depression, and anxiety disorder were associated with the risk of any bleeding (adjusted hazard ratios (HRs) 1.19 [1.12-1.27], 1.21 [1.13-1.30], and 1.21 [1.08-1.35], respectively). Additionally, any MHC and depression were associated with the risk of gastrointestinal and intracranial bleeding and anxiety disorder with gastrointestinal bleeding. Bipolar disorder and schizophrenia were not associated with risk of bleeding. Use of oral anticoagulants was associated with the risk of any bleeding (adjusted HR 1.24 [95% CI 1.21-1.28)]), and this association was similar in patients with and without MHCs. Serotonin reuptake inhibitors were not associated with bleeding risk.

CONCLUSIONS

MHCs are associated with a higher risk of bleeding in patients with AF.

Mental health conditions and risk of first-ever ischaemic stroke and death in patients with incident atrial fibrillation: A nationwide cohort study

BACKGROUND

Atrial fibrillation (AF) patients with mental health conditions (MHCs) have higher incidence of ischaemic stroke (IS) than patients without MHC, but whether this results from direct impact of MHCs or relates to higher prevalence of comorbidities and differences in the use of oral anticoagulant (OAC) therapy is unclear. We assessed the hypothesis that MHCs independently increase the risk of IS in patients with incident AF.

METHODS

The nationwide FinACAF cohort covered all 203,154 patients diagnosed with incident AF without previous IS or transient ischaemic attack in Finland during 2007-2018. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia and any MHC. The outcomes were first-ever IS and all-cause death.

RESULTS

The patients' (mean age 73.0 ± 13.5 years, 49.0% female) mean follow-up time was 4.3 (SD 3.3) years and 16,272 (8.0%) experienced first-ever IS and 63,420 (31.2%) died during follow-up. After propensity score matching and adjusting for OAC use, no MHC group was associated with increased IS risk (adjusted SHRs (95% CI): depression 0.961 (0.857-1.077), bipolar disorder 1.398 (0.947-2.006), anxiety disorder 0.878 (0.718-1.034), schizophrenia 0.803 (0.594-1.085) and any MHC 1.033 (0.985-1.085)). Lower rate of OAC use partly explained the observed higher crude IS incidence in patients with any MHC. Depression, schizophrenia and any MHC were associated with higher all-cause mortality (adjusted HRs [95% CI]: 1.208 [1.136-1.283], 1.543 [1.352-1.761] and 1.149 [1.116-1.175], respectively).

CONCLUSIONS

In this nationwide retrospective cohort study, MHCs were not associated with the incidence of first-ever IS in patients with AF.

Mental Health Conditions and Nonpersistence of Direct Oral Anticoagulant Use in Patients With Incident Atrial Fibrillation: A Nationwide Cohort Study

Background Mental health conditions (MHCs) are associated with poor outcomes in patients with atrial fibrillation. However, persistence of oral anticoagulation therapy in patients with atrial fibrillation and MHCs is unknown. We aimed to evaluate the effect of MHCs on the persistence of direct oral anticoagulant (DOAC) use in patients with atrial fibrillation based on a nationwide cohort. Methods and Results The nationwide registry-based FinACAF (Finnish Anticoagulation in Atrial Fibrillation) cohort included 67 503 patients with incident atrial fibrillation and indication for permanent oral anticoagulation (CHA2DS2-VASc score >1 in men and >2 in women) starting DOAC therapy between 2011 and 2018. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and composite of any MHC. The main outcome was nonpersistence of DOAC use, defined as the first 120-day period without DOAC purchases after drug initiation. The mean age of the patients was 75.3±8.9 years, 53.6% were women, and the prevalence of any MHC was 17.8%. Persistence after 1 year from DOAC initiation was 79.3% in patients without MHCs and 77.2% in patients with any MHC, and after 2 years were 64.4% and 60.6%, respectively (P<0.001). Higher incidence of nonpersistence to DOACs was observed in all MHC categories: adjusted subdistribution hazard ratios, 1.16 (95% CI, 1.11-1.21) for any MHC, 1.32 (95% CI, 1.22-1.42) for depression, 1.44 (95% CI, 1.15-1.80) for bipolar disorder, 1.25 (95% CI, 1.11-1.41) for anxiety disorder, and 1.30 (95% CI, 1.02-1.64) for schizophrenia. However, patients with only anxiety disorder without other MHCs were not at higher risk of nonpersistence. Conclusions MHCs are associated with nonpersistence of DOAC use. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537.

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

OBJECTIVE

Medication 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).

METHODS

The 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.

RESULTS

The 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)).

CONCLUSION

Adherence to DOACs in AF patients in Finland was relatively high, and no meaningful differences between patients with and without MHCs were observed.

The effect of mental health conditions on the use of oral anticoagulation therapy in patients with atrial fibrillation: The FinACAF Study

Aims

Little is known about the effects of mental health conditions (MHCs) on the utilization of oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients. We aimed to assess whether MHCs affect initiation of OAC therapy among AF patients with special focus on non-vitamin K antagonist oral anticoagulants (NOACs).

Methods and results

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) registry included all 239 222 patients diagnosed with incident AF during 2007–18 in Finland identified from national registries covering primary to tertiary care and drug purchases. Patients with previous depression, bipolar disorder, anxiety disorder, or schizophrenia diagnosis or a fulfilled psychiatric medication prescription within the year preceding the AF diagnosis were classified to have any MHC. The main outcome was OAC initiation, defined as first fulfilled OAC prescription after AF diagnosis. The patients’ mean age was 72.7 years and 49.8% were female. The prevalence of any MHC was 19.9%. A lower proportion of patients with any MHC compared with those without MHCs were initiated on OAC therapy (64.9% vs. 73.3%, P < 0.001). Any MHC was associated with lower incidence of OAC initiation [adjusted subdistribution hazard ratio (aSHR) 0.867; 95% confidence interval (CI) 0.856–0.880], as were depression (aSHR 0.868; 95% CI 0.856–0.880), bipolar disorder (aSHR 0.838; 95% CI 0.824–0.852), anxiety disorder (aSHR 0.840; 95% CI 0.827–0.854), and schizophrenia (aSHR 0.838; 95% CI 0.824–0.851), during the entire follow-up. Any MHC remained associated with impaired incidence of OAC initiation also in the NOAC era during 2015–18 (aSHR 0.821; 95% CI 0.805–0.837).

Conclusion

MHCs are common among AF patients, and they are associated with a lower rate of OAC initiation even during the NOAC era.