Objective:

To evaluate the association between mood and psychotic disorders, anticoagulation adherence, and ischemic stroke among patients with non-valvular atrial fibrillation (NVAF) in a Southern California integrated health system.

Background:

NVAF increases ischemic stroke risk, making adherence to anticoagulation critical. Direct oral anticoagulants (DOACs) and warfarin rely on consistent use. While depression has been linked to lower adherence, the impact of other psychiatric disorders on adherence and stroke risk is less understood.

Design/Methods:

We retrospectively collected data from 15 hospitals between January 1, 2017, and December 31, 2022. Baseline demographics, vascular risk factors, anticoagulation type, and mental health disorders were recorded. Adherence was quantified using proportion of days covered (PDC) and categorized as nonadherent (<80%), adequate (≥80% to <90%), or optimal (≥90%) for one year after NVAF diagnosis. Ischemic stroke incidence included any cerebral infarction diagnosed after NVAF diagnosis. Bivariate comparisons used chi-squared and Wilcoxon rank-sum tests. Multinomial logistic regression assessed associations between mental health disorders, adherence, and stroke incidence.

Results:

Among 18,139 NVAF patients initiating DOACs or warfarin (56.4% male, mean age 72.6 ± 5.3 years), 18.8% had a documented mental health disorder. Mental health disorders were not associated with adequate adherence (PDC ≥80% to <90%) for DOACs or warfarin. Patients with mental health disorders had lower odds of optimal adherence with DOACs in minimally adjusted models (OR 0.86, 95% CI 0.78–0.96; P = .006), but not with warfarin. Mental health disorders were not associated with incident ischemic stroke (OR 0.92, 95% CI 0.81–1.05; P = .22). 

Conclusions:

Mental health disorders were not associated with adequate anticoagulation adherence or incident ischemic stroke but were linked to lower optimal adherence with DOACs, an effect attenuated by clinical and social factors. These findings suggest that system-level supports within an integrated healthcare setting may mitigate gaps in adherence and stroke risk among NVAF patients with psychiatric comorbidities.