Association of Depression and Adherence to Oral Anticoagulation in Patients With Atrial Fibrillation

Abstract

Background: Adherence to oral anticoagulation is essential for stroke prevention in atrial fibrillation (AF). Depression has been associated with decreased adherence to medications in multiple disease states and in AF is further associated with increased risk of stroke. We hypothesized that individuals with depression and AF have decreased adherence to anticoagulation than those without depression.

Methods and results: We used administrative claims data to identify individuals with AF initiating anticoagulation with direct-acting oral anticoagulants (DOACs) or warfarin between 2013 and 2019. We quantified adherence using proportion of days covered, categorized as limited (proportion of days covered, <80%), adequate (proportion of days covered, ≥80% to <90%), or optimal (proportion of days covered, ≥90%). We related depression to 12-month adherence to anticoagulation in logistic regression models, adjusting for demographics, medical and psychiatric comorbidities, household income, educational attainment, and insurance type. As a secondary analysis, we determined the association of depression to adherence for each DOAC agent. We identified 101 041 individuals (aged 74.5±8.9 years; 50.6% women; 29.5% race or ethnicity other than White, including Asian or Black race and Hispanic ethnicity) who initiated either DOACs or warfarin. The odds of adequate adherence to DOACs was 11% (95% CI, 0.85-0.93), and the odds of optimal adherence was 12% (95% CI, 0.83-0.91) less in individuals with depression than those without. Depression was not associated with adherence to warfarin.

Conclusions: We identified an association between depression and decreased adherence to DOACs but not warfarin in individuals with AF. Recognizing depression in AF may guide interventions to improve anticoagulation adherence and reduce stroke risk.

Keywords: adherence; anticoagulation; atrial fibrillation; depression.

Figure 1. Percentage of individuals with limited, adequate, and optimal adherence to DOACs and warfarin, defined by PDC.

Bar graph of the percentage of individuals with limited (PDC, <80%), adequate (PDC, ≥80% to <90%), and optimal (PDC, ≥90% to 100%) adherence. Individuals are categorized on the basis of depression status. DOAC indicates direct‐acting oral anticoagulant; and PDC, proportion of days covered.

Figure 2. Odds of adequate (A) and optimal (B) adherence to DOACs and warfarin in individuals with depression in reference to those without depression.

A, Adjusted odds ratio of adequate medication adherence (defined as PDC, 80% to <90%). B, Adjusted odds of optimal medication adherence (PDC, ≥90%). A, Adjusted for age, sex, and race and ethnicity. B, Additional inclusion of number of medical comorbidities listed in the Elixhauser Comorbidity Index and number of psychiatric comorbidities. C, Additional inclusion of educational attainment, annual household income, and insurance type. DOAC indicates direct‐acting oral anticoagulant; and PDC, proportion of days covered.