VTE RISK IN ACUTE PSYCHIATRIC CARE
Hospital Associated Thrombosis (HAT) is defined as venous thromboembolism (VTE) diagnosed during hospitalisation or within 90 days of discharge following an in-patient stay.1
VTE in Psychiatric Patients
The 2018 NICE VTE Guidelines on HAT (NG89) recommended that acute psychiatric in-patients should have VTE risk assessment and appropriate thromboprophylaxis.1 Despite this, the existing Department of Health VTE risk assessment tool does not include specific mention of factors relevant to psychiatric inpatients.
There is limited data on the incidence of HAT in psychiatric in-patients, however in 2024 Codling D, Mueller C, Patel J, Stewart R, Arya R, and Roberts L. published a paper on ‘Rates of venous thromboembolism associated with acute psychiatric admission: A retrospective cohort study15’.
The study was a retrospective cohort study looking at VTE incidence in patients admitted to a psychiatric unit compared to community controls. The incidence of VTE within 3 months of admission to a psychiatric ward was 1.5 per 1,000 admissions. Although the study was not powered to find a statistically significant difference, it was striking that there were 11 cases amongst admitted patients with none in the control group of community mental health patients.
While there is no data on HAT morbidity and mortality in psychiatric in-patients in the British system; although we know HAT cases do occur and reach the coroner, requiring post-mortem. 3 There is an increasing body of evidence that patients with severe mental illness are at increased risk of VTE.
Prevention of Future Deaths Reports - Regulation 28 Reports
Regulation 28 ‘Hospital Death (Clinical Procedures and medical management) related deaths (VTE)
Regulation 28 ‘Mental Health related deaths’ (VTE)
Evidence
There is considerable evidence that antipsychotic medicines are associated with VTE 5-10.
A recent meta-analysis, identified differences in risk between different antipsychotics.
- First Generation Antipsychotics (FGA) were associated with an increased VTE risk (OR 1.83; 95% CI 1.47-2.27). 8
- Low potency FGAs were said to have a higher risk of VTE (OR 2.68; 95% CI 1.75-4.1) than high-potency FGAs (OR 1.85; 95% CI 1.36-2.52). 8
- Second Generation Antipsychotic (SGA) use was associated with a two-fold increased VTE risk (OR 2.06; 95% CI 1.5-2.82). 8
This, and another meta-analyses9 found high levels of heterogeneity among the studies, and scarce data for individual antipsychotics, meaning these results must be interpreted with caution. 8-9
The association of antidepressant medication with VTE and bleeding risks were interpreted differently in MHTs, with one citing them as a thrombotic risk factor, and two listed SSRIs/SNRIs antidepressants as a bleeding risk.
Evidence suggests that antidepressant use carries a slightly increased VTE risk. 11-12Two meta-analyses identified that VTE risk when comparing antidepressant use with no antidepressant was small RR 1.27( 95% CI 1.06-1.51) 11 in one and OR 1.27 (95% CI 1.09-1.49) in the other.12
The current evidence does not suggest inclusion of antidepressants as a thrombotic risk factor in RAT, but further research is required.
Bleeding risk with SSRI use was assessed in a meta-analysis of 42 observational studies demonstrating a significant association (OR 1.41; 95% CI 1.27-1.57), 13 while another meta-analysis of 22 studies identified that upper GI bleeding was greater in SSRI users compared to non- users (OR 1.55; 95% CI 1.35-1.78), and the association was greatest for those also taking NSAIDs or anti-platelet medications. 14
Bleeding risks and thrombotic risks associated with antidepressants require further research in the context of VTE RAT.
2024 HSSIB report
The investigation also identified incidents where physical health monitoring had not supported recognition of changes in a patient’s long-term condition or prevented known complications from care.
2.2.25 ‘…where patients had developed blood clots contributed to by inactivity and dehydration. The assessment for and prevention of blood clots was a further concern in reports to prevent future deaths.’
2024 BMJ report
Showed a risk rate increase of VTE of about 1.5 and concluding, ‘any potential benefits of antipsychotic treatment need to be weighed against risk of serious harm and treatment plans should be reviewed regularly.’
Freedom of Information – A National Picture
In 2021, a group of interested physicians joined with Thrombosis UK to assess HAT prevention practice in all 71 NHS England Mental Health Trusts (MHTs) via a survey sent by Thrombosis UK, through a Freedom of Information (FOI) request, in June 2021. Information requested included details of HAT policy, risk assessment tools (RAT), and HAT rates in the last five years. Data was analysed using simple statistical analysis.
The group and activity received no funds, grants, or support. There were no competing relevant financial or non-financial interests and all members authors contributed to the group and subsequent study conception and design. Material preparation, data collection and analysis were performed by A Purcell, BJ Hunt, M Cheah, J Jerrome and A Mohamed. All authors contributed to the manuscript and read and approved the final manuscript.
Prevention Of Hospital Associated Venous Thromboembolism In Psychiatric Inpatients: A Survey Of Current Practice Within Mental Health Trusts In England
Dr. A. Mohamed, Dr. M. Cheah, Professor B. Hunt, Dr J. Jenkinson, J. Jerrome, A. Purcell
Presented at the Royal College of Psychiatrists International Congress June 2022
The study highlighted that MHTs have identified multiple issues unique to mental health care they consider as risk factors for HAT. These include:
- immobilisation due to catatonia,
- psychomotor retardation,
- severe depression and seclusion.
- Bleeding risks associated with self-injurious behaviour, and a ligature risk associated with anti-embolism stockings were included by some.
While many of these factors seem logical to consider, there is scanty published evidence on these risk factors.
The groups considers priority questions should include:
- Whether the use of antipsychotic medications should be included as a risk factor for HAT.
- What are the underlying rates of HAT in psychiatric in-patients.
- How effective is thromboprophylaxis in these patients?
The survey results indicate an urgent need for policy and guideline makers to review the variation in RATs used in psychiatric in-patients, with a priority goal to harmonise a national risk assessment tool. In the interim, we wish to encourage those MHTs without a HAT prevention policy to implement one, for those with adapted RATs to review their tools, and for all to collect HAT rates systematically.
References
- National Institute for Health and Care Excellence .Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism NICE guideline [NG89]: Updated August 2019. Available on https://www.nice.org.uk/guidance/NG89 (accessed 12 Dec 2022)
- Delluc A, Montavon S, Canceil O, Carpentier M, Nowak E, Mercier B et al. Incidence of venous thromboembolism in psychiatric units. Thromb Res. 2012 Dec; 130 (6):e283-288. Available on https://doi.org/10.1016/j.thromres.2012.10.002.Epub 2012 Oct 23. (accessed 12 Dec 2022)
- Personal communication: Professor Sebastian Lucas, former Professor of Pathology , King’s College, London.
- Department of Health UK. Risk Assessment for Venous Thromboembolism 2010. Available on https://www.nice.org.uk/guidance/ng89/resources/department-of-health-vte-risk-assessment-tool-pdf-4787149213 (accessed 12 Dec 2022)
- Hippisley-Cox J, Coupland C. Development and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism: prospective cohort study. BMJ. 2011 Aug 16; 343: d4656. Available on https://doi.org/ 10.1136/bmj.d4656 (accessed 12 Dec 2022)
- Barbui C, Conti V, Cipriani A. Antipsychotic drug exposure and risk of venous thromboembolism: a systematic review and meta-analysis of observational studies. Drug Saf. 2014 Feb;37(2):79-90.Availabel on https://doi.org/10.1007/s40264-013-0127-6 (accessed 12 Dec 2022)
- Zhang R, Dong L, Shao F, Tan X, Ying K. Antipsychotics and venous thromboembolism risk: a meta-analysis. Pharmacopsychiatry. 2011 Jul; 44(5):183-8. Available on https://doi.org/10.1055/s-0031-1280814 (accessed 12 Dec 2022)
- Xuan D, Chen M, Shen S, Cui X. Antipsychotic use and risk of Venous thromboembolism: a meta-analysis. Psychiatry Research 2021. Available on https://doi.org/10.1016/j.psychres.2020.113691 (accessed 12 Dec 2022)
- Liu Y, Xu J, Fang K, Xu Y, Gao J, Zhou C, Tang X, Fang X, Chen J, Xie C, Zhang F, Zhang X, Wang C. Current antipsychotic agent use and risk of venous thromboembolism and pulmonary embolism: a systematic review and meta-analysis of observational studies. Ther Adv Psychopharmacol. 2021 Jan 14; 11:2045125320982720. Available on https://doi.org/10.1177/2045125320982720 (accessed 12 Dec 2022)
- Purcell, A., Clarke, M. & Maidment, I. Venous thromboembolism prophylaxis in mental health in-patient services: a qualitative study. Int J Clin Pharm. 2018;40: 543–549 (2018). Available on https://doi.org/10.1007/s11096-018-0599-7(accessed 12 Dec 2022)
- Kunutsor S, Seidu S, Khunti K. depression, antidepressant use, and risk of Venous Thromboembolism: a systematic review and meta-analysis of published observational evidence. Annals of Medicine 2018; 50: 6, 529-537. Available on https://doi.org/10.1080/07853890.2018.1500703 (accessed 12 Dec 2022)
- Wang Y, Ye Z, Liu L, Cui X. Antidepressant Use and Risk of Venous Thromboembolism: A Systematic Review and Meta-Analysis. J Pharm Sci. 2019; 22(1):57-71. Available on https://doi.org/10.18433/jpps30129(accessed 12 Dec 2022)
- Laporte S, Chapelle C, Caillet P, Beyens M-N, Bellet F, Delavenne X. Bleeding risk under antidepressants; a meta-analysis of observational studies . Pharmacol Res 2017 Apr; 118:19-32. Available on https://doi.org/10.1016/j.phrs.2016.08.017 (accessed 12 Dec 2022)
- Jiang H-Y, Chen H-Z, Hu X-J e, Yu Z-H, Yang W, Deng M et al. Use of serotonin reuptake inhibitors and risk of upper gastrointestinal bleeding: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2015 Jan; 13(1):42-50.e3. Available on https://doi.org/10.1016/j.cgh.2014.06.021 (accessed 12 Dec 2022)
- Codling D, Mueller C, Patel J, Stewart R, Arya R, Roberts L. Rates of venous thromboembolism associated with acute psychiatric admission: A retrospective cohort study. Exp Ther Med. 2024 Mar 8;27(5):188.
Available on https://doi.org/10.3892/etm.2024.12476. PMID: 38533433; PMCID: PMC10964734