Anxiety and depression in non-cardiac surgical patients and associations with adverse outcomes: A systematic review and meta-analysis.

BACKGROUND

Mental health disorders such as anxiety and depression are associated with advanced disease at presentation, reduced treatment uptake, and worse postoperative outcomes. Despite this, preoperative screening remains underutilized. This systematic review and meta-analysis aimed to characterize the prevalence of preoperative anxiety and depression in non-cardiac surgery patients and assess their associations with adverse postoperative outcomes.

METHODS

The protocol was registered with PROSPERO (CRD42024578357) and followed PRISMA guidelines. MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and CENTRAL were searched. All studies included were prospective cohorts that enrolled a minimum of 100 adults undergoing non-cardiac surgery, used validated preoperative mental health screening tools, and reported postoperative outcomes. Studies involving cardiac, neurosurgical, or bariatric procedures were excluded. Random-effects meta-analysis generated pooled prevalence, mean difference (MD), and odds ratios (OR) with 95 % confidence intervals (CI) and 95 % prediction intervals (PI).

RESULTS

Forty-six studies (n = 23,628; mean age 58.5 ± 19.2 years; 61 % female) met inclusion criteria. Pooled prevalence of anxiety was 26 % (95 % CI, 21 %-31 %; 95 % PI, 20 %-33 %; I² = 95 %) while depression was 23 % (95 % CI, 14 %-31 %; 95 % PI, 14 %-36 %; I² = 100 %). The prevalence of anxiety ranged from 19 % in orthopedic to 29 % in cancer surgery. It was associated with a greater hospital length of stay (MD 0.55 days; 95 % CI, 0.29-0.82; 95 % PI, -0.04-1.14; I² = 0 %). The prevalence of depression ranged from 17 % in orthopedic to 30 % in cancer surgery and 24 % in mixed surgery. Preoperative depression was associated with increased odds of postoperative delirium (OR 2.33; 95 % CI, 1.74-3.11; 95 % PI, 1.5-3.5; I² = 0 %).

CONCLUSIONS

Anxiety and depression affect one-fifth of non-cardiac surgical patients, with highest prevalence in cancer surgery. Preoperative anxiety was associated with a greater hospital length of stay, while preoperative depression was associated with twofold risk of postoperative delirium. Therefore, routine preoperative mental health screening could identify high-risk patients and enable targeted perioperative interventions to reduce adverse outcomes.