Analysis of psychological problems and intervention effects in patients undergoing digital subtraction angiography neurointervention: A retrospective study

Abstract

BACKGROUND

Perioperative anxiety and depression are common in patients undergoing invasive procedures and can adversely affect recovery; however, the prevalence and modifiable factors in digital subtraction angiography (DSA) neurointerventional populations remain understudied.

AIM

To evaluate anxiety, depression, and social support status in patients undergoing DSA neurointerventional procedures and to analyze the effectiveness of structured psychological interventions in improving patients' psychological status.

METHODS

The medical records of 328 patients who underwent DSA neurointerventional procedures at Nantong First People’s Hospital between January 2022 and June 2024 were collected in this retrospective cohort study. The patients were divided into an intervention group (n = 168) and a routine care group (n = 160) based on whether they received a systematic psychological intervention during hospitalization. The Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), and Social Support Rating Scale (SSRS) scores and abnormal detection rates at discharge were compared between the two groups. Logistic regression analysis was used to identify the factors influencing anxiety status.

RESULTS

The intervention group showed significantly lower SAS scores (42.1 ± 7.8 vs 48.6 ± 9.2, P < 0.001) and SDS scores (43.5 ± 8.4 vs 49.3 ± 9.7, P < 0.001) at discharge compared with the routine care group, while SSRS scores (41.2 ± 6.3 vs 37.8 ± 7.1, P < 0.001) were significantly higher. The detection rates of anxiety (SAS ≥ 50) and depression (SDS ≥ 53) in the intervention group were 21.4% and 26.2%, respectively, significantly lower than 46.9% and 48.1% in the routine care group (both P < 0.001). Multivariate logistic regression showed that receiving psychological intervention was an independent protective factor for anxiety at discharge (odds ratio = 0.32, 95% confidence interval: 0.19-0.53), while low-level social support (SSRS < 40) was an independent risk factor (odds ratio = 2.87, 95% confidence interval: 1.68-4.90).

CONCLUSION

Patients undergoing DSA interventional procedures commonly experience anxiety, depression, and insufficient social support. Systematic psychological interventions can effectively improve patients’ negative emotions and enhance their perceived social support, thereby representing a key measure for promoting psychological recovery.

Key Words: Digital subtraction angiography; Interventional procedures; Anxiety; Depression; Social support; Psychological intervention; Retrospective cohort study

Core Tip: This retrospective study of 328 patients demonstrates that structured psychological interventions significantly reduce anxiety and depression while enhancing social support in patients undergoing digital subtraction angiography (DSA) neurointerventional procedures. Multivariate analysis revealed that psychological intervention independently reduced anxiety risk by 68%, whereas low social support increased risk nearly threefold. These findings provide the first systematic evidence from the broader DSA interventional population - extending beyond cardiac patients - and identify modifiable risk factors. We recommend integrating psychological assessment and intervention as routine components of DSA perioperative care, particularly for female patients and those with weak social support networks.

INTRODUCTION

Digital subtraction angiography (DSA)-guided interventional therapy is an important diagnostic and therapeutic modality for the treatment of cardiovascular and cerebrovascular diseases. Although this technique offers the advantages of minimal invasiveness and precision[1,2], the surgical procedure itself, as a stressor, often leads to significant anxiety, depression, and other negative psychological reactions[3,4]. Perioperative anxiety and depression are not limited to DSA procedures and represent widespread clinical challenges. A systematic review and meta-analysis of 46 prospective cohorts (23628 participants) reported a pooled preoperative anxiety prevalence of 26% [95% confidence interval (CI): 21%-31%] and a preoperative depression prevalence of 23% (95%CI: 14%-31%) in non-cardiac surgery populations, with anxiety associated with a prolonged hospital stay and depression linked to a two-fold increased risk of postoperative delirium[5]. Studies have shown that among patients undergoing diagnostic angiography, the proportion with clinically significant preoperative anxiety symptoms (Hospital Anxiety and Depression Scale-Anxiety score ≥ 8) can reach 24%-26%, while depressive symptoms (Hospital Anxiety and Depression Scale-Depression score ≥ 8) account for approximately 19%-21%[6]. In patients undergoing coronary angiography or angioplasty, preoperative anxiety rates ranged from 24% to 72%; one study found that 70.4% of cardiac patients experienced perioperative anxiety, and a lack of preoperative procedural information increased the likelihood of high anxiety by more than five-fold [odds ratio (OR) = 5.12][7]. Adverse perioperative psychological states not only reduce patient compliance and treatment experience but may also interfere with physiological homeostasis through neuroendocrine and immune mechanisms, affecting postoperative recovery and long-term treatment outcomes[8].

Recently, perioperative psychological interventions have attracted increasing attention. There is a growing body of evidence supporting its effectiveness. A systematic review and meta-analysis of randomized controlled trials (RCTs) found that preoperative psychological prehabilitation significantly reduces anxiety (SMD = -1.51) and depression (SMD = -1.48)[9]. Another large meta-analysis, including 16 RCTs, confirmed that preoperative psychological interventions resulted in significant anxiety reduction (SMD = 1.13)[10]. Studies of patients undergoing cardiac intervention and cerebral angiography have demonstrated that systematic psychological support can effectively alleviate anxiety and depression levels[6]. However, existing evidence has primarily focused on cardiac interventions, with most interventional studies targeting this population. In patients undergoing diagnostic and therapeutic DSA across the neurological, peripheral, and pelvic regions, the overall incidence of psychological problems and influencing factors remains poorly understood. Although a recent prospective study of 25 patients undergoing elective neurointerventional treatment (including aneurysms, arteriovenous malformations, and carotid stenoses) found that state anxiety scores improved from baseline to discharge[11], large-scale retrospective analyses examining negative emotions and social support concurrently in DSA neurointerventional cohorts are still lacking. Furthermore, the role of social support as an important psychological resource for alleviating medical stress during perioperative DSA has not been fully explored. Social support, defined as emotional, informational, or practical assistance from family, friends, or healthcare providers, has been shown to exert a protective effect on preoperative anxiety; a meta-analysis reported a pooled correlation coefficient of r = -0.372 (95%CI: -0.578 to -0.122), indicating a modest but significant inverse association[12]. However, its specific contribution to psychological outcomes of patients undergoing DSA neurointerventions remains unclear.

Notably, the DSA results themselves also had a moderating effect on patients’ psychological status. Patients with obstructive stenosis on angiography who underwent revascularization showed the most significant improvement in anxiety and depressive symptoms within 6 months, whereas patients with normal angiography results or only mild lesions showed relatively limited relief from psychological symptoms[6]. These findings suggest that different psychological support strategies should be adopted for patients with different angiographic findings and clinical backgrounds.

Given the above evidence gaps - namely, the lack of comprehensive data on the concurrent prevalence of anxiety, depression, and social support specifically in DSA neurointerventional populations, and the limited evaluation of structured psychological interventions in this context - the present study was designed with the following objectives: (1) To comprehensively evaluate the occurrence characteristics of anxiety and depression and the level of social support in patients undergoing DSA neurointerventional procedures through a retrospective cohort analysis; (2) To analyze the clinical effectiveness of a structured psychological intervention in improving patients’ emotional status and perceived social support levels; and (3) To identify independent factors (including intervention exposure and social support level) influencing post-procedural anxiety status. These findings are intended to provide an evidence-based foundation for constructing individualized, whole-process perioperative psychological nursing pathways for patients with neurointerventional DSA.

MATERIALS AND METHODS

Study design

This was a single-center retrospective cohort study. The study protocol was approved by the Ethics Review Committee of Nantong First People’s Hospital (Approval No. P2025022028), and the requirement for informed patient consent was waived.

Study subjects

Research data were obtained from the electronic medical record system of Nantong First People's Hospital from January 1, 2022 to June 30, 2024.

Inclusion criteria: (1) Age ≥ 18 years; (2) First-time DSA-guided neurointerventional procedures (including but not limited to cerebral angiography/stenting, peripheral vascular intervention, etc.) for diagnostic or therapeutic purposes; and (3) Hospitalization duration ≥ 3 days with structured data entry in electronic medical records and complete documentation of pre-discharge psychological assessment scale results.

Exclusion criteria: (1) Severe cognitive impairment, history of mental illness, or inability to cooperate with the assessment; (2) Emergency surgery or severe perioperative complications ( massive bleeding, stroke, or myocardial infarction); and (3) Missing key demographic or clinical data. DSA procedural standards followed the “Chinese Guidelines for DSA Procedure”[13].

A total of 328 patients were included in the study. Based on nursing records, patients who received structured psychological interventions implemented by trained nurses or psychotherapists with complete documentation during hospitalization were assigned to the intervention group (n = 168), whereas those who received routine preoperative education and nursing care were assigned to the routine care group (n = 160).

Variables and measurements

Sociodemographic and clinical characteristics: Data on age, sex, education level, diagnosis, procedural type, and comorbidities were collected from medical records.

Psychological intervention: Referencing the literature[14-16], the following interventions were provided by professional personnel: (1) Disease and surgical cognitive education: One-on-one explanation, group education, or provision of illustrated manuals; content covering the role of DSA, the operating room environment, intraoperative cooperation points, common postoperative sensations (such as puncture site compression), and normalization of anxiety; (2) Relaxation training guidance (such as deep breathing and progressive muscle relaxation); and (3) Therapeutic communication based on psychological support. In a safe, accepting atmosphere, patients were guided to discuss their concerns, fears, or expectations regarding surgery; specific affirmation was given to patients’ positive efforts, and personalized stress-coping strategies were explored. All nursing staff and psychotherapists involved in delivering the structured psychological intervention received a standardized training program prior to the implementation of the clinical protocol. The training, which was conducted by a licensed clinical psychologist with expertise in perioperative psychological care, comprised the following components: (1) Theoretical module (4 credit hours), covering the theoretical foundations of cognitive-behavioral approaches, therapeutic communication techniques, and the anatomical and procedural knowledge of DSA neurointerventions; (2) Skills training module (6 credit hours), including role-play scenarios for delivering disease education, facilitation of relaxation training, and conducting emotion-focused therapeutic conversations; and (3) Clinical assessment module (2 credit hours), focusing on the administration and interpretation of the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), and Social Support Rating Scale (SSRS). Trainees were required to achieve a passing score on a combined written and practical examination (≥ 85%) before being authorized to independently deliver the intervention. Refresher training sessions were provided quarterly to ensure the fidelity and consistency of the intervention across the study period.

Outcome indicators assessed before discharge: (1) Anxiety level was evaluated using Zung’s SAS, which contains 20 items with a standard score cutoff of 50 points. Scores of 50-59, 60-69, and ≥ 70 indicate mild, moderate, and severe anxiety, respectively; (2) Depression level was evaluated using Zung’s 20-item SDS, with a standard score cutoff of 53 points. Scores of 53-62, 63-72, and ≥ 73 indicate mild, moderate, and severe depression, respectively; and (3) Social support level was evaluated using the SSRS, containing 10 items, with a total score ≤ 40 indicating low-level social support. Based on the literature and clinical experience, age, sex, education level, procedural type (cardiac/neurological/peripheral vascular), and the number of chronic comorbidities were considered potential confounding factors.

Bias control

Continuous enrollment was adopted to reduce selection bias. To reduce information bias, two researchers who were unaware of the study hypothesis independently extracted scale score data from the medical records, with discrepancies resolved by a third party. For possible confounding bias, statistical correction was performed using multivariate analysis. The SAS, SDS, and SSRS data for all 328 patients were extracted from the electronic medical record system by two independent research assistants who were blinded to the study hypotheses. Inter-rater agreement for scale data extraction was 98.2% (κ = 0.96), indicating excellent reliability. Discrepancies in data extraction were resolved through discussions under the supervision of a third independent researcher.

Statistical analysis

SPSS software (version 26.0; IBM, Armonk, NY, United States) was used for all analyses. Continuous data with normal distribution were expressed as mean ± SD, with between-group comparisons using the independent samples t-test, and non-normally distributed data were expressed as median (interquartile range) using the Mann-Whitney U test. Categorical data were expressed as n (%), with between-group comparisons using the χ² test or Fisher’s exact test.

Main analyses included: (1) Comparison of SAS, SDS, SSRS scores and abnormal detection rates between the two groups; and (2) Multivariate binary logistic regression analysis with the presence of anxiety at discharge (SAS ≥ 50) as the dependent variable, including variables with P < 0.1 in univariate analysis and the research-focused “intervention” variable, calculating ORs and 95%CIs. Model fit was assessed using the Hosmer-Lemeshow test. All statistical tests were two-sided, and statistical significance was set at P < 0.05.

RESULTS

Study subject flow and baseline characteristics

During the study period, 415 patients who underwent interventional DSA procedures were screened. Based on the inclusion and exclusion criteria, 328 patients were included in the analysis: 168 in the intervention group and 160 in the routine care group. The intervention and routine care groups were well balanced at baseline. The mean age was 57.9 ± 10.1 years in the intervention group vs 59.5 ± 10.7 years in the routine care group (P = 0.166). Male patients comprised 61.3% (103/168) of the intervention group and 59.4% (95/160) of the routine care group (P = 0.722). No significant differences were observed between the two groups in terms of education level (college degree and above: 41.7% vs 45.6%, P = 0.593), patient type distribution (P = 0.954), or number of comorbidities (1.7 ± 1.0 vs 1.9 ± 1.2, P = 0.095; Table 1).

Table 1 Comparison of baseline characteristics between the two groups, mean ± SD/n (%).

Characteristic	Overall (n = 328)	Intervention group (n = 168)	Routine care group (n = 160)	χ2/t value	P value
Age (years)	58.7 ± 10.4	57.9 ± 10.1	59.5 ± 10.7	-1.389	0.166
Sex				0.127	0.722
Male	198 (60.4)	103 (61.3)	95 (59.4)
Female	130 (39.6)	65 (38.7)	65 (40.6)
Education level				1.045	0.593
High school and below	185 (56.4)	98 (58.3)	87 (54.4)
College degree and above	143 (43.6)	70 (41.7)	73 (45.6)
Patient type				0.335	0.954
Acute ischemic stroke thrombectomy	135 (41.2)	70 (41.7)	65 (40.6)
Intracranial aneurysm embolization	116 (35.4)	56 (33.3)	60 (37.5)
Intracranial/extracranial artery stenosis stenting	50 (15.2)	28 (16.7)	22 (13.8)
Cerebral vascular malformation embolization	27 (8.2)	14 (8.3)	13 (8.1)
Number of comorbidities	1.8 ± 1.1	1.7 ± 1.0	1.9 ± 1.2	1.672	0.095

Comparison of psychological scale scores

At discharge, the intervention group demonstrated significantly lower SAS scores (42.1 ± 7.8 vs 48.6 ± 9.2, MD = -6.5, 95%CI: -8.3 to -4.7, P < 0.001) and SDS scores (43.5 ± 8.4 vs 49.3 ± 9.7, MD = -5.8, 95%CI: -7.7 to -3.9, P < 0.001) compared with the routine care group. These reductions are clinically meaningful, as a difference of ≥ 5 points on the SAS and SDS scales is generally considered to reflect a noticeable improvement in symptom severity. Conversely, SSRS scores were significantly higher in the intervention group (41.2 ± 6.3 vs 37.8 ± 7.1, MD = 3.4, 95%CI: 2.0-4.8, P < 0.001; Table 2).

Table 2 Comparison of pre-discharge psychological scale scores between the two groups, mean ± SD.

Scale	Intervention group (n = 168)	Routine care group (n = 160)	t value	P value
SAS score	42.1 ± 7.8	48.6 ± 9.2	-7.125	< 0.001
SDS score	43.5 ± 8.4	49.3 ± 9.7	-6.052	< 0.001
SSRS score	41.2 ± 6.3	37.8 ± 7.1	4.728	< 0.001

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; SSRS: Social Support Rating Scale.

Comparison of psychological problem detection rates

Using the standard cutoff scores (SAS ≥ 50 for anxiety; SDS ≥ 53 for depression), the detection rate of anxiety was 21.4% (36/168) in the intervention group compared with 46.9% (75/160) in the routine care group (χ² = 24.624, P < 0.001). This represented a 54.4% relative risk reduction, indicating that for every five patients receiving the intervention, approximately one additional case of postoperative anxiety was prevented. Similarly, the detection rate of depression was 26.2% (44/168) in the intervention group vs 48.1% (77/160) in the routine care group (χ² = 17.469, P < 0.001). Regarding severity distribution, the proportion of moderate-to-severe anxiety was 4.8% in the intervention group compared to 12.5% in the routine care group, while the proportions of moderate-to-severe depression were 5.4% and 11.9%, respectively (Table 3). The greater reduction in moderate-to-severe cases (a decrease of 61.6% for anxiety and 54.6% for depression) suggests that the intervention may be particularly effective in preventing more severe psychological morbidities.

Table 3 Comparison of pre-discharge anxiety and depression detection rates between the two groups, n (%).

Psychological problem	Intervention group (n = 168)	Routine care group (n = 160)	χ2 value	P value
Anxiety (SAS ≥ 50)	36 (21.4)	75 (46.9)	24.624	< 0.001
Mild	28 (16.7)	55 (34.4)
Moderate to severe	8 (4.8)	20 (12.5)
Depression (SDS ≥ 53)	44 (26.2)	77 (48.1)	17.469	< 0.001
Mild	35 (20.8)	58 (36.3)
Moderate to severe	9 (5.4)	19 (11.9)

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Multivariate logistic regression analysis of factors influencing pre-discharge anxiety status

Multivariate logistic regression was performed with the presence of anxiety at discharge (SAS ≥ 50) as the dependent variable. After controlling for other factors, receiving psychological intervention was an independent protective factor against anxiety (OR = 0.32), whereas low social support (SSRS < 40) was an independent risk factor (OR = 2.87). Female patients showed a higher anxiety risk (OR = 1.82); however, age, educational level, and procedural type showed no independent associations in this model (Table 4). From a clinical perspective, the OR of 0.32 for psychological intervention translates to a number needed to treat of approximately four (95%CI: 3-6), meaning that four patients would need to receive structured psychological intervention to prevent one additional case of postoperative anxiety. Conversely, an OR of 2.87 for low social support indicates that patients with low social support have nearly three times the odds of developing postoperative anxiety, highlighting the importance of assessing and enhancing social support networks in routine clinical practice.

Table 4 Multivariate logistic regression analysis of factors influencing pre-discharge anxiety (Self-Rating Anxiety Scale ≥ 50) in patients.

Variable	β value	SE	Wald χ2 value	P value	OR	95%CI
Receiving psychological intervention (yes vs no)	-1.139	0.257	19.664	< 0.001	0.32	0.19-0.53
Social support (low vs medium-high)	1.054	0.275	14.692	< 0.001	2.87	1.68-4.90
Sex (female vs male)	0.598	0.248	5.813	0.016	1.82	1.12-2.96
Age (per 10-year increase)	-0.182	0.119	2.338	0.126	0.83	0.66-1.05
Education level (college and above vs high school and below)	-0.321	0.251	1.636	0.201	0.73	0.44-1.19
Surgery type (neurointervention vs cardiac)	0.402	0.285	1.991	0.158	1.49	0.86-2.61
Surgery type (peripheral intervention vs cardiac)	0.105	0.377	0.078	0.780	1.11	0.53-2.33
Constant	-1.234	0.489	6.364	0.012	0.29

Hosmer-Lemeshow test: χ² = 7.203, P = 0.515, indicating good model fit. OR: Odds ratio; CI: Confidence interval.

DISCUSSION

This retrospective cohort analysis found that the detection rates of anxiety and depression at discharge in patients undergoing DSA neurointerventional procedures with routine care were as high as 46.9% and 48.1%, respectively, similar to previous research findings regarding significant negative emotions in the perioperative period of cardiac intervention patients[11,17]. In a perioperative evaluation of 121 patients with unruptured intracranial aneurysms scheduled for endovascular embolization using the Hospital Anxiety and Depression Scale, 42 (34.7%) reached critical or clinical anxiety levels, and 40 (33.1%) reached critical or clinical depression levels. Riccietti et al[11] evaluated patients undergoing elective neurointerventional treatment and found that 17/23 cases (74%) had preoperative anxiety symptoms. Studies have shown that psychological interventions before and after interventional treatment for cardiac disease can significantly improve patients' anxiety and depressive symptoms, thereby promote postoperative recovery and improve their quality of life[18]. Building on existing evidence, this study’s innovation lies in three aspects: (1) Extending the research scope to the broader DSA neurointerventional field; (2) Simultaneously incorporating social support as an important psychological resource indicator; and (3) Identifying low social support as an independent risk factor for postoperative anxiety (OR = 2.87).

After implementing structured interventions (disease education, relaxation training, and therapeutic communication), the patients in the intervention group showed positive changes. The SAS and SDS scores were significantly lower than those for the routine care group, whereas the SSRS scores were significantly higher. Moreover, the detection rates of postoperative anxiety and depression in the intervention group decreased by more than 50% compared to those in the routine care group. To better understand these improvements, we propose a cascading mechanism framework: (1) Cognitive education reduces information uncertainty, attenuating fear of the unknown; (2) Relaxation training interrupts the positive feedback loop between physiological stress and anxiety appraisal; and (3) Therapeutic communication facilitates cognitive reappraisal of threats. These mechanisms collectively explain the observed reductions in the SAS and SDS scores. This conclusion is supported by several similar studies. For example, García et al[19] showed that preoperative consultation with animated videos significantly improved patients’ knowledge (from 5.1 to 10.5) and reduced trait anxiety (from 45.7 to 42.9). Liu et al[20] demonstrated that a virtual reality intervention reduced state anxiety and improved self-efficacy in patients undergoing carotid artery stenting. Wu et al[21] explored a whole-process health education model based on “Internet + science popularization” in patients undergoing DSA. These studies indicate that addressing psychosocial needs is the key to improving clinical outcomes.

Multivariate analysis further revealed the protective effects of psychological interventions. Even after adjusting for confounders, the psychological intervention reduced anxiety risk by approximately 68% (OR = 0.32, 95%CI: 0.19-0.53). This magnitude corresponds to a number needed to treat of approximately 3-4, suggesting high practical utility. Meanwhile, low social support increased anxiety risk by nearly threefold (OR = 2.87, 95%CI: 1.68-4.90). Recent evidence indicates that social support buffers preoperative anxiety through multiple pathways, including by reducing uncertainty, enhancing coping resources, and modulating physiological stress responses[12]. Therefore, assessing and mobilizing patients’ families and social support systems are crucial. Female patients showed a higher anxiety risk (OR = 1.82), which may reflect biological (e.g., hormonal influences), psychological (e.g., higher illness uncertainty), and social (e.g., differential distress disclosure) factors, suggesting that female patients may benefit from targeted screening and support.

Mechanisms underlying the effectiveness of psychological interventions involve multiple factors. First, DSA is an invasive procedure that is a major stressor; psychological intervention reduces fear of the unknown and loss of control[22]. Second, structured interventions such as cognitive-behavioral therapy help correct catastrophic thinking regarding disease prognosis and procedural risks. Third, psychological interventions (e.g., the Roy adaptation model) promote positive coping strategies and self-efficacy[23]. Finally, neuroplasticity provides a biological basis; effective psychological interventions (mindfulness, cognitive-behavioral therapy) enhance functional connectivity in emotion-related brain networks (default mode, salience, and central executive networks)[24,25] and induce structural plasticity in the limbic regions[26-28]. In summary, psychological interventions promote neuroplasticity and provide a neurobiological foundation for clinical efficacy.

This study has several limitations. First, the retrospective, non-randomized design may introduce selection bias; future prospective RCTs with concealed allocation are needed. Second, psychological assessment was conducted only at discharge, lacking preoperative baseline and long-term follow-up; longitudinal studies with multiple time points are warranted. Third, social support data were self-reported; future studies could supplement them with objective indicators. Fourth, no prior sample size estimation was conducted; subgroup analyses (e.g., procedural type) may be underpowered, and the null findings for the procedural type (OR = 1.49, neurointervention vs cardiac, P = 0.158) should be interpreted cautiously.

CONCLUSION

This study confirmed that patients undergoing DSA interventional procedures commonly face high risks of anxiety and depression during the perioperative period with insufficient social support. This retrospective cohort analysis showed that a structured psychological intervention could effectively alleviate patients’ negative emotions, enhance their perceived social support levels, and serve as a key protective factor in reducing the risk of postoperative anxiety. Systematic psychological assessments and interventions are recommended as routine components of DSA perioperative care, with particular attention paid to female patients and those with weak social support to promote comprehensive physical and mental recovery.