Global epidemiology of mental disorder in atrial fibrillation between 1998-2021: A systematic review and meta-analysis

Table 1 Characteristic of included studies

Ref.	Study year	Study type	Region (country)	Type of MH	Diagnostic criteria of MH	Age (mean ± SD) (yr)1	Generation (yr)	AF (n)	P (MH in AF); Total (M/F) (%)
Thrall et al[20]	-	-	Europe (United Kingdom)	D and A	Depression-BDI; anxiety-STAI	66.30 11	Adult (≥ 18 y)	101	D (38.00); A (28.00/38.00)
Ariansen et al[35]	-	-	Europe (Norway)	D	HADS	-	Adult (≥ 75 y)	27	11.10
Gehi et al[32]	2008-2011	Cohort study	North America (United States)	D and A	Depression-PHQ-9; anxiety-HADS	61.70 13.50	Adult (≥ 18 y)	300	D (50.00); A (17.00)
Ball et al[31]		SAFETY	Oceania (Austria)	D	CES-D	75 13	Adult (≥ 45 y)	335	29.00
Schnabel et al[30]	2007	Population-based Gutenberg Health Study	Europe (Germany)	D	PHQ-9	64.8 8.2	Adult (35-74 y)	309	8.00
Thompson et al[19]	2009-2012	Cohort study	North America (United States)	D and A	Anxiety-HADS-A Depression-PHQ-9	61.60 13.30	Adult (≥ 18 y)	378	D (39.40/16.9); A (17.72)
von Eisenhart Rothe et al[21]	2005-2008	Cross-sectional study	Europe (Germany)	D	MDI scale	-	Adult (≥ 18 y)	702	73.00
Hsu et al[29]	-	Population based community health survey	Asia (China)	D and A	HADS	74.90 6.90	Adult (≥ 65 y)	1732	D (14.00); A (36.00)
Wändell et al[28]	2001-2007	Cohort study	Europe (Sweden)	D and A	ICD-10	-	Adult (≥ 45 y)	12283 (6702/5750)	D (8.50) (6.10/10.90); A (4.03) (2.70/5.40)
Hu et al[12]	2000-2010	Cohort study	Asia (China)	D and A	ICD-9-CM	72.70 13.40	Adult (≥ 18 y)	88259	D (1.57); A (1.06)
Rewiuk et al[13]	2007-2012	Population-based, multicenter study	Europe (The Republic of Poland)	D	GDS	78.0 7.7	Adult (65-104)	788	41.24
Polikandrioti et al[15]	-	-	Europe (Greece)	D and A	HADS	-	Adult (≥ 18 y)	170	Anxiety-low (38.25) (39.80/35.30); anxiety-moderate (26.47) (31.40/15.70); anxiety-high (34.71) (28.80/49.00); depression-low (63.53) (65.80/60.80); depression-moderate (15.29) (14.50/17.60); depression-high (20.00) (19.70/21.60)
Hagengaard et al[16]	2005-2014	Cohort study	Europe (Denmark)	D and A	ICD-10	-	-	146377	D (0.29); A (0.07)
Uchmanowicz et al[17]	2019	Cross-sectional study	Europe (The Republic of Poland)	D	HADS GDS	70.27 3.48	Adult (≥ 65y)	100	Anxiety (HADS 8-10) (22.00); anxiety (HADS 11-21) (20.00); depression (HADS 8-10) (26.00); depression (HADS 11-21) (28.00); depression (GDS 6-15) (51.00)
Krupenin et al[18]	2017-2018	-	Europe (Russia)	D and A	GDS	782	Adult (≥ 65 y)	48	41.67
Wang et al[22]	-	SAGE-AF Study	North America (United States)	D and A	Anxiety-GAD Depression-PHQ-9	76.00 7.00	Adult (≥ 65 y)	1244	D (29.00); A (24.00)
Kim et al[23]	2009-2018	Cohort study	Asia (Korea)	D	ICD-10	46.99 14.06	Adult (≥ 20 y)	5031222	3.00 (1.04/1.92)
Jankowska-Polańska et al[24]	-	Cohort study	Europe (The Republic of Poland)	D and A	HADS	70 7	Adult (≥ 60 y)	158	Depression (8-10) (37.97); depression (11-21) (37.87); anxiety (8-10) (32.91); anxiety (11-21) (48.10)
Feng et al[25]	2006-2008	HUNT study	Europe (Germany)	D and A	HADS	53.4 15.2	Adult (≥ 20y)	37402	D (2.20); A (4.90)
Wändell et al[28]	1998-2012	Cohort study	Europe (Sweden)	D and A	ICD-10	-	Adult (≥ 45 y)	537513 (287959/249554)	D (3.91) (3.46/4.44); A (2.70) (2.23/3.25)
Piwoński et al[27]	-	Cross-sectional study	Europe (The Republic of Poland)	D	BDI	-	Adult (18-79 y)	124 (57/67)	47.58 (43.86/50.75)
Wu et al[33]	2020-2021	-	Asia (China)	D	PHQ-9	-	Adult (≥ 18 y)	329	35.56
Fenger-Grøn et al[34]	2005-2016	-	Europe (Denmark)	D	ICD-8/ICD-10	78.7 10.1	Adult (18-100 y)	147162	12.16
Rosman et al[36]	-	Cohort study	North America (USA)	D and A	ICD-9	30.29 9.19	Adult (18-60 y)	988090	9.04
Zhang et al[37]	2012-2013	Cross-sectional study	Asia (China)	D	PHQ-9	63.3 9.5	Adult (≥ 35 y)	134	63.00

¹Ages in atrial fibrillation patients.

²Median age.

A: Anxiety; AF: Atrial fibrillation; BDI: Beck depression inventory; CES-D: Centre for epidemiological studies depression scale; D: Depression; GAD-7: 7-item generalized anxiety disorder-7 scale; GDS: Geriatric depression scale; HADS: Hospital anxiety and depression scale; HUNT study: The trøndelag health study; ICD: International classification of diseases; MDI: Major depression inventory; MH: Mental health; PHQ: Patient health questionnaire; SAFETY: Standard versus atrial fibrillation specific management study; SAGE-AF: Systematic assessment of geriatric elements in atrial fibrillation; STAI: Stait-trait anxiety inventory.

Table 2 Prevalence of mental health in atrial fibrillation patients

Study or subgroup	Prevalence (95%CI)	I² (%)	P value
Depression
Overall prevalence	22.0 (0.207, 0.233)	100	< 0.001
Prevalence in adults	24.3 (0.228, 0.257)	100	< 0.001
Gender
Male	11.7 (0.088, 0.147)	97.3	< 0.001
Female	19.8 (0.144, 0.252)	98.7	< 0.001
Age group
≥ 60 yr	40.3 (0.264, 0.541)	100	< 0.001
Other ages	20.4 (0.188, 0.221)	100.0	< 0.001
Study design
Cross-sectional study	58.2 (0.468, 0.695)	91.7	< 0.001
Cohort study	15.3 (0.124, 0.182)	100	< 0.001
Others	24.4 (0.217, 0.271)	99.9	< 0.001
Region
Asia	8.6 (0.072, 0.100)	100	< 0.001
Europe	30.2 (0.274, 0.330)	99.9	< 0.001
North America	28.8 (0.145, 0.431)	99.3	< 0.001
Oceania	29.0 (0.242, 0.341)	0	-
Diagnostic criteria
BDI	43.4 (0.370, 0.499	0	-
HADS	32.3 (0.187, 0.459)	99.5	< 0.001
PHQ-9	34.4 (0.225, 0.463)	98.3	< 0.001
MDI	72.8 (0.693, 0.761)	0	-
CES-D	29.0 (0.242, 0.341)	0	-
ICD	6.3 (0.039, 0.087)	100	< 0.001
GDS	44.1 (0.380, 0.503)	41.2	0.183
Anxiety
Overall prevalence	13.0 (0.117, 0.142)	99.9	< 0.001
Prevalence in adults	14.5 (0.132, 0.158)	99.7	< 0.001
Gender
Male	8.7 (0.063, 0.111)	97.9	< 0.001
Female	10.1 (0.069, 0.133)	97.3	< 0.001
Age group
≥ 60yr	33.6 (0.246, 0.425)	95.2	< 0.001
Other ages	7.6 (0.063, 0.088)	99.7	< 0.001
Region
Asia	1.1 (0.010, 0.012)	-	-
Europe	13.9 (0.118, 0.159)	99.2	< 0.001
North America	19.8 (0.149, 0.248)	-	-
Study design
Cross-sectional study	42.0 (0.322, 0.523)	0	-
Cohort study	8.1 (0.053, 0.109)	99.2	< 0.001
Other	24.8 (0.218, 0.277)	99.6	< 0.001
Diagnostic criteria
STAI	28.7 (0.201, 0.386)	-	-
HADS	31.2 (0.174, 0.449)	99.4	< 0.001
ICD	2.6 (0.013, 0.039)	-	-
GAD	24.0 (0.217, 0.265)	-	-

BDI: Beck depression inventory; CES-D: Centre for Epidemiological Studies Depression Scale; GAD: Generalized anxiety disorder scale; GDS: Geriatric depression scale; HADS: Hospital anxiety and depression scale; ICD: International classification of diseases; MDI: Major depression inventory; PHQ-9: Patient health questionnaire; STAI: Stait-trait anxiety inventory.

Table 3 Meta-regression analysis of prevalence of mental health in atrial fibrillation

Possible source of heterogeneity	Number of studies	Coef (95%CI)	P value
Depression
Study design	24	0.40 (-0.18, 0.98)	0.18
Cross-sectional study	4	1.34 (0.21, 2.47)	0.02
Cohort study	6	-1.76 (-3.03, -0.49)	0.01
Others	14	-1.11 (-2.28, 0.05)	0.06
Region	24	0.46 (-0.12, 1.04)	0.11
Asia	5	-0.82 (-2.29, 0.64)	0.27
Europe	14	-0.12 (-1.33, 1.10)	0.85
North America	4	0.29 (-0.87, 1.44)	0.63
Oceania	1	0.16(-2.38, 2.70)	0.90
Age group	24	-0.67(-1.67, 0.33)	0.19
≥ 60	7	0.33 (-0.70, 1.36)	0.53
Other ages	17	-0.33 (-1.36, 0.70)	0.53
Diagnostic criteria	24	-0.22(0.45, 0.02)	0.07
BDI	2	0.28 (-2.22, 2.78)	0.83
HADS	6	-2.96 (-2.23, 1.64)	0.76
PHQ-9	6	0.02 (-1.86, 1.91)	0.98
MDI	1	0.93 (-1.56, 3.42)	0.47
CES-D	1	0.40 (-1.95, 2.76)	0.74
ICD	6	-1.73 (-3.64, 0.17)	0.07
GDS	2	0.44 (-1.60, 2.48)	0.67
Anxiety
Region	13	-0.24 (-1.01, 0.52)	0.53
Asia	2	-1.03 (-2.87, 0.81)	0.27
Europe	8	1.00 (-0.98, 2.97)	0.32
North America	3	1.14 (-1.16,3.43)	0.32
Study design	13	-0.21 (-1.07, 0.65)	0.63
Cross-sectional study	1	1.95 (-0.59, 4.50)	0.13
Cohort study	4	-1.30 (-2.61, 0.01)	0.05
Others	8	1.22 (-0.15, 2.60)	0.08
Age group	13	-1.38 (-2.53, -0.24)	0.02
≥ 60	5	1.15 (-0.13, 2.43)	0.08
Other ages	8	-1.15 (-2.43, 0.13)	0.08
Diagnostic criteria	14	-0.84 (-1.63, -0.05)	0.04
STAI	1	0.15 (-2.01, 2.32)	0.89
HADS	9	0.07 (-1.54, 1.67)	0.94
ICD	3	-2.36 (-4.11, -0.61)	0.01
GAD	1	0.51 (-2.10, 3.13)	0.70

BDI: Beck depression inventory; CES-D: Centre for Epidemiological Studies Depression Scale; GAD: Generalized anxiety disorder scale; GDS: Geriatric depression scale; HADS: Hospital anxiety and depression scale; ICD: International classification of diseases; MDI: Major depression inventory; PHQ-9: Patient health questionnaire; STAI: Stait-trait anxiety inventory.