Efficacy of pharmacological and non‐pharmacological interventions for pre‐operative anxiety: a systematic review with network meta‐analysis of randomised clinical trials

Summary Pre‐operative anxiety is distressing for patients and is associated with peri‐operative complications, yet the relative effectiveness of available pharmacological and non‐pharmacological interventions remains unclear. We conducted a systematic review with network meta‐analysis to compare anxiolytic strategies in the pre‐operative setting. We searched six databases for randomised controlled trials in patients aged ≥ 16 years undergoing surgery, evaluating pharmacological or non‐pharmacological anxiolytic interventions. Study selection, data extraction and risk‐of‐bias assessment were performed in duplicate. We performed pairwise and network meta‐analysis for pre‐operative anxiety and secondary outcomes (postoperative pain, patient satisfaction, pre‐operative sedation and minor or major complications) and used the Grading of Recommendations Assessment, Development and Evaluation to rate certainty of evidence. A total of 350 studies were included. Data from 309 studies (27,218 patients) were analysed for the primary outcome (pre‐operative anxiety). Fifteen interventions reduced pre‐operative anxiety compared with placebo or sham or no intervention and usual care, including spiritual training standardised mean difference (95% CrI) −6.07 (−9.33 to −2.84), mirtazapine −3.37 (−5.55 to −1.17), binaural beats −2.99 (−5.00 to −0.97), benzodiazepines −1.27 (−1.67 to −0.86), gabapentinoids −1.13 (−1.78 to −0.48) and melatonin −0.90 (−1.65 to −0.16). Other interventions associated with lower anxiety included relaxation techniques, herbal medicines, massage, hydroxyzine, acupoint stimulation, audiovisual distraction, aromatherapy, clonidine and educational strategies. Five interventions improved peri‐operative patient satisfaction compared with placebo: parecoxib, acupoint stimulation, psychological intervention, audiovisual distraction and education. No significant differences were identified between interventions for postoperative pain, pre‐operative sedation or minor and major complications. Multiple pharmacological and non‐pharmacological interventions reduce pre‐operative anxiety and may improve peri‐operative patient satisfaction. No single intervention appears clearly superior and comparative safety differences remain uncertain.