Abstract 087: Postdiagnostic Anxiety and Depression Increase Rupture Risk but Reduce Preventive Treatment in Unruptured Intracranial Aneurysms: A Multi‐national Multi‐institutional Study

Background and Purpose The impact of postdiagnostic development of anxiety and depression on management decisions and outcomes in patients with unruptured intracranial aneurysms (UIAs) is underexplored, despite their high prevalence. We aimed to assess the relationship between these conditions and treatment choices, rupture rates, mortality, and healthcare utilization using a large, multi‐institutional database. Methods This retrospective cohort study utilized electronic health records from the TriNetX Global Collaborative Network (2015‐2025) to identify adult patients (18‐80 years) with documented UIAs. We created two cohorts based on presence/absence of anxiety and/or depression diagnoses developing after unruptured aneurysm diagnosis but before rupture events, excluding patients with pre‐existing psychiatric conditions or post‐rupture symptoms. We conducted 1:1 propensity score matching based on demographics (age, sex, race/ethnicity), comorbidities (hypertension, diabetes, hyperlipidemia, obesity, smoking), and neuroimaging patterns (CT, CTA, MRA). Primary outcomes included endovascular treatment rates, aneurysm rupture, all‐cause mortality, and psychiatric medication utilization. Secondary analyses examined medication adherence (proportion of days covered), specific psychiatric diagnoses, medication classes, treatment timing, and healthcare utilization patterns. Statistical methods included Kaplan‐Meier survival analysis, Cox proportional hazards regression, and multivariable modeling with subgroup analyses by diagnosis type, comorbidity burden, and medication adherence levels. Results After propensity score matching, 14,915 patient pairs were included with balanced baseline characteristics. Patients with anxiety/depression had significantly higher endovascular treatment rates (4.8% vs. 4.1%, P=0.016), aneurysm rupture (3.8% vs. 2.5%, P<0.001), and all‐cause mortality (8.1% vs. 5.1%, P<0.001) over median follow‐up of 1,045 vs. 579 days. Despite 52% higher rupture rates, psychiatric patients received less preventive treatment (1.6% vs. 2.0%, P<0.05), though equivalent emergency treatment rates (85% both groups). Multivariable Cox regression confirmed anxiety/depression as independent mortality predictor (HR 1.31, 95% CI 1.19‐1.43). Clear dose‐response relationships emerged between medication adherence and mortality: low adherence (HR 1.56, 95% CI 1.30‐1.87), moderate adherence (HR 1.34, 95% CI 1.12‐1.60), high adherence (HR 1.18, 95% CI 1.01‐1.38). Mortality risk varied by diagnosis: major depressive disorder (HR 1.38, 95% CI 1.19‐1.60), mixed anxiety/depression (HR 1.36, 95% CI 1.15‐1.61), generalized anxiety disorder (HR 1.25, 95% CI 1.08‐1.44). Benzodiazepine users had highest mortality risk (HR 1.45, 95% CI 1.20‐1.75) versus SSRIs (HR 1.18, 95% CI 0.98‐1.42, non‐significant). Treatment delays were longer (median 136 vs. 98 days, P=0.003). Healthcare utilization increased substantially: hospitalizations (26.0% vs. 19.0%, OR 1.50), emergency visits (38.0% vs. 29.0%, OR 1.49), annual outpatient visits (12.6 vs. 8.4, difference 4.2). Psychiatric medication utilization was 58.1% vs. 17.7% (RR 3.28). Sensitivity analyses with alternative matching methods confirmed robustness of findings. Conclusion Anxiety and depression developing after UIA diagnosis significantly increase rupture risk and mortality. Despite elevated risk, these patients receive less preventive treatment, highlighting critical management gaps. Findings underscore the need for integrated psychiatric care, systematic mental health screening, and improved preventive treatment access in UIA management.

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