Impact of the 2025 India-Pakistan conflict on perioperative anxiety: A natural experiment using the State-Trait Anxiety Inventory

Dear Editor,

Perioperative anxiety is associated with adverse outcomes, yet macro-level stressors such as armed conflict are rarely studied in surgical settings. The India–Pakistan hostilities in May 2025 provided an opportunity to examine whether acute geopolitical stress influences perioperative psychological states. Our research question explored whether the 2025 conflict heightened anxiety in surgical patients undergoing procedures during the war versus after the ceasefire, using the State-Trait Anxiety Inventory (STAI) score.^[1]

This prospective observational study was conducted at an institution located 110 km from a military installation. Elective surgical patients scheduled for general anaesthesia between May 7 and May 16, 2025, were recruited for the study. Group C comprised of patients operated during the active conflict (May 7-May 11), and group P included the patients operated in the period after the ceasefire (May 12– May 16). We used STAI-State (Form Y-1; range 20–80) to measure anxiety pre-operatively and 1 hour post-extubation. The study was conducted during the war, which was a time when the nation was facing an acute crisis. Also, this was an observational study, which involved no risk to the patients. Hence, our institutional review board retrospectively waived ethics committee permission for the study.

Fourteen patients (7 per group) were included in this study after obtaining written informed consent from them. The baseline demographics (age, gender, weight, height, diagnosis, co-existing illness, American Society of Anesthesiologists physical status, duration of surgery, duration of anaesthesia) and surgery types were comparable.

Pre-operative STAI scores were significantly higher in Group C compared with Group P (32.6 ± 2.64 vs 24.9 ± 3.29; mean difference 7.7; 95% confidence interval (CI) for Group C 30.13–35.01 and for Group P 21.82–27.90; p = 0.004). Post-operative STAI scores were markedly elevated in Group C (47.5 ± 3.1, 95% CI 44.46 to 50.68) compared with Group P (29.3 ± 3.8, 95% CI 25.52 to 33.05; p = 0.002) using the Mann-Whitney U test [Figure 1]. The change in anxiety (ΔSTAI = post–pre) was significantly greater in Group C (14.9 ± 5.10; 95% CI 10.28–19.72) than in Group P (5.3 ± 3.46; 95% CI 1.23–7.63; p = 0.006). Intraoperative physiological and anaesthetic parameters were comparable between the two groups. The doses of induction and maintenance agents (propofol, fentanyl, and atracurium), minute ventilation, inspired oxygen fraction (FiO₂), end-tidal carbon dioxide concentration (EtCO₂), peripheral oxygen saturation (SpO₂), and minimum alveolar concentration (MAC) remained within normal ranges throughout the procedures. No statistically significant differences were observed between group C and group P with respect to heart rate (HR), systolic blood pressure (SBP), or diastolic blood pressure (DBP) at any recorded 3-minute interval (p > 0.050, Wilcoxon test) [Figure 2].

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Figure 1:

Comparison of mean post-operative STAI scores with duration of anaesthesia. STAI: State-Trait Anxiety Inventory

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Figure 2:

Box and Whisker plot depicting the change in haemodynamic trend over time. HR: Heart rate; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; SpO₂ : Peripheral oxygen saturation; Post-op: Postoperative; Pre-op: Preoperative

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Regression analysis was exploratory (r² = 0.568); surgical duration emerged as a predictor of higher anxiety, while other covariates were not significant.

In the study by Ahmetovic-Djug et al, pre-operative anxiety was a significant predictor of the administered dose of anaesthetic. Each additional score on the Spielberg scale reduced the dose of anaesthetic by 0.304 mg/kg.^[2] Skwirczyńska et al. studied anxiety levels using STAI in 510 participants. Females had a higher level of anxiety (p = 0.000). Also, first-year students had significantly higher anxiety than the fifth-year students (p = 0.001).^[3] However, in our study, we could not elucidate this effect of higher anxiety in females, most likely due to the small sample size of the cohort.

The intraoperative parameters were recorded in our study primarily to rule out any confounding influence of anaesthetic depth or haemodynamic variation on perioperative anxiety levels. The absence of intergroup differences in HR, SBP, DBP, MAC, FiO₂, or EtCO₂ indicates that both groups received comparable anaesthetic management and that the observed differences in post-operative STAI scores are unlikely to be attributable to intraoperative physiological factors. This reinforces the interpretation that heightened anxiety in group C patients reflected the external geopolitical stress rather than intraoperative or anaesthetic variables.

The present study provides preliminary evidence that acute geopolitical crises may amplify perioperative anxiety. Media exposure, fear of personal safety, and disrupted social support may have been contributors. Clinical implications include the need for proactive psychological assessment during national crises. Practical measures include counselling, anxiolytic premedication, and engagement of mental health professionals in perioperative care.

Several additional factors are known to influence perioperative anxiety. These include personality traits, baseline psychiatric status, prior surgical experience, level of education, socioeconomic background, pre-operative counselling, and exposure to media coverage of the conflict. Furthermore, use of premedication (such as benzodiazepines), timing and duration of pre-operative waiting, and interaction with anaesthesiology staff can modulate anxiety levels. Environmental stressors, such as noise in the operating room, temperature, and perceived competence of staff, have also been reported to influence perioperative psychological states. Because the study was conducted during an acute geopolitical crisis, individual differences in resilience, media exposure, and perceived personal threat may have further amplified anxiety in some patients. These confounders were not controlled for, and thus, the observed differences in anxiety scores should be interpreted with caution.

Neuroanaesthesia predictive models^[4] for testing patient anxiety by physiological monitoring variables can be considered in the near future. Perioperative teams should remain attentive to external socio-political stressors when preparing patients for surgery. Even in hospitals distant from conflict zones, psychological spillover can meaningfully impact perioperative anxiety.