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Predictors of anxiety in patients undergoing magnetic resonance imaging scans: a multicenter cross-sectional study

BMC Psychiatry volume 24, Article number: 633 (2024) Cite this article

Abstract

Background

Magnetic resonance imaging (MRI) is a noninvasive diagnostic tool that is commonly used to visualize soft tissues and anatomical structures. Many patients who undergo MRI scans experience anxiety. This multicenter study was conducted to assess anxiety levels experienced by patients who underwent MRI scans in the Palestinian radiology departments and identify the risk factors associated with higher levels of anxiety experienced by the patients.

Methods

This multicenter cross-sectional study was conducted in the radiology departments of different hospitals in the West Bank of Palestine using a questionnaire. The questionnaire collected different demographic data of the patients. A 100-mm visual analog scale (VAS) was used to assess the level of anxiety experienced by the patients who received MRI scans. The data were analyzed using SPSS version 28.

Results

A total of 383 patients participated in this study. Of the patients, 255 (66.6%) reported experiencing low, moderate, or high anxiety levels during the MRI scan. The median anxiety was 20.0 with an interquartile range (IQR) of 0.0–50.0 as measured using the 100-mm VAS. Higher anxiety levels were reported by the patients who were female (p-value < 0.001), unemployed (p-value = 0.009), and did not receive an MRI scan before (p-value = 0.001). In addition, the patients who received pelvis scans reported higher levels of anxiety compared to those who received scans for upper extremities (p-value = 0.031), abdomen (p-value = 0.033), pelvis (p-value = 0.043), and lower extremities (p-value = 0.016). In addition, the patients who received scans for the head/neck reported higher levels of anxiety compared to the patients who received scans for the lower extremities (p-value = 0.021).

Conclusion

The findings of this study showed that a considerable proportion of the patients who received MRI scans in Palestinian hospitals experience anxiety. Radiologists and other decision-makers in the healthcare system should design effective measures to reduce anxiety and improve the experiences of patients who are female, unemployed, and those who are scheduled to receive MRI scans for the first time. Moreover, these interventions should particularly focus on the patients who are scheduled to receive scans for the pelvis and head/neck.

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Background

Magnetic resonance imaging (MRI) is a noninvasive diagnostic tool that is commonly used to visualize soft tissues and anatomical structures [1]. Over the years, MRI has emerged as one of the most preferred tools used in clinical practice to diagnose health issues related to the cardiovascular, musculoskeletal, and nervous systems [2]. In clinical practice, patients scheduled for an MRI scan are screened for contraindications, receive a briefing about the procedure delivered by the medical or technical staff, and have any medical objects removed [2, 3]. Patients then are instructed to enter the MRI machine feet-first or head-first. To obtain clear and undistorted scans, the patients should remain immobile throughout the whole procedure [4]. On average, the duration of the procedure can be between 15 and 90 min [1,2,3].

Over the last decades, healthcare providers have increasingly relied on imaging to make faster and more accurate diagnoses, reduce the number of diagnostic procedures that patients might undergo, and reduce misdiagnosis and diagnosis errors [5,6,7]. As a result, there has been a significant increase in the number of diagnostic procedures including MRI scans over the last few years. As the number of MRI scans obtained increased, there has been increasing attention drawn to the anxiety and stress caused by the procedure [8,9,10].

Claustrophobia has been reported as a reaction to being confined in an MRI machine in approximately 1–15% of patients [8]. Other forms of anxiety, such as unfamiliarity with the procedure, anticipation of pain, and anxiety regarding screening results, have also been reported among the patients who underwent MRI [11]. Anxiety and stress can negatively affect the quality of patient experience. In addition, this anxiety and stress can cause scanning delays, premature termination of the diagnostic procedure, use of sedatives, motion artifacts, patient dissatisfaction, and increased costs of the procedure [8, 12,13,14].

Different factors could be explored when investigating anxiety. Gender is a well-documented factor when interpreting anxiety levels, as females are more likely to express negative emotions including anxiety [15]. Weight is another factor, as anxiety occurs more frequently in obese patients compared to normal-weight patients [16]. However, the causal relationships between obesity and anxiety have not been fully demonstrated [17]. On the other hand, high awareness of the disease and the diagnostic procedures could be considered as a protective factor against anxiety and stress [18]. Moreover, other personal traits related to resilience can also be considered protective factors against anxiety and stress.

To reduce anxiety and improve patient experience, engineers have designed more patient-friendly MRI machines. The new designs allowed more of the patient’s body to be outside the scanner, produced less noise, and provided augmented reality goggles [19, 20]. It is noteworthy to mention that these patient-friendly MRI machines are not available in all healthcare systems, hospitals, and care centers. Therefore, different cognitive and behavioral interventions have been developed and tested to reduce anxiety and improve the experience of patients undergoing MRI scans [21,22,23]. These interventions included procedural education, prior MRI-simulator rehearsal, relaxation exercises, noise reduction, ambient lighting, aromatherapy, a phone call with the radiographer, and an information booklet on MRI [21, 22, 24,25,26]. Many of these interventions have proven effective in reducing anxiety and improving the experience of the patients, and their satisfaction.

The prevalence of anxiety among patients undergoing MRI in resource-limited settings was not sufficiently investigated, notably in the Palestinian healthcare system. In addition, few studies were conducted to determine the association between anxiety and various demographic and clinical variables of the patients undergoing MRI [27]. Therefore, this study was conducted to assess the prevalence of anxiety among patients undergoing MRI in Palestine. In addition, the study also investigated the associations between anxiety and the various demographic and clinical variables of the patients undergoing MRI.

Methods

Study design and settings

The study was conducted in a cross-sectional design. The study settings were hospitals and healthcare centers with MRI services provided to inpatients and outpatients in the Palestinian healthcare system in the West Bank. MRI services are provided from 8 am to 6 pm on weekdays. Shifts and on-call shifts covered the services during the weekends. The MRI scanners currently used within the Palestinian healthcare system are 1.5 and 3 Tesla, closed-bore Siemens machines (Siemens Healthineers, Germany).

Study population, sample size, and sampling method

The study population was all adult patients undergoing MRIs within the Palestinian healthcare system in the West Bank. During the study period, about 50 patients underwent MRIs per day, giving 18,250 MRI scans per year. The sample size needed for this study was calculated using Eq. (1) which is commonly used to calculate the sample size for cross-sectional studies assessing prevalence and employing a convenience sampling approach to recruit the participants. The theories and hypotheses behind the equation are detailed in Daniel and Cross (2018) [28].

$$\:n=\frac{{Z}^{2}P\left(1-P\right)}{{d}^{2}}\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\left(1\right)$$

Where: n = the needed sample size, Z = the Z statistic for 95% confidence interval (1.96), P = the expected prevalence/proportion (assumed as 50% when unknown), and d = precision/margin of error.

Tolerating a margin of error of 5%, the sample size needed for this study was 384 patients. To account for potential refusals, we decided to increase the number of invited patients by about 10%.

Field researchers approached potential participants at relevant healthcare facilities and invited them to take part in the study. The patients were included when they were 18 years or older, scheduled for MRI, expressed readiness to respond to items in a questionnaire, and provided informed consent. The patients were excluded from the study when they underwent emergent MRI, had acute pain, were diagnosed with cognitive disorders, and/or were unconscious/anesthetized while undergoing MRI. All patients provided written informed consent before taking part in this study.

Data collection

The data were collected using a questionnaire that was designed specifically for this study. The questionnaire was based on previous studies [29,30,31,32]. The questionnaires were administered to the patients immediately after the end of the scan. The sociodemographic variables of the patients like age, gender, employment, marital status, height, weight, and presence of comorbidities were collected. The patients were also asked if they received any information from the MRI staff before their scan and how helpful was the information they received. The information included details about the duration of the procedure, what to anticipate, the importance of staying still and breathing calmly, and methods of requesting assistance or managing any discomfort during their scan. Anxiety can be measured using different methods, including physiological and observational methods. To ensure the collection of a large number of participants and to accommodate the design and nature of this study, anxiety was measured using a self-reporting method. In this study, the patients were asked to self-rate their level of anxiety regarding the MRI procedure on a 100 mm visual analog scale (VAS), where 0 indicated “no anxiety” and 100 represented “highest level of anxiety” [32]. Since its introduction, the VAS has emerged as a reliable and easily applicable method to measure the level of anxiety. In addition, the VAS was used in previous studies to measure anxiety experienced by patients undergoing different radiological procedures [29,30,31]. Other ratings were reported on a 4-point Likert scale. where 1 was the lowest rating, meaning “Not at all”, 2 meant “Barely”, 3 meant “Somewhat”, and 4 was the highest rating, meaning “Very much so.”

Data analysis

We used SPSS version 28 for data analysis. Descriptive analysis was used to describe clinical and socio-demographic variables. The Kolmogorov-Smirnov test was used to test the normality for continuous variables. Categorical variables were presented as frequencies and percentages and continuous data were presented as medians with their corresponding interquartile ranges (IQR). Kruskal-Wallis H and Mann Whitney U tests were then used to test the associations between these variables and anxiety levels. Pairwise multiple comparison post hoc tests with Bonferroni corrections were conducted to assess the differences in the anxiety ratings between the patients who underwent MRI scans for the different body parts. A p-value < 0.05 was considered significant.

Ethical considerations

The Institutional Review Board (IRB) of An-Najah National University approved the study protocol in its entirety as well as its ethical values (Ref: Med. Sept. 2022/18). The conduct of the study adhered to the Declaration of Helsinki’s standards for scientific and medical research. Each patient in this study provided written informed consent.

Results

Characteristics of the patients

Of the 417 patients invited to take part in this study, questionnaires were completed by 383 patients who underwent MRI, giving a response rate of 91.8%. The mean age of patients was 43.0 ± 15.6 years. Of the patients, 195 (50.9%) were male, 293 (76.5%) were overweight or obese, and 164 (42.8%) lived in urban areas. Of the patients, 289 (75.5%) were married, 203 (53.0%) had a university degree, and 173 (45.2%) were employed. The detailed variables of the patients are shown in Table 1.

Table 1 General characteristics of the patients ( n = 383)
Full size table

Undergoing MRI scans and levels of anxiety experienced

The most scanned body parts were the head/neck (39.4%) and spine (29.5%). The majority of the patients (70.5%) did not receive IV contrast. Similarly, the majority of the patients (60.8%) did not undergo an MRI scan before. Moreover, the majority of patients (89.0%) reported that they had received information before their MRI scans and the majority of the patients (66.0%) rated the usefulness of the information as ‘very much so’.

When the patients were asked if the staff was reassuring, 155 (60.8%) patients stated that the staff was ‘very much so’ reassuring. The characteristics related to the scans, receiving information, and being assured by the staff are shown in Table 2.

Table 2 Characteristics related to the scans, receiving information, and being assured by the staff
Full size table

Anxiety levels were reported by the patients using a 100-mm VAS, where 0 represented ‘no anxiety’ and 100 represented ‘highest anxiety’. The median anxiety rating was 20.0 with an IQR of 0.0–50.0. Of the patients, 255 (66.6%) reported experiencing anxiety during the MRI scan. Of the patients, 96 (25.1%) reported experiencing low anxiety (1–33), 94 (24.5%) reported experiencing moderate anxiety (34–66), and 65 (17.0%) reported experiencing high anxiety (67–100). The reported anxiety levels are shown in Fig. 1.

Fig. 1
figure 1

Reported anxiety levels during the scans

Full size image

Anxiety levels by subgroups based on the demographics of the patients and characteristics of the scans

Out of all the variables tested, both from the patient and MRI scan characteristics, several were found to be associated with the anxiety levels experienced by the participants. Gender, body part, employment status, and receiving a previous MRI scan were all found to have a significant association with the reported anxiety levels. The other variables studied were not significantly associated. Table 3 shows the association between levels of anxiety and the different variables in this study.

Female patients reported significantly higher anxiety levels compared to their male counterparts. This was evidenced by a median score of 40.0 with an IQR of 11.25-70.0. The patients who received a previous MRI scan reported significantly lower levels of anxiety compared to the patients who did not receive an MRI scan before. This was evidenced by a median score of 10.0 with an IQR of 0.0–40.0. The unemployed patients reported significantly higher anxiety levels compared to their employed counterparts. Multiple comparison post hoc tests showed that the patients who received pelvis scans reported higher levels of anxiety compared to those who received scans for upper extremities, abdomen, pelvis, and lower extremities. In addition, the patients who received scans for the head/neck reported higher levels of anxiety compared to the patients who received scans for the lower extremities. The multiple comparisons are shown in Supplementary Table S1.

Table 3 Association between anxiety levels and demographic and scan characteristics
Full size table

Discussion

Our present study examined anxiety in patients undergoing MRI scans in two large MRI departments in the city of Nablus, Palestine. We looked into the different procedure-related and patient-related factors that influence anxiety levels. This study yielded a myriad of associations, which can act as a stepping stone to better patients’ experience during these scans.

Anxiety levels reported by patients were measured using a 100-mm VAS in our research study. The majority of patients reported anxiety (65.3%), with an overall mean of 30.75 (SD, 30.88). This percentage is higher compared to other studies [26, 33]. In addition, 89.0% of patients in our study reported receiving information before their scan, and of those patients, 66.6% reported the helpfulness information as being ‘very much so’ helpful. This percentage is similar to the results of a study done in Australia, where 83.0% of patients reported receiving information before their scans [26]. Although patients who received information had a lower median of anxiety (20.0) compared to those who did not (25.0), no significant association was found between the two variables in our study. This is in contrast to the case in other studies [26, 34]. This could be because there might be other factors that play a bigger role than just merely receiving information. Such factors include the quality of the received information, the way the relevant information was communicated, and the patient’s material conditions, among other factors.

We found a significant association between anxiety and the body part scanned. Patients who underwent pelvic scans experienced the highest levels of anxiety, followed by chest and head/neck scans. This is similar to other studies that found the highest levels of anxiety in patients undergoing brain and head MRIs [35, 36]. This could be because these scans are usually ordered for more serious problems like cancer, which could make patients more anxious [37, 38]. On the contrary, patients undergoing scans for the upper and lower extremities experienced the lowest levels of anxiety. This is similar to other studies that have reported lower anxiety levels associated with musculoskeletal scans [35, 36].

Anxiety levels were significantly associated with gender, with females experiencing higher levels of anxiety than their male counterparts. This association was supported by previous studies [39,40,41], while the opposite relationship was reported in one study [11]. It is well known that females experience more anxiety compared to males during different radiological procedures [15]. This could be because females are more likely to express negative emotions, such as anxiety, worry, and fear while males tend not to do [42].

Employment was found to be associated with anxiety levels among the patients who participated in this study. A meta-analysis showed that unemployed people have a higher risk of having psychological problems, including anxiety, especially in countries with weak economies and a lack of unemployment protection [43]. Lastly, patients who had previously undergone an MRI scan experienced significantly lower levels of anxiety. This association can be explained by the process of habituation, where participants undergoing repeated MRI scans become more familiar and cope easier with the scan, and subsequently experience lower levels of anxiety [44].

Strengths and limitations

Our study has many strengths. First of all, the study included a large sample size (n = 383), which could help make its results more generalizable than many other previously published articles. Additionally, this large sample size included a diverse patient population. This is because data was collected in the two largest MRI departments in the city of Nablus, Palestine; one of these departments is in a university tertiary hospital, while the other is in a charitable organization. Furthermore, the questionnaire used in this research covered most of the pertinent demographic data and allowed the examination of different variables and their association with anxiety. However, a few limitations must be taken into consideration while interpreting the results of this research. First, anxiety was self-reported by patients, which could be subject to response bias where patients might underreport or overreport their levels of anxiety. Second, our study might have not accounted for all the variables that might affect anxiety levels. Social and cultural factors may have influenced the reporting of anxiety, which might not have been fully explored in our study. Third, we did not use the State-Trait Anxiety Inventory or the Magnetic Resonance Imaging-Anxiety Questionnaire in this study. Using these validated tools could have strengthened the findings reported in this study. Fourth, we did not assess whether the patients have experienced claustrophobia in other non-MRI settings. Future studies might consider comparing the anxiety caused by experiencing claustrophobia in MRI and non-MRI settings. Fifth, future studies should consider comparing the differences in anxiety levels among male and female patients as associated with other demographic and clinical variables. Finally, the MRI scans in this study were made using closed-bore MRI machines. In other healthcare systems, open-bore MRI machines are currently used. These machines are more patient-friendly compared to those used in this study. This could have limited comparability of the findings obtained in this study to those reported in more advanced healthcare systems.

Conclusion

The findings of this study showed that a considerable proportion of the patients who received MRI scans in Palestinian hospitals reported anxiety. Radiologists and other decision-makers in the healthcare system should design effective measures to reduce anxiety and improve the experiences of patients who are female, unemployed, and those who are scheduled to receive MRI scans for the first time. Moreover, these interventions should particularly focus on the patients who are scheduled to receive scans for the pelvis and head/neck.

Data availability

All data relevant to this study were included in the manuscript or provided as supplementary materials. The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors would like to thank the radiology technicians who helped with the collection of data, as well as the patients for their participation. An-Najah National University Hospital and Al-Rahma Clinic are acknowledged for making this study possible.

Funding

This study did not receive any specific funding.

Author information

Authors and Affiliations

  1. Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine

    Raed Masalma, Thabet Zidan, Sima Amasheh & Mosab Maree

  2. Department of Radiology, An-Najah National University Hospital, Nablus, 44839, Palestine

    Mosab Maree

  3. Al Rahma Clinic, Nablus, Palestine

    Mohammad Alhanbali

  4. Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, New Campus, Building: 19, P.O. Box 7, Nablus, 1340, Palestine

    Ramzi Shawahna

  5. Clinical Research Center, An-Najah National University Hospital, Nablus, 44839, Palestine

    Ramzi Shawahna

  6. Department of Medical Imaging, London Health Sciences Center, Western University , London, Canada

    Mosab Maree

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  1. Raed Masalma
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Contributions

RS, MM, and MA were involved in the conception and design of the work, analysis, and interpretation of data, drafting, and final approval of the manuscript. RM, TZ, and SA were involved in the data acquisition, analysis, drafting of the work, and final approval of the version to be published.

Corresponding authors

Correspondence to Mosab Maree or Ramzi Shawahna.

Ethics declarations

Ethics approval and consent to participate

This study was conducted in adherence to the local and international ethical principles including those in the Declaration of Helsinki. The protocol of this study was approved by the Institutional Review Board (IRB) of An-Najah National University (Ref: Med. Sept. 2022/18). Written informed consent was obtained from all patients before participating in the research project.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Masalma, R., Zidan, T., Amasheh, S. et al. Predictors of anxiety in patients undergoing magnetic resonance imaging scans: a multicenter cross-sectional study. BMC Psychiatry 24, 633 (2024). https://doi.org/10.1186/s12888-024-06091-6

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  • DOI: https://doi.org/10.1186/s12888-024-06091-6

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BMC Psychiatry

ISSN: 1471-244X

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