scholarly journals One Year of Evidence on Mental Health in the COVID-19 Crisis - A Systematic Review and Meta-Analysis

2021 ◽  
Author(s):  
Xi Chen ◽  
Jiyao Chen ◽  
Meimei Zhang ◽  
Richard Z. Chen ◽  
Rebecca Kechen Dong ◽  
...  
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
Healthcare Workers ◽  
Meta Analysis ◽  
Prevalence Rates ◽  
Meta Regression ◽  
One Year ◽  
Meta Analyses ◽  
Frontline Healthcare Workers ◽  
Anxiety Depression

ABSTRACTObjectiveThis paper provides a systematic review and meta-analysis on the prevalence rate of mental health issues of the major population, including general population, general healthcare workers (HCWs), and frontline healthcare workers (HCWs), in China over one year of the COVID-19 crisis.DesignA systematic review and meta-analysis.Data sourcesarticles in PubMed, Embase, Web of Science, and medRxiv up to November 16, 2020, one year after the first publicly known confirmed COVID-19 case.Eligibility criteria and data analysisany COVID-19 and mental disorders relevant English studies with frontline/general healthcare workers, general adult population sample, using validated scales. We pooled data using random-effects meta-analyses to estimate the prevalence rates of anxiety, depression, distress, general psychological symptoms (GPS), insomnia, and PTSD and ran meta-regression to tease out the heterogeneity.ResultsThe meta-analysis includes 131 studies and 171 independent samples. The overall prevalence of anxiety, depression, distress, GPS, insomnia, and PTSD are 11%, 13%, 20%, 13%, 19%, and 20%, respectively. The meta-regression results uncovered several predictors of the prevalence rates, including severity (e.g., above severe vs. above moderate, p<0.01; above moderate vs. above mild, p<0.01) and type of mental issues (e.g., depression vs. anxiety, p=0.04; insomnia vs. anxiety p=0.04), population (frontline HCWs vs. general HCWs, p<0.01), sampling location (Wuhan vs. non-Wuhan, p=0.04), and study quality (p=0.04).LimitationsFirst, we only focus on China population, which may limit the generalizability of the results. Second, 96.2% studies included in this meta-analysis were cross-sectional. Last, since we only included studies published in English, we expect to have a language bias.ConclusionOur pooled prevalence rates are significantly different from, yet largely between, the findings of previous meta-analyses, suggesting the results of our larger study are consistent with, yet fine-tune, the findings of the smaller, previous meta-analyses. Hence, this meta-analysis not only provides a significant update on the mental health prevalence rates in COVID-19 but also suggests the need to update meta-analyses continuously to provide more accurate estimates of the prevalence of mental illness during this ongoing health crisis. While prior meta-analyses focused on the prevalence rates of mental health disorders based on one level of severity (i.e., above mild), our findings also suggest a need to examine the prevalence rates at varying levels of severity. The one-year cumulative evidence on sampling locations (Wuhan vs. non-Wuhan) corroborates the typhoon eye effect theory. Our finding that the prevalence rates of distress and insomnia and those of frontline healthcare workers are higher suggest future research and interventions should pay more attention to those mental outcomes and populations.

scholarly journals Burden of predominant psychological reactions among the healthcare workers and general during COVID-19 pandemic phase: a systematic review and meta-analysis

2021 ◽  
Author(s):  
Bhaskar Thakur ◽  
Mona Pathak
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
Healthcare Workers ◽  
Global Mental Health ◽  
Meta Analysis ◽  
Random Effect ◽  
Anxiety And Depression ◽  
Psychological Reactions ◽  
Frontline Healthcare Workers ◽  
Anxiety Depression

ABSTRACTAimPresent systematic review and meta-analysis examined the burden of psychological reactions predominantly anxiety, depression, stress and insomnia during novel COVID-19 pandemic phase among the frontline healthcare, non-frontline healthcare and general.MethodologyPubMed, EMBASE and SCOPUS were searched for studies between Jan 1, 2020 to May 25, 2020. Brief protocol of the systematic review was registered with the PROSPERO database, (CRD42020186229).Any study that reported the burden of at least one of psychological reactions including anxiety or depression or stress or insomnia was eligible. Heterogeneity was assessed using I2 statistic and results were synthesized using random effect meta-analysis.ResultsOut of 52eligible studies, 43 reported anxiety, 43 reported depression, 20 reported stress and 11 reported insomnia. Overall prevalence for anxiety, depression, stress and insomnia were 26.6%, 26.2%,26.2% and 34.4% respectively. Anxiety and depression were found highest among the COVID-19 patients (43.3% and 51.75 respectively). Apart from COVID-19 patients, prevalence of anxiety, depression, stress and insomnia were found highest among the frontline healthcare (27.2%, 32.1%,55.6% and 34.4% respectively) as compared to general healthcare workers (26.9%, 15.7%, 7.0% and 34.0% respectively) and general population (25.9%, 25.9%,25.4% and 29.4% respectively).ConclusionAnxiety and depression were found highest among the COVID-19 patients. Apart from COVID-19 patients, the anxiety, depression, stress and insomnia were more prevalent among frontline healthcare workers compared to general. Such increased prevalence is prompting towards the global mental health emergency. Therefore a call of urgent attention and pan-region effective mental-health intervention are required to mitigate these psychological reactions.

scholarly journals Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis

2019 ◽  
Vol 53 (11) ◽  
pp. 700-706 ◽  
Author(s):  
Vincent Gouttebarge ◽  
João Mauricio Castaldelli-Maia ◽  
Paul Gorczynski ◽  
Brian Hainline ◽  
Mary E Hitchcock ◽  
...  
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
Alcohol Misuse ◽  
Elite Athletes ◽  
Meta Analysis ◽  
Mental Health Symptoms ◽  
Health Symptoms ◽  
Meta Analyses ◽  
Former Elite Athletes ◽  
Anxiety Depression

ObjectivesTo present an overview of the existing epidemiological evidence regarding the occurrence of mental health symptoms and disorders among current and former elite athletes.DesignSystematic review and meta-analysis.Data sourcesFive electronic databases were searched from inception to November 2018: PubMed (MEDLINE), SportDiscus via EBSCO, PSycINFO via ProQuest, Scopus and Cochrane.Eligibility criteria for selecting studiesWe included original quantitative studies that were written in English, were conducted exclusively among current or former elite athletes, and presented incidence or prevalence rates of symptoms of mental disorders.ResultsTwenty-two relevant original studies about mental health symptoms and disorders among current elite athletes were included: they presented data especially on symptoms of distress, sleep disturbance, anxiety/depression and alcohol misuse. Meta-analyses comprising 2895 to 5555 current elite athletes showed that the prevalence of mental health symptoms and disorders ranged from 19% for alcohol misuse to 34% for anxiety/depression. Fifteen relevant original studies about mental health symptoms and disorders among former elite athletes were included: they similarly presented data especially about symptoms of distress, sleep disturbance, anxiety/depression and alcohol misuse. Meta-analyses comprising 1579 to 1686 former elite athletes showed that the prevalence of mental health symptoms and disorders ranged from 16% for distress to 26% for anxiety/depression.ConclusionsOur meta-analyses showed that the prevalence of mental health symptoms and disorders ranged from 19% for alcohol misuse to 34% for anxiety/depression for current elite athletes, and from 16% for distress to 26% for anxiety/depression for former elite athletes.

scholarly journals Mental burden and its risk and protective factors during the early phase of the SARS-CoV-2 pandemic: systematic review and meta-analyses

2021 ◽  
Vol 17 (1) ◽  
Author(s):  
Angela M. Kunzler ◽  
Nikolaus Röthke ◽  
Lukas Günthner ◽  
Jutta Stoffers-Winterling ◽  
Oliver Tüscher ◽  
...  
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
General Population ◽  
Protective Factors ◽  
Early Phase ◽  
Healthcare Workers ◽  
Meta Analysis ◽  
Risk And Protective Factors ◽  
Comparative Data ◽  
Meta Analyses

Abstract Background Mental burden due to the SARS-CoV-2 pandemic has been widely reported for the general public and specific risk groups like healthcare workers and different patient populations. We aimed to assess its impact on mental health during the early phase by comparing pandemic with prepandemic data and to identify potential risk and protective factors. Methods For this systematic review and meta-analyses, we systematically searched PubMed, PsycINFO, and Web of Science from January 1, 2019 to May 29, 2020, and screened reference lists of included studies. In addition, we searched PubMed and PsycINFO for prepandemic comparative data. Survey studies assessing mental burden by the SARS-CoV-2 pandemic in the general population, healthcare workers, or any patients (eg, COVID-19 patients), with a broad range of eligible mental health outcomes, and matching studies evaluating prepandemic comparative data in the same population (if available) were included. We used multilevel meta-analyses for main, subgroup, and sensitivity analyses, focusing on (perceived) stress, symptoms of anxiety and depression, and sleep-related symptoms as primary outcomes. Results Of 2429 records retrieved, 104 were included in the review (n = 208,261 participants), 43 in the meta-analysis (n = 71,613 participants). While symptoms of anxiety (standardized mean difference [SMD] 0.40; 95% CI 0.15–0.65) and depression (SMD 0.67; 95% CI 0.07–1.27) were increased in the general population during the early phase of the pandemic compared with prepandemic conditions, mental burden was not increased in patients as well as healthcare workers, irrespective of COVID-19 patient contact. Specific outcome measures (eg, Patient Health Questionnaire) and older comparative data (published ≥5 years ago) were associated with increased mental burden. Across the three population groups, existing mental disorders, female sex, and concerns about getting infected were repeatedly reported as risk factors, while older age, a good economic situation, and education were protective. Conclusions This meta-analysis paints a more differentiated picture of the mental health consequences in pandemic situations than previous reviews. High-quality, representative surveys, high granular longitudinal studies, and more research on protective factors are required to better understand the psychological impacts of the SARS-CoV-2 pandemic and to help design effective preventive measures and interventions that are tailored to the needs of specific population groups.

scholarly journals The Mental Health Under the COVID-19 Crisis in Africa: A Systematic Review and Meta-Analysis

2021 ◽  
Author(s):  
Jiyao Chen ◽  
Nusrat Farah ◽  
Rebecca Kechen Dong ◽  
Richard Z Chen ◽  
Wen Xu ◽  
...  
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
Meta Analysis ◽  
Adult Population ◽  
Prevalence Rates ◽  
Mental Health Symptoms ◽  
African Countries ◽  
Health Symptoms ◽  
Pooled Prevalence ◽  
Anxiety Depression

Objective: In this paper, we aim to provide a systematic review and meta-analysis on the prevalence rates of mental health symptoms of anxiety, depression, and insomnia among the major populations during the COVID-19 pandemic in Africa. Design: A systematic review and meta-analysis. Data sources: We search and include articles using PubMed, Embase, Web of Science, PsycINFO, and medRxiv databases between Feb 202 and Feb 6th, 2021. Eligibility criteria and data analysis: The meta-analysis targets the prevalence rates of mental health symptoms of major populations including frontline/general healthcare workers (HCWs), the general adult population, and medical students during the COVID-19 pandemic in Africa. To estimate the prevalence rates of anxiety, depression, and insomnia, we pooled data using random-effects meta-analyses. Results: In this meta-analysis, we identify and include 28 studies and 32 independent samples from 12 countries with a total of 15,072 participants in Africa. Ethiopia (7) and Egypt (6) had the largest number of studies. While many countries including, but not limited to, Algeria, Kenya, and Ghana had a high number of COVID-19 cases, as many as three quarters of African countries have no studies. The pooled prevalence of anxiety in 27 studies was 37% (95%CI: 31-43%, I2 = 99.0%) and that of depression in 24 studies was 45% (95%CI: 36-51%, I2 = 99.5%) and that of insomnia in 9 studies was 28% (95%CI: 20-41%, I2 = 99.2%). The pooled prevalence rates of anxiety, depression, and insomnia in North Africa (44%, 55%, and 31%, respectively) are higher than the rates in Sub-Saharan Africa (31%, 30%, and 24%, respectively). Our analysis indicated high heterogeneity and varying prevalence rates of mental health symptoms during the COVID-19 pandemic in Africa. Discussion: We discuss our findings that a) a scarcity of studies in several African countries with a high number of COVID-19 cases, b) high heterogeneity among the studies, c) the extent of prevalence of mental health symptoms in Africa to be high, and d) the pattern of mental health symptoms in Africa differs from elsewhere, i.e., more African adults suffer from depression rather than anxiety and insomnia during COVID 19 compared to adult population in other countries or regions. Hence, our findings carry crucial implications for healthcare organizations and future research to enable evidence-based medicine in Africa. Our findings also call for increased scholarly attention on Africa, the least studied continent with a limited amount of research on mental health symptoms under the COVID 19 pandemic. Keywords: Mental Health; Prevalence; Pandemic; General Population; Healthcare Workers; Anxiety; Depression; Insomnia Trial registration: CRD42020224458  

Online interventions for reducing anxiety, depression, and stress among adolescents: A systematic review and meta-analysis (Preprint)

2021 ◽  
Author(s):  
Dabok Noh ◽  
Hyunlye Kim
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
Meta Analysis ◽  
Online Intervention ◽  
Cochrane Library ◽  
Universal Prevention ◽  
Online Interventions ◽  
Meta Analyses ◽  
Anxiety Depression ◽  
Selective Prevention

BACKGROUND As the coronavirus 2019 disease pandemic has emerged as a threat to mental health, demand is increasing for online interventions that can replace face-to-face programs to prevent mental health problems. Adolescents not only have willingness to use an online mental health intervention, but also have generally positive perceptions of online intervention. However, there is still no general agreement regarding the effects of online interventions on adolescent mental health. OBJECTIVE This study aimed to evaluate the effectiveness of online interventions for reducing anxiety, depression, and stress among adolescents through a systematic review and meta-analysis. METHODS A systematic search of studies was performed using PubMed, EMBASE, and Cochrane Library CENTRAL. The Cochrane Collaboration’s tool was used for assessing risk of bias in randomized controlled trials (RCT). We performed meta-analyses to synthesize effect sizes of the included studies, which were calculated as standardized mean differences (SMD) with 95% confidence intervals (CI). RESULTS A total of 19 studies met the inclusion criteria, and 16 studies that reported sufficient numerical data were used for quantitative data synthesis. Regarding prevention level in the included interventions, universal prevention for general adolescents and selective prevention for vulnerable adolescents were conducted by 12 and seven studies, respectively. Among the interventions in this review, cognitive behavior therapy (CBT) and family-based interventions were most often used. In the result of a meta-analysis, online interventions have shown beneficial effect on reducing depression (SMD, -0.096; 95% CI. -0.175 to -0.017). Subgroup meta-analyses by preventive level found a significant effect of universal prevention on reducing depression (SMD, -0.102; 95% CI, -0.197 to -0.008) but no statistically significant effect of selective prevention on reducing depression (SMD, -0.082; 95% CI, -0.224 to 0.061). The effects of online interventions in reducing anxiety (SMD, -0.107; 95% CI, -0.231 to 0.018) and stress (SMD, -0.071; 95% CI, -0.157 to 0.016) among adolescents were not statistically significant in meta-analyses. CONCLUSIONS The findings of meta-analyses showed that online interventions significantly reduced depression among adolescents, and especially that universal prevention interventions significantly reduced depression. However, there is limited evidence for the effectiveness of online interventions for reducing anxiety and stress among adolescents. We suggest further RCTs regarding effectiveness of online intervention for adolescent anxiety and stress.

scholarly journals Meta-Analytic Evidence of Depression and Anxiety in Eastern Europe during the COVID-19 Pandemic

2021 ◽  
Author(s):  
Stephen X. Olivia Zhang ◽  
Saylor Olivia Miller ◽  
Wen Xu ◽  
Allen Yin ◽  
Bryan Chen ◽  
...  
Keyword(s):  
Mental Health ◽  
General Population ◽  
Eastern Europe ◽  
Healthcare Workers ◽  
Meta Analysis ◽  
Anxiety And Depression ◽  
Prevalence Rates ◽  
Pooled Prevalence ◽  
Eastern European Countries ◽  
Frontline Healthcare Workers

Objective: To perform a systematic and meta-analysis on the prevalence rates of mental health symptoms including anxiety and depression during the COVID-19 pandemic in the general population in Eastern Europe, as well as three select sub-populations: students, general healthcare workers, and frontline healthcare workers. Data sources: Studies in PubMed, Embase, Web of Science, Psycinfo, and medRxiv up to February 6, 2021. Eligibility criteria and data analysis: Prevalence rates of mental health symptoms in the general population and key sub-populations during the COVID-19 pandemic in Eastern Europe. Data were pooled using a random-effects meta-analysis to estimate the prevalence rates of anxiety and depression. Results: The meta-analysis identifies and includes 21 studies and 26 independent samples in Eastern Europe. Poland (n=4), Serbia (n=4), Russia (n=3), and Croatia (n=3) had the greatest number of studies. To our knowledge, no studies have been conducted in eleven Eastern European countries including Hungary, Slovakia, and Slovenia. The pooled prevalence of anxiety in 18 studies with 22 samples was 30% (95% CI: 24%-37%) and pooled prevalence of depression in 18 studies with 23 samples was 27% (95% CI: 21%-34%). Implications: The cumulative evidence from the meta-analysis reveals high prevalence rates of clinically significant symptoms during the COVID-19 pandemic in Eastern Europe. The findings suggest evidence of a potential mental health crisis in Eastern Europe during the ongoing COVID-19 pandemic. Our synthesis also reveals a relative lack of studies in certain Eastern European countries as well as high heterogeneities among the existing studies, calling for more effort to achieve evidence-based mental healthcare in Eastern Europe. Keywords: COVID-19; Epidemic; General Population; Healthcare Workers; Frontline Healthcare Workers; Psychiatry Highlights: The pooled prevalence of anxiety and depression were 30% and 27% in Eastern Europe, respectively.

scholarly journals Prevalence of psychiatric disorders among refugees and migrants in immigration detention: systematic review with meta-analysis

BJPsych Open ◽  
2021 ◽  
Vol 7 (6) ◽  
Author(s):  
Irina Verhülsdonk ◽  
Mona Shahab ◽  
Marc Molendijk
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
Mental Health Problems ◽  
Meta Analysis ◽  
Prevalence Rates ◽  
Post Traumatic Stress ◽  
Immigration Detention ◽  
Alternative Measures ◽  
Meta Analyses ◽  
Estimate Prevalence

Background The number of forced migrants is increasing worldwide. Some governments detain refugees and migrants in immigration detention centres, which is associated with adverse mental health outcomes. Aims To estimate prevalence rates of depression, anxiety and post-traumatic stress disorder (PTSD) in child and adult refugees and migrants in immigration detention. Method Pre-registered systematic review with meta-analysis (Prospero ID: CRD42020196078). Results Systematic searches in Medline, Embase and Web of Science (final search date 1 October 2020) yielded nine eligible studies on the mental health of detained refugees and migrants (total n = 630 refugees and migrants, 522 of them in detention, among which 26 were children). For adults, prevalence rates for depression were 68% (95% CI 0.53–0.83%), for anxiety 54% (95% CI 0.36–0.72%) and for PTSD 42% (95% CI 0.22–0.63%). Theoretical comparisons with data from other meta-analyses revealed that prevalence rates and symptom severity were higher in detained, relative to non-detained samples. Conclusions Our data show a huge burden of mental health problems in detained refugees and migrants of all ages, also relative to non-detained samples. This suggests that immigration detention independently and adversely affects the mental health of refugees and migrants. This insight should encourage countries to minimise the use of immigration detention and implement alternative measures instead.

scholarly journals A Systematic Review and Meta-Analysis of the Mental Health Symptoms during the Covid-19 Pandemic in Southeast Asia

2021 ◽  
Author(s):  
Sofia Pappa ◽  
Jiyao Chen ◽  
Joshua Barnett ◽  
Anabel Chang ◽  
Rebecca Kechen Dong ◽  
...  
Keyword(s):  
Mental Health ◽  
General Population ◽  
Southeast Asia ◽  
Healthcare Workers ◽  
Meta Analysis ◽  
Prevalence Rates ◽  
Health Symptoms ◽  
Pooled Prevalence ◽  
Anxiety Depression ◽  
Insomnia Symptoms

Aims: The Covid-19 pandemic has had a substantial impact on the mental health of the general public and high-risk groups across the globe. Southeast Asia, one of the first regions to be affected by the outbreak, is of particular interest given its proximity and close links to China, experience with recent epidemics (i.e. SARS), and the variable course of the outbreak in the region thus far. The aim of this study was to systemically review and assess the prevalence of anxiety, depression and insomnia symptoms in the general adult population, frontline and general healthcare workers (HCWs), and adult students in Southeast Asia during the course of the first year of the Covid-19 pandemic. Methods: Several literature databases (PubMed, Embase, PsycINFO, Web of Science, and medRxiv) were systemically searched for articles published up to February 2021. Two reviewers independently evaluated all the relevant studies using pre-determined criteria and assessed the risk of bias for each included study. The prevalence rates of mental health symptoms were estimated using a random-effect meta-analysis model. Results: In total, 32 samples from 25 studies with 20,352 participants were included. Anxiety symptoms was assessed in all 25 studies and depressive symptoms in 15 studies with pooled prevalence rates of 22% and 16% respectively. Only two studies evaluated insomnia, whose prevalence was estimated to be 19%. The overall prevalence of mental health disorders was similar amongst frontline HCWs (18%), general HCWs (17%), and students (20%) whilst being noticeably higher in the general population (27%). Conclusions: The results indicate that a considerable proportion of participants report the presence of anxiety, depression and insomnia symptoms. However, the pooled prevalence rates in Southeast Asia are significantly lower than those reported in other meta-analyses from other areas such as China and Europe. This meta-analysis may provide valuable evidence for more targeted identification of mental health needs and guide future research of long-term outcomes. Keywords: meta-analysis; Covid-19; mental health; pandemic; general population; healthcare workers; students; anxiety; depression; insomnia

Abstract 16037: Hybrid Convergent Ablation for Atrial Fibrillation: Updated Systematic Review and Meta-analysis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
suvash shrestha ◽  
David DeLurgio ◽  
Andy Kiser ◽  
Saumil Oza ◽  
Yisachar Greenberg ◽  
...  
Keyword(s):  
Systematic Review ◽  
Patient Monitoring ◽  
Event Rate ◽  
Meta Analysis ◽  
Adverse Event Rate ◽  
Likelihood Estimator ◽  
Search Terms ◽  
Limited Effectiveness ◽  
One Year ◽  
Meta Analyses

Introduction: Hybrid convergent epicardial/endocardial ablation was developed in response to the limited effectiveness of endocardial catheter ablation for persistent (PersAF) and longstanding PersAF (LSPAF). The objective of this study was to perform a systematic review and meta-analysis of reported safety and efficacy outcomes with convergent procedures. Methods: Predefined search terms were used in PubMed; the initial search was performed in June 2019 and updated in May 2020. Abstracts and full text in English were reviewed for peer-reviewed, primary clinical studies of hybrid convergent procedures in PersAF/LSPAF. Meta-analysis was performed with using a random effects model with a restricted maximum likelihood estimator and forest plots. Heterogeneity was tested using Cochran’s Q-test. Results: The updated search yielded 325 unique results. Two articles from meta-analyses were added. Nineteen articles met inclusion with safety and/or efficacy data. Three overlapping studies were excluded. Results from the randomized CONVERGE trial were added, for a total of 1084 patients in 17 studies; 94% had PersAF or LSPAF. The 30-day major adverse event rate was 3.1% (95% CI 1.9% - 4.3%; n=1084; 17 studies), excluding pericardial effusions (PE) (non-emergent inflammatory response) and 5.1% (95% CI 3.6% - 6.6%) overall. The PEs may be mitigated by anti-inflammatory prophylaxis, pericardial drainage and appropriate patient monitoring. Freedom from AF/atrial arrhythmia at one year or later was 75.0% (95% CI 66.0%-83.9%; n=805; 14 studies) regardless of anti-arrhythmic drugs (AAD) and 64.9% (95% CI 54.7%-75.1%; n=494; 8 studies) off AADs/ absent increased dosage of failed AADs. Heterogeneity across studies was detected for effectiveness (p<0.0001), but not for safety (p=0.12). Conclusions: This meta-analysis shows high efficacy of hybrid convergent ablation at one year, even off AADs, and a reasonable safety in mostly persistent or long-standing persistent AF.

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