Anxiety and Depression in Adults with Congenital Heart Disease.

Anxiety and Depression in Adults with Congenital Heart Disease.

Kovacs AH, Luyckx K, Thomet C, Budts W, Enomoto J, Sluman MA, Lu CW, Jackson JL, Khairy P, Cook SC, Chidambarathanu S, Alday L, Estensen ME, Dellborg M, Berghammer M, Johansson B, Mackie AS, Menahem S, Caruana M, Veldtman G, Soufi A, Jameson SM, Callus E, Kutty S, Oechslin E, Van Bulck L, Moons P; APPROACH-IS Consortium, International Society for Adult Congenital Heart Disease. J Am Coll Cardiol. 2024 Jan 23;83(3):430-441. doi: 10.1016/j. JACC. 2023.10.043. PMID: 38233017

Take-home Points:

1. High Prevalence of Psychological Distress: Anxiety and depression are common in ACHD, with anxiety being especially prevalent. Routine screening and documentation in clinical practice are essential.
2. Impact on QOL and Health: Both mild and severe symptoms of anxiety and depression lead to significant reductions in QOL and HS. Managing these issues is crucial to improving patient outcomes.
3. Integrating Mental Health Care: Embedding mental health professionals in ACHD care teams or developing strong referral systems is vital for comprehensive care.
4. Targeted Interventions: Younger, female, unemployed, and functionally impaired patients are at higher risk of psychological distress, requiring focused attention and support.

Commentary from Dr. Pradeep Kumar Charla (Cleveland, USA), section editor of ACHD Journal Watch

Introduction: This study investigates the prevalence and impact of anxiety and depression in adults with congenital heart disease (ACHD). a population known to be at higher risk of psychological distress compared to the general population. It explores how these psychological issues affect patients’ quality of life (QOL) and health status (HS), providing valuable insights into the need for better psychological care in this group.

Study Design: This was a sub study of the APPROACH-IS, a large international study that included 3,815 ACHD patients from 15 countries. The participants were assessed using the Hospital Anxiety and Depression Scale (HADS), quality of life linear analogue scale (QOL-LAS), and health status visual analogue scale (HS-VAS)

Key Findings

Prevalence of Anxiety and Depression:

• Nearly 30% of ACHD patients had elevated anxiety and/or depression, with anxiety (27.2%) being more common than depression (11.8%).
• Intercountry variations were notable, with France showing the highest anxiety levels (38.2%) and Japan the highest depression levels (21.2%).
• Only 9.3% of patients had documentation of a mood and/or anxiety disorder in their medical charts.

Impact on Quality of Life (QOL) and Health Status (HS):

• Both QOL and HS worsened with increasing anxiety and depression severity, even with mild symptoms showing a substantial negative effect.
• Severe symptoms led to clinically meaningful reductions in QOL and HS, highlighting the need for psychological intervention.

Associated Factors:

• Anxiety was more prevalent among younger patients, females, and those unemployed or not studying.
• Depression was associated with older age, female sex, unemployment, and worse functional status (NYHA class II-IV).
• Greater CHD complexity was linked to anxiety but not strongly related to depression.

Strengths:

1. Large Global Sample: This study, with 3,815 participants from 15 countries, provides a broad view of anxiety and depression in ACHD patients.
2. Standardized Assessment: The use of the Hospital Anxiety and Depression Scale (HADS) ensures consistent measurement across countries, enhancing comparability.

Limitations:

1. Cross-sectional Design: The study only captures a single point in time, limiting insight into long-term psychological trends.
2. Selection bias.
3. Self-reported Data: Reliance on self-reported HADS scores may introduce bias, as these are not as precise as clinical interviews.
4. Narrow Focus: Other psychological conditions, such as PTSD, bipolar disorder, panic disorder or substance use were not assessed, potentially underestimating overall distress.

Discussion: The authors advocate for:

• Enhanced identification and management of psychological distress in CHD clinical settings
• Implementation of routine screening with available resources
• Integration of mental health professionals into CHD care teams
• Increased clinician awareness and proactive inquiry about mental health

Conclusion:

Anxiety and depression are common and significantly impact the health and quality of life of adults with congenital heart disease. Proper clinical documentation and mental health care integration into ACHD programs are necessary to improve both psychological and overall health outcomes.