CHD is one of the most common types of birth defects, occurring in about 1% of live births. Various studies have reported the prevalence of these disorders in young adults to be about five cases per 1000 people. Reference Liu, Chen and Zühlke1,Reference Van Der Linde, Konings and Slager2 In addition, due to advances made in the diagnosis and treatment of CHDs, more than 95% of babies born with CHDs now reach adulthood. Reference Warnes3
They face complications related to this disease as it is a chronic condition that affects various aspects of life, including quality of life and mental and psychological well-being. Reference Gan, Gong and Tong4,Reference Park, Tahk and Bae5 As a matter of fact, it can be said that these patients have several risk factors for psychiatric disorders, which increase with age due to the need for more hospitalisations and longer hospital stays. Reference Opotowsky, Siddiqi and Webb6
Furthermore, the disruption of individual performance and daily activities caused by various surgeries and the type of disease can increase the risk of mental disorders. Reference Jobson7,Reference Marelli, Miller, Marino, Jefferson and Newburger8 This can lead to an increased risk of developing psychiatric disorders, such as depression and anxiety. Reference Calderon and Bellinger9
Potential psychological challenges include stressors related to the environment, concerns about mortality, decision-making about treatment options, preparation for surgery, and adaptation to implanted cardiac devices. Reference McGrath and Kovacs10 Young people with CHDs may have a higher prevalence of psychiatric disorders, such as depression, anxiety, impatience, and insomnia, due to the lasting consequences of invasive interventions, frequent chest pain, wound sites from previous surgeries, and the development of arrhythmia compared to the general population. Reference Crossland, Jackson and Lyall11–Reference Amedro, Dorka and Moniotte14
However, there is a lack of comprehensive understanding of the medical and social predictors of mental health problems in adults with CHD. Additionally, only a few studies have addressed the psychological experiences of this group. Reference Kovacs, Saidi and Kuhl15
Furthermore, the results of similar studies investigating depression and anxiety disorders in these patients have been contradictory, possibly due to factors such as small sample sizes, low response rates, differences in socio-cultural factors, and variations in the measurement of different parameters (e.g., disease severity). Reference Roseman and Kovacs16–Reference Rao19
Moreover, despite searches of domestic databases such as SID, Iranmedex, and Irandoc, as well as international databases including PubMed, Scopus, WOS, Embase, and PsychINFO, no comprehensive studies on mental illness in young adults with CHD have been conducted in Iran. Therefore, we aimed to investigate the prevalence of anxiety and depression in adults with CHD in the city of Kerman, Iran.
Methods
Design
This cross-sectional descriptive-analytical study was conducted on adult patients above 18 years of age with CHD who visited the heart clinic in Kerman, Iran. The sample was selected using a simple random method. Diagnosis of CHD was made by an adult congenital cardiologist based on echocardiographic findings and other paraclinical methods. After obtaining the necessary permissions from the university and the ethics committee of Kerman University of Medical Sciences, 130 adult patients with CHD were included in the study. Of these, 105 patients (80.7% response rate) completed the questionnaire. The inclusion criteria were patients aged over 18 years without any underlying disease other than CHD, and with a complete and accurate history of previous diseases and medications. Patients who did not wish to participate in the study were excluded.
Instrument
After providing necessary information and obtaining informed consent, patients were given a checklist to complete, which included age, sex, marital status, and educational and employment status, as well as the standard Beck Anxiety and Depression and Depression Anxiety Stress Scales (DASS) questionnaires. All patients underwent transthoracic echocardiography to check ventricular size and function, as well as pulmonary pressure. Other items of the questionnaire, such as the type of underlying disease (simple, moderately complex, great complex), type of previous surgery (corrective, palliative, or none), presence of residual defect, New York Heart Association function class, and the presence or absence of cyanosis (saturation of O2 less than 94%), were completed by the researcher based on available documents. Cardiac dysfunction was diagnosed and graded based on left ventricular function (systemic ventricle) on echocardiography as follows: an ejection fraction above 55% was considered normal, between 55 and 45% was considered mildly reduced, between 44 and 30% was considered moderately reduced, and below 30% was considered severely reduced. After completing the questionnaires (without name and with a special code), the score of the questionnaire was considered final based on the criteria explained below
Assessment of psychological functioning
We used two standard questionnaires to assess psychological disorders. The first questionnaire was Beck’s Anxiety Inventory, a 21-item self-report scale designed to measure the intensity of anxiety in adolescents and adults. Each item offers four response options (ranging from 0 to 3) that indicate the severity of anxiety symptoms experienced by the respondent. The total score on this questionnaire ranges from 0 to 63, with higher scores indicating greater levels of anxiety. This questionnaire is specifically designed to assess anxiety symptoms and does not measure depression. Studies have demonstrated high validity of the Beck’s Anxiety Inventory, and Kaviani and Mousavi reported a Cronbach’s alpha of 0.92 for the Persian version of the questionnaire. Reference Kaviani and Mousavi20
The second questionnaire was the DASS, which consists of three self-report subscales designed to measure negative emotional states of depression, anxiety, and stress. Each subscale contains seven items, and patients were asked to rate the extent to which they experienced each state in the last week using a 4-point intensity/frequency scale. The items in DASS were selected to represent all three subscales, and full 42-decimal scales of DASS-42 could be derived by multiplying the subscale scores by two. The Persian version of the DASS questionnaire demonstrated good internal consistency for the three subscales, with a Cronbach’s alpha of 0.77 for depression, 0.79 for anxiety, and 0.78 for stress, as calculated by Sahibi and colleagues. Reference Sahebi, Asghari and Salari21
Statistical analysis
Descriptive statistics including frequency, relative frequency, and measures of central tendency were used to summarise the data. For quantitative data analysis, a t-test was conducted, while for qualitative data analysis, a Chi-square test was performed. The results were analysed using SPSS version 26 software.
Ethical statement
The study was approved by ethics committee of Kerman University of Medical Sciences (IR.KMU.REC.1401.129). We ensured that the information of patients who were eligible for inclusion in the study was kept confidential. Participation in the study was completely voluntary, and patients had the right to withdraw from the study at any time
Results
Participant characteristic
In this study, the mean age of the participants was 29.94 ± 12.36 years. Of the participants, 63.8% were female and 36.2% were male. The majority of participants (55.2%) were single, while 40% were married, and 4.8% were divorced. In terms of education, 46.7% of participants had less than a high school diploma, 40% had a high school diploma, and 13.3% had university education. Regarding occupation, 46.7% of participants were housewives, 8.6% were students, 14.3% had part-time jobs, and 30.5% had full-time jobs (see Table 1).
Demographic data of studied subjects.
Among the patients studied, 34.2% had simple disease, 35.2% had moderate complexity, and 30.5% had high complexity. Among the studied patients, 53.3% had undergone complete correction surgery, 6.7% had undergone palliative surgery, and 40% had not undergone surgery. Regarding ventricular dysfunction, 13.3% of patients did not have ventricular dysfunction, while 44.8%, 24.8%, and 17.1% had mild, moderate, and severe ventricular dysfunction, respectively. In terms of disease complexity, 34.2% had simple disease, 35.2% had moderate complexity, and 30.5% had high complexity. Among the participants, 77.1% had remaining CHDs, while 22.9% did not have any remaining defects. Based on the New York Heart Association functional classification, 42.9% of patients were in class I, 26.7% were in class II, 29.5% were in class III, and 1% were in class IV. Additionally, 25.7% of patients had cyanotic heart disease, while 74.3% had a cyanotic heart disease (see Table 2).
Studied subjects by CHDs.
Prevalence of psychological disorders
According to the DASS questionnaire, the mean scores for depression, anxiety, and stress among the participants were 6.5 ± 5.73, 7.56 ± 6.22, and 9.26 ± 5.79, respectively. In terms of depression, 9.5% of participants had mild depression, 17.1% had moderate depression, and 73.4% did not have depression. Regarding anxiety, 8.6% had mild anxiety disorder, 12.4% had moderate anxiety disorder, 20% had severe anxiety disorder, and 1% had very severe anxiety disorder, while 61% did not have anxiety. Of the participants, 76.2% did not have stress disorder, while 19% had mild stress and 4.8% had moderate stress.
The results of the chi-square test showed that none of the individual characteristics of the participants had a significant relationship with the degree of depression, but the participants' gender and type of surgery had a significant relationship with the intensity of their anxiety. Additionally, the results of the chi-square test indicated that the presence of cyanotic or acyanotic disease had a significant relationship with participants' stress levels. The logistic regression test was conducted to determine the factors predicting anxiety and stress in the participants. The results of the test showed that none of the variables including gender and type of surgery were able to predict participants' anxiety (P-value < 0.05). Similarly, the presence or absence of cyanosis in congenital heart patients was not a predictor of their stress levels (P-value < 0.05).
The mean anxiety score of the participants based on the Beck’s anxiety questionnaire was 18.24 ± 13.6. Among the participants, 27.6% did not suffer from anxiety, 26.7% had mild anxiety, 20% had moderate anxiety, and 25.7% had severe anxiety. The chi-square test results indicated that the participants' gender and age had a significant relationship with their anxiety. However, the logistic regression test results showed that neither gender nor age were able to predict the degree of anxiety in the participants (P-value < 0.05).
Relation between individual characteristics of patients with the degree of psychologic disorder based on the Beck and DASS Questionnaire score are summarised in Table 3.
Relation between individual characteristics and the degree of psychologic disorder based on the Beck and DASS questionnaires.
Dass = Depression Anxiety Stress Scales.
* Indicates the difference is significant at P < 0.05.
Discussion
The aim of this study was to investigate the prevalence of anxiety and depression in adults with CHD. The results showed that the highest frequency of participants belonged to the age group of 18–28 years (61.9%), which is consistent with previous studies. Donovan et al. reported an average age of 32 years among the participants in their study, Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22 while Kovacs et al. found an average age of 31.9 years. Reference Kovacs, Saidi and Kuhl15 These findings suggest that the majority of individuals with CHD are young people. Given the importance of mental health in the young population, it is crucial to have a proper understanding of anxiety, depression, and other mental health issues in these patients.
In our study, a majority of the participants were married (80.4%). This rate is higher than that reported by Donovan et al., where only 47% of participants were married. Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22 Conversely, Eslami et al. reported that more than half of their study participants were married. Reference Eslami, Sundin, Macassa, Khankeh and Soares23 Given that a significant proportion of individuals with CHD are married, their mental health status can potentially impact their marital relationships and lead to mental health problems for their partners and children. Therefore, it is essential to investigate the mental health issues of these patients and identify their associated factors.
The educational profile of the participants in our study was as follows: 46.7% had less than a high school education, 40% had completed high school, and 13.3% had a college degree. Eslami et al. reported that 28.5% of participants had primary education, 44.1% had completed high school, and 24.2% had a university education, which was comparable to our study. Reference Eslami, Sundin, Macassa, Khankeh and Soares23 Similarly, Donovan et al. found that only 26% of their participants had a university education, while the rest had lower levels of education. Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22 These findings suggest that a small proportion of individuals with CHD have higher educational attainment, and there are conflicting results regarding the relationship between education and psychiatric disorders among these patients. Reference Westhoff-Bleck, Briest and Fraccarollo24,Reference Cocomello, Dimagli, Biglino, Cornish, Caputo and Lawlor25 This is noteworthy because higher education is often associated with a better quality of life, longer lifespan, and better health outcomes. In our study, 14.3% of participants were employed. Eslami et al. reported that 62.2% of their participants were not employed, which is a concern along with our findings. Low income can lead to various socio-economic problems that can adversely affect an individual’s mental health. Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22,Reference Eslami, Sundin, Macassa, Khankeh and Soares23
In our study, 34.2% of participants had a simple CHD, 35.2% had moderate complexity, and 30.5% had high complexity. In contrast, Kovacs et al. reported that only 10% of their participants had a simple disease, while the rest had moderate or severe complexity. Reference Kovacs, Saidi and Kuhl15 Donovan et al. found a higher frequency of moderate and high complexity diseases compared to our study. Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22 These differences in disease complexity may be attributed to geographic and genetic factors. According to present study, 53.3% of participants underwent complete correction surgery, 6.7% had palliative surgery, and 40% had not undergone surgery. Westhoff-Bleck et al. reported that 83.3% of their participants had undergone at least one corrective surgery, with 18.6% having undergone three or more corrective surgeries. Reference Westhoff-Bleck, Briest and Fraccarollo24 Prior research has suggested that preoperative preparation, surgery, and postoperative complications can cause lasting psychological distress in these patients. Reference Burchill, Gao and Kovacs26,Reference Westhoff-Bleck, Winter and Aguirre Davila27
Our study examined the effects of CHDs on the health of patients' hearts and bodies. We found that 77.1% of participants had residual CHDs, which can lead to stressful conditions for patients and their families and adversely affect their mental health. Frequent hospital visits for residual defect evaluation and the need for re-surgery can also put patients' mental health at risk. Reference Miller, Sorabella and Padilla28 Regarding cardiac function, 42.9% of participants were in class 1, 26.7% were in class 2, 29.5% were in class 3, and 1% were in class 4. Kovacs et al. reported that 65% of their participants were in New York Heart Association function class 1, indicating better cardiac function than our study findings. Reference Kovacs, Saidi and Kuhl15 Similarly, Westhoff-Bleck et al. found that 74.3% of their participants were in class 1, indicating better cardiac function in the majority of their participants. Reference Westhoff-Bleck, Briest and Fraccarollo24 CHDs and their effects on New York Heart Association function class can significantly impact the quality of life of individuals with these defects. Previous research has suggested that the New York Heart Association function class of patients can have a significant impact on their mental health. Reference Utens, Verhulst and Erdman18,Reference Westhoff-Bleck, Briest and Fraccarollo24
Based on the findings of the DASS questionnaire in our study, we found that 26.6% of participants had symptoms of depression, 42% had symptoms of anxiety, and 21% had severe or very severe anxiety disorders, which is concerning. However, 23.8% of participants had mild to moderate stress, which is promising. Previous studies have also examined the degree of depression, anxiety, and psychiatric disorders in individuals with CHD. Reference Roseman and Kovacs16,Reference Bromberg, Beasley, D'Angelo, Landzberg and DeMaso17,Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22,Reference Eslami, Sundin, Macassa, Khankeh and Soares23,Reference Westhoff-Bleck, Winter and Aguirre Davila27 Adults with CHD face various potential psychosocial challenges, which can increase their likelihood of experiencing symptoms consistent with mood and anxiety disorders. Reference Bromberg, Beasley, D'Angelo, Landzberg and DeMaso17 Donovan et al. reported that 23% of their participants had symptoms of depression and 30% had anxiety, which is lower than the rates found in our study. Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22 This difference may be due to socio-economic conditions, better care and treatment services, or other environmental factors.
The present study found no significant relationship between individual patient characteristics and degrees of depression. However, patient gender and type of surgery had a significant relationship with patient anxiety, while the presence of cyanosis had a significant relationship with stress levels. One of the underlying factors contributing to this issue may stem from the systemic repercussions of cyanosis on multiple organs and their associated side effects. As evidenced by prior research, Reference Khajali, Maleki and Amin29 chronic hypoxia can lead to a spectrum of complications affecting the brain, haematological system, pulmonary function, and renal function, among others. Each of these complications may have a detrimental effect on an individual’s quality of life, potentially culminating in the development of psychological disorders. Donovan et al. also reported that a patient’s initial perception of their disease could predict their quality of life, anxiety, and depression in the following year. Reference O’Donovan, Painter, Lowe, Robinson and Broadbent22 Bromberg’s study showed that among patients deemed to be “adjusting well to their illness,” 36.4% experienced a diagnosable psychiatric disorder with prominent symptoms of anxiety or depression. Additionally, there was a significant relationship between the severity of CHD and the diagnosis of depression. Reference Bromberg, Beasley, D'Angelo, Landzberg and DeMaso17
The findings of the present study, along with previous research, highlight the significant concerns regarding psychological trauma and the occurrence of psychiatric disorders, including depression, anxiety, and stress, among adults with CHD, particularly in those with complex lesions such as cyanosis. It is crucial to prioritise the psychological evaluation of these patients. Early identification, diagnosis, and treatment of these disorders, even in patients who appear to be coping well with their illness, can prevent physical and mental disability in these patients
In our study, the average anxiety score of patients based on the Beck anxiety questionnaire was 18.24 ± 13.6. Additionally, 72.4% of patients were found to be suffering from anxiety, and 25.7% of them had severe anxiety. Compared to the anxiety results of the DASS questionnaire, more patients in our study suffered from anxiety with greater severity, which may be due to the higher scoring of the Beck anxiety questionnaire. Furthermore, the results showed that patient sex and age had a significant relationship with their anxiety. In Kovacs et al.’s study, the average anxiety score of participants based on the State-Trait Anxiety Inventory-Trait Subscale (STAI-T) anxiety questionnaire was 36.5 (with a maximum score of 70), and 36% of participants were diagnosed with an anxiety disorder. Loneliness and fear of others' opinions about the patient were predictive factors of this disorder. Reference Kovacs, Saidi and Kuhl15 Bromberg et al.’s study Reference Bromberg, Beasley, D'Angelo, Landzberg and DeMaso17 found that based on the 4th version of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the Brief Symptom Inventory, about 36.4% of adults with CHD had detectable psychological disorders, with symptoms of anxiety and depression being more prevalent. However, Jan Muller et al.’s study, Reference Müller, Hess and Hager30 showed that the prevalence of depressive symptoms in people with CHD is lower than that of the general population (with a prevalence of 8.6%). Nonetheless, even mild depressive symptoms can significantly impact the quality of life of these individuals. In a study conducted by Amelia E. Mercado et al. Reference Mercado, Well and Lamari-Fisher31 it was found that approximately 15.6% of hospitalised patients with CHD had at least one psychological disorder, and these patients differed from healthy individuals in terms of demographic characteristics. The difference in depression prevalence between this study and ours could be due to cultural differences and differences in the patients' place of residence. Michal Benderly et al.’s study, Reference Benderly, Kalter-Leibovici and Weitzman32 showed that depression and anxiety disorders in adults with CHD are more prevalent in older age and among women. The presence of these disorders can increase the number of medical visits, mortality rates, and ultimately, healthcare costs. Anxiety can be distressing and debilitating, particularly in young patients with CHD. Therefore, healthcare workers' adequate training and awareness of these patients can effectively help reduce this mental disorder.
Conclusion
In summary, this study highlights the prevalence of mental disorders, including depression, anxiety, and stress, in a population of young patients diagnosed with CHD. The prevalence of these disorders is intricately related to individual characteristics, such as age and gender, in addition to disease severity. In such a way that patients with a history of palliative surgery and the presence of cyanosis in the patients increase the prevalence of psychological disorders. This issue shows that the chronicity of the disease (one of the signs of which is the presence of cyanosis) can cause psychological disorders and negative effects on the quality of life. Therefore, timely diagnosis and treatment of such heart defects can have beneficial effects on the future life of these patients.
Acknowledgment
This paper constitutes a segment of an MD thesis conducted at Kerman University of Medical Sciences. We extend our gratitude to the authorities at Kerman University of Medical Sciences for their generous support. Furthermore, we express our appreciation to all the patients whose participation made this study possible.
Competing interests
No competing interests to declare.
