Psychiatric Disorders Common in Adolescent Survivors of Congenital Heart Disease

By Will Boggs MD

February 03, 2017

NEW YORK (Reuters Health) - Psychiatric disorders are common in adolescents with single-ventricle congenital heart disease (CHD) who have undergone the Fontan procedure, researchers report.

"As opposed to previous studies which have used self-report measures, we uniquely used structured clinical interviews, the gold standard of clinical diagnosis, to determine the presence of psychiatric disorders," explained Dr. David R. DeMaso from Boston Children's Hospital.

"In taking this approach, we found both current and lifetime increases in attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders in adolescents facing this critical congenital heart disease. The ADHD diagnosis was expected; however, the anxiety disorder finding was surprising," he told Reuters Health by email.

Children who undergo the Fontan procedure show deficits in visual-perceptive skills and executive function, ADHD symptoms, and reduced quality of life, but there are few data available on the mental health outcomes of these CHD survivors in adolescence.

Dr. DeMaso and colleagues assessed neurodevelopmental, psychiatric, and brain MRI outcomes in 156 adolescents with single-ventricle CHD who had undergone the Fontan procedure and in 111 healthy adolescents.

Significantly more CHD patients (65%) than controls (22%) had a lifetime psychiatric diagnosis, the team reports in Pediatrics, online February 1.

There were significantly higher percentages of CHD patients than controls with ADHD (34% vs. 6%) and with anxiety disorders (35% vs. 7%).

Total scores on the Brief Psychiatric Rating Scale for Children were also greater for patients than controls, reflecting a higher degree of psychiatric symptom severity.

Patients fared worse than controls regarding parent- and self-reported measures of anxiety, disruptive behavior, and depressive symptoms.

Eighty-five percent of patients scored in the pathologic range on the Children's Global Assessment Scale (CGAS), indicating substantial psychosocial functioning difficulties in different environments (school, at home, and with peers).

Higher risk of lifetime anxiety was associated with lower birth weight and with longer duration of deep hypothermic circulatory arrest during surgery, whereas higher risk of lifetime ADHD was associated with lower IQ scores and male gender.

Brain MRI abnormalities were not associated with lifetime diagnosis of anxiety or ADHD.

"While the importance of neurodevelopment vulnerabilities has long been known for critical congenital heart diseases, this study adds heightened or disabling anxiety as an important symptom to screen for in the management of these youngsters," Dr. DeMaso said.

"The long-term care of children facing critical congenital heart disease requires a patient- and family-centered approach to the early diagnosis and treatment of neurodevelopmental (ADHD) and anxiety disorders," he said.

"There are effective treatment interventions including psychotherapies and medication for disabling childhood anxiety - it would be a shame not to reach these children with these therapies," Dr. DeMaso said.

Dr. Adrienne H. Kovacs from Oregon Health & Science University's Knight Cardiovascular Institute in Portland, who works with adult survivors of CHD, told Reuters Health by email, "This study affirms my belief that the collective responsibility to helping young people with congenital heart disease goes beyond extending lives. We have an opportunity to identify and address psychological, social and neurodevelopmental challenges with the ultimate goal of improving overall quality of life of patients and families. To do so, however, would require an interdisciplinary model of care."

"Adolescents with complex congenital heart disease will soon become young adults with congenital heart disease, and thus faced with a new set of challenges (e.g., employment) in the absence of daily structure typically provided in adolescence," she said. "Thus, the results of this study have important implications for both pediatric and adult congenital cardiology programs."

"I anticipate that patient advocacy and a focus on patient engagement will continue to grow," said Dr. Kovacs, who was not involved in the research. "Further, with increased public access to the results of studies such as this one, I suggest that CHD providers be prepared to answer questions from patients and families about available services targeting psychiatric, psychosocial, and neurocognitive needs."


Pediatrics 2017.