Cochrane Corner: ‘Psychological Interventions for Depression in Adolescent and Adult Congenital Heart Disease’
Funding: The authors received no specific funding for this work.
1 What Is the Review About?
What are the effects of psychological interventions for the treatment of depression in adolescents and adults with congenital heart disease?
2 What Are the Findings?
- Psychological interventions, including cognitive behavioural therapy, psychotherapy and talking/counselling therapy, may reduce depression more than usual care at both three-month and 12-month follow-up intervals for adolescents and adults with congenital heart disease.
- Three new randomised controlled trials including 480 participants were identified since the last iteration of this review in 2013, at which time no published studies were available.
- The absolute change in depression scores was low for both follow-up periods.
- The quality of evidence for both follow-up periods was low-certainty evidence.
- There was insufficient evidence to draw conclusions about changes in quality of life.
- Secondary outcomes including acceptability of treatment, quality of life, hospital re-admission, non-fatal cardiovascular events, cardiovascular behavioural risk factors, health economics, cardiovascular mortality or all-cause mortality were not reported.
3 What Are the Findings Based on?
Randomised controlled trials (RCTs) directly assessing the use of psychological interventions for depression in patients with congenital heart disease were included. The initial literature review yielded 887 studies. However, 870 were ineligible, and 12 did not meet the inclusion criteria. Therefore, five articles reporting on three studies were included. The three studies had sample sizes ranging from 42 to 324 participants, with a mean age ranging from 32.8 to 43.3 years old. The studies were conducted in Canada, the Netherlands and Sweden. These studies used the Hospital Anxiety and Hospital Depression Scale to quantify depression symptoms. The length of the intervention ranged from 90 min to 12 weeks. Included studies are summarised in Table 1.
| Psychological intervention versus usual care for depression in people with congenital heart disease |
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Patient or population: Adolescents and adults with congenital heart disease Setting: Worldwide Intervention: Psychological intervention (talking/counselling therapy) Comparison: Usual care |
| Outcomes | Illustrative comparative risks (95% CI) assumed risk for usual care | Illustrative comparative risks (95% CI) corresponding risk for psychological interventions | Relative effect (95% CI) | Number of participants (studies) | Quality of evidence (GRADE) | Comments |
|---|---|---|---|---|---|---|
| Change in depression Score (measured with HADS; 3-month follow-up) | Mean change in HADS score ranged across the control groups from 0.1 to 0.2 | Mean difference in the intervention groups was 1.07 lower (1.84 lower to 0.30 lower) | Not estimable | 156 (2 RCTs) | ΘΘOO Low a | MD −1.07, 95% CI −1.84 to −0.30 |
| Change in depression score (measured with HADS; 12-month follow up) | Mean change in HADS score ranged across the control groups from 0 to 0.2 | Mean difference in the intervention groups was 1.02 lower (1.92 lower to 0.13 lower) | Not estimable | 287 (2 RCTs) | ΘΘOO Low a | MD −1.02, 95% CI −1.92 to −0.13 |
- Note: GRADE Working Group grades of evidence. High certainty: We are very confident that the true effect is close to the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate, but it may be substantially different. Low certainty: Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate. Very low certainty: We have very little confidence in the effect estimate; the true effect is likely to differ substantially from the estimate of the effect.
- Abbreviations: CI, confidence interval; HADS, Hospital Anxiety and Depression Scale; MD, mean difference; RCT, randomised controlled trial.
- a Down-graded two levels due to difference in interventions (applicability).
4 Implications for Practice
- Psychological interventions for depression may be effective in patients with congenital heart disease; evidence is low-certainty and the changes seen are limited in magnitude.
- More research is needed to identify the optimal type and length of intervention and its effect on quality of life and other secondary healthcare outcomes.
5 Clinical Perspective
Congenital heart disease (CHD) affects approximately 1% of live births [1]. Through improvements in medical and surgical care, more children affected by CHD survive to adulthood [2]. Recent evidence suggests that approximately 31% of adults with CHD are affected by mood disorders and 28% by anxiety [3]. Another cross-sectional evaluation reveals that 50% of patients met criteria for a mood or anxiety disorder over the lifetime, and 39% of those affected never received therapy or medications [5]. Given the increased risk in this population, the American College of Cardiology and American Heart Association have recommended routine screening for mental health disorders in patients and families affected by CHD [4].
There are innumerable consequences of mental health disorders for adolescents and adults with CHD, including financial, employment, family, social, and physical health domains [6]. Depression in patients with CHD is associated with systemic inflammation, heart failure, functional impairment, lower quality of life, longer hospital stays, and increased risk of mortality [7, 8]. Among hospitalised ACHD patients, those with a mental health disorder had longer lengths of stay relative to unaffected patients [9]. It is critical not only to identify mental health disorders in patients with CHD, but also to refer to accessible, affordable mental health care promptly.
Challenges in accessing care are common for all patients. A recent evaluation found that 40% of ACHD patients in New York were uninsured or self-pay [10]. National data among a relatively young ACHD sample demonstrates a rate of uninsurance of 8.8% [11]. Uninsured patients demonstrated a high frequency of depression (22.5%), were less likely to access routine care, and were more likely to visit an emergency room [11]. Among 123 surveyed ACHD patients, 72% reported concerns about insurance [12]. This same survey found that 60% of patients were concerned about mental health [12].
When offered, the rate of treatment for mental health disorders is relatively high. In one nonrandomized single-centre study of 100 patients, psychotherapy was offered to 87 patients, with 75 pursuing treatment [13]. Of these, 64 completed psychotherapy, and 54 reported a reduction or absence of symptoms [13]. This program was integrated with the centre's ACHD program and advocated for the inclusion of behavioural health services in ACHD and general cardiology programs [13].
Though limited due to the lack of available evidence on the topic, this review supports the importance of the recognition and treatment of depression in adolescents and adults affected by CHD [2]. The implementation of this screening adheres to previously cited ACC/AHA recommendations [4]. Further, this study speaks to the roles of paediatric and adult cardiology subspecialists in screening for and mitigating the impact of mental health and identifying other contributory social drivers of health.
A myriad of validated questionnaires, including the Hospital Depression Scale and Patient Health Questionnaire-9, is easily implementable for adolescents and adults to self-report depression symptoms. In addition, recent evaluations have aimed to develop a disease-specific form for adults with congenital heart disease [14]. This tool, the ACHD PRO, has proven valid and reliable in multicenter studies [14].
Multiple modalities were assessed in this review, including cognitive behavioural therapy, a mindfulness-based stress reduction (MBSR) technique, and a single educational session using virtual learning. There is inadequate evidence to identify a best-practice psychological intervention. Further research is required to understand the needs of this population and develop interventions tailored to those with congenital heart disease [15].
This Cochrane Review highlights the potential benefit of multiple psychological interventions but is limited in generalisability due to small numbers, heterogeneity in patients, and varied treatment lengths. Patients must first be identified and appropriately referred to receive any benefit. This review revealed a lack of high-quality RCTs addressing depression treatment strategies in ACHD patients. The previous Cochrane Review in 2013 was notable for the absence of RCTs identified from 1980 to 2013 that met the inclusion criteria [16]. It is critical to advocate policies that improve care access for ACHD patients. Further, understanding available resources and partnering with psychologists and psychiatrists is imperative to building a care network for this population.
Conflicts of Interest
The authors declare no conflicts of interest.
