Depression and Anxiety in The Pediatric Heart Failure Population

As a provider caring for children with advanced heart failure as well as those needing ventricular assist device (VAD) support or heart transplantation, this month’s article about anxiety disorders in children was a welcome read and resource.¹ The burden of pediatric heart failure in the US continues to rise, with congenital heart disease (CHD) remaining the leading cause of pediatric heart failure.² And children with heart failure are, after all, children first.

It is no surprise that mental health conditions including anxiety and depression are a common concern among children with heart failure, heart transplant, or those on VAD support. Half or more of children awaiting heart transplantation demonstrate impaired psychosocial functioning, and 25–35% of these children meet the criteria for an emotional disorder diagnosis.³ As I chat with these patients and families when they are admitted to the hospital, these numbers make complete sense. After receiving the diagnosis of heart failure, the lives of these patients and families change completely. Staples of childhood existence such as school, play dates, and a trip to the park become tasks that may be fraught with the possibility of a deterioration in their clinical state, and the parents are always on high alert. Frequent medical appointments and laboratory testing involving blood draws become a “norm.” As I was reading the paragraph about specific phobias, I paused to wonder how many of our patients experience these feelings when they visit the hospital or during the morning “lab rounds” while in the hospital.

For children who have CHD as the underlying etiology of HF, the journey as a “heart warrior” starts as early as before birth. And along the way, through one or more surgeries and scores of clinic appointments and testing, they receive an update that their “mended heart” is now starting to fail. So it is no surprise that children with CHD as the underlying etiology of heart failure are at higher risk for depression and behavioral problems.⁴    

The field of pediatric heart failure is seeing technical advances at a fast clip, with an expanding ability to support patients with advanced heart failure with VADs. With all their life-saving advantages, these mechanical circulatory support strategies also carry a burden of mental health comorbidities in as high as 40% of patients.⁴ The ongoing responsibility for device management and living with a mechanical support device is a causative factor for depression.⁵ Children discharged home on VAD support are at increased risk of emotional, physical, and psychosocial obstacles.⁴ This is important to address because data suggest the presence of depression and anxiety interfere with physical rehabilitation and medication compliance.³ Providing a multidisciplinary program with support from both social workers and psychologists has been shown to reduce both anxiety and depression and improved overall perception of health.^6,7 Hence optimizing mental health and psychosocial counseling to maximize rehabilitation while on device support is a vital theme within the community of children with heart failure and on VAD support.

It is heartening to see the increase in awareness about mental health conditions in the pediatric community, also supported by resources such as this excellent review. As we care for these children with life-altering diagnoses in the hospital, it is encouraging to know that they and their families can be supported by a pediatrician that also appreciates their mental health. A heightened awareness from all providers caring for these high-risk patients and frequent screening can lead to timely diagnosis and treatment, which can help us support not just their hearts but also their minds and enable them to truly live their best lives. 

Acknowledgement: Kriti Puri, MBBS, Editorial Board Member, Pediatrics in Review, assisted in the drafting and revision of this blog.

References

1. Doyle MM. Anxiety disorders in children. Pediatr Rev. 2022:43(11).
2. Amdani S, Marino BS, Rossano J, Lopez R, Schold JD, Tand WHW. Burden of pediatric heart failure in the United States. J Am Coll Cardiol. 2022;79(19):1917–1928. https://doi.org/ 10.1016/j.jacc.2022.03.336
3. Hollander S, Callus E. Cognitive and psychologic considerations in pediatric heart failure. J Card Fail. 2014;20(10):782–785. https://doi.org/10.1016/j.cardfail.2014.07.001
4. Diaz I, Thurm C, Hall M, Auerbach S, Bearl DW, Dodd DA, Mettler BA, Smith AH, Fuchs C, & Godown J. Disorders of adjustment, mood, and anxiety in children and adolescents undergoing heart transplant and association of ventricular assist device support. J Pediatr. 2020;217:20–24. https://doi.org/1016/j.jpeds.2019.10.022
5. Ozbaran B, Kose S, Yagdi T, Engin C, Erermis S, Uysal T, Ayik F, Karakula S, Ulger Z, Atay Y, Ozbaran M. Psychiatric evaluation of children and adolescents with left ventricular assist devices. Psychosom Med. 2012;74(5):554–558. https://doi.org/10.1097/PSY.0b013e318258853a
6. Ferrario SR, Bacich D, Beltrame L, Balestroi G, Pistono M. Does a comprehensive inpatient rehabilitation program improve patient’s and caregiver’s emotional state in LVAD patients? Artif Organs. 2019;43(3):229–233. https://doi.org/10.1111/aor.13351
7. Kitagaki K, Ono R, Shimada Y, Yangai H, Konishi H, Nakanishi M. Depressive symptoms interfere with the improvement in exercise capacity by cardiac rehabilitation after left ventricular assist device implantation. Artif Organs. 2021;46:471–478. https://doi.org/10.1111/aor.14072