Psychosocial Issues in Adult Congenital Heart Disease

Anxiety and Depression

Early studies have shown that approximately one-third of adults with CHD experience difficulties with depression and/or anxiety. Furthermore, it has been found that half of the CHD population presents with at least one lifetime depressive or anxiety disorder. These prevalence rates are higher than those in the general population. However, these data are all from North America and are based on studies in small samples. European data demonstrate different psychological outcomes. Assessment of the longitudinal development of psychopathology in a Dutch cohort showed that the prevalence of psychopathology, including internalizing behaviors such as anxiety and depression, was similar or even better compared to reference norms. An Italian study similarly concluded that psychological well-being of patients was comparable to reference norms. In a large German study, the level of trait anxiety was similar to that of healthy controls, and the prevalence of depressive symptoms was lower in patients than in the general population. A recent Belgian study in young people with CHD found that patients scored significantly lower on depressive symptoms than community adolescents. Overall, it can be concluded that the majority of studies do not find a higher prevalence of mood and anxiety disorders in adults with CHD. Irrespective of whether the levels of anxiety and depression in patients are similar or lower, the importance of assessing persistent or chronic depressive symptoms has been emphasized. Indeed, patients with persisting or recurring depressive symptoms do worse in terms of QOL and patient-reported health than patients who are experiencing one or no depressive episodes. This reminds us of the need for regular and longitudinal assessments of anxiety and depression throughout clinical follow-up.

Psychological Resilience

The attention that is given to psychological resilience is relatively new in the area of CHD. It refers to a person’s ability to properly adapt to stress and adversity. Hence, it looks at individuals’ capacities for adaptive behaviors, rather than at limitations or maladjustment. A particularly interesting concept is “sense of coherence” (SOC). SOC represents an individual’s generalized worldview and expresses the extent to which the individual perceives (1) stimuli as structured and predictable (ie, comprehensibility); (2) that resources are available to meet the demands posed by these stimuli (ie, manageability); and (3) that these demands are challenges worthy of investment (ie, meaningfulness). The relation among SOC, psychosocial health, and QOL has been confirmed in diverse patient populations and individuals from the general population. Based on these prior findings, it was hypothesized that growing up with CHD may contribute to the development of a strong SOC, as patient feelings of comprehensibility, manageability, and meaningfulness may be reinforced by disease-related experiences from a young age. This hypothesis has been confirmed. Indeed, patients with CHD seem to have a stronger SOC than healthy counterparts. Clinicians ought to give more attention to aspects of resilience, because it gives notice to positive aspects of living with CHD.

Personality

The notion that personality might influence health is getting more attention. Numerous studies in acquired heart diseases have linked Type A (characterized by hostility, time-urgency, and competitiveness) and Type D personality (characterized by negative affect and social inhibition) to mortality and adverse health outcomes. However, in the area of CHD, personality research is sparse. To date, only two studies on personality in individuals with CHD have been published. Schoormans et al. found that one-fifth of the patients with CHD presented with a Type D personality. Patients with a Type D personality feel more functionally impaired, report poorer health status and a lower QOL, and use fewer health care resources. Rassart et al. investigated personality traits beyond Type D personality, using the Big Five model of personality in young persons with CHD. These investigators found that the distribution of personality dimensions in adolescents with CHD was similar to that of the general population, except for a lower score on Extraversion. Overall, Extraversion, Agreeableness, Conscientiousness, and Emotional Stability were associated with better QOL and several generic and disease-specific domains of patient-reported health.

These initial studies indicated that certain personality characteristics could enable patients to deal with the challenges of living with CHD, and contribute favorably to their disease adaptation. Conversely, other personality characteristics (eg, the tendency to experience negative affect) may put patients at risk for poor adaptation.