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- Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram. Adapted from: Moher et al.25 CINAHL indicates cumulative index to nursing and allied health literature.
Tables
Risk of Bias Domain Criterion I. Selection bias (1) Does the design or analysis control or account for >1 important confounding or modifying variables through matching, stratification, multivariable analysis, or other approaches? (Yes=1; No=0) II. Attrition and participation bias (2) If attrition (dropout, loss to follow‐up) or high rate of refusal was a concern, were missing data or characterization of refusers handled appropriately (eg, imputation, descriptions of reasons for refusal and/or drop‐out, comparison of refusers vs nonrefusers)? III. Reporting bias (3) Were potential outcomes prespecified by the researchers? Are all prespecified outcomes reported? IV. Detection bias (4) Were the outcomes assessed/defined using valid and reliable measures, implemented consistently across all study participants? (5) Were confounding variables assessed using valid and reliable measures, implemented consistently across study participants? First Author (Year) Study Location Design Sample Mental Health Category Measures Results Risk of Bias Assessment Cantwell‐Bartl (2013)30 Australia Cross‐sectional N=29 parents
55% mothersTrauma PTSD module of SCID 83% of PCCHDs met criteria for diagnosis of ASD or PTSD at time of hospital discharge for surgery. Low Franck (2010)32 UK Longitudinal N=326 parents
56% mothersParenting stress Parent Stressor Scale: Infant Hospitalization Parenting stress was highest before surgery and decreased slightly over time until an increase at 15 days postsurgery. Parents of infants with CHDs had greater parenting stress than parents of older children with CHDs. Low Franich‐Ray (2013)33 Australia Cross‐sectional N=132 parents
58% mothersTrauma ASDS 35% of mothers and 18% of fathers met criteria for ASD when assessed 1 month posthospital discharge from surgery.
83% of all parents reported at least one trauma symptom.Low Gronning‐Dale (2013)35 Norway Longitudinal N=60 parents Stress/distress Subjective Well‐Being Index Mothers of CCHD had significantly lower subjective well‐being than controls when assessed at 6 and 36 months postpartum.
Severity of CHD was a contributing factor in overall score; Parents of children with mild to moderate CHDs did not differ from controls.Low Hearps (2014)37 Australia Cross‐sectional N=39 parents
72% mothersAnxiety/depression stress/distress Psychosocial Assessment Tool 38% of PCCHDs reported psychosocial risk at a clinical level.
51% of mothers and fathers reported excessive worry (the most commonly endorsed item) and 25.6% of mothers and fathers reported having experienced sadness or depression.Low Helfricht (2008)39 Switzerland Longitudinal N=233 parents
58% mothersTrauma PDS 16.4% of mothers and 13.3% of fathers met diagnostic criteria for acute PTSD at hospital discharge.
14.9% of mothers and 9.5% of fathers met diagnostic criteria for PTSD when assessed again 6 months postsurgical repair.Low Landolt (2011)41 Switzerland Longitudinal N=232
58% mothersTrauma stress/distress PDS Medical Outcomes Study Short‐Form 36 25% of mothers and 26% of fathers reported PTSD 1 month postsurgery.
PTSD was associated with higher probability of low MHRQoL.
MHQoL was significantly lower than population norms for mothers upon discharge from the hospital.
MHRQoL changed significantly over time and, by 6 months postcardiac surgery, scores were higher than population norms for both mothers and fathers.Low Menahem (2008)43 Australia Longitudinal N=39 parents
74% mothersAnxiety/depression STAI Levels of anxiety and emotional distress in PCCHDs prior to surgery were significantly higher than published norms.
Levels of anxiety returned to normative values 12 months postsurgery.Low Rogers (1984)44 US Longitudinal N=20 mothers Anxiety/depression stress/distress Profile of mood states Psychosocial Adjustment to Illness Scale Prior to surgery, no difference between PCCHDs and controls.
PCCHDs reported significantly more symptoms of depression and distress compared with controls 1 week postsurgery.
Levels of distress remained significantly higher among PCCHDs compared with controls at 2 months postsurgery; levels of depression were not significantly different at 2 months postsurgery.Low Solberg (2011a)46 Norway Longitudinal N=242 mothers Anxiety/depression EPDS 29% of CCHD mothers reported clinically significant symptoms of depression.
CCHD mothers were 2.45 times more likely to have depression compared with mothers of children with mild or moderate CHDs at 6 months postpartum.Low Solberg (2011b)47 Norway Longitudinal N=162 mothers Anxiety/depression Hopkins Symptom Checklist Depression and anxiety symptoms increased at both 6 and 18 months postpartum.
Severity of CHD has prolonged effects on symptoms and results in overall higher depression scores.Low Solberg (2012c)48 Norway Longitudinal N=141 mothers Anxiety/depression Hopkins Symptom Checklist Mothers of CHD infants are at overall increased risk for symptoms of depression from pregnancy through 36 months postpartum.
Mothers of children with CCHDs reported more symptoms of anxiety and depression at 36 months postpartum compared with controls.Low Spijkerboer (2007)49 The Netherlands Cross‐sectional N=161 parents
62% mothersStress/distress GHQ PCCHDs exhibited significantly lower levels of distress compared with controls. Low Utens (2002)52 The Netherlands Longitudinal N=150 parents
50% mothersAnxiety/depression GHQ PCCHDs reported more distress and anxiety precardiac surgery when compared with parents of children who underwent catheterization, and controls; however these symptoms tended to decrease over time and PCCHDs scored lower than the control group on anxiety and depression when assessed 18 months postsurgery. Low Visconti (2002)55 US Cross‐sectional N=143 parents Parenting stress PSI PCCHDs reported significantly less stress and more social support than a normative sample 3 years postcardiac surgery. Low Vrijmoet‐Wiersma (2009)56 The Netherlands Cross‐sectional N=196
58% mothersAnxiety/depression stress/distress parenting stress STAI
GHQ
PSIMothers had significantly higher anxiety scores on the STAI compared with a normative reference group; no significant differences were found for fathers.
Both mothers and fathers scored comparable to instrument reference groups on the generic stress questionnaire of the GHQ.
Parenting stress levels on the PSI were comparable to normative reference groups.Low Wray (2004)57 UK Longitudinal N=102 parents
53% mothersStress/distress GHQ 65% of mothers and 48% of fathers reported being distressed immediately prior to surgery.
PCCHDs had significantly higher rates of distress than parents of healthy children.
PCCHDs experienced significant decreases in distress over time compared with no changes in parents of healthy children.Low Bevilacqua (2013)28 Italy Cross‐sectional N=38 couples Anxiety/depression stress/distress GHQ 46% of mothers and 20% of fathers were reported to be depressed.
82% of mothers and 61% of fathers reported psychological distress.
PCCHDs had significantly lower mental health component scores compared with controls.Medium Brosig (2007)29 US Cross‐sectional N=26 parents Parenting stress PSI Parenting stress was significantly lower for PCCHDs compared with controls. Medium DeMaso (1991)31 US Cross‐sectional N=99 mothers Parenting stress PSI Mean score on PSI was significantly different from the comparative mean for “normal healthy children.
PSI scores were positively and significantly correlated with child behavior problems.Medium Guan (2014)36 China Cross‐sectional N=29 parents 66% mothers Anxiety/depression GHQ Mothers of CCHDs reported higher levels of anxiety and depression compared with controls up to 5 years postsurgical repair.
Maternal anxiety was 4 times more likely if behavioral problems in the child were reported.
No significant differences were noted in fathers.Medium Helfricht (2009)38 Switzerland Longitudinal N=61 parents
57% mothersTrauma ASDS 25% of PCCHDs were diagnosed with ASD when assessed at 3 weeks postsurgical repair.
ASDS scores were significantly correlated with measures of anxiety and depression.
ASDS scores were significantly predictive of PTSD 6 months posttrauma.Medium Jordan (2014)40 Australia Cross‐sectional N=97 mothers Anxiety/depression EPDS Maternal depression was significantly associated with boding difficulties and feelings of attachment towards the CHD infant. Medium Majnemer (2006)42 Canada Longitudinal N=49 parents
82% mothersParenting stress PSI 27% of PCCHDs were classified as having high parenting stress.
If the child was cyanotic prior to first surgery, the odds of high parenting stress 5 years postsurgery increased by a factor of 4.5 (95% CI, 1.05–19.02).Medium Sarajuuri (2012)45 Finland Cross‐sectional N=54 parents
56% mothersParenting stress PSI PCCHDs reported significantly more parenting stress than healthy controls. Medium Tallon (2015)50 Australia Cross‐sectional N=91 mothers Anxiety/depression stress/distress Depression Anxiety Stress Scale 30% of mothers reported some level of stress, 25% reported “abnormal” levels of anxiety, and 20% reported symptoms of depression.
Severity of CHD corresponded to higher levels of depression in mothers.Medium Torowicz (2010)51 US Cross‐sectional N=129 mothers Parenting stress PSI Parenting demands of infants with critical CHD, regardless of single‐ventricle and biventricular physiology, were a source of increased parenting stress when compared with healthy controls (P<0.05). Medium Uzark (2003)53 US Cross‐sectional N=80 parents
86% mothersParenting stress PSI PCCHDs experience greater levels of parenting stress than population norms.
25% of PCCHDs experience clinically significant levels of parenting stress.Medium Van Horn (2001)54 US Longitudinal N=38 mothers Anxiety/depression How “depressed” and “anxious” on 7‐point scale At initial interviews, maternal anxiety was classified in high range; depressed mood determined in moderate‐high range.
At follow‐up, symptoms of anxiety and depression significantly decreased.Medium Gardner (1996)34 UK Longitudinal N=20 mothers Stress/distress GHQ CHD mothers were significantly more distressed than controls 2 days before surgery, but were indistinguishable from controls 6 months postsurgery. High Risk of bias based on 5‐item, 4‐domain, risk of bias assessment. Low risk=score=1 in domains I–IV; medium risk=study was insufficient in 1 domain (score=0 in domains I–III or score=1 in domain IV); high risk=study was insufficient in >1 domain (score of 0 or 1 in domain IV) in >1 domain. ASD indicates acute stress disorder; ASDS, Acute Stress Disorder Scale; CHDs, congenital heart defects; EPDS, Edinburgh Postnatal Depression Scale; GHQ, General Health Questionnaire; MHRQoL, mental health–related quality of life; PCCHDs, parents of children with critical congenital heart defects; PDS, Posttraumatic Stress Diagnostic Scale; PSI, Parenting Stress Index; PTSD, posttraumatic stress disorder; SCID, Structured Clinical Interview for DSM‐IV; STAI, State Trait Anxiety Inventory.
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- Mental Health Among Parents of Children With Critical Congenital Heart Defects: A Systematic Review
