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Systematic Review and Meta‐Analysis

Mental Health Among Parents of Children With Critical Congenital Heart Defects: A Systematic Review

Sarah E. Woolf‐King, Alexandra Anger, Emily A. Arnold, Sandra J. Weiss, David Teitel
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https://doi.org/10.1161/JAHA.116.004862
Journal of the American Heart Association. 2017;6:e004862
Originally published February 1, 2017
Sarah E. Woolf‐King
Department of Psychology, Syracuse University, Syracuse, NYDepartment of Medicine, University of California, San Francisco, San Francisco, CA
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Alexandra Anger
Department of Community Health Systems, School of Nursing, University of California, San Francisco, San Francisco, CADepartment of Pediatrics, Pediatric Heart Center, University of California, San Francisco, San Francisco, CA
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Emily A. Arnold
Department of Medicine, University of California, San Francisco, San Francisco, CA
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Sandra J. Weiss
Department of Community Health Systems, School of Nursing, University of California, San Francisco, San Francisco, CA
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David Teitel
Department of Pediatrics, Pediatric Heart Center, University of California, San Francisco, San Francisco, CA
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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.

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    Table 1. Assessment of Risk of Bias
    Risk of Bias DomainCriterion
    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?
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    Table 2. Summary of Studies Included in the Systematic Review (N=30)
    First Author (Year)Study LocationDesignSampleMental Health CategoryMeasuresResultsRisk of Bias Assessment
    Cantwell‐Bartl (2013)30AustraliaCross‐sectional N=29 parents
    55% mothers
    TraumaPTSD module of SCID83% of PCCHDs met criteria for diagnosis of ASD or PTSD at time of hospital discharge for surgery.Low
    Franck (2010)32UKLongitudinal N=326 parents
    56% mothers
    Parenting stressParent Stressor Scale: Infant HospitalizationParenting 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)33AustraliaCross‐sectional N=132 parents
    58% mothers
    TraumaASDS 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)35NorwayLongitudinalN=60 parentsStress/distressSubjective 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)37AustraliaCross‐sectional N=39 parents
    72% mothers
    Anxiety/depression stress/distressPsychosocial 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)39SwitzerlandLongitudinal N=233 parents
    58% mothers
    TraumaPDS 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)41SwitzerlandLongitudinal N=232
    58% mothers
    Trauma stress/distressPDS 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)43AustraliaLongitudinal N=39 parents
    74% mothers
    Anxiety/depressionSTAI 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)44USLongitudinalN=20 mothersAnxiety/depression stress/distressProfile 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)46NorwayLongitudinalN=242 mothersAnxiety/depressionEPDS 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)47NorwayLongitudinalN=162 mothersAnxiety/depressionHopkins 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)48NorwayLongitudinalN=141 mothersAnxiety/depressionHopkins 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)49The NetherlandsCross‐sectional N=161 parents
    62% mothers
    Stress/distressGHQPCCHDs exhibited significantly lower levels of distress compared with controls.Low
    Utens (2002)52The NetherlandsLongitudinal N=150 parents
    50% mothers
    Anxiety/depressionGHQPCCHDs 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)55USCross‐sectionalN=143 parentsParenting stressPSIPCCHDs reported significantly less stress and more social support than a normative sample 3 years postcardiac surgery.Low
    Vrijmoet‐Wiersma (2009)56The NetherlandsCross‐sectional N=196
    58% mothers
    Anxiety/depression stress/distress parenting stress STAI
    GHQ
    PSI
    Mothers 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)57UKLongitudinal N=102 parents
    53% mothers
    Stress/distressGHQ 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)28ItalyCross‐sectionalN=38 couplesAnxiety/depression stress/distressGHQ 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)29USCross‐sectionalN=26 parentsParenting stressPSIParenting stress was significantly lower for PCCHDs compared with controls.Medium
    DeMaso (1991)31USCross‐sectionalN=99 mothersParenting stressPSI 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)36ChinaCross‐sectionalN=29 parents 66% mothersAnxiety/depressionGHQ 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)38SwitzerlandLongitudinal N=61 parents
    57% mothers
    TraumaASDS 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)40AustraliaCross‐sectionalN=97 mothersAnxiety/depressionEPDSMaternal depression was significantly associated with boding difficulties and feelings of attachment towards the CHD infant.Medium
    Majnemer (2006)42CanadaLongitudinal N=49 parents
    82% mothers
    Parenting stressPSI 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)45FinlandCross‐sectional N=54 parents
    56% mothers
    Parenting stressPSIPCCHDs reported significantly more parenting stress than healthy controls.Medium
    Tallon (2015)50AustraliaCross‐sectionalN=91 mothersAnxiety/depression stress/distressDepression 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)51USCross‐sectionalN=129 mothersParenting stressPSIParenting 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)53USCross‐sectional N=80 parents
    86% mothers
    Parenting stressPSI PCCHDs experience greater levels of parenting stress than population norms.
    25% of PCCHDs experience clinically significant levels of parenting stress.
    Medium
    Van Horn (2001)54USLongitudinalN=38 mothersAnxiety/depressionHow “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)34UKLongitudinalN=20 mothersStress/distressGHQCHD 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
    Sarah E. Woolf‐King, Alexandra Anger, Emily A. Arnold, Sandra J. Weiss and David Teitel
    Journal of the American Heart Association. 2017;6:e004862, originally published February 1, 2017
    https://doi.org/10.1161/JAHA.116.004862

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    Sarah E. Woolf‐King, Alexandra Anger, Emily A. Arnold, Sandra J. Weiss and David Teitel
    Journal of the American Heart Association. 2017;6:e004862, originally published February 1, 2017
    https://doi.org/10.1161/JAHA.116.004862
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