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Mental Health Screening in Congenital Heart Disease: A Call For Inclusion as Standard of Care

Quick Takes

  • Screening for mental health symptoms is vital for identifying patients in need of mental health services and should be considered standard of care.
  • Ultrabrief screeners are available with validated cutoff scores, such as the four-item Patient Health Questionnaire, which can be incorporated easily into practice.
  • Simple steps can be taken to orient patients to their insurance providers' websites or offer online resources, such as Psychology Today, to encourage patients to identify in-network, local mental health providers.

Prevalence of Depression and Anxiety Among Adults With Congenital Heart Disease

The prevalence of depression and anxiety among adults with congenital heart disease (ACHD) is estimated to be similar to those with acquired cardiovascular disease (CVD; i.e., ~31-33% for a mood disorder and ~26-25% for an anxiety disorder) when using structured clinical interviews.1 Structured clinical interviews are the reference standard for determining whether criteria is met for a mental health diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The prevalence rates of depression and anxiety are higher than in the general population from which these studies originated.1 For reference, in the US general population, the lifetime prevalence is 21.4% for a mood disorder and 31.1% for an anxiety disorder,2 suggesting that a significant number of patients with ACHD are experiencing mental health concerns warranting attention. Nevertheless, most patients with mental health concerns may not be receiving treatment, likely resulting in increased health care use, morbidity, and mortality through multiple biological and behavioral pathways.1,3-5 Therefore, there is an urgent need to facilitate screening and receipt of mental health treatment. Optimally, mental health services would be embedded in cardiology care.6 In other patient groups, this care is incorporated into subspecialty care, such as oncology, in which mental health services are provided in 85% of cancer centers.7 While continuing advocacy for embedded mental health services in cardiology care, action can be taken by screening for mental health symptoms and having discussions with patients about treatment options. Indeed, routine screening for mental health concerns is recommended for individuals with acquired CVD.8 This approach may seem overwhelming in an already busy cardiac clinic, but brief screening tools and resources can facilitate this vital process.

The Four-Item Patient Health Questionnaire (PHQ-4): A Validated Ultrabrief Screening Tool

There are multiple validated screening tools available to assess mental health symptoms. The Hospital Depression and Anxiety Scale (HADS; 14 items), Center for Epidemiologic Studies Depression Scale (CES-D; 20 items), and Beck Anxiety Inventory (BAI; 21 items) are among the screening tools that have been used in research with ACHD, and all have suggested clinical cutoffs. Of note, some screening tools are not available for clinical use without permission and may not assess both depression and anxiety symptoms. Given that depression and anxiety often occur simultaneously, including among patients with ACHD,3 a screening tool that assesses both depression and anxiety symptoms is suggested. A validated, ultrabrief screening tool that is free of charge, does not require permission to use, and assesses both depression and anxiety symptoms is the PHQ-4.9 Table 1 provides the items and scoring interpretation. To the authors' knowledge, scores on the PHQ-4 have not been published among the population with ACHD, although intuitively the scores used in the general population would apply to the population with ACHD. In contrast, the nine-item version of the PHQ (i.e., the PHQ-9) has been used in the setting of ACHD. The PHQ-9 has also been modified for and validated among adolescents (13-18 years of age) and is available through the American Academy of Child and Adolescent Psychiatry (AACAP).10 Because the PHQ-9 contains an item addressing suicidal ideation, this screener should only be employed in clinical settings that allow for prompt interpretation of the items and a mental health assessment during the appointment. These requirements may limit the use of screeners with suicidal ideation items to clinical settings in which mental health professionals are more readily available.

Table 1: The Four-Item Patient Health Questionnaire (PHQ-4)9

Over the last 2 weeks, how often have you been bothered by the following problems? Not at All Several Days More Than Half the Days Nearly Every Day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
The total across all four items can be considered normal (0-2), mild (3-5), moderate (6-8), and severe (9-12).
A score of ≥3 on the first two items may suggest anxiety and warrants further evaluation.
A score of ≥3 on the second two items may suggest depression and warrants further evaluation.
Table 1: The Four-Item Patient Health Questionnaire (PHQ-4).9 Courtesy of Jackson JL, Saidi A.

Simple Steps to Assist Patients in Identifying Mental Health Professionals

Screeners, such as the PHQ-4, are not intended for the diagnosis of mental health disorders. Instead, scores that are at or above the suggested cutoffs suggest that a plan for connecting patients to mental health services is warranted. In the least, screeners can be used to initiate conversations with patients about their well-being. Whereas mental health services being embedded in the cardiology clinic is ideal, most clinics will not have this level of mental health resources. Some clinics may also lack local community mental health professionals for referral. This limitation should not deter screening and identifying patients with mental health concerns.

Other simple steps can be taken to facilitate connecting patients with mental health care. First, a brief conversation with the patient can determine whether they are already accessing mental health resources. For example, a patient may present with significant depression symptoms on a screener but is currently seeing a mental health professional and is in the early stages of treatment. Next, if a patient does not have mental health resources that they can readily access or know how to access, they can be offered tools in a few minutes to facilitate identifying a mental health care professional appropriate for them given location, insurance, and, in some cases, area of clinical expertise. Private insurance companies typically have provider directories that help patients identify mental health professionals that are "in-network." For those with Medicaid, each state has a separate Medicaid website that can be accessed to find services. Another potential resource is Psychology Today, which offers a list of mental health professionals by city or zip code, a description of fees and accepted insurance, and expertise. Searches for mental health professionals in a patient's area can be filtered by "Issues" addressed, such as "Chronic Illness."

A Call for Incorporating Mental Health Screening in Care Guidelines for ACHD

The scientific literature is clear on the importance of identifying mental health concerns among patients with ACHD, which is a growing population that has an elevated risk of mental health symptoms.6 In the quest to not only promote longer life among those with ACHD, but also quality of life, it is vital to identify patients in need of mental health services. Standard of care for treating ACHD must move toward embedding mental health services in outpatient cardiology clinic settings, modeling what most cancer centers offer. While clinicians work toward this goal, incorporating screening as standard of care can start now. Identifying patients with mental health concerns and having a brief conversation about resources may significantly improve lives and possibly prevent detrimental downstream consequences from untreated depression and anxiety symptoms.


  1. Jackson JL, Leslie CE, Hondorp SN. Depressive and anxiety symptoms in adult congenital heart disease: prevalence, health impact and treatment. Prog Cardiovasc Dis 2018;61:294-9.
  2. Harvard Medical School. National Comorbidity Survey (NCS) Data Table 1: NCS-R Lifetime Prevalence Estimates (Harvard Medical School website). 2007. Available at: Accessed 02/26/2024.
  3. Gleason LP, Deng LX, Khan AM, et al. Psychological distress in adults with congenital heart disease: focus beyond depression. Cardiol Young 2019;29:185-9.
  4. Desai R, Patel K, Dave H, et al. Nationwide frequency, sequential trends, and impact of co-morbid mental health disorders on hospitalizations, outcomes, and healthcare resource utilization in adult congenital heart disease. Am J Cardiol 2020;125:1256-62.
  5. Carazo MR, Kolodziej MS, DeWitt ES, et al. Prevalence and prognostic association of a clinical diagnosis of depression in adult congenital heart disease: results of the Boston Adult Congenital Heart Disease Biobank. J Am Heart Assoc 2020;9:[ePub ahead of print].
  6. Kovacs AH, Brouillette J, Ibeziako P, et al. Psychological outcomes and interventions for individuals with congenital heart disease: a scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes 2022;15:[ePub ahead of print].
  7. Niazi SK, Spaulding A, Brennan E, et al. Mental health and chemical dependency services at US cancer centers. J Natl Compr Canc Netw 2021;19:829-38.
  8. Levine GN, Cohen BE, Commodore-Mensah Y, et al. Psychological health, well-being, and the mind-heart-body connection: a scientific statement from the American Heart Association. Circulation 2021;143:e763-e783.
  9. Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics 2009;50:613-21.
  10. American Academy of Child and Adolescent Psychiatry. PHQ-9: Modified for Teens (AACAP website). 2010. Available at:
    . Accessed 02/26/2024.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Congenital Heart Disease, Cardiovascular Care Team

Keywords: Heart Defects, Congenital, Mental Health

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