Relationships among depression, anxiety and suicidal ideation in parents of children with congenital heart defects: A dynamic triad

Abstract

BACKGROUND

There is a possible link between depression and anxiety about suicidal ideation among parents of children with congenital heart disease (CHD).

AIM

To document the effects of depression and anxiety on parental suicidal ideation among children with CHD and the associated factors.

METHODS

This was a cross-sectional study among 50 parents of children with CHD who attended the Cardiac Clinic of University of Nigeria Teaching Hospital Ituku-Ozalla. Information was obtained using the Columbia Suicide Severity Rating Scale and the Hospital Anxiety and Depression Scale.

RESULTS

A greater percentage of parents whose child had a heart defect had anxiety symptoms (50.0%) than did those whose child had no heart defect (24.0%), and the difference in proportions was statistically significant (χ² = 7.250, P = 0.007). A greater percentage of parents whose child had a heart defect had suicidal ideation (28.0%) than did those whose child had no heart defect (8.0%), and the difference in proportions was statistically significant (χ² = 6.775 P = 0.009). A positive correlation was elicited between anxiety and suicide ideation, and this correlation was statistically significant (r = 0.748, P < 0.001). A positive correlation was elicited between depression and suicidal ideation scores, and this was statistically significant (r = 0.617, P < 0.001).

CONCLUSION

There is strong interconnectivity between anxiety and depression with suicidal ideation. There is an urgent need to start screening for the mental health of parents of children with CHD to avert the high propensity of complete suicide. In addition, policy makers may introduce a national clinical practice guideline on the importance of psychotherapy and mental health screening and targeted interventions for parents of children with CHD.

Key Words: Parents; Children; Congenital heart disease; Suicidal ideation; Depression; Anxiety

Core Tip: High scores for anxiety have been reported among parents of children with congenital heart disease (CHD). To date, studies on whether there is any connection between depression, anxiety and suicidal ideation among parents of children with CHD are rare. The parents of children with CHD tend to become anxious and depressed and are withdrawn following the diagnosis of heart disease. There are several frameworks that aptly describe the interconnectedness of depression, anxiety and suicidal ideation among parents of children with CHD.

INTRODUCTION

Approximately 36000 infants are born with congenital heart disease (CHD) in the United States every year[1]. Congenital heart defects are not uncommon in children[2-5]. In Southeast Nigeria, Chinawa and Chinawa[2], among 605 children, reported a prevalence rate of 0.22%, with a rising trend. CHD in children is the major cause of out-of-pocket spending in Nigeria. Notably, approximately 450 cases of cardiac intervention or surgical procedures for heart diseases are performed yearly in the Western world, but this number is lower in sub-Saharan African countries where there is a high burden of acquired heart disease and where the need for cardiac intervention and cardiovascular services is much greater, but parents may not be able to pay the bills there[1-4]. The major focus in developing countries is curbing and ameliorating morbidity and mortality in children under the age of five from tropical diseases such as severe malaria. Sadly, CHD poses an alarming mortality rate owing to neglect, and the management of such illness is usually left for nongovernmental bodies to handle.

It is very challenging for parents to have children with CHD; there is usually a high degree of pressure, pain and overwhelming emotions at the time of diagnosis and during open heart surgery, which may impact parents’ quality of life and mode of parenting[5]. A meta-analysis had shown that about a third of parents of children with CHD had posttraumatic stress symptoms, 30%-80% (median 60%) have severe psychological distress, and 25%-50% have symptoms of depression and/or anxiety[5]. A study in Uganda has shown that approximately 28% of parents of children with CHD are depressed. Several factors, such as low educational attainment and low social support, were linked with parental depression in this study[6]. Depression, if left untreated, may cause intense feelings of hopelessness, sadness, anger or frustration, which can last for a long time, over months or even years, thereby affecting productivity at work and at home[7,8]. Therefore, it is critical to recognize the symptoms of depression so that early treatment is initiated and pain, suffering and possible death are prevented. A high prevalence of anxiety among parents of children with CHD has also been reported[9]. To date, studies on whether there is any connection between depression, anxiety and suicidal ideation among parents of children with CHD are rare. The parents of children with CHD tend to become anxious and depressed and are withdrawn following the diagnosis of heart disease[10,11]. The volume of several work-ups and investigations tends to create considerable depression and anxiety among these patients and caregivers[9,10]. High scores for anxiety have been reported among parents of children with CHD[10]. To date, studies on whether there is any connection between depression, anxiety and suicidal ideation among parents of children with CHD are rare. The parents of children with CHD tend to become anxious and depressed and are withdrawn following the diagnosis of heart disease[11]. The volume of several work-ups and investigations tends to create considerable depression and anxiety among these patients and caregivers[12,13]. The cost of treatment is usually catastrophic. This tends to lead to delayed intervention with worsening outcomes[14-17].

Depression and suicidal ideation are prevalent across cultures and counties; however, the burden of suicidal ideation in children varies across diseases, but this burden is greater for CHD. For example, studies have shown that parents of children with heart disease may face higher rates of depression- and anxiety-related symptoms than parents of children with other chronic conditions do, with some studies showing 25%-50% experience elevated depression symptoms in heart disease patients, whereas other research has reported levels of approximately 26% among parents of children with cancer, diabetes, and asthma[15]. Cohn et al[16] reported that mothers of children with CHD may have greater risks of cardiovascular disease and mortality than parents of children with other chronic diseases.

Furthermore, the burden of suicidal ideation from CHD is not known compared with that of suicidal ideation from other chronic illnesses. There are several frameworks that aptly describe the interconnectedness of depression, anxiety and suicidal ideation among parents of children with CHD. These include but are not limited to the following[5-7].

The conceptual and theoretical frameworks for depression, anxiety and suicidal ideation include the interplay between biological, psychological, and social factors[5]. These factors are intertwined and may increase the vulnerability of parents of children with CHD and their progression from suicidal ideation to suicide[5,6]. There are interactions of key theoretical frameworks in the course of depression, anxiety and suicidal ideation in parents of children with CHD. These include the interpersonal theory of suicide, which includes perceived burdensomeness and feelings of disconnection and isolation[5-7]. The second theory is the theory of the integrated motivational-volitional model[7], which highlights the interplay of volitional and motivational factors and the conceptualization of the stress-vulnerability model, where individuals have varying levels of vulnerability to stress, with a high likelihood of developing depression, anxiety, and suicidal ideation[5-7]. There is also the biopsychosocial theorem, which emphasizes the interconnectedness of genetic predispositions and psychological and social factors[5,7]. Ideation-to-action theories focus on the progression from suicidal thoughts (ideation) to complete suicide. Here, impulsivity and hopelessness are major factors in the transition from suicidal ideation to suicide[6,7]. The theories of interconnectedness of depression, anxiety, and suicidal ideation suggest that the triad often occurs and can trigger each other. Depression can trigger hopelessness, whereas anxiety can cause intense rumination, both of which can lead to suicidal ideation[6,7].

Depression, anxiety and suicidal ideation among parents of children with CHD is an important public health issue. There is a gap in knowledge regarding the prevalence of suicidal ideation and its relationship with depression and anxiety, especially with respect to its impact on children with CHD. This study is very important because it helps to identify and curb depression- and anxiety-related suicidal ideation among parents whose children present with CHD. The burden of depression and anxiety among parents of children with CHD is increasing. Variation in the reported prevalence values in children with CHD has been established. No single study in Nigeria has documented the prevalence of suicidal ideation; in addition, most studies on this topic have been clustered among the adult population. These findings may reveal an established link between depression, anxiety and suicidal ideation in parents whose children have CHD. The link, if proven, will lead to policy development, especially in Nigeria, with respect to the need for interdisciplinary measures in the control of the disease and reduction of the burden of the disease in children with CHD. This study aimed to determine the effects of depression, anxiety and other factors on parental suicidal ideation among those whose children had CHD.

MATERIALS AND METHODS

Study population

The study population included parents of children with CHD who attended the Paediatric Cardiology Clinic of the area of study. Additionally, to avoid bias, both the subjects and the controls were matched for age and sex.

Study design

This was a cross-sectional study that was conducted at the Paediatric Cardiology Clinic of the Teaching Hospital. Subjects were recruited consecutively until the sample size was reached.

Study period

The study was conducted over two years, from February 2023 to January 2025.

Inclusion criteria for subjects and controls

The inclusion criteria involved parents of children with CHD who gave consent and children who gave assent. Parents of children with CHD with no psychological disorders and who provided consent were also included in the study. The control population included parents of apparently healthy children whose data were collected after their children recovered from minor illnesses such as resolved malaria and mild cough. These children who were used as controls were not on any medication and had to have completely recovered from their minor illnesses before being recruited as controls. Parents of children with CHD who gave consent and apparently healthy children who gave assent were also included in the study.

Exclusion criteria for subjects and controls

Parents of children with CHD with any form of psychiatric illness or psychological disorders were excluded from the study. Parents of children with CHD who gave no consent or children who gave no assent were also excluded from the study. For the control, parents of children with no cardiac disease who had any form of psychiatric illness or psychological disorders were excluded from the study. Parents of children used as controls who gave no consent or children used as controls who gave no assent were also excluded from the study.

Study instrument

Depression and anxiety were assessed via the Hospital Anxiety and Depression Scale (HADS), whereas the Columbia Suicide Severity Rating Scale was used to assess suicidal ideation[18]. The HADS has internal consistency and validity, with a mean Cronbach’s alpha of 0.82. The sensitivity and specificity for HADS is 0.80[18]. The Columbia Suicide Severity Rating Scale assessed the severity of suicidal ideation[19]. Internal consistency and validity were also documented in the questionnaire[19]. The questionnaire demonstrated good convergent and divergent validity with other suicidal ideation and behaviour scales with high sensitivity and specificity for suicidal behaviour[19]. The questionnaires used in the study were validated and have been used in previous studies[20-22].

The HADS questionnaire was also validated. It consisted of four-point Likert scale with minimum of zero and maximum of three[18-20]. The score of less than 7 shows no anxiety, while a score between eight and ten indicates mild anxiety and scores between eleven and fourteen indicates moderate anxiety while scores between fifteen and twenty indicates severe anxiety. Depression was also assessed with the same method.

The Columbia Suicide Severity Rating Scale was used to assess suicidal ideation of parents of children with CHD[19]. The scale is validated with 6 items, each of the items had an option of “Yes” or “No”. A score of one was given for each response, whereas no response was given a score of zero. No suicidal ideation is awarded the score of zero, a low risk score was awarded 1-2 marks, and moderate risk awarded 3-4, while severe suicidal ideation was awarded 4-6 marks. The questionnaires were administered by resident doctors and house officers in the Paediatric Cardiology Unit.

Method of data collection

An interviewer-administered questionnaire was used to collect data from the subjects and controls.

Sample size calculation

This is calculated using the following formula: n = (Z_α + Z_1-β)² × [P₁ × (1 - P₁) + P₂ × (1 - P₂)]/(P₁ - P₂)²[23], where n = sample size of the population, Z_α = 5% level of significance (standard normal deviation) = 1.96, Z_1-β = 80% level of significance (standard normal deviation) = 0.84, P₁ = number of parents of children with CHD who have symptoms of depression and/or anxiety, P₁ = 0.60[5]. P₂ = number of parents of children without CHD who have symptoms of depression and/or anxiety, P₂ = 0.28[6]. n = (1.96 + 0.84)² × [0.6 × (1 - 0.6) + 0.28 × (1 - 0.28)]/(0.60 - 0.28)² = 30. Therefore, the minimum sample size based on the above formula should have been seventy; however, this was a hospital-based study where the sample population was < 10000 and the total number of children with echocardiography data in the area of study was 439[2]. To determine the sample size in a fixed sample: N_f = n₀/1 + (n₀/N), N_f = the desired population when the proportion is < 10000, n₀ = the desired population when the proportion is > 10000, N = the population size. N_f = 54/1 + (54/439) = 28. Thus, using 28 as the minimum sample size, a further 20% attrition was added to the minimum sample calculated to ensure that the study remained adequately powered in the event of incomplete data or withdrawal of informed consent. This increased the sample size to 36, but this value was rounded to 50.

Case selection

Parents of children with CHD and controls were consecutively recruited for the study until the minimum sample size was reached.

Social class estimation

The socioeconomic class of the children’s family was calculated via the Onyedeji classification, which includes fathers’ occupation and mothers’ level of education.

Statistical analysis

The International Business Machine and the IM-SPSS version 2 were used in the data processing. Proportions, frequencies and continuous variables were presented as means ± SDs, if the data were skewed or medians were used. The χ² test of statistical significance, Student’s t test and, when the data were skewed, the Mann-Whitney U test, correlation analysis and multivariate analysis via binary logistic regression were used in the analysis. The level of statistical significance was determined by a P value of < 0.05. The main outcome measure of the study was the risk of suicidal ideation. To determine the factors affecting the outcome measure, the proportion of parents who were at risk of suicidal ideation was cross-tabulated with sociodemographic characteristics and other variables that followed a logical sequence. Comparisons between parents whose children had heart defects and those whose children did not were performed via the χ² test when comparisons were performed on uniformly distributed categorical data and Student’s t test for uniformly distributed continuous data and the Mann-Whitney U test (if the data were skewed) for comparisons of means.

RESULTS

Socio-demographic characteristics of respondents

Table 1 shows the sociodemographic characteristics of the parents. The mean age of fathers whose children had heart defects, 41.4 ± 7.0 years, was significantly lower than that of those whose children did not have heart defects, 47.4 ± 7.9 years (Student’s t = 4.026, P < 0.001). The highest proportion of mothers had attained tertiary education (heart defects = 56.0%; no defects = 58.0%), whereas the lowest proportion had primary education (heart defects = 12.0%; no defects = 4.0%) (χ² = 2.275, P = 0.321).

Table 1 Sociodemographic characteristics of the parents of the subjects and controls, n (%).

Variable	Child with heart defect (n = 50)	No defect (n = 50)	χ2	P value
Age of child in years
mean ± SD	5.0 ± 5.4	6.8 ± 6.2	1.5231	0.131
Median	3.0	4.5
Age of child in groups
< 1 year	13 (26.0)	6 (12,0)	3.741	0.291
1-4 years	18 (36.0)	19 (38.0)
5-9 years	10 (20.0)	11 (22.0)
≥ 10 years	9 (18.0)	14 (28.0)
Age of father in years
mean ± SD	41.4 ± 7.0	47.4 ± 7.9	4.026	< 0.001
Age of father in groups
< 40 years	17 (34.0)	5 (12.0)	11.023	0.004
40-49 years	28 (56.0)	28 (56.0)
≥ 50 years	5 (10.0)	16 (32.0)
Age of mother in years
mean ± SD	32.6 ± 6.7	38.9 ± 8.7	4.012	< 0.001
Age of mother in years
< 30 years	14 (28.0)	4 (8.0)	20.159	< 0.001
30-39 years	33 (66.0)	25 (50.0)
≥ 40 years	3 (6.0)	21 (42.0)
Educational attainment of father
No formal education	2 (4.0)	0 (0.0)	4.2032	0.240
Primary education	4 (8.0)	8 (16.0)
Secondary education	15 (30.0)	15 (30.0)
Tertiary education	29 (58.0)	27 (54.0)
Educational attainment of mother
Primary education	6 (12.0)	2 (4.0)	2.275	0.321
Secondary education	16 (32.0)	19 (38.0)
Tertiary education	28 (56.0)	29 (58.0)
Socioeconomic status
Low socioeconomic class	9 (18.0)	5 (10.0)	1.604	0.449
Middle socioeconomic class	14 (28.0)	13 (26.0)
High socioeconomic class	27 (54.0)	32 (64.0)

¹Mann-Whitney U test.

²Likelihood ratio.

Assessment of anxiety and depressive symptoms among the respondents

Table 2 shows the assessment of anxiety symptoms via the HADS. The mean score for being miserable and sad was significantly higher among parents whose child had a heart defect (1.2 ± 1.2) than among those whose child did not have a heart defect (0.5 ± 0.9) (Mann-Whitney U = 3.374, P = 0.001). The mean total score for anxiety symptoms was significantly greater among parents whose child had a heart defect (8.2 ± 4.8) than among those whose child had no heart defect (4.1 ± 4.0) (Mann-Whitney U = 4.555, P < 0.001). Table 3 shows the assessment of depressive symptoms via the HADS. The mean total score for depressive symptoms was significantly greater among parents whose child had a heart defect (8.9 ± 5.1) than among those whose child did not have a heart defect (5.1 ± 4.9) (Mann-Whitney U = 3.763, P < 0.001). Table 4 shows the prevalence of anxiety and depressive symptoms. A greater percentage of parents whose child had a heart defect had anxiety symptoms (50.0%) than did the control parents (24.0%) (χ² = 7.250, P = 0.007). A significantly greater percentage of parents whose child had a heart defect (52.0%) had depressive symptoms than did the control group (26.0%) (χ² = 7.104, P = 0.008).

Table 2 Assessment of anxiety symptoms via the Hospital Anxiety and Depression Scale, mean ± SD.

Variable	Child with heart defect (n = 50)	No defect (n = 50)	Mann-Whitney U	P value
I wake early and then sleep badly the rest of the night	1.8 ± 0.9	1.1 ± 1.1	3.611	< 0.001
I feel miserable and sad	1.2 ± 1.2	0.5 ± 0.9	3.374	0.001
I have lost interest in things	1.1 ± 1.0	0.3 ± 0.7	4.124	< 0.001
I have good appetite	1.0 ± 0.9	0.3 ± 0.7	3.927	< 0.001
I feel life is not worth living	0.8 ± 1.0	0.3 ± 0.8	2.672	0.009
I am restless and can’t keep still	0.7 ± 0.9	0.7 ± 1.0	0.411	0.682
I feel as if I have slowed down	1.6 ± 1.2	0.8 ± 1.0	3.582	0.001
Anxiety symptoms (total score)	8.2 ± 4.8	4.1 ± 4.0	4.555	< 0.001

Table 3 Assessment of depressive symptoms via the Hospital Anxiety and Depression Scale, mean ± SD.

Variable	Child with heart defect (n = 50)	No defect (n = 50)	Mann-Whitney U	P value
I get very frightened	1.3 ± 1.2	0.6 ± 1.0	3.102	0.002
I feel anxious when I get out of the house	0.8 ± 0.9	0.5 ± 0.9	1.703	0.092
I get palpitations	1.4 ± 1.1	1.0 ± 1.1	1.912	0.059
I feel scared or frightened	1.2 ± 1.1	0.5 ± 1.0	3.481	< 0.001
I still enjoy the things I used to	1.0 ± 0.9	0.5 ± 1.0	2.526	0.013
I am more irritable than usual	1.2 ± 1.2	0.8 ± 1.1	1.750	0.083
Worrying thoughts constantly go through my mind	2.0 ± 1.0	1.2 ± 1.2	3.309	0.001
Depressive symptoms (total score)	8.9 ± 5.1	5.1 ± 4.9	3.763	< 0.001

Table 4 Prevalence of anxiety and depressive symptoms, n (%).

Variable	Child with heart defect (n = 50)	No defect (n = 50)	χ2	P value
Prevalence of anxiety symptoms
Normal	25 (50.0)	38 (76.0)	8.873	0.031
Mild depression	13 (26.0)	8 (16.0)
Moderate depression	5 (10.0)	3 (6.0)
Severe depression	7 (14.0)	1 (2.0)
Anxiety symptoms
Yes	25 (50.0)	12 (24.0)	7.250	0.007
No	25 (50.0)	38 (76.0)
Prevalence of depressive symptoms
No symptom	24 (48.0)	37 (74.0)	9.517	0.036
Mild depression	8 (16.0)	5 (10.0)
Moderate depression	9 (18.0)	6 (12.0)
Severe depression	9 (18.0)	2 (4.0)
Depressive symptoms
Yes	26 (52.0)	13 (26.0)	7.104	0.008
No	24 (40.0)	37 (74.0)

Assessment of suicidal ideation severity risk among the respondents

Table 5 shows the assessment of suicidal ideation severity risk via the Columbia Suicide Severity Rating Scale. A greater percentage of parents whose child had a heart defect were at risk of suicidal ideation (28.0%) than were controls (8.0%) (χ² = 6.775, P = 0.009). Table 6 shows the factors associated with suicidal ideation severity risk among parents with heart defects. Among the parents whose child had a heart defect, those whose child had anxiety symptoms were approximately eight times more likely to have a suicidal ideation risk than the controls were adjusted odds ratio = 7.5, 95% confidence interval: 1.4-41.6. Among the parents whose child had a heart defect, those whose child had depressive symptoms were approximately three times more likely to have a suicidal ideation risk than the controls were adjusted odds ratio = 2.7, 95% confidence interval: 0.6-13.5. However, parental age, parental level of education and socioeconomic class do not affect suicidal ideation severity risk among parents with heart defects. Table 7 shows the correlation matrix for the parents of the subjects. A positive correlation exists between anxiety and depression scores (r = 0.754, P < 0.001). A positive correlation exists between anxiety and suicidal ideation scores (r = 0.748, P < 0.001). A positive correlation also exists between the depression and suicidal ideation scores (r = 0.617, P < 0.001).

Table 5 Assessment of suicidal ideation severity risk via the Columbia Suicide Severity Rating Scale, n (%)/mean ± SD.

Variable	Intervention group (n = 50)	Control group (n = 50)	Mann-Whitney U	P value
Have wished oneself dead or sleep and not wake up	0.24 ± 0.43	0.06 ± 0.24	2.578	0.012
Have actually has thoughts of killing oneself	0.24 ± 0.43	0.04 ± 0.20	2.979	0.004
Have had thoughts about how one might do this	0.20 ± 0.40	0.02 ± 0.14	2.973	0.004
Have had these thoughts and the intention of acting them	0.18 ± 0.39	0.0 ± 0.0	3.280	0.002
Have started to work out or worked out details of how to kill oneself	0.08 ± 0.27	0.0 ± 0.0	2.064	0.044
Have ever done anything or started to do anything to end one’s life	0.08 ± 0.27	0.02 ± 0.14	1.376	0.173
Columbia Suicide Severity Rating Scale (total score)	1.02 ± 1.93	0.14 ± 0.53	3.103	0.003
Columbia Suicide Severity Rating Scale
No risk	36 (72.0)	46 (92.0)	15.5912	0.001
Low risk	5 (10.0)	3 (6.0)
Moderate risk	0 (0.0)	1 (2.0)
High risk	9 (18.0)	0 (0.0)
Columbia Suicide Severity Rating Scale (categorized)
Risk	14 (28.0)	4 (8.0)	6.7751	0.009
No risk	36 (72.0)	46 (92.0)

¹χ² test.

²Likelihood ratio.

Table 6 Factors associated with suicidal ideation severity risk among parents with heart defects, n (%).

Variable	Suicidal ideation severity risk (n = 50)		P value1	aOR (95%CI)
	Yes	No
Age of child in years
< 5 years	10 (32.3)	21 (67.7)	0.392	N/A
≥ 5 years	4 (21.1)	15 (78.9)
Age of father in years
< 45 years	8 (24.2)	25 (75.8)	0.410	N/A
≥ 45 years	6 (35.3)	11 (64.7)
Age of mother in years
< 35 years	10 (37.0)	17 (63.0)	0.123	0.9 (0.8-1.1)
≥ 35 years	4 (17.4)	19 (82.6)
Educational attainment of father
Primary education and less	9 (31.0)	20 (69.0)	0.574	N/A
Secondary education and more	5 (23.8)	16 (76.2)
Educational attainment of mother
Primary education and less	8 (28.6)	20 (71.4)	0.919	N/A
Secondary education and more	6 (27.3)	16 (72.7)
Socioeconomic status
Low socioeconomic class	7 (30.4)	16 (69.6)	0.723	N/A
High socioeconomic class	7 (25.9)	20 (74.1)
Anxiety symptoms
Yes	12 (48.0)	13 (52.0)	0.002	7.5 (1.4-41.6)
No	2 (8.0)	23 (92.0)
Depressive symptoms
Yes	11 (42.3)	15 (57.7)	0.019	2.7 (0.6-13.5)
No	3 (12.5)	21 (87.5)

¹P value from bivariate analysis.

N/A: Not applicable; aOR: Adjusted odds ratio; CI: Confidence interval.

Table 7 Correlation matrix of variables for parents with heart defects.

Variable	Correlation coefficient (r), P value (n = 50)
	Age of child	Total anxiety score	Total depression score	Total suicidal ideation score
Age of child	1
Total anxiety score	r = -0.062, P = 0.667	1
Total depression score	r = 0.008, P = 0.957	r = 0.754, P < 0.001	1
Total suicidal ideation score	r = -0.105, P = 0.466	r = 0.748, P < 0.001	r = 0.617, P < 0.001	1

DISCUSSION

Prevalence of depressive and anxiety symptoms

This study aimed to determine the pattern of parental depression/anxiety in children with congenital heart defects and whether these patterns are associated with suicidal ideation. The present study revealed that 52.0% of parents whose children had CHD had depressive symptoms compared with 26.0% of parents whose children did not have CHD. On the other hand, 50.0% of parents whose children had CHD had anxiety symptoms compared with 24.0% of those whose children had no CHD. However, the observed prevalence rates of depression and anxiety are higher than the prevalence rates previously reported by other authors[22,23]. These authors did not use the Hospital Anxiety Depression Scale but rather the Depression Anxiety Stress Scales[22]. Tallon et al[22], among 91 mothers at the time of cardiac surgery, reported a low prevalence rate of 20% for depression and 25% for anxiety. On the other hand, Kasparian et al[23] reported rates of 26% and 27% for depression and anxiety, respectively, among 91 mothers and 20 fathers. Although our findings did not separate fathers and mothers of children with CHD, the prevalence reported in the current study was still higher than that reported in all studies. The reason for this high prevalence of depression could be the various types of extraneous physical stress, financial turmoil, and emotional drain they faced in the course of their children’s management. In some studies, more episodes of psychopathological changes were observed in parents of children with CHD[24-27]. This includes depression, anxiety, and somatization compared with healthy controls[24-27].

Prevalence of suicidal ideation

The current study provides some evidence of suicidal ideation among parents of children with CHD. Although a small proportion of the parents wanted to die or did not want to wake up again when they slept, a few had well-tailored plans on how to kill themselves, as seen in this study. Udholm et al[27], among children with CHD between 1977 and 2007, reported that among 14433 patients with CHD, 15 died by suicide, whereas 232 had suicidal ideations. Similarly, the authors also documented 336 events of self-harm among adult patients with CHD, with an increased overall risk of CHD compared with controls.

A greater percentage of parents whose child had a heart defect had suicidal ideation (28.0%) than did those whose child had no heart defect (8.0%). The prevalence of suicidal ideation observed in this study was greater than that reported by Lawoko and Soares[28]. These authors examined differences in depression, anxiety, somatization and suicidal ideation among parents of CHD patients compared with parents of children with other diseases and parents of healthy children. They noted that parents of children with CHD were generally at greater risk of suicidal ideation than other groups were. Mothers in all parent groups had higher levels of suicidal ideation in their reports. Although there is no single study in Nigeria on suicidal ideation in parents of children with CHD, the figures obtained among controls, i.e., the normal population, are greater than those reported in Nigerian studies[29-31].

Factors associated with depression, anxiety and suicidal ideation

There is no relationship between gender and anxiety, depression and suicidal ideation. Though males are commonly reported to have higher rates of suicidal ideation, as some research had documented a male-to-female ratio of at least 3:1[32-34]. Breed’s 5 “components of a basic suicidal ideation syndrome” aptly described gender-related differences in suicidal ideation[32-35]. The female population also receives much attention before a crucial decision is made, although it may be unstable[35]. They noted that suicidal attempts and ideation are “more acceptable” among females but that complete suicide is seen among males[35].

There was no difference in the prevalence of depression, anxiety or suicidal ideation between the father and the mother, as observed in this study. Similarly, Bevilacqua et al[32] noted no differences in stress and depression levels between fathers and mothers of children with CHD. However, mothers who were aware of the CHD diagnosis prenatally were more depressed. Cantwell-Bartl et al[33] noted a higher proportion of mothers than fathers to have posttraumatic stress disorder (posttraumatic stress disorder in a study where 18 parents of infants with a prenatal diagnosis of hypoplastic left heart syndrome.

The current study revealed that the prevalence of depression, anxiety, and suicidal ideation was not related to the age of parents or children with CHD. However, data on the impact of parental age on depression, anxiety and suicidal ideation are scarce[34-36]. However, in the normal population, Wagner et al[35] noted that older people aged 50-65 years suffer from recurrent depression, neuro-vegetative symptoms and comorbid physical disorders compared with younger adults aged 18-29 years, who often suffer from personality disorders. Similarly, adults aged 65-79 years were reported to have lower suicidal ideation than middle-aged people aged 50-64 years[37].

The present study revealed no associations between socioeconomic class or parental level of education and depression, anxiety or suicidal ideation. Madigan and Daly[37] noted that low socioeconomic status is an established risk factor for both depressive symptoms and suicidality. This could be because status confers access to material resources and social standing[38].

Interconnectivity between depression, anxiety and suicidal ideation

A correlation matrix revealed a strong positive correlation between the total anxiety score and total depression score among parents of children with CHD. In addition, there was a strong positive correlation between the total anxiety score and total suicidal ideation score and a strong positive correlation between the total depression score and total suicidal ideation score. This finding revealed the unique contributions of parental depression and anxiety symptoms to suicidal ideation[39]. Vigorous education and the use of psychotherapy in the management of parents of children with CHD are crucial.

The role of anxiety, depression and suicidal ideation in parents of children with congenital heart defects cannot be overemphasized. For example, ruminative thinking has been identified as a missing link that addresses the interrelationship between depression, anxiety, and suicidal ideation[39]. Parents of children with CHD may try to overcome the stress associated with the management of their children with CHD. They developed a tendency to persistently reflect in silence on stressful situations surrounding their child’s health, which may further lead to higher levels of stress, anxiety, and suicidal behavior[40,41]. One study suggested that reactions to stressful life events, such as physiological hyperarousal, intrusive thoughts, and cognitive/behavioral avoidance, are risk factors for suicidal ideation. Rumination, which is often linked to depression and anxiety, is a maladaptive coping mechanism that may worsen suicidal ideation. Polanco-Roman et al[39] noted a link between rumination and anxiety, depression, and suicidal ideation. They noted that brooding plays an important role in depressive symptoms, with an interplay between stress-related symptoms and suicidal ideation. The theoretical model described above could also explain the interrelationship between anxiety, depression and suicidal ideation among parents of children with CHD. For example, following the diagnosis of a child’s cardiac defect, parents may isolate themselves from others and avoid all social interactions[39-41]. These individuals may also experience stigmatization and negative perceptions. This may lead to rumination, self-pity, depression and suicidal thoughts. Furthermore, social stereotyping, an important theoretical model, could influence the coping behaviors of both parents and children with CHD, worsening stigmatization and making parents feel insecure[39-41].

Clinical implications

These findings revealed a very interesting contribution of depression and anxiety to suicidal ideation among parents of children with CHD. This simply means that a high index of suspicion is key in monitoring parents of children with CHD who have depression or anxiety and following them early to prevent the possibility of full-blown suicide. Besides, timely referral of parents with suicidal ideation for work-up to prevent suicide is necessary. The outcome from this study can also help in making policy in the introduction of national clinical practice guidelines regarding the level of mental health interventions these parents may require.

Limitations

This study is limited by its cross-sectional study design. A cohort study involving long-term follow-up of parents of children with CHD to determine the exact point at which depression and anxiety develop would have been better. This would help to avert suicidal ideation very easily. Co-founders such as current financial struggles and family schisms were not considered in the course of this work. In addition, the study is limited by potential biases due to sample size and single-location data collection.

CONCLUSION

There is a high prevalence of depression and anxiety. There is also strong interconnectivity between anxiety and depression with suicidal ideation. There is an urgent need to start screening for the mental health of parents of children with CHD to avert the high propensity of complete suicide. In addition, policy makers may introduce a national clinical practice guideline on the importance of psychotherapy and mental health screening and targeted interventions for parents of children with CHD.

ACKNOWLEDGEMENTS

We are grateful to the statistician who performed the analysis.