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Article

Anxiety and Depression Symptoms in Children and Adolescents with Congenital Heart Disease

by
Isabel Uphoff
1,
Charlotte Schöneburg
1,2,
Renate Oberhoffer-Fritz
1,2,
Peter Ewert
1 and
Jan Müller
2,*
1
Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, Klinikum Der Technischen Universität München, 80636 München, Germany
2
Institute of Preventive Pediatrics, TUM School of Medicine and Health, Technische Universität München, 80809 München, Germany
*
Author to whom correspondence should be addressed.
Hearts 2025, 6(3), 23; https://doi.org/10.3390/hearts6030023
Submission received: 27 May 2025 / Revised: 31 July 2025 / Accepted: 13 August 2025 / Published: 15 August 2025
(This article belongs to the Topic Cardiovascular Disease in Special Populations: From Basic Science to Clinical Practice)
Versions Notes

Abstract

Background: Congenital heart disease (CHD) is associated with an increased risk of anxiety and depression in adults. However, little is known about the mental health of children and adolescents with CHD. The aim of this study was to assess differences in anxiety and depression symptoms between children and adolescents with CHD and healthy controls. Methods: A total of 232 children and adolescents (age 7–18 years; mean age 13.5 ± 2.7 years, 50.9% female) were enrolled, consisting of 116 patients with CHD and 116 age- and sex-matched healthy controls. Participants were recruited during routine medical examinations at the German Heart Center and Munich schools, respectively. The Beck Anxiety Inventory (BAI) and the Depression Inventory for Youth (BDI-Y) were used to assess anxiety and depression symptoms. Results: The CHD cohort included patients with right heart obstruction (11.2%), left heart obstruction (19.8%), isolated shunts (15.5%), transposition of the great arteries (14.7%), univentricular heart (14.7%), and other defects (24.1%). According to published cut-off values, at least a mild form of anxiety was present in 46.5% CHD patients. However, no significant differences were observed between the CHD group and healthy controls in either the BDI-Y score (CHD: 7.9 ± 7.7 vs. controls: 8.6 ± 8.5; p = 0.569) or the BAI score (CHD: 9.3 ± 8.6 vs. controls: 9.3 ± 10.3; p = 0.429). The complexity of the heart defect was not associated with BAI scores (simple: 5.9 ± 5.7; moderate: 11.1 ± 8.1; complex: 9.3 ± 9.0; p = 0.073) or BDI-Y scores (simple: 7.4 ± 7.5; moderate: 9.0 ± 7.1; complex: 7.0 ± 7.7; p = 0.453). No significant differences in BAI (p = 0.141) or BDI-Y (p = 0.326) scores were found by type of heart defect. Conclusions: Children and adolescents with CHD did not exhibit significantly higher levels of depression or anxiety symptoms compared to healthy controls. Nevertheless, given the increased psychological risk observed in adults with CHD, ongoing mental health monitoring remains important to enable early identification and timely intervention. Further research, particularly through longitudinal studies, is needed to monitor mental health trajectories over time and to identify early predictors of psychological vulnerability in this population.

1. Introduction

Congenital heart disease (CHD) is the most common congenital anomaly, affecting approximately 1 in 100 live births worldwide [1]. It includes a broad spectrum of structural abnormalities, ranging from minor to complex conditions that often require lifelong care [2]. Advances in diagnostics and therapy have markedly improved survival, with over 97% of children with CHD now reaching adulthood [3]. However, individuals with CHD continue to face significant challenges, including recurrent hospitalizations, invasive treatments, and continuous monitoring, all of which can contribute to emotional distress and impaired quality of life [4,5,6,7].
Mental health challenges during adolescence are increasingly prevalent and represent a significant public health concern. According to the World Health Organization, one in seven adolescents aged 10 to 19 experiences a mental health disorder, accounting for approximately 15% of the global disease burden in this age group. Depression, anxiety, and behavioral disorders rank among the leading causes of illness and disability. In children and adolescents with CHD, mental health concerns have received growing attention. Children with CHD and frequent hospitalizations are at heightened risk for anxiety, depression, and behavioral difficulties [8]. These outcomes are often associated with physical limitations, restricted social participation, and peer isolation. In particular, children with complex CHD report increased anxiety and social withdrawal [8,9], with adolescents appearing especially vulnerable [10]. Lifestyle restrictions, body image concerns, and fear of medical procedures have been identified as central psychosocial stressors [4].
Nevertheless, findings on mental health outcomes remain mixed. While some studies suggest a link between disease severity and mental health problems, others do not confirm this association. A meta-analysis by Karsdorp et al. [10] showed that children and adolescents with congenital heart disease exhibited more internalizing problems such as anxiety and depression compared to healthy controls but showed that these psychological symptoms were not related to the severity of the heart defect. Another study found that CHD patients without physical limitations showed behavioral and psychological functioning comparable to their healthy peers [11]. While parents report increased social and academic concerns, affected children do not necessarily perceive increased anxiety [12]. Individual factors, such as perceived health, coping strategies, and familial support, significantly influence psychological outcomes [13].
The COVID-19 pandemic has introduced further stressors, potentially worsening existing vulnerabilities. Simultaneously, even healthy children have shown increased anxiety and depressive symptoms [14,15]. Given these developments, comprehensive mental health assessment in children with CHD is crucial. This study therefore aims to evaluate anxiety and depression symptoms in children and adolescents with CHD compared to healthy controls. We hypothesize that children and adolescents with CHD will exhibit higher levels of anxiety and depression symptoms than healthy controls.

2. Methods

2.1. Study Participants

In this cross-sectional study, we included 116 children and adolescents between 7 and 18 years with congenital heart disease (13.5 ± 2.7 years, 59 female) who underwent routine medical examinations at the German Heart Center Munich between August 2022 and October 2024. Medical information including age, sex, height, weight, diagnosis, treatment were extracted from the patient medical record. A control group of healthy children were matched 1:1 using exact matching based on age and sex (n = 116, 13.5 ± 2.7 years, 59 female) and were recruited simultaneously from schools in the greater Munich area to ensure demographic comparability. All patients and healthy controls completed the Beck Depression Inventory for Youth (BDI-Y) and the Beck Anxiety Inventory (BAI). Both instruments have been used previously in CHD populations, including children and adolescents [16,17,18,19]. The validated German versions were used in this study, and no further linguistic adaptation was required. All study subjects included in the study were able to complete the questionnaires without any help.
Congenital heart defects were categorized into six major subgroups: ‘right heart obstruction’, including pulmonic stenosis and Tetralogy of Fallot; ‘left heart obstruction’, including aortic stenosis and coarctation of the aorta; ‘isolated shunts’, encompassing isolated ventricular, atrial, and atrioventricular septal defects; ‘transposition of the great arteries’; ‘univentricular hearts’; and ‘other’, including all other structural heart defects. All CHD patients were classified as New York Heart Association class I or II. Subjects with genetic or chronic diseases, mental or psychomotor disabilities, or conditions that prevented them from understanding the task and completing the questionnaire independently were excluded from participation.
All subjects and their guardians were required to give their written informed consent to participate in the study. This study was conducted in accordance with the Declaration of Helsinki and the principles of Good Clinical Practice. The ethical committee of the Technical University of Munich approved the study (project number: 314/14).

2.2. Beck Depression Inventory for Youth (BDI-Y)

The Beck Depression Inventory for Youth (BDI-Y) was used to assess feelings of sadness, negative thoughts and symptoms associated with depression in children and adolescents between 7 and 18 years [20]. The BDI-Y consists of 20 items rated on a four-point Likert scale with the response options “never,” “sometimes,” “often,” and “always.” The internal consistency (Cronbach’s alpha) of the scales is between 0.86 and 0.96, and the retest reliabilities for the total sample range from 0.80 to 0.85 [20]. The manual provides T-scores and percentile ranks based on age- and gender-specific norm samples. However, in this analysis, only the raw scores were compared with our reference cohort.

2.3. Beck Anxiety Inventory (BAI)

The Beck Anxiety Inventory (BAI) was used to evaluate the severity of physical and cognitive anxiety symptoms over the past week [21]. This self-report instrument consists of 21 items, each rated on a four-point Likert scale ranging from 0 (“not at all”) to 3 (“very much, I could hardly stand it”), reflecting the extent to which symptoms were experienced. The total score ranges from 0 to 63, with established cut-offs for minimal (0–7), mild (8–15), moderate (16–25), and severe anxiety (26–63). The BAI demonstrates high internal consistency (Cronbach’s α = 0.92) and good test–retest reliability over a one-week interval (r = 0.75) [22].

2.4. Data Analysis

Descriptive data were expressed as mean values and standard deviation (mean ± SD), or absolute values and percentage if appropriate. The Shapiro–Wilk test was used to assess normality. A one-way ANOVA was conducted to compare mean differences in BDI-Y and BAI scores between patients and controls, as well as across different CHD categories. A post hoc Tukey’s HSD test was performed when applicable. The chi-squared test was used to examine relationships between categorical variables. Collected data were analyzed using R (version 4.2.2) and R Studio (2024.09.1 + 394). Two-sided p-values of less than 0.05 were considered statistically significant.

3. Results

Table 1 provides a detailed overview of the characteristics of the different types of CHD and healthy controls. No significant differences were found between patients with CHD and controls in terms of BDI-Y scores (7.9 ± 7.7 vs. 8.6 ± 8.5, p = 0.569) and BAI scores (9.3 ± 8.6 vs. 9.3 ± 10.3, p = 0.429).
No significant differences were observed in BAI scores across different levels of heart defect complexity (simple: 5.9 ± 5.7; moderate: 11.1 ± 8.1; complex: 9.3 ± 9.0; p = 0.073) or in BDI-Y scores (simple: 7.4 ± 7.5; moderate: 9.0 ± 7.1; complex: 7.0 ± 7.7; p = 0.453). There was no significant difference in the BAI score (p = 0.141) or the BDI-Y score (p = 0.326) based on the type of heart defect, as shown in Table 1.
Among patients with congenital heart disease, 53.5% had minimal or no anxiety symptoms, 23.7% mild, 17.5% moderate, and 5.3% severe, as measured by the BAI. There was no significant difference in the distribution of BAI symptom severity categories between the CHD and control groups (p = 0.511), as shown in Table 2.

4. Discussion

This study found no significant differences in symptoms of depression or anxiety between children and adolescents with CHD and their healthy peers. Symptom severity was not related to the type or complexity of the cardiac defect, nor to the number of surgical interventions.
In a similar study design, Kassa et al. [16] examined children and adolescents aged 8–17 years with VACTERL association in Sweden, a condition characterized by a combination of congenital malformations, including cardiac defects. The study found no significant differences in anxiety and depression symptoms between the study group and the Swedish normative group. Kourkoveli et al. [23] examined adolescents and adults and showed a mean depression score of 8.6, which was comparable to our study, reflecting a similar trend toward mild depressive symptoms in a population of Greek adolescents and adults with CHD. Westhoff-Bleck [24] found that among adults with CHD, more than half of the participants exhibited mild depressive symptoms. The average BDI-Y score of 7.7 in their study aligns with the BDI-Y scores observed in our own study.
In contrast to the present findings, Pike et al. [17] reported significantly higher BAI scores in adolescents with single-ventricle congenital heart defects compared to controls. Additionally, Noorani et al. [18] found significantly higher BAI scores in individuals with univentricular heart disease, indicating more anxiety symptoms. However, the BAI scores in our study were closer to those of the control group, and children with univentricular heart disease exhibited anxiety levels comparable to their healthy peers. Morrison et al. [19] investigated children and adolescents from Northern Ireland with similar age ranges and found that patients with major CHD, particularly those with cyanotic palliation, had higher anxiety scores compared to those with mild diagnoses. However, no control group was used, and no raw data was provided. In our study, neither children with more severe defects, such as univentricular heart disease, nor those with milder conditions showed elevated anxiety levels compared to healthy peers. These findings raise the question of potential moderating factors.
The COVID-19 pandemic has been associated with increased psychological distress in children and adolescents, with anxiety and depressive symptoms among the most frequently reported outcomes [25]. It is possible that, due to the COVID-19 pandemic—which had a particularly strong impact on children, both with and without preexisting health conditions—levels of anxiety and depression increased or converged in both groups. This convergence may be attributable to a ceiling effect in children with preexisting conditions, whose symptom levels were already elevated prior to the pandemic. Since psychosocial factors and pre-pandemic baseline data were not assessed, these potential influences remain speculative and should be explored in future research.
Furthermore, as shown in our prior studies on depression in CHD patients, trait anxiety levels remained similar across a large cohort, including individuals with even the most severe forms of CHD [13]. A possible explanation could be the psychological support routinely provided to both children with CHD and their parents at our institution, which may help reduce anxiety and depression symptoms. In addition, children with chronic illnesses are increasingly integrated into mainstream schools, promoting social inclusion and reducing psychosocial stress [26,27]. Such structural developments may contribute to a narrowing gap in mental health outcomes between chronically ill and healthy children.
Another possible explanation could be a response shift—a change in the way individuals evaluate their own quality of life or psychological well-being, not because their objective condition has improved or worsened, but because their perspective, priorities, or internal standards have shifted [28]. Children growing up with a chronic condition such as CHD may develop greater resilience and assess their quality of life differently than their healthy peers. Regular medical appointments and physical limitations may be perceived as a normal part of life. Their understanding of well-being or happiness may differ, with greater emphasis placed on social relationships or small everyday achievements rather than on physical performance. Being born with the condition could further facilitate adjustment, as children tend to perceive their illness as an inherent part of their identity. Beyond the psychosocial and clinical variables discussed, lifestyle-related factors such as fear of exercise may also contribute to psychological burden in children and adolescents with CHD. As shown by White et al. [29], although overall anxiety and depression scores were comparable to the general population, fear of exercise was significantly associated with increased psychological distress.

Limitations

While the BDI-Y and BAI are validated tools for assessing depressive and anxiety symptoms, several limitations should be considered. This study was conducted in a tertiary care setting where CHD patients routinely receive integrated psychological support, which may have biased results toward better mental health outcomes. However, this highlights the value of multidisciplinary care. The cross-sectional design and single time-point assessment limit the ability to capture daily fluctuations in symptoms. Repeated measurements over several days would provide a more stable and comprehensive picture of psychological well-being. The relatively small sample size may have limited the statistical power to detect subtle group differences. Furthermore, the generalizability of the findings to broader populations may be restricted due to the specific recruitment setting and potential selection biases, which should be considered when interpreting the results. Moreover, although the BDI-Y and BAI are widely used, they may not be sufficiently sensitive to detect specific fears or stressors associated with a chronic condition like CHD (e.g., fear of medical procedures, concerns about the future). Studies employing more tailored instruments or qualitative interviews might reveal different patterns. Additionally, unmeasured confounders such as socioeconomic status or environmental factors may have influenced the findings. Finally, differences in assessment settings (e.g., parental presence in the CHD group vs. classroom setting for controls) may have affected response patterns. Detailed data on age at diagnosis or surgery, current medication, and psychological support were not analyzed in the present study. Furthermore, no data on hospitalizations were available, although hospitalization likely increases psychological distress. Additionally, unmeasured contextual factors such as socioeconomic status, parental education, comorbid conditions, and developmental phases (e.g., childhood, puberty, adolescence) may have influenced the findings. Future research should aim to systematically incorporate both clinical and psychosocial parameters to better understand their interaction with mental health outcomes in this population.

5. Conclusions

Children and adolescents with CHD in this study exhibited depression and anxiety levels comparable to those of their healthy peers. However, the absence of significant group differences does not necessarily indicate a lack of psychological vulnerability. Rather, it may reflect the effectiveness of existing support structures or the presence of individual resilience factors. Given the elevated prevalence of mental health issues reported in adults with CHD, psychological monitoring and tailored support should therefore remain an integral part of care. Further research is warranted to investigate the transition from childhood to adulthood—particularly during puberty—and its implications for long-term psychological well-being.

Author Contributions

Conceptualization, J.M.; methodology, J.M.; software, J.M.; validation, J.M., P.E., R.O.-F. and C.S.; formal analysis, I.U.; investigation, I.U.; resources, P.E.; data curation, J.M.; writing—original draft preparation, I.U.; writing—review and editing, J.M.; supervision, J.M.; project administration, J.M.; funding acquisition, J.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by Robert-Enke-Stiftung.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Technical University of Munich (protocol code: 314/14, date: 27 August 2014 and protocol code: 314/14 S, date: 25 May 2020).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
CHDCongenital heart disease
BDI-YBeck Depression Inventory for Youth
BAIBeck Anxiety Inventory
TGATransposition of the great arteries
UVHUniventricular heart

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Table 1. Overview of children and adolescents with congenital heart disease classified by type of heart defect and controls.
Table 1. Overview of children and adolescents with congenital heart disease classified by type of heart defect and controls.
n (%)Sex, Female
[n (%)]		Age, Years
[M ± SD]		BMI, kg/m2
[M ± SD]		BDI-Y Score
[M ± SD]		BAI-Score
[M ± SD]
Right Heart Obstruction13 (11.2)6 (46.2)13.0 ± 1.919.7 ± 3.96.3 ± 4.59.9 ± 6.6
Left Heart Obstruction23 (19.8)11 (47.8)14.3 ± 2.521.7 ± 5.28.4 ± 6.69.1 ± 9.4
Shunts18 (15.5)10 (55.6)12.9 ± 2.719.7 ± 4.09.8 ± 9.17.5 ± 7.3
TGA17 (14.7)8 (47.1)14.2 ± 2.620.6 ± 4.16.3 ± 10.110.8 ± 11.2
UVH17 (14.7)8 (47.1)12.8 ± 2.217.0 ± 2.25.8 ± 5.96.2 ± 5.9
Other28 (24.1)16 (57.1)13.5 ± 3.319.5 ± 5.09.2 ± 7.811.4 ± 9.0
CHD11659 (50.9)13.5 ± 2.719.8 ± 4.47.9 ± 7.79.3 ± 8.6
Controls11659 (50.9)13.5 ± 2.718.8 ± 2.88.6 ± 8.59.3 ± 10.3
p-value *--0.8410.4240.5690.429
Mean ± standard deviation; CHD = congenital heart disease; TGA = transposition of the great arteries; UVH = univentricular heart; BMI = body mass index; BDI-Y = Beck Depression Inventory for Youth; BAI = Beck Anxiety Inventory; * significance level set at p < 0.05.
Table 2. Beck Anxiety Inventory categories among the CHD group and controls.
Table 2. Beck Anxiety Inventory categories among the CHD group and controls.
BAI Scores (0–63)CHD (n (%))Control (n (%))
Minimal (0–7)61 (53.5)69 (59.5)
Mild (8–15)27 (23.7)24 (20.7)
Moderate (16–25)20 (17.5)14 (12.1)
Severe (>26)6 (5.26)9 (7.8)
p-value * p = 0.511
Values are presented as n (%). BAI = Beck Anxiety Inventory; CHD = congenital heart disease; * significance level was set at p < 0.05.
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MDPI and ACS Style

Uphoff, I.; Schöneburg, C.; Oberhoffer-Fritz, R.; Ewert, P.; Müller, J. Anxiety and Depression Symptoms in Children and Adolescents with Congenital Heart Disease. Hearts 2025, 6, 23. https://doi.org/10.3390/hearts6030023

AMA Style

Uphoff I, Schöneburg C, Oberhoffer-Fritz R, Ewert P, Müller J. Anxiety and Depression Symptoms in Children and Adolescents with Congenital Heart Disease. Hearts. 2025; 6(3):23. https://doi.org/10.3390/hearts6030023

Chicago/Turabian Style

Uphoff, Isabel, Charlotte Schöneburg, Renate Oberhoffer-Fritz, Peter Ewert, and Jan Müller. 2025. "Anxiety and Depression Symptoms in Children and Adolescents with Congenital Heart Disease" Hearts 6, no. 3: 23. https://doi.org/10.3390/hearts6030023

APA Style

Uphoff, I., Schöneburg, C., Oberhoffer-Fritz, R., Ewert, P., & Müller, J. (2025). Anxiety and Depression Symptoms in Children and Adolescents with Congenital Heart Disease. Hearts, 6(3), 23. https://doi.org/10.3390/hearts6030023

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