Depression, Anxiety and ADHD in Youth with Cardiac Arrhythmias

Youth with cardiac arrhythmias are 9x more likely to be diagnosed with or on medication for depression or anxiety, and 4.7x more likely to be diagnosed with ADHD than the general population, according to a study presented at the 2019 American Heart Association’s Scientific Sessions.

“Depression and anxiety seem part and parcel with an arrhythmia disorder,” says Cleveland Clinic Children’s cardiologist Peter Aziz, MD. “Arrhythmia disorders are one of the few diagnoses in medicine where a patient looks and feels totally normal, though physicians are tasked with convincing them otherwise. I think that it’s hard for anybody, particularly a teenager or a young patient, to wrap their mind around the complexity of that dilemma.”

Dr. Aziz advises that clinical teams work with patients and their families when a new diagnosis is given to ensure that they feel as normal as possible. “Oftentimes,” he says, “that involves injecting a bit of what patients loved most pre-diagnosis into their daily lives somehow. If the patient is an athlete, we want to enable safe participation. It can be very tricky, but it’s certainly in the patient’s best interest. Altering their lives in an uncalculated fashion can have unintended consequences. Some of those consequences can be more detrimental than the disease we are intending to treat.”

After a child receives a diagnosis like cardiac arrhythmia, there’s a bit of a calibration process. Families go through phases, from detachment to overly concerned, before they settle somewhere in the middle. “As physicians, we walk them through those stages,” Dr. Aziz says.

ADHD in youth with cardiac arrhythmias

When it comes to ADHD, there are many confounding variables that may help explain the findings, according to Dr. Aziz. “For one, I think the patients that have arrhythmia disorders tend to be a little bit more on the radar of their primary care physician, and of course the subspecialist in cardiology who is managing their arrhythmia. There is also some hesitancy to prescribe medications to treat mental health disorders in these patients.

A breeding ground for anxiety

The study also compared depression/anxiety and ADHD rates between youth with arrhythmia and those with other chronic diseases (namely, cystic fibrosis and sickle cell disease). Although the differences were more modest, youth with arrhythmia still had higher rates of depression/anxiety and ADHD. Youth with arrhythmia were 1.6x more likely than those with cystic fibrosis — and 5x more likely than youth with sickle cell disease — to be diagnosed with or on medication for depression/anxiety. Adolescents with cardiac arrhythmia were also 1.8x more likely to have a diagnosis of ADHD than patients with sickle cell disease.

Again, Dr. Aziz believes that this speaks to the amorphous nature of cardiac arrhythmia. “Patients with these other conditions may feel better if they take their medications, and generally become symptomatic when things aren’t going as well. Cardiac arrhythmia is a breeding ground for anxiety; patients feel totally fine until they don’t.”

Reevaluating outcomes

“This study fills an important gap in the literature. Our naiveté about recognizing that mental health is an important aspect of managing patients with cardiac arrhythmia is now coming to the forefront. As electrophysiologists, our goal is to make patients safe without substantially disrupting their lives. We need to realize that their lives are disrupted from the moment they receive the diagnosis, regardless of our efforts to normalize it.”

“It’s possible that we’re not looking at all the right outcomes metrics,” Dr. Aziz continues. “We strive to avoid recurrence of arrhythmia, and obviously sudden cardiac death. However, youth are affected by their mental health every day, and for them, the arrhythmia may seem like a secondary issue. “

“The next step is for us to assess our ability to manage these situations. Is it reasonable to have every patient with a new diagnosis see a mental health specialist? Injecting a mental health provider into our routine is certainly worth exploring.”