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Undiagnosed depression in tuberculosis patients threatens control of the disease

24 March 2023 | Story Profs Gladys Kigozi-Male, Christo Heunis, and Michelle Engelbrecht | Photo Supplied

Prof Christo Heunis, Prof Michelle Engelbrecht, Prof Gladys Kigozi-Male — From the left, Prof Christo, Prof Michelle Engelbrecht, and Prof Gladys Kigozi-Male.

Opinion article by Profs Gladys Kigozi-Male, Christo Heunis, and Michelle Engelbrecht, Centre for Health Systems Research and Development, University of the Free State.

Each year on 24 March, the world commemorates World TB (Tuberculosis) Day. This date coincides with the day in 1882 when Robert Koch announced his discovery of the Mycobacterium Tuberculosis, the germ that causes TB. This infectious disease is transmitted through airborne droplets when an infected person coughs, sings, shouts, or sneezes. TB primarily affects the lungs (i.e., pulmonary TB), but other organs in the body such as the pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, or meninges (i.e., extra-pulmonary TB) can also be affected. TB can be cured; effective anti-TB drugs have been available for almost eight decades. Despite this, TB continues to wreak havoc across the world and in South Africa. According to a report released by the World Health Organisation (WHO), an estimated 304 000 new TB cases were reported in South Africa in 2021 and 56 000 people succumbed to the disease in the same year

A world without TB

In 2014, the sixty-seventh World Health Assembly endorsed a global strategy and targets for TB prevention, care, and control. The strategy envisions a world without TB, aiming to end the epidemic by 2035. By this target date, a reduction in TB deaths of 95% and new infections of 90% – compared to the respective levels in 2015 – are anticipated. Further to this, the United Nations’ Stop TB Partnership was mandated to drive activities to end the global TB epidemic. In 2015, the partnership launched the 90-(90)-90 targets; to reach at least 90% of people with TB and place them on appropriate treatment, including at least 90% of vulnerable populations such as people living with HIV, and to ensure that at least 90% of people with TB are successfully treated. Despite commendable progress, persisting high TB infection and death rates are adversely affecting global and national efforts to end the TB epidemic. With a treatment success rate of only 78% in 2020, South Africa is sorely challenged to attain the global target of 95%.

TB with mental health illness

One of the challenges confronting TB control is the frequent comorbidity of TB with mental health illness. There is compelling evidence linking TB to common mental health problems such as depression, anxiety, and alcohol misuse. Research indicates that TB patients can experience mental health problems at any time during the course of their TB treatment. Undiagnosed mental illness among TB patients may result in poor health-seeking behaviour and non-adherence to treatment, subpar quality of life, and negative treatment outcomes. The WHO's Global End TB Strategy thus recommends integrated patient-centred TB care. This implies that TB care should be provided in close collaboration with other primary health-care (PHC) programmes such as mental health. However, in many countries – South Africa included – efforts to integrate mental health and TB care are confronted by challenges such as limited capacity, nonrecognition of mental health as a problem, insufficient resources, and TB-related social stigma. Consequently, mental health conditions in TB patients are often un-/under-/mis-diagnosed.

Taking depression as a compelling example, a scoping review reported the prevalence of depression as high as 84% among people with TB in studies conducted internationally. However, little is known about the prevalence of depression among TB patients in South Africa. Using a nine-item Patient Health Questionnaire, we assessed probable depression among a sample of TB patients attending PHC facilities in the Free State. We found that almost half (46,1%) of the 208 patients interviewed had probable depression, with 22,6%, 18,8%, and 4,8% having mild, moderate, and severe symptoms, respectively. Probable depression was almost four times more likely among patients diagnosed with extra-pulmonary TB compared to pulmonary TB patients. HIV-infected TB patients undergoing antiretroviral therapy were more than twice as likely to experience symptoms of depression compared to their counterparts who were not undergoing such therapy. This could possibly be attributed to non-adherence to antiretroviral therapy. Studies elsewhere have established a significant association between depression and ART non-adherence. We further found that the longer patients were retained on TB treatment, the less likely they were to display symptoms of depression.

Important to monitor TB patients for depression

Based on these findings, it is important to monitor TB patients for symptoms of depression – particularly those with comorbid HIV – in PHC settings. At the same time, ensuring that patients stay on treatment by providing adequate support for treatment adherence may help to mitigate depression during TB treatment.

The theme for this year’s World TB Day is ‘Yes! We can end TB’. It is a call for concerted multi-sectoral collaboration between governments, civil society, communities, academia and technical partners, international aid and scientific organisations, the private sector, and disease control programmes in the country to eliminate the TB epidemic. To this end, TB patients attending PHC facilities in South Africa need to be routinely screened for mental health illness. Given the critical shortage of mental health specialists, screening for mental illnesses could be undertaken by trained and well-supervised non-specialist healthcare cadres such as community health workers.

News Archive

Official opening of Faculty of Health Sciences Rural Community Initiative

2017-01-01

Description: Karla Mostert Tags: Mail & Guardian, 200 Young South Africans, Candice Thikeson, Karla Mostert, Lerato Machetela, Mandela Rhodes Scholar, Thapelo Mokoatsi

Ribbon cutting, Prof van Zyl and Ms du Plessis
Venter (community member)

The Faculty of Health Sciences of the University of the Free State (UFS) has, as part of its commitment to student and community development, established a student residence in the town of Trompsburg in the Kopanong Local municipality, Xhariep District municipality in the Southern Free State. The Faculty officially opened the Faculty of Health Sciences Rural Community Initiative on 14 and 15 June 2017. The memorial plaque was unveiled by Prof Gert van Zyl (Dean of the Faculty of Health Sciences) and Prof Francis Petersen (Rector and Vice-Chancellor of the University of the Free State)

The importance of the residence

The goal of the ‘Kopanang le fodise – Unite to heal’ programme is to develop a community-centered collaborative framework for sustainable, holistic healthcare and social development incorporated in the curricula of the Faculty.

Background of the project

During 2016 a total of 324 fourth-year students of the Faculty have each spend at least a week in interprofessional groups in primary healthcare facilities in the Kopanong municipality on a Community Based Education, Interprofessional Education (CBE-IPE) platform in Trompsburg and Springfontein.

To facilitate student rural placement the former Midway guesthouse currently includes seven (7) facilitator units with on suite bathrooms, two (2) fully equipped lecture facilities, a recreation room and a library with computers and internet access. The newly developed student residence has 10 apartments that can each accommodate six (6) individuals. A housemaster resides on the premises and acts as manager of the facility. All areas of the residence are Wifi covered and 24h security service is in place.

The ceremony was attend by the following partners

University of the Free State (UFS)

Rector and Vice Chancellor of the University of the Free State, Prof Francis Petersen.
Members of the UFS council, Dr Vinger and Dr Swart
Dean of the Faculty of Health Sciences, Prof van Zyl.
The Head of the School of Allied Health Professions, Dr van Vuuren.
The Head of the School of Medicine, Prof Kruger.
Faculty from the Faculty of Health Sciences.
Members from UFS institutional support department: ICT, Finance, Facilities management

Kopanong local municipality

Councilor Basholo, representing the Kopanong local municipality.
Kopanong local community members
Free State Department of Education (DoE)
Free State Department of Health (DoH)

Private sector partners

Mr Burgess, CEO of MDG Heath Solutions
The Mother And Child Academic Hospital (MACAH) represented by Prof Venter, head of department of Paediatrics, donated two (2) state of the art baby scales to the rural health programme.

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