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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

New Rector and Chancellor inaugurated at UFS

2003-02-07

NEW RECTOR AND CHANCELLOR INAUGURATED AT UFS

Newly inaugurated Rector and Vice-Chancellor of the University of the Free State, Prof Frederick Fourie, has recommitted the university to the service of the broader community, through the pursuit of academic excellence and contributing to building a non-racial, democratic and just South Africa.

To make this a reality Prof Fourie proposed a social contract or accord between university constituencies and the community to chart the way forward to establishing a university that can meet the challenges of a developing democracy.

Prof Fourie was speaking at his inauguration ceremony on the Bloemfontein campus, where the former Ambassador to the United States, Dr Franklin Sonn, was also inaugurated as Chancellor of the UFS.

The twin inauguration ceremony – the first in the history of the UFS - was attended by former President Nelson Mandela, Education Minister, Kader Asmal, Free State Premier Winki Direko, and the executive mayor of Mangaung, Mr Pappie Mokoena, who all endorsed the appointments as evidence of the transformation of the UFS.

According to Prof Fourie, the greatest contribution that any university could make to social and economic development in South Africa was by being an excellent university that encouraged critical inquiry, scientific knowledge as well as community service.

“So whilst we cherish and foster the continuity of the university as part of the ageold international tradition of universities, this University embraces its particular role in this country now, embraces the changes in the form and scope of its role in this crucial period of our history. We are committed to making a real difference to the new nation,” he said.

His vision for the UFS was “to be a university of excellence, equity and innovation – a leader in research, teaching, community service, adult learning, transformation, non-racialism, non-sexism, multi-culturality and multilingualism – a contributor to our country and our continent’s growth and development – a truly South African university”.

Prof Fourie said the recent incorporation of the Qwaqwa campus of the University of the North into the University of the Free State, which is the first such incorporation to take place, would contribute to broadening access for poor communities to higher education. Introducing an innovation to the inauguration ceremony, Prof Fourie and the UFS staff pledged to their commitment to excellence and justice, quality and equity. Fourie is the 13th Rector of the University of the Free State, succeeding Prof. Stef Coetzee, and Dr Sonn is the 6th Chancellor, succeeding Ms Winkie Direko, Premier of the Free State.

In his inaugural address, Dr Sonn said the significance of today’s ceremony was that the UFS - as a former institution of the Afrikaner – had chosen to walk the path of justice and not merely survival. “This university has seemingly liberated itself. It is inclusively South African.

He said the academic community must play its role of vigilance and not indifference”. Referring to the stature of former president Mandela in international affairs, Dr Sonn said: “We must bring the weight ot science and critical analysis and interpretation to bear in support of Madiba and other moral giants.”

Inauguration Speech by Prof. Frederick C.v.N. Fourie (PDF format)

Inauguration Speech by Dr Franklin A. Sonn (PDF format)

Statement by the Minister of Education, Professor Kader Asmal (PDF format)

Speech by Prof. Viljoen (PDF format)

Speech by Executive Mayor Mokoena - Mangaung Local Municipality (PDF format)

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