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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

Statement on protest at the UFS

2005-03-04

Following a protest by student and non-student organisations today, the management of the University of the Free State (UFS) would like to place the following facts on record:

1. There is a well-documented process underway to further transform the UFS. At the official opening of the UFS on 4 February 2005 , the Rector and Vice-chancellor, Prof Frederick Fourie, announced that the UFS would draft a comprehensive Transformation Plan to guide the next phase of transformation at the institution.

The UFS appeals to student formations, staff associations, trade unions and other role-players to make a constructive input into this Transformation Plan.

The UFS management has been - and always will be - willing to engage with role-players and is prepared to do so even after today’s protest.

2. There is thus no regulation or policy prescription which separates students in hostels according to race.

The reality is that students exercise their freedom of choice as to which hostel they wish to be placed in. This was agreed upon by black and white students in 1997/8.

However, the unintended consequence and practice of this hostel placement policy has been that students themselves have tended to choose to stay in hostels which have over time become black hostels and white hostels.

This is a matter of concern for the management of the UFS as such a situation does not promote interaction across language, cultural and socio-economic groupings of students.

This matter is receiving attention and an intensive consultative process, which will include students, will be launched to review this policy.

The management is convinced that such interaction will enhance the learning experience of all students and sensitise them to the reality of a multicultural South Africa and a multicultural world.

3. No student organisation has been banned from operating at any of the three campuses of the UFS.

In the past few weeks, SASCO, the Young Communist League and the ANC Youth League (ANCYL) have held meetings on all three campuses, namely the Qwaqwa campus, the Vista campus and the main campus.

There are also regular interactions between top management and the leadership of SASCO and the ANCYL on campus.

In fact, the UFS upholds the right of students and staff to associate freely and to organise themselves as they see fit.

The UFS also upholds the rights of staff and students to engage in legal and peaceful protests.

The management however remains committed to discussing issues that affect staff and students in a constructive manner and appeals to student organisations in this case to engage with management.

4. The issues of registration, fees, debt and financial aid are continually monitored, and interventions to assist students are made regularly. To assist as far as possible those academically deserving students who face financial difficulties, the UFS management has put in place a structure called the Monitoring committee that includes management and student representatives.

The purpose of the Monitoring Committee is to review the cases of individual students to determine how best they can be assisted.

This applies to the Qwaqwa campus, the Vista campus and the main campus.

It is generally the case that students who perform academically will not have any difficulty in obtaining financial assistance. However, according to the requirements of National Student Financial Scheme, students who perform poorly will have difficulty in obtaining such assistance.

5. With regard to student governance, the process to institute an inclusive Central Student Representative Council (SRC), on which all three campuses will be equitably represented, was launched in July 2004, and a preliminary constitution has just been drafted. At the same time an inclusive process to review certain elements of the constitution of the main campus SRC was initiated at the end of 2004. This process, which includes all relevant student organisations and structures, is planned to produce an outcome within the next couple of months.

6. There is no policy at the UFS that is based on racism or that discriminates on the basis of the race of students and staff.

As part of the building of a new institutional culture within the broader transformation process, the UFS management is determined to eradicate all elements of racism that may occur on its campuses, and has already instituted inclusive forums on campus to discuss the issue of values and principles for a non-racial university.

Issued by: Mr Anton Fisher
Director: Strategic Communication
Cell: 072 207 8334
Tel: (051) 401-2749
4 March 2005

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