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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

UFS council elects Nwaila and Hancke

2005-03-15

Dr Charles Nwaila, Superintendent-General of Education in the Free State, was elected Vice-chairperson of the UFS Council and Judge Faan Hancke was re-elected as Chairperson today.

According to the Rector and Vice-Chancellor, Prof Frederick Fourie, the election of Dr Nwaila is an important achievement for the UFS as Dr Nwaila is a well known leader in education in the Free State.

Dr Nwaila pledged to work constructively with the UFS council and management to ensure that the UFS benefits all people of the province and the country.

The appointments are valid for a term of three years from 1 June 2005 to 31 May 2008.

The elections took place at the quarterly meeting of the UFS Council where a number of other key transformation steps were approved.

The Council approved a Strategic Plan for the UFS which reflects a renewed focus on transformation of the institution, calling it an important roadmap for the future of the UFS.

According to Prof Fourie, the Strategic Plan tried strike a balance between continuity and change, addressing the need to remain an excellent university in an ever-changing context and environment.

Prof Fourie said transformation had many aspects and dimensions and could not be reduced to an issue of numbers.

The Strategic Plan identifies five strategic priorities and corresponding challenges in the next phase of transformation.

The priorities are:

quality and excellence
equity, diversity and redress
financial sustainability
regional co-operation and engagement.
outward thrust

Prof Fourie said that besides the five strategic priorities the plan also reflected concrete actions and interventions to address them.

He said the renewed focus on transformation is embedded in the priorities and specific actions that are identified.

The Council congratulated the management for the roadmap and for the achievements that have already been achieved in terms of transformation.

In order to draft a comprehensive Transformation Plan that will give substance to certain aspects of the UFS Strategic plan – or roadmap – the Council approved the establishment of a Transformation Plan Team.

The team will consist of about 16 people, which includes the two coordinators, Prof Teuns Verschoor, Vice-Rector: Academic Operations, and Dr Ezekiel Moraka, Vice-Rector: Student Affairs.

According to Prof Verschoor, the team was chosen and approved by the Executive Management earlier for the individual contributions that they could make.

While the individuals do not represent particular constituencies on campus they are a very diverse group of persons in terms of race, gender and various sections of the campus and the satellite campuses.

Prof Fourie, said there was an urgency and importance attached to the work of the Transformation Plan Team.

He said that while the team must produce a plan within a tight deadline, the task must be carried out very well, which could mean different stages in the work of the team.

According to the Rector, the UFS must take the lead in best practice transformation, while not underestimating the complexity of the issues facing the UFS.

The full list of names will be finalized soon.

MEDIA RELEASE
Issued by: Mnr Anton Fisher
Director: Strategic Communication
Cel: 072 207 8334
Tel: (051) 401-2749
11 Maart 2005

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