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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

Moshoeshoe's legacy lives on in university's project: City Press - 2 May 2004

2004-10-14

CITY PRESS 2 MAY 2004 P8

NEWS

JOHANNESBURG FINAL

Moshoeshoe's legacy lives on in university's project

MATEFU MOKOENA

DRUMS were beaten and the sounds of traditional songs reverberated through corridors of the University of the Free State (UFS) as Basotho students gathered at the campus over the weekend to launch a project honouring their late great king, Moshoeshoe.

The launch was organised by the Lesotho Students Association and UFS management and was blessed by King Letsie III of Lesotho.

According to UFS rector and vicechancellor, Professor Frederick Fourie, the aim of the project is to make the legacy of Moshoeshoe a living part of the university.

He said the Moshoeshoe project will include a television documentary on his life as well as an anthology of creative writings, including prose and poetry, about him.

A television documentary is already being filmed and will be screened during an international conference at UFS in October.

Fourie said the university, as part of the project, is looking at the possibility of starting an annual Moshoeshoe memorial lecture that will focus on African leadership, nationbuilding and reconciliation.

He said the university would introduce a PhD-level research course into the life and legacy of Moshoeshoe.

The university management has also taken a decision to erect a statue of Moshoeshoe on the campus.

Fourie said the project was launched after the UFS delegation, led by him, met Letsie III.

"He wanted us to ensure the legacy of Moshoeshoe is honoured and treated with the respect he deserves."

His legacy "must live on -- not only for the Basotho, but for all South Africans, black and white, and for the entire African continent", he said.

"Living out such a legacy is indeed a fitting contribution to the New Partnership for Africa's Development (Nepad) and to the maturing democracy that is being built here in South Africa," said Fourie.

He emphasised Moshoeshoe was and remains a model of African leadership.

Fourie said Moshoeshoe's diplomacy and commitment to peace put him on a par with former president Nelson Mandela as a statesman.

It is Fourie's dream that, through this project, the UFS will be able to give real meaning to words such as reconciliation, respect for the diversity of languages and cultures and the unity that is needed to build a democratic nation.

The Lesotho Students Association secretary, Sofonea Shale, said for an institution like the UFS to honour Moshoeshoe demonstrates that he was a great leader. "For Basotho students, the project is very significant as it clearly defines who we are and what we stand for.

"We believe the research into the legacy of our great king Moshoeshoe will open doors for more research into the life of Basotho in general.

"Africa as a whole can learn from his leadership style," he said.

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