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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 can lead SA in race relations - Ramphele

2010-08-06

Pictured are: Dr Boesak and Dr Ramphele
Photo: Mangaliso Radebe

The University of the Free State (UFS) could well be a perfect model of excellence in race relations that the whole of South Africa could emulate.

This was said by Dr Mamphela Ramphele, the first African to be a Managing Director of the World Bank, during the Anti-Racism Network in Higher Education (ARNHE) Colloquium held at the UFS recently.

“Healing circles need to be constructed on this campus to address issues raised by the Reitz incident,” she said.

“You might yet be the pioneer of what needs to happen on a nation-wide level.

“Can we confidently commit today to go on this quest for a true humanity and walk together as fellow citizens and strive for a more human face for our society? That is our challenge. That is what the UFS is called to give leadership to.”

“It is this human face which has the power to liberate us from the body of death and strengthen us in our struggle for meaningful life together in South Africa,” added one of the main speakers, Dr Allan Boesak, a cleric and former anti-apartheid activist.

However, said Dr Ramphele, this could only be achieved if all South Africans, black and white, abandoned the fear for each other that was hindering, if not stalling, progress in this regard.

“Fear of each other is the most important impediment to the sustainability of our journey into a society united in our diversity,” she said.

“People in this country are afraid to stand up and be counted, including many vice-chancellors and clerics. They are afraid of being seen to be difficult, and that is a major problem. Fear is the most destructive emotion that you can have because it makes you really incompetent and unable to respond to challenges.”

She said the biggest impediment, though, to ending racism was denial. “White people deny vehemently that they are or have ever been racist,” she said.

“We need to go through a process of acknowledging our wounds and scars from our racist past and present missteps in public policy.”

“Instead of saying they are sorry, those who are conscious of their whiteness should rather say what they are sorry for,” said another main speaker, Prof. Dennis Francis, the Dean of the Faculty of Education at the UFS.

On the other hand, according to Dr Boesak, blacks were and still are, to a large extent, also to blame for their own ongoing oppression. “The key here was the acknowledgement of our sheepish timidity, our complicity,” he said.

The Chairperson of ARNHE, Prof. Norman Duncan, had this to say: “If we are to confront and eradicate racism in higher education institutions, we should not do so to create comfort zones for ourselves.”

The theme of this ARNHE Colloquium was Black consciousness and those conscious of their whiteness. It was presented by the International Institute for Studies in Race, Reconciliation and Social Justice at the UFS.

Media Release:
Mangaliso Radebe
Assistant Director: Media Liaison
Tel: 051 401 2828
Cell: 078 460 3320
E-mail: radebemt@ufs.ac.za
6 August 2010

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