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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

Nanotechnology breakthrough at UFS

2010-08-19

Ph.D students, Chantel Swart and Ntsoaki Leeuw

Scientists at the University of the Free State (UFS) made an important breakthrough in the use of nanotechnology in medical and biological research. The UFS team’s research has been accepted for publication by the internationally accredited Canadian Journal of Microbiology.

The UFS study dissected yeast cells exposed to over-used cooking oil by peeling microscopically thin layers off the yeast cells through the use of nanotechnology.

The yeast cells were enlarged thousands of times to study what was going on inside the cells, whilst at the same time establishing the chemical elements the cells are composed of. This was done by making microscopically small surgical incisions into the cell walls.

This groundbreaking research opens up a host of new uses for nanotechnology, as it was the first study ever in which biological cells were surgically manipulated and at the same time elemental analysis performed through nanotechnology. According to Prof. Lodewyk Kock, head of the Division Lipid Biotechnology at the UFS, the study has far reaching implications for biological and medical research.

The research was the result of collaboration between the Department of Microbial, Biochemical and Food Biotechnology, the Department of Physics (under the leadership of Prof. Hendrik Swart) and the Centre for Microscopy (under the leadership of Prof.Pieter van Wyk).

Two Ph.D. students, Chantel Swart and Ntsoaki Leeuw, overseen by professors Kock and Van Wyk, managed to successfully prepare yeast that was exposed to over-used cooking oil (used for deep frying of food) for this first ever method of nanotechnological research.

According to Prof. Kock, a single yeast cell is approximately 5 micrometres long. “A micrometre is one millionth of a metre – in laymen’s terms, even less than the diameter of a single hair – and completely invisible to the human eye.”

Through the use of nanotechnology, the chemical composition of the surface of the yeast cells could be established by making a surgical incision into the surface. The cells could be peeled off in layers of approximately three (3) nanometres at a time to establish the effect of the oil on the yeast cell’s composition. A nanometre is one thousandth of a micrometre.

Each cell was enlarged by between 40 000 and 50 000 times. This was done by using the Department of Physics’ PHI700 Scanning Auger Nanoprobe linked to a Scanning Electron Microscope and Argon-etching. Under the guidance of Prof. Swart, Mss. Swart en Leeuw could dissect the surfaces of yeast cells exposed to over-used cooking oil.

The study noted wart like outgrowths - some only a few nanometres in diameter – on the cell surfaces. Research concluded that these outgrowths were caused by the oil. The exposure to the oil also drastically hampered the growth of the yeast cells. (See figure 1)

Researchers worldwide have warned about the over-usage of cooking oil for deep frying of food, as it can be linked to the cause of diseases like cancer. The over-usage of cooking oil in the preparation of food is therefore strictly regulated by laws worldwide.

The UFS-research doesn’t only show that over-used cooking oil is harmful to micro-organisms like yeast, but also suggests how nanotechnology can be used in biological and medical research on, amongst others, cancer cells.

Figure 1. Yeast cells exposed to over-used cooking oil. Wart like protuberances/ outgrowths (WP) is clearly visible on the surfaces of the elongated yeast cells. With the use of nanotechnology, it is possible to peel off the warts – some with a diameter of only a few nanometres – in layers only a few nanometres thick. At the same time, the 3D-structure of the warts as well as its chemical composition can be established.

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

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