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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 takes 70 first-year students to the USA

2010-08-20

Mr Rudi Buys (middle, with tie) with some of the students selected for the F1 Programme
Photo: Gerhard Louw

The University of the Free State (UFS) has announced the names of the first ever group of 70 first-year students that will travel to the United States of America (USA) as part of the university’s Student Leadership Development Programme.

This group of students will spend two weeks at universities in the USA to experience student life and learn about leadership and diversity at these universities.

“This is a first for not only the UFS, but also for South Africa and we are incredibly proud. The programme is unique to any other student leadership development programme in the country. We are leading the way and are taking students to live and learn amongst students at various universities across the USA,” said Mr Rudi Buys, Dean of Student Affairs at the UFS.

The programme was one of the goals of Prof. Jonathan Jansen, Rector and Vice-Chancellor of the UFS, which he aimed to realise when he was appointed by the UFS in 2009.

“With the programme we want to develop participants’ thinking and capacity to lead in the contexts of diversity and change and we hope to direct them to programmes leading change in student life in general upon their return,” Mr Buys said.

The 70 students will leave for the USA on 22 September 2010. After spending some time there and learning more about their American peers’ lives and culture, they will return to the UFS on 7 October 2010.

“We took great care in selecting the 70 participants. They are representative of all our students, as well as students from our Qwaqwa Campus,” said Mr Buys.

A rigorous selection process was followed, which focused on the students’ academic excellence, their participation in student- and residence-life programmes and their interest in growing in the areas of, amongst others, leadership, diversity and citizenship. Each candidate had to undergo a pre-selection process, followed by a panel interview consisting of staff from various faculties and divisions at the UFS.

The students will stay in groups of about ten at the various universities, which include universities such as Cornell University, New York University, the University of Massachusetts, the Appalachian State University and Virginia Polytechnic University. “These universities will provide our students with accommodation and will present various academic and cultural programmes which our students will participate in and learn from,” said Mr Buys.

“We have also put a programme in place to prepare our students thoroughly for the trip. Because some of them have never travelled on an aeroplane, let alone travelled to a foreign country, we have made arrangements with the Department of Home Affairs for assistance with travel documentation, as well as special arrangements with the USA Embassy for assistance with visas. They will also be attending workshops focusing on, amongst others, research, leadership and diversity before their departure on 22 September 2010.

“Upon their arrival in the USA the group of students will firstly be taken to Washington DC where they will be briefed about American customs, etc. From there they will be placed at the various universities,” said Mr Buys.

Upon their return the students must be involved in student-life programmes on campus, establish volunteer programmes and initiate and establish mentoring programmes for their fellow students. “We want them to give back what they have learnt and experienced,” said Mr Buys.

“We are planning on implementing the Student Leadership Development Programme as an annual programme and are looking forward to this incredible programme through which this group of first-year students will have the opportunity of a lifetime to be true ambassadors of South Africa and, in particular, the UFS, as they leave for the USA,” he said.

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

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