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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

Address by the first Inaugural President of the Central SRC

2005-08-03

The UFS Central SRC

Address by the first Inaugural President of the Central SRC of the University of the Free State, Mr Tello Motloung on Wednesday 3 August 2003

The Chairperson of the UFS Council, Judge Faan Hancke,
The Vice-chancellor and Rector of the UFS, Prof Frederick Fourie
The Vice-Rector Student Affairs of the UFS, Dr Ezekiel Moraka
The Presidents of the main campus SRC and the Vista campus SRC
Colleagues in the Central SRC, campus SRCs, students and fellow South Africans

Please receive my heartfelt revolutionary greetings

Vice-chancellor and rector what I bring here with me assisted by facts, is just the work of my imagination. Like a love letter addressed to a sweetheart miles away, even though you do not know how she feels, what she wants to hear, and do not even know what she looks like.

I value speech as just an honest intimation, that’s why I got into a habit of establishing a dialogue with people, looking at each other’s face, and persuading one another of what we are saying.

Vice-chancellor, today marks an important milestone in the history of the existence of the UFS. Today reflects the confidence and trust that students of the UFS have placed in us. They are confident that the Central SRC has both the will and the capacity to take our university forward as we confront the challenge of transformation.

Students are confident that they are correct to trust the Central SRC as the principal agent of change in our university that is genuinely committed to the objective of building a non-racial, non-sexist and democratic university. We need to frankly ask ourselves, as CSRC members, whether are we up to all these challenges?

All Central SRC members have to understand this fully, internalize it, and ensure that everything we do, does not betray the confidence and trust of students, or disappoint their expectations. I say this knowing that all Central SRC members have committed themselves to serve the students of the UFS, black and white, and no one among us (CSRC) needs any special lectures about this central commitment.

The UFS should be an omnibus, welcoming everybody on board. But we should be a bus with a clear direction. We will certainly lose our way if we, as an institution, don’t have a clear road map spelling out where we are heading to.

There should be clear guidelines on the role of students in the transformation process. Students should also be viewed as role players in transformation along with the University management, and not just opposing forces. There is no right time, other than this one, to move away from the politics of opposition to politics of transformation.

However, we need the support of management to do so. The University should value the role and contribution of student leaders, hear our legitimate claims and consider them as part of political and policy decision making.

Vice-chancellor and Rector, it remains our task to ensure that the UFS is transformed into an institution that is seen to be playing a vigilant role in developing students academically, intellectually, socially, culturally, politically and otherwise. The process of transformation is not ending tonight, it is just beginning tonight.

Judge Hancke, Prof Fourie, Dr Moraka, fellow students and fellow South Africans, I lead students at this university with a sense of pride and duty, and I know very well that I lead men and women, students who are all determined that we reach our destination safely and on time.

A navy divided within its ranks will be destroyed and vanquished by the enemy, but the navy united in purpose and action, loyalty and commitment will not sink but sail on to victory.

It is befitting to mention that every drop of my blood is telling me that the UFS is my home. I firstly became a student here, I became the SRC treasurer in my first year here, I became the deputy president here, and I became the first president of the Central SRC of the UFS.

Therefore you should never doubt my commitment towards the transformation of this university. To paraphrase what was said by students at another institution, “If there is no UFS in heaven, then I am not going.”

Let me conclude by thanking my ancestors for teaching me that even if I wined and dined with kings and queens, I am not a king myself, so I should not turn my back on people who made me what I am today.

Most importantly, I would like to thank the Almighty God and the grace of our Lord Jesus Christ for giving me time and power to lead this university.

It will be theoretically irresponsible if I ended my speech without indicating that “Only a Kovsie knows the feeling”.

I thank you.

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