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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

During 2011: Sport

2011-12-01

Our sports stars set their gaols high and with hard work, dedication a good measure of determination they show that they will not give up until these goals are met. A place in the national team or a medal or award in hand is enough proof that our Kovsie sportsmen and women are serious about their successes on the sports field.

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Some of our stars this year were:

Athletics:

Thuso Mpuang, our Kovsie Sportsman of the year, represented South Africa during the World Athletic Championships in Deague, Korea. He obtained the silver medal in the 200m during the World Student Games in Shenzhen, China and a gold medal as a member of the 4 x 100m relay team.

Janette Siebert represented South Africa during the Southern Africa Championships in Maputo, Mozambique.

Boy Soke represented South Africa during the Africa Cross Country Championships in Cape Town. He also represented South Africa during the World Cross Country Championships in China.

Cricket:

The 21-year-old former Kovsie, Obus Pienaar, who was still playing cricket for our university club until the end of the season (end of March), has been playing abroad for the Irish cricket club Waringstown from the end of April 2011.
We are proud of Obus’ achievements, in particular his contribution to the match against the CIYMS. During this game, Obus hit the highest score ever in the Northern Cricket Unions when he scored 244 runs in only 114 balls. This included 22 sixes and 13 fours. During his innings in this match, Obus also broke the July 2004 record of his compatriot, AB de Villiers of the Proteas.

Hockey:

Lesley Ann George represented the Protea Women’s Hockey Team during the series against China, Belgium and Azerbaijan. She was also a member of the Protea Women’s Hockey Team during the Champs Challenge in Ireland. The team finished fifth.

Nicole de Vries represented the Protea Women’s Hockey Team during the series against China, Belgium and Azerbaijan. She was also a member of the Protea Women’s Hockey Team during the Africa Cup in Bulawayo. The team obtained a gold medal.

Hettie Oosthuizen represented the Protea Women’s Hockey Team during the series against China, Belgium and Azerbaijan.

Izelle Lategan represented the Protea Women’s Hockey Team during the series against China, Belgium and Azerbaijan.

Nicole Kemp was a member of the Protea Women’s Hockey Team during the Africa Cup in Bulawayo. The team obtained a gold medal.

Karate:

Elsabe le Roux was a member of the Protea JKA Shotokan Karate Team that participated in the Africa Zone 6 Championships in Maputo where she obtained a gold and silver medal.

Bruno Schwalbach was a member of the Protea JKA Shotokan Karate Team that participated in the Africa Zone 6 Championships in Maputo where he obtained two gold medals. He was also a member of the Protea JKA Shotokan Karate Team that participated in the Common Wealth Karate Championship in Australia where he obtained one silver and two bronze medals. He was a member of the Protea JKA Shotokan Karate Team that participated in the All Africa Games in Maputo Mozambique where he obtained a bronze medal.

Balungile Nchofe was a member of the Protea JKA Shotokan Karate Team that participated in the Africa Zone 6 Championship in Maputo, where he obtained a gold medal.

Netball:

Kovsies’ netball team has performed well over the past year with, amongst others, the inclusion of players in the SA Universities World-cup Group.

Karla Mostert and Maryka Holtzhausen participated during the World Cup in Singapore in the SPAR SA Protea team.

We are also proud of the eight players who have been included in the SA team. They are Zimari Smit, Sheri Duimpies, Ane Botha, Danique du Toit, Nieke Loubser, Karla Mostert, Fikile Mkhuzangwe and Lauren-lee Christians.

At the SA tournament, Ane Botha was named as the centre-court player of the tournament, whilst Karla Mostert was named as the best defending player. Karla has also been included in the SPAR SA Protea team to the All African Games, which start in Mozambique at the end of August.

Rugby:

Boom Prinsloo and Robert Ebershohn are representing the Springboks in the HSBC Sevens World Series.

Soccer:

Gabisile Hlumbane, our Kovsie Sportswomanof the year, is a member of the Banyana Banyana National Soccer Team. The team obtained a bronze medal at the African Women’s Championships during October 2010, a gold medal at the Unity Cup Hosted during December 2010, a silver medal at the COSAFA Women’s Championship hosted during July 2011 and qualified for the London Olympics in 2012.

Squash:

Paul Rodrigues represented the South African U/ 23 team at the All Africa Squash Championships in Johannesburg.

Triathlon:

Nelmaré Loubser represented the SA Elite Team during the World Championships in Spain.

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