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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

Legal elite tackle thorny issue of corruption

2013-01-24

Our Faculty of Law brought together top experts and judges for a Symposium on Corruption, to investigate one of the most pressing concerns of South Africans.
Photo: Stephen Collett
24 January 2013

YouTube Video

Chief Justice Mogoeng Mogoeng yesterday (24 January 2013) concluded the proceedings of the first day of the International Symposium on Corruption, hosted by the Faculty of Law of the University of the Free State (UFS). In his address Justice Mogoeng made no excuses as to the magnitude of the threat corruption presents to South African citizens.

“Urgent action and efficient measures are called for to arrest this scourge, for the sake of our constitutional democracy,” he warned. “Our vibrant constitutional democracy will not and cannot survive in the face of rampant corruption.”

Justice Mogoeng said the spate of civil and labour unrest erupting throughout the country can be attributed to corruption. According to him the scope and far-reaching implications of corruption drives South Africans to “boiling point” and evokes “anger, frustration and a don’t-care-attitude that often manifests in widespread protest actions” and disrespect for the rule of law.

“South Africans, irrespective of race or creed, must identify and focus on their common enemies and find a conciliatory and unifying way of dealing with what divides them, including the lingering prejudices of the past,” Justice Mogoeng urged.

Despite the threat corruption poses, he stressed that all South Africans have a role to play in the fight against corruption and that there are different role players that can become involved in the process. Especially important is the media and faith-based agencies which, according to Justice Mogoeng, can regenerate morals and secure a “national moral code.” The State must further ensure enforcement of anti-corruption measures and preside over the selection of individuals of “solid character” to reside in agencies meant to fight corruption.

He highlighted the need for an unbiased and independent judiciary, one immune to outside influences controlled by powerful forces, as well as personal agendas.

Although Justice Mogoeng believes that the private sector is most guilty of transgressions based on corruption, he stated that a “well-coordinated war” against it must be waged in all sectors in order to stamp it out.

Justice Mogoeng presided over the unveiling of the redesigned foyer of the CR Swart Building and praised the Faculty of Law for its innovation with regard to the symposium.

“I look forward with great optimism to more well-organised symposiums that strike at the nerve-centre of the well-being of our constitutional democracy,” he concluded.

Symposium seeks answers and solutions

The Faculty of Law at the University of the Free State (UFS) concluded its International Symposium on Corruption on Friday 25 January 2013. The event featured a stellar cast of speakers, including the Chief Justice of South Africa, three current Supreme Court of Appeal judges, high-court judges, advocates, prosecutors, journalists, as well as local and international legal academics.

Throughout the two-day symposium, corruption was dissected as a severe problem in the South African socio-economic landscape and solutions were sought to alleviate the pressing concern.

The main attractions of the symposium were undoubtedly the attendance and presentations delivered by Chief Justice Mogoeng Mogoeng, as well as Prof. Leon Wessels. Prof. Wessels was described as “one of the founding fathers of the constitution of South Africa” by Judge Fritz Brand, a current Appeal Court judge and the third-longest serving judge in the country.

“Corruption is stealing the constitutional dream of this country. Corrupt leaders are fearless, those who expose corruption, are fearful,” Prof. Wessels warned.

Judge Brand closely trails the second longest serving judge in the country in former Kovsie, as well as former UFS Council Chairman, Judge Faan Hancke. Both judges addressed the symposium and chaired sessions, along with Prof. Johan Henning, Dean of the Faculty of Law, and Judge Ian van der Merwe, Chairman of the UFS Council.

It was, however, not all doom and gloom, as several of the speakers offered tangible ideas in what was often termed the “war on corruption”. Celebrated Sunday Times journalist Mzilikazi wa Afrika who has been arrested following the police leasing scandal which he exposed, urged South Africans to stand together in their fight against corruption, before it is too late.

People on the front lines in the day to day fight against corruption also spoke at the symposium, giving the audience a better understanding of the intricacies and challenges involved in the process. The Head of the National Prosecuting Authority’s Asset Forfeiture Unit, Mr Willie Hofmeyer, as well as Advocate Xolisile Khanyile, who is the Director of Public Prosecutions in the Free State, elucidated this struggle.

The symposium also hosted Prof. Chizu Makajima, a celebrated academic from the United Kingdom.

The two-day symposium ended in style as the delegates gathered in the Centenary Hall on the Bloemfontein Campus for lunch, with a further address by Prof. Leon Wessels

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