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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 sets trend for higher education institutions

2005-09-21

The University of the Free State (UFS) offers more service-learning courses than any other higher education institution in the country and has the highest number of students enrolled for these service-learning courses.

This was the research findings on higher education institutions conducted between 2001 and 2004 by the Joint Education Trust (JET) into service-learning courses. These are courses which seek to integrate service to the community into the academic core of higher education institutions.

The results of this research indicated that the UFS is one of the few higher education institutions in South Africa that have made progress in integrating community engagement into the mainstream academy.

According to the findings 2 233 students at the UFS participated in service-learning courses supported by JET, while 858 students at the University of Transkei (UNITRA), 636 students at the University of the Western Cape (UWC) and only 600 students at the University of the Witwatersrand (WITS) participated in service-learning courses.

In total there were 6 930 students participating in service learning courses supported by the JET at 10 institutions throughout the country.

The research also found that out of a total of 182 service-learning courses supported by JET countrywide, the UFS had the highest number of such courses at 42, followed by WITS with 28, the University of Kwazulu Natal with 26, UWC 24 and UNITRA with 22.

Nationally, most of the service-learning courses at higher education institutions are offered in the human sciences (62), followed by health sciences (37), education (26), agriculture (14), and economic sciences (11).

According to leading academics, service-learning is a credit-bearing, educational exercise in which students participate in an organised service activity that meets identified community needs and helps the student to gain a deeper understanding of course content and a sense of civic responsibility.

Reacting to the research findings, the Rector and Vice-chancellor of the UFS, Prof Frederick Fourie, said the university feels strongly that there should be integration of service-learning into the academic core of the institution.

“Through service-learning modules the UFS can give expression to its role of service to the community as an institution of higher learning, producing quality graduates who understand the communities in which they will have to function for the rest of their lives,” Prof Fourie said.

According to Mr Jo Lazarus, the project manager of the Community-Higher Education – Service Partnership (CHESP), which falls under the JET, a number of institutions have identified community engagement as a strategic priority and have allocated significant resources from their central budget towards its implementation.

Mr Lazarus said most students have an overwhelmingly positive attitude towards service learning.

“A large percentage of students surveyed indicated that their service-learning course helped to improve their relationship skills, leadership skills and project planning abilities. As significant is the fact that these courses also benefited them in terms of their awareness of cultural differences and opened their eyes about their own cultural stereotypes,” said Mr Lazarus.

“The key challenge still hampering the integration of service-learning as a core function of academic activity is that some institutions still see service-learning as an add-on, and nice-to-have activity,” he said.

According to Mr Lazarus higher education must demonstrate social responsibility and commitment to the common good by making available expertise and infrastructure for service-learning as a form of community engagement.

Media release
Issued by:  Lacea Loader
   Media Representative
   Tel: (051) 401-2584
   Cell: 083 645 2454
   E-mail: loaderl.stg@mail.uovs.ac.za
   20 September 2005

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