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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

Another boost for sport at the UFS

2005-10-13

A contract formalizing the appointment of Sports Plan (Pty) Ltd was signed by Prof Verschoor and Mr Morne du Plessis in the historic Main Building of the UFS Bloemfontein campus.

The University of the Free State (UFS) has officially appointed Sports Plan (Pty) Ltd, which has former Springbok rugby captain Morné du Plessis as managing director, to manage its Centre for Exercise and Sport Science Services (CESSS) on the Bloemfontein campus.

According to Prof Teuns Verschoor, Vice-Rector: Academic Operations, the appointment of Sports Plan (Pty) Ltd is another step in the implementation of the UFS’s wide-ranging sport strategy to improve sport facilities and elevate formerly marginalized sports such as soccer, hockey, netball, tennis etc.

Sports Plan (Pty) Ltd is the manager of the Sports Science Institute of South Africa and coordinates and manages the national basketball high-performance programme of SA Basketball, as well as the Boxing Academy on behalf of Boxing South Africa.

“It is also actively involved with the sports plans of several tertiary institutions like that of the University of Johannesburg and the University of Stellenbosch,” said Prof Verschoor.

“Sports Plan (Pty) Ltd was also appointed by the Ministry of Sport and Recreation to manage the allocation of sports codes to high-performance centres and to oversee the allocation of monies received from the National Lottery to these centres – this includes the CESSS at the UFS,” Prof Verschoor added.

In unfolding its national sports plan, the Ministry of Sport and Recreation has already identified the UFS-based CESSS as the high-performance testing centre for the national basketball teams whilst the national boxing teams are also earmarked to be trained at the UFS.

“We are glad to be associated with a company of this stature and look forward to work with them in the further development of sports at the UFS,” said Prof Verschoor.

According to Prof Verschoor, the CESSS will act as a centralised body that is responsible for the coordination and management of joint initiatives between professional service providers, research projects and KovsieSport.

“The centre will also coordinate and manage joint initiatives between various academic programmes in different academic subject fields such as sports medicine, bio kinetics, physiotherapy, dietetics, etc. ,” said Prof Verschoor.

These initiatives will help the UFS to become a centre and catalyst of sports development, to become internationally recognised in the field of exercise and sports science research and to become a centre for high quality sports performance enhancement.

Some of the objectives of the CESSS are:

To provide sports science services like to athletes, students, the general public and other stakeholders including certain national sport teams.
To provide the necessary teaching and training facilities and internship opportunities for UFS students in sports related fields of study will also be provided by the centre like human movement science.
To present skills-transfer programmes directed at the broader community like development of skills in various sporting codes.
To continue and extend the current chronic risk reversal programmes presented by the Department of Human Movement Science such as obesity management, cardiac rehabilitation and other lifestyle related conditions.

The centre was founded in 2003 and was until now managed by Dr Louis Holtzhausen, from Kovsie Health and a consultant, Dr Gary Vorster.

A contract formalizing the appointment of Sports Plan (Pty) Ltd was signed today by Prof Verschoor and Mr Morne du Plessis in the historic Main Building of the UFS Bloemfontein campus.

The manager of the centre appointed by Sports Plan (Pty) Ltd is Mr Charles Store, an alumnus of the UFS, previously employed at the Sports Science Institute in Cape Town and by the SANDF at 3 Military Hospital, Bloemfontein.

Media release
Issued by: Anton Fisher
Director: Strategic Communication
072-207-8334
12 October 2005

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