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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

Multi-disciplinary research approach at UFS

2005-10-25

UFS follows multi-disciplinary research approach with opening of new centre

“A new way of doing business in necessary in the research and teaching of agriculture and natural sciences in South Africa. We must move away from departmentalised research infrastructures and a multi-disciplinary approach to research involving several disciplines must be adapted,” said Prof Herman van Schalkwyk, Dean: Faculty of Natural and Agricultural Sciences at the University of the Free State (UFS).

Prof van Schalkwyk delivered the keynote address during the launch of the Centre for Plant Health Management (CePHMa) at the Main Campus in Bloemfontein today (21 October 2005). CePHMa is an initiative of the UFS Department of Plant Sciences.

According to Prof van Schalkwyk a tertiary institution must practice multi-disciplinary research to be a world-class research institution. “It is difficult for researchers to admit that they do not know a lot about each other’s area of speciality. It is therefore necessary for researchers to make a paradigm shift and to focus on inter-disciplinary co-operation. To do this, we must encourage them to work together and to find a common language to communicate ideas en establish symbiotic relationships,” said Prof Van Schalkwyk.

“We tend to think that research is better and faster if it is specialised. This is not true. The new generation of scientists are young and they are trained to form a concept of the total system and not to focus on a specific area of speciality. At the UFS we encourage this approach to research. This was one of the main reasons for the establishment of CePHMa,” said Prof Van Schalkwyk.
CePHMa is the only centre of its kind in Africa and is established to extend the expertise in plant health management in South Africa and in Africa, to train experts in plant health and to conduct multi-disciplinary research about the health of agricultural crops.

“CePHMa is a virtual centre comprising of ten disciplines applicable to crop production and crop protection,” said Prof Wijnand Swart, Chairperson of CePHMa during the opening ceremony.

“The UFS is the leading institution in Africa in terms of news crop development and manages three research programmes that concentrate on new crops, i.e. the New Crop Pathology Programme, the New Crop Development Programme and the Insects on New Crops Programme. Other applied research programmes that are unique to the UFS are genetic resistance to rust diseases of small grain crops and sustainable integrated disease management of field crops,” said Prof Swart.

“Because the expected growth in population will be 80% in 2020 in sub-Saharan Africa, the future demands of food produce in Africa will be influenced. Therefore research will in future be focused on ways to improve food security by employing agricultural systems that are economically viable and environmentally sound,” said Prof Swart.

“Thorough knowledge of the concept of holistic plant health management is crucial to meet the challenge and it is therefore imperative that innovative crop protection and crop production strategies, with particular emphasis on plant health, be adopted. This is why the Department of Plant Sciences initiated the establishment of CePHMA,” he said.

According to Prof Swart there is a shortage of expertise in plant health management. “The UFS has shown the potential to address the demand of the sub-continent of Africa regarding expertise training and CePHMa is the leader in southern Africa to provide in this need,” he said.

The appropriateness and quality of training in plant health management is reflected in the fact that students from Ethiopia, Eritrea, Malawi, Uganda, Zambia, Ghana, Tanzania, Cameroon, Angola, Mozambique and Lesotho have already been trained or are in the process of being trained in at the UFS.

Scientists from CePHMa have forged partnerships with numerous national and international institutions including the Agricultural Research Council (ARC), various community trusts, seed, pesticide and agricultural chemical companies, in addition to overseas universities.

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

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