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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 boasts with most advanced chemical research apparatus in Africa

2005-11-23

Celebrating the inauguration of the NMR were from the left Prof Frederick Fourie (Rector and Vice-Chancellor of the UFS), Dr Detlef Müller (Development Scientist and Manager: Africa and Asia of Bruker in Germany, the supplier of the NMR), Prof Jannie Swarts (head of the head of the Division Physical Chemistry at the UFS) and Prof Herman van Schalkwyk (Dean: Faculty of Natural and Agricultural Sciences at the UFS). Photo: Lacea Loader

UFS boasts with most advanced chemical research apparatus in Africa

The University of the Free State’s (UFS) Department of Chemistry now boasts with some of the most advanced chemical research apparatus in Africa after the latest addition, a nuclear magnetic resonance (NMR) spectrometer, was inaugurated today by the Rector and Vice-Chancellor, Prof Frederick Fourie. The NMR is used to analyse molecular structures.

Last month the Department of Chemistry celebrated the installation of the most advanced single crystal X-ray diffractometer in Africa. The diffractometer provides an indispensable technique to investigate among others the solid state of compounds for medicinal application.

“Three years ago the UFS executive management realised that, if we want to build a university of excellence, we should invest in research. We started to think strategically about chemistry and decided to bring the apparatus at the Department of Chemistry on a more competitive standard. Strategic partnerships were therefore secured with companies like Sasol,” said Prof Fourie during the inauguration ceremony.

“The installation of the NMR symbolises the ability of the UFS to turn academic areas around. I hope that this is the beginning of a decade of excellence for chemistry at the UFS,” said Prof Fourie.

”The catalogue value of the Bruker 600 MHz NMR is approximately R11 million. With such an advanced apparatus we are now able to train much more post-graduate students,“ said Prof Jannie Swarts, head of the Division Physical Chemistry at the UFS.

”The NMR is the flagship apparatus of the UFS Department of Chemistry that enables chemists to look at compounds more easily at a molecular level. Research in chemistry is critically dependent on NMR, which is a technique that can determine the composition of reactants and products in complicated chemical reactions, with direct application is most focus areas in chemistry,“ said Prof Swarts.

”Parts of the spectrometer consists of non-commercial items that were specifically designed for the UFS Department of Chemistry to allow the study of unique interactions in e.g. rhodium and platinum compounds,” said Prof Swarts.

According to Prof Swarts the NMR enables chemists to conduct investigations on the following:

To evaluate for example the complex behaviour of DNA in proteins as well as the analysis of illegal drugs sometimes used by athletes.
It provides an indispensable technique to investigate compounds for medicinal application for example in breast, prostate and related bone cancer identification and therapy, which are currently synthesised in the Department of Chemistry.
It can also be applied to the area of homogeneous catalysis where new and improved compounds for industrial application are synthesized and characterised, whereby Sasol and even the international petrochemical industry could benefit. This analytical capacity is highly rated, especially in the current climate of increased oil prices.
The NMR can detect and identify small concentrations of impurities in feed streams in the petrochemical industry, e.g. at Sasol and also the international petrochemical industry. These minute amounts of impurities can result in metal catalyst deactivation or decomposition and can cause million of rands worth in product losses.
It is indispensable for studying the complexity of samples that is non-crystalline. These materials represent the vast majority of chemical compounds such as solvents, gasoline, cooking oil, cleaning agents and colorants as examples.

According to Prof Swarts the general medical technique of MRI (magnetic resonance imaging) in use at larger hospitals, is based on NMR technology.

”The NMR apparatus enabled the Department of Chemistry to characterise complex molecules that were synthesised for the multi-national company, FARMOFS-PAREXEL, and to negotiate research agreements with overseas universities,” said Prof Swarts.

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

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