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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

Moshoeshoe Memorial Lecture to focus on Leadership challenges

2006-03-27

Lecture to focus on Leadership challenges

n Thursday 25 May 2006 – Africa Day – the University of the Free State (UFS) will host the inaugural King Moshoeshoe Memorial Lecture in honour of this great African leader and nation-builder.

Prof Njabulo Ndebele, internationally renowned writer and academic, and Vice-Chancellor of the University of Cape Town (UCT), will deliver the inaugural lecture at the Main Campus in Bloemfontein on the topic: Reflections on the Leadership Challenges in South Africa.

“I see the lecture as part of a larger debate on leadership models, particularly the concept of African leadership, as well as the ongoing discourse about nation-building and reconciliation,” says Prof Frederick Fourie, Rector and Vice-Chancellor of the UFS.

According to Prof Fourie, the Moshoeshoe project was launched at the UFS in 2004 to coincide with South Africa’s first decade of democracy and was part of the University’s centenary celebrations, having been founded in 1904.

“Through this project the UFS seeks to honour a great African leader and demonstrate our commitment to transformation so as to create a truly inclusive and non-racial university,” said Prof Fourie.

“As the founder of the Basotho nation, King Moshoeshoe is widely credited for his exceptional style of leadership, displaying the characteristics of diplomacy, reconciliation and peaceful co-existence in his efforts to unite diverse groups into one nation,” said Prof Fourie.

As part of its ongoing Moshoeshoe project, the UFS commissioned a television documentary programme on the life and legacy of King Moshoeshoe. This was completed in 2004 and broadcast on SABC 2 later that year.

For further information, Me Tumi Tabane can be contacted at (051) 401-2828 or tabaneme.stg@mail.uovs.ac.za.

Abridged curriculum vitae of Njabulo S Ndebele

Professor Njabulo S Ndebele is currently Vice-Chancellor and Principal of UCT.

Njabulo Ndebele began his term of office at UCT in July 2000, following tenure as a scholar in residence at the Ford Foundation’s headquarters in New York. He joined the Foundation in September 1998, immediately after a five-year term of office as Vice-Chancellor and Principal of the University of the North in Sovenga, at the then Northern Province. Previously he served as Vice-Rector of the University of the Western Cape. Earlier positions include Chair of the Department of African Literature at the University of the Witwatersrand; and Pro-Vice-Chancellor, Dean, and Head of the English Department at the National University of Lesotho.

An established author, Njabulo Ndebele recently published a novel The Cry of Winnie Mandela to critical acclaim. An earlier publication Fools and Other Stories won the Noma Award, Africa’s highest literary award for the best book published in Africa in 1984. His highly influential essays on South African literature and culture were published in a collection Rediscovery of the Ordinary.

Njabulo Ndebele served as President of the Congress of South African Writers for many years. As a public figure he is known for his incisive insights in commentaries on a range of public issues in South Africa. He holds honorary doctorates from Universities in the Netherlands, Japan, South Africa and the United States of America. He is also a Fellow of UCT.

Njabulo Ndebele is also a key figure in South African higher education. He has served as Chair of the South African Universities Vice-Chancellor’s Association from 2002-2005, and served on the Executive Board of the Association of African Universities since 2001. He has done public service in South Africa in the areas of broadcasting policy, school curriculum in history, and more recently as chair of a government commission on the development and use of African languages as media of instruction in South African higher education. He recently became President of the Association of the AAU and Chair of the Southern African Regional Universities Association (SARUA).

Media release
Issued by: Lacea Loader
Media Representative
Tel: (051) 401-2584
Cell: 083 645 2454
E-mail: loaderl.stg@mail.uovs.ac.za
26 March 2006

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