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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

Walk to Cape Town closes on high note

2014-06-03

Photo Gallery of arrival in Cape Town
Dagbreek interview (kykNet) (YouTube)
Thank you from all UFS students (YouTube)

It was a gruelling road totalling a distance of 1 038 km, but the UFS #NSHstride team completed the challenge of walking all the way to Cape Town.

On Thursday 1 May 2014, Adéle van Aswegen and Ntokozo Nkabinde, both from the UFS, took on the road to Cape Town on foot in order to highlight the problem of food insecurity among students at the UFS.

Two kind-hearted Bloemfontein residents, Nico Piedt and Ronél Warner, tackled the journey together with them, not only to draw the country’s attention to food insecurity, but also to raise money to address the problem.

The hike, known as the No Student Hungry 1000/33 stride (or #NSHstride), came to an end at the St George’s Cathedral in Cape Town on Tuesday 3 June 2014.

About R500 000 were raised before, during and after the foursome’s hike.

The NSH bursary, established in 2011 by Prof Jonathan Jansen, the Vice-Chancellor and Rector of the UFS, and Rudi Buys, Dean of Student Affairs, aims to put food insecurity among students at the UFS under the spotlight.

Rudi Buys, Dean of Student Affairs, says: “We are completely inspired by the victory of a 1 000 km with one step at a time – as it reminds us of the courage of our students who beat hunger one day at a time.”

“The stride team challenges us to change our world for the better every day. We hope to continue their victory for students by challenging all universities to join the struggle for food security and will call a colloquium in this regard in October.”

These boots are made for walking ... to Cape Town (Article of 02 May 2014)
“Aren’t auntie and them hungry yet?” Country folk worried about NSH hikers (15 May 2014)
UFS hikers to Cape Town reflect on their journey (Article of 26 May 2014)

Daily updates:
(You can also follow us on @UFSweb for daily tweets)

Day 33: 2 June 2014
13:40
20 km
Sunset Beach, Cape Town

Day 32: 1 June 2014
16:05
26 km
Mervyn and Sanet Wessels, Belville

Day 31: 31 May 2014
16:31
39.6 km
Rhonell and Gavin Julain, Paarl

Day 30: 30 May 2014
14:00
16 km
Monte Rosa, Rawsonville

Day 29: 29 May 2014
13:16
31 km
The Habit, Worcester

Day 28: 28 May 2014
11:00
22.4 km
Monte Roza, De doorns

Day 27: 27 May 2014
17:00
21.1 km
Karoo Hotel

Day 26: 26 May 2014
18:27
43.3 km
Tows river

Day 25: 25 May 2014
12:18
Lord Milner Hotel, Matjiesfontein

Day 24: 24 May 2014
16:30
42 km
Laingsburg Country Lodge

Day 23: 23 May 2014
17:32
41.8 km
Vergenoeg

Day 22: 22 May 2014
16:42
43 km
Assendelft Lodge and Bush Camp, Prins Albert

Day 21: 21 May 2014
15:09
42 km
Leeu Gamka Hotel

Day 20: 20 May 2014
13:39
20 km
Alida, Springfontein

Day 19: 19 May 2014
12:31
27.6 km
Teri Moja Game Lodge

Day 18: 18 May 2014
First rest day
Nagenoeg Guesthouse, Beaufort West

Day 17: 17 May 2014
19:30
62.3 km
Nagenoeg Guesthouse, Beaufort West

Day 16: 16 May 2014
13:00
14 km
Taaibochfontein

Day 15: 15 May 2014
16:03
32 km
Travalia, Three Sisters

Day 14: 14 May 2014
18:33
43 km
Joalani Guest Farm

Day 13: 13 May 2014
17:30
33 km
Die Rondawels

Day 12: 12 May 2014
16:49
40 km
Aandrus B&B in Richmond

Day 11: 11 May 2014
39 km
Wortelfontein (Magdel and Christiaan)

Day 10: 10 May 2014
15:44
34 km
Hanover Lodge

Day 9: 09 May 2014
40.8 km
Camping between Colesberg and Hanover

Day 8: 08 May 2014
15:25
33.7 km
Colesberg, The Lighthouse Guesthouse

Day 7: 07 May 2014
15:08
23 km
Orange River Lodge

Day 6: 06 May 2014
15:57
51.06 km
Gariep Forever Resort

Day 5: 05 May 2014
12:18
28 km
Rondefontein

Day 4: 04 May 2014
15:27
35 km
Trompsburg: Fox Den

Day 3: 03 May 2014
17:30
46.74 km
Edenburg Country Lodge (Hotel)

Day 2: 02 May 2014
11:44 am
15.3 km
Tom's Place

Day 1: 01 May 2014
32 km
Leeuwberg

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