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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

Kovsie artists to rock at Vryfees

2014-06-18

Photo: Conrad Bornman

It is the dead of winter in the heart of the Free State. The Vryfees is laying full steam ahead.

However, the talent that makes of this annual arts festival such a phenomenal success doesn’t only come from outside of our Bloemfontein Campus. This year’s productions will abound with performances by Kovsie staff, students and alumni from our Department of Drama and Theatre Arts.

Behind the scenes, our people will also play a vital role in the achievement and progress of the festival. Prof Luwes is a member of the festival committee and together with Dr Venter and Godfrey Manenye, he also serves on the artistic selection committee for theatre.

Thys Heydenrych, lecturer in the above department, was appointed as the technical manager of this year’s Vryfees. This means that he is in charge of the placement and assigning of venues for productions on campus. All the technical aspects for these venues rest on Heydenrych’s shoulders. For this huge task, he is supported by a team of technical staff which includes mostly students.

Take a look at the list of all our Kovsie artists who are working hard to make the 2014 Vryfees better than ever:

Don Juan onder die Boere
Lecturers: Walter Strydom, Gerben Kamper (director),
Students: Mark Dobson, Michael Garbett, Helet de Wet
Former students: Marijda Kamper (Wynand Mouton theatre manager), Ilne Fourie, Hilletje Möller, Chanmari Erasmus, Michelle Hoffman, An-Mari Loots, Madré van Straten

S(t)out en Peper
Lecturers: Dr Pieter Venter (director), Thys Heydenrych
Former students: Ilne Fourie, Michelle Hoffman

Nag van die Hiëna
Head of Department: Prof Nico Luwes (author and director)
Lecturers: Gerben Kamper, Minette Grové
Former students: Carel Nel, Lindy-Lee Kleynhans, Ilne Fourie, Angelo Mockie (staff member at Student Affairs)
Student: Peter Taljaard (PhD student)

Rondomskrik
Former student: Chrystal-Donna Roberts (currently Pasella presenter and previously on the set of 7de Laan)

Slaaf
Former student: Carel Nel

Te Veel vir ? Coloured Girl
Former students: Angelo Mockie (staff member at Student Affairs), Olivie Sauer

The Bar
Lecturer: Godfrey Manenye (director)
Former students: Angela Edwards, Jane Mpholo
Students: Yoliswa Jacobs and Luandro Carstens

Victoria se Geheim
Lecturer: Dr Pieter Venter (director)
Former students: Chanmari Erasmus, Carel Nel, Gené McCaskill, Michelle Hetzel
Students: Helet de Wet, Marli van der Bijl (NRF Magister Intern), Jana Coetzer, Marnel Bester

Een Kleine Lientjie
Lecturer: Walter Strydom
Former student: Anna Visser (author and director, OFM presenter)
Students: Marli van der Bijl, Charl Henning, Jana Coetzer

For more information on the productions or the Vryfees programme, follow this link:
http://www.vryfees.co.za/

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