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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.

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New SRC: Records of support and a victory for women

2014-09-04

Ms Mosa Leteane and Ms Louzanne Coetzee
Photo: Johan Roux

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While campuses across South Africa regularly report falling voter turnout in campus elections of student representatives, the University of the Free State, in its recently completed SRC elections, registered record levels of support across our campuses with a total voter turnout of 44%. At the Bloemfontein Campus 34,4% of students voted (5052 votes) and 53,3% (1583 votes) at the Qwaqwa Campus.

Also, for the first time under the new SRC constitution, students elected a woman to lead the student body – Ms Mosa Leteane was elected as President. Another first was the election of a blind woman to the SRC – Ms Louzanne Coetzee. She will be responsible for student accessibility of our Bloemfontein SRC. This marks a victory for women in student governance.

Mr Tulasizwe Sithole was elected as the President of the SRC at our Qwaqwa Campus.

The election of Ms Leteane as President underscores the progress achieved for gender equality with near half of her SRC consisting of women (48%).

These successes are all the more significant, since this is the 4th year of elections under newly adopted SRC constitutions that allow for broader participation of diverse student constituencies in student governance.

This means that the crucial 3-year mark to test a new approach and method in governance and elections was not only successfully reached, but also in its 4th year shows the constitution as one that sustains its impact to deepen democracy and citizenship among our 30,000-strong student body.

“The results of the SRC elections across campuses show that our students are not only ready to lead our campus communities on issues relating to justice, freedom and democracy beyond our societal legacies of race and gender, but do so also for the student movement nationally. We’re immensely proud of our students, who show courage and resilience to choose leaders not for expediency, but for significance, and to lead not for some, but for all”, the Dean of Student Affairs, Rudi Buys, said.

The Qwaqwa SRC was installed on 2 September 2014, while the Bloemfontein SRC will be installed on 5 September. The Central SRC will be established on 14 September by joint sitting of the two SRCs.

The SRC members 2014/15 at the Bloemfontein and Qwaqwa Campuses are as follows:

Bloemfontein Elective portfolios:
President: Ms Mosa Leteane
Vice Pres: Mr Waldo Staude
Secretary: Ms Dineo Motaung
Treasurer: Ms Maphenye Maditsi
Arts & Culture: Mr Stefan van der Westhuizen
Accessibility & Student Support: Ms Louzanne Coetzee
First Generation Students: Ms Mpho Khati
Media, Marketing & Liaison: Ms Lethabo Maebana
Legal & Constitutional Affairs: Mr Lindokuhle Ntuli
Sport: Ms Dominique de Gouveia
Student development & Environmental Affairs: Mr Victor Ngubeni
Transformation: Mr Tumelo Rapitsi

Bloemfontein Ex officio Portfolios
Dialogue & Ex officio: Associations Student Council: Mr Piet Thibane
Academic Affairs & Ex officio: Academic Affairs Student Council: Mr Jonathan Ruwanika
Residence Affairs & Ex officio: Campus Residences Student Council: Ms Melissa Taljaard
City student Affairs & Ex officio: Commuter Student Council: Ms Kerry-Beth Berry
Post graduate Affairs & Ex officio: Post Graduate Student Council: Ms Masabata Mokgesi
International Affairs & Ex officio: International Student Council: Mr Makate Maieane
Student Media Affairs & Ex officio: Student Media Council: Mr Samuel Phuti
RAG Community Service & Ex officio: RAG Fundraising Council: Mr Johan du Plessis
RAG Community Service & Ex officio: RAG Community Service Council: Mr Manfred Titus

Qwaqwa Elective portfolios:
President General: Mr Thulasizwe Sithole
Deputy President: Ms Zethu Mhlongo
Secretary General: Mr Vukani Ntuli
Treasurer General: Mr Langelihle Mbense
Media & Publicity: Ms Nongcebo Qwabe
Politics & Transformation: Ms Nkosiphile Zwane

Qwaqwa Ex officio Portfolios
Student Development & Environmental Affairs: Mr Ndumiso Memela
Academic Affairs: Mr Simon Mofekeng
Arts & Cultural Affairs: Ms Samkelo Mtshali
Off-Campus Students: Mr Khanyisani Mbatha
RAG, Community Service & Dialogue: Mr Njabulo Mabaso
Religious Affairs: Mr Mfundo Nxumalo
Residence & Catering Affairs: Ms Ntombifuthi Radebe
Sports Council: Mr Luvuno

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