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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 takes lead in improving quality of training in economics in schools

2006-06-20

The fourth international workshop for trainers in the National Council on Economic Education’s (NCEE) outreach programme for Africa, Latin America, Asia and the Middle East will be presented in Bloemfontein from 18-24 June 2006.

“Because of the rapid success we achieved in the Free State with similar workshops in Economics education that were presented by the NCEE the past year, we have now invited representatives from education departments and universities of five other provinces to attend the international workshop for trainers,” said Prof Klopper Oosthuizen, lecturer at the University of the Free State’s (UFS) Department of Agricultural Economics and initiator of the cooperative agreement with the NCEE.

The UFS and the Free State Department of Education are the NCEE’s first partners in Africa who received this training. “The attendance of the five provinces and universities is the first step in the extension of the programme to the rest of the country,” said Prof Oosthuizen.

The NCEE is based in the United States of America (USA) and the workshop forms part of the council’s effort to improve the quality of the training of Economics teachers and lecturers across the world.

“South Africa is urgently in need of efforts to improve the integration of black people into the market economy. An understanding of how markets work is one of the pillars of democracy. Equipping young people with economic understanding and skills will help empower them for responsible roles as individuals and citizens,” said Prof Oosthuizen.

According to Prof Oosthuizen representatives from the education departments of the Northern Cape, Western Cape, Eastern Cape, KwaZulu-Natal and North West will also be attending the international workshop for trainers. Representatives from the Universities of Rhodes, of KwaZulu-Natal, North West and the Durban University of Technology as well as the Cape Peninsula University of Technology will also attend the workshop.

During this workshop teachers and lecturers in Economics will receive certificates.

Various subjects will be covered during the workshop such as world trade patterns, cost and benefits of free trade, exchange rates and international finance. The training will be done by representatives from the NCEE by using methods such as direct instruction and role play.

The NCEE is also in the process of training teachers and learning facilitators in the Free State in an effort to improve the quality of Economics classes in secondary schools.

“A group of 84 teachers and learning facilitators were trained in December 2005, 50 were trained in January 2006 and the last group of 40 will be trained at the UFS Main Campus in Bloemfontein from 26 June - 1 July 2006,” said Prof Oosthuizen.

During this seminar the teachers will be trained in issues such as broad social goals in an economy, economic decision making, government’s role in a market economy and fiscal policy. The training will also be done by representatives from the NCEE.

The NCEE has been working together with international partners since 1992 to strengthen their Economics teaching systems. They have already succeeded in increasing literacy in Economics at schools in the USA and more than 20 East Block countries. More than 1,5 million learners in the East Block countries have already been served by this initiative. Since 2004 the NCEE’s focus has moved away from the East Block countries to Africa, Asia, Latin America and the Middle East.

“Our future plans include strengthening the growing partnership between the UFS, the Free State Department of Education and the NCEE. We also want to establish a council and centres for economic education which will serve as an umbrella for our joint efforts,” said Prof Oosthuizen.

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

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