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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

Help to rural women to become entrepreneurs

2006-10-24

Some of the guests who attended the ceremony were, from the left: Mr Donray Malabie (Head of the Alexander Forbes Community Trust), Ms Jemina Mokgosi (one of the ladies from Tabane Village who is participating in the Women in Agriculture project), Dr Limakatso Moorosi (Head: Veterinary Services, Free State Department of Agriculture), Prof Johan Greyling (Head: UFS Department of Animal and Wildlife and Grassland Sciences) and Ms Khoboso Lehloenya (coordinator of the project from UFS Department of Animal and Wildlife and Grassland Sciences). Photo: Leonie Bolleurs\

Alexander Forbes and UFS help rural women to become entrepreneurs

Today, the Alexander Forbes Community Trust and the University of the Free State (UFS) joined forces to create an enabling environment for rural women to become players in the private sector.

Three years ago the UFS set up a unique small-scale household egg production project called Women in Agriculture in Thaba ‘Nchu as a pilot project. The project was officially launched today by Mr Donray Malabie, Head of the Alexander Forbes Community Trust.

The aim of the Women in Agriculture Project is to create jobs, provide food security and to help develop rural women into entrepreneurs. A total of 25 women based in Tabane Village in Thaba ‘Nchu are the beneficiaries of the project.

“This is the first project in the Free State the Alexander Forbes Community Trust is involved with. The project would help rural women acquire the skills they need to run their own egg-production business from their homes,” said Mr Malabie.

“The ongoing debate on the shortage of skills ignores the fact that people with little or no education at all also need training. This project is special to the Trust as it provides for the creation of sustainable jobs, food security and the transfer of much needed skills all at once, particularly at this level,” he said.

Every woman in the group started with two small mobile cages that housed 12 hens each. The units are low in cost, and made of commercially available welded mesh and a metal frame. Now, each woman has four cages with 48 hens. The group manages to collectively produce 750 eggs daily.

The eggs are currently sold to local businesses, including spaza shops and the women are using the income generated to look after their families and to further develop their business.

The Department of Animal and Wildlife and Grassland Sciences at the UFS identified the project and did the initial research into the feasibility of setting up such a project.

“A demonstration and training unit has been established at the Lengau Agricultural Development Centre and the women attended a short practical training course. Subsidies are provided for feeding, together with all the material and the lay hens necessary for the start of the business,” said Ms Khoboso Lehloenya, coordinator of the project from the Department of Animal and Wildlife and Grassland Sciences at the UFS.

“The advantage in using lay hens is that they are resistant to diseases and the women will not need electric heating systems for the egg production,” said Ms Lehloenya.

According to Ms Lehloenya, the women are already benefiting from their egg production businesses. “Some of them have used the profit to buy school uniforms and tracksuits for their children and others are now able to make a monthly contribution to their household expenses,” said Ms Lehloenya.
“In South Africa, possibly due to cultural reasons and circumstances, most black people prefer to eat older and tougher chickens, compared to younger soft commercially available broiler chickens. This preference creates a further advantage for the women. At the end of their production cycle, old hens can be sold for a higher price than point-of-lay or young hens. This brings in further money to pay for more hens,” said Ms Lehloenya.

The Alexander Forbes Trust contributed R191 000 towards the project aimed at expanding it to benefit 15 more women.

“We are in the process of recruiting an additional 15 women in Thaba ‘Nchu who will be trained by the Lengau Agricultural Development Centre in order to replicate the model and extend its reach”, said Ms Lehloenya.

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

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