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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 research sheds light on service delivery protests in South Africa

2015-01-23

UFS research sheds light on service delivery protests in South Africa

Service delivery protests in the country have peaked during 2014, with 176 major service delivery protests staged against local government across South Africa.

A study by the University of the Free State (UFS) found that many of these protests are led by individuals who previously held key positions within the ANC and prominent community leaders. Many of these protests involved violence, and the destruction had a devastating impact on the communities involved.

This study was done by Dr Sethulego Matebesi, researcher and senior lecturer at the UFS. He focused his research on the dynamics of service delivery protests in South Africa.

Service delivery protests refer to the collective taken by a group of community members which are directed against a local municipality over poor or inadequate provision of basic services, and a wider spectrum of concerns including, for example, housing, infrastructural developments, and corruption.

These protests increased substantially from about 10 in 2004 to 111 in 2010, reaching unprecedented levels with 176 during 2014.

The causes of these protests are divided into three broad categories: systemic (maladministration, fraud, nepotism and corruption); structural (healthcare, poverty, unemployment and land issues); and governance (limited opportunities for civic participation, lack of accountability, weak leadership and the erosion of public confidence in leadership).

In his research, Dr Matebesi observed and studied protests in the Free State, Northern Cape and the North-West since 2008. He found that these protests can be divided into two groups, each with its own characteristics.

“On the one side you have highly fragmented residents’ groups that often use intimidation and violence in predominantly black communities. On the other side, there are highly structured ratepayers’ associations that primarily uses the withholding of municipal rates and taxes in predominantly white communities.”

Who are the typical protesters?

Dr Matebesi’s study results show that in most instances, protests in black areas are led by individuals who previously held key positions within the ANC - prominent community leaders. Generally, though, protests are supported by predominantly unemployed, young residents.

“However, judging by election results immediately after protests, the study revealed that the ANC is not losing votes over such actions.”

The study found that in the case of the structured ratepayers’ associations, the groups are led by different segments of the community, including professionals such as attorneys, accountants and even former municipal managers.

Dr Matebesi says that although many protests in black communities often turned out violent, protest leaders stated that they never planned to embark on violent protests.

“They claimed that is was often attitude (towards the protesters), reaction of the police and the lack of government’s interest in their grievances that sparked violence.”

Totally different to this is the form of peaceful protests that involves sanctioning. This requires restraint and coordination, which only a highly structured group can provide.

“The study demonstrates that the effects of service delivery protests have been tangible and visible in South Africa, with almost daily reports of violent confrontations with police, extensive damage to property, looting of businesses, and at times, the injuring or even killing of civilians. With the increase of violence, the space for building trust between the state and civil society is decreasing.”

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