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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

Prof. Letticia Moja a winner in her category

2004-08-17

Prof. Moja a finalist in award
'Every member of staff is important to me'

Michelle Cahill - Bloemnuus

IF you are in need of a dose of inspiration, try and get an appointment with Prof. Letticia Moja, the Dean of the Faculty of Health Science at the University of the Free State. It will not be easy as she has an extremely tight schedule, over and above being a finalist in the 2004 Shoprite/Checkers Woman of the Year competition.

Although not a born and bred Free Stater, this dynamic woman has come to love the Free State. "Once you get past the mindset of a small town and all the negatives surrounding it, it is an absolutely wonderful experience," Moja said.

Moja was born in Pretoria and grew up in Garankuwa as the second eldest of five children. "That was nothing special. I was not the eldest and I wasn't the youngest," she quipped. She had two younger brothers, one of whom died in a car accident and then two sisters.

She went to school in Pretoria and her first contact with the Free State was when she wrote her matric at Moroka High School in Thaba Nchu. "That was one of the best schools for us at that time," she says. After completing matric, she went on to study medicine in KwaZulu-Natal.

In 1982 she returned "home" and completed her internship at the Garankuwa Hospital. Hereafter she specialised in gynaecological obstetrics at Medunsa.

She became the head of the gynaecological obstetrics unit and later opened a branch in Pietersburg.

"This was just about the most heart-rending time of my life. You saw people travelling for up to three days just to see a doctor," she says. "Here we really interacted with the community."

In 2001 she was invited by the University of the Free State to apply for the job of vice-dean of the Faculty of Health Science. "I wasn't too keen," she says, "but they kept on calling to find out if I had applied or not," she says with a smile. "Eventually I gave in and was appointed."

She thought she would work a couple of years under Prof. Kerneels Nel, then the dean of the faculty. "Unfortunately that was not to be. I had hoped that I could learn from him," Moja says.

Prof. Nel died of a heart attack in 2003 after which Moja deputised for him before being appointed as dean.

"This brought along a whole newset of challenges," she says, "Now I have to work out budgets and I need to know what human resources are," she jokes. This has prompted her to take up her studies again and she is currently doing her MBA.

"It has certainly been a challenge to go into management and without my support structure I most certainly wouldn't have been able to do it," Moja says.

Moja is actively involved in her church and serves on various committees including the Health Professional Council where she is acting president of the Medical and Dental Board and the Provincial Aids Council.

To her no job is menial. She recalls when she used to have "high tea" with her staff in Gauteng and Limpopo. "One of the cleaning ladies used to think her job was menial. That is just not so. No hospital can do without even the lowest position. Imagine stepping over rubbish while you're trying to catch a baby. To me everybody is important no matter what you do. "

Moja's eldest daughter is studying for her B.Accounting degree at Wits . Her youngest daughter is in Gr. 9 at Eunice and she has also brought along her niece, who is in Gr. 8 at Eunice. "You see, we need to be three girls in the house."
She feels honoured to have been nominated by the institution especially as it is traditionally male-dominated. "It is not about me, but about the support structure. Nobody can do it on their own. It is a team effort."
BLOEMNUUS - VRYDAG 9 JULIE 2004

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