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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 receives R13,7 Million for Research into Prehistoric Organisms

2007-03-27

Some of the guests attending the launch of the research contract are: Dr Siyabulela Ntutela (Deputy Director: Biotechnology at the Department of Science and Technology), Dr Godfrey Netswera (Manager of Thuthuka and the Support Programme at the National Research Foundation (NRF)), Dr Esta van Heerden (Platform Manager and lecturer at the Department of Microbial, Biochemical and Food Biotechnology at the UFS), Mr Butana Mboniswa (Chief Executive Officer of BioPAD), and Mr Vuyisele Phehani (Portfolio Manager for BioPAD).
Photo: Leonie Bolleurs

The University of the Free State (UFS) has been awarded a massive R13,7 million contract to conduct research into prehistoric micro-organisms which live under extreme conditions, for example in mineshafts.

This is one of the biggest research contracts awarded to the UFS in recent years.

The biotechnology research contract was awarded to the UFS by BioPAD, a South African biotechnology company that brokers partnerships between researchers, entrepreneurs, business, government and other stakeholders to promote innovation and create sustainable biotechnology businesses.

The project is endorsed by the Department of Science and Technology and the National Research Foundation (NRF), which contributes to the bursaries of the 17 postgraduate students on the programme.

The contract involves the establishment of a Platform for Metagenomics - a technique which allows researchers to extract the DNA from microbes in their natural environment and investigate it in a laboratory.

“Through this platform we will be able to understand deepmine microbial populations
and their potential application in the search for life in outer space. It is most likely
that, if life were to be found on other planets in our solar system, it would probably
resemble that which existed millions of years ago on earth. Apart from all this, these
organisms have unique properties one can exploit in biotechnological application for
South Africa and its community,” said Dr Esta van Heerden, platform manager and
lecturer at the UFS Department of Microbial, Biochemical and Food Biotechnology.
She is assisted by her collegues, Prof. Derek Litthauer and Dr Lizelle Piater.

“The platform aims to tap into the unique genetic material in South African mines
which will lead to the discovery of new genes and their products. These new and unique products will find application in the medical field (anti-cancer, anti-bacterial en anti-viral cures), the industrial sector (nanotechnology, commercial washing agents and the food industry), environmental sector (pollution management, demolition of harmful metals and other toxic waste),” said Dr Van Heerden.

According to Dr Van Heerden, the Metagenomics Platforms stems from the Life in
Extreme Environments (LExEN) programme which was started in 1994 by Princeton
University in the United States of America (USA) in South African mines with grants
from among others the National Aeronautics and Space Administration (NASA) and
the National Science Foundation (NSF) in the USA. Other international collaborators
on the project include Geosynec Consultants Inc. (USA), Oak Ridge National
Laboratory (USA), the University of Tennessee (USA) and in South Africa the
Universities of the Witwatersrand, North West and Limpopo and companies like BHP
Billiton, MINTEK and mining companies like Harmony, Gold Fields and AngloGold
Ashanti.

The research field laboratory of the Metagenomics Platform, which was situated in
Glen Harvey, was moved to the Main Campus of the UFS in Bloemfontein. “In this
way the university has become the central hub for all research programmes. We are
also the liaison between the LExEN programme and the various mining companies
involved,” said Dr Van Heerden. The new laboratory was introduced during the
launch of the research contract.

“Our decision to commit BioPAD to this project stems from the company’s commitment to advance human capacity development to strengthen South Africa’s research infrastructure. It is also part of our aim to create and protect intellectual property,” said Mr Butana Mboniswa, Chief Executive Officer of BioPAD.

Talking on behalf of the UFS senior management, Prof. Teuns Verschoor, Vice-Rector
of Academic Operations, said that the university shares the excitement to be part of
the exploration of unknown forms of life, the discovery of new genes and
their products and in applying newly gained knowledge to better understand our
universe.

Media release
Issued by: Lacea Loader
Assistant Director: Media Liaison
Tel: 051 401 2584
Cell: 083 645 2454
E-mail: loaderl@ufs.ac.za
27 March 2007

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