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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

Getting out of the dark

2015-06-10

ESKOM is making daily announcements on the status of the power grid.

Anton Calitz, Electrical Engineer at University Estates, is in continuous contact with Eskom and Centlec in an effort to stay abreast of load shedding.

According to Anton, Eskom has recently - the week of 20 April - been focusing on the evening peak, and has announced STAGE 1 load shedding from 17:00-22:00; thus, the Bloemfontein Campus should be able to continue business as usual during the day, except for Thursdays from 18:00 and, possibly, Fridays from 17:00.

Where can I get more information about load shedding stages?

Apart from Eskom’s webpage, staff can also visit GRID WATCH. Click on "Search", then under "Schedules". Look for "Mangaung Local Municipality", and select "GROUP 4". Save this location. “This can even be loaded onto your mobile device.”

“The time slots can be seen for a couple of days in advance, to allow us to plan around the possibility of load shedding in our daily lives,” said Anton.

Please note: ESKOM can change the STAGE level at any time. Therefore, keep an eye on GRID WATCH and News24.

View the typical seven-day planner for the Bloemfontein Campus (Group 4), which indicates the STAGE 2 and 3 possibilities. Take note that, on some days, the STAGE 2 and 3 time slots are the same.

More load shedding tips: Your IT needs

The UFS Data Centre (Computer Room) is fully serviced by a generator facility, and can function without external power supply for a few days.

The generator servicing the UFS data centre does NOT provide power to the outlying facilities. This implies that all digital equipment at gates, booms, and access points will be shut down until the power is restored to these facilities. “We are now, in collaboration with Nico Janse van Rensburg, in a process to install UPS facilities at these points, which will ensure two to three hours of power supply at these points, even during load shedding,” said Dr Vic Coetzee, Senior Director: ICT Services.

No Wi-Fi will be available, as it is dependent on the power supply to the buildings where it is installed.

All servers are contained in the data centre, and will be kept running by our generators.

How to manage load shedding and your IT needs:

1. Get into the habit of saving your work regularly on computer so that you don’t lose your work/files during load shedding.
2. Back up important data. Keep to a schedule of regular back-up. Make sure your computer back-ups are safe and recoverable.
3. Keep all electronic devices charged and ready to run on battery power. Keep your cellphone charged: some old-style Telkom landlines will still operate during power outages, but others won't.
4. Remember, when power supply is restored, it sometimes happens that a power surge is sent through the network, which will damage your computer. Fortunately, laptop computers will not suffer this fate as their power is provided through an external power pack. Often, this power pack will be damaged, but not the laptop itself.
5. It makes good sense to reboot your computer daily, not only in terms of power shedding, but also in terms of updating the drivers, software, etc.
6. Switch off all computers and other electrical equipment at the wall plug overnight and on weekends.
7. Should your IT equipment not switch on after a power outage, log a call with the ICT Services. You can also call them at x2000.

More information, guidelines and contact numbers

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