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Dr Denise Evans is a Principal Researcher at the Health Economics and Epidemiology Research Office (HE2RO), based in Johannesburg, South Africa. She has more than 10 years of research experience focused on optimising HIV, TB and drug-resistant TB treatment outcomes.
Depression, with a lifetime global prevalence of 12.9 percent, is the most prevalent disorder worldwide. It affects women and those that reside in low- and middle-income countries (LMICs) disproportionately (ref 1) and is often a co-morbid condition with other diseases, such as tuberculosis (TB). The prevalence of TB and mental illness in LMICs can be as high as 70 percent (ref 2). Many of those with co-morbid TB and depression are not diagnosed correctly and/or do not receive effective care. Global plans to end TB emphasize that both a person-centred-approach and social support are important for maximizing TB treatment success, but specific recommendations for providing integrated care for TB and co-morbid depression are lacking.
Comorbid TB and mental health
Mental health disorders, social stress, and poor health-related quality of life (HRQOL) are commonly reported among people with TB. One in four people with multidrug-resistant TB (MDR-TB) experience depression (25 percent) or anxiety (24 percent), and one in ten suffer psychosis (10 percent) (ref 3). MDR-TB patients report lower physical (PCS) and mental (MCS) component summary scores compared to healthy adults or those with drug-susceptible TB, with or without HIV coinfection (ref 4). Comorbid depression and anxiety, which are often associated with the more serious physical side effects experienced during the early months on TB treatment, can substantially impact the person’s quality of life4. If left untreated, comorbid depression and anxiety are associated with reduced TB treatment adherence, an increased risk of default, transmission to others, drug resistance, and mortality (ref 5).
In an ongoing observational TB cohort in four African countries, we have also observed a high prevalence of depression and anxiety at the start of drug-susceptible TB treatment. More than a third (33.8 percent) of patients starting TB treatment report any form of depression or anxiety, with one in ten experiencing severe psychological distress (9 percent) at the start of TB treatment. We have observed that while psychological distress and HRQOL improves with each month on TB treatment, there are still patients who continue to report a low MCS and psychological distress after treatment completion. Disability evaluated only during the episode of TB is likely to underestimate total disability-adjusted life years associated with the episode and therefore the overall burden of disease, by ignoring disability before or after treatment.
Integration of TB and mental health care services
Potential solutions to support patients through the entire continuum of care, and beyond, need to consider a person-centred-approach to integrating TB and mental health services. Integrating mental health services into TB programmes requires sufficient financial and human resources, which are often lacking in LMICs. To overcome this, countries could consider training non-specialists to screen and care for patients with mental health disorders (ref 6).
Integrating TB and mental health in primary health care, rather than specialist settings, has been identified as a potential solution to reduce costs of mental health care, increase its quality, maintain social integration, and promote better health outcomes (ref 7). Ambulatory primary health care services should consider a number of requirements for successful programmes, including 1) community involvement in planning, implementing, and monitoring health services; 2) a skilled multidisciplinary team of health care workers, including mental health nurses who can provide comprehensive care; 3) the integration of mental health services with other acute and chronic disease services; 4) clear referral systems; 5) outreach services to improve accessibility of services; and 6) improved communication between health care workers and patients so that patients can better understand and manage their mental health conditions (ref 8).
The COVID-19 pandemic and subsequent restrictions on movement imposed by lockdowns have not only had a significant impact on TB programmes but have also threatened the mental health of patients and health care workers alike. When considering ways to support mental wealth and psychological well-being of people with TB, it is important to consider not only the people and their families but also healthcare workers who provide services for a multitude of conditions, including TB and mental health. The COVID-19 pandemic has taught us to think outside the box and change the way services are delivered (e.g., telemedicine or eHealth, video consultations) to meet patient needs and reduce the burden on under-resourced healthcare systems. These may just become the new “best practices”.
Join the Union webinar TB and Mental Health: An overview on the 9 October, where panellists will discuss the psychological support for people with TB, patient support interventions for LMICs and how leadership can advocate for and invest in integrating mental health and TB services in primary care.
- Lim G Y, Tam W W, Lu Y, Ho C S, Zhang M W, Ho R C. Prevalence of depression in the community from 30 countries between 1994 and 2014. Sci Rep 2018; 8: 2861.
- Doherty A M, Kelly J, McDonald C, O’Dwyer A M, Keane J, Cooney J. A review of the interplay between tuberculosis and mental health. Gen Hosp Psychiatry 2013; 35: 398–406.
- Alene KA, Clements ACA, McBryde ES, Jaramillo E, Lönnroth K, Shaweno D, Gulliver A, Viney K. Mental health disorders, social stressors, and health-related quality of life in patients with multidrug-resistant tuberculosis: A systematic review and meta-analysis. J Infect 2018; 77(5):357-367.
- Sineke T, Evans D, Schnippel K, et al. The impact of adverse events on health-related quality of life among patients receiving treatment for drug-resistant tuberculosis in Johannesburg, South Africa. Health Qual Life Outcomes. 2019;17(1):94.
- Ambaw F, Mayston R, Hanlon C, Medhin G, Alem A. Untreated depression and tuberculosis treatment outcomes, quality of life and disability, Ethiopia. Bull World Health Organization. 2018; 96:243-255
- Walker IF, Kanal S, Baral SC, Farragher TM, Joshi D, Elsey H, Newell JN. Depression and anxiety in patients with MDR-TB in Nepal: an observational study. Public Health Action. 2019; 9(1):42-48
- Sweetland AC, Jaramillo E, Wainberg ML, Chowdhary N, Oquendi MA, Medina-Marino A. Tuberculosis: an opportunity to integrate mental health services in primary care in low-resource settings. The Lancet Psychiatry. 2018; 5(2): 952-954
- AfroPHC Workshop. Day 1. BS Nsibandze. Community expectations from ambulatory primary health care service delivery in Africa. https://afrophc.org/afrophc-workshop/workshop-videos/