Major Depression and Stigma among Individuals with Multidrug-Resistant Tuberculosis in South Africa

Mental Health Impacts of Multidrug-Resistant Tuberculosis in Patients and Household Contacts: A Mixed Methods Study

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) patients experience disproportionately worse mental health, with implications for adherence, outcomes, and families. Comprehensive assessments of comorbid depression/anxiety and related factors remain limited.

OBJECTIVE

This study aimed to assess the prevalence, predictors, and qualitative experiences of depression and anxiety in MDR-TB patients and household contacts.

METHODS

A sequential explanatory mixed methods study was conducted in Gujarat, India, with 403 smear-positive MDR-TB patients and 403 contacts. The quantitative phase administered structured questionnaires on sociodemographic factors, clinical history, depression/anxiety symptoms, and psychosocial stressors (like stigma and social support). Logistic regression models were used. The qualitative phase included in-depth interviews with 30 purposively sampled patients for thematic content analysis. Results were integrated to contextualize quantitative findings.

RESULTS

High rates of depression (37.5%, n = 151) and anxiety (45.2%, n = 182) were documented among the MDR-TB patients, significantly greater than household contacts (20.1%, n = 81 and 25.1%, n = 101, respectively). For depression, older age (adjusted odds ratio (AOR) 2.03, 95% CI 1.01-4.05), female gender (AOR 2.5, 95% CI 1.1-6.0), divorced/widowed status (AOR 3.8, 95% CI 1.1-8.0), financial constraints, substance abuse (AOR 1.7, 95% CI 1.1-2.7), greater disease severity (AOR 1.8, 95% CI 1.5-2.2), medication side effects (AOR 2.4, 95% CI 1.2-4.6), and perceived stigma (AOR 3.2, 95% CI 1.1-5.3) emerged as significant risk factors. For anxiety, significant predictors were less social support (AOR 0.81, 95% CI 0.71-0.86), higher perceived stigma (AOR 2.2, 95% CI 1.1-6.3), greater disease severity (AOR 2.6, 95% CI 1.3-4.0), and more medication side effects (AOR 3.3, 95% CI 1.1-5.5). Prominent themes included psychological impacts like depression and anxiety, experiences of stigma and caretaking challenges, and recommendations for comprehensive patient support services.

CONCLUSION

MDR-TB patients experience a substantially higher dual disease burden of depression and anxiety, elevating the risk for adverse outcomes and transmission. Improving psychosocial support is vital to patient-centric care pathways for vulnerable groups. Mixed methods provide comprehensive evidence to inform integrated physical and mental health services.

The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience

Drug-resistant tuberculosis (DR-TB) threatens to derail tuberculosis control efforts, particularly in Africa where the disease remains out of control. The dogma that DR-TB epidemics are fueled by unchecked rates of acquired resistance in inadequately treated or non-adherent individuals is no longer valid in most high DR-TB burden settings, where community transmission is now widespread. A large burden of DR-TB in Africa remains undiagnosed due to inadequate access to diagnostic tools that simultaneously detect tuberculosis and screen for resistance. Furthermore, acquisition of drug resistance to new and repurposed drugs, for which diagnostic solutions are not yet available, presents a major challenge for the implementation of novel, all-oral, shortened (6-9 months) treatment. Structural challenges including poverty, stigma, and social distress disrupt engagement in care, promote poor treatment outcomes, and reduce the quality of life for people with DR-TB. We reflect on the lessons learnt from the South African experience in implementing state-of-the-art advances in diagnostic solutions, deploying recent innovations in pharmacotherapeutic approaches for rapid cure, understanding local transmission dynamics and implementing interventions to curtail DR-TB transmission, and in mitigating the catastrophic socioeconomic costs of DR-TB. We also highlight globally relevant and locally responsive research priorities for achieving DR-TB control in South Africa.

Stigma and Associated Sex Disparities Among Patients with Tuberculosis in Uganda: A Cross-Sectional Study

Background

Tuberculosis (TB) is one of the leading causes of death from a single infectious agent globally. Stigma associated with TB encompassing self-, anticipated-, and public-stigma has significant negative effects on treatment adherence. In Uganda, limited data exist on the prevalence of stigma and its relationship with sex among patients with TB. We evaluate prevalence of three types of stigma and their relationship with the sex of patients undergoing TB treatment.

Methods

This cross-sectional study was conducted between July 2020 to March 2021 at selected TB clinics in Kampala, Uganda. Eligible participants were aged 18-65 with confirmed TB and starting their prescribed treatment. We collected data on socio-demographics and used 13 items to capture the self-, anticipated-, and public-stigma from which we composed the dependent variables. The primary independent variable was sex. We employed multivariable logistic regression analysis to evaluate the association between sex and the three stigma types. Additionally, we considered potential confounders such as age, HIV, and employment status. Statistical significance was defined as p<0.05.

Results

In this study we enrolled 144 participants with a mean age of 35.8 years (standard deviation = 12). Half of the participants (50%, n=72) were female, 44% had a secondary education, 37.5% were unemployed, and 32.6% were co-infected with HIV. The prevalence of self-stigma was 71.1%, anticipated stigma was 75.7%, and public stigma was 41.7%. Significant factors were associated with self-stigma were female sex (adjusted odds ratio (AOR): 2.35 95% CI: 1.02-5.74) and unemployment (AOR: 2.95 95% CI: 1.16-8.58). HIV-positive status was significantly associated with anticipated stigma (AOR: 3.58 95% CI: 1.38-11.23). However, none of the variables we evaluated showed a significant association with public stigma.

Conclusions

Our study showed a high prevalence of self, anticipated and public stigma among TB patients. Notably, females and unemployed individuals were at a higher risk of self-stigma, while those with HIV/AIDS and TB were more likely to report anticipated stigma. To combat stigma effectively, interventions should be tailored to cater to sex-specific needs and persons living with HIV. Future research should delve further in determinants of TB-related stigma in high-burden settings.

Adaptation and validation of a TB stigma scale for adolescents in Lima, Peru

BACKGROUND: TB-related stigma contributes to poor clinical outcomes and reduced wellbeing for affected individuals. Adolescents may be particularly susceptible to TB-related stigma due to their heightened sensitivity to peer acceptance, yet few studies have evaluated TB-related stigma in this group. Without a validated scale, it remains challenging to measure TB-related stigma in adolescents.METHODS: We adapted and validated the Van Rie TB Stigma Scale (VTSS) for adolescents on treatment for rifampicin-susceptible TB in Lima, Peru. The modified stigma scale was administered within a larger survey, which measured other psychosocial factors, including depression, adverse childhood experiences (ACEs), and social support. Data analysis included factor analysis, internal consistency, and convergent validity.RESULTS: From October 2020 to September 2021, 249 adolescents (individuals aged 10-19 years) completed the survey. Preliminary confirmatory factor analysis led to removal of two items. The final 10-item scale demonstrated good internal consistency (Cronbach's α = 0.82) and adequate model fit (χ²/df = 2.0; root mean square error of approximation: 0.06; comparative fit index: 0.94; Tucker-Lewis Index: 0.92: standardized root mean square residual: 0.05). Stigma was positively correlated with ACEs (γ = 0.13), depression (γ = 0.39), and suicidal ideation (γ = 0.27), and negatively correlated with social support (γ = -0.19).CONCLUSION: This adolescent TB stigma scale may serve as a practical tool to measure TB-related stigma and evaluate the impact of stigma-reduction interventions in adolescents.

Social distancing, community stigma, and implications for psychological distress in the aftermath of Ebola virus disease

Background

The 2013–2016 Ebola virus disease (EVD) epidemic resulted in more infections and deaths than all prior outbreaks in the 40-year history of this virus combined. This study examines how experiences of EVD infection, and preventive measures such as social distancing, were linked to experiences of stigma and social exclusion among those reintegrating into their communities.

Methods

Key informant interviews (n = 42) and focus group discussions (n = 27) were conducted in districts with a high prevalence of EVD and representing geographical and ethnic diversity (n = 228 participants). The final sample was composed of adults (52%) and children (48%) who were EVD-infected (46%) and -affected (42%) individuals, and community leaders (12%). Data were coded using a Grounded Theory approach informed by Thematic Content Analysis, and analyzed using NVivo. Interrater reliability was high, with Cohen’s κ = 0.80 or higher.

Findings

Participants described two main sources of EVD-related stress: isolation from the community because of social distancing and other prevention measures such as quarantine, and stigma related to infected or affected status. Participants linked experiences of social isolation and stigma to significant distress and feelings of ostracization. These experiences were particularly pronounced among children. Sources of support included community reintegration over time, and formal community efforts to provide education and establish protection bylaws.

Interpretation

This study found that social distancing and EVD-related stigma were each prominent sources of distress among participants. These results suggest that isolation because of infection, and the enduring stigmatization of infected individuals and their families, demand coordinated responses to prevent and mitigate additional psychosocial harm. Such responses should include close engagement with community leaders to combat misinformation and promote community reintegration.

Interventions pathways to reduce tuberculosis-related stigma: a literature review and conceptual framework

BACKGROUND

Prevention of tuberculosis (TB)-related stigma is vital to achieving the World Health Organisation's End TB Strategy target of eliminating TB. However, the process and impact evaluation of interventions to reduce TB-stigma are limited. This literature review aimed to examine the quality, design, implementation challenges, and successes of TB-stigma intervention studies and create a novel conceptual framework of pathways to TB-stigma reduction.

METHOD

We searched relevant articles recorded in four scientific databases from 1999 to 2022, using pre-defined inclusion and exclusion criteria, supplemented by the snowball method and complementary grey literature searches. We assessed the quality of studies using the Crowe Critical Appraisal Tool, then reviewed study characteristics, data on stigma measurement tools used, and interventions implemented, and designed a conceptual framework to illustrate the pathways to TB-stigma reduction in the interventions identified.

RESULTS

Of 14,259 articles identified, eleven met inclusion criteria, of which three were high quality. TB-stigma reduction interventions consisted mainly of education and psychosocial support targeted predominantly toward three key populations: people with TB, healthcare workers, and the public. No psychosocial interventions for people with TB set TB-stigma reduction as their primary or co-primary aim. Eight studies on healthcare workers and the public reported a decrease in TB-stigma attributed to the interventions. Despite the benefits, the interventions were limited by a dearth of validated stigma measurement tools. Three of eight studies with quantitative stigma measurement questionnaires had not been previously validated among people with TB. No qualitative studies used previously validated methods or tools to qualitatively evaluate stigma. On the basis of these findings, we generated a conceptual framework that mapped the population targeted, interventions delivered, and their potential effects on reducing TB-stigma towards and experienced by people with TB and healthcare workers involved in TB care.

CONCLUSIONS

Interpretation of the limited evidence on interventions to reduce TB-stigma is hampered by the heterogeneity of stigma measurement tools, intervention design, and outcome measures. Our novel conceptual framework will support mapping of the pathways to impacts of TB-stigma reduction interventions.

Risk Factors for Depression in Tuberculosis Patients: A Meta-Analysis

Purpose

Tuberculosis (TB) is a life threatening global infection. However, not only does TB have a high global prevalence, but it is also associated with several comorbidities. Depression is one of the most common and lethal comorbidities of TB patients. Therefore, in order to prevent depression in TB patients more effectively, it is necessary to investigate the factors associated with depression in TB patients by studying the pooled effect of each factor statistically. By concluding the associated factors through statistical analysis, it not only offers accurate guidance for further studies about programs targeted at preventing depression in TB patients, but provides health-care workers useful suggestions and warnings when treating TB patients.

Methods

We searched the published literatures from PubMed, Web of Science, EMBASE, and Cochrane Library to collect studies. The meta-analysis included articles from observational studies, including cross-sectional studies, cohort studies and case control studies that had information about factors associated with depression in tuberculosis patients. When the heterogeneity is defined as significant (I2>50%), a random-effect model with 95% confidence interval (CI) was used to estimate risk factors; otherwise, a fixed-effect model was used to combine the effect. A sensitivity test was conducted to examine which one of the studies may have potential bias that can affect the validity and reliability of the result. The funnel plots and Begg's and Egger's statistical tests were performed to assess the publication bias. Subgroup analysis was performed according to the prespecified variables in each group.

Results

Totally, 25 studies were included in the meta-analysis. The studies were conducted in various countries around the world between 2011 and 2021, representing the situation in the previous ten years. The final associated factors include female gender [OR=1.319, 95% CI=1.132-1.536, p<0.001], poor social support [OR=4.109, 95% CI=1.431-11.799, p<0.01], marriage status [OR=1.362, 95% CI=1.154-1.608, p<0.001], low education level [OR=1.921, 95% CI=1.475-2.503, p<0.001], residence in rural areas [OR=1.408, 95% CI=1.122-1.767, p<0.01], retreatment status [OR=2.515, 95% CI=1.226-5.159, p<0.01], and having perceived stigma[OR=4.131, 95% CI=1.412-12.088, p<0.05].

Conclusion

Depression prevention programs targeted at women TB patients are supposed to be carried out. Patients in retreatment status are supposed to be paid more attention of their psychological health by caring about their mental status. More social support is ought to be given to tuberculosis patients to reduce their chance of getting depressed. It is necessary to provide patients with a lower education level with psychological related courses to help them learn about their mental status. For patients living in rural areas, governments are supposed to offer psychotherapy for treatment as well as enhancing living condition. Suitable psychotherapy programs and plans is ought to be studied to eradicate perceived stigma of TB patients.

Practical and psychosocial challenges faced by caregivers influence the acceptability of multidrug-resistant tuberculosis preventive therapy for young children

Drug-resistant (DR) strains of Mycobacterium tuberculosis (M. tb) are increasingly recognised as a threat to global tuberculosis (TB) control efforts. Identifying people with DR-TB exposure/ infection and providing TB preventive therapy (TPT) is a public health priority. TB guidelines advise the evaluation of household contacts of newly diagnosed TB cases, with the provision of TPT to vulnerable populations, including young children (<5 years). Many children become infected with TB through exposure in their household. Levofloxacin is under evaluation as TPT in children exposed to M. tb strains with resistance to rifampicin and isoniazid (multidrug-resistant TB; MDR-TB). Prior to opening a phase 3 prevention trial in children <5 years exposed to MDR-TB, the pharmacokinetics and safety of a novel formulation of levofloxacin given daily was evaluated as part of a lead-in study. We conducted an exploratory qualitative study of 10 caregivers' experiences of administering this formulation. We explored how the acceptability of levofloxacin as TPT is shaped by the broader impacts of MDR-TB on the overall psychological, social, and financial wellbeing of caregivers, many of whom also had experienced MDR-TB. Caregivers reported that the novel levofloxacin formulation was acceptable. However, caregivers described significant psychosocial challenges in the process of incorporating TPT administration to their children into their daily lives, including financial instability, withdrawal of social support and stigma. When caregivers themselves were sick, these challenges became even more acute. Although new child-friendly formulations can ameliorate some of the pragmatic challenges related to TPT preparation and administration, the overall psychosocial burden on caregivers responsible for administering TPT remains a major determinant of effective MDR-TB prevention in children.