Integrating tuberculosis and mental health services: global receptivity of national tuberculosis program directors

Mental health issues associated with the management of tuberculosis in Homabay, Busia and Kakamega Counties, Kenya

BACKGROUND

Despite the implementation of patient-centred care, mental health issues remain a significant risk factor and comorbidity for Tuberculosis (TB) disease. Mental health issues being co-morbidities to TB are likely to increase the disease burden of the affected population. This study therefore investigated the prevalence and impact of mental health issues in Tuberculosis (TB) patients.

METHODS

This cross-sectional study design used mixed methods in data collection. The study used structured questionnaires, key informant interviews and focus group discussions. 127 TB patients were purposively selected from a group of patients who previously recovered successfully, with a history of relapse or are currently on TB treatment in high-volume facilities in Homa Bay, Busia and Kakamega Counties. 30 Key informant interviews were conducted with Healthcare workers. Quantitative data analysis was done using STATA version 14. Thematic analysis was employed to analyze qualitative data using NVivo version 10.

RESULTS

The findings showed that the most common mental health issues affecting TB patients were anxiety (66%) and depression (55%), which were commonly experienced during the presumptive stage of TB. Qualitative data revealed that stigma was the main barrier that hindered TB patients from accessing care. TB patients articulated the benefits of support structures ranging from positive encouragement, reminders on taking drugs, accompaniment to the clinic, and financial support in TB management. Furthermore, the study established that the majority of Health Care Workers (HCWs) were not prepared to handle TB patients' mental issues, a gap that is likely to impact the quality of care TB patients receive.

CONCLUSION

The study established that mental health issues impact TB treatment outcomes. Healthcare systems should prioritize the integration of mental health care into TB programs to address the high prevalence of mental health issues among TB patients.

Prioritizing Mental Health within HIV and Tuberculosis Services in PEPFAR

Underprioritization of mental health is a global problem and threatens the decades-long progress of the US President's Emergency Plan for AIDS Relief (PEPFAR) program. In recent years, mental health has become globally recognized as a part of universal healthcare, making this an opportune moment for the global community to integrate mental health services into routine programming. PEPFAR is well positioned to lead by example. We conceptualized 5 key strategies that might help serve as a framework to support mental health programming as part of PEPFAR's current 5-year strategic plan. PEPFAR and the global community have an opportunity to identify mental health service gaps and interweave global mental health priorities with actions to end the HIV and TB epidemics by 2030.

"As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model.

Results

Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Stigma, depression, quality of life, and the need for psychosocial support among people with tuberculosis in Indonesia: A multi-site cross-sectional study

Stigma towards people with tuberculosis (TB-Stigma) is associated with other psychosocial consequences of TB including mental illness and reduced quality of life (QoL). We evaluated TB-Stigma, depression, QoL, and the need for psychosocial support among adults with TB in Indonesia, a high TB burden country. In this primary health facility-based survey in seven provinces of Indonesia, from February to November 2022, we interviewed adults receiving (a) intensive phase treatment for drug-susceptible (DS) TB at public facilities, (b) treatment at private facilities, (c) those lost to follow up (LTFU) to treatment, and (d) those receiving TB retreatment. We used our previously validated Indonesian TB-Stigma Scale, Patient Health Questionnaire-9, and EQ-5D-5L to measure TB-Stigma, depression, and QoL. Additional questions assessed what psychosocial support was received or needed by participants. We recruited and interviewed 612 people, of whom 60.6% (96%CI 59.6-64.5%) experienced moderate TB-Stigma. The average TB-Stigma scores were 19.0 (SD 6.9; min-max 0-50; Form A-Patient Perspective) and 23.4 (SD 8.4, min-max 0-50; Form B-Community Perspective). The scores were higher among people receiving treatment at private facilities (adjusted B [aB] 2.48; 0.94-4.03), those LTFU (aB 2.86; 0.85-4.87), males (aB 1.73; 0.59-2.87), those losing or changing job due to TB (aB 2.09; 0.31-3.88) and those living in a rural area (aB 1.41; 0.19-2.63). Depression was identified in 41.5% (95% CI 37.7-45.3%) of participants. Experiencing TB-Stigma was associated with moderately severe to severe depression (adjusted odds ratio [aOR] 1.23; 1.15-1.32) and both stigma and depression were associated with lower QoL (aB -0.013; [-0.016]-[-0.010]). Informational (20.8%), emotional (25.9%) and instrumental (10.6%) support received from peers or peer-groups was limited, and unmet need for such support was high. There is a sizeable and intersecting burden of TB-Stigma and depression among adults with TB in Indonesia, which is associated with lower QoL. Participants reported a substantial unmet need for psychosocial support including peer-led mutual support groups. A community-based peer-led psychosocial support intervention is critical to defray the psychosocial impact of TB in Indonesia.

The COVID-19 pandemic as a catalyst for integrated global mental healthcare and tuberculosis care

Mental disorders are common among persons with tuberculosis (TB), and the COVID-19 pandemic has only amplified the mental and physical health consequences of this deadly synergy. Here, we call to attention the immense vulnerability of people with TB to mental disorders during the pandemic and highlight the unique challenges and opportunities that the pandemic brings to the future integration of global TB and mental healthcare. We argue that the pandemic era is an ideal period to accelerate this integration and we provide research and policy recommendations to actualise this urgent need.

Barriers and Facilitators to Integrating Depression Treatment Within a TB Program and Primary Care in Brazil

Tuberculosis (TB) and depression is common and is associated with poor TB outcomes. The World Health Organization End TB Strategy explicitly calls for the integration of TB and mental health services. Interpersonal Counseling (IPC) is a brief evidence-based treatment for depression that can be delivered by non-mental health specialists with expert supervision. The goal of this study was to explore potential barriers and facilitators to training non-specialist providers to deliver IPC within the TB Control Program and primary care in Itaboraí, Rio de Janeiro state. Data collection consisted of six focus groups (n = 42) with health professionals (n = 29), program coordinators (n = 7), and persons with TB (n = 6). We used open coding to analyze the data, followed by deductive coding using the Chaudoir multi-level framework for implementation outcomes. The main structural barriers identified were poverty, limited access to treatment, political instability, violence, and social stigma. Organizational barriers included an overburdened and under-resourced health system with high staff turnover. Despite high levels of stress and burnout among health professionals, several provider-level facilitators emerged including a high receptivity to, and demand for, mental health training; strong community relationships through the community health workers; and overall acceptance of IPC delivered by any type of health provider. Patients were also receptive to IPC being delivered by any type of professional. No intervention-specific barriers or facilitators were identified. Despite many challenges, integrating depression treatment into primary care in Itaboraí using IPC was perceived as acceptable, feasible, and desirable.

A Case of Delusional Disorder With Abuse of Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol, the First-Line Anti-tuberculosis Therapy Drugs in India

Tuberculosis (TB) and mental illnesses frequently coexist and are both extremely common worldwide. Through the National Program for Elimination of Tuberculosis (NTEP), anti-tuberculosis therapy (ATT) medications are used to treat tuberculosis in India. We want to report a case 45-year-old patient from the state of Andhra Pradesh, India with comorbid delusional disorder leading to daily ATT drug consumption for the past 20 years. This unusual presentation demonstrates that abuse of a Schedule "H" substance like ATT is also conceivable. To stop "Off-label" purchases, strict measures must be taken. Before beginning ATT, evaluating the patient's mental health may be a wise move.

Prevalence of Tuberculosis and Mental Disorders Comorbidity: A Systematic Review and Meta-analysis

Persons with tuberculosis (TB) also often have a mental disorder (MD). We examined TB-MD comorbidity prevalence and its impact on TB treatment outcomes as reported in studies set in the United States or in the top five countries of origin (Mexico, the Philippines, India, Vietnam, and China) for non-US-born persons with TB. We searched MEDLINE, EMBASE, OVID, PsycINFO, CINAHL, and Scopus for articles published from database inception through September 2018. Of the 9 studies analyzed, one was set in the United States. The estimated pooled prevalence of comorbid TB-MD from eight non-US studies, with 2921 participants, was 34.0% [95% confidence interval (CI) 21.1%-49.5%]. Comorbid TB-MD prevalence varied by country in the studies evaluated. Additional research might elucidate the extent of TB-MD in the United States and the top five countries of origin.

Psychiatric comorbidities among patients with complex drug-resistant tuberculosis in Mumbai, India

BACKGROUND

People with drug-resistant tuberculosis (DR-TB) are known to suffer from many mental-health disorders. This study aims to describe the proportion of patients diagnosed with psychiatric comorbidities, the different psychiatric diagnoses made, and treatment outcomes among DR-TB patients with or without psychiatric comorbidity and initiated on DR-TB treatment between January 2012 and March 2019 at Médecins Sans Frontières independent clinic in Mumbai, India.

METHODS

This is a retrospective study using routinely collected clinical data. DR-TB care included individualised treatment, psychosocial support, and integrated psychiatric care.

RESULTS

During the study period, 341 DR-TB patients were enrolled, with a median age of 25 years (IQR:20.0-36.5 years), 185 (54.2%) females, 143 (41.9%) with PreXDR-TB, and 140 (41.0%) with XDR-TB. All 341 patients were screened by a counsellor, 119 (34.9%) were referred for psychiatric evaluation, and 102 (29.9% of 341) were diagnosed with a psychiatric comorbidity. Among 102 diagnosed with a psychiatric comorbidity, 48 (47.0%) were diagnosed at baseline, and 86 (84.3%), or 25.2% of all 341 patients enrolled, were treated with psychotropic drugs. Depressive disorders were diagnosed in 49 (48.0%), mixed anxiety and depression in 24 (23.5%), neurocognitive disorders and anxiety in five (4.9%), and medication induced psychosis in two (2.0%). No anti-TB drugs were significantly associated with psychiatric comorbidities developed during treatment. Of 102 DR-TB patients with a psychiatric comorbidity, 75.5% (77) had successful DR-TB treatment outcomes, compared to 61.1% (146/239) not diagnosed with a psychiatric comorbidity (p = 0.014).

CONCLUSION

In our setting, among people started on DR-TB treatment, and with a complex TB resistance profile, about one in three patients experienced a psychiatric comorbidity, of which half developed this comorbidity during treatment. With comprehensive psychiatric care integrated into DR-TB care delivery, treatment outcomes were at least as good among those with psychiatric comorbidities compared to those without such comorbidities.

The relationship between mental health and risk of active tuberculosis: a systematic review

OBJECTIVES

Tuberculosis (TB) and mental illnesses are highly prevalent globally and often coexist. While poor mental health is known to modulate immune function, whether mental disorders play a causal role in TB incidence is unknown. This systematic review examines the association between mental health and TB disease risk to inform clinical and public health measures.

DESIGN

Systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

SEARCH STRATEGY AND SELECTION CRITERIA

MEDLINE, PsycINFO and PsycEXTRA databases were searched alongside reference list and citation searching. Inclusion criteria were original research studies published 1 January 1970-11 May 2020 reporting data on the association between mental health and TB risk.

DATA EXTRACTION, APPRAISAL AND SYNTHESIS

Data were extracted on study design and setting, sample characteristics, measurement of mental illness and TB, and outcomes including effect size or prevalence. Studies were critically appraised using Critical Appraisal Skills Programme (CASP) and Appraisal Tool for Cross-Sectional Studies (AXIS) checklists.

RESULTS

1546 records published over 50 years were screened, resulting in 10 studies included reporting data from 607 184 individuals. Studies span across Asia, South America and Africa, and include mood and psychotic disorders. There is robust evidence from cohort studies in Asia demonstrating that depression and schizophrenia can increase risk of active TB, with effect estimates ranging from HR=1.15 (95% CI 1.03 to 1.28) to 2.63 (95% CI 1.74 to 3.96) for depression and HR=1.52 (95% CI 1.29 to 1.79) to RR=3.04 for schizophrenia. These data align with evidence from cross-sectional studies, for example, a large survey across low-income and middle-income countries (n=242 952) reports OR=3.68 (95% CI 3.01 to 4.50) for a depressive episode in those with TB symptoms versus those without.

CONCLUSIONS

Individuals with mental illnesses including depression and schizophrenia experience increased TB incidence and represent a high-risk population to target for screening and treatment. Integrated care for mental health and TB is needed, and interventions tackling mental illnesses and underlying drivers may help reduce TB incidence globally.

PROSPERO REGISTRATION NUMBER

CRD42019158071.

Addressing TB multimorbidity in policy and practice: An exploratory survey of TB providers in 27 high-TB burden countries

In people with TB, co-existence of long-term conditions (e.g., depression, diabetes and HIV) and risk factors (e.g.,alcohol misuse, malnutrition, and smoking) are associated with increased mortality and poor treatment outcomes including delayed recovery, TB treatment failure and relapse. However, it is unclear as to what extent these comorbidities are addressed in TB policy and practice. Between August and October 2021, we conducted an online cross-sectional survey in high-TB burden countries. We recruited a purposive sample of TB health workers, managers, policy makers, advisors and advocates from these countries. The survey enquired about the extent to which various comorbid conditions are: (a) mentioned in TB policies, plans, and guidelines; (b) screened, diagnosed, treated or referred to specialist services by TB healthcare workers. We summarised using descriptive analysis. Of the 1100 potential respondents contacted in 33 countries, 543 responded but only 446 (41%) from 27 countries provided sufficient data for inclusion in the study. We found no notable differences between these providing insufficient data and those completing the survey. HIV, diabetes mellitus, depression and tobacco and alcohol use disorders were identified as the most common and concerning comorbid conditions in TB. HIV was screened for and managed by TB services in most countries. Screening for diabetes and/or tobacco and alcohol use disorders was offered by almost half of all TB services but only a few offered relevant treatments. Depression was rarely screened for, almost never treated, and only infrequently referred to specialist services. Most respondents felt confident in screening/diagnosing these comorbid conditions but not in treating these conditions. With the exception of HIV, chronic comorbid conditions are only partially screened for and rarely managed within TB services. Mental health conditions are for the most part neglected. Given their adverse impact on TB outcomes, integrating screening and management of these comorbidities within TB programmes offers a significant opportunity to meet TB targets, address non-communicable diseases and improve patient well-being.

Tuberculosis related disability: a systematic review and meta-analysis

BACKGROUND

The sustainable development goals aim to improve health for all by 2030. They incorporate ambitious goals regarding tuberculosis (TB), which may be a significant cause of disability, yet to be quantified. Therefore, we aimed to quantify the prevalence and types of TB-related disabilities.

METHODS

We performed a systematic review of TB-related disabilities. The pooled prevalence of disabilities was calculated using the inverse variance heterogeneity model. The maps of the proportions of common types of disabilities by country income level were created.

RESULTS

We included a total of 131 studies (217,475 patients) that were conducted in 49 countries. The most common type of disabilities were mental health disorders (23.1%), respiratory impairment (20.7%), musculoskeletal impairment (17.1%), hearing impairment (14.5%), visual impairment (9.8%), renal impairment (5.7%), and neurological impairment (1.6%). The prevalence of respiratory impairment (61.2%) and mental health disorders (42.0%) was highest in low-income countries while neurological impairment was highest in lower middle-income countries (25.6%). Drug-resistant TB was associated with respiratory (58.7%), neurological (37.2%), and hearing impairments (25.0%) and mental health disorders (26.0%), respectively.

CONCLUSIONS

TB-related disabilities were frequently reported. More uniform reporting tools for TB-related disability and further research to better quantify and mitigate it are urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42019147488.

Confirmatory factor analysis of the Patient Health Questionnaire-9: A study amongst tuberculosis patients in the Free State province

Background

There is growing evidence that depression is frequently comorbid with tuberculosis (TB) and is often associated with a decreased quality of life and poor treatment outcomes. The Patient Health Questionnaire (PHQ-9) is widely used to screen for depression in clinical settings in low-and middle-income countries. This study examined the construct validity and reliability of an interviewer-administered PHQ-9 in a sample of new TB patients in the Free State province of South Africa.

Methods

A pilot study was conducted in 2019 amongst 208 new adult TB patients attending primary healthcare facilities in the Lejweleputswa District in the Free State. Trained fieldworkers administered a structured questionnaire comprising of questions on patient’s socio-demographic characteristics and the nine-item PHQ-9 to the patients. Confirmatory factor analysis and Cronbach’s alpha were respectively used to investigate the construct validity and internal consistency of the PHQ-9.

Results

The model was a good fit, with a Tucker–Lewis index of 0.976, a comparative fit index of 0.982 and a root mean square error of approximation of 0.062 (90% CI: 0.032–0.089). All indicators showed significant positive factor loadings, with standardised coefficients ranging from 0.467 to 0.799. The PHQ-9 was characterised by a single factor latent structure – depression – underlying all items. The Cronbach’s alpha of the scale was 0.84.

Conclusion

The results support a unidimensional structure of the PHQ-9, with satisfactory internal consistency implying that the scale is valid and reliable. The TB programme can confidently consider the PHQ-9 for the routine assessment of depression amongst TB patients in the Free State province and similar settings.

Construct validity and reliability of the generalised anxiety disorder-7 scale in a sample of tuberculosis patients in the Free State Province, South Africa

BACKGROUND

Generalised anxiety disorder (GAD) frequently occurs amongst patients with tuberculosis (TB) and contributes to poor quality of life and treatment outcomes. This study evaluated the construct validity and reliability of the GAD-7 scale in a sample of patients with TB in the Free State Province.

METHODS

A pilot study was conducted amongst a convenience sample of 208 adult patients newly diagnosed with drug-susceptible TB attending primary healthcare (PHC) facilities in the Lejweleputswa District in the Free State. A structured interviewer-administered questionnaire comprising social demographic questions and the GAD-7 scale was used. Confirmatory factor analysis was used to investigate the construct validity of the GAD-7 scale. The reliability of the scale was assessed by calculating Cronbach's alpha.

RESULTS

The analysis showed that a modified two-factor (somatic symptoms and cognitive -emotional symptoms) model, in which the items 'Not being able to stop or control worrying' and 'Worrying too much about different things' were allowed to covary (Comparative Fit Index: 0.996, Tucker-Lewis Index: 0.993, Root Mean Square Error of Approximation: 0.070, 90% confidence interval: 0.032-0.089), fitted the data better than a unidimensional (generalised anxiety) or an unmodified two-factor model. The indicators all showed significant positive factor loadings, with standardised coefficients ranging from 0.719 to 0.873. The Cronbach's alpha of the scale was 0.86.

CONCLUSION

The modified two-factor structure and high internal consistency respectively provide evidence for construct validity and reliability of the GAD-7 scale for assessing GAD amongst patients with TB. Studies are necessary to assess the performance of this brief scale under routine TB programme conditions in the Free State.

Tuberculosis-associated depression: a population-based cohort study of people immigrating to British Columbia, Canada, 1985-2015

PURPOSE

To estimate the risk of tuberculosis (TB)-associated depression. A second aim was to estimate the extent to which any increased risk of depression among TB patients may be mediated by the length of hospital length stay (LOS) METHODS: Retrospective cohort study of linked healthcare claims and public health surveillance data. Our primary outcome, time-to-depression, was analyzed using Cox proportional hazards (PH) regressions. Causal mediation analysis was used to estimate the natural direct and indirect effect of TB mediated by hospital LOS.

RESULTS

Among 755,836 participants (52.2% female, median age=35 years, median follow-up=8.75 years), 2295 were diagnosed with TB (exposure), and 128,963 were diagnosed with depression (outcome). We observed a covariate-adjusted hazard ratio (aHR) of 1.24 (95% CI, 1.14-1.34) for depression by TB. The total effect of TB on depression was decomposed into a natural direct effect of TB of aHR=1.11 (95% CI, 1.02-1.21) and an indirect effect through hospital LOS of aHR=1.11 (95% CI, 1.10-1.12), indicating that TB's total effect was mediated by 50% (95% CI, 35-82%) through hospital LOS.

CONCLUSIONS

TB patients had a 24% higher risk of developing depression. TB's effect was mediated substantially by hospital LOS, requiring further study. Depression screening among TB patients is warranted.

Prevalence and associated factors of psychological distress in tuberculosis patients in Northeast China: a cross-sectional study

Background

Psychological distress, a major comorbidities of tuberculosis (TB) patients, has posed a serious threat to the progress being made in global TB programs by affecting treatment adherence and health outcomes. However, the magnitude and associated factors of psychological distress have not been fully studied in China. The aim of the current study was to assess the prevalence of psychological distress in TB patients and to further determine the effects of socio-demographic characteristics, health-related variables, substance use status, social support, and experienced stigma on psychological distress.

Methods

A cross-sectional survey was conducted among TB patients attending three medical institutions in Dalian, Liaoning Province, Northeast China from November 2020 to March 2021. A structured questionnaire was developed to collect data on patients’ socio-demographic characteristics, health-related information, substance use status, psychological distress, family function, doctor-patient relationship, policy support, experienced stigma and so on. The binary logistics regression model was used to determine the associated factors of psychological distress.

Results

A total of 473 TB patients were enrolled in this study, and the prevalence of psychological distress was 64.1%. Binary logistic regression analysis revealed that patients with a middle school education level or above (OR: 0.521, 95%CI: 0.279–0.974), no adverse drug reactions (OR: 0.476, 95%CI: 0.268–0.846), and regular physical exercise (OR: 0.528, 95%CI: 0.281–0.993) were more likely to stay away from psychological distress. However, patients who had a high economic burden (OR: 1.697, 95%CI: 1.014–2.840), diabetes (OR: 2.165, 95%CI: 1.025–4.573), self-rated illness severe (OR: 3.169, 95%CI: 1.081–9.285), perceived poor resistance (OR: 2.065, 95%CI: 1.118–3.815), severe family dysfunction (OR: 4.001, 95%CI: 1.158–13.823), perceived need for strengthen psychological counseling (OR: 4.837, 95%CI: 2.833–8.258), and a high experienced stigma (OR: 3.253, 95%CI: 1.966–5.384) tended to have a psychological distress.

Conclusions

The study found that the proportion of psychological distress among TB patients was high in Northeast China, and it was influenced by a variety of factors. Effective interventions to reduce psychological distress in TB patients urgently need to be developed, and greater attention should be given to patients with risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06284-4.

The Tuberculosis-Depression Syndemic and Evolution of Pharmaceutical Therapeutics: From Ancient Times to the Future

The interplay between tuberculosis and depression has been problematic since the humoralists. Over the centuries similarities in disease management have transpired. With the advent of isoniazid chemotherapy, transformation of tuberculosis patients from morbidly depressive to euphoric was noted. Isoniazid was thereafter widely prescribed for depression: hepatotoxicity ending its use as an antidepressant in 1961. Isoniazid monotherapy led to the emergence of drug resistant tuberculosis, stimulating new drug development. Vastly increased investment into antidepressants ensued thereafter while investment in new drugs for tuberculosis lagged. In the 21st century, both diseases independently contribute significantly to global disease burdens: renewed convergence and the resultant syndemic is detrimental to both patient groups. Ending the global tuberculosis epidemic and decreasing the burden of depression and will require multidisciplinary, patient-centered approaches that consider this combined co-morbidity. The emerging era of big data for health, digital interventions and novel and repurposed compounds promise new ways to treat both diseases and manage the syndemic, but absence of clinical structures to support these innovations may derail the treatment programs for both. New policies are urgently required optimizing use of the current advances in healthcare available in the digital era, to ensure that patient-centered care takes cognizance of both diseases.

Psychological profile of multi drug resistance TB patients: A qualitative study from a Tertiary care Centre of Kolkata

INTRODUCTION

There has been a new challenge to the already existing threat of tuberculosis (TB) and that is drug resistance TB (DR-TB). The causal relationships between mental disorders and TB are complicated and relatively unexplored. For this reason a qualitative study was done on DR-TB patients attending R G Kar Medical College.

MATERIALS AND METHODS

The study population consisted of the patients who are registered for the DR-TB regimen are followed up four times with General Health Questionnaire (GHQ). Those scoring poorly were sent for expert evaluation by psychologist, who counselled them, and followed them up after in-depth interviews. These records of in-depth interview were analysed as qualitative research inputs.

RESULTS

In our study out of 165 patients, (4.8%) needed interventions. The domains emerging from the study are worried about future and as well as family, disbelief about the diagnosis, embarrassment regarding the diagnosis, fear of death, blaming fate for the disease, stigma, suicidal ideation.

CONCLUSION

This study finds out the important domains of psychogical problems among the patients and also advocates a psychologist to remain at DR-TB centres.

"Death is a better option than being treated like this": a prevalence survey and qualitative study of depression among multi-drug resistant tuberculosis in-patients

Background

Understanding of the relationship between multi-drug resistant tuberculosis and mental health is limited. With growing prevalence of multi-drug resistant tuberculosis, addressing mental ill-health has potential to improve treatment outcomes and well-being. In several low and middle-income contexts hospitalisation during treatment is common. Understanding of the impact on mental ill-health are required to inform interventions for patients with multi-drug resistant tuberculosis.

Our aim was to identify the prevalence of comorbid depression among in-patients being treated for multi-drug resistant tuberculosis and to explore their experiences of comorbid disease and the care they received in a large specialist chest hospital in Dhaka, Bangladesh.

Methods

We conducted a quantitative cross-sectional survey among 150 multi-drug resistant tuberculosis in-patients (new cases = 34%, previously treated = 66%) in 2018. A psychiatrist assessed depression was assessed with the Structured Clinical Interview for Depression (SCID DSM-IV). We used multi-level modelling to identify associations with depression. Experience Bangladeshi researchers conducted qualitative interviews with 8 patients, 4 carers, 4 health professionals and reflective notes recorded. Qualitative data was analysed thematically.

Results

We found 33.8% (95% CI 26.7%; 41.7%) of patients were depressed. While more women were depressed 39.3% (95% CI 27.6%; 52.4%) than men 30.4% (95% CI 22%; 40.5%) this was not significant. After controlling for key variables only having one or more co-morbidity (adjusted odds ratio [AOR] = 2.88 [95% CI 1.13; 7.33]) and being a new rather than previously treated case (AOR = 2.33 [95% CI 1.06; 5.14]) were associated (positively) with depression. Qualitative data highlighted the isolation and despair felt by patients who described a service predominantly focused on providing medicines. Individual, familial, societal and health-care factors influenced resilience, nuanced by gender, socio-economic status and home location.

Conclusions

Patients with multi-drug resistant tuberculosis are at high risk of depression, particularly those with co- and multi-morbidities. Screening for depression and psycho-social support should be integrated within routine TB services and provided throughout treatment.

What quality of care means to tuberculosis survivors

Quality of care for patients of TB suffers in India as well as in other countries, because the commonly accepted definitions of high quality care, rarely goes beyond correct diagnosis, treatment and adherence. The problem with the existing definitions and metrics of quality careis that they leave out patients, and when high quality care is defined without patients' perspectives, their needs and expectations are not addressed. Thispaper, based on a workshop held by TB survivors, attempts to examine the current state of quality of care extended to patients of TB, and to improve the scope of this care for the affected individuals, by the government, the healthcare system, and the society. The aim of the workshop and this paperis to arrive at a comprehensive, inclusive, and most importantly, a patient-centric definition of what quality of care looks like - to them.

Depression among TB patients and associated factors in Kathmandu Valley, Nepal

INTRODUCTION

When tuberculosis (TB) and depression co-occur, there is greater risk for comorbidities, disability, suffering, and health-related costs. Depression is also associated with poor treatment adherence in patients with TB. The major aim of this study was to assess the symptoms of depression and associated factors among TB patients currently receiving directly observed treatment short-course (DOTS) treatment.

METHODS

A cross-sectional study was conducted among TB patients currently undergoing treatment in 27 DOTS centers in three districts of Kathmandu Valley. The study included 250 TB patients within 2 months of treatment initiation, aged 18 years and above. The previously validated Nepali Patient Health Questionnaire (PHQ-9) was used to screen for depression and semi-structured interviews were conducted to collect socio-demographic information and other factors related to TB and/or depression. Data analysis was conducted using IBM SPSS Statistics version 20.

RESULTS

The study found the mean PHQ Score to be 2.84 (s.d. 4.92, range 0-25). Among the respondents, 10% (n = 25) had PHQ-9 scores ⩾10, suggestive of probable depression. Multivariate linear regression indicated that depressive symptoms were significantly associated with being separated/widowed/divorced (p = 0.000) and having lower education (0.003). In addition, smoking (p = 0.02), alcohol use (p = 0.001), and experience of side effects from TB medications (p = 0.001) were risk factors for higher PHQ-9 scores.

CONCLUSIONS

Our findings suggest that patients on TB treatment have higher risk of depression and efforts should be made by the National Tuberculosis Program to address this issue.