Mental health of TB patients should not be overlooked

At least one in seven Indians experience a mental health condition at some point in their lives. In people with infectious diseases like Tuberculosis (TB) or HIV, this increases to anywhere between one-third to a half of those affected. TB takes a toll on not only physical but also mental health, either in the form of definite diagnosable conditions like depression, anxiety or psychoses or as emotional suffering worsened by social stigma. TB is fundamentally a disease of inequity, perpetuated by poverty and simultaneously contributing to increasing poverty. Unemployment, the lack of livelihood, food insecurity and malnutrition are social drivers for both TB and mental health conditions.

Studies from India have shown that at least one-third of people with TB experience symptoms of depression and anxiety, which often occur together as well. The mental health burden is estimated to be even higher among people with drug-resistant TB, with upto two-thirds having mental health issues. There are anecdotal accounts from TB survivors on suicidal ideation as well as documented instances of people with TB dying by suicide. There is not enough evidence about the prevalence of severe mental illnesses such as schizophrenia or bipolar disorders in people affected by TB.

The stigma associated with TB remains pervasive, and includes self-stigma, stigma within families, at workplaces and within communities. Many TB survivors have spoken of the guilt and shame they feel on being diagnosed with TB, despite knowing that it is an airborne disease that can affect anyone. For those with pulmonary TB, the guilt is driven primarily by the fear of transmitting the disease within their families, particularly to children. Those with depression or anxiety and TB must cope with an increased burden of stigma associated with both conditions, which can further worsen mental health.

TB and mental health

Given the high prevalence of common mental health disorders in the general population, it is possible that depression or anxiety could have been pre-existing and unidentified, even prior to the TB diagnosis; there have not been enough studies on this aspect. Depression or anxiety could delay care-seeking for TB. Long-standing untreated depression can also weaken the body’s immune responses which in turn could lead to active TB disease — this is yet again another under-researched aspect.

Post diagnosis, untreated mental health conditions can adversely affect TB treatment outcomes. A person with TB who is depressed, and has not received mental healthcare, is more likely to take TB treatment irregularly or discontinue treatment prematurely. This can lead to treatment failure, relapse, or drug-resistance.

Co-existing alcohol and tobacco use, in the absence of access to de-addiction programmes, are also crucial factors affecting the treatment for TB.

Screening and identifying

Integrating routine screening for all people with TB for depression and anxiety is the starting point. Building awareness about common mental health disorders among healthcare workers, equipping them with the knowledge and skills to provide mental health first-aid and ensuring early screening at the right point in the TB care cascade are the other essential steps. Primary healthcare workers and community supporters, who are often the first to notice any psychological distress, should be trained to elicit information about sleep, appetite, mood, stress etc. which can help early identification of mental health conditions.

Given that TB itself could trigger depression, mental health screening must ideally be done at multiple time points during the TB treatment period.

From an individual perspective, being treated for TB and depression at the same time can be a stressful experience. While India’s TB programme already provides decentralised access to free anti-TB drugs and financial aid for nutrition, strengthening the availability of drugs to treat depression or anxiety through the district mental health programme is vital. While antidepressants or antipsychotics can be used alongside anti-TB drugs, clinicians must monitor for any adverse drug reactions or interactions. Psychological interventions, including cognitive-behavioural therapy and participation in peer support groups, can also help reduce isolation. To provide these services, qualified and trained mental health professionals are needed, particularly in rural and tribal areas.

Looking out for everyone

Mental health interventions cannot be limited to people with TB. The task of caring for people with TB can place considerable strain on families. Studies in India have shown that up to 80% of caregivers may exhibit high levels of Expressed negative Emotions (EE) and high stress levels due to their caregiving responsibilities. Often, high EE leads to increased caregiver burden and poorer treatment outcomes. In India’s family-centred ecosystem, where most of the caregiving needs are met by family members, this can lead to critical or over-involved caregiving because of emotional, financial, and social strains.

Psychoeducation is important not just for persons with TB but also for their families and caregivers.

A blended and syndemic TB-mental health approach that considers mental healthcare as an essential part of TB care, rather than a standalone service, can significantly improve TB outcomes, reduce the burden on caregivers and improve long-term mental health.

Dr. R. Thara is Co-Founder and Vice-Chair of the Schizophrenia Research Foundation (SCARF)