Why is counseling important in TB treatment?

Dr Carolyn Kavita Tauro, CNS Correspondent, India
Rohani (name changed) was one of those quieter female TB patients. But they almost all are, including the one who had committed suicide the previous night by jumping out of the hospital ward window. It is difficult, though not impossible, to comprehend what goes behind the calm exterior of patients like Rohani. Another TB patient, Archana (name changed), was just told that she would have to take her TB medications for a period of two years and that she would not be able to see her one-year old baby for at least a year.

Stories of patients with TB trying to take their lives or even attempting to injure people around them have not been rare. While an alert ward attendant saved Archana, many others have not been so fortunate.

Health workers, too, face immense stress in dealing with this disease once they have contracted it, claiming they having problems with coping with issues at work and with the family after starting treatment. The more severe forms of TB like Multi-Drug Resistant TB (MDR-TB) or co-infection with HIV further complicate the situation.

According to the Global TB Report 2014, about 9 million people developed TB in 2013 with 1.5 million succumbing to it. Out of those who died, 360,000 were co-infected with HIV with the overall number of those co-infected being as high as 1.1 million. The proportion of new cases of MDR-TB is said to be about 3.5%. In India, out of the 2.8 million people with TB, 130,000 were estimated to be coinfected with HIV and another 128,000 suffered from MDR-TB.

Various issues can lead to patients with TB to have mental illness. The chronic and severe nature of the illness, loss of appetite and lack of energy to do daily activities of life, the severe side effects of the treatment and the stigma from family and society and the isolation from loved ones, could all contribute towards mental illness in these patients. With complications such as MDR-TB and/or coinfection with HIV, patients find their chances of being cured even more bleak.

Dr Upasna Agarwal, in-charge Anti-Retroviral Therapy, at National Institute of Tuberculosis and Respiratory Diseases (NITRD), New Delhi says, “There are many similarities between HIV and MDR-TB patients in that the patients themselves are very sick mostly. Their treatments are long-term, they have to ingest multiple number of drugs and take numerous injections, the side effects are many and often severe, and this often creates a barrier to adherence”.

While other diseases could be explained by a brief meeting with a doctor, these diseases require that extra attention in the form of counseling. Reasons for counseling could include, apart from the obvious psychological illness, a pathway to educate and support caretakers and family members, to help patients uptake diagnostic tests that will help avoid complications, help avoid risky behavior and other steps to avoid further transmission. Dr Agarwal stated, “Counselling patients is very essential to gain patient confidence. Patient education that explains why he or she should take the medications and what the possible side effects one could have - prepares the patient for what she/he is in for. Clear indications as how to deal with mild side effects and whom to contact in the event of an emergency lead to a hand holding of sorts which makes the problems seem much easier to overcome”.

Counselling during TB treatment can occur at various levels. While it begins with patient counseling at a treatment center when initiating the treatment, frequent periodic counseling at community level can be very effective. Motivating discussions with the DOTS providers, outreach workers, community volunteers and group sessions with other TB patients could increasingly help these patients to cope through their long treatments with hope.

A study in Mumbai that documented levels of depressive symptoms in patients on MDR-TB therapy and then monitored any alteration found that 16% of the patients developed depressive symptoms-- a quarter of these had moderate to severe symptoms. Studies have also shown how anti TB drugs used to treat more complicated forms of the disease may cause central nervous system toxicity. Individualised psychosocial support is also suggested for patients to prevent poor outcomes of treatment.

With evidences of greater incidence of mental illness in people suffering with and on treatment for TB, it could be worthwhile for future Global TB Reports to include specifically TB cases associated with mental illness or suicides. Reporting of such incidences would help to further highlight the magnitude of the co-morbidity so that through regular monitoring and counselling many more lives may be saved before the patients refuse to give themselves a chance.

Dr Carolyn Kavita tauro, Citizen News Service - CNS
28 March 2015