Connecting the dots: Mental health and tuberculosis

Alice Tembe, CNS Special Correspondent, Swaziland
Dr Annika Sweetland
As I get totally swathed by the very inspiring and tiring 46th Union World Conference on Lung Health, a serious thought that came to my mind was the connect between mental health and TB. This was a question also posed by Dr Annika Sweetland, a Research Scientist in the Department of Psychology from Columbia University, also tried to answer a similar question in one of the sessions: Does TB predispose patients to mental health disorders, and, are mental health disorders a risk factor to developing active TB?

Dr Sweetland expressed that people with mental illnesses and substance use disorders are more likely to be exposed to TB and develop active TB mainly due to malnutrition, poor communal living conditions and sometimes also due to exposure to extreme weather conditions on the streets. People with mental health disorders are also likely to delay seeking care because of the stigma associated with mental health illness. This late presentation to seek medical advice is more likely to happen if they do not have a carer at home. Due to their delicate state mind, they themselves may not realize that they are sick until very late into disease progression.

Dr Sweetland also added that patients also are more likely to miss treatment doses, and thus interrupt treatment for a variety of reasons - they may be intoxicated, or they may be in a fragile state of mind, or have a migrant nature of life. It is against this backdrop therefore that patients in this demography present themselves with advanced disease. They are thus more likely to develop multidrug-resistant TB (MDR-TB); they experience high rate of treatment failure; they remain infectious for prolonged periods in their community/family and also have a high death rate.

Dr Alistair Story
Dr Alistair Story, a Clinical Lead of the Find and Treat Strategy for TB Control on the streets in London (through mobile vans), reiterated that TB rates are unfortunately highest among hardest to reach and hardest to treat communities.  Dr Story shared that there is a persistent cycle on the streets of drug addiction, homelessness and imprisonment.  He expressed that in whatever order, all this exacerbates and accelerates TB. Homeless populations are exposed to extreme weather conditions, are generally poor and suffer from malnutrition. These are critical risk factors to development of active TB if exposed to infection. Also, because they are living on the street, the tendency is to bounce from one communal home/ shelter to another. These homes are generally overcrowded and are hot spots for active TB exposure. To add fuel to fire, they seek comfort in recreational drugs-- both on the street and in these homes-- that also exposes them to exploitation as drug peddlers/ dealers and crime. This leads to imprisonment in communal settings prisons which again are hot spots for active TB and drug dealing.

Any of these components (drug addiction, homelessness and imprisonment) are prerequisites to mental health disorders, in particular depression and anxiety. Dr Story noted that even though the Find and Treat intervention has registered significant success with approximately 84% of cases on the street found, diagnosed, and put on treatment by them, complete treatment with less than 6% default rate. But his main concern was as as to where these people go once cured. For him it would be a catastrophic loss if they fallback into the unending cycle of going back to a life of homelessness, and falling back into drug use, disorder and crime.

It is unfortunate that the WHO has very limited data and evidence to make a strong case for mental health and TB linkage. Dr Saira Nadia Khowaja, a social development professional with the Interactive Research and Development in Pakistan, expressed the concern over the low documentation and publicity of evidence of TB and mental health issues linkages as 'most evidence is circumstantial, collected sporadically in small and short term research.'   As Dr Story put it: "Unmeasured = untreated… this is a circular argument. You cannot measure what you are not testing for and you cannot treat what is not found."

However, what came to the fore of the discussions was that while depression is largely considered a luxury illness, evidence and logic shows that by addressing mental health disorders there are multiple, positive health and socio-economic outcomes.  Without good mental health, individuals can be employed indiscriminately and have social status.

Mental health disorders are not just an entry or exit point of the ‘find and treat’ challenge; attention is required from pre-treatment till the end of the treatment and beyond. Currently TB patients already have a high medicine burden, and with other co-morbidities it is essential to approach additional medication (especially oral) to the already challenging pill-burden. 

Clinicians managing TB, need capacity building to respond to this multiplicity of TB patients who sit in front of them. In TB high burden yet low-income countries,  the doctors might often not have time to engage with patients long enough to be able to help them. So these roles can be built in the multidisciplinary team members including community caregivers.

Alice Tembe, CNS Special Correspondent, Swaziland
7 December 2015 
(Alice Tembe is providing thematic coverage from 46th Union World Conference on Lung Health in Cape Town, South Africa, with kind support from Lilly MDR TB Partnership. Follow her on Twitter: @Tembe3)