The syndemic of tuberculosis and mental health

In 2022, 2.42 million Indians were diagnosed with tuberculosis. A silent crisis, TB is associated with a deep stigma, and those affected have stories of being ostracised and mistreated by families, communities, and even the health system. All of this has a significant impact on the mental health of those fighting TB. In truth, TB and mental illness are co-epidemics. 

Evidence suggests that people with mental health issues are more likely to develop TB. Also, TB-related stigma adversely impacts a TB-affected individual’s mental health from diagnosis through treatment and its side effects.  TB-related mental health issues also significantly diminish an individual’s quality of life. 

Why does this happen? TB is stigmatised due to the fear of contagiousness, association of the disease with poverty, and unhealthy behaviour. This leads to both social and self-stigma, which leads to mental health challenges. These mental health issues lead to general feelings of hopelessness, despair, and impaired decision-making skills, which can also lead the individual to lose hope in recovery, not be able to follow medical advice, discontinue treatment, etc. 

Physical scars

TB treatment is long and comes with extreme side effects. This leads to several mental health issues that affect the individual and sometimes even families who are providing care. Those affected see changes in physical appearance, extreme side effects from rashes to psychotic episodes, and loss of self-confidence. It comes as no surprise that the mental toll often parallels the physical damage. Up to 84% of patients with TB have concomitant depression.

It’s important for policy and programmes to recognise that the association of TB and poor mental health is bidirectional. While the TB stigma, prolonged treatment, and adverse side effects can have deleterious effects on an individual’s mental health, poor mental health can also predispose a person to TB.  A weakened immune system known to be associated with mental stress and depression possibly contributes to vulnerability. In addition, addiction to tobacco, alcohol, and narcotics, all associated with mental health disorders, has been associated with a high incidence of TB, suggesting a causal association. The global burden of disease study estimates that in 2017, 197·3 million (95% UI 178·4–216·4) Indians had mental health disorders, making such persons a sizable TB high-risk population.

Standards of care in TB now mandate screening for diabetes and HIV infection among those diagnosed. Shouldn’t we also screen for depression and other mental health issues? In a global survey of national TB programmes (NTPs) of 26 countries, it was found that only two NTPs included routine screening for any mental disorder, four assessed alcohol or drug use, and five had standard protocols for the co-management of disorders. 

India needs to lead the way with a comprehensive framework and policy on TB and mental health. This should incorporate mental health screening as part of TB care. Studies have used simple questionnaires to screen all patients with TB at the time of diagnosis and these have yielded a good sensitivity. These questionnaires can be self-administered, or administered by community health workers or DOTS providers. Offering psychological support during treatment should also be a standard of care, with the knowledge that treatment can be arduous and stressful.

Screening for mental stress

Offering mental health supportive services is needed not only from the perspective of the individual patient but also from a perspective of arresting TB transmission. Studies have demonstrated that those with unaddressed mental health disorders are less likely to adhere to treatment, more likely to drop out of the treatment programme, and have a higher risk of poorer outcomes.

Once screened, we need to address the need for psychological support. While the challenges of limited personnel numbers remain, multiple studies have demonstrated the effectiveness of remote digital therapies such as cognitive behavior therapy for mild depression. App-based solutions, augmented with artificial intelligence, have been promising. India could leverage smartphone penetration to deliver such services if they are not available locally. As is the case for most community-based mental health interventions, we need to move out of hospitals and deliver such services close to communities.

There is also an urgent need to engage with communities not just to be spokespersons but also to work with those affected through support groups and informational support both to affected individuals and families. This has been done successfully in certain small experiments but now needs to be expanded at a national level to create community-based support systems and destigmatize mental health and TB. The community needs to be stakeholders at all levels in both policy and programme design. 

When care needs to be escalated, pathways for early referral to psychiatrists and prompt initiation of treatment need to be in place. This is likely to be challenging, considering the dearth of psychiatrists in the country. Given the magnitude of the burden of mental health disorders in the country, training more psychiatrists to serve an unmet need needs to be prioritised.

We cannot eliminate TB from India unless we comprehensively address the mental health care needs of TB-affected individuals. Addressing the intersection of TB and mental health demands a collaborative and comprehensive approach. Policymakers must focus on creating integrated policies that provide MH support. They also need to allocate resources and prioritise MH services within TB programmes. We need to start by recognising that TB and mental health are commodities, and the integration of mental health care in TB care is needed at every step of the TB care cascade.

(Chapal Mehra is an independent public health consultant: chapal@piconsulting.in; Lancelot Pinto is a consultant pulmonologist and an epidemiologist at P.D. Hinduja National Hospital, Mumbai: lance.pinto@gmail.com)