Tuberculosis (TB) in India continues to present a major threat to the overall health and social- and economic-well being of the country. Along with China and Russia, India accounts for half the world’s TB cases. The proliferation of drug-resistant strains of the disease is an added challenge to the government’s goal of eliminating TB by 2025.
TB is one of the top 10 causes of death worldwide. TB incidence in India has always been cause for concern and the fight to end this epidemic gained momentum with the government resolution to end TB by 2025 under the National Strategic Plan (NSP) 2017 - 2025.
Despite this, one critical aspect of TB care – it’s correlation with mental health – remains overlooked. A 2016 study in the Journal of Family Medicine and Primary Care said that 74o f 100 patients diagnosed with TB, referred to the psychiatry department of the same hospital, demonstrated psychiatric symptoms.
Still, TB is rarely associated with mental health. Health service providers and researchers have restricted their focus to the physiological effects of the disease and the connection between TB and mental health remained unexplored. While TB can affect anyone, regardless of socio-economic status, it is especially prolific among the underserved. Cramped and unhygienic living conditions, as in the country’s most populated cities, gives the air-borne infectious disease opportunity to thrive. Malnourishment and health conditions such as diabetes also increase the risk of infection.
Patients with HIV are most vulnerable and account for the high incidence of TB in India, with 80% affected of HIV patients being infected by TB. Stigma associated with both diseases prompts many to hide the infection and not access diagnostic or treatment services. The case for ending TB globally has repeatedly shown that a multi-faceted approach is key to effectively eliminating the diseases. Mental health is a key part of that.
With survivors speaking out more frequently about their experience of TB and mental health, there is evidence of depression, loneliness, anxiety and low self-esteem associated with the disease. Besides cases of drug-induced psychiatric symptoms, TB-related stigma can also have a debilitating effects on patients.
The long duration of treatment — typically six to eight months — often leads to fatigue and treatment discontinuation. The resulting adverse outcomes include morbidity, mortality, drug resistance and disease transmission. Frequent absences from school or work resulting in lost productivity, turbulent inter-personal relationships and poor social support can foster feelings of worthlessness. Common mental disorders, such as substance abuse, also increases the risk to TB patients. Smoking is also a major risk factor.
Psychological support
The need for addressing mental health in TB has gained momentum in recent years. The evidence base is small but compelling. It indicates that better treatment outcomes are possible when psychological support is provided. In Peru, group-based psychological support for patients with multidrug resistant tuberculosis (MDR-TB) significantly improved treatment outcomes; in Ethiopia, an educational and psychological intervention improved adherence and ‘TB clubs’ successfully reduced stigma leading to improved outcomes.
In India, too, there is evidence that counselling results in better adherence. Initiatives such as Saksham Pravah Project provide home-based counselling to MDR-TB patients and caregivers. Patients are encouraged to share fears and talk about the discrimination, depression, and familial discord they face. In Kerala, treatment support groups encourage the community to provide social help to patients, also resulting in positive outcomes.
The ‘Guidelines on Programmatic Management of Drug Resistant TB’ by the Revised National Tuberculosis Control Programme (RNTCP) state that counselling is an important part of treatment. But translating this into action is challenging.
Psychiatric symptoms are often overlooked due to a lack of trained counsellors. Stigma prevents people from seeking counselling services and gets in the way of developing support systems. To address this, the need for health systems strengthening takes increasing precedence. Training providers and communities about the risks mental health disorders pose to the continued spread of TB, as well as the psychological effects of TB on patients, is key to eliminating the disease by 2025.
Incorporating messaging to end stigma around TB in community programs and having the government encourage social mobilization, like in Kerala, is also key. Providing screening and counselling services as part of the DOTS program can integrate mental health in the TB treatment process too.
India accounts for 27% of the world’s TB burden. The resulting losses in productivity, growth and wellbeing are enormous. As part of the effort to meet Sustainable Development Goal (SDG) 3 – ending the TB epidemic by 2030 – it is imperative that the government and partner organizations take into consideration that an inclusive approach that addresses mental health is the need of the hour.
(Dr. Lakshmi Vijayakumar is founder of SNEHA and member of the World Health Organisation's network on suicide research and prevention. She is also member of the International Academy of Suicide Research; Dr. Sukriti Chauhan is a lawyer who specializes in communications, advocacy and strategic engagement in public health and Priyasha Banerjie is an advocacy and communications professional with experience in public health)
