How mental health contributes to Tuberculosis bacillus

India is one of the countries where TB (tuberculosis bacillus) is still a dreaded disease and continues to ravage and cause havoc. Drug-resistant strains of the disease have only added to the challenges. WHO in the global TB report 2022 has laid down that 21.4 lakh TB cases have been notified in India in 2021 which is higher than what was reported in 2020. The stigma associated with TB acts as a deterrent to getting the right treatment at the right time as well as hinders adherence to treatment which results in increased mortality rates.

When it comes to stigma, mental health matters are an equal if not an even more stigmatised affair. The increasing number of suicides in India is an indication of our deteriorating mental health status. The global prevalence of depression stands at a staggering 300 million people which accounts for 4.4 % of the world’s population. National Crime Records Bureau has reported a surge in completed suicides in the year 2021 with a number of 1,64, 033 individuals. The state of Kerala has also witnessed a parallel surge. Recent data indicates that there was a 12.34 % increase in the number of completed suicides with Kollam district alone leading with 45.3 %.

Apart from being a stigmatised affair, TB and mental illness both share common risk factors including homelessness, HIV-positive serology, and alcohol/substance abuse thus leading to frequent comorbidity. Studies have found that the incidence of TB was found to be greater in those with mental disorders when compared to controls. Common mental disorders like depression, anxiety and somatoform disorders were found to be with higher odds for having TB. Individuals with schizophrenia are also found to be at high risk for developing TB.

One of the reasons for this is the presence of a pre-existing mental health issue which can negatively affect one’s immune system thus putting them at a higher risk for contracting TB. The immunological changes associated with psychosocial stressors have been found to increase susceptibility to TB.

Although the exact pathways with regard to the immunological changes are unknown, mental health could be one factor which influences the progression to active TB. This suggests that mental health is a risk factor for active TB and that suffering from a mental illness might pose a risk factor for contracting TB. Studies have also indicated that some of the medications used in the treatment of TB can cause depression and psychosis.

The recent Covid-19 pandemic has brought with it devastating psychosocial and socio-economic issues. The result is a 25% increase in anxiety/depression cases along with sleep disturbances and substance abuse. It is evident that mental health has a direct bearing on one’s physical health as well and it can compromise one's immune system. So, for those individuals with TB, it is all the more important that mental health be routinely reviewed and psychological support taken if needed.

Even though Kerala seems to be leading in the total eradication program of TB, ignoring mental health issues might prove as a dampener. A recent study reported the prevalence of depression in individuals with TB to be 16.1%, in the district of Ernakulam alone. This is an indicator of the importance of regular screening for mental health issues in TB- affected individuals. The presence of depressive symptoms alongside TB can affect medication adherence and thus delay treatment and eventually worsen the prognosis. Substance abuse is another co-morbid condition observed to be present in those with TB. The prevalence of any co-morbidities can complicate help-seeking behaviour. The presence of mental health issues in TB can further pull back the momentum Kerala has gathered unless appropriate steps are taken to address both issues as focusing on TB alone is not going to win the battle for the state

What stands in the way of seeking help?

An individual with TB is already laden with the perceived burden of being isolated and being looked down upon in society. They also fear being isolated at their job places or being laid off. Women fear reduced prospects for marriage and those already married, fear separation/divorce /rejection from family members etc. Along with it the fear of being labelled by society to be “mentally ill” and the fear of being kept away or being talked about, prevent people from seeking help at the right time. Moreover, the stigma doesn’t end with the illness. It persists. So it is also important to have gender-sensitive interventions targeting stigma. Also, focus on integrating them into the community. Addressing stigma is key to the prevention of TB.

Among those individuals who make it to the clinic, most of the psychiatric/psychological symptoms are often overlooked or brushed aside. This is mostly due to a paucity of trained personnel. The existing systems need to be strengthened for the same. The screening process for mental health issues need not take more than 5 minutes and those screened positive should be referred for additional care. Incorporating ASHA workers and TB survivors and enabling them to screen for MH issues can go a long way but a proper referral system also needs to be followed up.

Mental health support systems which had been in place for tackling Covid -19 can still be used and incorporated with the existing systems. Qualified and trained clinicians/clinical psychologists should be integrated into the program. In the matter of the appointment of well-trained personnel who otherwise can make a difference in tackling the epidemic of mental health issues, an apathetic attitude has been noticed. Recently there had been reports of a dearth of clinical psychologists and a laxity in their appointments across the government sector hospitals in the district of Alleppey. The situation in other districts is not much different. The alternative option to consult clinicians outside the government sector often proves to be a costly affair and the allowance of Rs 500 allowed for TB patients would not be sufficient for them to seek help from the private sector.

Another reason would be that since there aren’t any exclusive health centres for TB, consultation is a hurried affair for both the TB-affected and health workers alike. On any day, there will be other conditions too to be dealt with which increases the burden on the healthcare workers. The unfriendly/weary approach coupled with a lack of adequate know-how about the condition of individuals with TB can also affect the treatment and its outcome. When this happens, there will be an increase in the pre-treatment loss to follow-up. This can be solved by proper counselling and psycho-education.

Possible Remedial Measures

Community intervention from the grassroots level can be utilized for sensitizing as well as for intervention. Socially influential persons may be made roped in for the same. Mandatory screening of migrant labourers and testing at the school level and involving organizations like student cadets and NCC can also help achieve the purpose. Awareness programs need to be conducted at various community levels including schools.

Gender disparity exists even in the attitude towards the patients as well, with women displaying more stigma-induced behaviours compared to men. Thus it is important to have gender-sensitive interventions in relieving stigma.

It has been found that tackling poverty and associated poor mental health through investment in wider social policies could help reduce the incidence of TB. This highlights the need for integrated programmes providing care for mental health and TB and suggests that interventions that tackle mental illnesses and their underlying drivers may help reduce its incidence globally.

Other helpful aspects for tackling the disease include workshops for health care providers on the use of soft skills, including suitable tone of voice, counselling techniques, avoidance of stigmatizing language, and encouraging health care providers to openly discuss TB with persons with TB and their inner circle. Educating medical personnel involved in the provision of TB care on the use of non -stigmatizing language at all levels of health/medical education, service delivery, and program management.

Can also go a long way. For this social scientists may be engaged to deal with the social aspects of TB. Educating on patient rights - to be treated with dignity and respect - can help in the fight against stigma. Engaging social workers and psychologists in the support and management of persons with TB can help establish links between TB service providers and mental health specialists.

When it comes to changes with regard to policy and clinical practice, a holistic approach which integrates services for both mental health and TB can enable rapid diagnosis and treatment of TB, as well as provide better mental health support for individuals with TB. WHO has recommended that treatment for TB and mental health be brought together. Providing high-quality mental health support and ensuring treatment adherence for TB both require substantial engagement with patients.

The overlap in TB and mental health issues indicates the need for a mandatory bidirectional screening wherein the mental health of individuals with TB are reviewed and those with mental health issues are routinely screened for TB as well. High-quality counselling and/or psychotherapy and integrating TB with mental health care services can help in strengthening the overall TB care as well as in achieving the goal of eliminating TB by 2025.

Credits to: Dr Sabir M C (Senior Consultant Pulmonology), and Dr Soji Anna Philip (Consultant-Clinical Psychologist -Kochi)

The author is a senior sub-editor with madhyamam daily