Addressing the tuberculosis–depression syndemic to end the tuberculosis epidemic

Abstract

Tuberculosis (TB) and depression act synergistically via social, behavioral, and biological mechanisms to magnify the burden of disease. Clinical depression is a common, under-recognized, yet treatable condition that, if comorbid with TB, is associated with increased morbidity, mortality, community TB transmission, and drug resistance. Depression may increase risk of TB reactivation, contribute to disease progression, and/or inhibit the physiological response to anti-tuberculosis treatment because of poverty, undernutrition, immunosuppression, and/or negative coping behaviors, including substance abuse. Tuberculous infection and/or disease reactivation may precipitate depression as a result of the inflammatory response and/or dysregulation of the hypothalamic-pituitary-adrenal axis. Clinical depression may also be triggered by TB-related stigma, exacerbating other underlying social vulnerabilities, and/or may be attributed to the side effects of anti-tuberculosis treatment. Depression may negatively impact health behaviors such as diet, health care seeking, medication adherence, and/or treatment completion, posing a significant challenge for global TB elimination. As several of the core symptoms of TB and depression overlap, depression often goes unrecognized in individuals with active TB, or is dismissed as a normative reaction to situational stress. We used evidence to reframe TB and depression comorbidity as the ‘TB–depression syndemic’, and identified critical research gaps to further elucidate the underlying mechanisms. The World Health Organization’s Global End TB Strategy calls for integrated patient-centered care and prevention linked to social protection and innovative research. It will require multidisciplinary approaches that consider conditions such as TB and depression together, rather than as separate problems and diseases, to end the global TB epidemic.

Factors associated with delay in treatment initiation for pulmonary tuberculosis

“…Therefore, non-language barriers to presentation such as stigma, TB knowledge and healthcare eligibility issues [7] may confound this relationship. Mental health barriers were associated with a doubling of presentation delay on complete case analysis, which would be consistent with the literature suggesting that mental health disorders (specifically depression) can delay healthcare seeking [14]. However, mental health barriers were not associated with presentation delay on sensitivity analysis removing the 1% of outlying (longest) delays, suggesting that our estimates for mental health barriers were overly influenced by cases with outlying delays.…”

Prevalence of tuberculosis among mentally ill patients in conflict-stricken Afghanistan: A cross-sectional study

“…Poverty is a common driver of TB (WHO, 2013;Figueroa-Munoz and Ramon-Pardo, 2008;Lund et al, 2011) and mental illnesses (Lund et al, 2011). Mental illness can result from having TB disease because of stigma, social vulnerabilities such as malnutrition, and the side effects of TB drugs (Sweetland et al, 2017). The poor lack adequate housing and food; experience more stress than people who are better off; and lack access to health care.…”

Tuberculosis: renewed challenge in Brazil

“…Globally, in spite of the implementation of these strategies, the access and detection of TB cases remain unchanged, mainly among those living in large urban areas, with drug resistance, vulnerable populations (HIV-infected individuals, inmates, drug users, homeless, children, and adolescents) or with comorbidities [human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), mental health disorders, diabetes mellitus, and smoking] [6][7][8][9] .…”

“…Recently, clinical and operational research have indicated that the approaches are more effective when they respond to local socio-cultural characteristics, organization of health service delivery, and type of community activities. These approaches should cover the cascade of actions that include local TB transmission control, screening, and diagnostic investigation of active and latent TB, followed by its antimicrobial treatment, incorporating biomedical approaches [9][10][11][12][13] , biopsychosocial 8,14 , strengthening social protection 15,16 , community participation 17 , and political commitment 18 . However, in high TB burden countries, operational research performed to cover such approaches are limited.…”