Internalized and Perceived Stigma and Depression in Pulmonary Tuberculosis: Do They Explain the Relationship Between Drug Sensitivity Status and Adherence?

Abstract

BackgroundAdherence to medication for tuberculosis (TB) has been found to be deleteriously affected by psychosocial issues, including internalized and perceived stigma (IPS) and depression, usually resulting in the emergence of multidrug-resistant TB (MDR-TB). The objective of the study was to find the prevalence of depression among patients receiving treatment for pulmonary TB, and how stigma and depression affect the relationship between drug sensitivity status (DSS) and treatment adherence.MethodIt was a cross-sectional observational study conducted between January 2019 and July 2020 in two centers in Sikkim, India. The Patient Health Questionnaire-9 (PHQ-9), Internalized Social Stigma Scale (ISSS), and Tuberculosis Medication Adherence Scale were used to assess depression, IPS, and medication adherence, respectively. A path analysis was performed with DSS, treatment adherence, IPS, and depression. Education in years was included in the model as it was significantly correlated with IPS.ResultsA total of 71 patients who were on drug-sensitive TB (DS-TB) regimen (n = 26) and MDR-TB regimen (n = 45) participated in the study. Notably, 56.3% (n = 40) of the participants were found to have depression. Among the depressed participants, 32.5% were on the DS-TB regimen and 67.5% were on the MDR-TB regimen. The path analysis indicated that IPS and depression were serially mediating the relationship between DSS and treatment adherence (β = −0.06, p < 0.05, 95% CI = −3.20, −0.02). Finally, years of education had an exogenous predictor role, not only directly affecting IPS (β = −0.38, p < 0.001, 95% CI = −0.99, −0.31) but also affecting treatment adherence through IPS and depression (β = 0.08, p = 0.02, 95% CI = 0.03, 0.47). This indicated that with more years of education, the IPS decreases, which decreases depression and ultimately leads to better adherence.ConclusionWe found an important relationship between different psychosocial factors which may affect treatment adherence. Patients who have higher IPS are more likely to develop depression which negatively affect adherence. Patients on the MDR-TB regimen have higher stigma. There is an urgent need to integrate mental health services with TB Control Programs.

Stigma, depression, and quality of life among people with pulmonary tuberculosis diagnosed through active and passive case finding in Nepal: a prospective cohort study

“…It is also interesting to note the findings that despite the decrease in depression towards the end of treatment, stigma persisted for both ACF and PCF groups. Stigma has been associated with years of education, poor knowledge regarding TB and its transmission, perceived risks of transmission, poverty, and socioeconomic class [19,30]. In our study, more than half of our participants did not have basic literacy and are poor which might be the reason for enduring stigma in this cohort.…”

“…Our study found that a high proportion of people with TB perceived TB stigma. The association between stigma and depression is well established and individuals having internalized or TB stigma have a higher likelihood of having depression [30]. This suggests that psychosocial support programs including stigma reduction interventions, especially when implemented early in treatment, could be effective in mitigating the impact of TB on mental health and internalized stigma.…”

“…Stigma, depression, and quality of life (QoL) are known to be intricately related. There is evidence that depression, stigma, and low QoL exhibit clustering at the individual level [28,29], which can, collectively, have an adverse effect on TB treatment adherence and outcomes [30]. Stigma can be a precursor to depression and having depression can impede individuals' capacity to engage in daily activities and mitigate stigmatizing thoughts and actions [28,30,31].…”

“…There is evidence that depression, stigma, and low QoL exhibit clustering at the individual level [28,29], which can, collectively, have an adverse effect on TB treatment adherence and outcomes [30]. Stigma can be a precursor to depression and having depression can impede individuals' capacity to engage in daily activities and mitigate stigmatizing thoughts and actions [28,30,31]. QoL is lower in people with TB than those without, for multifactorial reasons which include a complex interplay of physical illness, financial burden, and psychosocial consequences of the disease.…”

Editorial: Community series in mental health promotion and protection, volume II

“…Other factors like lack of access to appropriate care, poor social support and economic hardship can contribute to poor SWB despite adequate MHL. The role of education and awareness about both mental illnesses and physical illnesses ( 5 ) has an important role to play in adherence and better prognosis.…”