Globally, stress, fear, anxiety and isolation stemming from the Covid-19 pandemic have made mental health a prominent topic in public discourse.
While this is a welcome change from the deafening silence on mental health issues, we need to put our money where our mouth is when it comes to managing mental health and infectious diseases together. Not just in the context of Covid-19, but also for tuberculosis.
TB is an epidemic which kills over 1,200 Indians on an average daily, and has dire mental health effects. As per the World Health Organization, between 40% and 70% of TB patients have comorbid mental health disorders. Add to this fact that a WHO report also cites that India has the dubious distinction of having the highest burden of tuberculosis cases globally.
TB and mental health are twin comorbidities that affect a significant number of people in India and yet, the National TB Elimination Programme does not even list mental health as a comorbidity for TB, much less invest in managing these comorbidities.
The medical community is also generally focused on diagnosis and treatment and does not consider mental health concerns to be a relevant factor in TB treatment outcomes. This is because historically, physical health has been given more importance than mental health. So, the diagnosis of TB and adherence to TB are considered important hardcore medical issues. Mental health is seen as a “soft” concern.
Effects on mental health
In order to understand how catastrophic this lack of investment and attention in managing these twin comorbidities is, we need to understand the effect TB has on the mental health of patients.
Given that certain forms of TB are contagious, isolating the patient is a strategy of containment even in TB care like we are currently witnessing in Covid-19 care. This isolation and the stigma around TB both have a significant impact on a patient’s mental health.
In addition to this, medication for drug-resistant forms of TB have severe mental health side effects such as depression, anxiety and in extreme cases even psychosis. Moreover, there are other factors such as the long duration of the treatment and the loss of opportunity or stable permanent income that are stressful for the patient.
All of these factors make the patient susceptible to another epidemic – depression. Contract one epidemic, get one free is the story of TB patients. With the pandemic now, the mental health condition of TB patients is only further exacerbated with fears about catching Covid.
Completing treatment is critical to curtailing the spread of TB. However, a patient facing mental health challenges, in the absence of mental health support finds it difficult to continue treatment and many give up on treatment. This affects the quality of life of the patient but also has grave public health consequences in that an untreated patient is likely to infect others.
Providing mental health support
As India is dealing with Covid-19 pandemic, we cannot afford to see a surge in the infectious TB epidemic. Therefore, investment in providing mental health support that allows patients to complete treatment is critical if we want to stop TB from spreading.
In the context of TB care, this investment needs to happen at multiple levels.
The first step is to integrate mental health care into TB care at a programmatic level and make ongoing mental health support available to patients at every step of the TB care cascade. Integration of mental health as a comorbidity in TB care requires investment in mental health care on the preventive front (awareness and screening) as well as the curative front (treatment and counselling). From an investment perspective, the first question that comes up in India is the resource constraint argument.
Given that we work with resource constraints getting communities invested in providing mental health support is critical in such settings. This is on account of the fact that because of the shortage of mental health professionals in India, communities are often the first line of support.
The way to get communities invested in this project is by treating them as equal stakeholders in not just implementing but designing mental health care strategy and skilling them in providing basic mental health support.
Skilling of all health personnel in basic mental health screening and counselling is also important as is investing in training individuals to become mental health professionals.
Finally, investment in research on the relationship between mental health and TB is critical to the national program develops a nuanced understanding of these twin comorbidities and is better able to cater to patient needs in this context.
We cannot fight TB successfully unless we invest in fighting the attendant invisible mental health challenges it presents.
Diptendu Bhattacharya is an educationist and Ashna Ashesh is a lawyer and public health professional. Both are MDR-TB survivors and Fellows associated with Survivors Against TB, a collective of survivors, advocates and experts working on TB and related comorbidities.