Tuberculosis, which killed 1.5 million people worldwide in 2018 according to the World Health Organisation, is a rising public health concern. Its more dangerous forms – such as multiple drug resistant TB or MDR-TB and extreme drug resistant TB or XDR-TB – are also on the rise, posing a major challenge to countries like India.
However, in our single-minded approach to controlling the disease, we often ignore its relationship with mental health. We already know that TB patients can develop significant mental health issues, but what is less commonly discussed is that those with mental health issues are also prone to getting TB.
According to World Health Organisation estimates, 40%-70% of TB patients experience mental health disorders – treatment-induced as well as pre-existing. They struggle with anxiety, depression, fear, anger, uncertainty, loss of control, feelings of hopelessness, social isolation and low self esteem. In some cases, medication may even lead to psychosis.
These issues either develop as a psychological reaction to the treatment or as a side effect of anti-tubercular drugs, and can also arise from fear of stigma, discrimination, job loss and financial issues.
Amplifying the disease
Depression can amplify the negative impacts of the disease itself – by increasing functional impairment, leading to inactivity and poor diet, in turn increasing health care costs and mortality.
Those suffering from both TB and a medical illness are more likely to delay seeking treatment, not stick to medication, or not complete the treatment at all. This puts them at greater risk of advanced forms of the disease, drug resistance, treatment failure and even death. Moreover, they develop a higher chance of transmitting it to others, leading healthcare staff to develop a negative bias against them.
Lack of awareness is the biggest reason for these cases going undiagnosed and untreated. While they are seen as understandable in the context of the situation, there is still discomfort around addressing and discussing them. Health workers also find it time-consuming to tackle such questions and are, more often than not, inadequately trained.
The path ahead
In order to address TB patients’ mental health issues, interventions should be planned at various levels. To begin with, the Revised National Tuberculosis Control Programme must put greater emphasis on this. This can be achieved by training health workers, educating the public, integrating mental health services with TB treatment, and ensuring adequate manpower and funds.
Health workers must be trained to identify mental illnesses and manage them through basic counselling. Further, they should be able to educate the patients and their family about the issues and refer them to mental health care professionals, if needed, for advanced care. Mental healthcare professionals too can help in providing such training.
The patients’ family members also play an important role. They must immediately report any red flags to the doctor, and ensure effective communication, support and reassurance to the patient. Most importantly, the patients themselves must fully understand the condition, the medication and its side effects.
For any programme working towards eradicating TB, there must be a renewed focus on the patients’ mental health. A strong link must be developed between the state, doctors, mental health professionals, the patients and their families. The programmes must be designed to look at individuals, not just the disorder.
Treating mental health issues will improve medication adherence and treatment completion, and reduce drug resistance, transmission and mortality rates. It is hard to achieve a healthy body without a healthy mind – and any disease eradication programme cannot afford to ignore this link.
Saurabh Mehrotra is a consulting psychiatrist and mental health expert at Medanta Hospital.
March 24 is World Tuberculosis Day.
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