Treating TB patients' mental health
Treating depression and increasing the quality of social support should improve the overall management of TB infection and raise the cure rate, write PAMELA NAIDOO and KELVIN MWABA.
Despite the fact that tuberculosis (TB) is a completely curable disease, it is one of the leading causes of death among the age group five years and older. Adherence to treatment regimens is critical to changing that.
TB-related deaths were estimated at 1.3 million in 2007 with an additional 456 000 deaths among HIV-positive TB patients. Many people with TB are co-infected with HIV. Consequently, the HIV/AIDS pandemic has placed an additional burden on health authorities’ attempts to contain the cost of the treatment and prevention of TB.
People who have a lifelong or infectious disease and who have limited social, psychological and economic resources, find it extremely difficult to maintain a reasonable quality of life.
Based on a previous qualitative study at a public health clinic in the Cape Metropole, our study put forward the idea that assessing the prevalence and severity of the psychosocial factors of helplessness and depression, as well as the quality of social support among people with TB, may provide indicators of how to provide interventions. The findings indicated that helplessness and depression had a negative influence on adherence to the directly observed treatment short-course (DOTS) strategy. We concluded that assessment and treatment should include screening for depression and provide the necessary interventions.
The social determinants of health, such as anxiety, insecurity, low self-esteem, social isolation, lack of control over one’s home and working life, are well established. People who have a lifelong or infectious disease and who have limited social, psychological and economic resources, find it extremely difficult to maintain a reasonable quality of life.
The pioneering research by MEP Seligman (1975) examined learned helplessness and described how, when individuals are unable to control the events in their lives, they learn that they cannot affect outcomes and, therefore, cease to try. Learned helplessness is the reaction to repeated exposure to uncontrollable events that do not allow the individual to effect change.
According to Seligman, individuals become helpless in three specific areas, namely, motivational (when efforts to change the outcome cease), cognitive (when no new responses that could help avoid aversive outcomes in the future are learned), and emotional (when depression sets in).
Depression is one of the emotional reactions to a physical disorder. Individuals may develop depression because of a continued sense of helplessness about their poor quality of life. Thus helplessness and depression are integrally linked and negatively affect individual’s health outcomes. Limited social support or negative social support is also known to reduce an individual’s wellbeing and is positively associated with depression.
In this sample, a high percentage of participants infected with TB were co-infected with HIV, which makes them more susceptible to developing a mood disorder, such as depression, because they are experiencing the double burden of disease.
It is clear, therefore, that the interrelationship between helplessness, depression, and poor social support should be understood in order to improve health outcomes. In this study, participants – adults infected with TB attending a public health TB clinic in the Cape Metropole – completed a battery of questionnaires. They also completed a semi-structured questionnaire designed to assess helplessness.
Results: Depression is high
Participants numbered 166 (82 men and 84 women) with a mean age of 30.5 years, which was consistent with national and international statistics on the vulnerable age ranges for becoming infected with TB. In sub-Saharan Africa, TB and HIV co-infection is particularly prevalent among young adults. Significantly, 65% of the participants had a monthly household income of less than R500. Of the participants, 36.7% were HIV positive, of whom 31.1% were men. Bearing in mind that there was an almost equal number of male and female participants, it is important to note that the number of HIV-positive females was more than twice the number of HIV-positive males. The high HIV prevalence rate and the high TB co-infection rate of 36.7% found in this study is representative of sub-Saharan Africa. There was a high incidence of clinical depression in the sample (64.3%), categorised as mild mood disturbance – 26.1%, borderline clinical disturbance – 10.3%, moderate depression – 15.8%, severe depression – 9.7%, and extreme depression – 3.6%. The finding is consistent with the literature on mood disorders among chronically and terminally ill individuals. In this sample, a high percentage of participants infected with TB were co-infected with HIV, which makes them more susceptible to developing a mood disorder, such as depression, because they are experiencing the double burden of disease.
Participants in this study experienced the social support of close relatives in a positive way. This result is encouraging within the context of the way in which social support and health are currently conceptualised.
However, most participants did not report feelings of helplessness (89.1%). This finding, therefore, does not support the theoretical position that underpins this paper, in that Seligman described a sequence in which continual feelings of helplessness lead to learned helplessness, which eventually leads to depression.
This is notable because of their under-resourced social and economic environments, disease status, and the prevalence of depression among the group.
The finding has implications for health interventions. One might assume that if the depression is treated then these people should have better health outcomes because their depression has not evolved from a sense of helplessness in the face of adversity.
Social support a boon
The groups of people within the social network of the participants who were considered to be supportive were spouses, parents, children, siblings, relatives, friends and neighbours.
There is ample evidence in the literature that social support serves as a buffer to the challenges associated with illness. Participants in this study experienced the social support of close relatives in a positive way. This result is encouraging within the context of the way in which social support and health are currently conceptualised.
Participants’ low incidence of helplessness and high incidence of depression imply that effective management of the depression can improve the wellbeing of the TB patients. This finding can be used to advocate for a more holistic approach to healthcare programmes, particularly the inclusion of mental health services.
The DOTS approach to treating TB is demanding of the infected individual, so it stands to reason that in addition to the support of health practitioners, the support provided by members of the patient’s social network will probably help to improve their health status. The high co-infection rate of TB and HIV meant that participants were having dual therapies and were involved in dual treatment programmes. An enabling and supportive environment becomes even more crucial in this situation.
Ultimately, the goal of healthcare providers is to increase the cure rates for TB. In the setting in which this study took place, we advocate that treating depression should be prioritised by healthcare practitioners. In addition, improving and engaging social support should be seen as central to their health management. Increasing the quality of social support should decrease the severity of depression, which should, in turn, facilitate the overall management of TB infection.
Summary of an article published in Social Behaviour and Personality (2010).
Prof. Pamela Naidoo, chief research specialist, HSRC, and extraordinary professor, University of the Western Cape; Kelvin Mwaba, head of the Department of Psychology, University of the Western Cape.