The relationship between mental health and risk of active tuberculosis: a systematic review

Mental illness and pulmonary tuberculosis: a bidirectional two-sample Mendelian randomization study

Background

Observational studies have confirmed that mental illness and pulmonary tuberculosis are closely related and increase each other's incidence; however, whether there is a causal genetic association between the two diseases remains unknown. We attempted to answer this question using bidirectional two-sample Mendelian randomization (MR) in a large cohort study.

Method

We performed a bidirectional MR analysis between mental illness (major depressive, anxiety disorder, bipolar disorder, and schizophrenia) and pulmonary tuberculosis using summary statistics from genome-wide association studies in European individuals. The inverse-variance weighted method was used as the primary analytical method to assess causality. In addition, other additional MR methods (weighted median, MR-Egger, and weighted mode) were used to supplement the inverse-variance weighted results. Furthermore, several sensitivity analyses were performed to assess heterogeneity, horizontal pleiotropy, and stability.

Result

We identified no causal genetic association between mental illness and pulmonary tuberculosis after applying the inverse variance weighted method (major depressive: odds ratio (OR) = 1.00, 95% confidence interval (CI) = 0.59-1.71, P = 0.98; anxiety disorder: OR = 1.72, 95% CI = 0.05-67.67, P = 0.76; bipolar disorder OR = 0.89, 95% CI = 0.66-1.22, P = 0.48; and schizophrenia: OR = 1.05, 95% CI = 0.91-1.20, P = 0.51). Similarly, pulmonary tuberculosis was not caustically associated with mental illness (major depressive: OR = 1.01, 95% CI = 1.00-1.02, P = 0.17; anxiety disorder: OR = 1.00, 95% CI = 0.99-1.01, P = 0.06; bipolar disorder: OR = 1.02, 95% CI = 0.98-1.07, P = 0.38; and schizophrenia: OR = 1.01, 95% CI = 0.97-1.05, P = 0.66).

Conclusion

Our research does not support a bidirectional causal association between the aforementioned mental illnesses and pulmonary tuberculosis.

Characteristics of Comorbid Physical Disease in Patients With Severe Mental Illness in South Korea: A Nationwide Population-Based Study (2014-2019)

OBJECTIVE

The purpose of this study was to identify the associations of chronic physical disease between patients with severe mental illness (SMI) and the general population of South Korea.

METHODS

This study was conducted with National Health Insurance Corporation data from 2014 to 2019. A total of 848,058 people were diagnosed with SMI in this period, and the same number of controls were established by matching by sex and age. A descriptive analysis was conducted on the sociodemographic characteristics of patients with SMI. Conditional logistic regression analysis was performed to identify the associations between comorbid physical disease in patients with SMI and those of the general population. SAS Enterprise Guide 7.1 (SAS Inc, Cary, NC, USA) were used to perform all statistical tests.

RESULTS

The analysis revealed significant differences in medical insurance, income level, and Charlson Comorbidity Index weighted by chronic physical disease, between patients with SMI and the general population. Conditional logistic regression analysis between the two groups also revealed significant differences in eight chronic physical diseases except hypertensive disease.

CONCLUSION

This study confirmed the vulnerability of patients with SMI to chronic physical diseases and we were able to identify chronic physical disease that were highly related to patients with SMI.

A longitudinal prospective study of active tuberculosis in a Western Europe setting: insights and findings

PURPOSE

This study investigates the potential of inflammatory parameters (IP), symptoms, and patient-related outcome measurements as biomarkers of severity and their ability to predict tuberculosis (TB) evolution.

METHODS

People with TB were included prospectively in the Stage-TB study conducted at five clinical sites in Barcelona (Spain) between April 2018 and December 2021. Data on demographics, epidemiology, clinical features, microbiology, and Sanit George Respiratory Questionnaire (SGRQ) and Kessler-10 as Health-Related Quality of Life (HRQoL) were collected at three time points during treatment. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil/lymphocyte, and monocyte/lymphocyte ratios (NLR and MLR), complement factors C3, C4, and cH50, clinical and microbiological data, and HRQoL questionnaires were assessed at baseline, 2 months, and 6 months. Their ability to predict sputum culture conversion (SCC) and symptom presence after 2 months of treatment was also analysed.

RESULTS

The study included 81 adults and 13 children with TB. The CRP, ESR, NLR, and MLR values, as well as the presence of symptoms, decreased significantly over time in both groups. Higher IP levels at baseline were associated with greater bacillary load and persistent symptoms. Clinical severity at baseline predicted a delayed SCC. Kessler-10 improved during follow-up, but self-reported lung impairment (SGRQ) persisted in all individuals after 6 months.

CONCLUSIONS

IP levels may indicate disease severity, and sustained high levels are linked to lower treatment efficacy. Baseline clinical severity is the best predictor of SCC. Implementing health strategies to evaluate lung function and mental health throughout the disease process may be crucial for individuals with TB.

Association between tuberculosis and psychotic experiences: Mediating factors and implications for patient care in low- and middle-income countries

Background

Tuberculosis may play a role in the aetiology of psychosis. However, little is known about the association between tuberculosis and psychotic experiences (PEs) or the mediating factors of this association.

Methods

We analysed cross-sectional data from 48 low- and middle-income countries of the World Health Survey (WHS). Tuberculosis assessment was based on past 12-month symptoms of active tuberculosis. We assessed four types of past 12-month PEs with the Composite International Diagnostic Interview. We performed multivariable multinomial logistic regression and mediation analysis.

Results

We analysed data on 224 842 individuals aged ≥18 years (mean age = 38.3 years, standard deviation = 16.0; 50.7% women). Tuberculosis was associated with 1.84 (95% confidence interval (CI) = 1.41-2.40), 2.18 (95%CI = 1.58-3.03), and 3.79 (95%CI = 2.88-4.98) times higher odds for 1, 2, and ≥3 PEs, respectively. The mediation analysis showed that the association between tuberculosis and at least one PE is mainly explained by anxiety (31.5%), sleep/energy (27.8%), and pain/discomfort (23.5%).

Conclusions

Tuberculosis was associated with increased odds of PEs. Factors such as affect, sleep, and pain should be considered in tuberculosis patients to target those who might be particularly vulnerable to PEs, and consequently, to psychotic disorders and other adverse effects of PE.

A model-based approach to estimating the prevalence of disease combinations in South Africa

BACKGROUND

The development of strategies to better detect and manage patients with multiple long-term conditions requires estimates of the most prevalent condition combinations. However, standard meta-analysis tools are not well suited to synthesising heterogeneous multimorbidity data.

METHODS

We developed a statistical model to synthesise data on associations between diseases and nationally representative prevalence estimates and applied the model to South Africa. Published and unpublished data were reviewed, and meta-regression analysis was conducted to assess pairwise associations between 10 conditions: arthritis, asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, HIV, hypertension, ischaemic heart disease (IHD), stroke and tuberculosis. The national prevalence of each condition in individuals aged 15 and older was then independently estimated, and these estimates were integrated with the ORs from the meta-regressions in a statistical model, to estimate the national prevalence of each condition combination.

RESULTS

The strongest disease associations in South Africa are between COPD and asthma (OR 14.6, 95% CI 10.3 to 19.9), COPD and IHD (OR 9.2, 95% CI 8.3 to 10.2) and IHD and stroke (OR 7.2, 95% CI 5.9 to 8.4). The most prevalent condition combinations in individuals aged 15+ are hypertension and arthritis (7.6%, 95% CI 5.8% to 9.5%), hypertension and diabetes (7.5%, 95% CI 6.4% to 8.6%) and hypertension and HIV (4.8%, 95% CI 3.3% to 6.6%). The average numbers of comorbidities are greatest in the case of COPD (2.3, 95% CI 2.1 to 2.6), stroke (2.1, 95% CI 1.8 to 2.4) and IHD (1.9, 95% CI 1.6 to 2.2).

CONCLUSION

South Africa has high levels of HIV, hypertension, diabetes and arthritis, by international standards, and these are reflected in the most prevalent condition combinations. However, less prevalent conditions such as COPD, stroke and IHD contribute disproportionately to the multimorbidity burden, with high rates of comorbidity. This modelling approach can be used in other settings to characterise the most important disease combinations and levels of comorbidity.

Cost-effectiveness of interferon-γ release assay for screening of latent tuberculosis infection in individuals with schizophrenia

Schizophrenia is recognized as a significant risk factor for tuberculosis (TB). This study aimed to evaluate the effectiveness and cost-effectiveness of interferon-γ release assay (IGRA) with preventive treatment for screening of latent tuberculosis infection (LTBI) in individuals with schizophrenia. A state transition model was developed from a healthcare payer perspective on a lifetime horizon. Ten strategies were compared by combining two different tests for LTBI, i.e. IGRA and tuberculin skin test (TST), and five different preventive treatments, i.e. 9-month isoniazid (9H), 3-month isoniazid and rifapentine (3HP) by directly observed therapy, 3HP by self-administered therapy, 3-month isoniazid and rifampin (3RH), and 4-month rifampin (4R). The main outcomes were costs, quality-adjusted life-years (QALYs), life expectancy life-years (LYs), incremental cost-effectiveness ratios, drug-sensitive tuberculosis (DS-TB) cases, and TB-related deaths. For both bacillus Calmette-Guérin (BCG)-vaccinated and non-BCG-vaccinated individuals, IGRA with 4R was the most cost-effective and TST with 3RH was the least effective. Among schizophrenic individuals in Japan, IGRA with 4R saved US$17.8 million, increased 58,981 QALYs and 935 LYs, and prevented 222 DS-TB cases and 75 TB-related deaths compared with TST with 3RH. In individuals with schizophrenia, IGRA with 4R is recommended for LTBI screening with preventive treatment to reduce costs, morbidity, and mortality from TB.

Validation of a brief screener for broad-spectrum mental and substance-use disorders in South Africa

In low-resource settings, valid mental health screening tools for non-specialists can be used to identify patients with psychiatric disorders in need of critical mental health care. The Mental Wellness Tool-13 (mwTool-13) is a 13-item screener for identifying adults at risk for common mental disorders (CMDs) alcohol-use disorders (AUDs), substance-use disorders (SUD), severe mental disorders (SMDs), and suicide risk (SR). The mwTool-13 is administered in two steps, specifically, only those who endorse any of the initial three questions receive the remaining ten questions. We evaluated the performance of mwTool-13 in South Africa against a diagnostic gold standard. We recruited a targeted, gender-balanced sample of adults, aged ≥18 years at primary and tertiary healthcare facilities in Eastern Cape Province. Of the 1885 participants, the prevalence of CMD, AUD, SMD, SR, and SUD was 24.4%, 9.5%, 8.1%, 6.0%, and 1.6%, respectively. The mwTool-13 yielded high sensitivities for CMD, SMD, and SR, but sub-optimal sensitivities for AUD and SUD (56.7% and 64.5%, respectively). Including a single AUD question in the initial question set improved the tool's performance in identifying AUD and SUD (sensitivity > 70%), while maintaining brevity, face-validity, and simplicity in the South African setting.

"This is an illness. No one is supposed to be treated badly": Community-based stigma assessments in South Africa to inform TB stigma intervention design

Background

Though TB-related stigma is a recognized barrier to care, interventions are lacking and gaps remain in understanding the drivers and experiences of TB-related stigma. We undertook community-based mixed methods stigma assessments to inform stigma intervention design.

Methods

We adapted the Stop TB Partnership stigma assessment tool, and trained three peer research associates (PRAs; two TB survivors, one community health worker) to conduct surveys with people with TB (PWTB, n=93) and caregivers of children with TB (n=24) at peri-urban and rural clinic sites in Khayelitsha, Western Cape, and Hammanskraal, Gauteng Province, South Africa. We descriptively analyzed responses for each stigma experience (anticipated, internal, and enacted), calculated stigma scores, and undertook generalized linear regression analysis. We further conducted 25 in-depth interviews with PWTB (n=22) and caregivers TB (n=3). Using inductive thematic analysis, we performed open coding to identify emergent themes, and selective coding to identify relevant quotes. Themes were organised using the CARD (Constraints, Actions, Risks and Desires) framework.

Results

Surveys revealed at least one-third of PWTB and one-quarter of caregivers report experiences of anticipated, internal, and/or enacted stigma, which affected engagement throughout the care cascade. Participants in rural locations (compared to peri-urban) reported higher anticipated, internal, and enacted stigma (β-coefficient 0.72, 0.71, and 0.74). Interview participants described how stigma experiences, including HIV intersectional stigma, act individually and in concert as key constraints to impede care, and underpins failure to disclose a TB diagnosis, isolation, and exclusion. Stigma resilience arose through understanding that TB can affect anyone and should not diminish self-worth. Risks of stigma, driven by fears related to disease severity and infectiousness, led to care disengagement and impaired psychological wellbeing. Participants desired counselling, identifying a specific role for TB survivors as peer counsellors, and community education.

Conclusions

Stigma is highly prevalent and negatively impacts TB care and the well-being of PWTB, warranting its assessment as a primary outcome indicator rather than intermediary contributor to poor cascade outcomes. Multicomponent stigma interventions are needed, including counselling for PWTB and education for health workers and communities. Such interventions must incorporate contextual differences based on gender or setting, and use survivor-guided messaging to foster stigma resilience.

Anxiety and depression level of patients with multidrug-resistant tuberculosis (MDR-TB) in two hospitals in Banten province, Indonesia

Purpose

Anxiety and depression can be found in patients diagnosed with multidrug-resistant Tuberculosis (MDR-TB). The purpose of this research is to measure the level of anxiety and depression in new patients with MDR-TB.

Methods

One hundred two new patients newly diagnosed with MDR TB in two hospitals in Banten province, Indonesia, are measured for depression and anxiety symptoms. The measurements used the Indonesian language version of the Zung Anxiety Self-Assessment Scale Questionnaire and the Indonesian version of Zung Self-Rating Depression Scale Questionnaire for Pulmonary Tuberculosis Patients that have been validated. The results include the demographic data presented descriptively as tables and charts.

Results

The mean age of the patients is 39,57+12,48 years. The monthly income of the patients is 54,9% low and 45,1% medium with no high income. Male is 61,8%, and 38,2% are female. The mean score of the anxiety index is 57,32+10,23. The mean score of the depression index is 55,02+12,36. The percentage of patients with no anxiety is 13,7%, minimal to moderate anxiety 46,1%, marked to severe anxiety 33,3%, and most extreme anxiety 6,9%.

Conclusions

A significant proportion of patients newly diagnosed with MDR-TB experience anxiety and depression.

Building bridges: multidisciplinary teams in tuberculosis prevention and care

People with or affected by tuberculosis (TB) experience complex social and cultural constraints that may affect treatment outcomes by impeding access to proper care or by hindering treatment adherence. Low levels of health literacy which leads to inadequate disease information; stigma, discrimination and other forms of prejudice that may result in marginalisation and ostracisation; and socioeconomic vulnerabilities that hamper one's capacity to access essential goods or increase the risk of exposure to the disease are some of the barriers highlighted. These complex hurdles are also disproportionately felt by people with or affected by TB due to gender-related inequalities that need to be properly addressed. Additionally, TB prevention and care should encompass interventions aimed at improving and promoting mental health, given that mental unhealth may further thwart treatment adherence and success. A multifaceted and multidisciplinary approach to TB is required to answer these complex barriers.

Clinical standards for the dosing and management of TB drugs

BACKGROUND: Optimal drug dosing is important to ensure adequate response to treatment, prevent development of drug resistance and reduce drug toxicity. The aim of these clinical standards is to provide guidance on 'best practice´ for dosing and management of TB drugs.METHODS: A panel of 57 global experts in the fields of microbiology, pharmacology and TB care were identified; 51 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all participants.RESULTS: Six clinical standards were defined: Standard 1, defining the most appropriate initial dose for TB treatment; Standard 2, identifying patients who may be at risk of sub-optimal drug exposure; Standard 3, identifying patients at risk of developing drug-related toxicity and how best to manage this risk; Standard 4, identifying patients who can benefit from therapeutic drug monitoring (TDM); Standard 5, highlighting education and counselling that should be provided to people initiating TB treatment; and Standard 6, providing essential education for healthcare professionals. In addition, consensus research priorities were identified.CONCLUSION: This is the first consensus-based Clinical Standards for the dosing and management of TB drugs to guide clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment to improve patient care.

Social Support and Depression Among Pulmonary Tuberculosis Patients in Anhui, China

Introduction

Pulmonary tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis affecting multiple tissues and organs. It is one of the leading causes of death and is a social disease in China. Increasing studies have revealed that the state of mental health and the social support are associated with the morbidity, mortality and community transmission of pulmonary TB patients. However, the previous global TB control and research strategy focused almost solely on the biomedical aspects. Therefore, in this study, we evaluated the level of depression and explored potential factors, including social support domains and socio-demographic characteristics in pulmonary TB patients to research the mental health state and the association between social support and pulmonary TB, ultimately implementing a multilevel intervene.

Methods

A cross-sectional study was carried out to describe the status of depression and social support, and explore related factors associated with depression among pulmonary TB patients in Anhui Province, China. Five counties (districts) in Anhui Province, China were selected by simple random sampling method. Patients diagnosed with pulmonary TB eligible to the study criteria were investigated. A structured questionnaire composed of information on socio-demographic characteristics, self-rating depression scale (SDS) and social support rating scale (SSRS) was used to collect the data.

Results

In this study, a total of 250 questionnaires were issued, and the effective questionnaires 237 were actually returned. Of the 237 patients with pulmonary TB, 71.3% of them were male and the mean age was 46.16 years (SD = 13.09). Depression symptoms were observed in 125 (52.7%) participants. Objective support (β = −0.192, P=0.002) and subjective support (β = −0.158, P = 0.015) had significantly negative effects on depression, while the effect of support utilization was not statistically significant. In contrast, being female (β = 0.119, P = 0.036) and patients with positive sputum smear results (β = 0.140, P = 0.014) were positively related to depression. Patients with monthly income between 500 and 999 were less likely to suffer from depression (β = −0.134, P = 0.024) than those who were poorer. Additionally, both education level and marital status were found to be correlated with social support and depression state (all P<0.05).

Discussion

In summary, the prevalence of depressive symptoms in pulmonary TB patients were high in Anhui Province, China. Low levels of social support can be an important predictor of depression symptoms. Therefore, screening for depression among pulmonary TB patients in the primary care setting is greatly warranted. Furthermore, psychological interventions should focus on providing available and adequate social support in order to improve mental health of them.