Prevalence and associated factors of depression among tuberculosis patients in Eastern Ethiopia

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.

Prevalence and risk factors of anxiety and depression in patients with multi-drug/rifampicin-resistant tuberculosis

Background

Mental health disorders in patients with multi-drug or rifampicin-resistant tuberculosis (MDR/RR-TB) receive consistent attention. Anxiety and depression can manifest and may impact disease progression in patients with MDR/RR-TB. Given the heightened stressors resulting from the COVID-19 pandemic, this scenario is even more concerning.

Objective

To evaluate the prevalence of and risk factors associated with anxiety and depression among patients with MDR/RR-TB in southern China.

Methods

A facility-based cross-sectional study was undertaken at Guangzhou Chest Hospital in southern China, encompassing a cohort of 219 patients undergoing outpatient and inpatient treatment for MDR/RR-TB. Anxiety and depressive symptoms were assessed using the 7-Item Generalized Anxiety Disorder (GAD-7) scale and Patient Health Questionnaire-9 (PHQ-9). The ramifications of anxiety and depression were examined using univariate and multivariate logistic regression analyses, with odds ratios (ORs) and age- and sex-adjusted ORs (AORs) employed to quantify their influence. All data underwent statistical analysis using SPSS 25.0, with statistical significance established at P < 0.05.

Results

Two hundred and nineteen individuals with MDR/RR-TB were included in the study. The prevalence of anxiety and depression was 57.53% (n = 126) and 65.75% (n = 144), respectively, with 33.3% (n = 73) of the participants experiencing both conditions simultaneously. Multivariate logistic regression analysis revealed that an age of 20-40 years [anxiety AOR = 3.021, 95% confidence interval (CI): 1.240-7.360; depression AOR = 3.538, 95% CI: 1.219-10.268], disease stigma (anxiety AOR = 10.613, 95% CI: 2.966-37.975; depression AOR = 4.514, 95% CI: 2.051-10.108) and poor physical health (anxiety AOR = 7.636, 95% CI: 2.938-19.844; depression AOR = 6.190, 95% CI: 2.468-15.529) were significant risk factors for moderate levels of anxiety and depression.

Conclusions

We found that individuals with MDR/RR-TB had an elevated risk of anxiety and depression. To decrease the likelihood of unfavorable treatment outcomes, it is imperative to carefully monitor the psychological wellbeing of patients with MDR/RR-TB and promptly address any detrimental psychiatric conditions.

Maternal and household factors affecting the dietary diversity of preschool children in eastern Ethiopia: a cross-sectional study

OBJECTIVE

Investigate the association between the dietary diversity of preschool children and proximate factors including household food insecurity, maternal food choice, preferences, khat use, and levels of depressive symptoms.

DESIGN

Cross-sectional survey of randomly selected households.

SETTING

Haramaya Health and Demographic Surveillance site in Eastern Ethiopia, predominantly smallholder farming households.

PARTICIPANTS

678 preschool children (24-59 months) and their mothers.

METHODS

The key outcome, the adequacy of dietary diversity of preschool children, was calculated using a 24-hour parental dietary recall. Binary logistic regression was then used to identify maternal and household factors associated with dietary adequacy versus inadequacy.

RESULTS

The majority (80.53%) of surveyed children had low dietary diversity (mean Dietary Diversity (MDD)) score of 3.06±1.70 on a 7-point scale). Approximately 80% of households exhibited food insecurity. Households with greater food security (adjusted OR (AOR)=1.96, 95% CI 1.19 to 3.23), healthier maternal food choice (AOR=2.19, 95% CI 1.12 to 4.31) and broader maternal food preferences (AOR=4.95, 95% CI 1.11 to 21.95) were all associated with higher dietary diversity of their preschool children (p≤0.05). Other covariates associated with adequate child dietary diversity included improved household drinking water sources (AOR=1.84, 95% CI 1.16 to 2.92) and family planning use (AOR=1.69, 95% CI 1.00 to 2.86). Despite predictions, however, maternal depression and khat consumption were not identified as factors.

CONCLUSIONS

The dietary diversity of preschool children is extremely low-a pattern observed in both food-secure and food-insecure households. Key factors include maternal selection of food for convenience and ease, preferences that do not include animal protein or healthier food choices, and lack of access to improved drinking water sources. Interventions around maternal food choice and preferences could improve preschool children's nutritional health.

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.

Prevalence and Factors Associated with Depression in Patients with Diabetes Mellitus and Pulmonary Tuberculosis (DM-PTB): A Hospital-Based Cross-Sectional Study

Background and Objectives

A high incidence of depression has been reported in patients with pulmonary tuberculosis and diabetes mellitus (DM-PTB). However, the association between depression and DM-PTB is poorly understood and requires further investigation. This study aimed to evaluate the prevalence of depression and the associated factors in patients with DM-PTB.

Methods

A cross-sectional study was conducted among DM-PTB patients at the Tuberculosis Department of Shanghai Pulmonary Hospital Affiliated to Tongji University, China, enrolled between June 2021 and October 2021. The depression status, nutritional status, and the quality of life of the patients were evaluated using Patient Health Questionnaire-9 (PHQ-9), Nutritional Risk Screening 2002 (NRS2002), and Quality of Life Instruments for Chronic Diseases-Pulmonary Tuberculosis (QLICD-PT), respectively.

Results

A total number of 280 DM-PTB patients were screened, of whom 22 were excluded for missing data. Among the 258 DM-PTB patients subjected to analysis, 199 patients (77.13%) had PHQ-9 scores above 10. The patients with depression are more likely to have a lower monthly income, body mass index (BMI), and QLICD-PT than those without depression. The NRS2002 score and glutamic pyruvic transaminase (GPT) and glutamic oxaloacetic transaminase (GOT) levels in the depression group were more likely to be higher than those in the control group. Multivariate logistic regression analysis showed that physical function [OR = 0.798, 95% confidence interval (CI), 0.716-0.889, P < 0.001] was a protective factor against depression, whereas NRS2002 ≥ 3 (OR = 2.299, 95% CI, 1.095-4.825, P = 0.028), GPT (OR = 1.048, 95% CI, 1.018-1.079, P = 0.002), and social function (OR = 1.103, 95% CI, 1.033-1.179, P = 0.004) were risk factors of depression.

Conclusion

Depression in DM-PTB patients may be associated with monthly income, BMI, QLICD-PT scores, NRS2002 scores, GPT, and GOT levels.

Barriers and facilitators to integrating depression care in tuberculosis services in South Asia: a multi-country qualitative study

BACKGROUND

Depression is common among people with tuberculosis (TB). The condition is typically unrecognised or untreated despite available and effective treatments in most low- and middle-income countries. TB services in these countries are relatively well established, offering a potential opportunity to deliver integrated depression screening and care. However, there is limited evidence on how such integration could be achieved. This study aimed to understand the barriers and facilitators to integrate depression care in TB services.

METHODS

We conducted nine workshops with 76 study participants, including people with TB, their carers, and health service providers in Bangladesh, India, and Pakistan, seeking views on integrating depression care into TB clinics. We used a deductive thematic approach to analyse the translated transcripts of audio recordings, contemporaneous notes made during workshops for Bangladesh and India and workshop reports for Pakistan. Using the SURE (Supporting the Use of Research Evidence) thematic framework, we extracted and categorised barriers and facilitators into various domains.

RESULTS

Reported barriers to integrating depression care in TB services included lack of knowledge about depression amongst patients and the staff, financial burden, and associated stigma for people with TB and their carers. Government buy-in and understanding of how to identify and screen for depression screening were potential facilitators reported. Additionally, breaking through mental health stigma and providing the additional resources required to deliver this service (human resources and consultation time) were essential for integrating depression and TB care.

CONCLUSIONS

Depression is a common condition found among people with TB, requiring early identification among people with TB. Integrating depression care into Tb services by health workers requires the availability of political support and the provision of resources.

The role of self-esteem as moderator of the relationship between experienced stigma and anxiety and depression among tuberculosis patients

Anxiety and depression are very common in tuberculosis (TB) patients and can adversely affect TB treatment adherence, ultimately leading to higher morbidity, mortality and drug resistance. Therefore, the aim of this study was to identify the association among experienced stigma, self-esteem and anxiety and depression, and to further explore whether self-esteem could be a moderator in the association between experienced stigma and anxiety and depression in TB patients. A total of 473 TB patients from Dalian, Liaoning Province, Northeast China participated in a cross-sectional survey. A structured questionnaire was developed to collect data. Hierarchical multiple regression was used to analyze the association among experienced stigma, self-esteem and experienced stigma × self-esteem interaction with anxiety and depression. Simple slope analysis was applied to visualize the interaction. Experienced stigma was positively associated with anxiety (B = 0.307, P < 0.01) and depression (B = 0.277, P < 0.01), and self-esteem was negatively associated with anxiety (B = - 0.215, P < 0.01) and depression (B = - 0.351, P < 0.01) in TB patients. The association between experienced stigma and anxiety was different in the low (1 standard deviation (SD) below the mean, B = 0.376, standard error (SE) = 0.056, P < 0.01) and high (1 SD above the mean, B = 0.228, SE = 0.060, P < 0.01) groups of self-esteem. Additionally, the association between experienced stigma and depression was also different in the low (1 SD below the mean, B = 0.363, SE = 0.053, P < 0.01) and high (1 SD above the mean, B = 0.179, SE = 0.056, P < 0.01) groups of self-esteem. Self-esteem could moderate the association between experienced stigma and anxiety and depression. In addition to reducing experienced stigma, enhancing self-esteem as a way to reduce the impact of experienced stigma on anxiety and depression can also help improve the mental health of TB patients.

Chronic Mycobacterium avium infection differentially affects the cytokine expression profile of three mouse strains, but has no effect on behavior

One of the most remarkable findings in the immunology and neuroscience fields was the discovery of the bidirectional interaction between the immune and the central nervous systems. This interplay is tightly regulated to maintain homeostasis in physiological conditions. Disruption in this interplay has been suggested to be associated with several neuropsychiatric disorders. Most studies addressing the impact of an immune system disruption on behavioral alterations focus on acute pro-inflammatory responses. However, chronic infections are highly prevalent and associated with an altered cytokine milieu that persists over time. Studies addressing the potential effect of mycobacterial infections on mood behavior originated discordant results and this relationship needs to be further addressed. To increase our understanding on the effect of chronic infections on the central nervous system, we evaluated the role of Mycobacterium avium infection. A model of peripheral chronic infection with M. avium in female from three mouse strains (Balb/c, C57BL/6, and CD-1) was used. The effect of the infection was evaluated in the cytokine expression profile (spleen and hippocampus), hippocampal cell proliferation, neuronal plasticity, serum corticosterone production and mood behavior. The results show that M. avium peripheral chronic infection induces alterations not just in the peripheral immune system but also in the central nervous system, namely in the hippocampus. Interestingly, the cytokine expression profile alterations vary between mouse strains, and are not accompanied by hippocampal cell proliferation or neuronal plasticity changes. Accordingly, no differences were observed in locomotor, anxious and depressive-like behaviors, in any of the mouse strains used. We conclude that the M. avium 2447 infection-induced alterations in the cytokine expression profile, both in the periphery and the hippocampus, are insufficient to alter hippocampal plasticity and behavior.

Depression, anxiety and medication adherence among tuberculosis patients attending treatment centres in Fako Division, Cameroon: cross-sectional study

BACKGROUND

Tuberculosis remains a public health problem, particularly in developing countries. Patients with tuberculosis often suffer from anxiety and depression, which is likely to affect adherence to the long course of tuberculosis treatment.

AIMS

This study sought to investigate depression, anxiety and medication adherence among Cameroonian tuberculosis patients.

METHOD

A cross-sectional study was conducted from March to June 2022 across five treatment centres in Fako Division, Southwest Region, Cameroon. Data were collected via face-to-face interviews with tuberculosis patients using a structured questionnaire. Sociodemographic information was obtained, and the following tools were administered to participants: the Hospital Anxiety and Depression Scale, the Oslo Social Support Scale, and the Medication Adherence Rating Scale. Multiple logistic regression models were fitted to investigate determinants of depression and anxiety.

RESULTS

A total of 375 participants were recruited (mean age: 35 ± 12.2 years; 60.5% male). The prevalence rates of depression and anxiety among tuberculosis patients were 47.7% and 29.9%, respectively. After adjusting for confounders, the odds of depression were significantly increased by having extrapulmonary tuberculosis, non-adherence to treatment, having no source of income, household size <5 and poor social support. Predictors for anxiety included extrapulmonary tuberculosis, defaulting tuberculosis treatment for ≥2 months, family history of mental illness, HIV/tuberculosis co-infection, being married, poor social support and non-adherence to treatment.

CONCLUSIONS

The prevalence of depression and anxiety in tuberculosis patients is relatively high, and diverse factors may be responsible. Therefore, holistic and comprehensive care for tuberculosis patients by mental health practitioners is highly encouraged, especially for the high-risk groups identified.

Prevalence of depression in people with tuberculosis in East Africa: a systematic review and meta-analysis

BACKGROUND

Depression is one of the most common mental health problems comorbid with tuberculosis. However, a consolidated picture of the prevalence of depression among tuberculosis patients in East Africa remains unknown. This systematic review and meta-analysis provide new understandings by systematically examining evidence concerning the prevalence of depression among tuberculosis patients in East Africa.

METHODS

Literature was found in a database of HINARI, SCOPUS, PubMed, Science Direct, and Google Scholar. The Newcastle-Ottawa quality assessment scale was used to appraise the quality of the selected studies. Then, the DerSimonian and Laird random-effects model was applied because of the presence of heterogeneity among studies.

RESULTS

A total of 409 studies were accessed. However, only 29 qualified for a full-text review, and 9 studies with a population of 2838 were included in the qualitative description and quantitative analysis. The pooled prevalence estimate of depression amongst tuberculosis patients was 43.03 % (34.93, 51.13). The highest prevalence was observed in Kenya, with 45.71% (29.26, 62.16); a similar rate was observed in Ethiopia, with 45.11 % (34.60, 55.62). Subgroup analysis based on screening tool was used: 45.71% with BDI and 41.53% with PHQ.

Depression, anxiety and their associated factors among patients with tuberculosis attending in Gondar city health facilities, North West Ethiopia

INTRODUCTION

Depression and anxiety are the most prevalent mental disorders in the general population and are expected to be the number one global burden of disease by the year 2030. They are also common comorbid conditions for patients with tuberculosis.

OBJECTIVE

This study aimed to assess the prevalence of symptoms of depression, and anxiety and their associated factors among patients with tuberculosis attending Gondar city health facilities.

METHODS

An institution-based cross-sectional study was conducted from September 01 to 30/2020. A census sampling technique was employed to select 390 patients. A structured interviewer-administered questionnaire was used to collect data, and a standardized hospital anxiety and depression scale was used to measure the symptoms of anxiety and depression. Data were entered in Epi-Info version 7 and analyzed using SPSS version 23. Binary and multivariable logistic regressions were computed to identify factors associated with the symptoms of depression and anxiety. P-value < 0.05 and adjusted odds ratios were used to declare the significance and strength of the association.

RESULTS

The overall prevalence of symptoms of depression and anxiety were found to be 35.8% with 95% CI (34.6, 36.6). Perceived stigma and duration of illness > 12 months were associated positively ([AOR = 3.60; 95% CI (2.74, 4.43)], and [AOR = 3.19; 95% CI (2.17, 4.19)]) for both depression and anxiety respectively. Separate analyses revealed that the prevalence of symptoms of depression was 55.9% (95% CI (51.0%, 60.3%) and was significantly associated with duration of illness 4-6 months and > 12 months (AOR = 1.21; 95% CI (1.17, 2.73)] and [AOR = 2.36; 95% CI (2.16, 3.79)], comorbid chronic disease (AOR = 0.12; 95% CI (0.08, 0.91)] and perceived stigma [AOR = 0. The prevalence of anxiety symptoms was 39.5 percent, with 95% confidence intervals of 34.6% and 44.6%, and it was significantly associated with comorbid chronic disease [AOR = 2.53; 95% CI (1.96, 6.32)] and perceived stigma [AOR = 3.31; 95% CI (1.22, 7.74)].

CONCLUSION

The prevalence of symptoms of depression and anxiety was high. Duration of illness, comorbid chronic disease, and perceived stigma were significantly associated with symptoms of depression. Comorbid chronic disease and perceived stigma were significantly associated with symptoms of anxiety.

Depression Among Patients With Tuberculosis at a Directly Observed Treatment Short-Course (DOTS) Center in Rural Delhi

Background Psychiatric disorders, particularly depression is prevalent among patients with tuberculosis (TB) and affect their treatment compliance. Patients with tuberculosis can develop depression due to multiple factors like longer treatment duration, social stigma, lack of family support, etc. In this study, depression and its associated factors were examined among patients with tuberculosis enrolled in a directly observed treatment short-course (DOTS) center in North Delhi. Methods In this DOTS center-based, cross-sectional study, 320 patients with pulmonary and extra-pulmonary TB above 18 years old were included. Basic socio-demographic information was gathered using a Hindi questionnaire, and depression was identified using the patient health questionnaire-9. People who received a score of 10 or higher were deemed to have depression. The Statistical Package for Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY, USA) was used for data analysis. Analysis between depression and no-depression groups was done by the chi-square test and a p-value < 0.05 was considered statistically significant. Results The study involved 320 patients in all, 193 (60.3%) of whom were men. The median age was 38 years, and the interquartile range (IQR) was 24 to 52 years. Depression was found to be present in half of the patients. Patients with a higher proportion of depression were male, belonged to the middle or below socio-economic status, were currently unemployed and literate, had monthly family income less than 8000 rupees, weight below 45 kg, used alcohol and tobacco, and were undergoing intensive phase (IP) of TB treatment (p-value< 0.05). Depression was not found to be associated with age, site of TB, previous history of anti-tubercular treatment (ATT) intake, marital status, and family size. Conclusion Depression among patients with TB is common and affects half of the patients afflicted with it. When evaluating patients with TB, physicians and DOTS providers should have a high index of suspicion for depression.

Association between depression and malnutrition in pulmonary tuberculosis patients: A cross-sectional study

BACKGROUND

Depression has been reported to be prevalent in patients with pulmonary tuberculosis (PTB). Moreover, several clinical symptoms of PTB and depression overlap, such as loss of appetite and malnutrition. However, the association between depression and malnutrition in TB patients has not been fully elucidated.

AIM

To explore the association between depression and malnutrition in patients with PTB.

METHODS

This hospital-based cross-sectional study included patients with PTB in Shanghai Pulmonary Hospital Affiliated to Tongji University from April 2019 to July 2019. The Patient Health Questionnaire-9 (PHQ-9) scale was used to evaluate depre-ssion. The cut-off value was set at 10, and the nutritional state was determined by the body mass index (BMI). In addition, the Quality of Life Instruments for Chronic Diseases was employed to establish the quality of life (QOL). Univariable analysis and multivariable analysis (forward mode) were implemented to identify the independent factors associated with depression.

RESULTS

A total of 328 PTB patients were screened for analysis. Eight were excluded for missing demographic data, four excluded for missing nutrition status, and sixteen for missing QOL data. Finally, 300 PTB patients were subjected to analysis. We found that depressive state was present in 225 PTB patients (75%). The ratio of malnutrition in the depressive PTB patients was 45.33%. Our results revealed significantly lower BMI, hemoglobin, and prealbumin in the depression group than in the control group (P < 0.05). Moreover, the social status differed significantly (P < 0.05) between the groups. In addition, glutamic pyruvic transaminase and glutamic oxaloacetic transaminase in the depression group were significantly higher than those in the control group (P < 0.05). Multivariable logistic regression analysis showed that BMI [odds ratio (OR) = 1.21, 95% confidence interval (CI): 1.163-1.257, P < 0.001] and poor social function (OR = 0.95, 95%CI: 0.926-0.974, P = 0.038) were independently associated with depression.

CONCLUSION

Malnutrition and poor social function are significantly associated with depressive symptoms in PTB patients. A prospective large-scale study is needed to confirm these findings.

Risk Factors for Depression in Tuberculosis Patients: A Meta-Analysis

Purpose

Tuberculosis (TB) is a life threatening global infection. However, not only does TB have a high global prevalence, but it is also associated with several comorbidities. Depression is one of the most common and lethal comorbidities of TB patients. Therefore, in order to prevent depression in TB patients more effectively, it is necessary to investigate the factors associated with depression in TB patients by studying the pooled effect of each factor statistically. By concluding the associated factors through statistical analysis, it not only offers accurate guidance for further studies about programs targeted at preventing depression in TB patients, but provides health-care workers useful suggestions and warnings when treating TB patients.

Methods

We searched the published literatures from PubMed, Web of Science, EMBASE, and Cochrane Library to collect studies. The meta-analysis included articles from observational studies, including cross-sectional studies, cohort studies and case control studies that had information about factors associated with depression in tuberculosis patients. When the heterogeneity is defined as significant (I2>50%), a random-effect model with 95% confidence interval (CI) was used to estimate risk factors; otherwise, a fixed-effect model was used to combine the effect. A sensitivity test was conducted to examine which one of the studies may have potential bias that can affect the validity and reliability of the result. The funnel plots and Begg's and Egger's statistical tests were performed to assess the publication bias. Subgroup analysis was performed according to the prespecified variables in each group.

Results

Totally, 25 studies were included in the meta-analysis. The studies were conducted in various countries around the world between 2011 and 2021, representing the situation in the previous ten years. The final associated factors include female gender [OR=1.319, 95% CI=1.132-1.536, p<0.001], poor social support [OR=4.109, 95% CI=1.431-11.799, p<0.01], marriage status [OR=1.362, 95% CI=1.154-1.608, p<0.001], low education level [OR=1.921, 95% CI=1.475-2.503, p<0.001], residence in rural areas [OR=1.408, 95% CI=1.122-1.767, p<0.01], retreatment status [OR=2.515, 95% CI=1.226-5.159, p<0.01], and having perceived stigma[OR=4.131, 95% CI=1.412-12.088, p<0.05].

Conclusion

Depression prevention programs targeted at women TB patients are supposed to be carried out. Patients in retreatment status are supposed to be paid more attention of their psychological health by caring about their mental status. More social support is ought to be given to tuberculosis patients to reduce their chance of getting depressed. It is necessary to provide patients with a lower education level with psychological related courses to help them learn about their mental status. For patients living in rural areas, governments are supposed to offer psychotherapy for treatment as well as enhancing living condition. Suitable psychotherapy programs and plans is ought to be studied to eradicate perceived stigma of TB patients.

Assessment of prevalence of depression and its associated factors among tuberculosis patients in Ernakulam district, Kerala

BACKGROUND

India is one of the few countries where Tuberculosis is still widely prevalent. People with TB, often suffers from depression. It is estimated that more than 300 million people suffer from depression at the global level, accounting to 4.4 percent of the world's population.

OBJECTIVES

Primary objective-To assess the prevalence of depression among tuberculosis patients in Ernakulam district using PHQ9. Secondary objective-To assess the factors associated with depression among tuberculosis patients in Ernakulam district.

METHODOLOGY

A cross sectional study was carried out among the tuberculosis patients who were currently under treatment from December 2019 to March 2020 in Ernakulam district of Kerala. From the 8 TUs of Ernakulam, 8 clusters were selected using PPS. 485 adult TB patients from these clusters were interviewed using PHQ9 questionnaire to assess prevalence of depression.

RESULTS

The prevalence of depression among the TB patients in Ernakulam district was found to be 16.1%. The proportion of TB patients with depression were significantly higher among the age group of 18-40 years (36.3%), unmarried (54%) and from urban area of residence (19%). It was also significantly higher among previously treated patients (45.7%) & MDR TB patients (43.8%).

CONCLUSION

It was observed that one-sixth of TB patients suffered from depression. Hence it is crucial that TB patients need to be regularly assessed for depression and managed appropriately. Since depression has affects adherence to TB treatment & thereby result in delay of TB elimination in the state.

Magnitude of Depression and Associated Factors Among Patients on Tuberculosis Treatment at Public Health Facilities in Harari Regional State, Eastern Ethiopia: Multi-Center Cross-Sectional Study

BACKGROUND

Depression among tuberculosis patients remains a significant public health concern. Its burden and severity is increasing in low-income countries, especially in sub-Saharan Africa. Although it has negative impacts on quality of life, depression among tuberculosis patients is rarely studied in Ethiopia, particularly in the study area. Therefore, this study aimed to determine the magnitude of depression and associated factors among tuberculosis patients in Eastern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from April 15 to May 15, 2021, among 213 tuberculosis patients in public health facilities of the Harari Regional State, Eastern Ethiopia. Study participants were selected using a systematic sampling technique. Data were collected using interviewer-administered questionnaire. Depression was assessed using Patients Health Questionnaire-9 (PHQ-9). Epi-data and SPSS were used for data processing and analysis. Bi-variable and multivariable logistic regressions were employed to determine the effects of predictors on depression. Statistical significance was considered at a p-value <0.05.

RESULTS

The magnitude of depression among tuberculosis patients was 52.1% [95% CI (45.4, 58.8%)]. Patient's age of 25-34 years [AOR = 0.31, 95% CI (0.128, 0.75)], female sex [AOR = 5.04; 95% CI (2.18, 11.62)], intensive phase of tuberculosis treatment [AOR = 2.56; 95% CI (1.118, 5.876)], HIV-positive status [AOR = 7.143; 95% CI (1.55, 32.93)], smoking history [AOR = 9.08; 95% CI (3.35, 24.61)] and having poor social support [AOR = 4.13; 95% CI (1.29, 13.22)] were factors statistically associated with depression.

CONCLUSION

In this study, the magnitude of depression was relatively high as more than half of the participants had depression. Advanced age, female sex, intensive phase of tuberculosis treatment, HIV-positive status, smoking history, and poor social support were identified as associated factors with depression. Therefore, this result calls all stakeholders to give duly emphasis on incorporating and integrating mental health support programs as routine practice in tuberculosis follow-up clinics, as screening, early detection and treatment, and training for all health care providers are very crucial in tackling depression among tuberculosis patients.

Integrating tuberculosis and noncommunicable diseases care in low- and middle-income countries (LMICs): A systematic review

BACKGROUND

Low- and middle-income countries (LMICs) are facing a combined affliction from both tuberculosis (TB) and noncommunicable diseases (NCDs), which threatens population health and further strains the already stressed health systems. Integrating services for TB and NCDs is advantageous in tackling this joint burden of diseases effectively. Therefore, this systematic review explores the mechanisms for service integration for TB and NCDs and elucidates the facilitators and barriers for implementing integrated service models in LMIC settings.

METHODS AND FINDINGS

A systematic search was conducted in the Cochrane Library, MEDLINE, Embase, PubMed, Bibliography of Asian Studies, and the Global Index Medicus from database inception to November 4, 2021. For our search strategy, the terms "tuberculosis" AND "NCDs" (and their synonyms) AND ("delivery of healthcare, integrated" OR a range of other terms representing integration) were used. Articles were included if they were descriptions or evaluations of a management or organisational change strategy made within LMICs, which aim to increase integration between TB and NCD management at the service delivery level. We performed a comparative analysis of key themes from these studies and organised the themes based on integration of service delivery options for TB and NCD services. Subsequently, these themes were used to reconfigure and update an existing framework for integration of TB and HIV services by Legido-Quigley and colleagues, which categorises the levels of integration according to types of services and location where services were offered. Additionally, we developed themes on the facilitators and barriers facing integrated service delivery models and mapped them to the World Health Organization's (WHO) health systems framework, which comprises the building blocks of service delivery, human resources, medical products, sustainable financing and social protection, information, and leadership and governance. A total of 22 articles published between 2011 and 2021 were used, out of which 13 were cross-sectional studies, 3 cohort studies, 1 case-control study, 1 prospective interventional study, and 4 were mixed methods studies. The studies were conducted in 15 LMICs in Asia, Africa, and the Americas. Our synthesised framework explicates the different levels of service integration of TB and NCD services. We categorised them into 3 levels with entry into the health system based on either TB or NCDs, with level 1 integration offering only testing services for either TB or NCDs, level 2 integration offering testing and referral services to linked care, and level 3 integration providing testing and treatment services at one location. Some facilitators of integrated service include improved accessibility to integrated services, motivated and engaged providers, and low to no cost for additional services for patients. A few barriers identified were poor public awareness of the diseases leading to poor uptake of services, lack of programmatic budget and resources, and additional stress on providers due to increased workload. The limitations include the dearth of data that explores the experiences of patients and providers and evaluates programme effectiveness.

CONCLUSIONS

Integration of TB and NCD services encourages the improvement of health service delivery across disease conditions and levels of care to address the combined burden of diseases in LMICs. This review not only offers recommendations for policy implementation and improvements for similar integrated programmes but also highlights the need for more high-quality TB-NCD research.

Tuberculosis related disability: a systematic review and meta-analysis

BACKGROUND

The sustainable development goals aim to improve health for all by 2030. They incorporate ambitious goals regarding tuberculosis (TB), which may be a significant cause of disability, yet to be quantified. Therefore, we aimed to quantify the prevalence and types of TB-related disabilities.

METHODS

We performed a systematic review of TB-related disabilities. The pooled prevalence of disabilities was calculated using the inverse variance heterogeneity model. The maps of the proportions of common types of disabilities by country income level were created.

RESULTS

We included a total of 131 studies (217,475 patients) that were conducted in 49 countries. The most common type of disabilities were mental health disorders (23.1%), respiratory impairment (20.7%), musculoskeletal impairment (17.1%), hearing impairment (14.5%), visual impairment (9.8%), renal impairment (5.7%), and neurological impairment (1.6%). The prevalence of respiratory impairment (61.2%) and mental health disorders (42.0%) was highest in low-income countries while neurological impairment was highest in lower middle-income countries (25.6%). Drug-resistant TB was associated with respiratory (58.7%), neurological (37.2%), and hearing impairments (25.0%) and mental health disorders (26.0%), respectively.

CONCLUSIONS

TB-related disabilities were frequently reported. More uniform reporting tools for TB-related disability and further research to better quantify and mitigate it are urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42019147488.

Psychological stress and health-related quality of life among tuberculosis patients: a prospective cohort study

Economic, social and psychological distress is common in individuals affected by tuberculosis (TB). However, the magnitude of distress, psychological interventions and their effect on the treatment outcomes are often under-evaluated. We examined the level of psychological stress and health-related quality of life (HRQoL) of such patients and the effect of antituberculosis therapy on them.

 Our prospective cohort study included newly diagnosed adult pulmonary and extrapulmonary TB patients. Assessment of psychological stress was done using the seven-item Generalised Anxiety Disorder questionnaire for anxiety and the nine-item Patient Health Questionnaire for depression. HRQoL was assessed by using the WHOQOL-BREF questionnaire.

 Of the 86 patients studied, 21 (24.4%) had anxiety symptoms at the baseline, which reduced to 5.8% and 1.2% at 2 months and treatment completion, respectively (p<0.001). Among the subjects, 18 (20.9%) patients had depression, which reduced to 7% and 2.3% at 2 months and treatment completion, respectively (p<0.001). All the mean domain scores of HRQoL were poor at the baseline, which showed improvement at treatment completion (p<0.001).

 Anxiety and depression were common among TB patients, and there was significant progressive reduction during and after treatment. TB had remarkable negative impacts on HRQoL, with the physical domain being the most affected, and all the domain scores showed significant improvement at treatment completion. Routine screening for depression and anxiety and timely referral to a psychiatrist are required in TB patients to improve the outcome of the disease and quality of life.

Tuberculosis patients experience significant psychological stress that can negatively impact their quality of life and warrants proper screening and intervention.https://bit.ly/3jfMEjA

Prevalence and associated factors of psychological distress in tuberculosis patients in Northeast China: a cross-sectional study

Background

Psychological distress, a major comorbidities of tuberculosis (TB) patients, has posed a serious threat to the progress being made in global TB programs by affecting treatment adherence and health outcomes. However, the magnitude and associated factors of psychological distress have not been fully studied in China. The aim of the current study was to assess the prevalence of psychological distress in TB patients and to further determine the effects of socio-demographic characteristics, health-related variables, substance use status, social support, and experienced stigma on psychological distress.

Methods

A cross-sectional survey was conducted among TB patients attending three medical institutions in Dalian, Liaoning Province, Northeast China from November 2020 to March 2021. A structured questionnaire was developed to collect data on patients’ socio-demographic characteristics, health-related information, substance use status, psychological distress, family function, doctor-patient relationship, policy support, experienced stigma and so on. The binary logistics regression model was used to determine the associated factors of psychological distress.

Results

A total of 473 TB patients were enrolled in this study, and the prevalence of psychological distress was 64.1%. Binary logistic regression analysis revealed that patients with a middle school education level or above (OR: 0.521, 95%CI: 0.279–0.974), no adverse drug reactions (OR: 0.476, 95%CI: 0.268–0.846), and regular physical exercise (OR: 0.528, 95%CI: 0.281–0.993) were more likely to stay away from psychological distress. However, patients who had a high economic burden (OR: 1.697, 95%CI: 1.014–2.840), diabetes (OR: 2.165, 95%CI: 1.025–4.573), self-rated illness severe (OR: 3.169, 95%CI: 1.081–9.285), perceived poor resistance (OR: 2.065, 95%CI: 1.118–3.815), severe family dysfunction (OR: 4.001, 95%CI: 1.158–13.823), perceived need for strengthen psychological counseling (OR: 4.837, 95%CI: 2.833–8.258), and a high experienced stigma (OR: 3.253, 95%CI: 1.966–5.384) tended to have a psychological distress.

Conclusions

The study found that the proportion of psychological distress among TB patients was high in Northeast China, and it was influenced by a variety of factors. Effective interventions to reduce psychological distress in TB patients urgently need to be developed, and greater attention should be given to patients with risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06284-4.

Association of psychological status with first diagnosed pulmonary tuberculosis in men

The aim. Assessment of the initial psychological status of men with first diagnosed pulmonary tuberculosis and the study of its associations with the clinical course of the disease. Materials and methods. The study involved 54 men with first diagnosed pulmonary tuberculosis. Patients had a dynamic complex clinical, laboratory and instrumental examination with an assessment of the psychological status according to the State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI). Results. The evaluating of initial psychological status in patients with first diagnosed pulmonary tuberculosis, depressive states of varying severity were found in 47.05 % of patients, moderate state anxiety – in 74.51 % of patients, moderate trait anxiety – in 35.29 %. We revealed associations of the levels of anxiety and depression with the degree of bacterial excretion and the duration of the intensive phase of therapy. Conclusions. To assess the psychological status of patients with first diagnosed infiltrative pulmonary tuberculosis, it is advisable to use the STAI and the BDI. Patients with first diagnosed infiltrative pulmonary tuberculosis in 100 % of cases have psychological status disorders with a predominance of moderate state anxiety and the absence of depressive disorders in only half of them. More expressed violations of the psychological status (anxiety, depression) identifies patients who are married and have a steady job. In patients with first diagnosed infiltrative pulmonary tuberculosis, an increase in the severity of anxiety and depression is associated with more expressed bacterial excretion, decrease in body weight, greater frequency of destruction of lung tissue, prevalence of the tuberculosis process by more than 2 lung segments, decrease in the effectiveness of standard therapy and prolongation intensive phase of treatment.

Prevalence of depressive symptoms and associated factors among patients with tuberculosis attending public health institutions in Gede'o zone, South Ethiopia

Background

Depression is a common mental disorder among patients with tuberculosis and it is associated with a greater risk of suicide, multidrug-resistant tuberculosis, and poor quality of life. Evidence suggests the early identification of depression among patients with tuberculosis is important to decrease adverse outcomes. However, there are limited studies that examined the prevalence and determinants of depressive symptoms among patients with tuberculosis. This study aimed to assess the prevalence and associated factors of depressive symptoms among patients with tuberculosis attending public health institutions in Gede’o zone, South Ethiopia.

Methods

An institution-based a cross-sectional study was conducted from November 1 to December 30, 2018, among a randomly selected sample of 415 patients with tuberculosis attending public health institutions in Gede’o zone, South Ethiopia. Patient Health Questionnaire (PHQ-9) was used to assess depressive symptoms. Logistic regression was used to identify the potential risk factors of depressive symptoms. The strength of the association was presented by crude odds and adjusted odds ratio with their corresponding 95% CI. Finally, the statistical significance was set at p < 0.05.

Results

The prevalence of depressive symptoms was found to be 45.5% (95% CI; 41.1–50.1%) among patients with tuberculosis; 33.3% had moderate, 9.8% had moderately severe, and 2.4% had severe depression. After adjusting for the possible confounders, being on re-treatment for tuberculosis (AOR = 2.47, 95% CI: 1.17–5.22), aged ≥45 years (AOR = 2.41, 95% CI: 1.09–5.32), having poor social support (AOR = 4.21, 95% CI: 2.10–8.47), and Tuberculosis/Human Immunodeficiency Virus (TB/HIV) co-infection) (AOR = 3.96, 95% CI 2.0, 7.84) were significantly associated with depressive symptoms among patients with TB.

Conclusions

This study suggests that a substantial percentage of patients with TB had depressive symptoms (45.5%). TB/HIV coinfection, being on re-treatment for tuberculosis, those having poor social support, patients aged 45 and above were factors associated with depressive symptoms. Routine screening of depression among patients with TB is warranted. Moreover, patients with TB falling into the risk categories should be more carefully monitored for depression and when possible referred to mental health professionals.

ECMO-assisted resection of left main bronchial malignant tumor and left pneumonectomy with comprehensive nursing support: a case report

Background

Patients with Extracorporeal Membrane Oxygenation (ECMO) undergoing primary bronchial malignancy resection and left pneumonectomy via bilateral thoracic approach are rare for there exist few reports available to date. And the nursing experience about this disease is rare reported.

Case presentation

This study reported a 50-year-old man with adenoid cystic carcinoma in left main bronchus by computed tomography (CT), fiberoptic bronchoscopy, and puncture biopsy. The case is the first report about operation method and the comprehensive nursing care, including conventional nursing, airway management, fluid management, nutritional support, and psychosocial support for patients undergoing primary bronchial malignancy resection and left pneumonectomy. After multidisciplinary treatment and comprehensive care, the patient was cured and discharged on the 17th day after surgery.

Conclusion

This study reported a rare case with bronchial malignancy resection and left pneumonectomy and discussed its nursing care. A skilled management of ECMO, intraoperative position transformation, and prevention, as well as control of pulmonary complications are fundamental in caring patients with bronchial tumors. Monitoring of pulmonary function and blood pressure, adequate nutrition, and psychological support could be contributing factors for successful treatment during the postoperative stage.

Depression and delayed tuberculosis treatment initiation among newly diagnosed patients in Botswana

Comorbidity of tuberculosis (TB) and depression may lead to delayed TB treatment initiation. A cross-sectional study was conducted between January and December 2019 to examine the association between depression and delayed TB treatment initiation among newly diagnosed TB patients in Botswana. We used the Patient Health Questionnaire-9 and the ZUNG self-rating anxiety scale to assess depressive and anxiety symptoms, respectively. Delayed TB treatment was defined as experiencing common TB symptoms for more than 2 months before treatment initiation. We used Poisson regression models with robust variance to assess the association between covariates and delayed treatment initiation. Majority of the enrolled 180 study participants were males (n =116, 64.4%). Overall, 99 (55%) were co-infected with HIV; depression and anxiety symptoms were reported by 47.2% and 38.5% of the participants respectively. The prevalence of delayed TB treatment was 42.6% and 18.8% among participants who indicated symptoms of depression and among participants without depression respectively. After adjusting for age, HIV status, gender and anxiety symptoms, depression was still associated with delayed TB treatment (adjusted prevalence ratio [aPR] = 2.09; 95% CI = 1.23-3.57). Integrating management of depressive symptoms during TB treatment may help in improving overall TB treatment outcomes.

Prevalence and Associated Factors of Depression and Anxiety Among Patients with Pulmonary Tuberculosis Attending Treatment at Public Health Facilities in Southwest Ethiopia

BACKGROUND

Depression and anxiety are the most commonly occurring psychiatric comorbidities among patients with pulmonary tuberculosis (PTB). Co-occurring anxiety and depression in PTB patients result in poor adherence to anti-tuberculosis medication. This in turn results in lower success rate of treatment and an upsurge in morbidity and mortality. Despite this problem existing globally, little has been explored in southwest Ethiopia.

OBJECTIVE

The aim of this study was to assess the prevalence and associated factors of depression and anxiety among patients with pulmonary tuberculosis receiving treatment at public health facilities in southwest Ethiopia.

MATERIALS AND METHODS

A facility-based cross-sectional study was conducted from April to May 2019. Data were collected from 410 PTB patients using hospital anxiety and depression scale (HADS). Epi data version 3.1 and SPSS version 23 were used to enter and analyze data respectively. Multiple logistic regressions were fitted to identify the strength of association between outcome and explanatory variables. P <0.05 was considered statistically significant.

RESULTS

Prevalence of depression and anxiety among PTB patients were 229 (55.9 %) and 224 (54.6%), respectively. High perceived stress [AOR=3.61 (1.99, 6.53)], perceived stigma [AOR=10.13 (5.52, 18.63)], being in an intensive phase of treatment [AOR= 3.33 (1.83, 6.07)], and low body mass index [AOR=2.07 (1.13, 3.80)] were significantly associated with depression. Being female [AOR=2.42 (1.39, 4.22)], perceived stigma [AOR=3.58 (1.99, 6.42)], high perceived stress [AOR=4.40 (2.52, 7.69)], and family history of mental illness [AOR=2.66 (1.19, 5.94)] had significant association with anxiety.

CONCLUSION

More than half of the study participants were found to have probable depression and anxiety. This indicates the need to pay attention to the mental health condition of patients with PTB, particularly to those with identified risk factors.

The prevalence of depression among patients with tuberculosis: a systematic review and meta-analysis

BACKGROUND

Evidence has shown that the prevalence of depression is much higher among patients with tuberculosis (TB) and this, in turn, may adversely impact compliance with anti-TB medications. Therefore, this systematic review and meta-analysis aimed to quantitatively summarize epidemiologic evidence on the prevalence of depression among patients with TB and formulate a recommendation for future clinical practice as well as research.

METHODS

We followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines to conduct this review. We searched PubMed, EMBASE, SCOPUS and Psych INFO to identify relevant studies that investigated the prevalence of depression among TB patients. We also supplemented our electronic search with manual searching to include all pertinent studies in the analysis. We used a Comprehensive Meta-Analysis software version 3.0 (CMA 3.0) to conduct a meta-analysis. We conducted a subgroup and sensitivity analysis and Cochran's Q- and the I ²-statistics were used to assess heterogeneity. The evidence for the presence of publication bias was checked by using Egger's test and visual inspection of the symmetry in funnel plots.

RESULTS

We identified a total of 25 studies that included 4903 participants across seven countries. In our analysis, the pooled estimated prevalence of depression among TB patients was found to be 45.19% (95% CI 38.04-52.55). The prevalence was higher in MDR-TB 52.34% (95% CI 38.09-66.22) than non-MDR-TB 43.47% (95% CI 35.88-51.37) patients. We also found that the pooled prevalence of depression was higher among females 51.54% (95% CI 40.34-62.60) when compared to males 45.25% (95% CI 35.19-55.71). The pooled prevalence of depression was 45.45% as measured by HRDS, and it was 55.62%, 45.52%, and 38.36% as measured by BDI, HADS and PHQ-9, respectively.

CONCLUSION

Our finding suggested that the pooled estimated prevalence of depression among tuberculosis patients was relatively high. Screening and management of depression among TB patients were warranted to alleviate suffering. Moreover, the integration of tuberculosis program with regular psychiatry services may substantially reduce the burden.

Depression among TB patients and associated factors in Kathmandu Valley, Nepal

INTRODUCTION

When tuberculosis (TB) and depression co-occur, there is greater risk for comorbidities, disability, suffering, and health-related costs. Depression is also associated with poor treatment adherence in patients with TB. The major aim of this study was to assess the symptoms of depression and associated factors among TB patients currently receiving directly observed treatment short-course (DOTS) treatment.

METHODS

A cross-sectional study was conducted among TB patients currently undergoing treatment in 27 DOTS centers in three districts of Kathmandu Valley. The study included 250 TB patients within 2 months of treatment initiation, aged 18 years and above. The previously validated Nepali Patient Health Questionnaire (PHQ-9) was used to screen for depression and semi-structured interviews were conducted to collect socio-demographic information and other factors related to TB and/or depression. Data analysis was conducted using IBM SPSS Statistics version 20.

RESULTS

The study found the mean PHQ Score to be 2.84 (s.d. 4.92, range 0-25). Among the respondents, 10% (n = 25) had PHQ-9 scores ⩾10, suggestive of probable depression. Multivariate linear regression indicated that depressive symptoms were significantly associated with being separated/widowed/divorced (p = 0.000) and having lower education (0.003). In addition, smoking (p = 0.02), alcohol use (p = 0.001), and experience of side effects from TB medications (p = 0.001) were risk factors for higher PHQ-9 scores.

CONCLUSIONS

Our findings suggest that patients on TB treatment have higher risk of depression and efforts should be made by the National Tuberculosis Program to address this issue.

The interplay between depression and tuberculosis

Depression is a major mental health condition and is expected be the most debilitating and widespread health disorder by 2030. Tuberculosis (TB) is also a leading cause of morbidity and mortality worldwide and interestingly, is a common comorbidity of depression. As such, much attention has been paid to the association between these 2 pathologies. Based on clinical reports, the association between TB and depression seems to be bidirectional, with a substantial overlap in symptoms between the 2 conditions. TB infection or reactivation may precipitate depression, likely as a consequence of the host's inflammatory response and/or dysregulation of the hypothalamic-pituitary-adrenal axis. Nevertheless, few studies have considered whether patients with depression are at a higher risk for TB. In this review, we discuss the hypotheses on the association between depression and TB, highlighting the immuno-inflammatory response and lipid metabolism as potential mechanisms. Improving our understanding of the interplay between these 2 disorders should help guide TB clinical care and prevention both in patients with comorbid depression and in the general population.