Opinion: Mental health screening for people with TB will change lives and boost SA’s TB response

Opinion: Mental health screening for people with TB will change lives and boost SA’s TB responseAccording to some estimates, over a third of tuberculosis (TB) patients have high levels of psychological distress and a quarter have an alcohol use disorder. PHOTO: Michael Summers
Comment & Analysis

After two years of COVID-19 and disruption of normal healthcare services such as those for tuberculosis (TB), welcome-back initiatives were started across provinces to get people back on treatment and back into care. Spotlight reported on some of these campaigns here.

However, when lockdown restrictions eased, there were reports of clients who had their TB treatment interrupted but who were not returning to health facilities despite initiatives like the welcome back campaign.

In an attempt to understand why and how to support them, the Atlantic Institute started a project in KwaZulu-Natal where for three months in early 2022, a group, including counsellors, provided psycho-social support counselling to people affected by TB in Cato Manor and Savannah Park in eThekwini. The intervention was aimed at supporting people affected by TB to access psychological interventions that will support them in navigating the challenges of adherence, support for the infected and individual journey to recovery, and treatment completion.

hand with stop TB
IMAGE: Health24

The findings were eye-opening and may have wider relevance for South Africa’s response to TB.

It builds on previous research on the intersection of TB with issues such as mental health conditions (most notably depression and anxiety) and substance use. These issues can impact health outcomes for these patients. One 2011 local research study of public primary care TB patients, for example, found high rates of psychological distress among tuberculosis patients. According to the study, “improved training of providers in screening for psychological distress, appropriate referral to relevant health practitioners, and providing comprehensive treatment for patients with TB who are co-infected with HIV is essential to improve their health outcomes”. Another study investigated the association between stigma and depression in MDR-TB patients. The study was conducted among 200 DR-TB inpatients in KwaZulu-Natal (KZN) who simultaneously suffered from mental illness. There was a significant correlation found between various forms of stigma (self and societal) and depression.

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What the project entailed

Our sessions in KwaZulu-Natal were conducted by a qualified psycho-social counsellor for two community-based organisation (CBO) leaders, their employees, and people with TB. In total, there were 27 participants (6 men and 21 women, aged between 18 and 54 years).

mobile X-ray clinic
In facilities, there is still a gap in integrating mental health screening with TB (and any other illness). PHOTO: WC Health

The programme was implemented in three phases.

The first phase consisted of closed psycho-social support groups for CBO employees (conducted separately for the two organisations). The second phase consisted of group and individual sessions for people with TB and the third phase of group and individual sessions for CBO leaders.

Among the therapeutic interventions provided were trauma counselling, psycho-education, brief psycho-dynamic therapy, and grief/bereavement counselling. The psycho-social support group interventions provided a safe environment for people to share their personal experiences. Selecting clients for individual sessions was based on the counsellor’s observation from the group sessions. People were selected for individual sessions at the discretion of the counsellor.

Employees from community-based organisations selected the clients for the project. This is because they know members of the community through their household visits as part of work in linkage and retention in care. The household either had family members who died from TB and HIV-related symptoms, had interrupted TB treatment, and /or was dealing with other illnesses or trauma like a recent HIV diagnosis, breast cancer, or rape.

During the group sessions, the counsellor noted that there were various stigma-related issues among families and friends. There was also confusion among community health workers about treatment and education. The counsellor also made some observations of pain, grief, and loss of children, family and friends from TB, as well as challenges of adherence among family members with drug addiction and past traumatic experiences.

From the sessions, it was clear that there is a need for more work on self-care and building self-esteem, as well as identifying depressive symptoms and working towards improving them.

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People awaiting TB testing and treatment at Kuyasa Clinic in Khayelitsha, Cape Town. PHOTO: MSF

Screening is key

There were important lessons learned in this project. The group and individual sessions demonstrated that a diagnosis of an illness requires mental health screening for readiness, adherence, and overall well-being. It was interesting to note that the issue of readiness and adherence is not about the illness or the medication. They are about overall well-being in terms of family support, employment, addressing past trauma, and grief.

Another lesson learned is that this support must also extend to CBO leaders and their employees. The CBO employees used the platform to share how their work with poor communities and vulnerable populations traumatises them. They shared how targets from funders are sometimes detrimental to the implementation of the programme because they have to work in unsafe environments and visit homes without knowing who they will find and how they will be treated.

Ultimately, it is clear that mental health screening must be included in primary healthcare, but it is not happening consistently across primary healthcare facilities.

South Africa’s National Mental Health Policy Framework 2013 – 2020 expired two years ago.

Part of the reason for this has to do with policy shortcomings and the poor implementation of existing policies. South Africa’s National Mental Health Policy Framework 2013 – 2020 expired two years ago. Currently, the national health department is in a consultation process for a new policy framework.

Based on the lapsed policy, mental health had to be integrated into all aspects of general healthcare by 2015, particularly those identified as priorities within the 10-point plan, for example, TB and HIV. However, in the sessions with the people affected by TB in our study, no one mentioned being screened for mental health or even being referred for any mental health services when returning to care.

In facilities, there is still a gap in integrating mental health screening with TB (and any other illness). The reality is that healthcare providers often do not provide guidance on treatment initiation or probe for treatment interruption so that they can offer comprehensive care.

Mental health screening and support for people with TB can help improve the lives of many individuals, but it can also help boost the country’s TB response by contributing to better treatment adherence, higher treatment completion rates, and ultimately more people being cured. It is high time we give it greater priority.

*Fononda is an Atlantic Institute Tekano fellow working on improving TB health outcomes and director of the TB programme at TB/HIV Care.