Depression: a silent driver of the global tuberculosis epidemic
Open accessAbstract
Depression is a common comorbid condition for patients with tuberculosis (TB) 1-3, and is associated with higher morbidity and mortality 4, 5, antibiotic drug resistance 1, 3, 6, and community transmission. Depressed individuals with TB are less likely to seek care promptly, if at all, and once in treatment are significantly less likely to take medications consistently and/or completely 2, 4, 7. These treatment irregularities can lead to drug resistance, morbidity and mortality. Therefore, depression may be an unrecognized driver of the TB and multidrug resistant TB (MDR-TB) epidemics. MDR-TB treatment is significantly more expensive, takes approximately four times as long to complete, and produces acute physical and psychiatric side effects, which makes treatment adherence and completion a considerable challenge. Since few low-income settings have the resources or capacity to deliver the specialized care that is required, ensuring prompt and complete TB management in all settings is critical to curb the global TB and emerging MDR-TB epidemics. Using a two-stage snowball approach to reviewing the literature, first searching MEDLINE (1946-2013), PubMed (1966-2013), and PsycINFO (1806-2013) databases with key relevant search terms, then reviewing the references of those articles, we identified 31 studies from 11 countries that assessed depression prevalence among individuals with active TB. These included one low-income (Kenya), three lower-middle income (India, Nigeria, Pakistan), five upper-middle income (South Africa, Peru, Romania, Russia, Turkey), and two high-income countries (Greece, United States). The studies were of mixed methodological quality. A majority of them relied on brief screening instruments to identify probable cases of depression, seven used clinical diagnostic interviews, and two did not specify the method of assessment. Only two studies included a healthy comparison group. Sample sizes ranged from 30 to 691 (mean 158, median 100). Two-thirds were conducted among outpatient populations and the remaining among inpatients in hospitals. The current prevalence of depression among individuals receiving treatment for TB ranged from 11.3% to 80.2%, with a mean weighted prevalence of 48.9% (95% CI 48.3%-49.6%). In the two studies that compared the prevalence of depression among TB outpatients to healthy controls, that prevalence was three to six times higher among the former. Though we expected to find consistent rates within or between countries of similar income levels, a great deal of variability was observed. The widest variation occurred within countries (India, Nigeria, Pakistan, Peru and Russia). However, in these cases, the weighted mean prevalence within countries revealed relatively narrow confidence intervals with a strong central tendency. There was little difference in rates between studies using structured diagnostic interviews versus brief screening instruments, and no single screening instrument produced higher or lower rates than any other used. The most commonly used brief screening tool, adopted in eight studies, was the Beck Depression Inventory. Though available evidence is of mixed methodological quality, it suggests that the prevalence of depression among individuals with active TB may be equally high or higher than in people with other chronic medical conditions. However, more research is sorely needed to estimate the true community prevalence of depression among individuals with TB. Treating comorbid depression has been associated with better TB outcomes, including medication adherence, treatment completion, and cure. A prospective controlled study in India found that TB patients who received individual psychotherapy during treatment were significantly more likely to adhere to and complete treatment and, thus, be cured of their disease 8. In rural Ethiopia, the organization of peer-led "TB clubs" increased clinic attendance and adherence, case detection, and community awareness about TB 9. In Peru, a psychosocial support group intervention was developed for MDR-TB patients which improved treatment adherence and completion, as well as social rehabilitation after treatment 1. Finally, antidepressants, in isolation or in conjunction with other therapies, have also been effectively used to treat depression among patients with TB 10. Though TB disproportionately affects individuals in low-resource settings with few mental health specialists, a growing body of evidence suggests that non-specialist health workers can be trained to deliver basic mental health care, including case detection, symptom management and triage, and such strategies may be very useful and relevant in the context of TB. Annika Sweetland1,2, Maria Oquendo1,2, Priya Wickramaratne1,2, Myrna Weissman1,2, Milton Wainberg1,2 1Department of Psychiatry, Columbia College of Physicians and Surgeons, New York, NY, USA; 2New York State Psychiatric Institute, New York, NY, USA
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Poor adherence with TB treatment leads to multi drug resistant TB (MDR-TB).
“Poor adherence with TB treatment leads to multi drug resistant TB (MDR-TB)5”
From Pharmacological or non-pharmacological interventions for treatment of common mental disorders associated with Tuberculosis: A systematic review (2021) · cites this paper as [5]
In the main text, the paper says inconsistent or incomplete TB treatment can lead to drug resistance and may contribute to MDR-TB epidemics. The claim states more definitively that poor adherence leads to MDR-TB, omitting those qualifications. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThe prevalence of depression in patients receiving treatment for TB ranges from 11.3% to 80.2%, with a mean weighted prevalence of 48.9%.
“The prevalence of depression in patients receiving treatment for TB ranges from 11.3% to 80.2%, with a mean weighted prevalence of 48.9%.5”
From Pharmacological or non-pharmacological interventions for treatment of common mental disorders associated with Tuberculosis: A systematic review (2021) · cites this paper as [5]
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“Background Depression may affect as many as half of all individuals with tuberculosis (TB) (Sweetland et al., 2014), which presents significant challenges to the management of these comorbid illnesses.”
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“…of time variable; re2 ¼ residual variance within individuals. workers could be trained to deliver basic mental health care for the elderly TB patients (Sweetland et al., 2014), so in some resource-poor communities that have few mental health professionals, health workers can receive training…”
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“The combination of depression with TB can lead to poor quality of life, poor medication adherence, progression to multidrug-resistant TB, and finally ending up with mortality [17, 18].”
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“Co-morbid depression, a common disorder in people with TB (Trenton & Currier, 2001; Doherty et al., 2013; Sweetland et al., 2014; Sweetland et al., 2017, 2018), may negatively affect timely diagnosis and service utilization (Sweetland et al., 2018).”
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“적 치료로 인해 다제내성 폐결핵으로 진행될 가능성을 높이며 [1] 이는 다시 우울이 지속되도록 하는 악순환으로 이어진다”
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“Depression has also been found to lower treatment adherence and increase mortality in people with tuberculosis (Sweetland et al., 2014, 2017).”
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Self-citationThe Impact of Maladaptive Coping Styles on Psychological Outcomes in Tuberculosis Patients
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“Estimates show that 40–70% of TB patients report symptoms of anxiety or depression, particularly in settings where stigma and limited psychosocial support are prevalent [6–9].”
Tuberculosis and comorbid depression: Association with serum indoleamine 2,3-dioxygenase activity
Rana, P., Varughese, B., Roy, V., Khanna, S., Kapoor, S., & Khanna, A. K. (2025) · Indian Journal of Pharmacology · doi:10.4103/ijp.ijp_252_23 · Cited by 1 · see citing works
“[2] Considering 10% as nonresponse, the sample size of 106 was calculated.”
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“Prevalence rates of depression and mental disorders among TB patients in low income countries ranged between 46 and 80 % [1].”
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“Depression often coexist with TB ((5)).”
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“Age is of great importance, so in patients over 35 years of age, the risk of developing depression reaches 40–70 % [12, 13], and after 65 years, this index becomes even higher [14].”
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5. THỰC TRẠNG TRẦM CẢM THEO THANG ĐIỂM PHQ-9 Ở NGƯỜI BỆNH LAO KHÁNG THUỐC TẠI VIỆT NAM NĂM 2023
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Tuberculosis and Mental Health
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“20–23 Our study extends this by showing how MDR-TB acts as a stressor that re-shapes household structure and co-residence patterns.”
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“Sweetland and colleagues [2] reported that depression severely worsens TB treatment by causing poor treatment adherence, leading to treatment failures and refractoriness, drug resistance, prolonged infectiousness, and increased morbidity and mortality.”
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- Authors
- Sweetland, A., Oquendo, M., Wickramaratne, P., Weissman, M., & Wainberg, M.
- Affiliations
- New York State Psychiatric Institute (US)
- Department of Psychiatry; Columbia College of Physicians and Surgeons; New York, NY USA
- Venue
- World Psychiatry
- Publisher
- Wiley
- Published
- 2014-10
- Volume
- 13
- Issue
- 3
- Pages
- 325-326
- ISSN
- 1723-8617 (ISSN-L)
- PMC
- PMC4219079
- OpenAlex
- W2061535079
- Cited by
- 90
- References
- 10
- Citations by year
- 2026: 7 · 2025: 10 · 2024: 10 · 2023: 10 · 2022: 16 · 2021: 6 · 2020: 7 · 2019: 7 · 2018: 5 · 2017: 7 · 2016: 3 · 2015: 2
- FWCI
- 2.80
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- World Psychiatry (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Columbia Academic Commons (Columbia University)
- Funders
- National Institute of Mental Health (T32MH096724)
- Topics
- Health Sciences › Medicine › Infectious Diseases › Tuberculosis Research and Epidemiology
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Health Sciences › Medicine › Surgery › Infectious Diseases and Tuberculosis
- Keywords
- depression, tuberculosis, multidrug-resistant tuberculosis, depression prevalence, comorbidities, medication adherence, drug resistance, mental health screening, low-income settings, community transmission, help-seeking
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