Cited by 178Tuberculosis Research and EpidemiologyInfectious Diseases and TuberculosisMental Health Treatment and Access

Addressing the tuberculosis–depression syndemic to end the tuberculosis epidemic

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Sweetland, A. C., Kritski, A., Oquendo, M. A., Sublette, M. E., Norcini Pala, A., Silva, L. R. Batista, Karpati, A., Silva, E. C. +3 more·2017·The International Journal of Tuberculosis and Lung Disease

Abstract

Tuberculosis (TB) and depression act synergistically via social, behavioral, and biological mechanisms to magnify the burden of disease. Clinical depression is a common, under-recognized, yet treatable condition that, if comorbid with TB, is associated with increased morbidity, mortality, community TB transmission, and drug resistance. Depression may increase risk of TB reactivation, contribute to disease progression, and/or inhibit the physiological response to anti-tuberculosis treatment because of poverty, undernutrition, immunosuppression, and/or negative coping behaviors, including substance abuse. Tuberculous infection and/or disease reactivation may precipitate depression as a result of the inflammatory response and/or dysregulation of the hypothalamic-pituitary-adrenal axis. Clinical depression may also be triggered by TB-related stigma, exacerbating other underlying social vulnerabilities, and/or may be attributed to the side effects of anti-tuberculosis treatment. Depression may negatively impact health behaviors such as diet, health care seeking, medication adherence, and/or treatment completion, posing a significant challenge for global TB elimination. As several of the core symptoms of TB and depression overlap, depression often goes unrecognized in individuals with active TB, or is dismissed as a normative reaction to situational stress. We used evidence to reframe TB and depression comorbidity as the 'TB-depression syndemic', and identified critical research gaps to further elucidate the underlying mechanisms. The World Health Organization's Global End TB Strategy calls for integrated patient-centered care and prevention linked to social protection and innovative research. It will require multidisciplinary approaches that consider conditions such as TB and depression together, rather than as separate problems and diseases, to end the global TB epidemic.

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Crossref · 10.5588/ijtld.16.0584

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  • The psychological burden associated with TB is a particularly important determinant of treatment engagement and outcomes, yet it is still insufficiently addressed in routine TB care.

    “Among these, the psychological burden associated with TB has emerged as a particularly important determinant of treatment engagement and outcomes, yet it is still insufficiently addressed in routine TB care [6].”

    From Psychosocial Interventions for Improving Treatment Adherence in Tuberculosis Patients: A Scoping Review of Evidence-Based Approaches. (2026) · cites this paper as [6]

    The Abstract (page unavailable) links depression in people with TB to poorer health behaviors and outcomes, and the ‘Responding to the tuberculosis–depression syndemic’ section says depression often goes undiagnosed and may need more support than TB programs provide. But the paper describes effects on adherence as possible and says rigorous TB-specific evidence is lacking; it does not establish psychological burden broadly as a determinant of treatment outcomes. (LLM, conf=0.84)

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  • Stigma may contribute to depression and anxiety through internalized shame and experiences of discrimination; delay help-seeking because of fear of disclosure; interfere with adherence by making treatment-taking visible; and intensify social isolation through both self-protective withdrawal and rejection by others.

    “It may contribute to depression and anxiety through internalized shame and experiences of discrimination; delay help-seeking because of fear of disclosure; interfere with adherence by making treatment-taking visible; and intensify social isolation through both self-protective withdrawal and rejection by others [6,27,35].”

    From Psychosocial Interventions for Improving Treatment Adherence in Tuberculosis Patients: A Scoping Review of Evidence-Based Approaches. (2026) · cites this paper as [6]

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  • TB may precipitate depression as a result of altered inflammatory responses and/or dysregulation of the hypothalamic-pituitary-adrenal axis, or the side effects of ATT.

    “Conversely, TB may precipitate depression, as a result of altered inflammatory responses and/or dysregulation of the hypothalamic-pituitary-adrenal axis, or the side effects of ATT.9”
  • The relationship between depression and TB is bidirectional.

    “The relationship between depression and TB is bidirectional.”
  • Depression may increase risk of TB reactivation, antibiotic drug resistance, contribute to disease progression, and/or inhibit the physiological response to anti-tuberculosis treatment (ATT).

    “Depression may also increase risk of TB reactivation, antibiotic drug resistance, contribute to disease progression, and/or inhibit the physiological response to anti-tuberculosis treatment (ATT).”

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Research works printed but not linked: 3

  1. [82]World Health Organization mhGAP Mental Health Gap Action Programme: scaling up care for mental, neurological, and substance use disorders Geneva, Switzerland WHO 2008 26290926
  2. [84]Alipanah N Nguyen LN Falzon D Systematic review and meta-analysis of adherence interventions in tuberculosis treatment The 21st Annual Conference The Union North America Region 23 February 2017 Vancouver, BC, Canada
  3. [90]Sweetland A TB and mental health: a survey of national TB programme directors. 47th Union World Conference on Lung Health: Confronting resistance: fundamentals to innovations, 26–29 October 2016, Liverpool, UK [Symposium] Int J Tuberc Lung Dis 2017 20 Suppl 1 S54

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Authors
Sweetland, A. C., Kritski, A., Oquendo, M. A., Sublette, M. E., Norcini Pala, A., Silva, L. R. B., Karpati, A., Silva, E. C., Moraes, M. O., Silva, J. R. L. E., & Wainberg, M. L.
Affiliations
  • New York State Psychiatric Institute (US)
  • Universidade Federal do Rio de Janeiro (BR)
  • University of Pennsylvania (US)
  • Department of Psychiatry, Columbia College of Physicians and Surgeons, New York, New York, USA; New York State Psychiatric Institute, New York, New York, USA
  • Vital Strategies (US)
  • State University of Norte Fluminense (BR)
Venue
The International Journal of Tuberculosis and Lung Disease
Published
2017-08-01
Volume
21
Issue
8
Pages
852-861
ISSN
1027-3719 (ISSN-L)
OpenAlex
W2743140206
Cited by
177
References
85
Citations by year
2026: 17 · 2025: 29 · 2024: 28 · 2023: 23 · 2022: 18 · 2021: 18 · 2020: 21 · 2019: 15 · 2018: 8
FWCI
9.26
Type
journal article
Language
en
Open access
Locations
  • The International Journal of Tuberculosis and Lung Disease (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Arca - Repositório Institucional da Fiocruz (submittedVersion)
Funders
  • Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro
  • National Institute of Mental Health (T32MH019139, K01MH104514, T32MH096724)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Tuberculosis Research and Epidemiology
  • Health Sciences › Medicine › Surgery › Infectious Diseases and Tuberculosis
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords
tuberculosis, depression, comorbidities, tuberculosis reactivation, tuberculosis transmission, drug resistance, TB stigma, medication adherence, health-seeking behavior, hypothalamic-pituitary-adrenal axis, inflammation, substance abuse, poverty, malnutrition, integrated care, tuberculosis elimination
MeSH terms
Antitubercular Agents, Depression, Humans, Tuberculosis, Health Behavior, Cost of Illness, Disease Progression, Patient-Centered Care, Drug Resistance, Bacterial, Medication Adherence, Social Stigma

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