World Tuberculosis Day: How Social Stigma Associated With TB Affects Patients' Mental Health

Care delivery is often jeopardised due to the prevailing stigma associated with TB. Delays in care-seeking and diagnosis fueled by stigma lead to an increase in the size of the infectious pool of TB.

According to an article published in the journal Expert Review of Respiratory Medicine, a community-based survey conducted in 30 districts in India found that 73 per cent of the people had a stigmatising attitude towards tuberculosis patients. (Representative photo)

World Tuberculosis Day 2023: India has the highest burden of tuberculosis patients globally, and the Indian government aims to eradicate the disease from the country by 2025. Tuberculosis control has been the focus of the government's Revised National Tuberculosis Control Programme. 

Based on the achievements of the last National Strategic Planning, the NSP 2017-2025 has embarked on the bold vision of tuberculosis eradication.

How social stigma associated with tuberculosis affects the mental health of patients

Care delivery is often jeopardised due to the prevailing stigma associated with tuberculosis. Delayed care-seeking behaviour, delayed diagnosis or poor anti-tuberculosis treatment adherence are a result of stigma, which is a social determinant of health.  

According to an article published in the journal Expert Review of Respiratory Medicine, a community-based survey conducted in 30 districts in India found that 73 per cent of the people had a stigmatising attitude towards tuberculosis patients. 

How social stigma leads to increased number of tuberculosis cases

According to the study, delays in care-seeking and delayed diagnosis fueled by stigma lead to an increase in the size of the infectious pool of tuberculosis, which enhances the risk of household contact transmission and community transmission. Therefore, addressing stigma is one of the keys to the prevention of tuberculosis transmission.

More than 50 per cent of tuberculosis patients experience stigma after being diagnosed, the study said, citing a report. Another study conducted in India estimated that over 200,000 patients experience pre-treatment loss to follow-up annually in the national tuberculosis programme, which refers to the dropout of patients after diagnosis but before treatment registration. This is a major gap in tuberculosis care in India and globally. 

Stigma plays a vital role in the high rates of pre-treatment loss to follow-up. Patients often do not go for treatment because they fear disclosing their disease to their family. 

Healthcare providers often look down upon tuberculosis patients

Moreover, healthcare providers often exhibit an unfriendly approach to tuberculosis patients. There has been a lack of adequate counselling, another important reason behind losing tuberculosis patients to care. 

The fact that tuberculosis patients receive stigma from healthcare providers, who people look up to alleviate them of their pain due to illness, is worrisome, the study said.

Not only does this behaviour go against the principles of healthcare, but is also a major impediment for tuberculosis elimination. 

The study authors noted that it is a matter of concern that the focus of tuberculosis control has been largely on biomedical approaches with not much attention to behavioural interventions to mitigate stigma. 

Elevated risk of depression, anxiety and psychosis among tuberculosis patients

According to a statement by United for Global Mental Health, a London-based non-governmental organisation, the theme for World Tuberculosis Day 2023, "Yes! we can end TB!", draws attention to the disease and the collective power to end it globally by 2030. 

United for Global Health said in the statement that tuberculosis does not only cause physical disease, but there is also an elevated risk of depression, anxiety and psychosis among people with the disease, including multidrug-resistant tuberculosis. 

United for Global Mental Health has emphasised on the fact that there is an urgent need to integrate mental health services into tuberculosis programmes. 

Sarah Kline, the CEO of United for Global Mental Health, said that globally, depression among individuals with any form of tuberculosis could reach as high as 50 per cent due to biological, social and behavioural factors. 

Kline also said that depression is associated with delays in tuberculosis diagnosis, treatment and poor treatment outcomes such as disability, poor quality of life, treatment failure and death. 

Integrated mental health interventions within tuberculosis services can boost the rates of treatment completion, Kline said.

Social stigma leads to feelings of shame and isolation

The physical symptoms caused by tuberculosis can affect the patient’s quality of life, experts say. Also, the social stigma can lead to feelings of shame and isolation.

“Tuberculosis can have a significant impact on a person's mental health. The physical symptoms of tuberculosis, such as coughing, fatigue, and difficulty breathing, can be distressing and affect a person's daily life. Tuberculosis treatment can also be challenging and require lifestyle changes, such as avoiding alcohol and tobacco use. The social stigma associated with tuberculosis can also cause feelings of shame and isolation, leading to depression and anxiety,” Dr Ambarish Joshi, Senior Consultant – Pulmonary & Sleep Medicine, Primus Super Speciality Hospital, New Delhi, tells ABP Live.

Psychological issues complicate tuberculosis treatment outcomes

The drugs used in the treatment of tuberculosis, and the duration of the treatment can also lead to depression and anxiety. Moreover, tuberculosis interferes with the health-related quality of life.

“Major mental health problems associated with tuberculosis are anxiety and depression which is due to many attributing factors such as social stigmata of the disease, drug used in the treatment of the disease, and long duration of the treatment. Apart from this, tuberculosis infection interferes with the health-related quality of life (HRQOL), including physical, social, mental, emotional and financial domains of individuals,” Dr Arun Chowdary Kotaru, Consultant, Respiratory/ Pulmonology & Sleep Medicine at Artemis Hospitals Gurgaon, tells ABP Live.

According to Dr Kotaru, psychological issues complicate treatment outcomes. 

Undiagnosed mental illness can exacerbate tuberculosis symptoms

Apart from anxiety and depression, tuberculosis can also lead to alcoholism. Moreover, undiagnosed mental illness can exacerbate the symptoms of tuberculosis due to poor health-seeking behaviour.

“There is compelling evidence linking tuberculosis to common mental health issues like depression, anxiety, and alcoholism. According to research, tuberculosis patients can develop mental health issues at any time during their treatment. Undiagnosed mental illness in tuberculosis patients can lead to poor health-seeking behaviour and non-adherence to treatment, as well as a low quality of life and poor treatment outcomes,” Dr. Babina NM, Chief Medical officer, Jindal Naturecure Institute, Bangalore, tells ABP Live.

Yoga and exercises can improve mental health of tuberculosis patients

Therefore, patients must practise yoga and perform other exercises to improve their mental health.

“Yoga and other exercises can help you improve your mental health. Yoga can help with stress reduction because it promotes relaxation, which is the natural antithesis of stress. Yoga can help three aspects of our lives that are frequently harmed by stress: our body, mind, and breathing,” says Dr NM.

People from all walks of life can be affected by stigma associated with tuberculosis

One of the main reasons behind social stigma associated with tuberculosis is that many people think that the disease affects the patient forever. People from a good socio-economic background can also be subject to social stigma.

“Due to the stigma attached to the diagnosis of tuberculosis, patients find it difficult to believe the diagnosis. They often claim that they have an excellent socio-economic background, because of which tuberculosis could not affect them. Tuberculosis can affect any patient from any socio-economic stratum of society,” Dr Arjun Khanna, Head, Department of Pulmonary Medicine, Amrita Hospital, Faridabad, tells ABP Live.

Although most patients suffer anxiety or stress after hearing about their diagnosis, the feelings can be handled through counselling and mental health improvement techniques.

Importance of the need to integrate mental health services into tuberculosis care

According to United for Global Mental Health's "Bending the Curve Report", integrating mental health into tuberculosis care will help avoid about 14 million tuberculosis cases, which is more than the predicted number of cases for any year between 2023 and 2030. Also, it will allow faster progress towards global targets set against HIV infection and tuberculosis, improve the quality of life for vulnerable groups, ensure better adherence to drugs, and consequently better treatment outcomes, and address the long-term effects of the Covid-19 pandemic on those affected by tuberculosis and HIV infection. 

Therefore, United for Global Mental Health has urged governments, health organisations and other stakeholders to prioritise the integration of mental health services into tuberculosis programmes, and to ensure that political declarations at the United Nations High Level Meeting on Tuberculosis, which will be held in September 2023, have strong messages that support the integration of mental health services into tuberculosis programmes.