A global overview of tuberculosis and mental health during the COVID-19 era

Although COVID-19 recently surpassed tuberculosis (TB) as a leading global cause of mortality by an infectious disease, TB continues to kill millions of people annually.¹ The World Health Organization (WHO) estimates that 1.6 million people died from TB in 2021, representing a continued reversal in mortality trends since 2019.¹ The mortality increase has largely been attributed to the COVID-19 pandemic, which has severely disrupted routine TB diagnostic and treatment services as well as reallocated many healthcare resources, personnel and spending away from TB.^{Reference McQuaid, Vassall, Cohen, Fiekert and White2} Furthermore, persons with TB make up an important population at risk for severe COVID-19 infection.³ At the same time, the burden of mental disorders, previously leading causes of disability worldwide, has surged during the COVID-19 pandemic. Compared with pre-pandemic estimates, the WHO estimated a 25% increase in the prevalence of anxiety and depression during the early stages of the pandemic, translating into an absolute increase of approximately 53.2 million cases of depression (~49 million additional disability-adjusted life-years, DALYs) and 76.2 million cases of anxiety (~45 million additional DALYs).^{Reference Santomauro, Mantilla Herrera, Shadid, Zheng, Ashbaugh and Pigott4,5} Like TB services, the pandemic has also upended mental health services worldwide, with significant disruptions and fewer available services despite adaptive shifts to care delivery strategies such as telepsychiatry.⁵ However, the collective distress caused by the pandemic has also led to increased awareness of the pervasiveness and deleterious impact of mental disorders, the social determinants that exacerbate them and the urgent need to address them.

Mental disorders among people with TB

Mental disorders, especially depression, are highly prevalent among persons with TB. It has been estimated that 45% of individuals with TB have depression, with estimates exceeding 50% in those with multidrug-resistant TB.^{Reference Duko, Bedaso and Ayano6} Furthermore, comorbid mental disorders such as depression are well documented to be associated with poor TB treatment outcomes; individuals exhibiting depressive symptoms at the time of TB diagnosis have more than four times the odds of poor TB treatment outcomes, including death and loss to follow-up.^{Reference Ruiz-Grosso, Cachay, de la Flor, Schwalb and Ugarte-Gil7} Poor mental health is also the leading cause of disability post-TB and may be a contributing factor to a shortened lifespan among TB survivors.^{Reference Alene, Wangdi, Colquhoun, Chani, Islam and Rahevar8} With recent studies reporting high prevalence estimates of common mental disorders such as depression and anxiety among persons with TB, the COVID-19 pandemic has presented numerous challenges that may exacerbate poor mental health in this population. These range from increased psychosocial stressors from disruption of routine TB services to cycles of prolonged social isolation and/or lack of support.^{Reference McQuaid, Vassall, Cohen, Fiekert and White2,Reference Sunjaya, Paskaria, Pramayanti, Herawati and Parwati9} Persons with TB are therefore often an overlooked and vulnerable population for developing and suffering from mental disorders and their consequences – even well before the pandemic.

Pandemic-related challenges to TB and mental health

We list in this section some of the key challenges to the global TB and mental health landscape during the COVID-19 pandemic.^{Reference McQuaid, Vassall, Cohen, Fiekert and White2,Reference Sunjaya, Paskaria, Pramayanti, Herawati and Parwati9} System-level challenges include but are not limited to: (a) redirection of healthcare funding away from routine TB diagnostic and care services; (b) reallocation of healthcare personnel and resources to COVID-19 care responses; (c) reduced overall focus on TB and slowing in the momentum of advocacy for TB-related issues and policies; (d) lack of or insufficient emergency health and/or social support policies for vulnerable populations and communities. Care delivery challenges include: (a) limitations in accessing patient care imposed by lockdown policies; (b) rapidly adapting and applying new modes of care delivery (e.g. community-based health innovations and conducting appointments remotely). Finally, patient-related challenges include: (a) social and physical isolation and restricted movement; (b) financial and socioeconomic stressors (e.g. inability to work); (c) fear, stigma and mental vulnerability.

Integrating mental health services with TB care

Despite evidence of receptivity to integration of mental health treatment among directors of national TB programmes (NTPs), comorbid mental disorders and mental health issues among persons with TB are not routinely assessed and addressed.^{Reference Sweetland, Galea, Shin, Driver, Dlodlo and Karpati10} However, the mental health spotlight brought by the pandemic has led to initial and promising signs of change. In late 2021, the United States Agency for International Development (USAID) released guidance on integrating mental health services into TB programmes by offering best practices to provide and support a complete mental health package for individuals with TB. These include adequate and appropriate training and supervision of staff knowledgeable in both mental health and TB, use of validated and standardised mental health screening tools, use and implementation of evidence-based mental health interventions such as those outlined by the WHO Mental Health Gap Action Programme (mhGAP), monitoring and evaluation, and supporting and implementing collaborative TB and mental health services and future research needs.^{Reference Fujiwara11} The WHO also incorporated the screening and management of comorbid mental health conditions and issues for the first time in its 2022 national strategic TB planning guidance.¹² Further WHO recommendations and guidelines for integrating mental health services into NTPs are underway. Recently, the Global Fund underwent its seventh replenishment in September 2022, and the Global Fund strategy for 2023–2028 includes integration of mental healthcare into TB and HIV care platforms as priorities for the first time. Given the new, dynamic challenges to delivery of mental healthcare and TB care brought on by the COVID-19 pandemic and the mental health vulnerability of persons with TB, there is no better time to capitalise on these recent changes and accelerate the integration of mental healthcare and TB care worldwide. In fact, the COVID-19 pandemic has been argued to be a prime opportunity to improve mental health service organisation and delivery worldwide, and nowhere is this more important and urgent than for persons with TB.^{Reference Moreno, Wykes, Galderisi, Nordentoft, Crossley and Jones13}

Research and policy recommendations to accelerate integration

Part of accelerating the integration of TB care and mental healthcare necessitates a robust evidence base. Over the past two decades, multiple studies have evaluated various psychosocial and pharmacological mental health interventions in persons with TB in low- and middle-income countries (LMICs). In general, those who receive some form of mental health intervention tend to have better mental health and TB outcomes (e.g. adherence or TB cure rates) compared with those who do not receive the intervention or compared with the pre-intervention period.^{Reference Farooq, Tunmore and Comber14} Thus, such studies demonstrate that mental health interventions can be not only effective in improving both mental health and TB outcomes but also feasibly implemented in high TB burden settings. However, further research is needed to better understand the burden of mental disorders among persons with TB in the era of the COVID-19 pandemic, explore other modalities and models of delivering mental healthcare within NTPs and evaluate different mental health screening tools in persons with TB and populations at risk for TB across diverse settings. We have identified and highlighted key research gaps and recommendations in Table 1.

Table 1 Key knowledge gaps and recommendations for future research on integrating global mental healthcare and tuberculosis (TB) care

In addition to research recommendations, we highlight in Table 2 practical policy recommendations that may assist decision makers and stakeholders in facilitating the integration of mental healthcare and TB care in the near and distant future. Many of these policy recommendations, such as promoting task-sharing and mental healthcare delivery models, are consistent with WHO mental health recommendations and have informed recent efforts to integrate global mental healthcare and HIV care. For example, the WHO recently published detailed guidance on integrating interventions and services to address both mental illness and HIV.¹⁵ These guidelines were drawn from existing mental health tools and service provision guidelines, including those that have been outlined in the WHO mhGAP for improving and scaling up mental healthcare capacity in LMICs. In fact, one of the listed purposes of the recent guidance is to provide transferable policy considerations and applications to the care of other HIV-related comorbidities, including TB. Thus, there is immense value now during the pandemic to utilise and build on the collective lessons learned and the successes and setbacks of other global health endeavours and initiatives such as those in HIV and COVID-19 to advance the necessary policies needed for integration of global mental healthcare and TB care. Given the mental health spotlight and support brought on by the pandemic, ongoing and forthcoming changes in mental healthcare and TB care and existing guidelines and tools, we are better positioned to accelerate their integration than ever before. Importantly, building and strengthening healthcare systems should remain a key overarching policy goal to ensure effective integration of mental health and TB services.

Table 2 Recommendations for future policies on integrating global mental healthcare and tuberculosis (TB) care