SUMMARY

RÉSUMÉ

RESUMEN

METHODS

RESULTS

Between October 2015 and June 2017, we interviewed NTP directors from 26 countries face-to-face (n = 8), over the telephone/Skype (n = 13), or in writing (n = 5) in the interviewee’s preferred language (English, Spanish, Portuguese or French). NTP directors represented 3 (12%) high-, 4 (15%) upper middle-, 8 (31%) lower middle- and 11 (42%) low-income countries (Figure), of which 21 (81%) were classified as high incidence and/or burden countries for TB, TB-HIV coinfection, and/or DR-TB (Table 1).²⁸ Whereas the range of country income levels were well represented in the sample, regional representation was limited due to non-response, unavailability of contact information, or language barriers. Eighteen (69%) of the countries were from sub-Saharan Africa; this overrepresentation was likely because the initial recruitment was done at the 2015 Union Conference in South Africa.

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Figure

Geographic and income representation of the 26 countries whose NTP directors participated in the survey, 2015–2017.²⁸ Countries were Angola, Botswana, Brazil, Cameroon, Central African Republic, Chad, Democratic Republic of Congo, Estonia, Ethiopia, Ghana, India, Liberia, Madagascar, Malawi, Moldova, Mozambique, Namibia, Nigeria, Pakistan, Republic of Korea, South Africa, South Sudan, Tajikistan, Tanzania, United States, and Zimbabwe.

Table 1

Sample characteristics (n = 26)

	n (%)
Region
East Asia & Pacific	1 (4)
Europe & Central Asia	3 (12)
Latin America & the Caribbean	1 (4)
North America	1 (4)
South Asia	2 (8)
Sub-Saharan Africa	18 (69)
High-burden countries*
TB	11 (42)
TB-HIV	12 (46)
DR-TB	7 (27)
High-incidence countries*
TB	4 (15)
TB-HIV	6 (23)
DR-TB	3 (12)
Income level28
High	3 (12)
Upper-middle	4 (15)
Lower middle	8 (31)
Low	11 (42)

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^*Some countries are included on more than one list.

TB = tuberculosis; HIV = human immunodeficiency virus; DR-TB = drug-resistant TB.

Perceived barriers to tuberculosis treatment success

Table 2 summarizes the top perceived barriers to treatment success, including general challenges and those related to the co-management of medical and psychiatric comorbidities. With regard to barriers to TB treatment success, the most frequent responses were lack of knowledge (58%), side effects (35%), distance and/or transportation difficulties (35%), poverty (31%), substance abuse (27%), system failures (27%) and TB-related social stigma (23%). Nobody (0%) reported depression or other non-substance use-related mental health issues as one of the top five barriers to TB treatment success.

Table 2

Likelihood of and receptivity to TB and mental health integration^*

	n (%)
Likelihood of integration into NTP guidelines
Highly likely	17 (65)
Somewhat likely	5 (19)
Unlikely	4 (15)
Receptivity of TB providers
Very	12 (46)
Somewhat	12 (46)
Not receptive	1 (4)
Missing	1 (4)

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^*If training for effective and low-cost interventions²⁹ were available.

TB = tuberculosis; NTP = National Tuberculosis Program.

The most frequent co-occurring medical disorders cited to be challenges for TB care in each country were HIV (92%), diabetes mellitus (65%), heart disease and/or hypertension (19%), and other medical complications (15%). In relation to co-occurring psychiatric disorders, the most commonly perceived challenges were related to depression (58%), psychosis (50%), anxiety (42%), and trauma-related disorders (23%). Most interviewees identified problem alcohol use (88%) as a difficulty, and nearly half (46%) identified tobacco use. Respectively four (15%) and eight (31%) countries identified marijuana and other illicit drugs to be a challenge to TB care and prevention.

Receptivity to tuberculosis and mental health treatment integration

When asked about the likelihood of integrating TB and mental health services if training was offered for low-cost, effective interventions, 22 expressed high (65%) or some (19%) receptivity to the integration of TB and mental health treatment; only four (15%) believed it would be highly unlikely in their current environment (Table 3). The receptivity of frontline TB providers was perceived to be less strong (46% very and 46% somewhat receptive). However, several NTP directors qualified their answers by saying that TB providers were likely to comply with national guidelines and protocols if given appropriate guidance. When asked to rate the degree to which capacity, awareness, resources, and stigma were barriers to mental health care integration at the national level, they identified limited capacity (73%), not recognizing mental health as a problem (62%), not having enough resources (50%), and social stigma (35%).

Table 3

Potential for TB-HIV/mental health service integration

	TB (n = 26)	HIV (n = 22)
Primary care integration of TB services
Fully integrated	19 (73)
Somewhat integrated	3 (12)
Not integrated	4 (15)
Primary care integration of TB and HIV services
Fully integrated	6 (23)
Somewhat integrated	15 (58)
Not integrated	3 (12)
Missing	2 (8)
Psychosocial services routinely provided
Peer support groups	14 (54)	19 (86)
Mental health counseling	5 (19)	5 (23)
Referral for psychiatric consultation	6 (23)	3 (14)

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TB = tuberculosis; HIV = human immunodeficiency virus.

DISCUSSION

The majority of NTP directors in our study sample would support the integration of mental health care within their TB care delivery systems if service provision for patients receiving anti-tuberculosis treatment was low and if effective and low-cost mental health treatment models were available. The high level of declared receptivity by NTP directors is a sign that evidence of the added value that mental health services can bring by improving patient outcomes and reducing overall TB program expenditure may be growing. Furthermore, we found that most NTPs have integrated TB programs in primary care and/or HIV care, and some have already taken steps to integrate mental health and TB care. These findings suggest that many countries have existing infrastructures that may facilitate national integration of TB and mental health services.

Our findings come at a time of rapid expansion of the Global Mental Health movement,²⁹ whose aims are directly in line with the integration of mental health- and substance-related services into TB treatment programs, and eventually moving most mental health service delivery out of the psychiatric hospital setting into community and primary care settings.¹⁹ In low-resource settings with few mental health specialists, this is achieved through ‘task shifting’, whereby non-specialists are trained to deliver basic mental health services with expert supervision.³⁰ Given the high comorbidity of TB and mental health and substance use disorders, and the treatment of TB at the primary care level in the highest burden countries, mental health services could be added to the existing TB care delivery platform as a first step in providing enhanced care to patients in need.¹⁹

Our findings also highlight significant challenges to integrating TB and mental health care. While most NTP directors expressed high receptivity to integrating mental health care into their TB programs, mental disorders other than substance abuse were not mentioned among the top five barriers to TB treatment completion. This may be due, at least in part, to considerable variations in the global burden of psychiatric and substance use disorders,³¹ and/or the limited knowledge of the respondents about mental health problems. NTP directors may also have difficulty prioritizing mental health care, given the numerous competing priorities and limited resources. However, many of the barriers and priorities mentioned by NTP directors, including TB-related stigma, poverty, homelessness, and HIV infection, are also risk factors for mental and substance use disorders. Additional outreach may be needed to position mental health as an essential component of patient-centered TB care. The WHO intends to develop a collaborative framework for TB and mental health,³² and has, for the first time, included a chapter dedicated to mental health in the forthcoming second edition of the WHO Companion Handbook for the Management of TB.¹⁹ Stronger evidence based on intervention trials of mental health treatment on improving TB outcomes may increase the perceived importance of integrating mental health care into existing TB programs.

The primary barriers to the integration of mental health services into TB treatment programs, such as the lack of effective, low-cost models, limited capacity and lack of recognition of mental health as a problem, are increasingly becoming surmountable. The WHO’s End TB mandate explicitly includes provision of a mental health service as a pillar of its TB eradication strategy,²⁰ and the WHO has also created a suite of ‘off-the-shelf’ packages of evidence-based mental health interventions, particularly for depression, as part of its Mental Health Gap Programme (mhGAP).^30,33 The mhGAP Intervention Guide provides a blueprint for first-line integration of mental health services at the primary care level among non-specialist clinicians³⁰—who may also be treating TB—and also includes three low-intensity community-based, non-pharmacologic interventions for depression designed for delivery by laypersons (e.g., community health workers) with no previous experience in mental health. While not designed specifically for TB, these interventions could be adapted to the specific needs of patients being treated for TB.

Limited capacity and training are also barriers for which solutions are increasingly available as part of the broader Global Mental Health Movement. The WHO provides Member States with support in rolling out mhGAP, including training programs prescribing first-line antidepressants and antipsychotics by general practitioners. However, the integration of the mental health services into TB programs cannot be ensured unless it is coupled with strong capacity-building efforts among primary care workers. A major first step for NTPs worldwide would be to scale up routine screening of mental and substance use disorders. With only two of 26 (8%) of countries reporting the availability of routine mental health screening in their TB programs, introducing a simple and short screening tool for depression, such as the Patient Health Questionnaire 9 (PHQ-9) or the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST),^34,35 would be a major step towards characterizing the most prevalent of comorbid mental health issues during anti-tuberculosis treatment, and provide NTPs the data needed to leverage funding for mental health services.

Global organizations, such as The Union’s TB & Mental Health Working Group, could also help educate policy makers and program managers, not only at international conferences, but also through the dissemination of educational materials. There appears to be a high demand for training; a recent webinar on TB and mental health drew over 150 attendees from 33 countries, and a recently uploaded video describing the mental health management of multidrug-resistant TB patients in Peru³⁶ drew 235 views from 24 countries in its first month online. These are certainly small steps, but they represent a critical shift in awareness that, if sustained, could result in meaningful change.

There were several limitations to our study. Due to language and logistic barriers, we did not achieve full geographic representation in the sample. Given the high proportions of African countries, high TB burden countries, and low-income countries included in our sample, our findings may be most relevant to countries in these categories. In addition, responses were based on the perceptions and opinions of the NTP directors, which were subject to social desirability bias. Future research should implement scientific methods to evaluate specific approaches for integrating TB and mental health care in real life settings.

CONCLUSIONS

We reported findings from the first survey on the integration of TB and mental health care services by NTP directors. Our most noteworthy finding was the lack of attention to mental health and substance use in current practice, but high receptivity to integrating such services into TB care and prevention. Our findings suggest that the integration of TB and mental health care should be supported as part of TB elimination goals. We identified significant obstacles that need to be addressed: low levels of awareness and inadequate prioritization of mental health, limited resources, and lack of training. Future work should leverage the promising receptivity among NTP directors and the momentum of the Global Mental Health Movement to address the obstacles presented in our study.

Acknowledgements

Footnotes

References