Operational Handbooks

People with mental disorders (such as schizophrenia, which is characterized by symptoms of psychoses) are at greater risk than the general population for exposure to infectious diseases, including TB (51). Psychosis is characterized by distorted thoughts and perceptions, disturbed emotions and behaviours, and the possibility of incoherent or irrelevant speech (see Table 1).

Many individuals experience symptoms of anxiety (not necessarily an anxiety disorder) as a common reaction to a TB diagnosis and the required treatment, which can often be mitigated by social support (28, 32). Symptoms of anxiety in TB may present as fear of infecting others or mortality, or because of stigma and discrimination. Acute anxiety may also be an adverse reaction to a particular anti-TB agent.

Depression is a common and treatable mental health condition, associated with immunosuppression, which is often unrecognized and undiagnosed in individuals with TB and results in poor treatment outcomes, including treatment failure, loss to follow-up and death (17).

Mental health care is one of the health services to be integrated with TB services as outlined in the End TB Strategy and the WHO Framework for collaborative action on tuberculosis and comorbidities (2, 30).

TB disproportionately affects people living in poverty and other socially vulnerable populations, which amplifies their risk for mental health conditions. Providers of TB care can undertake various actions to influence both the impact of disease-specific triggers on poor mental health and social determinants of mental health. In particular, social support, including education and facilitating access to psychological and material support, is critical to mitigate the impact of poverty, TB, its treatment, and the related stigma and discrimination, on people’s mental health (28).

Mental disorders¹ are prevalent in all countries (8). Nearly 1 billion people worldwide are living with a mental disorder, which has become the leading cause of years of living with disability. The risk factors for developing a mental disorder are multi-faceted and may include any combination of individual factors (psychological or biological), family or community factors (such as poverty or violence), and structural factors (such as inequality or environmental emergencies) (11).

Comorbidity: A concurrent disease or health condition in a person with TB.

ASSIST      Alcohol, Smoking and Substance Involvement Screening Test

AUDIT        Alcohol Use Disorders Identification Test

GAD           generalized anxiety disorder

GAD-7       Generalized Anxiety Disorder Assessment-7

HIV            human immunodeficiency virus

MDR-TB   multidrug-resistant TB

This section of the operational handbook was prepared by Ernesto Jaramillo, Farai Mavhunga, Marzia Calvi and Annika Sweetland (consultant) from the World Health Organization (WHO) Global Tuberculosis Programme Department (GTB), and Aiysha Malik and Mark van Ommeren from the WHO Department of Mental Health and Substance Use (MSD), under the overall direction of Tereza Kasaeva, Director of the GTB department and Dévora Kestel, Director of the MSD Department.