Comorbidities

Individuals who are homeless or in temporary housing have a significantly greater risk of exposure to TB, developing active TB and acquiring drug resistance (68); as well as an increased likelihood of having a mental health condition (69). Assessment of their situation and related socioeconomic risk factors is required (such as poor quality or no housing, low or no income), followed by referral to the necessary support (such as social care or financial, housing or employment support). Ongoing close monitoring then is needed to provide people-centred services.

Psychological support is a critical element of palliative care where the overall goal is to relieve pain and distress and sustain a person’s well-being. Psychological support needs to be tailored to local settings with a culturally sensitive approach and respect for individual values and beliefs. Moreover, caregivers and healthcare providers providing palliative care frequently experience psychological distress themselves, for which psychological support can be beneficial (67).

Stigma refers to negative attitudes that involve discriminatory actions towards, for example, people who are receiving treatment for TB or towards those living with mental health conditions. Unfortunately, this is very common, and this stigma can result in serious violations of human rights (66). Since TB and mental health conditions can affect people who are socially vulnerable, health-related stigma and discrimination can exacerbate other social stigmas which can adversely affect a person’s personal, social, health and financial well-being.

Over 700 000 people a year die by suicide worldwide (64). One of the four key interventions in WHO’s LIVE LIFE: An implementation guide for suicide prevention in countries (65) is the early identification of anyone affected by suicidal behaviours, and their assessment, management and follow-up. Suicidal behaviours include suicidal thoughts (or ideation), plans of suicide, suicide attempts and suicide.

Substance use disorders (both alcohol and drug use disorders) comprise two major health conditions: “harmful substance use” and “dependence”. Harmful substance use is defined as a pattern of continuous, recurrent or sporadic use of a psychoactive substance that has caused clinically significant damage to a person’s physical or mental health. Dependence is defined as a disorder of regulation of psychoactive substance use arising from repeated or continuous use.

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).