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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 1  |  Page : 39-43  

Depression among tuberculosis patients attending a DOTS centre in a rural area of Delhi: A cross-sectional study


1 Junior Resident, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
2 Senior Resident, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
3 Director-Professor, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Surabhi Sethi
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_109_18

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   Abstract 


Background: Studies have shown that the prevalence of psychiatric disorders, particularly depression, is high among tuberculosis (TB) patients, and may adversely affect treatment compliance. A person suffering from TB can develop depression in due course of time owing to a number of factors, namely the long duration of treatment for TB, stigmatization faced by the patient due to the disease and lack of family support to name a few. Objectives: The present study aimed to determine the prevalence of depression and its correlates among TB patients enrolled at a Directly Observed Treatment Short-course (DOTS) center in a rural area of Delhi. Methods: The study was a DOTS center-based, cross-sectional study, among 106 patients of pulmonary and extrapulmonary TB, above 18 years of age. An interviewer-administered questionnaire in Hindi was used to collect basic sociodemographic data and the Patient Health Questionnaire (PHQ)-9 was used for detecting depression. Those with a score of 10 or more were considered to be suffering from depression. Data analysis was done using SPSS licensed version 20. Chi-square was used to test for association between qualitative variables, and a P < 0.05 was considered statistically significant. Results: A total of 106 patients participated in the study, of which 61 (57.5%) were males. The median age was 30 years (inter-quartile range 24–40 years). Depression was found to be present in 25 (23.6%) participants. A higher proportion of patients with depression were unemployed currently, and also belonged to middle or lower class (P < 0.05). Depression was not found to be associated with religion, gender, marital status, HIV status, presence of diabetes, DOTS category nor with the phase of treatment. Conclusion: Depression among TB patients is common, affecting almost one in four TB patients. Physicians and DOTS providers should have a high index of suspicion for depression when assessing TB patients.

Keywords: Depression, Directly Observed Treatment Short-course, patient health questionnaire-9, psychiatric disorder, tuberculosis


How to cite this article:
Salodia UP, Sethi S, Khokhar A. Depression among tuberculosis patients attending a DOTS centre in a rural area of Delhi: A cross-sectional study. Indian J Public Health 2019;63:39-43

How to cite this URL:
Salodia UP, Sethi S, Khokhar A. Depression among tuberculosis patients attending a DOTS centre in a rural area of Delhi: A cross-sectional study. Indian J Public Health [serial online] 2019 [cited 2019 May 20];63:39-43. Available from: http://www.ijph.in/text.asp?2019/63/1/39/253881




   Introduction Top


Tuberculosis (TB) has existed for many years and still remains a major global health problem, particularly in the developing countries. As per the Global TB report 2017, India accounted for about a quarter of the world's TB cases.[1] In 2015, an estimated 28 lakh cases occurred, and 4.8 lakh people died due to TB.[2]

Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration.[3] Depression affects almost 350 million people worldwide and is the single largest contributor to the global burden of disease in the age group of 15–45 years.[4],[5] By the year 2020, it is projected to rank second among contributors to disability-adjusted life year, calculated for all ages and sex, second only to heart diseases.[6]

A number of studies have shown that the prevalence of psychiatric disorders, particularly depression is high among TB patients.[7],[8] Studies also suggest that TB patients are at higher risk to develop psychological problems.[9] TB patients who were found to be depressed when treated with cognitive therapy have resulted in less percentage of defaulter rate and increased number of treatment completion.[10]

A person suffering from TB can develop depression in due course of time owing to a number of factors, namely the long duration of treatment for TB, stigmatization faced by the patient due to the disease, and lack of family support to name a few. The present study was conducted with an aim to determine the prevalence of depression and its correlates among TB patients enrolled for Directly Observed Treatment Short-course (DOTS) center at the Rural Health Training Centre (RHTC), Najafgarh.


   Materials and Methods Top


The study was a DOTS center based, cross-sectional study conducted over a period of 2 months extending from January 2018 to March 2018. All patients of pulmonary and extrapulmonary TB, above 18 years of age, seeking treatment from the DOTS center at RHTC Najafgarh were eligible for the study. Patients of all categories, new, previously treated, and even those taking treatment for multidrug-resistant (MDR) TB were included. Patients who had a known history of any psychiatric disorder (other than depression), compromising the ability to consent were excluded from the study.

Sample size estimation was done using the formula n = 4 pq/l 2 where, p = known prevalence of the disease, q = 1 − p, l = error. According to Basu et al.,[11] the prevalence of depression is 40% among patients attending DOTS, and considering an absolute error of 10% was 96. Taking 10% as nonresponse, the final sample size came out to be 106. Consecutive enrolment of all the patients attending DOTS center during the 2 months of study duration was done till the sample size was achieved.

Informed consent of the patient was taken, after explaining the purpose of the study and assuring them of confidentiality. An interviewer-administered questionnaire in Hindi, containing questions pertaining to the basic socio-demographic profile; details of TB, status of Human Immunodeficiency Virus (HIV), Diabetes Mellitus; family history and the patient health questionnaire (PHQ-9) for diagnosis of depression was used for data collection.[12]

PHQ-9 is a nine-item self-reported questionnaire that asks participants to rate how often they have been affected by any of the listed problems during the previous 2 weeks. These nine items reflect the DSM-IV criteria for major depressive disorder: (i) little interest or pleasure in doing things, (ii) feeling down, depressed or hopeless, (iii) trouble falling asleep or sleeping too much, (iv) feeling tired or having little energy, (v) poor appetite or overeating, (vi) feeling bad about yourself – or that you are a failure or have let yourself or your family down, (vii) trouble concentrating on things, such as reading the newspaper or watching television, (viii) moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual, and (ix) thoughts that you would be better off dead or of hurting yourself in some way. The score of each question varies from 0 to 3 (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day) with a result range of 0–27. A score of 0–4 indicates none/minimal depression; 5–9 mild depression; 10–14 moderate depression; 15–19 moderately severe depression; and 20–27 severe depression. Those with a score of 10 or more were considered to be suffering from depression. PHQ-9 also contains a question to assess the difficulty level due to any of the symptoms of depression on the routine daily activities of the study participants.

Data was cleaned for errors and missing values, and was entered into Microsoft Excel. Data analysis was done using IBM Corp. IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: USA, IBM Corp). The minimum, maximum, range, mean and standard deviation, were calculated of the PHQ-9 score. Chi-square test was used to test for association between categorical variables, and P < 0.05 was considered statistically significant. Approval of the Institutional Ethics Committee, Vardhman Mahavir Medical College and Safdarjung Hospital was taken before the study was conducted. All patients diagnosed with depression were prescribed treatment and referral to the visiting psychiatrist at RHTC Najafgarh.


   Results Top


A total of 106 patients participated in the study, of which more than half of the study participants were males (61; 57.5%). The median age of the study participants was 30 years, with an inter-quartile range (IQR) of 24–40 years. Majority were Hindu by religion (100, 94.3%), literate (86, 81.1%), married (75, 70.8%), and currently employed (71, 67%). With regard to the size of the family, the mode was five members per household, and the median monthly per capita income was Rs. 3,000 (IQR-Rs. 2,000 to Rs. 5,000 per month).

Most of the participants were New cases (71, 67%), and there was an almost equal distribution of participants in the Intensive Phase and Continuation Phase of each DOTS Category of treatment. None of the participants had any history or family history of depression. Three (2.8%) and six (5.7%) participants had comorbid HIV and Diabetes as well.

Depression was found to be present in 25 (23.6%) participants, whose score was more than 10 on the PHQ-9 [Table 1].
Table 1: Distribution of study participants on the basis of the severity of depression (n=106)

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A higher proportion of patients with depression were unemployed currently, and also belonged to middle class or lower (P < 0.05). Depression was neither found to be associated with religion, gender, marital status, HIV/diabetes status, DOTS category nor with the phase of treatment [Table 2].
Table 2: Distribution of study participants according to the determinants of depression (n=106)

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   Discussion Top


The prevalence of depression among TB patients in our study was found to be 23.6%, which is lower than that reported by Basu et al. (40%).[11]

Gross regional variations are present in the prevalence of depression estimated by various authors, which differ according to study setting of rural and urban areas, and also on the basis of screening tool used. Using PHQ-9 in a tertiary care hospital of South India, Mandaknalli and Giriraj have documented a prevalence of 41.5%, whereas Sulehri et al. from Faisalabad have reported a prevalence as high as 80% using Beck Depression Inventory-II.[14],[15]

In our study, depression was found to be more prevalent among those unemployed, and those belonging to low socio-economic status (P < 0.05). Financial hardships may be contributing to the development of depression among these patients. Similar findings have been reported by Sulehri et al.[15]

The proportion of patients with depression was higher among those with HIV-TB comorbidity than those who were either HIV nonreactive or whose HIV status was unknown (P = 0.558). Duko et al. from Ethiopia, described a similarly high proportion but found a significant difference. As there were a very small number of HIV reactive patients in our study group, it may have led to our finding not being statistically significant.[16]

We found no association of depression with gender, religion, marital status, or education. Depression conventionally is believed to have a higher preponderance in females, those who are separated or single, and among those with lower educational status.[17] Our findings suggest that male and female patients of TB suffer from depression alike. Also being married or educated does not offer any protection or benefit when suffering from TB and depression comorbidity. However, some other studies have reported that older age, extensive pathology, unmarried status, and lack of social support could be risk factors for depression in TB patients.[18],[19]

In our study, we did not find any patient to be on drugs known to be causing depression (other than a few anti-tubercular drugs). Isoniazid, cycloserine, and ethionamide are drugs known to contribute to the development of depression.[20] While the drug regimens of the new and previously treated cases include isoniazid and those on MDR treatment contain cycloserine and ethionamide, it was difficult to infer whether the contribution of drug-induced depression was of a similar magnitude in all the categories in our study. As we did not find any significant association of depression with the category of TB treatment, nor with the phase of treatment, the possibility of drug-induced depression in patients appears to be low. Since the study was a cross-sectional study, we could not actually comment on the role of these drugs in the depression of TB patients. A longitudinal study with baseline and follow-up evaluation of depression with PHQ and multivariate analysis is recommended. A study by Vega et al. reports that 52% of all MDR TB patients were depressed at baseline (before initiating treatment), and their symptoms improved with time, despite being on treatment with drugs such as cycloserine.[21] A prospective study design with a higher number of MDR patients and repeated assessments of depressive symptoms thus appears to be a more suitable study design for studying drug-induced depression.

The strength of the present study includes the usage of a standardized and validated tool (PHQ-9 in Hindi) for the assessment of depression among the TB patients. A single investigator conducted the study, so possible investigator bias was excluded. The sample size was scientifically calculated; however, as the present study was conducted in only one DOTS center, findings cannot be generalized to all TB patients from rural areas of Delhi. The cross-sectional nature of the study does not permit commenting on causality of depression due to the lack of temporal association. Another limitation in our study may arise due to the cut-off score used for classifying depression on the basis of PHQ-9. Participants with a score of 5–9, needed a repeat administration of the study tool to validate the previous score, to determine whether or not they have mild depression. Since their initial score was inconclusive, we have excluded these participants from the analysis; as including them may grossly over-estimate the prevalence of depression among TB patients.


   Conclusion Top


Depression among TB patients is a common entity, affecting almost one in four TB patients. Physicians and DOTS providers should have a high index of suspicion for depression when assessing TB patients. Those from lower socioeconomic status and those who are unemployed during their illness are especially prone to depression. Their lack of employment may be contributory to the financial hardships of the family, predisposing them to depression. Thus, it is recommended that during the treatment, psychiatric evaluation of all the TB patients should be done at least once, and proper counseling and management should be made available to those who need it. The staff of DOTS center and the caregivers should be educated about symptoms of depression, and in case the patient has any symptom then they should be referred to a counselor/psychiatrist. To ascertain the most suitable time period during the course of treatment for the detection of depression, prospective studies are advised with repeated measurements to track the progression of depressive symptoms in TB patients with time, starting with the day of the diagnosis itself.

Acknowledgment

We would like to thank Dr. Charan Singh (Director, RHTC), Mrs. Renu (DOTS provider), Mr. Vivek (Lab Technician) and Miss Rekha (ANM) from RHTC Najafgarh, for their active help and support throughout the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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