Stigma Stings Tuberculosis Since its Discovery

The discrimination and social isolation associated with the contagiousness of the disease prevents the patient and his family members from accepting the diagnosis, disclosing it to the people around and seeking health care. The heterogeneity in behavioral responses spans from psychological distress to psychiatric illness in extremes of cases. The manifestation exhibits as anxiety, depression, adjustment disorders, delirium, mood disorders, neurocognitive disorders, obsessive–compulsive disorders, paranoid disorders, personality changes, psychosis, and somatoform disorders. The pronouncement of a concomitant psychological morbidity stings the individual all the more, preventing him from seeking expert opinion, further leading to an underestimation of psychological comorbidities. The physicians of primary contact need to don the role of a psychiatrist as the patient has already reposed faith in them. The requirement of additional resources to handle such a crisis in an already constrained society will also be eliminated with this approach. Panibatla et al., have made an appreciable effort to highlight anxiety and depression in patients with tuberculosis (TB).[1] However, the attempt is undermined by the limitation in the number of studies and its subgroup analysis. Anxiety and depression may be synonymous for a common man, but in scientific reviews, the results obtained from studies pertaining to depression cannot be interpolated to anxiety. The time of evaluation of the patient with respect to the point in disease trajectory is important. Screening tools have questions related to incidents in the near past and therefore, in circumstances where the duration of spacing between the two consecutive follow-up visits is longer, there could be an inappropriate estimation of a psychological comorbidity. This article clubs studies using different screening and diagnostic tools interchangeably in its methodology, and hence, the results need to be considered with reservation. It should be made clear to the readers that the screening questionnaires can provide an idea of psychological distress only, and therefore, utilizing the same for interpreting the burden of psychiatric illnesses may be misleading. The actual burden can be scientifically established only after evaluation by a psychiatrist and concomitant usage of diagnostic tools. The presence of psychological distress does not necessarily reflect psychiatric illness, though it is a precursor of the same in some patients. Correction of psychological distress can avert the development of full-blown psychiatric illness in most of the patients. The treatment protocols for psychological distress and psychiatric illness are entirely different; therefore, the distinction between the two states is of utmost importance. Over the years, it has been shown that counseling and psychological support in an assiduous and sustained manner is fruitful in patients with milder distress and hence, should be provided by the health-care worker (HCW) as a part of routine care. Every method should be exhausted by the HCW in collaboration with the ancillary staff, family, and friends to correct this psychological distress. Patients with higher levels of distress should be sent for psychiatric consultation and treatment under the supervision of a psychiatrist if need be. In the event of the delay/refusal of a psychiatric opinion, which is not uncommon, HCWs should continue donning the role of a “confidante,” to decrease the psychological morbidity. Under the national program, screening questionnaires, which are patient-friendly, simple, quick, and easy to use and can be administered as well as interpreted by any HCW, should be developed and included in standard screening protocols to identify patients for “possible” psychological distress at the point of first contact. Mental health professionals should be made an integral part of multidisciplinary management plans. However, the resource-constrained settings lack the capacity to collaborate mental health programs with majority of the diseases. The primary care physicians, who are the harbingers of health-care delivery, should closely integrate with a psychiatrist during the administration of anti-tubercular treatment to the patient. At times, when contact with the psychiatrist is elusive despite requirement, various information, education, and communication methods should be used to establish and maintain this close and continuous coordination. Another facet of this systematic review and meta-analysis needs to be investigated. The reported burden of the psychological comorbidity associated with drug-resistant TB (DRTB) and drug-sensitive TB (DSTB) is controversial. It is expected to be higher in patients with DRTB than patients with DSTB due to previous multiple regimens of drugs, treatment failures, pill burden, duration of therapy, adverse drug reactions, physical debility, extended periods of work absenteeism, and financial constraints. Surprisingly contrasting results could possibly be due to erroneous criteria of arbitrary inclusion in the methodology, as discussed above. The variability in psychological comorbidities at the global level needs elaboration in this systematic review and meta-analysis, as the studies included are limited to four continents majorly. Differences in the psychological burden in nonidentical geographical regions and, sometimes, even within the same areas emanate from gross disparities in the degree of generalized evolution of the society in the past few decades apart from socioeconomic and cultural diversities. Different areas have experienced divergent changes in the burden of communicable and noncommunicable diseases, contingent on the pace of advancements in modernization. Another deterrent in this article is the predominance of hospital-based studies over community-based studies. It is expected that the psychological comorbidities would be maximal in the inpatient hospital setting, followed by outpatient hospital setting, and least in community settings. The intricacies of hospital-based studies cannot reflect the comorbidities at the community level, which harbors most of the TB patients. In the coming years, mental health comorbidities will be associated with almost every disease. The WHO has called up for upscaling of the coverage of services for mental disorders at all levels, particularly in the middle- and low-income countries. Hence, the phenomenal expansion of mental health services through a single-window delivery system in a methodologically phased manner is the need of the hour. Extensive longitudinal research, with emphasis on the impact of psychological interventions on adherence, quality of life, TB treatment outcomes, and overall well-being, under programmatic management of TB should be encouraged for recasting evidence-based recommendations from time to time. This will establish a robust mechanism of wholesome TB care.