Depression in people with tuberculosis: Assessing the effectiveness of interventions for depression, and the barriers and facilitators for their implementation in Pakistan and other low-and-middle income countries

Background: Depression is a common comorbidity in people with tuberculosis (TB). Treating depression in people with other conditions often improves both physical and mental health outcomes. However, the impact of treating depression in people with TB on their mental health and TB-related outcomes remains unclear. Additionally, there is limited understanding of how to implement and deliver mental health interventions for depression for people with TB within existing TB services. Aims: This thesis aims to assess the effectiveness of depression treatment for people with TB and explore the barriers and facilitators to implementing mental health interventions in TB services in low-and-middle-income countries (LMICs). Methods: A meta-analysis was conducted to evaluate the effectiveness of depression interventions for people with TB. Barriers and facilitators to implementation were explored through a systematic review. Lastly, a qualitative case study of the implementation of a psychological mental health intervention in Karachi, Pakistan which aimed to integrate diagnosis and treatment for depression in people with drug-susceptible TB attending primary and tertiary care facilities for TB care. Findings: Psychological interventions showed a small but positive effect on improving depression in people with TB, though the evidence quality was low. The most common interventions combined psychological and pharmacological approaches. All interventions required additional funding and training resources. The case study emphasized the importance of funding, training, and strong relational connections within TB facilities for successful implementation. Despite feasibility and evidence of effectiveness, none of the interventions described in this thesis have been sustained over time. Conclusions: Psychological interventions can improve both mental health and TB-related outcomes for people with TB in LMICs. However, successful delivery requires adequate funding and training. Future research should prioritize sustainable integration of mental healthcare into existing TB services.