SYSTEMATIC REVIEW

published: 31 May 2022

doi: 10.3389/fpubh.2022.855515

Mental Health Status and Its Impact

on TB Treatment and Its Outcomes: A
Scoping Literature Review
Charles Kwaku Agbeko 1 , Manthar Ali Mallah 2 , Biyu He 1 , Qiao Liu 1 , Huan Song 1 and
Jianming Wang 1,3*
1
Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China,
2
College of Public Health, Zhengzhou University, Zhengzhou, China, 3 Key Laboratory of Infectious Diseases, School of Public
Health, Nanjing Medical University, Nanjing, China

Background: Tuberculosis (TB) infection interferes with the health-related quality of

life (HRQOL), including physical, social, mental, emotional and financial domains of
individuals. The goal of this scoping review is to outline the most frequent mental issues
encountered by TB patients and evaluate the effects of mental health on TB treatment
outcomes. Our findings identify research gaps that could help bridge the overall treatment
outcomes in the near future.
Method: A systematic stepwise approach was adopted to search online resource
databases like PubMed, Web of science, and gray literature to retrieve published scientific
articles for the review. Titles and abstracts of selected studies were examined for their
Edited by: possible eligibility. The studies matching our eligibility criteria were taken into account for
Harshavardhan Sampath,
Sikkim Manipal University, India this scoping review.
Reviewed by: Results: One hundred and ninety three articles were retrieved out of which 26 met the
Anmol Pradhan,
final inclusion criteria. We found that studies adopting interventional approaches reported
Sikkim Manipal University, India
Shijo Joseph, good mental wellbeing outcomes and better medical compliance as compared with
Mar Sleeva Medicity, India studies that just investigated the subjects. The data represented 15 countries including
*Correspondence: three low-income countries (LICs), four low-middle-income-countries (LMICs), seven
Jianming Wang
jmwang@[Link]
upper-middle-income countries (UMICs), and one high-income country (HIC).
Conclusion: Depression, anxiety, and poor social support, and stigma affect the
Specialty section:
This article was submitted to
wellbeing of individuals across the globe irrespective of age, race, demographic
Public Mental Health, characteristics, geographical location, and social status.
a section of the journal
Frontiers in Public Health Keywords: tuberculosis, mental health, health-related quality of life, treatment, adherence

Received: 15 January 2022

Accepted: 25 April 2022
Published: 31 May 2022
INTRODUCTION
Citation: Ever since its discovery and first global outbreak in the year 1882 (1), tuberculosis (TB) has been
Agbeko CK, Mallah MA, He B, Liu Q,
the leading infectious disease cause of death worldwide and remains a public health concern (2).
Song H and Wang J (2022) Mental
Health Status and Its Impact on TB
A report released by the World Health Organization (WHO) estimated the TB-related death toll
Treatment and Its Outcomes: A at 1.3 million as of 2017 with a projection of millions more getting infected in subsequent years
Scoping Literature Review. (3). Despite the global implementation of Directly Observed Therapy, Short Course (DOTS), TB
Front. Public Health 10:855515. incidence is decreasing by only 1–2% per year (4). This is substantially lower than the estimated
doi: 10.3389/fpubh.2022.855515 speed through mathematical modeling. The World Health Organization (WHO) clearly defines

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Agbeko et al. Mental Health and TB

health as an overall state of complete physical, mental and social effects of mental health on TB treatment outcomes. Our findings
wellbeing and not merely the absence of any infirmity or disease identify research gaps that could help bridge the overall treatment
(5). TB infection interferes with the health-related quality of outcomes in the near future.
life (HRQOL), including physical, social, mental, emotional and
financial domains of individuals (6). Adherence and HRQOL MATERIALS AND METHODS
are both important indicators of the overall TB treatment
spectrum. Evaluating psychiatric comorbidities in HRQOL is Search Strategy and Study Selection
needed alongside the diagnosis of TB and likewise assessment We systematically searched for studies in PubMed, Web of
with the continuity of anti-TB treatment (7). Science, and the gray literature. A systematic stepwise approach
Major mental health problems associated with TB are based on the methodological framework proposed by Arksey
anxiety and depression (8). Anxiety disorders are characterized and O’Malley in 2005 (19) was adopted. An incorporated
extensively by excessive worrying, apprehensiveness, the fear of recommendation by Levac was also used to make the search
future events, and uneasiness (9). Anxiety disorders make up more comprehensive (20) and up to date. Additionally,
one of the most common complications of psychiatric disorders. the Preferred Reporting Items for Systematic Reviews and
In 2013 alone, it was estimated that 8.2 million cases were Meta-analysis (PRISMA) (21) was employed to guide this
reported in the general population of the UK with women being review. The search approach was updated to February 2018
twice the number of people becoming anxious than men (10). and publications in English were included. Keywords for
Depression on the other hand is a common mental disorder that database searching included “mental health status”, “mental
allows people to experience low mood, loss of self-interest or health”, “treatment outcomes”, “social support”, “depression”,
pleasure, the feeling of guilt or low self-worth, disturbed sleep or “anxiety”, “stigma”, “tuberculosis”, and “Mycobacterium
appetite, low energy, and poor concentration (11). According to tuberculosis” amongst others (full search strategies are detailed
the estimation by WHO, 300 million people are currently living in Supplementary File 1). Titles and abstracts of selected studies
with depression (12) and with no doubt, most people falling in were examined for their possible eligibility. The studies matching
this category are likely to be a patient suffering from TB or other our eligibility criteria were taken into account for this scoping
chronic diseases (12). This has been reported in many studies that review. Studies were required to have all of the following
there is a three to six times increase in the tendency of becoming characteristics: Papers included in our research included both
depressed due to TB and associated co-morbidities (13). These qualitative and quantitative if they fit the mental health status.
co-conditions pose a greater public health threat because it may Articles were also included if they conformed with the search
lead to medication default. terms of TB and mental health co-morbidity with HIV/AIDS
However, psychological issues complicate treatment outcomes since the majority of studies showed that most people in Africa
in people with infectious diseases like TB and chronic diseases living with HIV are co-infected with TB. The paper selection
such as diabetes, multiple sclerosis, Alzheimer’s, HIV, and cancer flow chart is shown in Figure 1.
(14). Maneuvering the gaps between the physical, mental and
social aspects of health will affect the overall outcome of Data Extraction
diseases. Therefore, assessing the association of TB on the At each stage of review, two reviewers extracted data
mental wellbeing of its victims is usually underestimated in independently and they subsequently met to resolve
most institutions. Moreover, social support and stigma could discrepancies. In case of continued disagreement, a third
be an important factor in the treatment outcomes of TB reviewer adjudicated study inclusion. The information extracted
patients, leading to a decrement in mental wellbeing (15). The from the selected papers included Author(s) name, year
socioeconomic burden on households and individuals could of publication, country, aim or purpose of the study, the
pose a devastating effect if a strong social network within one’s sample size of population, methodology, intervention type (if
outreach is lost. Social support is defined as various means by applicable), implications, concept, and key findings (Table 1).
which individuals help others or social interactions making the Supplementary File 2 summarizes the data extracted for this
subject or individual believe he/she is being valued and cared scoping review.
for (16). Social support helps individuals to seek the appropriate
and timely help when conditions and network interactions are Quality Control
strong and reliable for psychological support through stressful The quality of the articles retrieved was evaluated using different
events especially when it’s solely demonstrated through health- tools. Cross-sectional and observational articles included in this
seeking behaviors (17). Stigma on the other hand is defined as a review were cross-checked with the STROBE (strengthening
mark of disgrace or a form of disgrace associated with a particular the reporting of observational studies in epidemiology) (22).
circumstance. It’s a process that usually begins when a trait of Longitudinal designs were subjected to a check using the PICO
an individual is identified as disvalued or undesirable (15). This (P stands for population, I stands for intervention, C stands
is a complex setting involving the community, institutions, and for control and O stands for outcome) (23). Qualitative studies
intrapersonal relationships leading to decrement of self-worth were identified and were also cross-checked by critical appraisal
and self-value for one self (18). checklist (24). This article was also guided by adopting the
The goal of this scoping review is to outline the most frequent PRISMA (21) checklist. The data we retrieved were separated into
mental issues encountered by TB patients and evaluate the anxiety, depression and social support, and stigma. The quality

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Agbeko et al. Mental Health and TB

FIGURE 1 | Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) flow diagram for scoping review.

check was scored with a reference range of 0–5, where 0 was one pdf file from the current WHO report on TB. The first
the least score if articles didn’t meet the quality tool checklist electronic extraction resulted in a total number of 193 papers.
and 5 was the highest score if the articles meet the checklist In PubMed after extraction hits, using Boolean extractions and
protocol. The three main categorized articles were then combined screening it yielded a total of 119 articles, and the same was
in one folder using endnote to check for duplications of articles. applied to the Web of Science database which consequently
All studies included in this review met the quality assessment also yielded a total result of 74 papers. We screened both
framework of their respective studies. Table 2 shows the quality databases using abstracts and titles and handpicked 103 articles
assessment for eligible studies included in Data extraction. after duplication. Sixteen articles were further excluded after
screening by abstract and titles. Eighty seven articles were eligible.
Furthermore, 54 articles were pulled out after accessing their
RESULTS
full text. A second reviewer provided recommendations after
Study Selection going through the list and screening. Twenty eight articles were
The results primarily yielded an overall number of 1,972 papers excluded due to non-relevant outcomes and some study designs
during the initial hit in the search engines. We then applied were mathematical in a model, which didn’t fit our criteria,
the combination of the mesh terms to yield 193 papers. Our and some were also excluded due to information overlap. We
online search also yielded two links from the mental health then thoroughly read the full text and were able to get 26
foundation, three quality checklist kits, three WHO online available articles that met our inclusion criteria during our
searches for statistics on depression, MDGs, and SDGs, and search (Figure 1). After cross-checking carefully, duplication

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Agbeko et al.
TABLE 1 | Data extraction summary.

# References Year Country Method Size Objective Intervention Findings Implications

1 Fahad D 2014 Saudi Case Report 1 A case of anxiety associated with YES Association of TB causing mental When TB was treated, it elevated the
Alosaimi Arabia military tuberculosis disorders. metal disorders.
2 Fentie 2015 Ethiopia Prospective 703 Examine the relationship between NO A sparse evidence based on mental Anticipated impact
Ambaw cohort design depression and TB among people health, TB and other chronic diseases
newly diagnosed and accessing care in low-middle income countries
for TB in a rural Ethiopian setting
3 Muhammad 2014 Malaysia Prospective 216 Follow up to measure the HRQOL of YES Compromised physical and mental Timely actions for addressing physical
Atif follow up TB patients health among study patients even at and/or mental well-being of the
the end of their TB treatment. patients.
4 Sushil C Baral 2007 Nepal Qualitative study 34 To take the first steps toward NO Causes of self-discrimination A comprehensive package of
determining the causes of identified included fear of transmitting interventions, tailored to the local
discrimination associated with TB. TB, and avoiding gossip and potential context, will be needed.
discrimination.
5 K. Chalco 2006 Peru Qualitative study Focus To identify the forms and means of YES An emotional support provided by The nurse as a provider of emotional
groups emotional support that nurses provide both formal and informal means. support in the development or
to patients living with implementation of similar programs.
multidrug-resistant tuberculosis
(MTR-TB)
6 M.J. 2017 Africans Qualitative study 10 To explore the experiences and NO Men were unable to recognize TB Multidisciplinary teams supporting
Chinouya (Zm = 3; meanings of stigma among African symptoms and subsequently made ongoing TB education programs
Ug =3; Ni men with a previous TB diagnosis. late clinical presentation when they should include African men’s
4

=2; Gh=1; were also diagnosed with HIV organizations.

Sd=1).
7 Dos Santos 2017 Brazil Cross sectional 750 beds To evaluate the HRQL and the NO Found a possible high prevalence of Health care workers should be aware
prevalence of symptoms of depression and anxiety in this of these psychological disorders to
depression and anxiety in hospitalized population. enable a better management of these
patients with TB. patients
8 Juman 2015 Iraq Prospective 18 years To determine how tuberculosis (TB) NO FACIT-TB is a reliable tool to monitor Therapeutic intervention had a
Abdulelah cohort study and older treatment affects the health-related HRQL during the course of TB positive impact on patient HRQL
Dujaili quality of life (HRQL) of patients with treatment.
pulmonary TB and to identify the
predictors of favorable TB treatment
outcomes in Baghdad, Iraq.
9 Bereket Duko 2015 Ethiopia Cross-sectional 417 To assess prevalence and correlation NO The prevalence of depression and Developing guidelines and training of
study of depression and anxiety among anxiety among patients with TB were health workers in TB clinics is useful
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patients with TB 43.4 % (181) and 41.5 % (173)

respectively.
10 Ian F. Walker 2018 Nepal Mixed 135 Assessed the feasibility and YES Psychosocial support package is This requires additional investment of
quantitative and acceptability of a psychosocial acceptable to patients counselors in TB clinics.
qualitative support package for people receiving

Mental Health and TB

approach treatment for MDR-TB in Nepal.

(Continued)
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Agbeko et al.
TABLE 1 | Continued

# References Year Country Method Size Objective Intervention Findings Implications

11 Mohammed 2008 Pakistan Cross sectional 108 To determine the presence of NO Found that about a half of patients in Depression and lack of perceived
O Husain depression, anxiety and illness our sample met the criteria for control are predictors of poor
perceptions in patients suffering from probable depression and anxiety adherence
Tuberculosis (TB) in Pakistan. based on HADS score.
12 Petros 2013 India Qualitative study 12 To understand patients’ challenges in YES Family caregivers were crucial to Requires high levels of support from
Isaakidis adhering to treatment for maintaining the mental and physical family and caregivers to encourage
MDR-TB/HIV health of patients, but reported high patient adherence and retention in
levels of fatigue and stress. care.
13 Ammar Ali 2016 Yemen Prospective 243 To evaluate and to find the factors NO Highly risk depression was found Efforts should be made to improve
Saleh Jaber study influencing the HRQoL of TB patients among TB patients their QoL.
in two major TB-prevalent cities.
14 Tanja 2017 South Observational The aim of this study was to assess NO HRQOL of the study participants was The need for an integrative
Kastien-Hilka Africa longitudinal the overall impact of TB on the health impaired in all physical, mental and understanding of TB with HRQOL as
study. status psycho-social health domains at core element.
treatment start but improved during
the course of standard TB treatment
15 Jean P. 2015 Malawi Cross sectional 35 To investigate differences in NO Malawians were mostly inpatients, Suggests that patients coming from
Mukasa Australia study Australian satisfaction rates among ethnically with recurrent TB episodes, and were similar ethnic backgrounds may
and 104 similar and different patients coming more seriously ill with impaired express similar satisfaction.
Malawian from two dissimilar health systems. physical and mental wellbeing.
16 Olanrewaju 2016 Nigeria Cross sectional 98 To assessed the psychosocial NO Prolonged hospitalization resulted There is a need to consider alternative
5

Oladimeji study wellbeing of multidrug resistant TB insignificant psychosocial burden for approaches that place less
(MDR-TB) patients in voluntary and the MDR-TB patients in our study psychosocial burden on patients
isolated long-term hospitalization in centers without compromising quality of care.
Nigeria.
17 Benvinda 2016 Angola Cross-sectional 81 To determine levels of anxiety, NO Found high rates of anxiety, Mental health services should be an
Xavier Paulo study depression and emotional distress in depression and emotional distress integral part of TB programs.
patients with several types of TB among TB patients.
18 Valerie A 2013 Peru Qualitative 43 To understand psychosocial wellbeing NO Patients described the need for Extending educational opportunities
Paz-Soldán during treatment. psychosocial support to mitigate the to patients’ families and the wider
difficulty of continually going to the community.
clinic to take medications.
19 Karl Peltzer 2012 South Cross sectional 4,900 Assessed the prevalence and NO High rates of psychological distress Improved training of providers in
Africa predictors of psychological distress among tuberculosis patients screening for psychological distress.
as a proxy for common mental
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disorders among tuberculosis (TB)

patients in South Africa, where over
60 % of the TB patients were
co-infected with HIV.
20 Grant 2015 Zambia Randomized - Correlation of psychological distress NO Severe psychological distress is Targeted interventions to alleviate

Mental Health and TB

Theron1 Zimbabwe (1:1), and their association with frequent amongst TB patients in psychological distress, alcohol use,
Tanzania parallel-arm, non-adherence to anti-TB treatment. Southern Africa and improve health literacy in
South multi-centric trial newly-diagnosed TB patients.
Africa

(Continued)
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Agbeko et al.
TABLE 1 | Continued

# References Year Country Method Size Objective Intervention Findings Implications

21 Cesar 2013 Peru Longitudinal 325 To estimate the significance and YES The presence of MDE at baseline is Targeting detection and treatment of
Ugarte-Gi study magnitude of major depressive associated to negative outcome of MDE may improve TB treatment
episode as a hazard factor for TB treatment outcomes.
negative outcomes.
22 Annelies Van 2008 Thailand Cross sectional 47 To develop scales to measure YES Identified two sub-scales associated Their use will help document the
Rie HIV;480 TB tuberculosis and HIV/AIDS stigma in a with both tuberculosis and HIV/AIDS burden of stigma.
developing world context. stigma: community and patient
perspectives
23 Paulo 2015 Angola Cross sectional 81 To determine levels of anxiety, NO Found high rates of anxiety, Mental health services should be an
Benvinda depression and emotional distress in depression and emotional distress integral part of programs against
Xavie patients with several types of TB and among TB patients. tuberculosis.
to determine the association between
social-demographic and economic
factors, clinical variables and anxiety,
depression and emotional distress.
24 Shaoru Zhang 2016 China Qualitative 22 To explore the overall illness NO Their serious lack of awareness of TB, Educational and medical institutions
studies experience of Chinese high school TB caused by the ignorance of school, should develop more effective TB
patients and to investigate the parents and the students, becomes Control strategies based on
individual and social causes of such the biggest obstacle to timely these factors.
experience. diagnosis and treatment
25 Shao-Ru 2010 China Qualitative 17 To explore the experiences and NO Psychological pressure was Colleges should follow governmental
6

Zhan studies psychological process of college significant during the treatment policies on TB.
students with pulmonary tuberculosis
in Shaanxi, China.
26 Tanja 2017 South Observational 131 Aimed to evaluate the association YES HRQOL improved over 6-month TB HRQOL is affected by a number of
Kastien-Hilka Africa longitudinal between HRQOL and adherence in treatment different factors and not limited to
TB patients in South Africa effects of adherence.
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Mental Health and TB

Agbeko et al. Mental Health and TB

TABLE 2 | Quality assessment for eligible studies included in data extraction.

Type of studies Number of studies Article number Checklist Reference score (0–5)

Qualitative studies 7 4, 5, 6, 12, 18, 24, 25 Glasgow Critical Appraisal 4.0

Cross sectional 9 7, 9, 11, 15, 16, 17, 19, 22, 23 STROBE 4
Cohort studies 3 2, 8, 13 STROBE 4.5
Mixed qualitative and quantitative studies 1 10 - -
Case report 1 1 - -
Follow up 1 3 - -
Longitudinal studies 3 14, 21, 26 PICO 4.5
Randomized 1 20 - -

methods were applied and handpicked to prevent a repetition Depression

of a particular study. Longitudinal studies were checked using Depression in TB patients leads to the outcome of delay
the PICO element, cross-sectional and observational studies was in seeking medical care which eventually leads to negative
cross-checked using the STROBE checklist and qualitative papers medication adherence (6). Psychiatric comorbidity being
were crossed checked by the critical appraisal checklist. All the reported as depression was a major decrement to health leading
articles screened passed for eligibility. Seven qualitative searches to a default in seeking appropriate health (26). In a research done
were found, one mixed method of qualitative and quantitative, in South Africa, a significant frequency of psychological distress
nine cross-sectional articles, and three cohort studies. We among tuberculosis patients was found, with most individuals,
also encountered one case report, one follow-up study, three particularly those from lower socioeconomic classes, becoming
longitudinal studies, and finally one randomized study. Our study depressed throughout treatment, resulting in a lack of negative
also comprised 15 different countries with three different multi- health-seeking behavior. (27). Furthermore, patients classified
country studies. Articles concluded that decrement in mental as MDR-TB experienced more depression (28). The impact of
health impacts TBs outcome and compliance hence there is an mental health on TB patients has hindered their wellbeing both
increase tendency to medication adherence and poor prognosis. emotionally and spiritually which makes it a hindrance to seeking
With prior inclusion and exclusion criteria, our search was a healthy behavior, hence affecting treatment outcomes in a long
narrowed down to a total of 103 papers. round (29, 30). In Peru, a study reported 37% depression
in newly identified TB cases (31). A cross-sectional survey
Location of Studies from 48 low and middle-income countries concluded that the
Of the 26 studies we analyzed, three were multi-country related, proportion of depression is relatively high among TB patients
three were in South Africa, two were in Peru, two were in with a consequent decrement in health status than in that among
Ethiopia, two were in Nepal, two were in China and the the general population (32). Depression peaks in patients on
other nine studies were conducted across the globe. Based on anti TB medications, hence we need strategic outlines and
the World Bank Report (25), we classified the countries into interventions to deal with the side effects of these medications.
upper-middle-income countries (UMICs), low-middle-income But fewer studies have been conducted on this subject
countries (LMICs), low-income countries (LICs), and high- matter (29).
income countries (HIC). Figure 2 illustrates the publications in
different regions and different years. Anxiety
The impact of anxiety has been demonstrated largely through
Interventional Outcomes the feeling of anger and ruminating over past events that led
We divided interventional outcomes into depression, anxiety, to contracting TB which could prolong treatment duration
and social support, and stigma. There were 18 articles reporting (31). Psychiatric co-morbidity increases the risk to decrement
depression but only four articles (#1, 3, 21, and 26) adopted in health and default (26). Anxiety was found to be a key
interventions, and the outcome of mental health with medication psychological domain in a Zambian study in which 37.6%
adherence were improved in patients making up 22.2% of total of patients were found to be suffering from anxiety (31). A
articles in the depression category. The remaining 14 articles (#2, similar study conducted in Huambo Angola had similar findings
7, 8, 9, 11, 13, 14, 15, 16, 17, 19, 20, 23, and 25) did not perform outlining emotional distress and anxiety to be present among TB
interventions but reported data on depression. There were four patients (33). Anxiety disorder and miliary TB were also reported
articles (#1, 3, 21, and 26) adopted interventions and the other in a case study of a 67-year-old Saudi man who qualified for
14 articles (#2, 7,8,9,11,13,14,15,16, 17, 19, 20, 23, 25) reported anxiety definition under the Diagnostic and Statistical Manual
data on anxiety. Regarding social support and stigma, there were of Mental disorders (DSM-5) with excessive anxiety, but his
4 articles (5, 10, 12, and 22) that adopted interventions and six symptoms elevated due to treatment of TB (34). This report
articles (#4, 6, 18, and 24) that had no intervention but reported limits the studies only to identifying anxiety symptoms in
data on social support and stigma. Table 3 gives the summary of association with TB but couldn’t go on further to outline the
the interventions and non-interventional outcomes. mechanism involved in it (34). In Porto Algero, Brazil a study

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FIGURE 2 | Publications in different regions and in different periods.

TABLE 3 | Interventional outcomes.

Category of mental health Article number; n% Intervention Outcomes (good or bad)

(if applicable)

Depression 1, 3, 21, 26; n = 22.22% Intervene Improve both physical and mental wellbeing
2, 7, 8, 9, 11, 13, 14, 15, 16, 17, No intervention Compromise mental wellbeing
19, 20, 23, 25; n = 77.77%
Anxiety 1, 3, 21, 26; n = 22.22% Intervene Improve both physical and mental wellbeing
2, 7, 8, 9, 11, 13, 14, 15, 16, 17, No intervention Compromise mental wellbeing
19, 20, 23, 25; n = 77.77%
Social support and Stigma 5,10,12,22; n = 50% Intervene Improve both physical and mental wellbeing
4, 6, 18, 24; n = 50% No Intervention Compromise mental wellbeing

also demonstrated generalized anxiety disorder prevalent in TB breeding depression, self-hate and disappointment, hindering
patients and quantified the number of psychiatry co-morbidity patients from accessing the required healthcare he/she needs
in 68% of hospitalized TB patients (6). Anxiety and mental (38). With a good support system, family members and loved
health disorder have been demonstrated to be in poor accordance ones served as advocates who constantly reminded TB clients to
with effective treatment outcomes (6). Poor medical compliance seek help (17). External stigma as well as familial stigma both
and adherence to treatment were also demonstrative in a study have huge impacts on the mental health wellbeing of people
conducted in Pakistan with an anxiety rating of 47% (35). Hence affected by TB. In the family settings, patients suffering from
anxiety is also a key mental health problem in TB patients. TB were sometimes left alone to fend for themselves, leading
to isolation and self-neglect (37). Stigma and discrimination
Social Support and Stigma have led to a negative effect on health-seeking behavior in
Despite the fear of being infected, family support and individual patients who suspects having TB due to long cough duration
relationships have proven to help most TB patients overcome the (39). Being highly portrayed in communities, especially in low
fear of public rejection (36). A study conducted in Peru outlined and middle-income countries (LMICs), people suffering from
that all patients with TB who disclosed their disease to their TB tend to hide their symptoms and rather spread the infection
families were welcomed and cherished with an abundance of (40). A research conducted in Peru assessed treatment outcomes
love, encouragement, financial support, and emotional strength when nurses served as emotional supporters to patients with
as compared to those who hid it away from their loved ones TB and concluded that social support and networking was vital
(17). However, a crucial factor leading to high default of TB to the recovery as it helped their spiritual wellbeing (41). It is
care is stigma (37). Stigma negatively affects the individuals by stipulated by other studies that, socio-cultural attributes of most

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communities due to lack of public education on TB interfere with DISCUSSION

treatment adherence and may lead to new infections in the future
(42, 43). Social support is hence an important determinant for a This review ascertained the effects of mental wellbeing on the
good outcome in all diseases. A study from Shaanxi province in impact of effective TB treatment around the world. Out of
China showed how lack of TB education among family members 26 articles retrieved, all articles well documented the observed
affected the outcome of TB and hence an integral program and impacts of mental health on treatment outcomes of TB and
campaign was needed to improve the outlook on TB (44, 45). consequent decrement in the mental aspects of TB victims.
The sparse evidence presented is also an indication of mental However, limited research existed on the effects of possible
health neglect. interventions to improve the balance between mental wellbeing
and improvement of TB outcome (6, 40, 47, 51, 52).
Interventional Approaches One qualitative study from Peru demonstrated how nurses
Quality of Life is a multifaceted notion that spans the physical, helped hospitalized MDR-TB patients serving as treatment
social, psychological, economic, spiritual, and other realms. As a supporters to cope well with their infirmity and there was
result, it’s difficult to define and measure, but it may be roughly significant progress in the outcome of treatment (41). We
defined as people’s judgments of their place in life in relation to subsequently think this type of intervention should be applied
their objectives, aspirations, standards, and worries in the context in different regions across the world to help promote the mental
of the culture and value systems in which they live. As part of health of TB patients in addition to encouraging family members
mitigations to improve patients’ quality of life, some countries and immediate friends circle to join in the support. One of
implemented interventions to combat clinical depression and the interventions was timely actions taken within the treatment
anxiety observed among TB patients. One study conducted in period to address mental wellbeing using feasible tools and
Malaysia reported addressing mental wellness on time manner designing indicators to help alleviate symptoms (46, 49). Another
by first accessing it at baseline and during the treatment course. intervention was to extend educational programs to families and
This aided early identification of depression and anxiety onset caregivers to encourage patient adherence to seeking positive
in TB patients for which psychosocial counseling was offered health behavior (48). Educational programs can take place on
to improve the mental wellbeing (46). Additionally, two studies different platforms such as social media, radio, and TV programs,
found that targeted detection and aggressive treatment of major marketplace campaigns in LMICs, and involving local celebrities
depressive episodes from baseline would also improve the mental to serve as ambassadors for educating the masses on such
wellbeing of TB throughout treatment (31, 34). In Peru, there issues. We think this could help patients establish strong self-
was a marked increase in mental health after providing necessary worth. A follow-up study in Penang General Hospital using
support to patients (41). Counselors were also provided in SF-36 questionnaire found that even though other symptoms
one setting in Nepal, which saw to counseling TB patients to improved significantly with treatment, 23% of patients were at
cope with their disease and treatment side effects (47). An risk of depression at the end of TB treatment, which may be
encouragement for a high level of support from family and due to lack of psychological support during the treatment period
friends also proved important and effective in the recovery (46). This implies that assessing psychological status at baseline
process in India (48). Implementing interventions that measure and working toward improving every domain of HRQOL is
and mitigate stigma at the local community level also proved an significant in the pathway to a free TB world in the near
effective way of the intervening potential for depression among future. We suggest that hospitals should include psychological
TB clients as was observed in Thailand (49). These interventions therapy such as counseling as part of the treatment program.
have a good impact on patients’ treatment outcomes and quality In another study, major depressive and anxiety episodes (MDE)
of life. Hence, we entreat that such interventions will have in- were measured using a 5-item version in 325 patients (31). The
depth research to help identify suitable measures in treating TB presence of major depressive episodes at baseline was associated
patients worldwide. with negative outcomes (31). Depressive and anxiety are mostly
The requirement for a multidisciplinary team, such as found during an initial stages of diagnosis and may lead to
incorporating the clinical psychologist when sent home or during negative outcomes if psychological packages are not strategized
an inpatient, was highlighted in certain literatures. The core of to encourage patients to adhere and retain care regimes (14, 48).
these disciplines will aid in bridging the gap between depression HRQOL in TB patients is usually underestimated in many
and home-based long-term care. Another intervention that may settings, especially in LMICs where major resources are usually
be used to reach remote settlers is the use of telemedicine. In its directed to improving only microbial symptoms, but neglecting
most basic form, telemedicine may be used. In the absence of a the mental, physical and other domains in relation to HRQOL.
smart phone, satellite tiny phones can be used to call clients on A South Africa study adopted the SF-12, EQ-5D and St. George’s
a regular basis for a phone checkup. This is an interventional respiratory scale, and observed a positive relationship between
strategy that will be quite beneficial. It will also assist if DOT treatment adherence and HRQOL in patients with TB (53). It
centers are established in health facilities or primary health care is therefore obvious that elevating microbial symptoms alone by
institutions. Health care workers who will staff these clinics using drugs will address some domains but others may be left
should be given extra training in basic psychological assessments out. LMICs with a high burden of TB may prioritize anti-TB
to aid in the rapid identification of symptoms for appropriate drugs over psychological support. We think this phenomenon
treatment or referral to a specialist (50). The examples above are may be due to an extra financial burden that will be invested
only a handful of the interventional strategies that are required. into getting more mental health workers which might not fit into

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Agbeko et al. Mental Health and TB

the budget plan of LMICs. Also, a prospective cohort study in link between depression, anxiety and TB excluding confounding
Nepal suggested psychological support package is acceptable to factors that may contribute to a compromised mental health
patients and hence requires additional investment to counselors (53). Considering general factors will help identify areas to be
in TB clinics (47). This supports the recommendation that there addressed so as to get a quick intervention in that area. The
is an urgent need for resource allocation to psychological support correlation of anxiety, depression, and TB has been established
training in clinics and DOT centers in LMICs. in most studies but factors have been poorly outlined (52).
There is a need for further studies and improvement on Irrespective of the above-noted limitations to the quality of the
caregivers training in recognizing, identifying, and implementing articles, a review of the data collated by them is highly informative
a social network approach to treating TB patients. National and and good enough to inform treatment policy formation and
provincial/district CDCs, primary care facilities, and other public upgrade. This review combined findings from a case report,
health agencies have to mobilize workforces that will look into all qualitative and quantitative studies together thereby ensuring the
aspects of health during the treatment course. Extra funding and capture of all relevant information on the topic making it one of
research are needed, especially in the field of mental health. An the strengths.
integral effort by all agencies to increase the capacity of mental
health workers in the field and national TB programs and the
need to support primary caregivers should also be frontier on CONCLUSION
the agenda in most countries. Catastrophic cost on the victim’s
The evidence of the effects of mental health on TB outcomes
finances and family, socio-economic status considerations in that
has been well captured in this review. Depression, anxiety and
area of study, and cultural beliefs of the society in question are
poor social support, and stigma evidently affect the mental
some of the driving factors we identified that could also lead to a
well-being of individuals across the globe, irrespective of age,
decrement in the mental wellbeing of patients.
race, demographic characteristics, geographical location, and
We further assessed the quality of reviewed studies and
social status. Moreover, there is an urgent need to address TB
observed some limitations with some articles which may have
in a multidisciplinary approach to combat the overall quality
affected the quality of the findings. For starters, interpreted
of treatment outcomes. Patients with all forms of TB may or
findings in some articles were not expressed clearly due to data
may not experience optimum mental wellbeing depending on
not being solely collected for analyzing the effect of mental
a variety of reasons influencing the patient and this needs
wellbeing on medication adherence. Also, some studies used
further research.
different measurements for assessing the mental wellbeing of
patients. Some articles investigated just specific effects of how TB
affects them mentally, while others considered measuring other Implication of Research
factors leading to a potential decrease of mental wellbeing among This review underscores the importance of studies in the field
TB patients. Other studies also focused on the measurement of of mental health in relation to TB patients across the globe.
physical wellbeing as compared to mental wellbeing but mostly Further research needs to be conducted in the field of mental
neglected to make it an exclusive inclusion of all factors leading to health to outline strategies that will help promote the mental
medication adherence. This review also observed that qualitative wellbeing of TB patients during treatment across the world.
studies mostly collected data only at one point in time without Furthermore, recent research on mental health and its association
follow-up. We deem this an important gap as results may not to medication adherence using causal inference analysis and
reflect the true context of mood alterations, which could have led meditational modeling will optimize treatment protocols for
to a bias. better outcomes as well as help understand limitations and
pathways leading to default in TB treatment.
LIMITATION AND STRENGTH
This systemic review was limited in a number of ways. The
DATA AVAILABILITY STATEMENT
search was limited to only 13 years from 2005 to 2018. During The original contributions presented in the study are included
the search, we might have limited ourselves to only papers in the article/Supplementary Material, further inquiries can be
which were available in the databases used and their titles directed to the corresponding author.
as well as abstracts matched our keywords. Moreover, taking
data samples representing the whole population is very vital
to understanding the variation and complexity of studies. The AUTHOR CONTRIBUTIONS
use of convenient sampling however seemed to be commonly
utilized in most research and is a vital limitation to most studies CA and JW: conceptualization, methodology, and software. CA:
(6, 17, 54). Representation of just a particular group of people, formal analysis and visualization. CA, MM, BH, QL, and HS:
for example, smear-positive TB patients alone, cannot be used investigation and writing—original draft preparation. MM, BH,
as a generalization for the whole population (46). Studies that QL, and HS: data curation and validation. JW: supervision,
were cross-sectional in nature did not really identify a clear- project administration, resources, writing—review and editing,
cut relation between anxiety, depression with reference to other and funding acquisition. All authors have given final approval of
factors that have been found to compromise the mental wellbeing the version to be published and agreed on the journal to which
(53). They were mostly focused on the determination of a the article has been submitted.

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Agbeko et al. Mental Health and TB

FUNDING ACKNOWLEDGMENTS
This study was funded by the National Natural Science All authors of the manuscript thank and acknowledge their
Foundation of China (81973103), Nanjing Major Science and respective Universities and Institutes.
Technology Project (2021-11005), Medical Research Project of
Jiangsu Health Commission (ZDB2020013), and Key Project SUPPLEMENTARY MATERIAL
of Philosophy and Social Science Research in Colleges and
Universities in Jiangsu Province (2020SJZDA096). The funding The Supplementary Material for this article can be found
agencies had no role in the study design, data collection, analysis, online at: [Link]
decision to publish, or preparation of the manuscript. 2022.855515/full#supplementary-material

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college students with pulmonary tuberculosis in Shaanxi, China: a qualitative
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