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Depression Among Patients with Tuberculosis Open Access Protocol BMJ Open: first published as 10.1136/bmjopen-2015-007653 on 8 July 2015. Downloaded from Depression among patients with tuberculosis: determinants, course and impact on pathways to care and treatment outcomes in a primary care setting in southern Ethiopia—a study protocol Fentie Ambaw,1,2 Rosie Mayston,3 Charlotte Hanlon,2,3 Atalay Alem2 To cite: Ambaw F, ABSTRACT regarding the delivery of mental healthcare in Mayston R, Hanlon C, et al. Introduction: Depression is commonly comorbid with primary care in Ethiopia. Depression among patients chronic physical illnesses and is associated with a with tuberculosis: range of adverse clinical outcomes. Currently, the determinants, course and literature on the role of depression in determining the impact on pathways to care and treatment outcomes in a course and outcome of tuberculosis (TB) is very limited. primary care setting in INTRODUCTION southern Ethiopia—a study Aim: Our aim is to examine the relationship between The relationship between depression and protocol. BMJ Open 2015;5: depression and TB among people newly diagnosed and e007653. doi:10.1136/ accessing care for TB in a rural Ethiopian setting. Our chronic physical illnesses is bidirectional. bmjopen-2015-007653 objectives are to investigate: the prevalence and Comorbidity is associated with a range of determinants of probable depression, the role of adverse outcomes, including functional ▸ Prepublication history for depression in influencing pathways to treatment of TB, impairment, increased medical costs, poor this paper is available online. the incidence of depression during treatment, the adherence to medication and self-care regi- http://bmjopen.bmj.com/ To view these files please impact of anti-TB treatment on the prognosis of mens, increased medical symptom burden visit the journal online depression and the impact of depression on the and increased mortality.12Individually, (http://dx.doi.org/10.1136/ outcomes of TB treatment. 34 45 bmjopen-2015-007653). depression and tuberculosis (TB) are Methods and analysis: We will use a prospective recognised as important public health con- Received 12 January 2015 cohort design. 703 newly diagnosed cases of TB (469 cerns, contributing to 2.5–2.0% of disability Revised 20 March 2015 without depression and 234 with depression) will be adjusted life years (DALYs) worldwide in Accepted 10 April 2015 consecutively recruited from primary care health 6 centres. Data collection will take place at baseline, 2 2010, respectively. In Ethiopia, the preva- lence of depression was found to be 9.1% in on September 30, 2021 by guest. Protected copyright. and 6 months after treatment initiation. The primary 7 exposure variable is probable depression measured a nationally representative sample; and in a using the Patient Health Questionnaire-9. Outcome population-based survey carried out in south- variables include: pathways to treatment, classical ern Ethiopia, depression was found to be the outcomes for anti-TB treatment quality of life and seventh leading cause of disease burden con- disability. Descriptive statistics, logistic regression and tributing to 6.5% of the DALYs in 1998.8 TB multilevel mixed-effect analysis will be used to test the is a key public health concern in Ethiopia: in study hypotheses. 2009/2010, it was the second most important Ethics and dissemination: Ethical approval has cause of death.9 Ethiopia is ranked seventh been obtained from the Institutional Review Board among the 22 high-burden countries that (IRB) of the College of Health Sciences, Addis account for 81% of all cases of TB and 80% Ababa University. Findings will be disseminated of all TB deaths worldwide. Ethiopia is also through scientific publications, conference fi presentations, community meetings and policy one of 27 countries identi ed as having a For numbered affiliations see briefs. high prevalence of multidrug resistant TB end of article. Anticipated impact: Findings will contribute to a (MDR-TB). The burden of MDR-TB in these sparse evidence base on comorbidity of depression countries accounts for 86% of cases 910 Correspondence to and TB. We hope the dissemination of findings will worldwide. Fentie Ambaw; raise awareness of comorbidity among clinicians and Evidence from cross-sectional studies [email protected] service providers, and contribute to ongoing debates (some of which were carried out in hospital Ambaw F, et al. BMJ Open 2015;5:e007653. doi:10.1136/bmjopen-2015-007653 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-007653 on 8 July 2015. Downloaded from settings in African countries) indicate a very high preva- responses.122324In addition, in chronic pulmonary lence of comorbid depression (ranging from 10% to conditions with hypoxia, the hypoxic condition can act – 52%) among patients with TB.11 18 However, because directly to make patients anxious and depressed. longitudinal research on TB and depression is scarce, Likewise, general factors associated with chronic disease the nature of the relationship and trajectory of such as weight loss, fatigue, psychological and social comorbidity is little understood. Most high-quality losses may trigger depressive reactions.21 studies examining the prevalence and impact of There is a consensus among experts that people who comorbid depression in the context of chronic physical have chronic diseases and comorbid depression can diseases were conducted among people with diabetes benefit from treatments for depression, including treat- mellitus, ischaemic heart diseases, cancer and chronic ment with antidepressants.114192526If depression in the obstructive pulmonary diseases.1219The extent to context of TB is associated with a biological pathway or is which the impact of comorbid depression in the context a response to the burden of chronic infection, it might of TB is comparable to depression comorbid with other be expected that treatment of TB may lead to reduced non-communicable chronic conditions is unclear. TB is symptoms of depression, perhaps without the need for a curable condition with relatively shorter treatment dur- further intervention. As intervention for depression ation and therefore has the potential for more favour- among patients with TB is likely to incur additional costs, able outcomes than many non-communicable chronic pill burden and potential stress, it is important to under- diseases.16 However, TB remains a debilitating, stigma- stand to what extent TB treatment alone may be an effect- tised communicable disease requiring complex and ive intervention for depressive symptoms. In addition, aggressive treatment. Similar to depression in the anti-TB medications, especially isoniazid, the first of the context of HIV/AIDS, the potential for depression to monoamine oxidase inhibitors to be considered for the impair adherence to complex TB medication regimens treatment of mental disorders in the 1950s,27 and now a is not only problematic in terms of individual patient core drug in anti-TB treatment,28 may have significant outcomes but also poses a threat to public health interactions with selective serotonin reuptake inhibi- through the potential for the development of multidrug tors,27 which are WHO-recommended drugs for the treat- resistance.20 For now, the literature on the role of ment of depression in the mental health gap action depression in determining TB treatment outcomes programme (mhGAP) guideline.29 The integration of (treatment default, interruption, completion, failure, mental healthcare into primary care settings is currently death) and treatment pathways (routes of help seeking being scaled up in Ethiopia,29 30 with depression as one for TB treatment within modern or traditional care of the priority disorders. The results of the proposed systems) is very limited. study will help to inform the targeting and delivery of mental health services in the context of TB in Ethiopia. http://bmjopen.bmj.com/ POSSIBLE MECHANISMS FOR THE ASSOCIATION BETWEEN TB AND DEPRESSION AIMS AND OBJECTIVES It is likely that pathways for associations between TB and Our overall aim is to carry out a longitudinal study of depression are complex and multidirectional. Biological depression in the context of TB, in order to determine and psychosocial pathways may be responsible for observed the impact of comorbid depression on TB outcomes. In associations. The extent to which different pathways con- this way, we hope to contribute to a sparse evidence base tribute to the burden of comorbidity is currently unclear. that lacks high-quality evidence from African countries, on September 30, 2021 by guest. Protected copyright. For example, some researchers have suggested that patients where the highest rates of cases and deaths relative to with TB may develop depression as a result of chronic population size occur.31 Our study has five objectives: infection or related psychosocioeconomic stressors21 or 1. To determine the prevalence of depression in people due to the effects of treatment such as isoniazid.22 An alter- with TB at the time of anti-TB treatment initiation, native pathway may be that TB is contracted as a result of 2. To assess factors associated with baseline depression, compromised immunity and neglected self-care associated 3. To determine the incidence (risk) of depression in with depression.23 Finally, there is evidence to suggest that patients with TB at 2 and 6 months after starting TB and depression may share risk factors.22324 anti-TB treatment, Immunological responses have been implicated
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