1. Mental health conditions and substance use disorders: background and rationale

Mental disorders¹ are prevalent in all countries (8). Nearly 1 billion people worldwide are living with a mental disorder, which has become the leading cause of years of living with disability. The risk factors for developing a mental disorder are multi-faceted and may include any combination of individual factors (psychological or biological), family or community factors (such as poverty or violence), and structural factors (such as inequality or environmental emergencies) (11).

People affected by TB have a higher risk for mental health conditions and substance use disorders (12, 13). This comorbidity negatively impacts a person’s capacity to adhere to their medication and infection control practices. It can also worsen morbidity and increase risk of poor TB treatment outcomes and poor overall health-related quality of life (14, 15). Studies suggest that depression may independently increase the risk for TB (16, 17). Several of the anti-TB medications are associated with depression, anxiety and/or psychoses (12, 18, 19), which may require either temporary or complete suspension of the suspected agent and/or initiation of adjunct psychopharmacological medication. There is an increased risk of depression, anxiety or psychoses in people with multidrug resistant TB (MDR-TB) (20, 21). Disorders due to alcohol use significantly increase the risk for developing TB (22). Psychological stress associated with stigma and discrimination may also trigger or aggravate mental health conditions or substance use disorders in affected individuals. Individuals with drug-resistant TB (23) and/or co-infected with HIV are at an even higher risk for mental health conditions including substance use disorders (24).

Many individuals with TB – and particularly those affected with drug-resistant TB – experience some degree of mental distress related to the illness, its treatment and complications, and/or TB-related stigma (25). In some cases, distress, which is not always a pathological issue, can be alleviated through preventive interventions such as health education or by providing access to social and financial resources, as described below.

For some people, however, the distress can become severe and persistent, leading to significant functional impairment or disability (such as inability to work, study or take care of family members, interpersonal strain and withdrawal from social connections) and a diagnosis of a mental disorder may be appropriate (26). In addition, people already living with mental health conditions may experience a worsening of their symptoms upon diagnosis of TB. Sustained autonomic and neuroendocrine responses associated with chronic psychological distress can weaken the immune system, as well as influence health behaviours that can jeopardize TB treatment (17). Since TB often affects people who are already socially vulnerable, TB-related stigma can intersect with and exacerbate other social stigmas related to poverty, mental health conditions and/or HIV co-infection, substance use, incarceration or use of social protection services. Issues created by diagnosis or treatment, such as loss of regular income, can worsen a person’s mental health. TB-related stigma and discrimination can have significant deleterious impact on the physical and mental health of individuals with drug-resistant TB and may trigger mental health conditions in individuals without a history of mental health conditions (17, 25). Prevention, early identification, monitoring and treatment of mental health conditions and substance use disorders are essential to ensure both alleviation of mental health conditions and positive TB treatment outcomes (27).

¹ A mental disorder - as defined by the International Classification of Diseases 11th Revision (ICD-11), is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour that reflects a dysfunction in the psychological, biological or developmental processes that underlie mental and behavioural functioning. These disturbances are usually associated with stress or impairment in personal, family, social, educational, occupational or other important areas of functioning. This section will use ‘mental disorder’ when explicitly referring to data that rely on defined categories of mental disorder. A mental health condition is a broad term covering mental disorders and psychosocial disabilities. It also covers other mental states associated with significant distress, impairment in functioning or risk of self-harm. The term ‘mental health conditions’ will be used throughout this section except when describing data which rely on defined mental disorder categories.

Book navigation