Many individuals experience symptoms of anxiety (not necessarily an anxiety disorder) as a common reaction to a TB diagnosis and the required treatment, which can often be mitigated by social support (28, 32). Symptoms of anxiety in TB may present as fear of infecting others or mortality, or because of stigma and discrimination. Acute anxiety may also be an adverse reaction to a particular anti-TB agent. People with TB and symptoms of anxiety can benefit from more social support than they have in their own personal or community networks, such as peer support among other TBaffected individuals. A person-centred approach in which health workers build trust and professional rapport and increase a person’s knowledge of TB and its treatment, contributes to providing a supportive environment (47). As with the PHQ-9 other screening tools are available to identify whether significant symptoms of anxiety are being experienced, such as the Generalized Anxiety Disorder Assessment-7 (GAD-7) (48).
If a person appears to be experiencing symptoms of anxiety that are not explained by their circumstances, and that are causing impairment in important areas of functioning, and/or that persist despite marked improvement in their physical or social environment (for example, reduced physical symptoms or increased social support), it may indicate an anxiety disorder that requires further assessment (see Table 1).
Many different anxiety- or fear-related disorders exist, such as social anxiety or panic disorders. Generalized anxiety disorder (GAD) is one type of anxiety disorder which is characterized by a generalized and persistent anxiety usually accompanied by physical symptoms such as motor tension and/or autonomic overactivity (26). Anxiety symptoms in GAD must persist for more days than not, over a 6-month period, and may be focused on multiple external factors, situations or triggers.
Depending on the onset, severity, and duration of symptoms, the provider may consider (i) suspending all TB medications temporarily or (ii) suspending the suspected drug for a brief period according to the principles described in the WHO operational handbook on tuberculosis, Module 4: Treatment - Drug-resistant tuberculosis treatment, 2022 update (49), and/or (iii) providing brief psychoeducation on anxiety, associated symptoms and relations to TB; offering brief training in stress management skills (e.g. mindfulness or relaxation training); offering advice on engaging in physical exercise, which can reduce symptoms of anxiety; providing brief psychological interventions based on the principles of cognitive behavioral therapy, such as PM+ or SH+, where possible and; prescribing a psychotropic medication, such as an SSRI² (38); and offering models of collaborative care in physical disease programmes to treat comorbid TB and anxiety disorders (50).
If the anxiety is associated with a drug that is part of the TB treatment regimen, any adjustment to the regimen should be done according to the principles for treatment regimen design (see WHO operational handbook on tuberculosis, Module 4: Treatment - Drug-resistant tuberculosis treatment, 2022 update) (49). WHO is developing guidelines on the clinical management of anxiety disorders (GAD and panic disorder), as well as guidance via mhGAP for anxiety disorders.