Stress, Depression and Coping in Tuberculosis Patients-A Hospital Based Study

The high prevalence of Mood disorder in people with TB may be attributed to a combination of biological and behavioural factors, social vulnerability, inade-ABSTRACT Context/Background: Tuberculosis (TB) often leaves its impact physically, socially and mentally on patients. Coping strategies refer to the specific efforts, both behavioural and psychological, that people employ to master, tolerate, reduce or minimize stressful events. The study was started to find out the prevalence of Depression in Tuberculosis patients, to find out the effect of Stress and Depression on Coping strategies in patients diagnosed with Tuberculosis. Methodology: The study was a Cross sectional study carried out for period of two years at District tuberculosis centre, SNR Hospital, Kolar. Sample size calculated was 288. All data entered in Microsoft office excel sheet, analyzed using SPSS v 22. Descriptive statistics applied where ever needed and to compare between groups t-test, ANOVA was used. To check for association between factors, Chi-square was applied. Results: Out of 302 Tuberculosis patients, 29.1% belonged to 41-50 years, 72.2%were male, 77.5% re-sided in rural area, 24.5% were unemployed, 4% had HIV comorbidity, 46.4% had Diabetes Mellitus. 138(45.7%) patients had Severe Depression. Age, Gender, HIV status, Diabetes status, Tb Patients who Perceived TB stigma, BMI, Perceived Family Support, type of family and occupation were few Clinico-social factors which were statistically significant for Perceived stress scores. Conclusions: Better management of psychiatric morbidities should be educated by the treating primary health care doctors and DOTS providers in chronic infectious diseases like Tuberculosis can have direct or indirect impact on improving treatment adherence, illness perception and patient coping skills.


INTRODUCTION
Tuberculosis (TB) is a leading cause of mortality and morbidity throughout the world and more so in developing countries. Burden of tuberculosis and depression is increasing. 1 It is of extreme importance for primary health care physicians and also Directly Observed Treatment Short course (DOTS) provider who treat TB patients, to be sceptical about clinical manifestations of depression in TB patients. 2 Tuberculosis (TB) often leaves its impact physically, socially and mentally on patients. Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite and poor concentration. Many times, symptoms of depression and tuberculosis can co-exist which might be missed. This makes it extremely important for primary care physicians to understand the importance of mental illness in TB patients so that proper treatment provisions can be implemented. 3 The high prevalence of Mood disorder in people with TB may be attributed to a combination of biological and behavioural factors, social vulnerability, inade-quate living conditions and socio-economic inequities. Psychological stress has been rarely investigated among tuberculosis patients despite the fact that mental ill health has far-reaching consequences for the health outcome of TB patients. 4 There is augmenting corroboration that emotional distress expressed in terms of anxiety and depression is very high among TB patients. 5 Coping strategies refer to the specific efforts, both behavioural and psychological, that people employ to master, tolerate, reduce or minimize stressful events. 6 Globally, to end tuberculosis, the approach stressed more on patient centric with social support. However, specific recommendations for people with comorbid depression or any other mental health is lacking. 7 Most of the times maladaptive coping strategies to chronic disease with comorbid mental health issues can lead to grave outcomes. Few established social events linking TB and mental health issues are Perception of illness severity of illness, Social Stigma, Poverty, Social isolation, Alcoholism, smoking and drug addiction. Smoking and drug addiction portrays Negative coping strategy towards the illness. The Causal pathways between TB and depression are both complex and multidirectional, manifesting in biological, pharmaceutical and psychosocial mechanisms. There are very scanty studies showing some association of tuberculosis with depression and stress and very few studies showing the coping abilities of tubercular patients with depression and stress. With this background, the study was started to find out the prevalence of Depression in Tuberculosis patients, to find out the effect of Stress and Depression on coping strategies in patients diagnosed with Tuberculosis

METHODOLOGY
The study was a Cross sectional study carried out for period of two years from January 2020 till December 2021. Study was done at District tuberculosis center, SNR Hospital, Kolar. The district TB center which is also the District Hospital in Kolar covers a population of 12 lakh with daily outpatient clinic fetching treatment to at least 30-40 sputum positive tuberculosis patients per day including those on regular treatment and freshly detected cases.
With the reported prevalence of depression in Tuberculosis patients as 23.6 % from the previous study, with 5% absolute precision and 95% confidence level, the required number of subjects was calculated to be 288. 8 The sample size was calculated by using Open epi software version 3.01(Open-Source Epidemiologic Statistics for Public Health) with a level of confidence of 1.96, prevalence (P) of depression as 23.6% and Precision (d) as 5%. Consecutive enrolment of all the patients attending Tuberculosis unit for 2 years of study duration fitting our inclusion criteria was done.
Tuberculosis patients diagnosed using Sputum microscopy with at least 1 month of anti-tuberculosis treatment, Study participants aged 18 years or older, have no plans to migrate out of the study area, had not been an inpatient for more than 5 days in a month after diagnosed with tuberculosis were included in the study . Patients with already diagnosed  mental illness, Patients diagnosed with multi-drug  resistant TB, new cases with severe forms of TB like  miliary TB, tuberculous meningitis, tuberculous pericarditis, tuberculous peritonitis, intestinal TB, genitourinary TB, bilateral or extensive TB pleurisy, spinal disease with neurological complications and patients who are bedridden were excluded. Patients who were screened for depression were also screened for perceived stress and coping strategies adapted to TB at the same time. Regarding sociodemographic profile, pretested semi-structured questionnaire was used. To assess depression Zung Self-Rating Depression Scale was used which is a short survey to quantify the depressed status of a patient consisting of 20 items on the scale that rate the four common characteristics of depression like the pervasive effect, the physiological equivalents, mood disturbances, and psychomotor activities. 9 To assess coping abilities of Tuberculosis patients with tuberculosis, Brief COPE inventory was used. The Brief-COPE is a 28-item questionnaire designed to measure effective and ineffective ways to cope with a stressful life event. The scale is often used in health-care settings to ascertain how patients are responding to a serious diagnosis. The scale can determine primary coping styles as either Approach Coping, or Avoidant Coping. Problem-focused coping targets the causes of stress in practical ways which sets one hand to tackle the problem or stressful situation that is causing stress, consequently undeviatingly reducing the stress. Problem focused strategies aim to remove or reduce the cause of the stressor. Emotion-focused coping is a type of stress management that attempts to reduce negative emotional responses associated with stress. Negative emotions such as embarrassment, fear, anxiety, depression, excitement and frustration are reduced or removed by the individual by various methods of coping. Avoidance coping (avoidant coping) which is escape coping. This is a maladaptive form of coping in which a person changes their behaviour to avoid thinking about, feeling, or doing difficult things. Avoidance coping involves trying to avoid stressors rather than dealing with them. 10 To assess stress, Cohen's perceived stress scale (PSS) was used which is a 10-item stress scale. It is one of the most widely used psychological instrument for measuring the perception of stress which measures degree to which situations in one's life are appraised as stressful. PSS is an easy-to-use questionnaire with established acceptable psychometric properties. 11 All three questionnaires used were in English which were translated into Kannada which were later verified by Language experts, Community Physician and Psychiatrist. A pilot testing was done before the start of study and Cronbach's alpha was calculated. Data collected by Interview technique. Each interview lasted not more than 15 minutes. All data entered in Microsoft office excel sheet, analyzed using SPSS v 22(IBM Corp, USA). Descriptive statistics applied wherever needed and to compare between groups ttest, ANOVA were used and to check for association between factors, Chi-square applied with level of significance defined as p value less than 0.05. Binary logistic Regression analysis was done to assess the association.
Ethical clearance was obtained from the Institutional Ethical Committee (IEC) before the start of study (SDUMC/KLR/IEC/182/2020-21). Informed written consent was taken from the study participants by informing them about the benefits and risks involved in the study. It was informed to them that Participation by the study participants will be voluntary, and Confidentiality will be maintained.     19 Cross sectional study done in Pakistan by Amreen and Nadeem Rizvi shows that depression assessed by PHQ-9 among tuberculosis patients shows that significant association. 20 Studies have shown that TB patients had higher risk for Depression because of the disease per se, prolonged treatment course, stigma associated with the disease, associated complications of Tuberculosis. 21 The study done by Alemayehu, Birhanie and Habtamu revealed that perceived TB stigma was also associated with depression showing that patients with perceived TB stigma were 2 times more likely to have depres-sion. 22 This might be due to a lack of social support, and somatic illness (TB) may lead to increased psychological distress (mental disorders), on the other hand, good social support is vital for good disease prevention. 23 Study done by Peltzer et al showed that tuberculosis (TB) and psychological distress has association and symptoms of depression and anxiety are common among Tuberculosis patients. 24 Once diagnosed with Tuberculosis, patients face in numerous social, psychological and economic issues, with a higher quantum issues seen in drug-resistant TB. Both tuberculosis and depression share common risk factor, which explains the high prevalence of their comorbidity. Different psychosocial problems and mild and moderate psychiatric features are very common among patients with TB.

Out
Study done by Yesuf Y shows that anxiety, depression and shame were the main psychosocial burdens experienced by TB patients and TB patients employed a host of cognitive and behavioural coping strategies to overcome burden of this disease. 25 Coping is a psychological adaptation to stress and serious life events. Psychological disorders of stress, depression, and anxiety experienced by tuberculosis patients are a manifestation of the maladaptive coping mechanisms, impacting on their physical health. The present study showed higher scores in emotion focused coping strategy. Study done by Makhfudli in Saudi to assess coping strategy among Tuberculosis patients showed adaptive mechanism which is use of better emotional support, better social support and family support. 26 Study done by Rashmi and Harneetpal Kaur among tuberculosis patients showed that the common coping strategy adopted by pulmonary tuberculosis patients was problem solving domain. 27 Study done in Indonesia regarding Coping in Tuberculosis patients by Anita, Soedarsono and Laily shows that low coping mechanisms .The study also revealed that Coping in Tuberculosis patients is one of the effort in the success of treatment from the psychological aspects. 28 Emerging literature shows that very effective Anti-tuberculosis medications like Isoniazid and ethambutol are known to alter serotonin reuptake playing a huge role in psychiatric disease like depression causing negative impacts on the progress of chronic physical illness such as decreased function, an increase in medical expenses, long-term adherence to treatment, and self-care as well as the increase of mortality rate. Initial emotional shock and increased mental health toll, along with lack of health education and emotional support during diagnosis and treatment initiation, elevate this period as critical for emotional and educational intervention. Depression and substance abuse affect self-care and increases non-adherence and overall outcome of the disease. On the other hand, a TB diagnosis can lead to shock, anxiety, and elevated psychological stress. People suffering from TB are almost at a fourfold increased risk of experiencing depressive episodes. Mental health in primary health care has been neglected in spite of various efforts at time. National TB programs of various countries does not address mental health issues confounding with tuberculosis. Better understanding and tackling of mental disorders in TB could strengthen the control of TB. Because of the chronicity of TB life is affected physically, psychologically, and economically which can result in physiological problems like weakness, psychogenic somatic pains, breathlessness, decreased libido, and weight loss, perception of being infected or source of infection additionally burdened with social stigma, and decreased social interaction, prolonged hospitalization resulting in job loss, worthlessness and hopelessness. Most of these symptoms are similar to mental health disorders symptoms which goes unnoticed. Strengths of the present study were many. The present study shows that Depression is common among Tuberculosis patients which should be addressed by the treating Physician. Routine mental health screening in chronic infectious disease like Tuberculosis will have indirect effect on treatment out. So, the present study stresses the importance of mental health screening. Limitation of the present study was it was a single center study making it poor to generalize the results. Second inherited issue with cross sectional study is temporal association cannot establish. Better study designs will help in establishing the causality of the disease. In the present study, Likert scale was used to diagnose depression. Severe Depression being very common in the present study, no any other Diagnostic tests were used to confirm this Severe Depression which in turn may need clinical attention. It's preferred to use two step diagnosis while using a Likert scale as over diagnoses of mental health conditions is common. Various published literature shows varying prevalence of Depression among Tuberculosis patients which could be attributed to dissimilar questionnaires used in several studies stressing the importance of need of one uniform mental health survey questionnaire. 29 The present study was planned during ongoing COVID-19 pandemic where mental health was impacted immensely due to the novel strain and no availability of vaccines. This could also be a reason for higher prev-alence of Depression among Tb patients in the present study as Tuberculosis was one of the risk factors for morbidity and mortality which could have deranged the mental equilibrium. 30

CONCLUSION
Tuberculosis being a chronic disease with chronic treatment course can disturb the mental health equilibrium at any stage either during the diagnosis or treatment or post cure phase. Screening for mental health for these chronic infectious diseases can identify patients who require further psychosocial assessment, support and treatment which can indirectly better clinical response to anti-TB treatment. Better management of these psychiatric morbidities should be educated by the treating primary health care doctors and DOTS providers which will have direct or indirect impact on improving treatment adherence, illness perception and patient coping skills. Doctors and DOTS providers should have a high index of suspicion of mental health problems when treating patients. Awareness needs to be given to all patients regarding mental health issues which could be probably faced during the course of the disease and possible non-pharmacological ways for managing these common mental health issues which are often neglected.