Suicide & tuberculosis

Tuberculosis (TB) continues to hold public health significance in developed and developing countries. Though its presence can be found in all countries, the continents of Asia and Africa constitute up to 85 per cent of the disease burden. It is recognised that the co-infection of HIV/AIDS and tuberculosis presents a formidable challenge to global efforts to reduce the incidence of tuberculosis. In addition, the phenomenon of multi-drug resistant tuberculosis (MDR-TB) has brought about a call for concerted efforts to stem the scourge of this infective disease. Though rates of new infection have declined over the last decade, tuberculosis still accounts for the highest mortality rates worldwide from a single infectious disease1.

Strategies like the World Health Organization's (WHO) Stop-TB programme2 aim to bring effective medications to infected individuals worldwide. As with most infectious diseases, available treatments mean that individuals infected may have longer periods of morbidity from treatment resistance, poor medication adherence or non-adherence and varied mental ill-health complications brought about by either stigma towards the illness, adjustment problems and/or side effects of medications.

Though often neglected, treatment goals should go beyond just symptom remission but must incorporate the improvement in the quality of life of individuals infected with tuberculosis. Co-morbid mental and behavioural disorders have been reported to impair the attainment of treatment outcomes and are associated with higher rates of morbidity and mortality when present.

Suicide and suicidality rank among the leading causes of mortality worldwide3. Though suicidality is common in developing and developed countries, little attention is paid to it outside of mental health or psychiatric settings. Either clinicians are wary of broaching the topic with their clients, or they have a low index of suspicion is debatable. On the contrary, individuals receiving medical care are not averse to being asked about suicide symptoms. In fact, talking about it does not increase the risk of completing a suicide, rather the opposite.

Surprisingly, there is a paucity of research on the relationship between suicide or suicidality and tuberculosis. Against this backdrop, the article by Peltzer and Louw in this issue4 provides answers to a neglected area of research on the relationship between suicide behaviour and tuberculosis and concludes with evidence for a fairly strong relationship for suicide behaviour among individuals infected with tuberculosis who were females, on a TB re-treatment plan, misusing alcohol and with previous psychological distress and post-traumatic stress disorders (PTSD). They also reported a fairly high rate of suicide attempts which was above the average rates reported for developing countries3.

The large size of the sample and the choice of recruiting participants from primary care clinics give some credence to the ease of generalizing the results reported to similar settings in developing countries, even though only participants from urban areas were recruited. Over half of those recruited had co-morbid HIV/AIDS, and the presence of this co-morbidity increased the odds of suicidal ideation and attempts. Going by recent epidemiological trends, it is difficult to disentangle the treatment for tuberculosis from HIV/AIDS. Clearly more studies are required, first to replicate these observations in varied population settings as well as the use of standardised measures for the assessment of suicide behaviour. Furthermore, cohort studies are also needed which can help determine the incidence of suicide behaviour. Such studies can help determine the factors during treatment that increase the risk of suicide behaviour. Evidence from methodologically varied research can help in the development of interventions that may mitigate the excess morbidity and mortality of suicide and other co-morbid mental or behavioural disorders.

Going forward, clinicians must begin to see the neglect of screening or enquiring about suicide behaviour and other mental disorders as a disservice to their clients. Enquiring can be made easy with the use of widely available screening instruments or the use of two or three question probes which are highly sensitive as well. Detecting and managing behavioural disorders improves quality of life on one hand and enhances the attainment of treatment goals on the other. Making these enquiries routine can also counteract the barrier of stigma, which has been reported by clinicians to hinder their enquiry5.