Depression and anxiety in patients with multidrug-resistant tuberculosis in Nepal: an observational study.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) patients in the national TB treatment programme of Nepal. OBJECTIVE: To estimate the prevalence of depression and anxiety in people receiving treatment for MDR-TB, identify potential risk factors for depression and anxiety and determine temporal changes in their severity during treatment. DESIGN: An observational study using a screening tool, the Hopkins Symptom Checklist (HSCL-25) for depression and anxiety, administered monthly to a group of 135 patients in Nepal. Logistic and multilevel linear regression models were used to identify any patient characteristics associated with depression and anxiety. RESULTS: Most of the 135 patients were male (76%) and living with their families (68%). The period prevalences of depression and anxiety were respectively 22.2% and 15.6%. Patients reporting physical side effects of MDR-TB treatment had a higher depression score on HSCL by 2.63 points (95%CI 0.77-4.48) and a 1.59 point higher anxiety score (95%CI 0.45-2.73) than those who did not report any side effects. Being single was associated with having anxiety (aOR 0.2, 95%CI 0.03-1.0). CONCLUSION: Given the high rates of depression observed among MDR-TB patients, national TB treatment programmes should ensure their patients are routinely screened for depression and anxiety, and effective treatment offered.

Depression among multidrug-resistant tuberculosis patients in Punjab, Pakistan: a large cross-sectional study.

BACKGROUND AND OBJECTIVES: Depression is likely to be a factor in the low global rates of successful treatment for multidrug-resistant tuberculosis (MDR-TB) due to poor adherence to treatment. We aimed to estimate the prevalence of depression among patients being treated for MDR-TB in Pakistan, explore rates of depression over the course of treatment and identify risk factors for depression. DESIGN: This cross-sectional study analysed health care service data from 12 treatment sites following a single screening event using the Patient Health Questionnaire 9 (PHQ-9). Logistic regression models were used to identify associations. RESULTS: Data were collected from 1279 patients with MDR-TB. The proportion of MDR-TB patients with depression was 42.8% (95%CI 40.1-45.5). Rates of depression varied according to duration of treatment, with the highest proportion (53.2%) found in those who were in months 10-12 of treatment. The odds of depression in women were higher than for men (adjusted odds ratio [aOR] 1.84, 95%CI 1.46-2.33). The odds of depression were higher in patients living in concrete-built houses than in those living in mud-built houses (aOR 1.37, 95%CI 1.03-1.82). CONCLUSION: Depression is common in MDR-TB patients, and should be screened for and treated within MDR-TB treatment programmes.

Dental Public Health In Action: Putting Oral Health on the Local Public Health Agenda.

Oral health is a key public health issue across England. In Wakefield in the north of England, local data suggested the oral health of local children was significantly worse than the national average. This paper describes the work undertaken by Wakefield Council to strategically address this issue. A structured process was adopted. Key lessons include; having senior ownership from the Director of Public Health, partnership working across all key stakeholders, utilising dental public health expertise from Public Health England and the use of extensive engagement with stakeholders. Through this work, oral health is now identified with greater importance in Wakefield as a public health issue. Actions are now strategically co-ordinated across stakeholders to improve oral health in local children.

Multidrug-resistant tuberculosis treatment programmes insufficiently consider comorbid mental disorders.

The successful treatment of multidrug-resistant tuberculosis (MDR-TB) is a global health priority and a key pillar of the World Health Organization's (WHO's) End TB strategy. There has been significant global investment in diagnostic capabilities in recent years. However, we argue that the mental distress of those with MDR-TB and their families continues to be overlooked by TB programmes. Priorities in the End TB Strategy of 'patient-centred care' and 'patient support' are still to be delivered in practice in many low-income settings, and in particular consideration of mental distress. Our experience of undertaking MDR-TB operational research in China, Pakistan, Bangladesh, Nepal and Swaziland has given us detailed insight into the challenges facing patients, their families, health professionals and wider health systems. We are increasingly concerned that psychosocial support, and particularly support focused on mental health, is being insufficiently addressed in national MDR-TB programmes. We suggest that the presence of comorbid mental disorders reduces treatment adherence. We recommend the trialling within TB programmes of brief screening tools for common mental disorders and the incorporation of principles from the WHO Mental Health Gap Action Programme programme into TB programme treatment guidance. Our work in Nepal also suggests that brief psychological counselling delivered by non-specialist counsellors may be feasible.

Redesign and commissioning of sexual health services in England - a qualitative study.

OBJECTIVES: Responsibility for the commissioning of sexual and reproductive health (SRH) services transferred from the National Health Service to local authorities in England in 2013. This transfer prompted many local authorities to undertake new procurements of these SRH services. This study was undertaken to capture some of the lessons learnt in order to inform future commissioning and system redesign. STUDY DESIGN: A qualitative study was carried out involving semi-structured interviews. METHODS: Interviews were conducted with 13 local authority sexual health commissioners in Yorkshire and the Humber from 11 interviews. Thematic analysis was used to identify themes from transcripts of the interviews with the 13 participants. RESULTS: Key themes identified were as follows: the challenge and complexity to those new to clinical commissioning; the prerequisites of robust infrastructural inputs to undertake the process, including technical expertise, a dependable project team, with clarity over the timescales and the budget; the requirement for good governance, stakeholder engagement and successful management of relationships with the latter; and the need to focus on the outcomes, aiming for value for money and improved system performance. CONCLUSIONS: Several key issues emerged from our study that significantly influenced the outcome of the redesign and commissioning process for sexual health services. An adapted model of the Donabedian evaluation framework was developed to provide a tool to inform future system redesign. Our model helps identify the key determinants for successful redesign in this context which is essential to both mitigate potential risks and maximize the likelihood of successful outcomes. Our model may have wider applications.