Depression care integration in tuberculosis services : a feasibility assessment in Pakistan

Background: The co-occurrence of depression among tuberculosis (TB) patients is a critical issue, contributing to poor treatment outcomes, prolonged hospitalisations and increased healthcare expenses. Objective: The objective of this study was to assess the feasibility of delivering a co-designed depression care pathway within TB services in Pakistan. Design: Mixed-method study. Setting and Participants: Routine depression screening for TB patients was conducted at three TB facilities in Peshawar, Pakistan, encompassing primary, secondary and tertiary care settings. All patients aged 18 or above (male and female) attending the three TB facilities between November 2021 and February 2022 were included in the study using the consecutive sampling technique. Results: A total of 301 people with confirmed TB, within the past 4 weeks, visited the three TB care facilities; 191/301 patients were screened for depression. Approximately 35% of the 191 TB patients screened positive for depression, with varying severity levels. Qualitative findings highlighted the acceptability of integrated depression care, emphasising the importance of open communication and empathetic attitudes. Barriers to integration include stigma, logistical challenges, patient noncompliance and cost burdens. Facilitators included the empathetic attitude of healthcare providers and the availability of mental health services within the same facility. Conclusion: There is a high burden of depression in patients with TB, highlighting the pressing need for mental health support in this population. Acceptability of integrated care was evident, with factors such as co-located mental health services, training healthcare providers and provider empathetic attitudes playing a crucial role. Further research is required to evaluate the effectiveness of the integrated TB-depression screening systems towards improved health outcomes, implementation, scalability and impact on the broader healthcare system. Patient and Public Contribution: To create a more inclusive and comprehensive TB and depression care pathway, we gathered input from both service providers and service users (TB patients, their carers). Reflective meetings with community leaders, social activists and health professionals from various sectors were also conducted during pathway delivery to get their insights. Power, gender and age imbalances were addressed by encouraging participation of patients and carers across gender and age groups. This approach ensured that the perspectives of all stakeholders were considered in the development of the care pathway.