Prevalence of psychological distress and associated factors in tuberculosis patients in public primary care clinics in South Africa.
ABSTRACT Psychological distress has been rarely investigated among tuberculosis patients in low-resource settings despite the fact that mental ill health has far-reaching consequences for the health outcome of tuberculosis (TB) patients. In this study, we assessed the prevalence and predictors of psychological distress as a proxy for common mental disorders among tuberculosis (TB) patients in South Africa, where over 60 % of the TB patients are co-infected with HIV.
We interviewed 4900 tuberculosis public primary care patients within one month of initiation of anti-tuberculosis treatment for the presence of psychological distress using the Kessler-10 item scale (K-10), and identified predictors of distress using multiple logistic regressions. The Kessler scale contains items associated with anxiety and depression. Data on socio-demographic variables, health status, alcohol and tobacco use and adherence to anti-TB drugs and anti-retroviral therapy (ART) were collected using a structured questionnaire.
Using a cut off score of ≥28 and ≥16 on the K-10, 32.9 % and 81 % of tuberculosis patients had symptoms of distress, respectively. In multivariable analysis older age (OR = 1.52; 95 % CI = 1.24-1.85), lower formal education (OR = 0.77; 95 % CI = 0.65-0.91), poverty (OR = 1.90; 95 % CI = 1.57-2.31) and not married, separated, divorced or widowed (OR = 0.74; 95 % CI = 0.62-0.87) were associated with psychological distress (K-10 ≥28), and older age (OR = 1.30; 95 % CI = 1.00-1.69), lower formal education (OR = 0.55; 95 % CI = 0.42-0.71), poverty (OR = 2.02; 95 % CI = 1.50-2.70) and being HIV positive (OR = 1.44; 95 % CI = 1.19-1.74) were associated with psychological distress (K-10 ≥16). In the final model mental illness co-morbidity (hazardous or harmful alcohol use) and non-adherence to anti-TB medication and/or antiretroviral therapy were not associated with psychological distress.
The study found high rates of psychological distress among tuberculosis patients. Improved training of providers in screening for psychological distress, appropriate referral to relevant health practitioners and providing comprehensive treatment for patients with TB who are co-infected with HIV is essential to improve their health outcomes. It is also important that structural interventions are promoted in order to improve the financial status of this group of patients.
- SourceAvailable from: Baba Awoye Issa[show abstract] [hide abstract]
ABSTRACT: Background Tuberculosis (TB) remains a leading infectious cause of morbidity and mortality throughout the world. Medication non-compliance has been recognised as one of the drawbacks in the successful management of this disease. Hence, different approaches for ensuring medication compliance have been adopted; these include the Directly Observed Therapy Short course (DOTS). TB is associated with psychiatric morbidity, particularly depressive disorder, and this has been recognised as a cause of poor compliance and a cause of increased morbidity and mortality from the disease. Despite this recognition, little attention is paid to the identification of depression among TB patients, particularly in the DOTS clinics that most of these patients attend. This study was designed to determine the prevalence of depression in patients with TB attending the DOTS outpatient clinic in a university teaching hospital in Nigeria, and to find out the factors that may be associated with this.Method All consenting TB patients attending the clinic completed a socio-demographic questionnaire and nine-item Patient Health Questionnaire (PHQ-9) designed to screen for depression, especially in outpatient and primary care settings.Results Sixty-five patients participated in the study of whom 41 (63.1%) were males. The mean age of the respondents was 35.1 ± 14.4 (range 15-70 years). Eighteen (27.7%) of the patients had depression, comprising 14 (21.5%) with mild depression and four (6.2%) with moderate depression. Socio-demographic factors (age groups, P=0.024; and financial status, P=0.02) and a clinical factor (persistent cough, P=0.04) were significantly associated with depression.Conclusion Measures to reduce depression among patients with TB should include effective symptom control, particularly of coughing, and measures to improve the financial status of this group of patients. Financial empowerment of patients may reduce depression in them, improve the compliance rate to anti-TB medication, and could furthermore bring an improvement to their quality of life.Mental Health in Family Medicine 09/2009; 6(3):133-8.
- [show abstract] [hide abstract]
ABSTRACT: As the rates of TB world over have increased during the past 10 years, there has been a growing awareness of depression and its role in the outcome of chronic disorders. Though depression is common in patients with TB no study as yet has examined the prevalence of depression in this group in Pakistan. We aimed to determine the presence of depression, anxiety and illness perceptions in patients suffering from Tuberculosis (TB) in Pakistan. 108 consecutive outpatients with tuberculosis completed the Hospital Anxiety and Depression scale (HADS) and the Illness Perception Questionnaire (IPQ). Out of 108 patients, 50 (46.3%) were depressed and 51 (47.2%) had anxiety. Raised depression and anxiety scores were associated with an increase in the number of symptoms reported (HADS Depression: r = 0.346, p = < 0.001), more serious perceived consequences (HADS Depression: r = 0.279, p = 0.004, HADS Anxiety: r = 0.234, p = 0.017) and less control over their illness (HADS Depression: r = 0.239, p = 0.014, HADS Anxiety: r = 0.271, p = 0.005). We found that about a half of patients in our sample met the criteria for probable depression and anxiety based on HADS score. Negative illness perceptions were clearly related to reports of mood symptoms. As depression and lack of perceived control over illness in those suffering from tuberculosis are reported to be independent predictors of poor adherence further studies to investigate their relationship with medication adherence are required.Clinical Practice and Epidemiology in Mental Health 02/2008; 4:4.
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ABSTRACT: Public Law 102-321 established a block grant for adults with "serious mental illness" (SMI) and required the Substance Abuse and Mental Health Services Administration (SAMHSA) to develop a method to estimate the prevalence of SMI. Three SMI screening scales were developed for possible use in the SAMHSA National Household Survey on Drug Abuse: the Composite International Diagnostic Interview Short-Form (CIDI-SF) scale, the K10/K6 nonspecific distress scales, and the World Health Organization Disability Assessment Schedule (WHO-DAS). An enriched convenience sample of 155 respondents was administered all screening scales followed by the 12-month Structured Clinical Interview for DSM-IV and the Global Assessment of Functioning (GAF). We defined SMI as any 12-month DSM-IV disorder, other than a substance use disorder, with a GAF score of less than 60. All screening scales were significantly related to SMI. However, neither the CIDI-SF nor the WHO-DAS improved prediction significantly over the K10 or K6 scales. The area under the receiver operating characteristic curve of SMI was 0.854 for K10 and 0.865 for K6. The most efficient screening scale, K6, had a sensitivity (SE) of 0.36 (0.08) and a specificity of 0.96 (0.02) in predicting SMI. The brevity and accuracy of the K6 and K10 scales make them attractive screens for SMI. Routine inclusion of either scale in clinical studies would create an important, and heretofore missing, crosswalk between community and clinical epidemiology.Archives of General Psychiatry 03/2003; 60(2):184-9. · 13.77 Impact Factor
RESEARCH ARTICLE Open Access
Prevalence of psychological distress and
associated factors in tuberculosis patients in
public primary care clinics in South Africa
Karl Peltzer1,2*, Pamela Naidoo1,3, Gladys Matseke1, Julia Louw1, Gugu Mchunu1and Bomkazi Tutshana1
Background: Psychological distress has been rarely investigated among tuberculosis patients in low-resource
settings despite the fact that mental ill health has far-reaching consequences for the health outcome of
tuberculosis (TB) patients. In this study, we assessed the prevalence and predictors of psychological distress as a
proxy for common mental disorders among tuberculosis (TB) patients in South Africa, where over 60 % of the TB
patients are co-infected with HIV.
Methods: We interviewed 4900 tuberculosis public primary care patients within one month of initiation of
anti-tuberculosis treatment for the presence of psychological distress using the Kessler-10 item scale (K-10), and
identified predictors of distress using multiple logistic regressions. The Kessler scale contains items associated with
anxiety and depression. Data on socio-demographic variables, health status, alcohol and tobacco use and
adherence to anti-TB drugs and anti-retroviral therapy (ART) were collected using a structured questionnaire.
Results: Using a cut off score of ≥28 and ≥16 on the K-10, 32.9 % and 81 % of tuberculosis patients had symptoms
of distress, respectively. In multivariable analysis older age (OR=1.52; 95 % CI=1.24-1.85), lower formal education
(OR=0.77; 95 % CI=0.65-0.91), poverty (OR=1.90; 95 % CI=1.57-2.31) and not married, separated, divorced or
widowed (OR=0.74; 95 % CI=0.62-0.87) were associated with psychological distress (K-10 ≥28), and older age
(OR=1.30; 95 % CI=1.00-1.69), lower formal education (OR=0.55; 95 % CI=0.42-0.71), poverty (OR=2.02; 95 %
CI=1.50-2.70) and being HIV positive (OR=1.44; 95 % CI=1.19-1.74) were associated with psychological distress
(K-10 ≥16). In the final model mental illness co-morbidity (hazardous or harmful alcohol use) and non-adherence
to anti-TB medication and/or antiretroviral therapy were not associated with psychological distress.
Conclusions: The study found high rates of psychological distress among tuberculosis patients. Improved training
of providers in screening for psychological distress, appropriate referral to relevant health practitioners and
providing comprehensive treatment for patients with TB who are co-infected with HIV is essential to improve their
health outcomes. It is also important that structural interventions are promoted in order to improve the financial
status of this group of patients.
South Africa has 0.7 % of the world’s population and
28 % of the world’s population of HIV and TB co-
infected individuals. It has been estimated that there is
approximately 60 % of people with TB who are co-
infected with HIV . Co-infected patients have almost
double the chance of contracting multiple drug resistant
TB (MDR-TB) as well as extra drug resistant TB (XDR-
TB). These patients also have a high mortality rate due
to co-infection with HIV .
Common mental disorders (CMDs), which include de-
pression, anxiety and somatoform disorders, make a sig-
nificant contribution to the burden of disease and
disability in low- and middle-income countries (LMICs)
[3,4].These conditions are responsible for up to 10 % of
the total global disease burden . At least one-third of
all patients seen in primary care facilities in LMICs
* Correspondence: email@example.com
1HIV/STI and TB (HAST) Research Programme, Human Sciences Research
Council, Pretoria, South Africa
2Department of Psychology, University of the Free State, Bloemfontein, South
Full list of author information is available at the end of the article
© 2012 Peltzer et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Peltzer et al. BMC Psychiatry 2012, 12:89
present with CMDs. CMDs are not recognised nor ef-
fectively treated in a majority of these patients . Al-
though depressive and anxiety disorders are classified as
separate diagnostic categories in the ICD-10 , the
concept of CMDs is valid for public health interventions
owing to the high degree of co-morbidity between these
disorders in primary care and the similarity in epidemio-
logical profiles and treatment responsiveness .
Several authors found frequent comorbidity of TB and
common mental disorders [8,9] . Few studies have inves-
tigated common mental disorders in TB patients in low
and middle income countries (LMICs) and have found
high rates of CMDs in Pakistan 46.3 %-80 % [10-12],
Nigeria 27.7 %-30 % [13,14], Ethiopia 64 % , India
76 % , South Africa 46 % [17,18] and Turkey
19 %-26 % .
Factors associated with CMDs in TB patients included:
male gender , older age groups, the young and the
elderly [11,13,14], low educational attainment , fi-
nancial status, no source of income [13,15], in day
labourers:  an increase in the number of symptoms
reported, more serious perceived consequences and less
control over their illness [10,13], in TB/HIV co-infected
 individuals : perceived stigma , poor perceived
health status , adverse effect on drug compliance
and TB treatment [11,20] and negative TB treatment
outcome (death) .
The aim of this study was to establish the prevalence
and associated factors of common mental disorders
(namely anxiety and depression) in tuberculosis public
primary care patients in South Africa.
This is a cross-sectional survey of tuberculosis patients
in public primary care clinics in South Africa.
Sample and procedure
Three provinces in South Africa with the highest TB
caseload were selected for inclusion in the study. One
district in each province (N=3) with the highest TB
caseloads were ultimately included. These districts were
Siyanda in Northern Cape Province, Nelson Mandela
Metro in the Eastern Cape Province and eThekwini in
KwaZulu-Natal Province. Within each of these three
study districts 14 public primary health care facilities
were selected on the basis of the highest TB caseloads
per clinic (N=42). The type of health facilities were pri-
mary health care clinic or community health centre. All
new TB and new retreatment patients were consecu-
tively interviewed within one month of initiation of anti-
tuberculosis treatment. The interview was conducted by
trained external research assistants for a period of
6 months from mid- April 2011 to mid- October 2011
in all 42 clinics. A health care provider who identified a
new TB treatment or retreatment patient (within one
month of initiating treatment) and 18 years and older
informed the patient about the study and referred the
patient for participation if they were willing. A re-
search assistant obtained informed consent from these
patients attending the primary care facility to partici-
pate in the interview. Questionnaires were translated
and back translated into the major languages of the
Zulu). Ethical approval was obtained from the Human
Sciences Research Council Research Ethics Committee
(Protocol REC No.1/16/02/11) and the Department of
Health in South Africa.
A researcher-designed questionnaire was used to record
information on participants’ age, gender, educational
level, marital status, income, employment status, dwell-
ing characteristics and residential status. Poverty was
assessed by 5 pertinent items on the questionnaire by
asking about the availability or non-availability of shelter,
fuel or electricity, clean water, food and cash income in
the past week. Response options ranged from 1=“Not
one day” to 4=“Every day of the week”. Participants
ranked high on poverty if they had higher scores on
non-availability of essential items. The total score ranged
from 5 to 20: 5=being low on poverty, 6-12=medium
level of poverty and 13-20=high levels of poverty. The
Cronbach alpha for the poverty index in this study
The Kessler Psychological Distress Scale (K-10) was
used to measure global psychological distress, including
significant pathology which does not meet formal cri-
teria for a psychiatric illness [22,23]. This scale measures
the following symptoms over the preceding 30 days by
asking: “In the past 30 days, how often did you feel: ner-
vous; so nervous that nothing could calm you down;
hopeless; restless or fidgety; so restless that you could
not sit still; depressed; that everything was an effort; so
sad that nothing could cheer you up; worthless; tired out
for no good reason?” The frequency with which each of
these items was experienced was recorded using a five-
point Likert scale ranging from “none of the time” to “all
the time”. These scores were then added with increasing
total scores reflecting an increasing degree of psycho-
logical distress. The K-10 has been shown to capture
variability related to non-specific depression and anxiety
but does not measure suicidality or psychoses . This
scale serves to identify individuals who are likely to meet
formal definitions for anxiety and/or depressive disor-
ders, as well as to identify individuals with sub-clinical
illness who may not meet formal definitions for a
Peltzer et al. BMC Psychiatry 2012, 12:89
Page 2 of 9
specific disorder . This scale is increasingly used in
population mental health research and has been vali-
dated in multiple settings  including HIV positive
individuals in South Africa  and a population-based
survey in South Africa . There was significant agree-
ment among HIV patients between the K-10 and the
MINI-defined depressive and anxiety disorders, with the
best screening cut off score of 28 . A receiver operat-
ing characteristic (ROC) curve analysis indicated that
the K-10 showed agreeable sensitivity and specificity in
detecting depression (area under the ROC curve, 0.77),
generalized anxiety disorder (0.78), and posttraumatic
stress disorder (PTSD) (0.77), with the best cut off of 28
. Further, the K10 demonstrated moderate discrimin-
ating ability in detecting depression and anxiety disor-
evidenced by area under the receiver operating curves of
0.73 and 0.72 respectively, with a cut off of 16 . We
examined the K-10 scale using two cut offs (16 and 28),
as found in validation studies in South Africa [26,27].
The internal reliability coefficient for the K-10 in this
study was alpha=0.92.
(AUDIT)  assesses alcohol consumption level (3
items), symptoms of alcohol dependence (3 items), and
problems associated with alcohol use (4 items). Heavy
episodic drinking is defined as the consumption of six
standard drinks (10 g alcohol) or more on a single occa-
sion . In South Africa a standard drink has 12 g of
alcohol. Because the AUDIT is reported to be less sensi-
tive at identifying risk drinking in women , the cut-
off point for binge drinking among women (4 units) was
reduced by one unit as compared to men (5 units), as
recommended by Freeborn et al. . Responses to
items on the AUDIT are rated on a 4-point Likert scale
from 0 to 4, for a maximum score of 40 points. Higher
AUDIT scores indicate more severe levels of risk; scores
8 indicate a tendency to problematic drinking. The Alco-
hol Use Disorders Identification Test (AUDIT) was
developed by the World Health Organization as an ef-
fective screening instrument for alcohol use problems
among patients seeking primary care for other medical
problems in international settings including African
countries (Kenya and Zimbabwe) [28,30] and has been
validated in HIV patients in South Africa showing excel-
lent sensitivity and specificity in detecting MINI-defined
dependence/abuse (area under the receiver-operating
characteristic curve, 0.96)  and among TB and HIV
patients in primary care in Zambia demonstrating good
discriminatory ability in detecting MINI-defined current
AUDs (AUDIT=0.98 for women and 0.75 for men) .
Cronbach alpha for the AUDIT in this sample was 0.92,
indicating excellent reliability. Hazardous drinking is
defined as a quantity or pattern of alcohol consumption
that places patients at risk for adverse health events,
while harmful drinking is defined as alcohol consump-
tion that results in adverse events (e.g. physical or psy-
chological harm) .
Two questions were asked about the use of tobacco pro-
ducts, namely 1) Do you currently use one or more of
the following tobacco products (cigarettes, snuff, chew-
ing tobacco, cigars, etc.)? with a response option of “yes”
or “no” and 2) In the past month, how often have you
used one or more of the following tobacco products
(cigarettes, snuff, chewing tobacco, cigars, etc.)? with the
response options of once or twice, weekly, almost daily
and daily. Current tobacco use was defined as having
used any tobacco in the past month.
Perceived general health
In order to ascertain participant’s perceived general
health they were asked,: In general, would you say your
health is: excellent, very good, good, fair or poor? This
measure was categorized based on participant response
(very good=excellent/very good, good, and poor=
TB treatment status, HIV status and antiretroviral
treatment was assessed by self-report and from medical
assessed with the question “In your tuberculosis treat-
ment in the past 3–4 weeks how many percent were you
taking your anti-tuberculosis medication?” using the Vis-
ual Analogue Scale. TB medication non-adherence was
defined as having taken less than 90 percent of their
anti-tuberculosis medication. Antiretrovitral Therapy
(ART) adherence was assessed with the question “How
many percent of your HIV medication did to take in the
past 4 weeks?” using the Visual Analogue Scale. ART
non-adherence was defined as having taken less than 90
percent of ART.
Data were analyzed using Statistical Package for the So-
cial Sciences (SPSS) for Windows software application
programme version 19.0. Frequencies, means, standard
deviations, were calculated to describe the sample. Data
were checked for normality distribution and outliers.
Interaction between predictor variables was also exam-
ined and it was found that none of the variables had a
Variance Inflation Factor (VIF) value above 2.5. Associa-
tions of psychological distress and harmful alcohol use
were identified using logistic regression analyses. Follow-
ing each univariate regression, multivariable regression
models were constructed. Independent variables from
Peltzer et al. BMC Psychiatry 2012, 12:89
Page 3 of 9
the univariate analyses were entered into the multivari-
able model if significant at P<0.05 level. For each
model, the R2is presented to describe the amount of
variance explained by the multivariable model. Probabil-
ity below 0.05 was regarded as statistically significant.
Sample characteristics and psychological distress
From the total sample (N=4935) included in the study
35 (0.7 %) refused to participate. As a result of the refu-
sals the final sample comprised 4900. More than half
(54.5 %) of the participants were men and 45.5 % were
women, with a mean age of 36.2 years (SD=11.5) and
the age range was 18 years to 93 years. Almost four-fifth
of the participants (78.4 %) were between 18 to 44 years
old, the majority (72.7 %) was never married, 27.7 % had
completed secondary education, and 17 % scored high
on the poverty index. The largest population group of
the participants was Black African (84.6 %), followed by
individuals of mixed race (Coloured: derived from Asian,
European, and Khoisan and other African ancestry)
(13.1 %) and Indian , Asian or White (2.3 %). 76.6 % of
the total sample were new TB patients and 23.4 % were
retreatment TB patients. Of those particpants that tested
for HIV 59.9 % were HIV positive, 22.1 % of the HIV
positive patients were on ART. 9.6 % had never tested
for HIV. One in five patients (20 %) were daily or almost
daily tobacco users, 23.3 % were hazardous or harmful
alcohol users (AUDIT 8 or more) and 46.3 % perceived
their health status as fair or poor. Regarding adherence
to TB medication, 33.9 % indicated that they had missed
at least 10 % their medication in the last 3–4 weeks. From
those who were on antiretroviral treatment, 42.1 %
reported that they had at least 10 % of their ARVs in the
last 4 weeks. The overall prevalence of psychological dis-
tress in this study was 32.9 % (K-10 ≥28) and 81.1 % (K-10
≥16), respectively (see Table 1). Of those who screened
positive for psychological distress (anxiety/depression)
(K-10 ≥28), 8.3 % were using anti-depression medication
currently. Those using anti-depression medication were
not more likely to screen positive for anxiety/depression
(8.7 % vs. 6.5 %; χ2=1.36, P=0.244).
Predictors of psychological stress
In univariate analysis older age, lower formal education,
poverty, not married, separated, divorced or widowed
and daily or almost daily tobacco use were associated
with psychological distress (K-10 ≥28). In multivariable
analysis older age (OR=1.52; 95 % CI=1.24-1.85), lower
formal education (OR=0.77; 95 % CI=0.65-0.91), pov-
erty (OR=1.90; 95 % CI=1.57-2.31) and not married,
separated, divorced or widowed (OR=0.74; 95 % CI=
0.62-0.87) were associated with psychological distress
(K-10 ≥28). Further, in univariate analysis older age,
lower formal education, poverty, being a retreatment TB
patient, being HIV positive, partner being HIV positive
and hazardous or harmful alcohol use were associated
with psychological distress (K-10 ≥16). In multivariable
analysis older age (OR=1.30; 95 % CI=1.00-1.69), lower
formal education (OR=0.55; 95 % CI=0.42-0.71), pov-
erty (OR=2.02; 95 % CI=1.50-2.70) and being HIV
positive (OR=1.44; 95 % CI=1.19-1.74) were associated
with psychological distress (K-10 ≥16). In the final model
mental illness co-morbidity (hazardous or harmful alco-
hol use) and non-adherence to anti-TB medication and/
or antiretroviral therapy were not associated with psy-
chological distress (see Table 2).
A high overall prevalence of psychological distress
(32.9 % and 81 % according to the K-10 score ≥28 and
K-10 score ≥16, respectively) was found in this large
sample of tuberculosis public primary care patients in
South Africa. Caseness of psychological distress or com-
mon mental disorder was assessed using two different
cut-offs (K-10 score ≥28 and K-10 score ≥16), as found
in two different previous validation studies in South Af-
rica [26,27]. The uncertainty regarding the correct K-10
cut-off for this study group is a major limitation of this
Several studies showed that the K-10 had good psy-
chometric properties [25,26] and can discriminate be-
tween cases and non-cases reported in the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV)
[15,34]. The finding of 32.9 % to 81 % (using cut off
scores of 28 and 16 respectively) the prevalence of
psychological distress in this study is in line with the
prevalence rates of depression or common mental dis-
orders in most other studies with tuberculosis patients
46 %-80 % in LMICs [10-12,15-18]. The differences in
prevalence of common mental disorders in the studies
cited in the literature could be attributable to several
factors including the population being studied, the
study periods during the TB treatment course and the
diagnostic tools used . It is possible that increased
rates of psychological distress were found in this study
because the assessment followed within a short time
(within one month) of the TB diagnosis which might not
have persisted at a later stage of the disease course or
upon completion of TB treatment. Andersen et al. 
have suggested that the Kessler scales had significantly
lower discriminating ability in regard to depression and
anxiety disorders among the Black African than among
the combined non-Black African population group in
South Africa, and they attribute this to differential
item biased measurement. The Black African popula-
tion group is usually highly represented among the
lowest socioeconomic status groups in South Africa and
Peltzer et al. BMC Psychiatry 2012, 12:89
Page 4 of 9
Table 1 Sample characteristics
Socio-demographicsTotalPsychological distress (≥28)Psychological distress (≥16)
45 or more1040 21.539638.188685.2
Never married 332372.71127 33.62723 81.1
Never married 332372.7112733.6272381.1
Separated/divorced/widowed2655.810237.1 78.4 85.5
Grade 7 or less126926.348738.4109186.0
Grade 8-112213 45.968330.9180481.5
Grade 12 or more133627.741831.3100074.9
Poverty index (5–20)
Low (5)159235.0 42226.1123876.6
Medium (6–12)219548.2757 34.0178280.0
High (13–20)768 16.9334 43.069889.9
Black African407884.6 140234.4332281.5
Coloured 63413.1 15824.9 48877.0
Indian/Asian/White or other114 2.335 31.58980.2
New TB patient365076.6 121932.9 297180.1
Retreatment TB patient1113 23.4380 33.7944 83.7
HIV negative1728 40.155531.6137077.9
Partner HIV positive119227.242735.3101083.5
Partner HIV negative or unknown status319472.8106732.9259079.8
Daily or almost daily tobacco use980 20.036337.079581.1
Hazardous or harmful alcohol use 112023.3 380 33.994184.0
Perceived health status
Excellent/very good91219.1 35037.774680.4
Fair/poor220546.3 87038.9 191685.6
On antiretroviral therapy97422.1 34237.7 76984.9
Non-adherence to TB treatment113833.9368 32.3903 79.3
Non-adherence to ART410 42.1170 41.5 34183.4
Peltzer et al. BMC Psychiatry 2012, 12:89
Page 5 of 9
often lack basic necessities as compared to the other
population groups in South Africa. Consequently, they
may more likely endorse K-10 items such as “How often
do you feel that everything is an effort?” In this
study, however, there were no significant differences
in psychological distress rates between Black African,
Indian/Asian or Whites population groups. Spiess et al.
 also did not find a significant difference in validity of
the K-10 in detecting depression and anxiety disorders
among HIV infected South Africans across gender, age,
education, or ethnicity categories.
Given the relatively large difference between the levels
of psychological distress using a cut-off score of 28
versus 16 on the K-10 in this study, it is important to
consider which cut-off score is more appropriate for
use in a clinical setting within the public health sector.
The authors in this study recommend the use of a
cut-off score of 16 for use in South Africa, particularly
within the public sector health clinics in order for
cost-efficient treatment programmes to be implemented
on a large scale.
In multivariable analysis the study found that lower
formal education and poverty were associated with psy-
chological distress. Low socioeconomic status has also
been found in other studies to be associated with com-
mon mental disorders in TB patients [13-15]. Most
Table 2 Association of socioeconomic and clinical characteristics and psychological distress among TB patients in 42
clinics, South Africa, 2011
K-10 (28 or more)K-10 (16 or more)
(95 % CI)a
(95 % CI)a,b
(95 % CI)a
(95 % CI)a,c
31-441.16 (1.01-1.33)*1.20 (1.03-1.40)*1.17 (1.00-1.37)1.04 (0.86-1.26)
45 or more 1.46 (1.24-1.71)***1.52 (1.24-1.85)***1.57 (1.28-1.93)*** 1.30 (1.00-1.69)*
Male1.07 (0.95-1.21) 1.06 (0.92-1.21) 0.96 (083–1.11)0.90 (0.75-1.07)
Married/cohabitating0.84 (0.72-0.98)*0.74 (0.62-0.87)*** 0.85 (0.71-1.01)
Separated/divorced/widowed1.17 (0.90-1.51)1.05 (0.36-3.91) 1.37 (0.97-1.93)
Grade 7 or less1.00 1.001.00 1.00
Grade 8-11 0.72 (0.62-0.83)***0.77 (0.65-0.91)**0.72 (0.59-0.87)***0.78 (0.62-0.99)*
Grade 12 or more0.73 (0.62-0.86)***0.85 (0.70-1.02)0.49 (0.40-0.59)***0.55 (0.42-0.71)***
Medium1.46 (1.27-1.68)***1.39 (1.20-1.62)***1.23 (1.05-1.43)** 1.07 (0.86-1.33)
Poverty high2.14 (1.78-2.56)*** 1.90 (1.57-2.31)*** 2.74 (2.11-3.56)***2.02 (1.50-2.70)***
New TB patient1.00—1.001.00
Retreatment TB patient1.04 (0.84-1.11) 1.27 (1.06-1.52)**1.19 (0.96-1.48)
TB/HIV co-infected1.09 (0.96-1.24)—1.39 (1.20-1.62)***1.44 (1.19-1.74)***
Partner HIV positive vs. negative or unknown1.11 (0.97-1.28)— 1.28 (1.08-1.53)**1.14 (0.93-1.41)
Daily/almost daily tobacco use 1.26 (1.09-1.45)**1.06 (0.89-1.25) 1.01 (0.84-1.21)—
Hazardous or harmful alcohol use1.05 (0.91-1.21)—1.33 (1.11-1.59)** 1.05 (0.83-1.31)
Non-ART adherence 1.22 (0.94-1.59)— 1.84 (0.70-4.80)—
TB non-adherence0.92 (0.79-1.07)—0.90 (0.75-1.07)—
aUsing “enter” LR selection of variables.
bHosmer and Lemeshow Chi-square 12.97, df 8, 0.113; Cox and Snell R20.02; Nagelkerke R20.03.
cHosmer and Lemeshow Chi-square 3.47, df 8, 0.902; Cox and Snell R20.03; Nagelkerke R20.04.
* P<0.05; ** P<0.01; *** P<0.001.
Peltzer et al. BMC Psychiatry 2012, 12:89
Page 6 of 9
studies in developing countries showed an association
between indicators of poverty and the risk of mental dis-
orders, the most consistent association being with low
levels of education [3,35,36]. Many patients in low and
middle income countries suffer from common mental
disorders because of the stress caused by poverty
[3,15,37] and associated factors such as the experience
of insecurity and hopelessness, rapid social change and
the risks of violence and physical ill-health may explain
the greater vulnerability of the poor to common mental
disorders . Financial empowerment of patients may
reduce their levels of depression, and improve the com-
pliance rate to anti-TB medication which could ultim-
ately result in an improved quality of life .
Older age in this study was associated with psycho-
logical stress. This finding is consistent with the findings
of other studies among TB patients [13,14] but was not
consistent with findings in general population studies
. . This increased prevalence of distress in older par-
ticipants may be due to increased responsibilities such
as child care, care of other family members, employment
and economic responsibilities, having to cope with
chronic illness conditions, including HIV in the older age
group . Marital status (being married or cohabitating)
has been found in this study to serve a protective factor
from psychological stress (K-10 ≥28) and this finding is
consistent with the findings of other studies [39,40].
Being married or cohabitating provides social support
thereby reducing the levels of psychological distress .
In contrast to some studies [11,13] but in agreement
with other studies , we did not find a significant
association between gender and psychological distress.
Being TB/HIV co-infected was found in this study to
be associated with a higher rate of common mental dis-
orders (using the K-10 cut off of ≥16) than among non-
coinfected patients, a finding consistent with other stud-
ies . Being diagnosed with HIV which is a terminal
life-long disease associated with high levels of stigma
may also lead to high rates of mental disorder . Sub-
stance use (hazardous or harmful alcohol use and
current tobacco use) in this study was associated with
psychological distress. This finding is similar to the find-
ings in other studies which found substance use to be
associated with depression and psychological distress in
general patient population groups [43-46]. Daily or al-
most daily tobacco use was also found in this study to
be associated with psychological distress a finding simi-
lar to the findings of other studies . In this study
there was no association found between TB and HIV
treatment non-adherence and common mental disorders
as found in other studies [11,15,20,47]. It is possible that
the impact of psychological stress on treatment adher-
ence may take longer to take effect than at the beginning
of TB treatment.
Caution should be taken when interpreting the results of
this study because of certain limitations. Generalisability
of our findings is limited to TB and HIV patients on
treatment in public primary care centres in South Africa.
Furthermore, measures of anxiety and depression at a
general population level in South Africa may be needed
so that the diagnostic accuracy of common mental disor-
ders among patients with anxiety and depression can be
compared to those without these disorders. This study
was a cross-sectional one which implies that no state-
ment of causality between the variables can be made. A
further limitation was that most variables were assessed
by self-report and socially desirable responses may have
been given. The Kessler 10 scale is not 100 % sensitive
and specific which may have resulted in misdiagnosis or
missed cases of common mental disorder. Some areas of
reported, illness perceptions [10,13,47] and perceived
stigma  were not included in the study. These factors
are known to be related to common mental disorder in
The study found high rates of psychological distress
among tuberculosis patients. Improved training of provi-
ders in screening for psychological distress, referral and
psychotropic and/or psychological intervention treat-
ment plans for adult patients with anxiety, depression or
mixed common mental health problems are indicated
. Accurate diagnosis of co-morbid depressive and
anxiety disorders in patients with chronic medical illness
is essential in understanding the cause and optimising
the management of somatic symptom burden . In
addition, measures to reduce psychological distress
among patients with TB should include a more compre-
hensive care approach which should involve sectors out-
side of health that are responsible for structural
adjustment programmes which will ultimately improve
the financial status of this group of patients. Ultimately
structural adjustments through government economic
policies to alleviate poverty combined with psychological
interventions are needed to improve the health out-
comes of TB patients and those co-infected with HIV.
The authors declare that they have no competing interests.
KP conceived and designed the study, analyzed the data and drafted the
manuscript. PN and GM participated in the design, conception and reviewed
the article. JL, GM and BT were involved in report writing and reviewing. All
authors read and approved the final manuscript.
The Department of Health in South Africa funded this study through a
tender "NDOH: 21/2010-2011 Implementation and monitoring of Screening
Peltzer et al. BMC Psychiatry 2012, 12:89
Page 7 of 9
and Brief Intervention for alcohol use disorders among Tuberculosis patients"
that was awarded to the HSRC.
1HIV/STI and TB (HAST) Research Programme, Human Sciences Research
Council, Pretoria, South Africa.2Department of Psychology, University of the
Free State, Bloemfontein, South Africa.3Department of Psychology, University
of the Western Cape, Cape Town, South Africa.
Received: 9 March 2012 Accepted: 27 July 2012
Published: 27 July 2012
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Cite this article as: Peltzer et al.: Prevalence of psychological distress
and associated factors in tuberculosis patients in public primary care
clinics in South Africa. BMC Psychiatry 2012 12:89.
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