Programmatic implementation of depression screening and remote mental health support sessions for persons recently diagnosed with TB in Lima, Peru during the COVID-19 pandemic

Abstract

Background: While mental health interventions have been shown to be feasible and associated with improvements in TB outcomes, few studies have reported on an integrated, stepped care model for delivering mental health interventions to persons with TB. Here, we evaluated the implementation of depression screening and low-intensity mental health interventions for persons initiating TB treatment as part of a community-based TB screening program in Lima, Peru during the COVID-19 pandemic.

Methods: We used the PHQ-9 to screen adults with TB for depressive symptoms (PHQ-9 scores ≥ 5). Participants with PHQ-9 scores 5-14 received remote sessions of Psychological First Aid (PFA) or Problem Management Plus (PM+) and were re-evaluated six months after completing the intervention. We compared changes in median PHQ-9 scores before and after the interventions were delivered. Those with PHQ-9 scores ≥15 were referred for higher-level mental health care.

Findings: We found 62 (45·9%) of 135 participants had PHQ-9 scores ≥5 at baseline. Fiftyfour (40·0%) individuals with PHQ-9 scores 5-9 received PFA support sessions, of which 44 (81·5%) were re-evaluated. We observed statistically significant reductions in median PHQ-9 scores from 6 to 2 (p<0·001). Four participants with PHQ-9 scores 10-14 received the PM+ intervention but were unable to be re-evaluated. Four participants with PHQ-9 scores ≥15 were
referred for higher-level mental health care.

Interpretation: Depressive symptoms were common among people initiating TB treatment. Screening for depression and implementing low-intensity mental health interventions were feasible, and we observed improvements in depressive symptoms six months later for most participants who received PFA support sessions.

Citation: Contreras, Carmen and Santa Cruz, Janeth and Galea, Jerome and L. Chu, Alexander and Puma, Daniela and Ramos, Lourdes and Tovar, Marco and Peinado, Jesús and Lecca, Leonid and Keshavjee, Salmaan and Yuen, Courtney and Raviola, Giuseppe, Programmatic Implementation of Depression Screening and Remote Mental Health Support Sessions for Persons Recently Diagnosed with TB in Lima, Peru During the COVID-19 Pandemic. Available at SSRN: https://ssrn.com/abstract=4442866

Full text

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Programmatic implementation of depression screening and remote mental health
support sessions for persons recently diagnosed with TB in Lima, Peru during the
COVID-19 pandemic
Carmen Contreras, BA1,2†, Janeth Santa Cruz, BA1, Jerome Galea, PhD, MSW3,4, Alexander
L. Chu, MPhilPH5, Daniela Puma, Mg1, Lourdes Ramos, MSc1,6, Marco Tovar, Mg1,7, Jesús
Peinado, MSc1,7, Leonid Lecca, MD1,3,10, Salmaan Keshavjee, MD, PhD3,8, Courtney Yuen,
PhD3,8,9, Giuseppe Raviola, MD, MPH3,10,11
Institutional Affiliations:
1Socios En Salud Sucursal Peru (SES), Lima, Peru
2Harvard Global Health Institute, Harvard University, Cambridge, MA, USA
3Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA,
USA
4School of Social Work, University of South Florida, Tampa, FL, USA
5Department of Medical Education, Dell Medical School, University of Texas at Austin,
Austin, TX, USA
6Escuela Profesional de Tecnología Médica, Universidad Privada San Juan Bautista, Lima,
Peru
7Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias
Aplicadas – UPC, Lima, Peru
8Harvard Medical School Center for Global Delivery, Boston, MA, USA
9Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
10Partners In Health, Boston, MA, USA
11Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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†Corresponding Author:
Carmen Contreras
Socios en Salud Sucursal Perú
Jr. Puno 279 Cercado de Lima, Lima, Perú
Email: ccontreras_ses@pih.org
Phone: +51-996-590-685
Abstract Word Count: 248
Manuscript Word Count: 3,530 (excluding references)
References: 25
Figure(s): 1
Table(s): 3
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Abstract
Background: While mental health interventions have been shown to be feasible and associated
with improvements in TB outcomes, few studies have reported on an integrated, stepped care
model for delivering mental health interventions to persons with TB. Here, we evaluated the
implementation of depression screening and low-intensity mental health interventions for
persons initiating TB treatment as part of a community-based TB screening program in Lima,
Peru during the COVID-19 pandemic.
Methods: We used the PHQ-9 to screen adults with TB for depressive symptoms (PHQ-9
scores
≥
5). Participants with PHQ-9 scores 5-14 received remote sessions of Psychological
First Aid (PFA) or Problem Management Plus (PM+) and were re-evaluated six months after
completing the intervention. We compared changes in median PHQ-9 scores before and after
the interventions were delivered. Those with PHQ-9 scores ≥15 were referred for higher-level
mental health care.
Findings: We found 62 (45·9%) of 135 participants had PHQ-9 scores ≥5 at baseline. Fifty-
four (40·0%) individuals with PHQ-9 scores 5-9 received PFA support sessions, of which 44
(81·5%) were re-evaluated. We observed statistically significant reductions in median PHQ-9
scores from 6 to 2 (p<0·001). Four participants with PHQ-9 scores 10-14 received the PM+
intervention but were unable to be re-evaluated. Four participants with PHQ-9 scores ≥15 were
referred for higher-level mental health care.
Interpretation: Depressive symptoms were common among people initiating TB treatment.
Screening for depression and implementing low-intensity mental health interventions were
feasible, and we observed improvements in depressive symptoms six months later for most
participants who received PFA support sessions.
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Funding: Harvard Medical School (2019-2020) with the Agreement Number 027562-746847,
Partners in Health (2021)
Key Words: Depression, Tuberculosis, Mental Health, Mental Health Interventions, Peru
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Research in context
Evidence before this study
We searched PubMed for studies reporting on the use of mental health interventions in
addressing comorbid depression among persons with TB. We searched for studies published
in English up to September 2022 using the keywords “tuberculosis,” “depression,” “mental
health,” and “emotional support.” We found one systematic review and one large interventional
study published after the review. Briefly, the systematic review included and summarized two
pharmacological and 11 psychosocial interventions for the treatment of common mental
disorders (depression, anxiety, and stress-related conditions) among persons with TB (n =
4,326) in various low-and middle-income countries. There was notable variability in the types
of interventions evaluated, duration and frequency of intervention administration, types of
studies, TB patient population, and mental health and TB outcomes assessed. They concluded
that persons with TB who received some form of mental health intervention generally had
better mental health and clinical TB outcomes (e.g., adherence or cure rates) compared with
those who did not receive the intervention or compared with the pre-intervention period.
Furthermore, one recent large interventional study in Pakistan evaluated the impact of
screening 3,500 persons recently diagnosed with TB for anxiety/depression and subsequently
offering a series of counseling-based sessions over the course of TB treatment. Participants
who completed four or more sessions had significantly higher rates of completing TB treatment
than those who completed fewer than four sessions.
Added value this study
This report describes one of the first experiences incorporating depression screening and low-
intensity mental health support interventions as part of a wider community-based active case
finding TB program. Furthermore, this study shows the feasibility and utility of a stepped care
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model within the context of integrating mental health care within the overall care of persons
with TB.
Implications of all the available evidence
Our findings reaffirm the high prevalence of depressive symptoms among persons recently
diagnosed with TB in northern Lima as well as the urgent need to evaluate for and address
comorbid mental disorders such as depression within this vulnerable patient population.
Importantly, our observations also provide further practical insight into how depression
screening and low-intensity mental health interventions may be integrated into existing TB
programs, including community-based TB screening programs. These insights include the
various programmatic challenges (e.g., difficulty achieving high follow-up/re-evaluation rates
and restrictions in budgeting, time, and personnel) and limitations (e.g., the generalizability of
findings to other settings in Peru and beyond) that warrant further consideration and
investigation in other settings and TB patient populations.
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Introduction
Tuberculosis (TB) is a debilitating infectious disease caused by Mycobacterium tuberculosis,
a human pathogen that affects the lungs and other organs, causing significant morbidity and
mortality.1 TB remains a leading cause of mortality due to a single infectious disease after the
coronavirus disease (COVID-19).2 The World Health Organization (WHO) estimated that in
2021 roughly 10·6 million people acquired TB and 1·6 million - 187,000 of which were HIV
positive - died from TB.2 In the Americas, Peru has one of the highest TB burdens with an
estimated annual TB incidence rate of 130 per 100,000 persons annually and is a hotspot for
drug-resistant TB.2
Mental disorders such as depression are common among persons with TB. It is estimated that
about 45% of persons with TB have depression with prevalence estimates exceeding 50% in
persons with MDR-TB.3 Similar depression prevalence estimates have been previously
reported among persons with TB and MDR-TB in Peru.4,5 Furthermore, comorbid mental
disorders have adverse impacts on TB treatment outcomes. Recent systematic reviews and
meta-analyses have reported that persons with TB and depressive symptoms have more than
four times the odds of poor TB treatment outcomes compared with those without depressive
symptoms.6 Taken together, the current evidence base suggests that addressing comorbid
mental disorders such as depression is integral to improving both mental well-being and
treatment success rates among those with TB.7
Various mental health interventions have demonstrated promise in improving treatment
outcomes in persons sick with TB. For example, across three randomized controlled trials,
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psycho-emotional interventions (including counseling, self-help groups, and psychotherapy)
were associated with an increased likelihood of achieving successful TB treatment outcomes
(pooled RR, 95% CI, 1·37, 1·08 - 1·73); however, these studies considered all persons with
TB and included those without comorbid mental disorders.8 A more recently published
systematic review by Farooq et al. considered two pharmacological and 11 psychosocial
interventions for addressing common mental disorders such as depression among persons with
TB (n = 4,326) in various low- and middle-income countries.9 They reported that persons with
TB who receive some kind of psychosocial intervention generally have higher TB treatment
adherence and cure rates compared with those who do not receive the intervention or when
compared with the pre-intervention period.
More recently, a large interventional study conducted by Pasha et al. in Pakistan evaluated the
implementation of screening for anxiety/depression and subsequent delivery of a series of
counseling sessions throughout the TB treatment period among 3,500 persons with TB disease.
They found that those who completed at least four sessions had significantly higher rates of
completing TB treatment compared with those who completed less than four sessions.10 While
these studies suggest that designing and implementing mental health interventions are both
feasible and effective in addressing comorbid mental disorders, none has evaluated the
implementation of depression screening and mental health support interventions embedded
within the context of a community-based TB screening program. Furthermore, few studies have
reported on the use of a stepped care model for allocating different low-intensity mental health
support interventions based on different severities of depressive symptoms at the time of initial
screening.11,12
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Here, as part of a community-based mass TB screening program, we report on the
programmatic implementation of depressive symptom screening and the subsequent delivery
of low-intensity mental health interventions among people initiating treatment for pulmonary
TB in the impoverished, peri-urban communities of northern Lima in Peru.
Methods
Study design and context
We conducted a secondary analysis of data collected as part of a mental health program run by
the non-profit organization Socios En Salud (SES) based in Lima, Peru. This program screened
persons with active TB for depressive symptoms and subsequently provided low-intensity
mental health interventions during their TB treatment period between 2019 and 2021. This
mental health program was incorporated as part of a wider community-based TB screening
program called “TB Móvil” (TB-M), which SES first implemented in collaboration with the
Ministry of Health (MINSA) of Peru in 2019 to identify persons with active TB across various
districts of Metropolitan Lima.13,14 Persons diagnosed with TB through the TB-M program
were referred to participate in the SES mental health program. The mental health program was
implemented remotely in parallel to the TB-M program between September 2020 and June
2021, during the COVID-19 pandemic.
Intervention procedures
Participant enrollment and data collection
Participants were eligible for depressive symptom screening if they satisfied the following
inclusion criteria: individuals were recently diagnosed with TB through the TB-M program and
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had subsequently initiated treatment; were referred by TB-M program staff members for further
mental health evaluation; were 18 years or older; and were residents of communities and
districts of northern Lima that were a part of the TB-M program catchment area. SES
psychologists contacted individuals who were referred by TB-M program staff by telephone
and invited them to be screened for depressive symptoms within 30 days of them initiating TB
treatment. Those who did not start TB treatment during this period were excluded. Participant
sociodemographic (e.g., age, sex, highest level of educational attainment, and region of origin),
clinical, and microbiological data (e.g., TB disease diagnosis, sputum smear microscopy status,
GeneXpert results, and rifampin resistance status) were obtained from the TB-M program’s
database.
Data preparation and handling
For this secondary data analysis, we accessed non-identifiable information for the TB-M
program within the SES informatics system (SEIS). To describe the socio-demographic and
clinical characteristics, we considered the following variables among all participants
evaluated for depressive symptoms: age, sex, highest educational level attained, region of
birth, BK results, Gene Xpert results, chest radiography status, and rifampin resistance status.
We considered the age of participants as a continuous variable. The highest level of education
attained was categorized into three groups: primary, secondary, and post-secondary. We
defined region of birth as born within or outside of the Lima region. Clinical variables like
BK and GeneXpert results were considered binary variables (negative or positive).
The main variables that were analyzed in this study were depressive symptoms at baseline and
follow-up, as well as the type of mental health intervention provided by mental health
professionals.
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Depressive symptom screening and definitions
SES psychologists interviewed participants using the validated Spanish version of the Patient
Health Questionnaire 9 (PHQ-9), a depression screening instrument widely used in clinical
practice and research.15 The score evaluates the number and frequency of nine depressive
symptoms and ranges from 0 (i.e., experiencing no depressive symptoms none of the time) to
27 (i.e., experiencing all depressive symptoms nearly every day). The PHQ-9 uses different
score ranges to classify different severities of depressive symptoms. They include: minimal
(PHQ-9 scores ≤4), mild (PHQ-9 scores 5-9), moderate (PHQ-9 scores 10-14), moderately
severe (PHQ-9 scores 15-19), and severe (PHQ-9 score
≥
20).16
Mental health interventions
The mental health interventions offered as part of the SES mental health program were
originally developed prior to the pandemic and underwent subsequent changes at the onset of
the pandemic. Here, we describe the mental health interventions that were delivered during the
pandemic period. Between September 2020 and June 2021, remote mental health support
sessions were offered to participants identified with signs and symptoms of depression. Those
with PHQ-9 scores 5-9 received one session of Psychological First Aid (PFA), and those with
PHQ-9 scores from 10-14 received five support sessions of Problem Management Plus
(PM+).17 People with PHQ-9 scores ≥15 received one session of PFA before they were
promptly referred for higher-level mental health care at public health care institutions. The
PFA and PM+ support sessions and referral process for patients with severe depressive
symptoms are further described in detail below.
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Psychological First Aid (PFA). The remote PFA sessions provided basic psychological
support in emergent and stressful situations. The primary aim of the remote PFA support
sessions was to help participants restore their emotional balance according to three principles:
(1) observe the person’s problem, needs, and possible solutions; (2) listen carefully to the
person and help them feel supported and address their basic needs; (3) connect them with public
or private mental health institutions if further specialized care was needed.18 This intervention
was administered on an individual basis by SES psychologists via a telephone call, consisting
of a single session lasting approximately 45 minutes.
Problem Management Plus (PM+). PM+ is a low-intensity, trans-diagnostic psychological
intervention recommended by the WHO in treating common mental disorders in many
resource-limited settings.19,20 Previous studies have shown that it is effective in reducing
symptoms of anxiety and depression.20,21 Its primary advantage is that it can be delivered
widely by trained non-specialists such as community health workers, volunteers, and
psychology students. The PM+ intervention has previously been adapted for use in the general
Peruvian population.22 The intervention consisted of five remote 90-minute sessions that were
delivered on an individual basis every week. In the first session, participants were oriented and
motivated to participate and receive psychoeducation and learn basic stress management and
control strategies. In the second session, participants learned problem-solving techniques for
life problems and were introduced to behavioral activation techniques. In the third and fourth
sessions, they were introduced to techniques for strengthening social support and continued to
practice problem-solving techniques, behavioral activation procedures, and relaxation
exercises. In the last session, all learned strategies were reviewed and demonstrated by
participants as a means of assessing understanding for future use and application.
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Referral process and criteria for further specialized mental health care
SES psychologists referred participants with PHQ-9 scores ≥5 for higher-level mental health
care at public health care institutions. The referral process included identifying public health
care facilities closest to the participant’s home, contacting the local facility, and arranging
appropriate follow-up to ensure that the referral process was successful. In areas without access
to mental health facilities, participants were referred to a nearby health care center instead.
Those experiencing mental health problems other than depression were referred to specialized
public mental health services run by the MINSA of Peru.
Depression re-evaluation
Among those who had received and completed remotely administered sessions of PFA or PM+,
SES psychologists contacted those same participants six months later and invited them to be
re-evaluated for depressive symptoms using the PHQ-9 questionnaire.
Data collection and statistical analysis
SES psychologists uploaded data collected from participants to the SES electronic data system.
These included PHQ-9 scores at the time of enrollment/baseline and at the time of follow-up,
type of remote mental health support sessions received (PFA or PM+), and whether participants
were referred to primary care facilities or public health centers for higher-level mental health
care. Continuous variables of characteristics of people with TB were reported as medians with
interquartile ranges (IQR), and categorical variables were reported as frequencies with
percentages. We reported the overall proportion of people initiating treatment for TB with
PHQ-9 scores ≥5 at the time of study enrollment. For participants who were re-evaluated, we
compared median PHQ-9 scores at baseline and follow-up using the Wilcoxon’s paired sign-
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rank test. All statistical analyses were conducted using Stata/SE 17.0 (Stata Corp., College
Station, TX) with a significance level of 0·05.
Ethics statement
The study was reviewed and approved by the Ethics Review Committee of SES.
Confidentiality was maintained throughout the study. All collected data were kept confidential
and used only for study purposes.
Results
During the pandemic, we identified a total of 161 individuals who were referred for mental
health evaluation after being assessed by the TB-M program (Figure 1). After excluding 26
participants, a total of 135 (83·9%) eligible participants underwent depressive symptom
screening at baseline. Among all persons with TB who had undergone depressive symptom
screening at baseline, the median age was 38·9 years (IQR: 28·4 years) and the majority were
male (56·3%) (Table 1). Most participants were born in the Lima region (75·4%) and
completed secondary education (70·5%). Microbiologically, 106 (81·5%) of 130 participants
were tested for TB using sputum samples. Of those who had available GeneXpert MTB
complex results (n = 100) and information on rifampin resistance status (n = 100), 90 (90·0%)
were positive and 31 (31·0%) were resistant to rifampin, respectively.
Among 135 participants who underwent screening for depression at baseline, 62 (45·9%) had
PHQ-9 scores ≥5 (Table 1). Persons with TB and PHQ-9 scores ≥5 tended to be younger
compared with those with PHQ-9 scores <5; albeit, the comparison was not statistically
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significant (median age and IQR for participants with depressive symptoms vs. without at
baseline: 37·2 years [22·0 years] vs. 41·6 years [30·5 years], p = 0·581) (Table 1). Furthermore,
we did not find any statistically significant difference in the proportion of participants with
PHQ-9 scores ≥5 at baseline neither by sex (p = 0·055) nor by education level (p = 0·816;
Table 2). However, those with PHQ-9 scores ≥5 at baseline were more likely to be born outside
of Lima compared with those with PHQ-9 scores <5 (PHQ-9 scores ≥5 vs. <5 for region of
birth outside of Lima: 52 [83·9%] vs. 46 [67·7%], p = 0·041). We did not find a statistically
significant difference in baseline depression status for those who had microbiological
confirmation of their TB compared with those diagnosed based on clinical/radiological
findings (p = 0·628).
Of the 62 participants who were found to have PHQ-9 scores ≥5 at baseline, almost all had
PHQ-9 scores 5-9 (54 [87·1%]); 4 (6·5%) participants had PHQ-9 scores 10-14; 3 (4·8%) had
PHQ-9 scores 15-19; and 1 (1·6%) had PHQ-9 scores ≥20 (Table 2; Figure 1). Among the 54
participants who were found to have PHQ-9 scores 5-9, 44 (81·5%) were re-evaluated six
months after completing remote PFA support sessions. The majority of participants re-
evaluated at six months of follow-up no longer had clinically significant depressive symptoms,
as evidenced by PHQ-9 scores <5 (n = 38 [86·4%]); only 6 (13·6%) had PHQ-9 scores 5-9.
We observed a statistically significant reduction in median PHQ-9 scores six months after
completing the remote PFA support sessions (median PHQ-9 score and IQR at baseline and at
follow-up: 6 [3] and 2 [3], respectively, p<0·001; Table 3). Remote PM+ support sessions were
delivered to four participants who were initially found to have PHQ-9 scores 10-14; however,
they all refused re-evaluation six months later, and, therefore, a comparison could not be made.
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All participants who were found to have PHQ-9 scores ≥15 successfully received a single
remote session of PFA and were immediately referred for higher-level mental health care.
Discussion
During the COVID-19 pandemic, we found that almost half of the persons with recently
diagnosed TB as part of a community-based mass TB screening program exhibited depressive
symptoms (PHQ-9 scores ≥5). Furthermore, our programmatic experience and findings also
indicate that implementation of a stepped care model for mental health screening and delivering
virtual, low-intensity mental health interventions were not only feasible for individuals
initiating TB treatment but also associated with overall improvements in median PHQ-9 scores
six months later.
Overall, we found that 45·9% of all persons with TB in our sample had depressive symptoms
at the time of TB treatment initiation. We recognize that this prevalence estimate was
determined using a liberal PHQ-9 cutoff score of 5. Nonetheless, our prevalence estimate is
much higher than that recently reported in the general Peruvian population during the pandemic
period (~20%).23 Our estimate is consistent with the pooled depressive symptom prevalence
estimate among persons with TB.3 In our program, most participants with depressive symptoms
exhibited mild depression, defined by PHQ-9 scores 5-9 (54/62 [87·1%]). Most were contacted
by SES psychologists within the first 30 days following TB diagnosis, a period that coincides
with the initiation of TB treatment. Thus, we considered the possibility that many participants
were beginning to experience symptoms of depression at or around the time of diagnosis,
suggesting that the integration of early depression screening within TB screening programs
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could be useful in identifying a large sample of patients who may require concurrent mental
health care during their TB treatment. However, we cannot rule out the possibility that some
of our study participants may have been suffering from an acute worsening of pre-existing
depression or some other unassessed mental disorders.
Previous studies addressing comorbid mental and health concerns among persons with TB
disease have primarily focused on delivering mental health interventions to those who screen
positive for depressive symptoms, regardless of symptom severity at the time of initial
screening.9 However, few studies have implemented a stepped care model of first screening for
mental disorders and subsequently delivering severity-appropriate mental health interventions.
In Nepal, Walker et al. conducted a feasibility and acceptability pilot study for a psychosocial
support package among patients with MDR-TB.12 Their package involved providing all
patients with information and educational materials and initially screening them for symptoms
of anxiety and depression using the Johns Hopkins Symptom Checklist. For those who
screened positive for either anxiety or depression, they were subsequently referred for
depressive symptom screening using the PHQ-9. Those who had PHQ-9 scores less than 10
were re-screened on a monthly frequency. Those who had PHQ-9 scores 10-19 received a series
of counseling sessions based on behavioral activation originally evaluated in India for treating
depression. Those who had PHQ-9 scores greater than 19 or who expressed suicidal intent were
referred for higher-level psychiatric and medical care. Although this study concluded that,
overall, it was feasible to design and implement a stepped care model for mental health care
within a National Tuberculosis Program, it suffered a couple of key limitations, including (a)
utilization of a complex two-step screening system that likely resulted in fewer number of
patients receiving the counseling intervention; and (b) inability to evaluate the potential impact
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of the mental health intervention on changes in depression and anxiety severity in relation to
the time of initial screening. Our present study utilized the PHQ-9 as the only standardized
screening tool and implemented a stepped care model with different severity-appropriate
virtual mental health support sessions. Although we were unable to re-evaluate enough
participants who received remote PM+ sessions, we were able to re-evaluate a high proportion
(~80%) of those who completed remote PFA sessions and gain a sense of the possible mental
health impact associated with providing severity-specific mental health interventions.
Our programmatic experience and findings have several implications for integrating mental
health care and TB care. First, we show that a stepped care model for screening for depressive
symptoms and delivering different mental health interventions can both be feasibly embedded
and implemented within a high-volume, community-based mass TB screening program like
TB-M. Integrated TB and mental health screening in high-risk populations, settings, or
communities offer an opportunity to detect a larger number of individuals with both TB and
mental health issues and at earlier stages of their TB treatment period. Second, we show that
low-intensity mental health interventions such as PFA and PM+ support sessions can be
administered virtually to persons recently diagnosed with TB during the pandemic era. This
type of care delivery modality is in line with the wider and accelerated shifts toward adapting
and utilizing telehealth-based technologies during the pandemic.24 Low-intensity psychosocial
interventions such as PFA are first-line psychosocial interventions that can be administered in
high-stress mental health crises and delivered by trained non-specialist personnel such as
community health workers. This may greatly expand service coverage in settings with limited
resources and fewer mental health professionals.25
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Our study has several notable limitations. First, although we observed statistically significant
reductions in the median PHQ-9 scores from baseline to six months following completion of
PFA sessions, we are limited in our ability to infer to what extent the mental health
interventions may have contributed to these reductions. Other plausible explanations include
natural improvements in depressive symptoms with time, improvements in TB disease because
of ongoing treatment, the impact of other unmeasured psychosocial and/or clinical factors (I.e.,
residual confounding), or a combination of these factors. In a similar vein, we were unable to
compare changes in median PHQ-9 scores over time with a control group, as every participant
who had PHQ-9 scores ≥5 at baseline was offered mental health support. Second, we were
unable to re-evaluate slightly less than 20% of those who had PHQ-9 scores 5-9 at baseline six
months after completing PFA support sessions. Assuming those with higher PHQ-9 scores are
less likely to follow-up, this could have led to an underestimation of the change in median
PHQ-9 scores between baseline and follow-up. Finally, we were unable to assess the
association between completing the mental health interventions and TB treatment outcomes,
including known mediators such as treatment adherence. Previous studies have demonstrated
a positive correlation between emotional support during TB treatment and improved treatment
adherence and success rates.6 Therefore, future mental health interventions could include
regular, monthly follow-up depression assessments throughout the TB treatment period,
particularly at the start of treatment when the severity of depressive symptoms is likely to be
the highest.
In conclusion, we found that depressive symptoms were common among people with TB who
were identified by a community-based mass TB screening program. Our professional
experience and findings indicate that integrating and implementing depression screening and
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delivery of low-intensity psychosocial interventions such as PFA or PM+ are feasible in a
resource-limited setting like Lima, Peru. Future studies are needed to assess the feasibility and
utility of frequent depression assessments during the TB treatment period as well as the impact
of severity-appropriate, low-intensity psychosocial interventions on TB treatment outcomes.
Contributors
CC is the corresponding author. CC, JS, and JG designed and oversaw the implementation of
the mental health interventions. DP, MT, JP, LL, SK, and CY designed and oversaw the
implementation of the community-based active TB case finding program “TB Móvil.” LR
devised the analytical approach and carried out the data analysis. CC and JS drafted the primary
version of the manuscript. ALC, CC, JS, DP, MT, JP, LL, SK, CY, and GR revised and edited
subsequent versions of the manuscript. All authors reviewed and approved the final version of
the manuscript.
Funding
Harvard Medical School (2019-2020) with the Agreement Number 027562-746847, Partners
in Health (2021)
Declarations of Interests
All authors have no conflicts of interest to declare.
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Acknowledgments
We express gratitude for the participants of communities in northern Lima as well as the
support provided by the Peruvian Ministry of Health (MINSA) in carrying out the TB Móvil
Program.
Data sharing statement
Not applicable
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Table 1. Characteristics of persons with TB during the COVID-19 pandemic, by baseline
depressive symptom status (PHQ-9 scores ≥5) (N = 135)
Baseline depressive
symptom status, no. %
(column)
Characteristics
Total no.
(%),
N = 135a
PHQ-9
scores <5
(n = 73)
PHQ-9
scores ≥5
(n = 62)
p-value
Age, years, median (IQR)
(n = 135)
135 (100.0)
41.6 (30.5)
37.2 (22.0)
0.581
Gender (n = 135)
Male
76 (56.3)
47 (64.4)
29 (46.8)
Female
59 (43.7)
26 (35.6)
33 (53.2)
0.055
Highest educational level
achieved (n = 129)
Primary or less
24 (18.6)
14 (20.6)
10 (16.4)
Secondary
91 (70.5)
46 (67.7)
45 (73.8)
Post-secondary
14 (10.9)
8 (11.8)
6 (9.8)
0.816
Region of birth (n = 130)
From Lima
98 (75.4)
22 (32.4)
10 (16.1)
Outside of Lima
32 (24.6)
46 (67.7)
52 (83.9)
0.041
TB diagnosis methodology
(n = 130)
Microbiological
confirmation
106 (81.5)
56 (83.6)
53 (86.9)
Clinical/radiological
criteria
24 (18.5)
11 (16.4)
8 (13.1)
0.628
BK results (n = 100)
Negative
53 (53.0)
33 (60.0)
20 (44.4)
Positive
47 (47.0)
22 (40.0)
24 (55.6)
0.159
GeneXpert MTB Complex
Detection Status (n = 100)
Negative/not detected
10 (10.0)
9 (16.4)
1 (2.2)
Positive/detected
90 (90.0)
46 (83.6)
44 (97.8)
0.021
Rifampin resistance statusb
(n = 100)
Sensitive
49 (49.0)
25 (54.4)
24 (54.6)
Resistant
31 (31.0)
19 (41.3)
12 (27.3)
Indeterminant
10 (10.0)
2 (4.4)
8 (18.2)
0.076
a Total number may be less than 135 due to missing data
b Numbers and percentages reported only among participants with a positive GeneXpert
test result
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Table 2. Breakdown of the severity of depressive symptoms among persons with TB
Depressive symptom
severities
PHQ–9 score range
No. (%)
None/ minimal
0 – 4
73 (54.1)
Mild
5 – 9
54 (40.0)
Moderate
10 – 14
4 (3.0)
Moderately severe
15 – 19
3 (2.2)
Severe
≥20
1 (0.7)
Total
135 (100.0)
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Table 3. Comparisons of median PHQ-9 scores at baseline and six months following
completion of remote PFA support sessions among persons with TB (n = 44)
Baseline PHQ-9 scores
Reevaluation PHQ-9 scores
Median
Min
Max
IQR
Median
Min
Max
IQR
P-value
6
5
9
3
2
0
5
3
<0.001
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Figure 1. Study flow chart
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TB patients screened by the TB Móvil program
who were then referred for depressive symptom
screening (n = 161)
Patients that underwent baseline depressive
symptom screening using the PHQ-9 (n = 135)

No depressive symptoms (PHQ-9 <5; n = 73)
Patients who were re-evaluated six months after
completing virtual PFA support sessions (n = 44)
•Declined re-evaluation (n = 3)
•Could not be reached (n = 7)
Patients with no
depressive symptoms
(PHQ-9 <5; n = 38)
Patients with mild
depressive symptoms
(PHQ-9, 5-9) who then
received PFA sessions
(n = 6)
Patients with mild depressive symptoms
(PHQ-9, 5-9) who received virtual PFA support
sessions (n = 54)
•Declined depressive symptom screening (n = 9)
•<18 years old (n = 8)
•Could not be reached (n = 8)
•Died (n = 1)
Patients with moderate
depressive symptoms
(PHQ-9, 10-14) who
received virtual PM+
support sessions (n = 4)

Patients with moderately
severe depressive
symptoms (PHQ-9, 15-19)
who received one PFA
session and were then
referred for higher-level
care (n = 3)
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