The connection between TB and mental health
In Myanmar, people with TB face not only the challenges of a long treatment regimen, but also the stigma and emotional burden that often accompany the disease. Many people with TB experience mental health issues such as depression, anxiety, or stress, often compounded by isolation from their families and communities.
Globally, the prevalence of depression among persons with TB is reported to be between 3–6 times higher than that of the general population. In Myanmar, security concerns and general instability further contribute to the risk of developing mental health problems. Addressing these mental health challenges is key to ensuring TB treatment adherence and achieving successful health outcomes.
The Private Provider Interface Agency for Integrated Service Delivery (PPIA-ISD) project, a collaboration between PATH and the Myanmar Health Assistant Association (MHAA) funded by the Stop TB Partnership, aims to provide TB and integrated services including for HIV, hepatitis C virus, mental health, and diabetes mellitus to people living with TB. Among these services, integrating mental health care into TB treatment is crucial for addressing the emotional and psychological needs of people living with TB, thereby improving their overall well-being.
Building trust and providing support
The agents of the PPIA-ISD project are key touchpoints for people living with TB. They interact with patients regularly, helping them navigate the treatment journey, manage medication side effects, and address concerns. Over time, agents build strong relationships with patients, enabling the agents to identify emotional distress or mental health concerns early on.
“TB often carries a significant stigma, and it’s not just the disease itself but the isolation and mental strain that affect patients," says Ma Nandar, a PPIA-ISD agent.
“I’ve had clients whose family members asked them to live elsewhere. Even if they didn’t have mental health issues before TB, over time, they may develop depression.”— Ma Nandar, PPIA-ISD agent, MHAA
This demonstrates the critical role agents play in monitoring not just the physical but also the emotional health of patients. By integrating regular mental health assessments—conducted twice, at the start of TB treatment and during follow-up visits in the intensive phase—using tools like the PHQ-9 (a validated depression questionnaire), agents can intervene and offer support or linkages to specialized care when necessary, helping patients cope with the psychological impact of TB.
While progress has been made in integrating mental health into TB care, it is crucial that agents and other heath care workers understand how to effectively use tools like the PHQ-9, including how to accurately interpret the results. Misunderstandings around symptom duration, impact, and cultural differences must also be addressed to provide personalized care.
“The agents have been incredibly kind and compassionate in taking care of me.”— Zar Ni Win, a client who has completed TB treatment
Capacity building as a turning point for TB and mental health care
Staff and agents supporting people with TB must have knowledge that goes beyond TB treatment and care—they require skills in mental health education, communication, active listening, and empathy. Developing these skills enables them to provide mental health support that vital for effective TB treatment.
To build this capacity, PATH supported a training on Psychological First Aid, Basic Counseling, and Utilization of PHQ-9, held in Yangon in May 2024. This training marked a pivotal moment for the staff involved in the PPIA-ISD project. It equipped health care staff including agents with the tools to better recognize and respond to the mental health needs of people with TB.
Training participants practice active empathic listening techniques during a Psychological First Aid and Basic Counselling Health Training organized by PATH and MHAA for all PPIA-ISD project staff. Photo: PATH/MHAA.
The training deepened their understanding of mental health and equipped them to implement integrated mental health interventions in the project by:
- Conducting mental health screenings of people with TB, using the PHQ-9.
- Providing psychosocial support and counseling to clients with mild depression.
- Facilitating referrals for clients with moderate or severe depression.
Moreover, the training transformed the way agents interacted with patients, allowing them to build rapport, encourage openness, and better address the mental strain associated with TB.
The changes had a positive impact on both the quality of care and patient outcomes. According to an analysis of assessment scores, 75 percent of people with TB who had moderate depression (scores of 5–9) during their first assessment improved to no depression (scores of 0–4) by the second assessment, conducted at the end of the two-month intensive phase of treatment.
“The PHQ-9 is an essential tool in our mental health assessment toolkit. Strengthening our understanding and application of this tool is critical for delivering high-quality care.”— Dr. Kyi Min Tun, consultant psychiatrist and trainer
“By addressing the areas of weakness identified during the training, we can enhance our proficiency and confidence in using the PHQ-9, ultimately leading to better outcomes for our clients,” Dr. Tun adds.
Reflecting on her experience, Ma Shoon, an agent, shared, “Initially, we approached the PHQ-9 questionnaire as just another checklist task. But after the training, we came to understand how each question truly reflects a patient’s level of depression. We learned that building rapport first is essential, so patients feel comfortable sharing their thoughts and emotions. Now, instead of focusing on the form, we listen carefully to what the patient is saying without obviously referring to the questionnaire. This shift has made the PHQ-9 results more meaningful and better aligned with the patients’ actual conditions.”
Resilience and empowering patients through trust and communication
Effective communication and emotional support are central to the success of TB treatment. Agents offer ongoing encouragement, letting patients know they are not alone in their journey. The constant contact not only reassures patients but also allows agents to monitor their progress closely, ensuring timely interventions when needed.
“Patients’ mental health scores often improve after our second assessment. We make sure they know we are here for them throughout the treatment journey, which makes a huge difference. It’s not just about physical health—it’s about keeping their spirits up,” says Ma Shoon.
PPIA agents conduct a home visit to assess mental health using PHQ-9 (a validated depression questionnaire), while also checking TB treatment adherence and providing counseling to a person with TB. Photo: PATH/MHAA.
A call for action to end TB in Myanmar through a people-centered approach
At PATH, we believe that mental health is a core component of universal health coverage and integrating mental health services into TB care (and other primary health care services) is essential to achieving a holistic, people-centered care model. The knowledge gained from PPIA-ISD project training has equipped agents with the tools they need to support patients on multiple levels—physically, mentally, and emotionally. As Myanmar continues to fight TB, it is clear that mental health support and psychoeducation are crucial components of this battle.
Incorporating mental health care into TB treatment not only helps patients survive but empowers them to thrive. By addressing the full spectrum of their needs and helping to combat stigma, we can ensure that no patient is left behind, and we can move closer to ending TB in Myanmar.
We call upon all TB stakeholders and funding agencies to strengthen their focus on integrating mental health care into TB services. The road to ending TB must be paved with mental health support, compassion, and a people-centered approach.
