Tuberculosis and suicide: An overlooked association

Sir,

Tuberculosis (TB) is a major global public health concern, which affects >10 million individuals annually and results in over 1.3 million deaths, according to the World Health Organisation (WHO) Global TB Report 2024. ¹ Despite advances in TB management, associated mental-health aspects have received insufficient attention, and the tendency to suicide is often overlooked. Growing evidence demonstrates a robust association between TB and an increased risk of suicidal behaviour, underlining the need to address it in both clinical management and public health policy. ² We performed a literature search in PubMed, Google Scholar, and Web of Science using the terms ‘tuberculosis’, ‘suicidality’, ‘suicidal ideation’, ‘suicide attempts’, and ‘suicide’.

The prevalence of mental illness among individuals with TB is high. Systematic reviews and meta-analyses have found depression in TB patients as high as 45%, and anxiety disorders up to 32.5%.^3,4 These psychiatric disorders are well-established risk factors for suicide. Studies examining TB and suicide report notably elevated rates across diverse settings. The most definitive evidence comes from a 2023 systematic review and meta-analysis by Patwal et al., which analysed data from nine studies comprising 8770 TB patients. They found a pooled 12-month prevalence of suicidal ideation of 8.5%, markedly higher than the 2% observed in general populations. The suicide-attempt rate was 3.1%, versus approximately 0.3–0.4% in community samples. Completed suicide accounted for 2.2–8.4% of all deaths among TB patients. ² Although our search was unrestricted geographically, the available literature is mainly clustered in high-burden regions, particularly South-East Asia and sub-Saharan Africa. WHO regions such as the Americas and Europe are underrepresented in the TB-suicide literature, potentially limiting generalisability to other settings.

A study in Ethiopia, which surveyed 415 adult TB patients at a specialised outpatient hospital, found a lifetime prevalence of suicidal ideation at 17.3% and suicide attempts at 7.5% among TB patients. ⁵ Two cross-sectional studies from India found suicide rates of 8.4% and 2.2%, respectively. One study analysed deaths among patients registered in the district TB programme, while another used verbal autopsies with the families of 71 multidrug-resistant TB patients.^6,7 A South African study included 4900 (54.5% men and 45.5% women) TB patients from 42 public primary care clinics in three districts documented suicidal thoughts in 9.0% and attempts in 3.1% of TB patients, ⁸ while a recent study in Kenya which included 367 TB patients at a tertiary referral hospital, found suicidality present in 8.2% of TB patients. ⁹

Factors influencing suicidality in TB range from clinical to psychosocial and demographic. Comorbid depression, psychological distress, and post-traumatic stress disorder increase the risk of suicidal ideation and attempts.^5,8 Among clinical factors, TB retreatment status, multidrug resistance, HIV co-infection, and neuropsychiatric side effects of drugs such as cycloserine further increase risk.^8,10 Psychosocial stressors, particularly stigma, social isolation, and the economic hardship of poverty and unemployment, can triple the risk of self-harm.^5,11 Female patients and those lacking formal education are disproportionately affected demographic groups. ²

TB and psychiatric illness share a bidirectional relationship. Not only does the inflammatory and psychosocial burden of TB precipitate mental illness, including suicide, but pre-existing mental disorders such as depression and schizophrenia also increase an individual's risk of developing TB. ¹² The stress-diathesis model posits that TB acts as a psychological stressor, while the neuro-endocrine model suggests that chronic infection and stress dysregulate the hypothalamic-pituitary-adrenal axis and the noradrenergic system. Elevated proinflammatory cytokines (e.g. interleukin-1 and tumour necrosis factor) have also been linked to increased risks of depression and suicidality. ² Similarly, chronic somatic illnesses such as HIV, diabetes mellitus, cancer, epilepsy and chronic obstructive pulmonary disease, previous personal and/or family history of suicide and attempted suicide, have been shown to elevate the risk of depression and suicide through shared pathways of inflammation, disability, and social stigma.^13-16

The high prevalence of undiagnosed psychiatric conditions mandates the integration of mental health screening and care into current TB programmes. Training programmes for clinicians need to emphasise the detection of suicide risk factors, such as depressive symptoms and substance-related problems. The WHO End TB Strategy's recommendation to integrate TB and mental health services should be made operational with dedicated funding for psychosocial care and task-shifting approaches in TB clinics. ¹² Other key stakeholders are health sciences training institutions (medical, nursing, and allied health schools) in low- and middle-income countries, which should integrate mental health and suicide prevention into their pre-service curricula. Given international travel and migration, clinicians in low-TB-burden, high-income countries should also be vigilant for depression, anxiety, and suicide risk among patients presenting with TB.

Further longitudinal cohort studies are required to establish the incidence of suicidal behaviour and better understand the causal associations throughout the course of TB treatment. Overlooking suicide in TB can lead to reduced quality of life, decreased treatment adherence, and obviously leads to suicidal deaths. It is time for clinicians, researchers, and policymakers to acknowledge and address suicide as a significant and preventable cause of mortality in patients with TB.