Case study 1: When 37-year-old Mr X was diagnosed with TB, he became visibly upset and held his head with his hands. “I’ll lose my job if anyone finds out,” he says. He tells you that his son was in a recent accident and now he (Mr X) is the only person in his household who is able to work and bring money home. He says this could have a devastating impact on his family. In a follow-up appointment several weeks later when Mr X comes to pick up his TB medications, he seems a little withdrawn. He speaks in a low tone with his head down. “Is everything okay?” you ask. He responds, “I haven’t been sleeping. My wife and I are constantly arguing. I worry all the time for the future of my family if I’m not able to get better.” 

Question 1: What is your impression of Mr X’s mental health? Select the statement that you think applies best to Mr X’s mental health status:

Why has he had trouble sleeping?Is Mr X’s current distress affecting his ability to work, take his TB medications, or carry out his normal daily activities?Is he the first person in his family to have TB?When did Mr X’s distress symptoms begin?Case study 1: When 37-year-old Mr X was diagnosed with TB, he became visibly upset and held his head with his hands. “I’ll lose my job if anyone finds out,” he says. He tells you that his son was in a recent accident and now he (Mr X) is the only person in his household who is able to work and bring money home. He says this could have a devastating impact on his family. In a follow-up appointment several weeks later when Mr X comes to pick up his TB medications, he seems a little withdrawn. He speaks in a low tone with his head down. “Is everything okay?” you ask. He responds, “I haven’t been sleeping. My wife and I are constantly arguing. I worry all the time for the future of my family if I’m not able to get better.” 

Question 2: In order to help Mr X, what additional information would you want to know? Select all that apply:

a. When did Mr X’s distress symptoms begin?

b. Is he the first person in his family to have TB?

c. Is Mr X’s current distress affecting his ability to work, take his TB medications, or carry out his normal daily activities?

d. Why has he had trouble sleeping?

Case study 2: After two months of treatment for drug-resistant TB, a young man and his mother come for a second-month check-up, but his behavior seems different. Whereas during previous appointments he would always warmly greet all staff before sitting in the waiting room, this time he walks directly to his seat. He sits down quietly, gazing at his lap with an odd expression on his face. His mother appears to be worried, glancing at him frequently with a concerned expression. 

When they come into the consultation room, the mother tells you, “I don’t know what is going on with my son. He used to be very sociable. He was always happy and playing with his little brothers and sisters but recently he’s just been staying in his room.” The young man says, “I’ve been feeling a little anxious and nervous lately, and I find it difficult to focus on conversations, so I prefer to go to my room and be by myself. My body feels strange. I have a feeling as if worms are crawling on my skin and are eating me from the inside. But when I look down, there’s nothing there.” The mother adds, “I have never seen this behavior in my son before”

Based on this information, what should you do first? Select all that apply:

a. Discontinue his TB treatment immediately until you can work out what is causing these symptoms. 

b. Tell the young man that he does not need to worry because there are no worms on his arm

c. Examine his arms for any rash or other sign of skin irritation that could explain the worm-crawling sensation.

d. Check the list of medications in his drug-resistant TB regimen to see if any of them have been associated with mental health side-effects (e.g. cycloserine, fluoroquinolones).

e. Tell the young man and his mother to pay very close attention to all of the symptoms and alert the clinic staff if the symptoms worsen.

Case study 3: As a first step, Country X decides to organize a planning meeting among local TB and mental health care providers to create a set of care pathways and referral strategies for supporting people affected with TB who experience problems with their mental health. 

Complete the following sentence. Select all that apply. The main goal(s) of the meeting would be to:

a. decide what approach will be taken to identify people with mental health conditions accessing TB care

b. strengthen links between the TB programme and existing mental health services

c. identify what options are available for support such as psychoeducation, self-help interventions, peer support and brief psychological interventions delivered by non-specialists

d.  identify whether mental health specialists are available to be consulted or to accept referrals for more intense care (which can include psychological interventions and pharmacological care)

e. create care pathway protocols for people who may require specialist support – such as people identified as having psychoses, severe depression, suicidal behaviours or substance use