Stigma and depression among patients with tuberculosis in Khyber Pakhtunkhwa Pakistan: a cross-sectional study

BACKGROUND: Tuberculosis (TB), a highly stigmatized disease, remains a major public health challenge globally, with stigma and mental health issues such as depression significantly impacting patient outcomes. TB-related stigma undermines patient engagement with testing and treatment, driven by factors at the individual, community, and health-system levels. In Pakistan, particularly in the Khyber Pakhtunkhwa region, the interplay between TB-related stigma and depression is underexplored. Understanding these relationships is critical to improving patient engagement, treatment adherence, and overall TB control efforts in this context. AIMS AND OBJECTIVES: To investigate the frequency of depression among TB patients, assess the level of TB stigma, and examine the association between stigma and depression in Districts Peshawar and Haripur. DESIGN & METHODS: A cross-sectional study was conducted, from June to December 2023, in Khyber Pakhtunkhwa Province. Non-random convenience sampling was used to recruit 349 participants, of whom 311 were from Peshawar and 38 from Haripur. All participants were evaluated for tuberculosis stigma using the Van Rie TB Stigma Scale. Patients were initially screened for depression via Patient Health Questionnaire-2. A severity assessment was done on 159 depressed participants, using Patient Health Questionnaire-9. RESULTS: Patient and community perspective stigma were reported as 64.8% and 49.9% in the participants. The frequency of depression among all participants was 45.6%. To evaluate predictors of depression, logistic regression was applied at 5% significance level using STATA 18. In the multivariable analysis, community perspective stigma and residence showed a significant association with depression. However, residence lost its significance when the model was adjusted for patient perspective stigma. Notably, as both patient and community perspective stigma increased, the severity of depression also rose, underscoring the strong association between TB stigma and poor mental health outcomes. CONCLUSIONS: Depression is highly prevalent among tuberculosis patients, and it has a strong relationship with both patient and community perspective stigma. The findings indicate that the higher levels of stigma are associated with greater depression severity while residence shows a context-specific association with mental health outcomes. Integrating stigma reduction and mental health interventions into TB care is essential to improve psychological wellbeing and treatment outcomes among affected individuals.