Management of DR-TB ADR: Depression

Adverse Drug Reaction (ADR), such as depression, may occur from the Drug-resistant TB (DR-TB) treatment regimen.

Suspected agent(s): Cycloserine (Cs), Fluoroquinolone (FQ), Isoniazid (H), Ethionamide (Eto)

Psychological and socioeconomic circumstances, chronic disease are also important factors of depression.

Suggested Management Strategies

• Assess and address the underlying emotional and socioeconomic issues. 
• Assess patients for coexisting substance abuse and refer to treatment if appropriate. 
• Initiate individual counselling (or group counselling if the patient is sputum smear and culture-negative).
• When depression is more significant, initiate antidepressant treatment with Amitriptyline (not with Bedaquiline (Bdq)), Fluoxetine or similar. 
• Tricyclic antidepressants and selective serotonin reuptake inhibitors and Bdq should NOT be given together.
• Lower the dose of the suspected agent if this can be done without compromising the regimen (reducing the dose of Cycloserine (Cs) and Ethionamide (Eto) to see if depression lessens is a common strategy). 
• Discontinue the suspected agent if this can be done without compromising the regimen.

Points to Note

• Socioeconomic conditions and chronic illness should not be underestimated as contributing factors to depression.
• Depressive symptoms may fluctuate during treatment and improve as an illness is successfully treated.
• History of previous depression is not a contraindication to the use of agents listed but may increase the likelihood of depression developing during treatment. 
• If significant depression is present at the start of treatment, avoid a regimen with Cs, if possible; and question the patient regarding suicidal ideation any time the depression is judged to be more than mild.

Resources

• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021.
• Ready Reckoner for Medical Officer - Adverse Drug Reactions Associated with Anti-TB Drugs Identification and Management, 2019.
• Technical and Operational Guidelines for TB in India, 2016.

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