PESHAWAR: More than 60 percent of tuberculosis (TB) patients screened across Khyber Pakhtunkhwa were found to be suffering from clinical depression, while nearly 90 percent of those affected exhibited moderate to severe depressive illness, according to preliminary findings of a Pakistan-United Kingdom collaborative research project unveiled on Wednesday.
Health experts involved in the study warned that untreated depression is emerging as a critical but overlooked obstacle to tuberculosis control in Pakistan, contributing to poor treatment adherence, prolonged illness, and the development of drug-resistant or multidrug-resistant (MDR) TB, a threat they described as entirely preventable.
The trial currently underway on 570 patients, enrolled from a screened population of around 1,200 TB patients, to receive either culturally adapted cognitive therapy alongside standard TB treatment or standard care alone, is stated to be the world’s largest clinical trial on patients.
The findings were shared during a media briefing organised by the Office of Research, Innovation and Commercialisation (ORIC) of the Khyber Medical University (KMU), Peshawar, one of Pakistan’s fastest-growing research universities, currently ranked 13th among all universities nationwide despite receiving no financial support from the provincial government, sustaining itself entirely through fee income and an international research portfolio valued at approximately $20 million.
The research forms part of the CONTROL Programme (COgNitive Therapy for depression in tuberculosis treatment to improve outcomes for depression and TB in Pakistan and Afghanistan), a landmark initiative jointly led by Professor Saeed Farooq of Keele University, United Kingdom, and Dr Zohaib Khan of Khyber Medical University.
Funded by the United Kingdom’s National Institute for Health and Care Research (NIHR) under its highly competitive RIGHT Call 3 mechanism (Reference: NIHR201773), a funding round in which only four applications out of all global submissions were successful, the five-year programme is examining the impact of integrating mental health support into routine tuberculosis care.
Researchers said the prevalence of depression among TB patients in the province is substantially higher than global estimates, which suggest that around 40 percent of TB patients experience depressive symptoms.
“The findings highlight a major gap in TB care,” researchers told the briefing. “We have traditionally focused on treating the disease, but not the psychological challenges that directly affect whether patients complete treatment successfully,” said Prof Dr Saeed Farooq, a former head of the Psychiatry Department at the Lady Reading Hospital, Peshawar.
According to researchers, depression significantly reduces the likelihood that patients will complete the standard six-month anti-tuberculosis treatment regimen. Treatment interruption or default is one of the key drivers of drug-resistant tuberculosis, which is far more difficult and costly to treat and carries significantly higher mortality rates.
Drug-resistant TB can require treatment lasting up to two years and can spread resistant strains within communities. Public health experts noted that a single untreated MDR TB patient may infect between 10 and 15 other individuals.Khyber Pakhtunkhwa records an estimated 45,000 to 60,000 new TB cases annually, making effective treatment adherence a major public health priority.
Dr Zohaib said it was the first time they strengthened a health system rather than depending on low-paid health workers on the ground, as happens with the foreign-funded project. He appreciated the contribution of the Khyber Pakhtunkhwa TB Control Programme that made their trial successful.
The economic case for action is stark. Researchers demonstrated that the per-patient cost of delivering cognitive therapy is a fraction of a single cardiac procedure, the budget for one coronary stent, approximately Rs300,000 on average, and bypass surgery is much higher, arguing that the cost of a single coronary stent could fund depression treatment for over 100 TB patients.
The cost of continued inaction, measured in drug resistance, prolonged illness, onward transmission, and lost productivity, is incalculably higher.To address the challenge, the CONTROL Programme developed a culturally adapted Cognitive Behavioural Therapy (CBT) intervention specifically tailored for TB patients in Pakistan, refined over 18 months through ethnographic research, community consultations, focus group discussions, and stakeholder engagement exercises, and carefully translated into Urdu, Pashto, and Hindko to ensure cultural relevance and accessibility.
Researchers said one of the programme’s most innovative features is that the therapy is delivered by trained TB healthcare workers already working within treatment facilities, rather than requiring referral to specialist mental health services, an approach designed to overcome the deep-rooted stigma surrounding mental illness, improve access to care, and integrate psychological support into existing TB services without imposing additional costs on patients.
A pilot randomised controlled trial conducted in Peshawar and Haripur during 2024 demonstrated the feasibility and acceptability of the intervention and confirmed the effectiveness of the healthcare worker training model.
Building on these results, researchers launched what they describe as the world’s largest randomised controlled trial evaluating cognitive therapy for depression within a tuberculosis treatment setting.
The trial is currently underway across 13 healthcare facilities in Peshawar, Haripur, Mardan, and Abbottabad, including government hospitals, private-sector clinics, and public-private partnership facilities.
Approximately 570 patients have been enrolled from a screened population of around 1,200 TB patients, randomly assigned to receive either culturally adapted cognitive therapy alongside standard TB treatment or standard care alone.
The study is evaluating whether the intervention improves both mental health outcomes and adherence to anti-tuberculosis medication. Secondary outcomes under examination include anxiety, perceived stigma, quality of life, caregiver burden, traumatic stress, functional impairment, and cost-effectiveness.
Final results are expected following completion of six-month follow-up assessments at the end of June 2026.Beyond its clinical objectives, the programme has made a significant investment in Pakistan’s health research infrastructure. Of its total £4.7 million budget, approximately £3.1 million has been spent directly in Pakistan, generating employment for around 350 individuals, establishing a Clinical Trial Unit at KMU, and positioning major hospitals across KP as formal clinical research centres.
