Psychological and social risk factors and mental health interventions in tuberculous meningitis: A research progress

Abstract

Tuberculous meningitis (TBM), which accounts for 1%-5% of global tuberculosis cases, is a severe neurological infection with a mortality rate of 30%-50%. Its high fatality and disability rates disproportionately affect low- and middle-income regions (e.g., sub-Saharan Africa and Southeast Asia), threatening the lives of patients and imposing significant psychosocial burdens. Recent studies have highlighted the crucial role of psychosocial factors, including socioeconomic status, disease severity, and social support systems in recovery. However, research gaps persist in developing TBM-specific psychosocial interventions. This narrative review summarizes and organizes the key findings of observational studies, cohort studies, and intervention trials published between 2015 and 2024. Databases including PubMed, Scopus, and Web of Science were searched for terms related to TBM, psychosocial risk factors and mental health interventions. Studies were screened for relevance and quality, focusing on those that examined the psychological and social determinants of mental health outcomes in patients with TBM.

Key Words: Mental health; Social support; Mental health interventions; Psychosocial risk factors; Tuberculous meningitis

Core Tip: Tuberculous meningitis poses severe psychosocial risks, including depression and anxiety, exacerbated by low socioeconomic status and lack of social support. Effective interventions like cognitive behavioral therapy and community-based programs can improve mental health outcomes, especially in low-income regions. Integrating mental health services with tuberculosis control is crucial for comprehensive care.

INTRODUCTION

Although the clinical severity of tuberculous meningitis (TBM) is well-documented, emerging evidence highlights the influence of the underexplored role of psychosocial determinants on patient outcomes. This review aimed to move beyond pathophysiology to examine how socioeconomic adversity, social isolation, and cultural factors intersect and influence the mental health trajectory of survivors of TBM. We critically evaluated existing interventions and proposed a culturally sensitive, multidisciplinary framework for integrating mental healthcare into TBM management[1].

In patients with TBM, family dysfunction and lack of social support significantly affect their mental health. Studies have shown that individuals experiencing multiple psychological and social risk factors, such as poverty and social isolation, are more likely to develop mental health problems[2]. Based on these findings, clinicians should pay attention to the psychological and social backgrounds while treating the physiological symptoms of TBM, and develop comprehensive intervention measures

Several studies have indicated that mental health interventions, such as psychological counseling and cognitive behavioral therapy (CBT), can significantly enhance psychological adaptability and alleviate symptoms of depression and anxiety in patients with TBM. Psychological interventions targeting traumatized adolescents have been shown to improve mental health and promote social adaptability[3]. Mental health interventions not only improve patients’ psychological states but may also indirectly enhance their coping abilities by strengthening their social support networks. The cultural sensitivity of such interventions is a key factor in improving their effectiveness. Psychological and social factors manifest and function differently in various cultural contexts. Therefore, when designing mental health interventions for patients with TBM, it is necessary to consider their cultural backgrounds and social environments to develop more targeted strategies[4]. Such strategies can improve the acceptability of interventions and enhance their effectiveness in practical applications.

A systematic search of the PubMed and Web of Science databases was conducted on March 15, 2025, and restricted to English-language publications. The search strategy combined MeSH major topic and free-text terms: (“tuberculous meningitis” OR “TBM”) AND (“psychosocial” OR “mental health” OR “depression” OR “anxiety” OR “cognitive impairment” OR “social support” OR “intervention”).

The inclusion criteria were as follows: (1) Peer-reviewed original research published between January 1, 2015, and March 15, 2025; (2) Participants diagnosed with TBM according to the World Health Organization (WHO) or national guidelines; (3) Studies reporting quantitative or qualitative data on psychosocial risk factors or mental health interventions; and (4) No restrictions on age group or geographical setting. The exclusion criteria were as follows: (1) Animal or in vitro studies; (2) Articles focusing solely on microbiology, pharmacology, or imaging without addressing psychosocial or mental health outcomes; (3) Non-research articles, such as reviews, conference abstracts (lacking sufficient data); and (4) Duplicate publications. The final result showed that 31 studies fulfilled the inclusion criteria (Figure 1).

Figure 1 PRISMA flowchart detailing stages of the narrative review. WOS: Web of Science.

EPIDEMIOLOGY AND DISEASE BURDEN OF TBM

Global and regional epidemiological characteristics

TBM is a severe infectious disease with high mortality and disability rates, particularly among children and immunocompromised individuals. According to a 2019 study, approximately 24000 children (aged 0-14 years) were diagnosed with TBM globally, with only 13000 receiving treatment[5]. Among these, approximately 16100 children died from the disease in 2019, with approximately 68.3% remaining untreated. The global epidemiological characteristics of TBM show a significantly higher incidence in low- and middle-income countries, particularly in sub-Saharan Africa and Southeast Asia. Poor hygiene, scarce medical resources, and a high-prevalence of tuberculosis (TB) in these regions have led to a substantial increase in the incidence of TBM. Although TBM accounts for 1%-5% of all TB cases, its mortality rate is as high as 30%-50%[5-7]. The primary reason for this high mortality rate is the delayed diagnosis and treatment.

In sub-Saharan Africa, the prevalence of TBM is particularly high and strongly correlated with human immunodeficiency virus (HIV) infection. Studies have shown that the incidence of TBM is significantly higher in HIV-positive individuals than in HIV-negative individuals, with a mortality rate of TBM in HIV-co-infected patients reaching 70%[8]. Southeast Asia faces similar challenges with an increasing number of TBM cases, particularly in children and immunocompromised patients, resulting in high fatality and disability rates[9,10]. Global epidemiological studies have shown that the incidence and mortality rates of TBM are closely associated with socioeconomic factors. In economically underdeveloped countries, insufficient TB control measures, uneven distribution of medical resources, and lack of public health education have contributed to the high incidence and mortality rates of TBM[11,12]. Therefore, the epidemiological characteristics of TBM not only reflect the dangers of the disease itself but also reveal the vulnerability of the global public health system in addressing TB and its complications. To effectively address this public health challenge, countries need to strengthen early detection and treatment of TB, improve hygiene conditions, and promote public health education in high-prevalence areas to reduce the incidence and mortality of TBM.

The economic and psychological impact of the disease on patients and their families

TBM is a fatal infectious disease that imposes a significant economic and psychological burden on patients and their families. First, the long-term treatment costs of TBM often lead to increased financial strain on the families. According to a previous study, treatment requires prolonged medication, and patients may need to be hospitalized during treatment, thus increasing medical expenses[13]. In some low-income countries, families of patients with TBM often face higher economic pressures, as they not only have to cover medical costs but also consider income losses because of absenteeism from work[14]. Additionally, patients may be unable to work, leading to further financial stress, which exacerbates psychological stress and affects their overall quality of life[5].

Patients with TBM often suffer from neurological sequelae that can lead to a loss of labor capacity, profoundly impacting the family economy. Patients with TBM may experience neurological complications, such as cognitive impairment and motor function disorders, after rehabilitation, which not only affect their daily lives and social functioning but also limit their work capacity[12]. Studies have shown that a considerable proportion of TBM survivors experience long-term disabilities, which can significantly impact their careers and family financial situations[15]. For instance, many patients are unable to return to work even after treatment[16].

The diagnosis and treatment of TBM are often accompanied by significant psychological stress. Patients and their family members frequently experience negative emotions, such as anxiety and depression. Negative emotions are closely related to disease severity, treatment uncertainty, and challenges during the recovery process[10]. Patients may feel lonely and helpless during treatment. Their family members may also experience a substantial psychological burden in caring for them, thereby affecting the overall harmony and happiness of the family[17].

Consequently, psychological and economic interventions for patients with TBM and their families are of paramount importance. Medical institutions and social support systems should enhance psychological health support for patients and their families and provide the necessary economic assistance and resources to alleviate their burden and improve their quality of life[14,18]. Comprehensive intervention measures can effectively promote patient recovery, help them reintegrate into society, restore their labor capacity, and reduce economic pressure on families.

Sex disparities exist in the disease burden associated with TBM. A study by Martino et al[19] revealed that female patients were significantly more likely to be diagnosed with TB/HIV coinfection than male patients, indicating that females in certain high-burden regions may face a greater risk of developing TBM.

ANTECEDENT PSYCHOSOCIAL RISK FACTORS FOR MENTAL HEALTH COMORBIDITIES IN TBM

Psychosocial factors, including socioeconomic status (SES), mental health, educational level, family support, and social networks, play significant roles in the development and outcomes of TBM. These factors significantly influence disease progression and treatment effectiveness[5,20,21].

SES and educational level

SES and educational level can affect diagnosis and treatment. Individuals with low-income and educational levels are more prone to delays in diagnosis and treatment, which leads to poor health outcomes. Low-income patients, burdened by financial pressures, often hesitate to seek medical services and may even abandon treatment because of economic burdens, making timely medical care difficult to access and exacerbating the disease, thereby increasing the mortality rate[5].

A low educational level affects the ability of the patient to obtain and comprehend health information, as they lack essential knowledge and have insufficient understanding of the disease and treatment options. This may create a barrier to understanding the disease and treatment plans, which affects treatment adherence[22]. In contrast, patients with higher educational levels actively seek medical assistance and comply with treatment, potentially resulting in better prognoses.

Additionally, SES affects the mental health status of patients during TBM treatment. A study showed that patients from low socioeconomic backgrounds often face higher levels of psychological stress and anxiety, which, in turn, affect treatment outcomes and quality of life[23]. Therefore, improving economic conditions is necessary for enhancing mental health and promoting disease recovery.

The lack of social support systems

A 2023 cohort study found that 65% of patients with TBM with limited family support developed moderate-to-severe depression, compared with 22% in well-supported groups[16]. Social isolation further leads to treatment nonadherence, as seen in cases where stigma prevents patients from seeking community resources. Social support is crucial for patients' mental well-being because emotional and tangible assistance from families can effectively alleviate psychological burdens. Patients lacking family support tend to exhibit higher levels of depression and anxiety, which can negatively affect treatment adherence and may even lead to disease progression. The effectiveness of mental health interventions largely depends on the social support network of the patients. The absence of family involvement or emotional connections can further deteriorate the mental health status of a patient[12]. In addition, stigma within communities can result in the psychological isolation of patients. Misconceptions and stigmatization of TB can discourage patients from seeking help, leaving them feeling lonely and helpless, thereby intensifying psychological stress and anxiety[16]. Therefore, an inclusive community and strong family support and understanding are vital for patient recovery, as they can reduce psychological isolation and improve mental health. Enhancing public awareness and education about TB, reducing social stigma, and promoting the social integration of patients also improve overall treatment outcomes[15,20].

Disease severity and neurological sequelae

The severity of TBM is closely associated with neurological sequelae. Neurological conditions, such as paralysis and aphasia, can significantly increase the risk of anxiety and depression. These impairments not only affect the physical well-being of the patients but also can affect their mental health. Studies have shown that approximately 32% of child TBM survivors experience long-term neurological sequelae, including cognitive and motor function impairments, leading to difficulties in daily living and mental health challenges[16]. Furthermore, the mental health of children with TBM is significantly affected by the severity of their neurological impairments, and anxiety and depression symptoms are commonly observed[23].

Cognitive impairment further weakens the psychological adjustment of patients. Cognitive decline is closely associated with the mental state. This also applies to patients with TBM and has significant effects. Cognitive impairment also reduces the adaptability of the patients to life challenges, resulting in psychological issues[12,24]. Therefore, psychological interventions for patients with TBM should consider the profound effects of neurological sequelae on mental health and provide comprehensive support and treatment plans. In clinical practice, healthcare professionals should regularly assess the neurological and mental health status of patients with TBM to identify potential mental health issues. Intervention measures that integrate psychological support and cognitive training can help patients effectively adjust their mental states and improve their quality of life. Establishing a holistic care model can alleviate patients’ physical suffering and psychological distress, thereby enhancing overall treatment efficacy[25,26]. These risk factors combine to trigger acute and chronic mental health sequelae, as detailed in the next section.

COMMON MENTAL HEALTH ISSUES IN TBM PATIENTS

TBM has a high fatality rate and a propensity to cause long-term neurological complications. Additionally, the interplay between the gut microbiota and immune cells (e.g., macrophages) modulates systemic inflammation in patients with TBM, suggesting novel avenues for adjuvant therapies targeting microbial-immune crosstalk[27]. Therefore, mental health issues associated with TBM cannot be overlooked. According to one study, patients with TBM face various mental health challenges, including anxiety, depression, and cognitive impairment, which manifest differently across various disease stages and patient groups[5,12].

Anxiety and depression are the most common mental health problems among patients with TBM. Research indicates that the incidence of depression ranges from 30% to 50%, whereas anxiety disorders occur in 20%-40% of the cases. These conditions not only diminish the quality of life but also may adversely affect treatment outcomes. Confronted with the severity of the disease and the potential risk of death, patients often experience intense anxiety. Additionally, physical discomfort and prolonged hospitalization during treatment can lead to a depressed mood. Such psychological states not only impact the quality of life but may also negatively influence disease recovery[28]. Cognitive impairment is common in patients with TBMs. The disease and its complications, particularly cerebral inflammation, can lead to a decline in cognitive abilities. Studies have shown that patients with TBM may exhibit memory loss and difficulty concentrating after treatment. These cognitive impairments not only affect daily life but also have long-term consequences for social interactions and work capacity[12,21]. These sociopsychological factors cause psychological distress. For instance, research has shown that a lack of social support is negatively correlated with anxiety and depression. Therefore, enhancing social support may contribute to improved mental health[16]. Physicians should prioritize mental health issues of the patients and consider implementing appropriate psychological interventions to enhance their quality of life and optimize treatment effectiveness. To address these mental health challenges effectively, future research should focus on monitoring psychological states of the patients and evaluating the intervention strategies[10,17].

Acute psychological issues are typically triggered by sudden events or short-term stressors such as traumatic incidents or abrupt changes[29]. In contrast, chronic psychological problems are more often associated with long-term stressors or persistent life adversities, such as prolonged economic hardship, chronic illness, or ongoing family conflicts[30]. Acute psychological distress may produce short-term neurological responses, such as transient anxiety or depressive symptoms, whereas chronic psychological strain can lead to enduring neurobiological alterations, including sustained stress responses and neurotransmitter imbalances that underlie long-term depressive or anxiety disorders[31,32].

THEORETICAL FRAMEWORK FOR MENTAL HEALTH INTERVENTIONS

A theoretical framework for mental health interventions guides and optimizes the design and implementation of such interventions to enhance their effectiveness and sustainability. According to existing research, particularly in the context of mental health interventions for patients with TBM, constructing an effective theoretical framework is crucial. This framework should include various factors, such as an individual's psychosocial characteristics, family and social support, and cultural background.

First, they must focus on the psychosocial characteristics of individuals. Studies have shown that mental health status is closely related to life experiences and social support networks. For example, social isolation, low self-esteem, and traumatic life events can significantly affect mental health[5]. In the context of TBM, particularly in children, psychosocial interventions are particularly important because of the severity of the disease and the potential for long-term neurological sequelae. Therefore, tailored intervention strategies can be developed by assessing psychosocial characteristics. Second, the roles of family and social support should not be overlooked. In mental health interventions, family support can alleviate the anxiety and depression of patients and improve their treatment adherence[16]. Therefore, the framework should include strategies to enhance family support, such as education and training programs for family members to improve their understanding of mental health and their ability to support patients. The cultural background is a vital component of the theoretical framework. Cultures vary in their understanding and acceptance of mental health, which can influence the effectiveness of interventions. In certain cultures, mental health issues are stigmatized, discouraging individuals from seeking help[16]. Therefore, the framework should incorporate cultural sensitivity to improve patient acceptance and participation in the interventions. Finally, the framework must address the sustainability and evaluation of intervention measures. Studies have shown that the absence of systematic evaluation mechanisms can lead to suboptimal intervention outcomes and resource waste[20]. Detailed evaluation indicators should be established within the framework to monitor the intervention process and outcomes and provide a basis for future adjustments and enhancements.

Application of the biopsychosocial model

The biopsychosocial model (BPSM) is a crucial framework for understanding individual health and disease, emphasizing the interplay between biological, psychological, and social factors. This model provides a comprehensive approach to medical research and a theoretical foundation for multidisciplinary interventions. In TBM research, the application of this model is particularly significant, as the impact of the disease extends beyond the physiological realm to include mental health and social support.

A combination of biological, psychological, and social factors influences the occurrence and progression of TBM. In terms of biological factors, the mechanisms of Mycobacterium tuberculosis infection and immune status, such as immune deficiency caused by HIV, are closely associated with disease risk and progression. Genetic susceptibility and nutritional status may also play a role. Psychologically, mental health issues, such as anxiety and depression, are prevalent among patients, which can reduce treatment adherence and affect their quality of life. Psychological interventions, such as CBT, have demonstrated significant improvements in these conditions[21,22]. Social factors are equally critical because social support networks, economic conditions, and cultural backgrounds influence disease perception and treatment adherence. In resource-limited regions, patients with lower SES are more prone to delayed diagnosis and treatment obstacles[21,28]. Therefore, TBM interventions should integrate biomedical treatment, psychological support and social assistance to achieve optimal therapeutic outcomes. BPSM not only highlights the importance of multidisciplinary collaboration but also provides theoretical guidance for clinical practice, promoting the comprehensiveness and effectiveness of healthcare services. Further exploration and validation of the application of this model will enhance treatment outcomes and the quality of life of patients with TBM.

Adaptability of CBT

CBT can effectively alleviate emotional issues caused by diseases, such as anxiety and depression, helping patients cope better with the challenges of being unwell. For example, patients with TBM receiving CBT exhibit significant improvements in emotional and cognitive functions, particularly stress management and coping strategies[33]. This form of therapy is suitable for patients in high-income countries and has demonstrated positive results in low-income regions. In low-income areas, simplified versions of CBT, such as group CBT, have demonstrated significant efficacy. Through collective discussions and interactions, group CBT can effectively reduce individuals' sense of loneliness and provide social support, thereby enhancing their coping abilities[34]. Studies have indicated that in group settings, patients can share their experiences and support each other, improving treatment adherence and effectiveness. Furthermore, group CBT reduces the economic burden of treatment, enabling more patients to access the therapy. For patients in low-income regions, the adaptability and flexible implementation of CBT are advantageous. CBT can be delivered through face-to-face consultations, telephone counseling, or online platforms adapted to the needs and accessibility of the patients. Particularly in the post-pandemic era, as many mental health services have shifted to online platforms, the accessibility and application scope of CBT have expanded significantly, offering more convenient treatment options for patients in low-income regions[25]. Recent studies have highlighted the role of immune metabolic pathways in the prognosis of TBM. For instance, autophagy-dependent ferroptosis has been identified as a critical mechanism in infectious diseases, potentially influencing neuronal damage and therapeutic responses in patients[35].

EXISTING MENTAL HEALTH INTERVENTIONS AND THEIR EFFECTIVENESS

Psychological counseling and supportive therapy

Among existing mental health interventions, school- and community-based mental health education is considered effective. These interventions aim to raise awareness of mental health issues, reduce stigma, and provide necessary support. For instance, mental health promotion programs implemented among adolescents have demonstrated positive outcomes in reducing the incidence of depression and anxiety[36]. Psychological interventions tailored for patients with TBM have gained increasing attention. Studies have indicated that psychotherapy and social support can significantly improve patients’ mental well-being, thereby enhancing their quality of life and treatment adherence[12,15].

Additionally, digital interventions (e.g., mobile apps) have gained prominence during the coronavirus disease 2019 pandemic, offering remote support to 72% of patients with TBM in rural areas[37]. These interventions not only offer convenience but also mitigate the health risks associated with in-person interactions. Despite the increased accessibility of digital interventions, their effectiveness and patient acceptance remain areas of concern[38,39]. Some studies have suggested that trust and willingness to use digital interventions are influenced by cultural and social backgrounds, indicating the need to consider cultural adaptability when implementing these measures[40,41]. CBT is an evidence-based intervention that effectively addresses negative cognitive patterns (e.g., catastrophizing) and behavioral avoidance in patients with TBM. Studies have demonstrated that CBT reduces anxiety and depression symptoms by 40%-60% in low-resource settings[33], particularly through group formats that enhance social support[34]. Supportive psychotherapy can effectively relieve psychological distress in patients and enhance their cooperation with treatment by providing emotional support and establishing trustworthy relationships.

However, despite the significant effects of mental health interventions, challenges such as resource shortages, a lack of professionals, and low acceptance rates persist in their implementation. To further enhance the mental well-being of patients with TBM, multidisciplinary team collaboration should be strengthened, and mental health services should be integrated with medical care. This ensures that patients receive the necessary psychological support along with biomedical treatment, ultimately improving their overall treatment outcomes[42].

The application of BPSM in patients with TB highlights the importance of multidimensional treatment, including pharmacological therapy, psychological, and social interventions. A 2024 cross-sectional study conducted in Jordan found that mindfulness showed a significantly positive correlation with the psychological quality of life in patients with TB (r = 0.211, P < 0.05), suggesting that mindfulness training may help alleviate psychological distress[43]. Trauma-focused psychological interventions, such as CBT and Problem Management Plus, have been recommended by the WHO for use in patients with TB, highlighting their role in improving treatment adherence, reducing psychological distress, and enhancing quality of life[44]. To date, no study has applied the BPSM specifically in the context of TBM; further research is required to address this gap.

Combination of pharmacological treatment and psychological intervention

The combination of pharmacological treatments and psychological interventions has been increasingly emphasized in research. Mental health issues, such as depression, are prevalent among patients with TB, particularly those who have experienced severe illnesses. Therefore, a combined approach involving antidepressant medication and psychotherapy can effectively improve the overall health and quality of life of patients. The combination of antidepressants and psychotherapy can significantly enhance the treatment outcomes. For instance, research has indicated that patients receiving antidepressant medication in conjunction with psychotherapy exhibit greater improvement in anxiety and depression symptoms[20,21]. Psychotherapy can provide emotional support to patients, helping them better understand and cope with the psychological burden of their illness, thereby enhancing the effectiveness of pharmacological treatment. However, potential drug interactions must be carefully considered when integrating pharmacological and psychological interventions. For example, rifampicin, a medication commonly used in standard TB treatment regimens, significantly reduces the concentration of certain antidepressants, leading to diminished efficacy[12,23]. Therefore, physicians must meticulously review the medication histories of patients to avoid potential drug interactions and ensure the synergistic effects of pharmacological and psychological treatments. Furthermore, studies have indicated that although both pharmacological treatments and psychotherapy are effective in alleviating depressive symptoms, their mechanisms of action may differ. Antidepressants primarily alter neurotransmitter levels in the brain through biochemical pathways, whereas psychotherapy relies more on changes in cognition and emotions[45,46]. Patients who receive both treatments may experience improvements at both the biological and psychological levels, thereby achieving better overall treatment outcomes.

Community and peer support programs

Community and peer support programs have demonstrated their importance and effectiveness in studies on psychological and social support for patients with TBM. First, peer support groups can significantly reduce the sense of loneliness in patients, a finding that has been validated in numerous studies. Research indicates that patients participating in peer support groups often experience a stronger sense of social connection and belonging[47]. Emotional support from peers plays a positive role in recovery, as these groups provide a platform for sharing experiences in which patients can understand and encourage one another, thereby reducing their sense of isolation. Through these interactions, patients can jointly explore coping strategies and address mental health issues, thereby enhancing their psychological resilience and self-confidence[48].

Community health education is crucial for improving public awareness of TBM. Effective health education initiatives not only enhance the understanding of TBM but also reduce the stigma associated with the disease, encouraging patients to seek timely medical attention. For instance, community-organized health lectures and awareness campaigns have increased public knowledge of TBM symptoms, transmission routes, and preventive measures[49]. These educational programs typically utilize diverse communication channels, such as social media, posters, and face-to-face consultations, ensuring that information reaches a broad audience and improves the likelihood of early screening and timely treatment. Community and peer support models are of great significance in enhancing the overall quality of life and health outcomes[50]. Future research should explore and optimize these programs.

CHALLENGES AND INNOVATIONS IN MENTAL HEALTH INTERVENTIONS IN LOW-INCOME REGIONS

In low-income regions, mental health interventions face multiple challenges, including resource scarcity and weak medical infrastructure. Mental health services in these areas are often inaccessible and unaffordable, leaving many residents without timely and effective support for mental health issues. Research indicates that low- and high-stress environments significantly affect an individual’s mental health, particularly in cases of traumatic events or prolonged poverty[51]. Additionally, residents of low-income regions face heightened social discrimination and economic pressure, further increasing their mental health problems.

Community-based intervention strategies offer effective solutions to these challenges. By collaborating with local community organizations and leveraging existing resources, mental health services tailored to local cultural and contextual needs can be provided. For example, training community mental health workers could enhance their capacity to deliver primary mental health services and strengthen their ability to respond to mental health issues[52,53]. The application of digital health technology presents new opportunities for mental health interventions. Utilizing digital tools, such as mobile applications, online counseling, and social media platforms, can expand the reach of mental health services, making support accessible to a wider population[33,54]. Despite their scalability, digital tools face barriers in low-income regions, including low digital literacy (reported in 58% of cases) and unreliable Internet access[54]. Digital mental health interventions not only reduce costs but also improve flexibility and accessibility, with their advantages becoming increasingly evident during the pandemic[15,55]. However, several innovative measures face critical obstacles. For instance, insufficient funding and lack of policy support can limit the effective implementation of mental health services[56,57]. Cultural sensitivity and social acceptance are key factors that influence the success of interventions. Intervention measures tailored to the specific needs and contexts of communities can enhance resident participation and satisfaction, thereby improving the outcomes[51,58].

Globally, the management and treatment of TBM face resource and personnel shortages, particularly in mental health. The scarcity of mental health professionals affects treatment outcomes because the existing workforce is insufficient to meet demand, particularly in low- and middle-income countries. Medical systems in these countries often lack adequate personnel and leave patients without timely treatment support[5,12].

Telepsychological health services, such as telephone counseling and video conferencing, have shown significant potential. Research indicates that remote mental health interventions can substantially enhance patient accessibility and participation, with many patients relying on these services for psychological support and treatment during the pandemic[5,12]. For example, a study on adolescent mental health found that the convenience and flexibility of remote services enabled more adolescents to receive psychological therapy, particularly when face-to-face consultations were restricted[17,59]. However, the implementation of remote mental health services remains challenging. Many patients and providers lack proficiency in technology and digital literacy, which may compromise effectiveness. For some complex mental health issues, face-to-face interactions may be more effective because they can better capture nonverbal cues and emotional responses[60,61]. When promoting remote mental health services, it is essential to consider these limitations and improve technological accessibility and acceptance. In the long-term, addressing personnel shortages requires a comprehensive strategy that includes increasing the training and education of mental health professionals, advocating for policy reforms to support remote services, and providing personalized mental health support to patients from diverse backgrounds[17,62]. These measures could mitigate the impact of resource and personnel shortages, thereby enhancing the effectiveness of mental health interventions in patients with TBM.

The integration of cultural adaptability and localized interventions is crucial when responding to the psychological and social risk factors for TBM. Combining traditional treatment methods with Western psychotherapy can provide patients with treatment plans that align with their cultural backgrounds. The integration of traditional treatment methods with modern psychotherapeutic techniques can enhance patient acceptance and satisfaction. In some cultural contexts, traditional therapies, such as herbal medicine and spiritual healing, are still widely used, and the trust of the patients in these methods makes their integration with modern treatments an effective strategy[63,64].

Using local languages and case studies to enhance the acceptability of interventions is key to achieving cultural adaptability. Patients who receive psychotherapy in a familiar language with content relevant to their life experiences often exhibit higher participation rates and better treatment outcomes[17,65]. For example, the involvement of traditional healers not only strengthens the trust of patients in treatment but also, through the use of the patient’s mother tongue and cultural characteristics, makes the treatment closer to their actual needs[64].

FUTURE RESEARCH DIRECTIONS AND POLICY RECOMMENDATIONS

The necessity of multicenter clinical trials

The need for multicenter randomized controlled trials (RCTs) has become increasingly evident in studies on TBM interventions. First, although some intervention measures have been proposed and applied to certain patient groups, there is a lack of sufficient RCT data to validate their effectiveness. Research has indicated that the feasibility and effectiveness of intervention measures can only be ensured across different populations through systematic RCTs, thereby providing a solid basis for clinical practice[16]. Second, long-term follow-up is crucial for assessing the sustained effects of the intervention measures. Therefore, the effectiveness of short-term interventions may not reflect their long-term outcomes. For instance, initial improvements in TBM interventions may weaken or disappear over time. Therefore, multicenter RCTs must assess the immediate and long-term intervention effects, considering their impact on health over a broader timeframe. Long-term evaluations can assist clinicians in decision-making when developing treatment strategies[12]. Furthermore, multicenter clinical trials can enhance sample diversity and representation, thereby reducing the risk of biases. A more comprehensive understanding of the applicability and limitations of intervention measures can be achieved by conducting studies in different regions and populations. For example, one study demonstrated that a multicenter design was more effective in identifying variations in patient responses to the same intervention, thereby supporting the use of personalized medicine[15]. Finally, multicenter RCTs should promote closer collaboration between academia and clinical practice. Through cross-institutional collaboration, researchers can share resources, technologies, and data, improve research efficiency, and enhance the credibility and generalizability of the results. More resources and effort must be devoted to the design and implementation of multicenter RCTs to advance TBM research.

Integrating mental health services with TB control programs

As TB control efforts have progressed, TBM, the most severe form of TB, has garnered increasing attention. Therefore, integrating mental health services into TB control programs, particularly mental health screening and routine TBM care, is essential. Mental health issues are prevalent among patients with TBM and can significantly affect treatment outcomes and quality of life. Therefore, introducing mental health assessments into TBM care can provide a more comprehensive understanding of patient conditions and enable the development of personalized treatment strategies. Mental health issues are closely linked to the prognosis of TB, particularly in patients who are HIV-positive. Anxiety and depression can significantly reduce treatment adherence and quality of life in patients with TBM. Implementing mental health screening in routine TBM care can help identify psychological issues early, facilitate timely interventions to improve overall health, and enhance treatment outcomes and quality of life[16]. Policy support and funding are critical for expanding the service coverage. Many countries lack the resources to integrate mental health services into TB control measures. To effectively integrate these services, policy support and adequate funding are necessary to provide the essential training and resources. More locally adapted success stories are needed to inform ethical dimensions of digital health. Researchers and clinicians can take concrete steps, such as co-designing digital tools with affected communities, ensuring data privacy through end-to-end encryption, and using local languages to enhance accessibility and trust. Research indicates that medical institutions offering mental health training and support exhibit significantly higher service quality and patient satisfaction[66]. Governments and relevant organizations should establish clear policy frameworks to promote the effective integration of mental health services into TB control. More importantly, the integration of mental health services requires sufficient financial support to ensure their sustainability. Many countries have not adequately allocated funds for mental health services within their TB control budgets. By increasing investment in mental health services, medical institutions can form interdisciplinary teams and enhance their capacity to manage complex cases. This not only improves patient outcomes but also alleviates the burden on healthcare systems. In summary, the key to integrating mental health services with TB control lies in policy support and funding to regularize mental health screening, thereby improving the overall treatment outcomes and quality of life of patients with TBM.

This mini-review has some limitations. First, most of the included studies originated from high-TBM-burden regions (e.g., sub-Saharan Africa), limiting their generalizability to high-income countries. Second, heterogeneity in intervention designs (e.g., varying CBT protocols) precluded the meta-analysis. Third, reliance on observational studies introduces confounding bias, and few randomized trials have assessed long-term mental health outcomes. In addition, cultural variability in psychosocial measures complicates cross-study comparisons. Future studies should prioritize multicenter RCTs that use standardized metrics.

CONCLUSION

Key research findings on psychosocial risk factors and interventions in TBM are summarized in Table 1. Patients with TBM have multiple psychosocial risk factors that not only affect their physical health but also significantly increase the risk of mental health issues. A comprehensive analysis of existing research revealed that low SES, insufficient social support, and disease severity are the primary factors contributing to mental health problems among patients with TBM. These factors interact, leaving patients feeling isolated and helpless, reducing their ability to cope with the disease, and contributing to the onset of mental health issues such as depression, anxiety, and post-traumatic stress disorder.

Table 1 Key research findings on psychosocial risk factors and interventions in tuberculous meningitis.

Category	Key findings	Ref.
Psychosocial risk factors
Socioeconomic status	Low socioeconomic status correlates with delayed diagnosis and treatment abandonment. Patients from low-income backgrounds report higher psychological stress (e.g., anxiety)	[5,16,23]
Social support deficiency	65% of tuberculous meningitis patients with limited family support develop moderate-severe depression (vs 22% in well-supported groups). Stigma-driven social isolation reduces treatment adherence	[12,16,20]
Disease severity and sequelae	32% of pediatric tuberculous meningitis survivors experience long-term neurological sequelae (cognitive/motor impairments). Neurological deficits (e.g., paralysis) increase anxiety/depression risk	[12,16,24]
Effective interventions
Cognitive behavioral therapy	Reduces anxiety/depression symptoms by 40%-60% in low-resource settings. Group cognitive behavioral therapy enhances social support and cost-effectiveness	[33,34]
Digital interventions	72% of rural tuberculous meningitis patients accessed remote support via mobile apps during coronavirus disease 2019. Challenges: Low digital literacy (58%), unstable internet	[37,55]
Integrated pharmaco-psychological therapy	Antidepressants + psychotherapy synergistically improve mood symptoms. Caution: Rifampicin reduces antidepressant efficacy (drug interaction)	[12,20,23]
Community/peer support	Peer groups reduce loneliness and improve coping strategies. Community education reduces stigma, increases early care-seeking	[47,49,65]

When evaluating existing mental health interventions, CBT, psychological counseling, and community support programs have shown potential for improving the psychological state of patients with TBM. These adaptive interventions have demonstrated positive effects, particularly in low-income regions with limited resources. However, resource limitations and cultural differences are the two main obstacles. Owing to a lack of adequate social support and economic resources, many patients are unable to access the mental health services they require. Furthermore, cultural differences may reduce the acceptance of psychological interventions in patients, thereby affecting their effectiveness.

A multidisciplinary model integrating mental health services into TB control programs is critical for improving the prognosis and quality of life of patients with TBM, as demonstrated by pilot programs in South Africa, which achieved 40% higher treatment adherence.