Psychosocial factors associated with depression and sleep quality in patients with tuberculosis: a multicenter cross-sectional study.

Background: Patients with tuberculosis (TB) often experience stigma alongside emotional distress and impaired sleep quality. These difficulties tend to co-occur and interact, yet prior studies have usually examined them in isolation or assumed simple unidirectional relationships. This study aimed to examine the interrelationships among stigma, perceived stress, anxiety, depression, and sleep quality in Chinese patients with TB. Methods: A cross-sectional study was conducted among 584 adult patients with TB recruited from three tertiary hospitals in China between July 2023 and October 2024. Validated instruments were used to assess stigma, perceived stress, anxiety, depression, and sleep quality. Non-recursive structural equation modeling was applied to examine direct, indirect, and reciprocal relationships among these variables. Results: Higher levels of stigma were associated with more severe depression (β=0.165, P=0.002) and poorer sleep quality (β=0.323, P<0.001). These associations were both direct and indirect, mediated by increased perceived stress and anxiety. Perceived stress and anxiety served as key psychological pathways linking stigma to depression and sleep quality. Moreover, depression and sleep quality showed a reciprocal relationship, with significant paths from depression to sleep quality (β=0.179, P<0.001) and from sleep quality to depression (β=0.089, P<0.001). Conclusions: These findings suggest that stigma in patients with TB is embedded within a network of interconnected psychological distress and sleep problems. The reciprocal relationship between depressive symptoms and sleep implies that interventions targeting single symptoms domains may be insufficient. Integrated care strategies that address stigma, emotional distress, and sleep disturbances are likely to be more effective in improving patient-centered outcomes concurrently.