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Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review

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• Published: 20 August 2020
• volume  55 ,  pages 1397–1413 ( 2020 )

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• Andrea B. Martinez   ORCID: orcid.org/0000-0002-4437-769X 1 , 2 ,
• Melissa Co 3 ,
• Jennifer Lau 2 &
• June S. L. Brown 2  

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This systematic review aims to synthesise the evidence on behavioural and attitudinal patterns as well as barriers and enablers in Filipino formal help-seeking.

Using PRISMA framework, 15 studies conducted in 7 countries on Filipino help-seeking were appraised through narrative synthesis.

Filipinos across the world have general reluctance and unfavourable attitude towards formal help-seeking despite high rates of psychological distress. They prefer seeking help from close family and friends. Barriers cited by Filipinos living in the Philippines include financial constraints and inaccessibility of services, whereas overseas Filipinos were hampered by immigration status, lack of health insurance, language difficulty, experience of discrimination and lack of acculturation to host culture. Both groups were hindered by self and social stigma attached to mental disorder, and by concern for loss of face, sense of shame, and adherence to Asian values of conformity to norms where mental illness is considered unacceptable. Filipinos are also prevented from seeking help by their sense of resilience and self-reliance, but this is explored only in qualitative studies. They utilize special mental health care only as the last resort or when problems become severe. Other prominent facilitators include perception of distress, influence of social support, financial capacity and previous positive experience in formal help.

We confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as primary barrier, while resilience and self-reliance as coping strategies were cited in qualitative studies. Social support and problem severity were cited as prominent facilitators.

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Introduction.

Mental illness is the third most common disability in the Philippines. Around 6 million Filipinos are estimated to live with depression and/or anxiety, making the Philippines the country with the third highest rate of mental health problems in the Western Pacific Region [ 1 ]. Suicide rates are pegged at 3.2 per 100,000 population with numbers possibly higher due to underreporting or misclassification of suicide cases as ‘undetermined deaths’ [ 2 ]. Despite these figures, government spending on mental health is at 0.22% of total health expenditures with a lack of health professionals working in the mental health sector [ 1 , 3 ]. Elevated mental health problems also characterise ‘overseas Filipinos’, that is, Filipinos living abroad [ 4 ]. Indeed, 12% of Filipinos living in the US suffer from psychological distress [ 5 ], higher than the US prevalence rate of depression and anxiety [ 1 ]. Long periods of separation from their families and a different cultural background may make them more prone to acculturative stress, depression, anxiety, substance use and trauma especially those who are exposed to abuse, violence and discrimination whilst abroad [ 6 ].

One crucial barrier to achieving well-being and improved mental health among both ‘local’ and overseas Filipinos is their propensity to not seek psychological help [ 7 , 8 ]. Not only are help-seeking rates much lower than rates found in general US populations [ 9 ], they are also low compared to other minority Asian groups [ 10 ]. Yet, few studies have been published on Filipino psychological help-seeking either in the Philippines or among those overseas [ 11 ]. Most available studies have focused on such factors as stigma tolerance, loss of face and acculturation factors [ 12 , 13 ].

To date, no systematic review of studies on Filipino psychological help-seeking, both living in the Philippines and overseas, has been conducted. In 2014, Tuliao conducted a narrative review of the literature on Filipino mental health help-seeking in the US which provided a comprehensive treatise on cultural context of Filipino help-seeking behavior [ 11 ]. However, new studies have been published since which examine help-seeking in other country contexts, such as Norway, Iceland, Israel and Canada [ 6 , 14 , 15 , 16 ]. Alongside recent studies on local Filipinos, these new studies can provide basis for comparison of the local and overseas Filipinos [ 7 , 8 , 12 , 17 ].

This systematic review aims to critically appraise the evidence on behavioural and attitudinal patterns of psychological help-seeking among Filipinos in the Philippines and abroad and examine barriers and enablers of their help-seeking. While the majority of studies undertaken have been among Filipino migrants especially in the US where they needed to handle additional immigration challenges, studying help-seeking attitudes and behaviours of local Filipinos is important as this may inform those living abroad [ 10 , 13 , 18 ]. This review aims to: (1) examine the commonly reported help-seeking attitudes and behaviors among local and overseas Filipinos with mental health problems; and (2) expound on the most commonly reported barriers and facilitators that influence their help-seeking.

The review aims to synthesize available data on formal help-seeking behavior and attitudes of local and overseas Filipinos for their mental health problems, as well as commonly reported barriers and facilitators. Formal psychological help-seeking behavior is defined as seeking services and treatment, such as psychotherapy, counseling, information and advice, from trained and recognized mental health care providers [ 19 ]. Attitudes on psychological help-seeking refer to the evaluative beliefs in seeking help from these professional sources [ 20 ].

Eligibility criteria

Inclusion criteria for the studies were the following: (1) those that address either formal help-seeking behavior OR attitude related to a mental health AND those that discuss barriers OR facilitators of psychological help-seeking; (2) those that involve Filipino participants, or of Filipino descent; in studies that involve multi-cultural or multi-ethnic groups, they must have at least 20% Filipino participants with disaggregated data on Filipino psychological help-seeking; (3) those that employed any type of study designs, whether quantitative, qualitative or mixed-methods; (4) must be full-text peer-reviewed articles published in scholarly journals or book chapters, with no publication date restrictions; (5) written either in English or Filipino; and (6) available in printed or downloadable format. Multiple articles based on the same research are treated as one study/paper.

Exclusion criteria were: (1) studies in which the reported problems that prompted help-seeking are medical (e.g. cancer), career or vocational (e.g., career choice), academic (e.g., school difficulties) or developmental disorders (e.g., autism), unless specified that there is an associated mental health concern (e.g., anxiety, depression, trauma); (2) studies that discuss general health-seeking behaviors; (3) studies that are not from the perspective of mental health service users (e.g., counselor’s perspective); (4) systematic reviews, meta-analyses and other forms of literature review; and (5) unpublished studies including dissertations and theses, clinical reports, theory or methods papers, commentaries or editorials.

Search strategy and study selection

The search for relevant studies was conducted through electronic database searching, hand-searching and web-based searching. Ten bibliographic databases were searched in August to September 2018: PsychInfo, Global Health, MedLine, Embase, EBSCO , ProQuest , PubMed , Science Direct, Scopus and Emerald Insight. The following search terms were used: “help-seeking behavior” OR “utilization of mental health services” OR “access to mental health services” OR “psychological help-seeking” AND “barriers to help-seeking” OR “facilitators of help-seeking” AND “mental health” OR “mental health problem” OR “mental disorder” OR “mental illness” OR “psychological distress” OR “emotional problem” AND “Filipino” OR “Philippines”. Filters were used to select only publications from peer-reviewed journals. Internet searches through Google Scholar and websites of Philippine-based publications were also performed using the search term “Filipino mental health help-seeking” as well as hand-searching of reference lists of relevant studies. A total of 3038 records were obtained. Duplicates were removed and a total of 2659 records were screened for their relevance based on their titles and abstracts.

Preliminary screening of titles and abstracts of articles resulted in 162 potentially relevant studies, their full-text papers were obtained and were reviewed for eligibility by two reviewers (AM and MC). Divergent opinions on the results of eligibility screening were deliberated and any further disagreement was resolved by the third reviewer (JB). A total of 15 relevant studies (from 24 papers) published in English were included in the review and assessed for quality. There were seven studies with multiple publications (two of them have 3 papers) and a core paper was chosen on the basis of having more comprehensive key study data on formal help-seeking. Results of the literature search are reported in Fig.  1 using the PRISMA diagram [ 21 ]. A protocol for this review was registered at PROSPERO Registry of the Centre for Reviews and Dissemination of the University of York ( https://www.crd.york.ac.uk/PROSPERO ; ID: CRD42018102836).

PRISMA flow diagram

Data extraction and quality assessment

Data extracted by the main author were crosschecked by a second reviewer (JB). A data extraction table with thematic headings was prepared and pilot tested for two quantitative and two qualitative studies to check data comparability. Extraction was performed using the following descriptive data: (1) study information (e.g. name of authors, publication date, study location, setting, study design, measurement tools used); (2) socio-demographic characteristics of participants (e.g. sample size, age, gender); and (3) overarching themes on psychological help-seeking behavior and attitudes, as well as barriers and facilitators of help-seeking.

Two reviewers (AM and MC) did quality assessment of the studies separately, using the following criteria: (1) relevance to the research question; (2) transparency of the methods; (3) robustness of the evidence presented; and (4) soundness of the data interpretation and analysis. Design-specific quality assessment tools were used in the evaluation of risk of bias of the studies, namely: (1) Critical Appraisal Skills Programme Qualitative Checklist [ 22 ]; and (2) Quality Assessment Tool for Quantitative Studies by the Effective Public Health Practice Project [ 23 ]. The appraisals for mixed-methods studies were done separately for quantitative and qualitative components to ensure trustworthiness [ 24 ] of the quality of each assessment.

For studies reported in multiple publications, quality assessment was done only on the core papers [ 25 ]. All the papers ( n  = 6) assessed for their qualitative study design (including the 4 mixed-methods studies) met the minimum quality assessment criteria of fair ( n  = 1) and good ( n  = 5) and were, thus, included in the review. Only 11 out of the 13 quantitative studies (including the 4 mixed-methods studies) satisfied the minimum ratings for the review, with five getting strong quality rating. The two mixed-methods studies that did not meet the minimum quality rating for quantitative designs were excluded as sources of quantitative data but were used in the qualitative data analysis because they satisfied the minimum quality rating for qualitative designs.

Strategy for data analysis

Due to the substantial heterogeneity of the studies in terms of participant characteristics, study design, measurement tools used and reporting methods of the key findings, narrative synthesis approach was used in data analysis to interpret and integrate the quantitative and qualitative evidence [ 26 , 27 ]. However, one crucial methodological limitation of studies in this review is the lack of agreement on what constitutes formal help-seeking. Some researchers include the utilization of traditional or indigenous healers as formal help-seeking, while others limit the concept to professional health care providers. As such, consistent with Rickwood and Thomas’ definition of formal help-seeking [ 19 ], data extraction and analysis were done only on those that reported utilization of professional health care providers.

Using a textual approach, text data were coded using both predetermined and emerging codes [ 28 ]. They were then tabulated, analyzed, categorized into themes and integrated into a narrative synthesis [ 29 ]. Exemplar quotations and author interpretations were also used to support the narrative synthesis. The following were the themes on barriers and facilitators of formal help-seeking: (1) psychosocial barriers/facilitators, which include social support from family and friends, perceived severity of mental illness, awareness of mental health issues, self-stigmatizing beliefs, treatment fears and other individual concerns; (2) socio-cultural barriers/facilitators, which include the perceived social norms and beliefs on mental health, social stigma, influence of religious beliefs, and language and acculturation factors; and (3) systemic/structural and economic barriers/facilitators, which include financial or employment status, the health care system and its accessibility, availability and affordability, and ethnicity, nativity or immigration status.

Study and participant characteristics

The 15 studies were published between 2002 and 2018. Five studies were conducted in the US, four in the Philippines and one study each was done in Australia, Canada, Iceland, Israel and Norway. One study included participants working in different countries, the majority were in the Middle East. Data extracted from the four studies done in the Philippines were used to report on the help-seeking behaviors and attitudes, and barriers/facilitators to help-seeking of local Filipinos, while the ten studies conducted in different countries were used to report on help-seeking of overseas Filipinos. Nine studies were quantitative and used a cross-sectional design except for one cohort study; the majority of them used research-validated questionnaires. Four studies used mixed methods with surveys and open-ended questionnaires, and another two were purely qualitative studies that used interviews and focus group discussions. Only three studies recruited participants through random sampling and the rest used purposive sampling methods. All quantitative studies used questionnaires in measures of formal help-seeking behaviors, and western-standardized measures to assess participants’ attitudes towards help-seeking. Qualitative studies utilized semi-structured interview guides that were developed to explore the psychological help-seeking of participants.

A total of 5096 Filipinos aged 17–70 years participated in the studies. Additionally, 13 studies reported on the mean age of participants, with the computed overall mean age at 39.52 (SD 11.34). The sample sizes in the quantitative studies ranged from 70 to 2285, while qualitative studies ranged from 10 to 25 participants. Of the participants, 59% ( n  = 3012) were female which is probably explained by five studies focusing on Filipino women. Ten studies were conducted in community settings, five in health or social centre-based settings and 1 in a university (Table 1 ).

Formal help-seeking behaviors

12 studies examined the formal help-seeking behaviors of Filipinos (Table 2 ), eight of them were from community-based studies and four were from centre-based studies. Nine studies reported on formal help-seeking of overseas Filipinos and three reported on local Filipinos.

Community-based vs health/social centres Data from quantitative community studies show that the rates of formal help-seeking behaviors among the Filipino general population ranged from 2.2% [ 30 ] to 17.5% [ 6 ]. This was supported by reports from qualitative studies where participants did not seek help at all. The frequency of reports of formal help-seeking from studies conducted in crisis centres and online counseling tended to be higher. For instance, the rate of engagement in online counseling among overseas Filipinos was 10.68% [ 31 ], those receiving treatment in crisis centers was 39.32% [ 17 ] while 100% of participants who were victims of intimate partner violence were already receiving help from a women’s support agency [ 8 , 32 ].

Local vs overseas Filipinos’ formal help-seeking The rate of formal psychological help-seeking of local Filipinos was at 22.19% [ 12 ] while overseas rates were lower and ranged from 2.2% of Filipino Americans [ 30 ] to 17.5% of Filipinos in Israel [ 6 ]. Both local and overseas Filipinos indicated that professional help is sought only as a last resort because they were more inclined to get help from family and friends or lay network [ 7 , 16 ].

Attitudes towards formal help-seeking

13 studies reported on participants’ attitudes towards seeking formal help. Seven studies identified family and friends as preferred sources of help [ 7 , 14 , 16 ] rather than mental health specialists and other professionals even when they were already receiving help from them [ 17 , 32 ]. When Filipinos seek professional help, it is usually done in combination with other sources of care [ 13 ] or only used when the mental health problem is severe [ 14 , 16 , 33 ]. Other studies reported that in the absence of social networks, individuals prefer to rely on themselves [ 32 , 33 ].

Community-based vs health/social centres Community-based studies reported that Filipinos have negative attitudes marked by low stigma tolerance towards formal help-seeking [ 7 , 14 , 16 ]. However, different findings were reported by studies conducted in crisis centres. Hechanova et al. found a positive attitude towards help-seeking among users of online counseling [ 31 ], whereas Cabbigat and Kangas found that Filipinos in crisis centres still prefer receiving help from religious clergy or family members, with mental health units as the least preferred setting in receiving help [ 17 ]. This is supported by the findings of Shoultz and her colleagues who reported that Filipino women did not believe in disclosing their problems to others [ 32 ].

Local vs overseas Filipinos Filipinos, regardless of location, have negative attitudes towards help-seeking, except later-generation Filipino migrants who have been acculturated in their host countries and tended to have more positive attitudes towards mental health specialists [ 10 , 13 , 15 , 34 ]. However, this was only cited in quantitative studies. Qualitative studies reported the general reluctance of both overseas and local Filipinos to seek help.

Barriers in formal help-seeking

All 15 studies examined a range of barriers in psychological help-seeking (Table 3 ). The most commonly endorsed barriers were: (1) financial constraints due to high cost of service, lack of health insurance, or precarious employment condition; (2) self-stigma, with associated fear of negative judgment, sense of shame, embarrassment and being a disgrace, fear of being labeled as ‘crazy’, self-blame and concern for loss of face; and (3) social stigma that puts the family’s reputation at stake or places one’s cultural group in bad light.

Local vs overseas Filipinos In studies conducted among overseas Filipinos, strong adherence to Asian values of conformity to norms is an impediment to help-seeking but cited only in quantitative studies [ 10 , 13 , 15 , 34 ] while perceived resilience, coping ability or self-reliance was mentioned only in qualitative studies [ 14 , 16 , 33 ]. Other common barriers to help-seeking cited by overseas Filipinos were inaccessibility of mental health services, immigration status, sense of religiosity, language problem, experience of discrimination and lack of awareness of mental health needs [ 10 , 13 , 18 , 34 ]. Self-reliance and fear of being a burden to others as barriers were only found among overseas Filipinos [ 6 , 16 , 32 ]. On the other hand, local Filipinos have consistently cited the influence of social support as a hindrance to help-seeking [ 7 , 17 ].

Stigmatized attitude towards mental health and illness was reported as topmost barriers to help-seeking among overseas and local Filipinos. This included notions of mental illness as a sign of personal weakness or failure of character resulting to loss of face. There is a general consensus in these studies that the reluctance of Filipinos to seek professional help is mainly due to their fear of being labeled or judged negatively, or even their fear of fueling negative perceptions of the Filipino community. Other overseas Filipinos were afraid that having mental illness would affect their jobs and immigration status, especially for those who are in precarious employment conditions [ 6 , 16 ].

Facilitators of formal help-seeking

All 15 studies discussed facilitators of formal help-seeking, but the identified enablers were few (Table 4 ). Among the top and commonly cited factors that promote help-seeking are: (1) perceived severity of the mental health problem or awareness of mental health needs; (2) influence of social support, such as the presence/absence of family and friends, witnessing friends seeking help, having supportive friends and family who encourage help-seeking, or having others taking the initiative to help; and (3) financial capacity.

Local vs overseas Filipinos Studies on overseas Filipinos frequently cited financial capacity, immigration status, language proficiency, lower adherence to Asian values and stigma tolerance as enablers of help-seeking [ 15 , 30 , 32 , 34 ], while studies done on local Filipinos reported that awareness of mental health issues and previous positive experience of seeking help serve as facilitator [ 7 , 12 ].

Community-based vs health/social centres Those who were receiving help from crisis centres mentioned that previous positive experience with mental health professionals encouraged their formal help-seeking [ 8 , 17 , 31 ]. On the other hand, community-based studies cited the positive influence of encouraging family and friends as well as higher awareness of mental health problems as enablers of help-seeking [ 12 , 14 , 16 ].

To the best of our knowledge, this is the first systematic review conducted on psychological help-seeking among Filipinos, including its barriers and facilitators. The heterogeneity of participants (e.g., age, gender, socio-economic status, geographic location or residence, range of mental health problems) was large.

Filipino mental health help-seeking behavior and attitudes The rate of mental health problems appears to be high among Filipinos both local and overseas, but the rate of help-seeking is low. This is consistent with findings of a study among Chinese immigrants in Australia which reported higher psychological distress but with low utilization of mental health services [ 35 ]. The actual help-seeking behavior of both local and overseas Filipinos recorded at 10.72% ( n  = 461) is lower than the 19% of the general population in the US [ 36 ] and 16% in the United Kingdom (UK) [ 37 ], and even far below the global prevalence rate of 30% of people with mental illness receiving treatment [ 38 ]. This finding is also comparable with the low prevalence rate of mental health service use among the Chinese population in Hong Kong [ 39 ] and in Australia [ 35 ], Vietnamese immigrants in Canada [ 30 ], East Asian migrants in North America [ 41 ] and other ethnic minorities [ 42 ] but is in sharp contrast with the increased use of professional help among West African migrants in The Netherlands [ 43 ].

Most of the studies identified informal help through family and friends as the most widely utilized source of support, while professional service providers were only used as a last resort. Filipinos who are already accessing specialist services in crisis centres also used informal help to supplement professional help. This is consistent with reports on the frequent use of informal help in conjunction with formal help-seeking among the adult population in UK [ 44 ]. However, this pattern contrasts with informal help-seeking among African Americans who are less likely to seek help from social networks of family and friends [ 45 ]. Filipinos also tend to use their social networks of friends and family members as ‘go-between’ [ 46 ] for formal help, serving to intercede between mental health specialists and the individual. This was reiterated in a study by Shoultz et al. (2009) in which women who were victims of violence are reluctant to report the abuse to authorities but felt relieved if neighbours and friends would interfere for professional help in their behalf [ 32 ].

Different patterns of help-seeking among local and overseas Filipinos were evident and may be attributed to the differences in the health care system of the Philippines and their host countries. For instance, the greater use of general medical services by overseas Filipinos is due to the gatekeeper role of general practitioners (GP) in their host countries [ 47 ] where patients have to go through their GPs before they get access to mental health specialists. In contrast, local Filipinos have direct access to psychiatrists or psychologists without a GP referral. Additionally, those studies conducted in the Philippines were done in urban centers where participants have greater access to mental health specialists. While Filipinos generally are reluctant to seek help, later-generation overseas Filipinos have more positive attitudes towards psychological help-seeking. Their exposure and acculturation to cultures that are more tolerant of mental health stigma probably influenced their more favorable attitude [ 41 , 48 ].

Prominent barrier themes in help-seeking Findings of studies on frequently endorsed barriers in psychological help-seeking are consistent with commonly reported impediments to health care utilization among Filipino migrants in Australia [ 49 ] and Asian migrants in the US [ 47 , 50 ]. The same barriers in this review, such as preference for self-reliance as alternative coping strategy, poor mental health awareness, perceived stigma, are also identified in mental health help-seeking among adolescents and young adults [ 51 ] and among those suffering from depression [ 52 ].

Social and self-stigmatizing attitudes to mental illness are prominent barriers to help-seeking among Filipinos. Social stigma is evident in their fears of negative perception of the Filipino community, ruining the family reputation, or fear of social exclusion, discrimination and disapproval. Self-stigma manifests in their concern for loss of face, sense of shame or embarrassment, self-blame, sense of being a disgrace or being judged negatively and the notion that mental illness is a sign of personal weakness or failure of character [ 16 ]. The deterrent role of mental health stigma is consistent with the findings of other studies [ 51 , 52 ]. Overseas Filipinos who are not fully acculturated to the more stigma-tolerant culture of their host countries still hold these stigmatizing beliefs. There is also a general apprehension of becoming a burden to others.

Practical barriers to the use of mental health services like accessibility and financial constraints are also consistently rated as important barriers by Filipinos, similar to Chinese Americans [ 53 ]. In the Philippines where mental health services are costly and inaccessible [ 54 ], financial constraints serve as a hindrance to formal help-seeking, as mentioned by a participant in the study of Straiton and his colleagues, “In the Philippines… it takes really long time to decide for us that this condition is serious. We don’t want to use our money right away” [ 14 , p.6]. Local Filipinos are confronted with problems of lack of mental health facilities, services and professionals due to meager government spending on health. Despite the recent ratification of the Philippines’ Mental Health Act of 2018 and the Universal Health Care Act of 2019, the current coverage for mental health services provided by the Philippine Health Insurance Corporation only amounts to US$154 per hospitalization and only for acute episodes of mental disorders [ 55 ]. Specialist services for mental health in the Philippines are restricted in tertiary hospitals located in urban areas, with only one major mental hospital and 84 psychiatric units in general hospitals [ 1 ].

Overseas Filipinos cited the lack of health insurance and immigration status without health care privileges as financial barrier. In countries where people have access to universal health care, being employed is a barrier to psychological help-seeking because individuals prefer to work instead of attending medical check-ups or consultations [ 13 ]. Higher income is also associated with better mental health [ 56 ] and hence, the need for mental health services is low, whereas poor socio-economic status is related to greater risk of developing mental health problems [ 57 , 58 ]. Lack of familiarity with healthcare system in host countries among new Filipino migrants also discourages them from seeking help.

Studies have shown that reliance on, and accessibility of sympathetic, reliable and trusted family and friends are detrimental to formal help-seeking since professional help is sought only in the absence of this social support [ 6 , 8 ]. This is consistent with the predominating cultural values that govern Filipino interpersonal relationships called kapwa (or shared identity) in which trusted family and friends are considered as “hindi-ibang-tao” (one-of-us/insider), while doctors or professionals are seen as “ibang-tao” (outsider) [ 59 ]. Filipinos are apt to disclose and be more open and honest about their mental illness to those whom they considered as “hindi-ibang-tao” (insider) as against those who are “ibang-tao” (outsider), hence their preference for family members and close friends as source of informal help [ 59 ]. For Filipinos, it is difficult to trust a mental health specialist who is not part of the family [ 60 ].

Qualitative studies in this review frequently mentioned resilience and self-reliance among overseas Filipinos as barriers to help-seeking. As an adaptive coping strategy for adversity [ 61 ], overseas Filipinos believe that they were better equipped in overcoming emotional challenges of immigration [ 16 ] without professional assistance [ 14 ]. It supports the findings of studies on overseas Filipino domestic workers who attributed their sense of well-being despite stress to their sense of resilience which prevents them from developing mental health problems [ 62 ] and among Filipino disaster survivors who used their capacity to adapt as protective mechanism from experience of trauma [ 63 ]. However, self-reliant individuals also tend to hold stigmatizing beliefs on mental health and as such resort to handling problems on their own instead of seeking help [ 51 , 64 ].

Prominent facilitator themes in help-seeking In terms of enablers of psychological help-seeking, only a few facilitators were mentioned in the studies, which supported findings in other studies asserting that factors that promote help-seeking are less often emphasized [ 42 , 51 ].

Consistent with other studies [ 44 , 49 ], problem severity is predictive of intention to seek help from mental health providers [ 18 , 30 ] because Filipinos perceive that professional services are only warranted when symptoms have disabling effects [ 5 , 53 ]. As such, those who are experiencing heightened emotional distress were found to be receptive to intervention [ 17 ]. In most cases, symptom severity is determined only when somatic or behavioral symptoms manifest [ 13 ] or occupational dysfunction occurs late in the course of the mental illness [ 65 ]. This is most likely due to the initial denial of the problem [ 66 ] or attempts at maintaining normalcy of the situation as an important coping mechanism [ 67 ]. Furthermore, this poses as a hindrance to any attempts at early intervention because Filipinos are likely to seek professional help only when the problem is severe or has somatic manifestations. It also indicates the lack of preventive measure to avert any deterioration in mental health and well-being.

More positive attitudes towards help-seeking and higher rates of mental health care utilization have been found among later-generation Filipino immigrants or those who have acquired residency status in their host country [ 10 , 15 ]. Immigration status and length of stay in the host country are also associated with language proficiency, higher acculturation and familiarity with the host culture that are more open to discussing mental health issues [ 13 ], which present fewer barriers in help-seeking. This is consistent with facilitators of formal help-seeking among other ethnic minorities, such as acculturation, social integration and positive attitude towards mental health [ 43 ].

Cultural context of Filipinos’ reluctance to seek help Several explanations have been proposed to account for the general reluctance of Filipinos to seek psychological help. In Filipino culture, mental illness is attributed to superstitious or supernatural causes, such as God’s will, witchcraft, and sorcery [ 68 , 69 ], which contradict the biopsychosocial model used by mental health care professionals. Within this cultural context, Filipinos prefer to seek help from traditional folk healers who are using religious rituals in their healing process instead of availing the services of professionals [ 70 , 71 ]. This was reaffirmed by participants in the study of Thompson and her colleagues who said that “psychiatrists are not a way to deal with emotional problems” [ 74 , p.685]. The common misconception on the cause and nature of mental illness, seeing it as temporary due to cold weather [ 14 ] or as a failure in character and as an individual responsibility to overcome [ 16 , 72 ] also discourages Filipinos from seeking help.

Synthesis of the studies included in the review also found conflicting findings on various cultural and psychosocial influences that served both as enablers and deterrents to Filipino help-seeking, namely: (1) level of spirituality; (2) concern on loss of face or sense of shame; and (3) presence of social support.

Level of spirituality Higher spirituality or greater religious beliefs have disparate roles in Filipino psychological help-seeking. Some studies [ 8 , 14 , 16 ] consider it a hindrance to formal help-seeking, whereas others [ 10 , 15 ] asserted that it can facilitate the utilization of mental health services [ 15 , 73 ]. Being predominantly Catholics, Filipinos had drawn strength from their religious faith to endure difficult situations and challenges, accordingly ‘leaving everything to God’ [ 74 ] which explains their preference for clergy as sources of help instead of professional mental health providers. This is connected with the Filipino attribution of mental illness to spiritual or religious causes [ 62 ] mentioned earlier. On the contrary, Hermansdottir and Aegisdottir argued that there is a positive link between spirituality and help-seeking, and cited connectedness with host culture as mediating factor [ 15 ]. Alternately, because higher spirituality and religiosity are predictors of greater sense of well-being [ 75 ], there is, thus, a decreased need for mental health services.

Concern on loss of face or sense of shame The enabler/deterrent role of higher concern on loss of face and sense of shame on psychological help-seeking was also identified. The majority of studies in this review asserted the deterrent role of loss of face and stigma consistent with the findings of other studies [ 51 ], although Clement et al. stated that stigma is the fourth barrier in deterring help-seeking [ 76 ]. Mental illness is highly stigmatized in the Philippines and to avoid the derogatory label of ‘crazy’, Filipinos tend to conceal their mental illness and consequently avoid seeking professional help. This is aligned with the Filipino value of hiya (sense of propriety) which considers any deviation from socially acceptable behavior as a source of shame [ 11 ]. The stigmatized belief is reinforced by the notion that formal help-seeking is not the way to deal with emotional problems, as reflected in the response of a Filipino participant in the study by Straiton et. al., “It has not occurred to me to see a doctor for that kind of feeling” [ 14 , p.6]. However, other studies in this review [ 12 , 13 ] posited contrary views that lower stigma tolerance and higher concern for loss of face could also motivate psychological help-seeking for individuals who want to avoid embarrassing their family. As such, stigma tolerance and loss of face may have a more nuanced influence on help-seeking depending on whether the individual avoids the stigma by not seeking help or prevent the stigma by actively seeking help.

Presence of social support The contradictory role of social networks either as helpful or unhelpful in formal help-seeking was also noted in this review. The presence of friends and family can discourage Filipinos from seeking professional help because their social support serves as protective factor that buffer one’s experience of distress [ 77 , 78 ]. Consequently, individuals are less likely to use professional services [ 42 , 79 ]. On the contrary, other studies have found that the presence of friends and family who have positive attitudes towards formal help-seeking can promote the utilization of mental health services [ 8 , 80 ]. Friends who sought formal help and, thus, serve as role models [ 14 ], and those who take the initiative in seeking help for the distressed individual [ 32 ] also encourage such behavior. Thus, the positive influence of friends and family on mental health and formal help-seeking of Filipinos is not merely to serve only as emotional buffer for stress, but to also favourably influence the decision of the individual to seek formal help.

Research implications of findings

This review highlights particular evidence gaps that need further research: (1) operationalization of help-seeking behavior as a construct separating intention and attitude; (2) studies on actual help-seeking behavior among local and overseas Filipinos with identified mental health problems; (3) longitudinal study on intervention effectiveness and best practices; (4) studies that triangulate findings of qualitative studies with quantitative studies on the role of resilience and self-reliance in help-seeking; and (5) factors that promote help-seeking.

Some studies in this review reported help-seeking intention or attitude as actual behaviors even though they are separate constructs, hence leading to reporting biases and misinterpretations. For instance, the conflicting findings of Tuliao et al. [ 12 ] on the negative association of loss of face with help-seeking attitude and the positive association between loss of face and intention to seek help demonstrate that attitudes and intentions are separate constructs and, thus, need further operationalization. Future research should strive to operationalize concretely these terms through the use of robust measurement tools and systematic reporting of results. There is also a lack of data on the actual help-seeking behaviors among Filipinos with mental illness as most of the reports were from the general population and on their help-seeking attitudes and intentions. Thus, research should focus on those with mental health problems and their actual utilization of healthcare services to gain a better understanding of how specific factors prevent or promote formal help-seeking behaviors.

Moreover, the majority of the studies in this review were descriptive cross-sectional studies, with only one cohort analytic study. Future research should consider a longitudinal study design to ensure a more rigorous and conclusive findings especially on testing the effectiveness of interventions and documenting best practices. Because of the lack of quantitative research that could triangulate the findings of several qualitative studies on the detrimental role of resilience and self-reliance, quantitative studies using pathway analysis may help identify how these barriers affect help-seeking. A preponderance of studies also focused on discussing the roles of barriers in help-seeking, but less is known about the facilitators of help-seeking. For this reason, factors that promote help-seeking should be systematically investigated.

Practice, service delivery and policy implications

Findings of this review also indicate several implications for practice, service delivery, intervention and policy. Cultural nuances that underlie help-seeking behavior of Filipinos, such as the relational orientation of their interactions [ 81 ], should inform the design of culturally appropriate interventions for mental health and well-being and improving access and utilization of health services. Interventions aimed at improving psychological help-seeking should also target friends and family as potential and significant influencers in changing help-seeking attitude and behavior. They may be encouraged to help the individual to seek help from the mental health professional. Other approaches include psychoeducation that promotes mental health literacy and reduces stigma which could be undertaken both as preventive and treatment strategies because of their positive influence on help-seeking. Strategies to reduce self-reliance may also be helpful in encouraging help-seeking.

This review also has implications for structural changes to overcome economic and other practical barriers in Filipino seeking help for mental health problems. Newly enacted laws on mental health and universal healthcare in the Philippines may jumpstart significant policy changes, including increased expenditure for mental health treatment.

Since lack of awareness of available services was also identified as significant barrier, overseas Filipinos could be given competency training in utilizing the health care system of host countries, possibly together with other migrants and ethnic minorities. Philippine consular agencies in foreign countries should not merely only resort to repatriation acts, but could also take an active role in service delivery especially for overseas Filipinos who experience trauma and/or may have immigration-related constraints that hamper their access to specialist care.

Limitations of findings

A crucial limitation of studies in this review is the use of different standardized measures of help-seeking that render incomparable results. These measures were western-based inventories, and only three studies mentioned using cultural validation, such as forward-and-back-translations, to adapt them to cross-cultural research on Filipino participants. This may pose as a limitation on the cultural appropriateness and applicability of foreign-made tests [ 73 ] in capturing the true essence of Filipino experience and perspectives [ 74 ]. Additionally, the majority of the studies used non-probability sampling that limits the generalizability of results. They also failed to measure the type of assistance or actual support sought by Filipinos, such as psychoeducation, referral services, supportive counseling or psychotherapy, and whether or not they are effective in addressing mental health concerns of Filipinos. Another inherent limitation of this review is the lack of access to grey literature, such as thesis and dissertations published in other countries, or those published in the Philippines and are not available online. A number of studies on multi-ethnic studies with Filipino participants do not provide disaggregated data, which limits the scope and inclusion of studies in this review.

This review has confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as a primary barrier resilience and self-reliance as coping strategies were also cited, especially in qualitative studies, but may be important in addressing issues of non-utilization of mental health services. Social support and problem severity were cited as prominent facilitators in help-seeking. However, different structural, cultural and practical barriers and facilitators of psychological help-seeking between overseas and local Filipinos were also found.

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Martinez, A.B., Co, M., Lau, J. et al. Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review. Soc Psychiatry Psychiatr Epidemiol 55 , 1397–1413 (2020). https://doi.org/10.1007/s00127-020-01937-2

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• Posted on: 10 October 2022

Pinoy youth in worse mental shape today, nationwide survey indicates

Close to one in five Filipino youth aged 15-24 have ever considered ending their life. This is among the key findings of the 2021 Young Adult Fertility and Sexuality Study (YAFS5), the fifth in the series of nationwide surveys on Filipino youth led by the University of the Philippines Population Institute (UPPI) and funded by the Department of Health (DOH).

Participated in by 10,949 randomly selected youth aged 15-24, the study examined two sets of mental health indicators, namely depressive symptoms and suicidal experiences, which the YAFS study has tracked since 2002.

The UPPI found that the percentage of youth who often felt depressive symptoms in the reference week substantially increased from 2013 to 2021, with the share of those who often felt loneliness, sadness, and being disliked by other people almost doubling over the period (see Figure 1). Incidentally, data collection for YAFS5 was conducted in the middle of the COVID-19 pandemic, whereby physical and social isolation may have gravely affected young people’s disposition.

Similarly, the share of youth who have ever experienced suicide ideation and suicide attempt more than doubled between 2013 and 2021, and the corresponding percentages among female youth are twice as high as that of male youth. This reverses the trend that was observed between 2002 and 2013 (see Figures 2A and 2B).

In 2013, more than 574,000 or 3% of Filipino youth ever tried ending their life. In 2021, the percentage rose to 7.5%, equivalent to almost 1.5 million youth with such experience.

Unfortunately, six in 10 of those who ever thought of committing suicide did not reach out to anyone about it. The few who did so mostly sought help from close friends or peers (25% of suicide ideators), followed by parents/guardians (7%) and other relatives (5%). Even among those who acted on their suicidal thought, seeking professional help was highly unpopular (4%). In every 10 young adults, only one is aware of any suicide prevention program or service.

These alarming findings indicate that today’s youth have poorer mental well-being than in the last few decades. The reasons for this are many and complex, but as it is, multiple challenges, including severe understaffing, the cost of consultation and treatment, and the stigmatization of mental health problems confront mental healthcare in the country.

On World Mental Health Day, October 10, the UPPI is one with the global call for making mental health and well-being for all a priority in all sectors of society.

The national dissemination of the full key findings of the YAFS5 will be on Friday, 14 October 2022, at Park Inn by Radisson Hotel in Quezon City. We invite members of the press and interested organizations to be there.

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Psychological impact of COVID-19 pandemic in the Philippines

Michael l. tee.

a Department of Physiology, College of Medicine, University of the Philippines Manila, Taft Avenue, Manila 1000, Philippines

b Philippine One Health University Network

Cherica A. Tee

c Department of Pediatrics, College of Medicine, University of the Philippines Manila, Taft Avenue, Manila 1000, Philippines

Joseph P. Anlacan

d Department of Psychiatry and Behavioral Medicine, College of Medicine, University of the Philippines Manila, Taft Avenue, Manila 1000, Philippines

Katrina Joy G. Aligam

Patrick wincy c. reyes.

e School of Statistics, University of the Philippines Diliman, Philippines

Vipat Kuruchittham

f South East Asia One Health University Network

Roger C. Ho

g Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Kent Ridge 119228, Singapore

• • Students report moderate-to-severe psychological impact of the COVID-19 pandemic.
• • Timely and adequate health information has protective psychological effect.
• • Health care workers are less likely to be psychologically affected.
• • Home quarantine is associated with depression, anxiety and stress symptoms.

The 2019 coronavirus disease (COVID-19) pandemic poses a threat to societies’ mental health. This study examined the prevalence of psychiatric symptoms and identified the factors contributing to psychological impact in the Philippines.

A total of 1879 completed online surveys were gathered from March 28-April 12, 2020. Collected data included socio-demographics, health status, contact history, COVID-19 knowledge and concerns, precautionary measures, information needs, the Depression, Anxiety and Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) ratings.

The IES-R mean score was 19.57 (SD=13.12) while the DASS-21 mean score was 25.94 (SD=20.59). In total, 16.3% of respondents rated the psychological impact of the outbreak as moderate-to-severe; 16.9% reported moderate-to-severe depressive symptoms; 28.8% had moderate-to-severe anxiety levels; and 13.4% had moderate-to-severe stress levels.

Female gender; youth age; single status; students; specific symptoms; recent imposed quarantine; prolonged home-stay; and reports of poor health status, unnecessary worry, concerns for family members, and discrimination were significantly associated with greater psychological impact of the pandemic and higher levels of stress, anxiety and depression ( p <0.05).

Adequate health information, having grown-up children, perception of good health status and confidence in doctors’ abilities were significantly associated with lesser psychological impact of the pandemic and lower levels of stress, anxiety and depression ( p <0.05).

Limitations

An English online survey was used.

During the early phase of the pandemic in the Philippines, one-fourth of respondents reported moderate-to-severe anxiety and one-sixth reported moderate-to-severe depression and psychological impact. The factors identified can be used to devise effective psychological support strategies.

1. Introduction

The 2019 coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. It may follow the influenza pandemic of 1918 in magnitude which affected about one-third of the world population and killed 50 million. To date, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19 disease, has affected 213 countries and territories around the world with 14 million cases and half a million deaths ( WHO, 2020 ). Control efforts worldwide led to travel bans and restrictions. In the Philippines, President Rodrigo Duterte placed the entire Luzon archipelago on enhanced community quarantine on March 16, 2020 ( Official Gazette, 2020 ). Curfew, check-points and travel restrictions were implemented ( PCOO, 2020 ; Yap and Jiao, 2020 ). Business and school activities were suspended indefinitely. People were forced to stay in their homes.

Previous disease outbreaks caused generalized fear to the public and induced fear-related behaviors and anxiety ( Shultz et al., 2016 ; Person et al., 2004 ). With the novel coronavirus plaguing the world, there are so many uncertainties with the disease with a possibility of a fatal outcome. There were reported manifestations of distress, anxiety, depression, and insomnia in general populations ( Wang et al., 2020a ; Wang et al., 2020b ; Rajkumar, 2020b ). The systematic review and meta-analysis done by Salari et al. (2020) among the general populations in Asia and Europe showed that the prevalence of stress was 29.6% (95% confidence interval, 24.3-35.4), anxiety was 31.9% (95% CI, 27.5-36.7) and depression was 33.7% (95% CI, 27.5-40.6).

Infection or death of family and friends could worsen the overall mental health well-being of an individual ( Ahmed et al., 2020 ). Patients with confirmed or suspected COVID-19 may experience fear, while those in quarantine might experience boredom, loneliness, and anger ( Xiang et al., 2020 ). Overwhelming deep emotional traumas and socio-economic stressors brought about by the pandemic and the lockdowns have even led the more vulnerable people to commit suicide ( Mamun & Griffiths, 2020 ; Mamun & Ullah, 2020 ; Miller, 2020 ; Rajkumar, 2020a ).

It is imperative to determine the prevalence of adverse mental health issues in a society during this pandemic and mitigate its psychological risks and consequences. To date, there are no studies that examine the psychological impact of the COVID-19 pandemic to the general population in the Philippines. Therefore, this study aims to establish the prevalence of psychiatric symptoms and identify risk and protective factors contributing to psychological stress among social media users in the Philippines during the COVID-19 pandemic.

2.1. Participants and procedures

From 28 March to 12 April 2020, when the entire Luzon Islands of the Philippines was under enhanced community quarantine, an online survey in English language was disseminated through the social media using snowball sampling technique. The survey included information on socio-demographics, personal symptoms, contact history, knowledge and concerns about COVID-19, precautionary measures about COVID-19, information update on COVID-19, the validated Depression, Anxiety and Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) instrument ( Cheung et al., 2019 ; Lovibond and Lovibond, 1995 ; Creamer et al, 2003 ).

2.2. Ethics

This study was approved by the Research Ethics Board of the University of the Philippines Manila (UPMREB 2020-198-01).

2.3. Statistical analysis

Data analysis was performed using the SPSS Statistic 24.0 (IBM SPSS, New York, NY, USA). Frequency and percentage were applied to describe variables. The scores of IES-R and DASS-21 subscales were expressed as mean and standard deviation (SD). Association analysis using chi-square test was performed. P value < 0.05 was considered statistically significant.

There were 2037 completed surveys out of 2700 total respondents with a completion rate of 75.4%. Excluding 158 respondents who have a pre-existing neuropsychiatric condition, a total of 1879 responses were analyzed. Table 1 shows the demographic characteristics of the participants. The majority were females (69%), well-educated (68.5%, at least a bachelor's degree), residents of the Philippines (96.6%), single (63.7%), employed (61.4%), non-health care professionals (67.6%), with no children (65.8%) and members of household size of 3-5 people (54.4%). The mean age of respondents was 34.5 years (SD, 13.4 years).

Demographic variables and association with psychological impact ( n =1879).

3.1. Mental health status of respondents

Respondents’ depression, anxiety and stress levels, measured using DASS-21 scale, revealed a sample mean score of 25.94 (SD =20.59). For the depression subscale, 1338 (71.2%) were considered to have a normal score (score: 0-9); 224 (11.9%) reported mild depressive symptoms (score: 10-12); 239 (12.7%) moderate depressive symptoms (scores 13-20); and 78 (4.2%) reported severe to extremely severe depressive symptoms (score: 21-42). For the anxiety subscale, 1157 (61.6%) reported normal scores (score: 0-6); 181 (9.6%) reported mild anxiety symptoms (score: 7-9); 333 (17.7%) reported moderate anxiety symptoms (score: 10-14); and 208 (11.1%) reported severe to extremely severe anxiety symptoms (scores 15-42). For the stress subscale, 1131 (60.2%) reported normal scores (score <10); 496 (26.4%) reported mild stress signals (scores 11-18); 179 (9.5%) reported moderate stress signals (scores 19-26); and 73 (3.9%) reported severe to extremely severe stress signals (scores 27-42).

The psychological impact of COVID-19 outbreak, measured using the IES-R scale, revealed a sample mean score of 19.57 (SD, 13.12). Of all respondents, 1277 (68%) reported minimal psychological impact (score: 0-23); 296 (15.8%) rated mild psychological impact (score: 24-32); and 306 (16.3%) reported a moderate to severe psychological impact (score: >33).

3.2. Sociodemographic factors and association with psychological impact

Table 1 shows that male respondents had significantly lower scores for stress ( p =0.018), anxiety ( p =0.038) and IES-R ( p =0.015) compared to females. The young age group of 12-21.4 years, single people and those who had no children had significantly high stress, anxiety, depression and IES-R scores. The non-health care professionals (non-HCP) had significantly higher levels of stress ( p =0.034) and depression signals ( p =0.028) and higher IES-R score ( p =0.001) than health care professionals (HCP). Student status was associated with high anxiety subscale scores ( p <0.001). Respondents who had higher level of education (Masters/Doctorate) and had (a) child/ren older than 16 years old had significantly lower DASS stress subscale, DASS anxiety subscale, DASS depression subscale and IES-R scores ( p <0.05). The socio-demographic variables household size and residential country during the outbreak were not associated with IES-R and DASS subscale scores.

3.3. Physical health status and association with psychological impact

Table 2 tabulates the self-reported physical health status of the respondents. Only 1% of the sample had fever of at least 1 day within the 2 weeks prior to the survey and 0.4% had fever in combination with either cough or breathing difficulty. Other respondents reported chills (2.1%), headache (22.6%), body pain (11.1%), cough (14.4%), breathing difficulty (6.7%), dizziness (5.5%), sore throat (12.6%) and nausea, vomiting or diarrhea (3.1%). These symptoms were significantly associated with higher scores for IESR, DASS stress subscale, DASS anxiety subscale and DASS depression subscale. The presence of runny nose in 12.4% of participants is associated with higher score for DASS stress ( p <0.001), anxiety ( p <0.001) and depression ( p =0.002) subscales. About 51.4% of respondents reported no symptom for the past 2 weeks.

Physical health status and association with psychological impact ( n =1879).

Overall, 5% of respondents consulted with a doctor in the clinic in the past 14 days; 0.3% were hospitalized; 0.5% were tested for COVID-19; and 2% had recent quarantine by health authority. Majority of the respondents rated their current health status as good; 20.1% reported suffering from a chronic illness and 57.6% had medical insurance coverage.

Recent consultation with doctors in clinics, recent placement in quarantine by a health authority and poor to very poor current health status were associated with high scores in IES-R, DASS stress subscale, DASS anxiety subscale and DASS depression subscale. Having medical insurance coverage was associated with a lower DASS anxiety subscale score ( p =0.008).

3.4. Travel and contact history and association with psychological impact

In the two weeks prior to the survey, only 31 respondents (1.6%) had international travel history ( Table 3 ). There were 201 (10.7%) respondents who had direct or indirect contact with patients suffering from COVID-19; 56 (3%) had close contact with a confirmed case of COVID-19; 104 (5.5%) had indirect contact with a confirmed case; 88 (4.7%) had contact with a suspected case; and 29 (1.5%) had contact with infected materials. Among these variables, direct contact with a confirmed case of COVID-19 was associated with higher depression subscale score ( p =0.044).

Travel and contact history and association with psychological impact ( n =1879).

3.5. Knowledge and concerns about COVID-19 and association with psychological impact

The proportions of respondents who perceive that the routes of transmission of the virus for COVID-19 were via droplets, via contaminated objects and airborne were 98.6%, 96.7% and 35.3%, respectively ( Table 4 ). About 76.8% were satisfied to very satisfied with the amount of health information available. Almost all knew about current numbers of cases, deaths and recoveries from COVID-19. Information was mainly sourced from social media and internet by 77.9% of the respondents with an average of 0-9 hours screen time. Three-fourths of respondents had confidence in their own doctors’ ability to recognize COVID-19. About 40.3% felt they will likely contract COVID-19 during the outbreak. There were 85% of respondents who felt they will likely survive if infected with COVID-19. On concerns about other family members getting COVID-19, 60.7% were very worried and 33.3% somewhat worried. Half of the respondents were somewhat to very worried about a child younger than 16 years old getting the illness.

Knowledge and concerns about COVID-19 and association with psychological impact ( n =1879).

Very high satisfaction on the amount of health information available about COVID-19 was associated with low scores in IES-R, DASS stress subscale, DASS anxiety subscale and DASS depression subscale ( p <0.001). Dissatisfaction with available health information was associated with high anxiety level ( p <0.001). Those who have not heard about the number of recovered cases had significant high scores on DASS stress subscale ( p =0.003), DASS anxiety subscale ( p =0.005) and IES-R ( p =0.002).

The proportion of those who primarily obtain their information through the social media and internet had high levels of anxiety ( p <0.001) and depression signals ( p <0.001). Those who had their family members as the main source of health information had high stress signals ( p =0.045).

High level of confidence in their own doctors’ ability to diagnose COVID-19 was associated with low scores in DASS stress subscale ( p =0.017), DASS anxiety subscale ( p =0.001), DASS depression subscale ( p =0.006) and IES-R ( p =0.006) scores.

Those who reported not likely contracting COVID-19 during the outbreak are either normal or have mild symptoms of stress ( p =0.017), anxiety ( p =0.001), and depression ( p =0.035). The respondents who felt unlikely to survive a COVID-19 infection and who felt worried about family members getting COVID-19 had high scores on stress, anxiety and depression subscales and IES-R. Those who felt very worried about a child younger than 16 years old getting COVID-19 had a significantly high score for DASS anxiety subscale ( p =0.005).

Majority did not feel being discriminated against by other countries due to the outbreak. However, to those who felt discriminated against, they had significantly high scores for stress ( p =0.001), anxiety ( p <0.001), depression ( p =0.004) and IES-R ( p <0.001).

3.6. Precautionary measures against COVID-19 and association with psychological impact

The majority practiced the precautionary measures against COVID-19 in the 14 days prior to responding to the survey as shown in Table 5 . Majority of the respondents stayed at home for 20-24 hours a day to avoid COVID-19. About 35.5% of respondents almost always felt that too much worry had been made about COVID-19.

Precautionary measures in the past 14 days and association with psychological impact ( n =1879).

The practice of washing hands after touching contaminated objects and the wearing of masks regardless of the presence or absence of symptoms were associated with low stress scores ( p <0.05). While the practice of always washing hands with soap and water was associated with both low stress ( p =0.034) and anxiety ( p =0.007) scores.

The long hours of staying at home (20-24 hours) was associated with high scores in the anxiety ( p =0.026) and depression ( p =0.005) subscales. Those who always felt that there was too much unnecessary worry about COVID-19 had high scores for IES-R ( p <0.001), and subscale scores for stress ( p <0.001), anxiety ( p =0.002) and depression ( p <0.001).

3.7. Additional health information and association with psychological impact

Table 6 shows that 70% of respondents wanted additional health information about COVID-19. Those who wanted additional information, details on symptoms, advice on prevention and treatment, regular updates for latest information and for the outbreaks in their local area, advice for people who might need more tailored information, information on the availability and effectiveness of medicine/vaccine for COVID-19 and updates on the route of transmission of the virus were all associated with significantly high scores for DASS anxiety subscale and IES-R. Those who need latest updates on the number of people infected and their location, travel advice and updates on how other countries handle the outbreak were associated with significantly high anxiety scores ( p <0.05).

Additional health information required and association with psychological impact ( n =1879).

4. Discussion

This survey was conducted in the first month that COVID-19 was declared a pandemic and enhanced community quarantine was implemented in the Philippines. To our knowledge, this was the first study that examined the psychological impact of COVID-19 to the general population in the country. During this time, 16.3% of the respondents reported moderate to severe psychological impact; 16.9% of the respondents reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 13.4% reported moderate to severe stress signals. However, these levels were lower than the rates reported by Salari et al. (2020) which were 33.7%, 31.9% and 29.6% for depression, anxiety, and stress respectively. In China, the majority reported worse psychological impact with overall mean IES-R scores more than 24 points, indicating the presence of post-traumatic stress disorder symptoms ( Wang et al., 2020a ; Wang et al., 2020b ). Different populations in the world have been experiencing pandemic fear which can worsen feelings of anxiety that can lead to mental health disorders. Previous experiences of outbreaks like those caused by SARS, Ebola, and MERS-CoV contribute to heightening the impact of the present pandemic.

The study shows that females are more affected than males. The less educated, single people, children and adolescents, those who have no children reported high levels of stress, anxiety, depression and psychological impact. These subgroups, considered at greater risk for adverse psychological outcomes during a public health crisis, may be experiencing low social and emotional support, increased perceived threat to well-being and feelings of fear, isolation and uncertainty ( Perrin et al., 2009 ).

The students reported greater psychological impact as well as more depressive, anxiety and stress symptoms compared to those who are employed. The results were comparable to reports among the Chinese students ( Wang et al., 2020b ). Contributing factors include effects on daily life and routine, academic delays, and perhaps reduced social support ( Cao et al., 2020 ).

During pandemics, healthcare workers are at the front lines. They are subjected to long working hours, risk of infection, shortages of protective equipment, loneliness, exhaustion and separation from families ( Kang et al., 2020 ). They are at a significant risk of adverse mental health outcomes. However, our study shows that HCPs had lower levels of psychological impact, and symptoms of stress and depression than non-HCPs, comparable to the survey done among health care workers in Singapore ( Tan et al., 2020 ). This can be due to their strong sense of duty and ability to adapt to crisis. It can also be because the survey was done during the early parts of the pandemic when cases were still low and the health care system was not yet overwhelmed. As the pandemic ensues, mental health policies are needed to support our HCPs and other front-line workers.

In this study, most respondents rated their current health status as good. They feel that they are less likely to contract COVID-19 and more likely to survive the infection if they do get infected. They were also confident of their own doctors’ abilities. These perceptions seemed to be protective against adverse mental health state. It was reported that almost half of the respondents had at least one physical symptom within the last two weeks, but only 5% had a recent visit with their doctors for consultation. This disparity between symptoms suggestive of COVID-19 and health-seeking behavior may be due to factors like physical limitations caused by community quarantine, closed outpatient clinics, fear of getting infected in hospitals, and lack of public transportation. The presence of any of these symptoms and consequent imposed quarantine by a health authority was associated with psychological distress as also found among the Chinese population ( Wang et al., 2020a ). In severe instances where presence of symptoms cause social discrimination and avoidance, or lack of basic needs cause hopelessness, the more vulnerable individuals commit suicide ( Garger, 2020 ; Mamun and Griffiths, 2020 ; Rajkumar, 2020a ; Sher, 2020 ).

In the Philippines where universal health care is not yet fully implemented, the 60% of respondents who had medical health coverage had less anxiety symptoms as compared to those who had none. The government's health aid through the Philippine Health Insurance Corporation (2020) which assured to cover the full cost of COVID-19 hospitalization to its members may have had a positive effect on the public's mental health.

During the initial phase of the lockdowns in the Philippines, majority of the respondents spent an average of 0-9 hours on social media to derive information and news. Those who had access and were satisfied to updated information experienced less psychological impact and lower levels of stress, anxiety and depression. Still many express the need for additional and up-to-date information. They were showing signs of anxiety and moderate psychological impact which may lead to “headline stress disorder” ( Dong and Zeng, 2020 ). Shared information that is relevant and unambiguous may alleviate panic and stress ( Hiremath et al., 2020 ). A more consistent public education is needed to decrease uncertainties that are associated with more emotional reactions.

It appeared that those who practice hand hygiene and wear face masks as precautionary measures have protective effects on psychological status. Wearing a face mask is generally recognized to prevent a sick person from transmitting the virus while also protecting the wearer from getting infected. At the time of the survey, many establishments have imposed a “no mask-no entry” policy.

The restriction in social mobility to control the pandemic is stressful as it prevents face-to-face connections and traditional social interactions ( Zhang et al., 2020 ). Those who can go out like the workers who provide essential services exhibited less symptoms of anxiety and depression compared to those who stay 20 to 24 hours at home. Those who exhibit COVID-related symptoms or potential contacts of COVID were isolated and separated from loved ones. The imposed quarantine as seen in previous outbreaks has associated negative psychological effects that may be linked to fears of having the infection and spreading it to family members; frustration and boredom from being isolated; duration of uncertainty and scarcity of basic supplies ( Brooks et al., 2020 ). While isolation may be a necessary preventive measure, adequate information, opening lines of communication and provision of essential supplies to those confined may improve psychosocial outcomes ( Brooks et al., 2020 ).

The present study has some limitations. First, the survey was done online and administered in the English language. Majority of respondents were well educated with access to the internet. Second, the snowball sampling strategy was initiated within the social network of academicians and healthcare professionals and may not be representative of the general population. Third, the survey was rolled in the early phase of the pandemic and the psychological outcomes may change over the course of the public health crisis.

5. Conclusion

During the early phase of the COVID-19 pandemic in the Philippines, one-fourth of the respondents reported moderate-to-severe anxiety, one-seventh reported moderate-to-severe stress levels and one-sixth reported moderate-to-severe depression and psychological impact of the outbreak. Female gender, youth age of 12-21 years, single status, students, presence of specific physical symptoms (i.e., headache, cough, chills), recent imposed quarantine by a health authority, prolonged stay at home, poor self-reported health status, feeling of too much unnecessary worry has been made about COVID-19, concerns about family members getting sick, and feeling of being discriminated by other countries were associated with a greater psychological impact of the pandemic and higher levels of stress, anxiety and depression. Timely and accurate health information, having children older than 16 years old, perception of good health status and confidence in their own health care providers were associated with lesser psychological impact of the pandemic and lower levels of stress, anxiety and depression. The findings of this study can be used to frame appropriate psychological interventions to avert occurrence of mental health problems preventing psychological crisis.

Financial disclosure

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Michael L. Tee: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing - original draft, Writing - review & editing, Supervision, Project administration. Cherica A. Tee: Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing - original draft, Writing - review & editing, Supervision, Project administration. Joseph P. Anlacan: Validation, Formal analysis, Data curation, Writing - original draft, Writing - review & editing. Katrina Joy G. Aligam: Validation, Formal analysis, Data curation, Writing - original draft, Writing - review & editing. Patrick Wincy C. Reyes: Software, Validation, Formal analysis, Data curation, Writing - original draft, Writing - review & editing, Visualization. Vipat Kuruchittham: Conceptualization, Methodology, Software, Validation, Writing - original draft, Writing - review & editing. Roger C. Ho: Conceptualization, Methodology, Formal analysis, Writing - review & editing, Supervision.

Declaration of Competing Interests

The authors declare that there is no conflict of interest regarding the publication of this paper.

Acknowledgement

The Philippine One Health University Networks leaders, Dr. Nieta C. Amit - University of Eastern Philippines, Dr. Luz T. Simborio - Central Mindanao University, Dr. Marieta O. Amatorio - Benguet State University, Dr. Clarissa Yvonne J. Domingo - Central Luzon State University, Dr. Loinda R. Baldrias - University of the Philippines Los Baños, Dr. Asuncion K. Raymundo - University of the Philippines Los Baños, Dr. Bernadette C. Mendoza - University of the Philippines Los Baños, Dr. Renard M. Jamora - University of the Philippines Los Baños, Dr. Romeo S. Gundran - Central Luzon State University, Dr. Melbourne Talactac - Cavite State University and Dr. Maria Fe S. Bulao - Pampanga State Agricultural University

The South East Asian One Health University Network

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Prevention and Management of Mental Health Conditions in the Philippines: The Case for Investment

Prevention and Management of Mental health Conditions in the Philippines: The Case for Investment

October 14, 2021

Mental, neurological and substance use conditions, including depression, anxiety disorders, psychosis, epilepsy, dementia and alcohol-use disorders, pose a significant challenge in the Philippines. In 2017, the two most common mental health conditions, anxiety and depression, accounted for over 800 000 years of life lived with disability in the country, leading not only to vast human suffering but also to economic losses due to the impact on the workforce productivity. Reported suicide rates in the Philippines have been increasing over the past several decades, particularly among young people, with the latest estimate (in 2015) indicating 17% of young people aged 13–15 had attempted suicide. 

This report provides an assessment of the current mental health situation in the country – including challenges and opportunities for development of the mental health system – and economic evidence for the attributable and avertable burdens of a number of leading mental, neurological and substance use conditions (psychosis, bipolar disorder, depression, anxiety disorders, epilepsy and alcohol use disorders). Intervention costs, health gains and economic benefits were estimated for these six conditions and their treatment as well as for three population-based prevention interventions: universal and indicated school-based interventions for preventing depression and suicide and a nationwide regulatory ban on highly hazardous pesticides to prevent suicide. These interventions will have co-benefits for the development agenda, contributing to many of the Sustainable Development Goals (SDGs) other than target 3.4, “to reduce by 2030 by one third premature mortality from noncommunicable diseases (NCDs) and promote mental health and well-being”. 

Document Type

Regions and countries, sustainable development goals, related publications.

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Many Filipinos battle anxiety, depression due to COVID-19, work from home: study

Katrina domingo, abs-cbn news.

Posted at Aug 10 2021 01:43 PM

MANILA - The Department of Health (DOH) on Tuesday said a quarter of Filipinos are having "moderate to severe" anxiety issues due to the COVID-19 pandemic and working from home.

This according to a 2020 study from the University of the Philippines involving 1,879 respondents, which showed that a sixth of respondents were also reported to have moderate to severe depression, said Dr. Agnes Joy Casiño, psychiatrist and technical consultant of the DOH Mental Health Division.

"Mayroong ibang nahihirapan if they are wearing different hats... Nahihirapan kapag hindi nila name-maintain 'yung work-life balance," she said.

(Some are having a hard time if they are wearing different hats... They are having a hard time when they cannot maintain work-life balance.)

For some Filipinos, being at home for 24 hours has blurred the line between personal and professional functions, she said.

"'Yung commute to work, it sets the tone na papunta ako ng trabaho (that I am going to work)... Psychologically, you are prepared that you are going to work," Casiño said.

"Because of work from home, nawala 'yun. Hindi ka psychologically prepared," she said.

(That was gone because of work from home. You are not psychologically prepared.)

• Work-from-home set-ups seen staying even after pandemic: CEO survey

Other people's mental health issues have either worsened or came to light as the COVID-19 pandemic stripped them of coping mechanisms, the psychiatrist said.

"Dati (Before) they can cope. They can go to the movies. They can go on vacation... Nawala 'yung other means nila of coping kaya lumalabas talaga 'yung mga issues," she said.

(Their other means of coping are gone that's why issues are surfacing.)

• Right to disconnect gains ground as pandemic brings work home

The DOH has yet to release more details about the socioeconomic profiles of Filipinos battling mental health difficulties during the COVID-19 pandemic, but Casiño noted that women are usually more open to seeking professional help or counseling.

"'Yung theory is that women kasi are more in tune sa feelings and are open to talking about it," she said.

(The theory is that women are more in tune with their feelings and are more open to talking about it.)

"Men don't tend to reach out until nandoon na sila sa point na hindi na nila kinakaya," she said.

(Men don't tend to reach out until they reach the point that they can no longer take it.)

Casiño said workers should not hesitate to inform their employers about their mental health concerns as the Department of Labor and Employment as well as the Civil Service Commission issued an earlier policy directing establishments to provide mental wellness programs and assistance for their employees.

• PH firms emphasize employee well-being as stress rises during pandemic, survey finds

"It is not a reflection that you are not doing your job," she said.

"We are not just grieiving those who died from COVID-19. Some are grieving because we lost our dreams, we lost our ambitions... We lost the previous life that we led," she said.

"This is a universal grieving on a large scale."

The DOH consultant advised those experiencing mental health issues to talk about their problems or vent to family and friends, exercise to boost happy hormones, and show kindness during these difficult times.

"We have to remember to be kind, to be kind to ourselves and to be kind to others."

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Case Study Hub | Samples, Examples and Writing Tips

Case study on depression in psychology, case study on depression in psychology:.

Depression is the psychological condition of the human organism which is characterized with the low mood, constant negative emotions and the specific negative treatment of the world. Depression is the most widespread psychological problem of the modern time and it is natural, because people live in the dynamic world which attacks them with information all the time, that is in the major part negative and the human organism reflects the same.

It is obvious that there are many factors, which can cause depression. To begin with, the constant stress and complete exhaustion of the organism can cause the state of low mood, because the person is oppressed by the surrounding world and the problems which occur there all the time. Next, if something bad happens with the human relatives, friends, close people, the human psychics can react in the negative way of depression.

We can write a Custom Case Study on Depression in Psychology for you!

Such problem as love affair is surely one of the most serious ones, because the person suffers emotional pain which can gradually transform into depression if she does not organize herself or if no one helps her to cope with it. Finally, problems at work and financial troubles are also the important factors, as nowadays one can not survive without money and if one has bankrupted, he will surely stress because of it. The most effective ways to cure depression in the psychological aspect is to help the patient rather in the emotional way. The patient should have a good rest, reveal his problems to the specialism, start leading an active way of life (sports, hobbies) and only in the complicated cases take antidepressants and the related medicine.

Depression is a complicated problem which requires professional help of the experienced psychologists and if one is writing a depression in psychology case study, he would have to spend much time to learn about the problem a lot. A good case study is a profound research on the definite case on depression and its psychological solution. One is expected to find the facts about the cause and the consequences of the problem, its complexity and solution. In order to demonstrate knowledge the student is obliged to evaluate the acquired facts objectively and suggest his own alternative solution to the given problem on depression.

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Case Study on Depression

A clear picture of the causes of depression and real ways of overcoming it is still missing.

Psychotherapy has not developed effective methods of combating depression, although it uses the results of studies of such sciences as neurobiology, sociology, biology and general medicine. Therefore, conducting a depression case study in the framework of psychotherapy gives scientists the opportunity to build hypotheses in different directions.

The Current Situation

Meanwhile, the scale of the problem is enormous. Doctors have long recognized depression as a disease of the century – it affects ten percent of the world’s population. Every year up to 800 thousand people in the world, decide to commit suicide because of this scourge.

Here we can see the practical application of a case study depression. The scientific development of this problem and the development of ways to overcome this disease will help to save a really large number of people.Acasestudy is a professional case study writing service ! We write only the best and unique works!In the past two decades, this condition has grown to the level of not only the most important medical, but also socioeconomic problem. As predicted by experts, by 2020, depression will occupy the second place among all human diseases. Neither living well-being nor high incomes nor stable economy protect from it- the prevalence of depression is high in both low-income and rich strata of the population, both in developing and in economically prosper countries.

This makes a psychological case study on depression even more ambiguous and contradictory.

Main Theories Why Depression Occurs

To date, there is no unified theory and understanding of why this disorder occurs. More than ten theories and basic scientific research are trying to explain the causes of this painful condition. All available theories, paradigms can be conditionally divided into two groups. The first one is biological.

Biological Theory

From biological theories, the most proven for today is the genetic predisposition.

The essence of the teaching is that somewhere in the genus of the patient at the genetic level there was a failure, which is inherited. This “erroneous” predisposition is inherited and may be more likely to manifest itself under a certain confluence of life circumstances (stress factors, prolonged stay in conflict, chronic illness, alcoholism, etc.).

One Real Example

jpg” alt=”Case Study on Depression” width=”2000″ height=”1000″ />Winston Churchill is one of the examples that prove this theory. So conducting a case study depression patient on the basis of his personality makes sense. When we talk about Churchill, we think of a great man with extraordinary abilities, who had a sharp mind and a great sense of honor. But few people know that the Prime Minister of Great Britain suffered from serious clinical depression. In the Churchill family, five of the seven last Dukes of Marlborough suffered from severe melancholy.

Pathologically burdened heredity not only determined the ups and downs of the mood of the greatest English politician but also influenced his political activity. Affective disorders in a noble family had a different cause. Churchill’s father, a member of the House of Commons and Chancellor of the Treasury, contracted syphilis long before his startling career. When the disease reached its climax, he began hallucinations, which often caused confusion and horror among others. Progressive paralysis led him to death at the age of 45 years.

 His mother, the daughter of a wealthy American businessperson, grew up a very nervous child and was considered one of the most beautiful women of her time. The genetic predisposition to pathologies also affected the fate of Churchill’s daughters. The eldest, Diana (1909), in 1953, fell into a long depression and, without a noticeable improvement in her condition, moved from one psychiatric clinic to another. And not recovered, began to seek consolation in alcohol. In the end, in 1963 she committed suicide.

Younger daughter Sarah also suffered from alcohol dependence.Read also  HR Management Case Study  AssignmentChurchill himself could work day and night during the ascent. He was unusually versatile, even universal, and tireless in his work, continuously writing letters, books and making speeches, impatient, impulsive and irritable, brave to imprudence, boundlessly authoritarian. In conformity with his own confessions, he had a two or three year period of depression in his youth with thoughts of suicide. The second period of depression was observed at the age of 31-32 years, and the third – at 45 years, when he even refrained from reading and talking with others.

Psychological Theory

Another group of theories of understanding the disease refers to the so-called psychological or socio-psychological approaches. Here the explanation of the onset and course of the disease is based on studying the problems of patient communication, the characteristics of his personality, the psychological problems of his growing up, living in the present, the level of stress.Therefore, a case study for depression is a difficult task. Researchers are faced with a large number of theories and hypothesis, and each of them has a right to exist. Depression is a very ambiguous condition, and a very large number of people are susceptible to this disease due to various factors.;

Related posts:

• Case study on Joseph Wesbecker’s major depression.
• Case study depression
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• Short Essay on Depression
• Case Study on Adolescent Depression
• Case Study on Clinical Depression

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BRIEF RESEARCH REPORT article

This article is part of the research topic.

Women in Psychiatry 2023: Perinatal Psychiatry

Automated Classification of Lay Health Articles Using Natural Language Processing: A Case Study on Pregnancy Health and Postpartum Depression

• 1 Weill Cornell Medical Center, NewYork-Presbyterian, United States
• 2 Kingsborough Community College, United States

The final, formatted version of the article will be published soon.

Objective: Evidence suggests that high-quality health education and effective communication within the framework of social support hold significant potential in preventing postpartum depression. Yet, developing trustworthy and engaging health education and communication materials requires extensive expertise and substantial resources. In light of this, we propose an innovative approach that involves leveraging natural language processing (NLP) to classify publicly accessible lay articles based on their relevance and subject matter to pregnancy and mental health.We manually reviewed online lay articles from credible and medically validated sources to create a gold standard corpus. This manual review process categorized the articles based on their pertinence to pregnancy and related subtopics. To streamline and expand the classification procedure for relevance and topics, we employed advanced NLP models such as Random Forest, Bidirectional Encoder Representations from Transformers (BERT), and Generative Pre-trained Transformer model (gpt-3.5-turbo).The gold standard corpus included 392 pregnancy-related articles. Our manual review process categorized the reading materials according to lifestyle factors associated with postpartum depression: diet, exercise, mental health, and health literacy. A BERT-based model performed best (F1=0.974) in an end-to-end classification of relevance and topics. In a two-step 1 Patra et al.approach, given articles already classified as pregnancy-related, gpt-3.5-turbo performed best (F1=0.972) in classifying the above topics.Discussion: Utilizing NLP, we can guide patients to high-quality lay reading materials as costeffective, readily available health education and communication sources. This approach allows us to scale the information delivery specifically to individuals, enhancing the relevance and impact of the materials provided.

Keywords: Online health information, Health Communication, Natural Language Processing, Pregnancy, postpartum depression

Received: 14 Jul 2023; Accepted: 25 Oct 2023.

Copyright: © 2023 Patra, Sun, Cheng, Kumar, Altammami, Liu, Joly, Jedlicka, Delgado, Pathak, Peng and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. Yiye Zhang, Weill Cornell Medical Center, NewYork-Presbyterian, New York City, United States

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Meta's Instagram linked to depression, anxiety, insomnia in kids - US states' lawsuit

• Meta Platforms Inc Follow
• Alphabet Inc Follow

Oct 24 (Reuters) - Dozens of U.S. states are suing Meta Platforms (META.O) and its Instagram unit, accusing them of fueling a youth mental health crisis by making their social media platforms addictive.

In a complaint filed on Tuesday, the attorneys general of 33 states including California and New York said Meta, which also operates Facebook, repeatedly misled the public about the dangers of its platforms, and knowingly induced young children and teenagers into addictive and compulsive social media use.

"Meta has harnessed powerful and unprecedented technologies to entice, engage, and ultimately ensnare youth and teens," according to the complaint filed in the Oakland, California federal court. "Its motive is profit."

Children have long been an appealing demographic for businesses, which hope to attract them as consumers at ages when they may be more impressionable, and solidify brand loyalty.

For Meta, younger consumers may help secure more advertisers who hope children will keep buying their products as they grow up.

But the states said research has associated children's use of Meta's social media platforms with "depression, anxiety, insomnia, interference with education and daily life, and many other negative outcomes."

Meta said it was "disappointed" in the lawsuit.

"Instead of working productively with companies across the industry to create clear, age-appropriate standards for the many apps teens use, the attorneys general have chosen this path," the company said.

Eight other U.S. states and Washington, D.C. are filing similar lawsuits against Meta on Tuesday, bringing the total number of authorities taking action against the Menlo Park, California-based company to 42.

Meta shares fell 0.6% on the Nasdaq.

TIKTOK, YOUTUBE ALREADY FACE LAWSUITS

The cases are the latest in a string of legal actions against social media companies on behalf of children and teens.

Meta, ByteDance's TikTok and Google's (GOOGL.O) YouTube already face hundreds of lawsuits filed on behalf of children and school districts about the addictiveness of social media.

Mark Zuckerberg, Meta's chief executive, has defended in the past his company's handling of content that some critics find harmful.

[1/3] Children playground miniatures are seen in front of displayed Instagram logo in this illustration taken April 4, 2023. REUTERS/Dado Ruvic/Illustration/File Photo Acquire Licensing Rights

"At the heart of these accusations is this idea that we prioritize profit over safety and well-being. That's just not true," he posted in October 2021 on his Facebook page.

In Tuesday's cases, Meta could face civil penalties of $1,000 to $50,000 for each violation of various state laws -- an amount that could add up quickly given the millions of young children and teenagers who use Instagram.

Much of the focus on Meta stemmed from a whistleblower's release of documents in 2021 that showed the company knew Instagram, which began as a photo-sharing app, was addictive and worsened body image issues for some teen girls.

The lawsuit by the 33 states alleged that Meta has strived to ensure that young people spend as much time as possible on social media despite knowing that they are susceptible to the need for approval in the form of "likes" from other users about their content.

"Meta has been harming our children and teens, cultivating addiction to boost corporate profits," said California Attorney General Rob Bonta, whose state includes Meta's headquarters.

'THREATS THAT WE CAN'T IGNORE'

States also accused Meta of violating a law banning the collection of data of children under age 13, and deceptively denying that its social media was harmful.

"Meta did not disclose that its algorithms were designed to capitalize on young users' dopamine responses and create an addictive cycle of engagement," the complaint said.

Dopamine is a type of neurotransmitter that plays a role in feelings of pleasure.

According to the complaint, Meta's refusal to accept responsibility extended last year to its distancing itself from a 14-year-old girl's suicide in the UK, after she was exposed on Instagram to content about suicide and self-injury.

A coroner rejected a Meta executive's claim that such content was "safe" for children, finding that the girl likely binged on harmful content that normalized the depression she had felt before killing herself.

States also alleged Meta is seeking to expand its harmful practices into virtual reality, including its Horizon Worlds platform and the WhatsApp and Messenger apps.

By suing, authorities are seeking to patch holes left by the U.S. Congress' inability to pass new online protections for children despite years of discussions.

Colorado Attorney General Philip Weiser said the whistleblower's revelations showed that Meta knew how Facebook and Instagram were harming children.

"It is very clear that decisions made by social media platforms, like Meta, are part of what is driving mental health harms, physical health harms, and threats that we can't ignore," he said.

Reporting by Jonathan Stempel in New York, Diane Bartz and David Shepardson in Washington, D.C., and Nate Raymond in Boston; Editing by Chris Sanders, Rod Nickel and Lisa Shumaker

Our Standards: The Thomson Reuters Trust Principles.

Thomson Reuters

Focused on U.S. antitrust as well as corporate regulation and legislation, with experience involving covering war in Bosnia, elections in Mexico and Nicaragua, as well as stories from Brazil, Chile, Cuba, El Salvador, Nigeria and Peru.

Nate Raymond reports on the federal judiciary and litigation. He can be reached at [email protected].

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Research Article

Factors Associated with Depressive Symptoms among Filipino University Students

* E-mail: [email protected]

Affiliation Department of Behavioral Sciences, de la Salle University, Manila, The Philippines

• Madelene Sta. Maria,

Affiliation Office of Counselling and Career Services, de la Salle University, Manila, The Philippines

• Romeo B. Lee, 
• Madelene Sta. Maria, 
• Susana Estanislao, 
• Cristina Rodriguez

• Published: November 6, 2013
• https://doi.org/10.1371/journal.pone.0079825
• Reader Comments

Depression can be prevented if its symptoms are addressed early and effectively. Prevention against depression among university students is rare in the Philippines, but is urgent because of the rising rates of suicide among the group. Evidence is needed to systematically identify and assist students with higher levels of depressive symptoms. We carried out a survey to determine the social and demographic factors associated with higher levels of depressive symptoms among 2,436 Filipino university students. The University Students Depression Inventory with measures on lethargy, cognition-emotion, and academic motivation, was used. Six of the 11 factors analyzed were found to be statistically significantly associated with more intense levels of depressive symptoms. These factors were: frequency of smoking, frequency of drinking, not living with biological parents, dissatisfaction with one’s financial condition, level of closeness with parents, and level of closeness with peers. Sex, age category, course category, year level and religion were not significantly related. In identifying students with greater risk for depression, characteristics related to lifestyle, financial condition, parents and peers are crucial. There is a need to carry out more surveys to develop the pool of local knowledge on student depression.

Citation: Lee RB, Maria MS, Estanislao S, Rodriguez C (2013) Factors Associated with Depressive Symptoms among Filipino University Students. PLoS ONE 8(11): e79825. https://doi.org/10.1371/journal.pone.0079825

Editor: Hamid Reza Baradaran, Iran University of Medical Sciences, Islamic Republic of Iran

Received: June 9, 2013; Accepted: October 4, 2013; Published: November 6, 2013

Copyright: © 2013 Lee et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors have no support or funding to report. The study was carried out as part of the community engagement activities of the authors.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Depression is a major source of the burden of disease throughout the world [ 1 ]. In much of the developing world, however, depression is largely unexplored as a research topic. A social mapping revealed that, even though the mental disorder has been recognized as a research priority, only a sparse number of relevant studies have been carried out in low- and middle-income countries [ 2 ]. Roughly 60% of these countries have contributed fewer than five articles to the international mental health indexed literature [ 2 ]. Strategic evidence is needed in order to prevent the occurrence of depression, including its pernicious effects and prohibitive treatment cost.

Prevention of depression, particularly among university students in developing countries, is urgent. With their large student populations and the developmental propensity of students for depression [ 3 ], the burden of the mental disorder is heavy on this demographic sector [ 4 – 6 ]. Preventive efforts in the developing world, however, are rare. Consistent with observations elsewhere [ 7 , 8 ], depression is widely perceived in this part of the world as innocuous and as part and parcel of normal adolescent development. Students with the mental disorder are not only suffering in silence, but are also placing their academic and future life goals in peril. Depression can be averted if students with depressive symptoms, comprising not only physical but also non-physical conditions (e.g., cognition-emotion and motivation) [ 9 ], are promptly and properly identified and helped.

Extant studies suggest that students with higher levels of symptoms tend to be women [ 10 , 11 ], older and in their senior year [ 5 ], and Catholics and/or Jews [ 12 , 13 ]. Moreover, research indicates that highly symptomatic students do not reside with their parents in one household [ 14 ], and are smoking [ 15 ] and drinking alcohol [ 16 ], and belong to the low-income bracket [ 6 ]. Furthermore, students with more severe levels of depressive symptoms have lower levels of closeness with their parents or with friends [ 7 ].

The context of the present study

The Philippines has a total population of 92.3 million that is very young (median age: 23) and growing at 1.9% annually. In 2009-2010, 2.8 million university students were enrolled in the country’s 2,247 higher education institutions. Of every 10 Filipino students, 6 and 4 are enrolled in private and public universities, respectively. Of these students, 26% are enrolled in business, 16% in medicine and allied programs, and 13% each are in engineering, information science and education [ 17 ]. In contrast to their counterparts throughout most of the world, Filipino students commence their university education at the age of 15 or 16 years.

Filipinos place a high premium on formal education; a university degree is strongly regarded as a primary requirement for social and economic mobility. In the context of the collective aspirations of Filipinos to go abroad for lucrative employments, the need for university education is even more compelling. Individual students are thus pressured to excel or complete a degree, lest they bring dishonor to their family and friends, and endanger their employment and life prospects. In this respect, academic-related matters are salient issues for individual students and in their relationships and conflicts with parents; these, too, can induce higher levels of depressive symptoms in students.

We carried out this research as part of our community engagement activities to help in the prevention of mental disorders, and subsequently, of suicide among Filipino university students. The connection between depression and suicide is well-established [ 18 ]. The spate of suicide events among local students had served as the impetus to conceive and implement this study. There is paucity of data on university student depressive symptomatology in the Philippines, and in the absence of published relevant articles in indexed journals, little is understood about depressive symptoms among Filipino university students at the international level. This survey examined the social and demographic factors associated with higher levels of depressive symptoms among Filipino university students. The University Student Depression Inventory (USDI), a newly-developed and psychometrically sound scale with measures on academic motivation in addition to lethargy and cognition-emotion, was used.

Participants

Data were derived from a complete enumeration survey undertaken in 2012 covering all 67 undergraduate classes in general social sciences (e.g., introductory sociology) at a large private university (total student population: >16,000) in Manila, the Philippines. Roughly half of the 67 classes were surveyed in the middle of Term 1 and the other half in the middle of Term 2. A total of 2,591 Filipino students anonymously completed the 10-page self-accomplished questionnaire. Only the questionnaires of 2,436 students were considered for the purpose of this report (126 questionnaires of international students were excluded and 29 questionnaires with at least 10 unanswered items were invalidated). Our sample represents about 15% of the university’s total undergraduate student population.

We utilized the USDI to measure depressive symptoms as a continuous variable. The USDI, developed by Khawaja & Kelly [ 9 ], measures the academic motivational aspect of depressive symptoms in addition to physical and cognitive-emotive dimensions. The USDI has 3 sub-scales having a total of 30 statements: lethargy (9 statements on lethargy, concentration difficulties and task performance); cognitive-emotional (14 statements on suicide ideation, worthlessness, emotional emptiness and sadness); and academic motivation (7 statements on class attendance and motivation to study) ( Table 1 ). Statements have score-bearing response options ranging from “none at all” (1) to “all the time” (5). The USDI has a high level of internal consistency (Cronbach α=0.95) [ 9 ].

Table 1. Statements used for measuring levels of closeness with parents and with peers, and depressive symptoms.

The socio-demographic characteristics include sex, age category, course category, year level, religion, frequency of smoking, frequency of drinking, living/not living with both biological parents, level of satisfaction with one’s financial condition, level of closeness with parents, and level of closeness with peers. The last 2 variables were measured using a series of 8 statements on parents and 9 statements on peers. The statements were drawn from published studies on parental and peer relationships among adolescents [ 7 , 19 ]. Each series had 4 score-bearing response options: definitely not true (1), mostly not true (2), mostly true (3), and definitely true (4) ( Table 1 ).

Ethical standards

The study was approved by the ethics review committee of the university. After evaluating the contents of the survey instrument, the Committee assessed that the study would have no known risk to research participants. Verbal consent was thus obtained; however, students were informed that they could decline participation and that they could stop completing the questionnaire if they wished to. The benefits of the study (i.e., findings would be used to draw attention towards mental health in Filipino students) were especially stressed in order to trigger a sense of social responsibility and citizenship, and therefore, research participation among students. These instructions were written on the cover page of the survey instrument that was administered. On the same cover page, we also included our full names and contact numbers in which we enjoined students to ask us questions about the study and related matters.

We did not seek the consent of the students’ parents anymore. The survey focused on real-life conditions (e.g., feeling bored and having low energy) which are normally shared between and among Filipino students. During our pre-test of the questionnaire, student-respondents perceived the topic of the study as personally acceptable, one they felt they would not be asking their parents for permission should they decide to discuss it. The foregoing ethical standards, especially with respect to studies with no known harmful risks and the waiving of a signed certification of consent, are in line with the practices of most Institutional Review Boards elsewhere.

We conducted the survey in classrooms during the first quarter of the 90-minute classes. Each class was informed about the importance and rationale, and the anonymity and confidentiality of the study. Afterwards, students were invited to participate and were each given a questionnaire to accomplish. Students were reminded not to write any mark in the instrument that would identify them. Whether completely accomplished or not, all questionnaires were collected. Students were thanked for their participation. No incentive of any form was given.

Using the Statistical Package for the Social Sciences Version 20, differences in the mean depressive symptoms scores were examined based on social and demographic characteristics. The characteristics that were statistically significantly related with higher levels of depressive symptoms were further examined at the sub-scale levels. The analysis of variance was used.

The independent variables, except for sex (male, female), were recoded into variables with 2-3 categories each ( Table 2 ). The levels of closeness with parents and with peers were constructed by adding the scores corresponding to responses given to the series of statements. For level of closeness with parents, the score range is 8 to 32 (low-moderate, 8-23; high, 24-32); and for level of closeness with peers, the range is 9 to 36 (low-moderate, 9-26; high, 27-36). Our analyses revealed a high level of internal consistency for both series (parents: α=0.77; peers α=0.79).

Table 2. Means and standard deviations for depressive symptoms scale scores by social and demographic characteristics.

Table 3. Means, F-values and p-values for depressive symptoms sub-scale scores by selected social and demographic characteristics.

The dependent variable (levels of depressive symptoms) was constructed by adding the scores corresponding to the responses given to the series of statements. The scale score ranges from 30 to 150 while the sub-scale scores range from 9 to 45 for lethargy, 14 to 70 for cognition-emotion, and 7 to 35 for academic motivation; higher scores suggest higher levels of depressive symptoms Our analyses revealed a high level of internal consistency for the USDI (α=0.93).

Profile of respondents

The majority were female while 43.6% were male. 42.5% were 16 years of age or younger, 29.8% were 17 years old and a similar number were older. 39.0% were in social sciences/humanities; 29.6% were in business/economics/management and 23.2% were in engineering/natural/computer sciences. Seven of every 10 were first year students. Most were Catholic (80.9%) and reported not having smoked in the past 30 days prior to the survey. In the past 30 days, about 6 of every 10 students had taken alcohol for more than 10 days, while 4 for ≤10 days. Most respondents (77.9%) currently lived with both biological parents. About 70% were satisfied and very satisfied with their financial condition; the rest were not or were only somewhat satisfied. Most had high levels of closeness with parents (82.5%) and peers (88.1%).

Differences in mean scale scores based on social and demographic characteristics

The means and standard deviations for depressive symptoms scale scores are shown in Table 2 . Higher means suggest higher or more severe levels of depressive symptoms. Results indicate that male and female students did not differ in their symptoms levels. No significant differences were observed across age groups. The level of depressive symptoms statistically significantly varied according to course category but only marginally (F (3,2410) =2.54, p<.06). Means were not significantly dissimilar across year level and religion.

Means comparison related to frequency of smoking suggests significant differences among the categories (F (2,2411) =9.65, p<.01). Results of post-hoc Tukey test indicate that those who smoked for ≤10 days had a higher level of depressive symptoms than those who did not smoke in the past 30 days (p<.01). Significant means differences were observed based on frequency of drinking (F (1,2424) =14.31, p<.01). Students not living with both parents had a significantly higher level of symptoms compared to those living with parents (F (1,2432) =4.87, p<.05). Moreover, depressive symptoms level significantly varied according to satisfaction with one’s financial condition (F (3,2423) =52.03, p<.01). Based on post-hoc Tukey test findings, students who were not satisfied with their financial status had a more elevated level of depressive symptoms than those who were somewhat satisfied (p<.05), satisfied (p<.01) and very satisfied (p<.01).

Students with a low to a moderate level of closeness with parents had a significantly higher level of depressive symptoms than students with a high level of closeness with parents (F (1,2431) =165.76, p<.01). Students with a low-moderate level of closeness with peers had a significantly higher level of symptoms than those with a high level of closeness with peers (F (1,2425) =176.91, p<.01).

The 6 independent variables with statistically significant relationships with higher levels of depressive symptoms were further examined for their interactions. The two-way analysis of variance results indicate an absence of any interaction.

Differences in mean sub-scale scores based on statistically significant social and demographic factors

Additional analyses using the one-way analysis of variance were performed to determine if the statistically significant associations of the 6 independent variables (i.e., frequency of smoking, frequency of drinking, living/not living with both biological parents, level of satisfaction with financial condition, level of closeness with parents, and level of closeness with peers) would hold at the sub-scale level. The means, F-values and p-values are given in Table 3 .

Results indicate that the associations of the 5 variables (i.e., frequency of drinking, level of satisfaction with financial condition, and levels of closeness with parents and with peers) persisted at all sub-scales of depressive symptoms (p-values at <0.01 or <0.05). The significant sub-scale association of the remaining variable (i.e., living/not living with both biological parents) was confined only to the cognitive-emotional sub-scale.

This survey identified a set of social and demographic factors that are statistically significantly associated with higher levels of depressive symptoms among Filipino university students. The aim is to help prevent depression among the domestic university student population. If students with elevated risks are known and assisted early, their depression would be promptly averted. Data suggest that the factors with significant associations with depressive symptoms, mostly at both the scale and sub-scale levels, were frequency of smoking, frequency of drinking, living/not living with both biological parents, level of satisfaction with one’s financial condition, and levels of closeness with parents and with peers.

The significant associations of frequencies of smoking and of drinking with depressive symptoms are aligned with extant empirical findings [ 20 , 21 ]. The present study revealed that Filipino students who smoked for some days (against those who did not smoke) and who took alcohol for some days (against those who consumed alcohol for longer durations) had higher depressive symptoms levels. In explaining the associations of smoking and drinking, some studies tend to highlight the psychopharmacological [ 20 ] and symbiotic [ 22 ] dimensions of these bivariate relationships. This implies that students could have smoked or taken alcohol as an escape route from the burdens of psychosocial difficulties. In the case of drinking, in particular, the use of alcohol usually precedes the symptoms of lethargy and social difficulties associated with depression [ 23 , 24 ]. Caution should be taken in appreciating these interpretations, however. The variables were measured in this study based on the number of days of smoking and drinking rather than the quantities of cigarettes and alcohol consumed (these two are not necessarily equivalent indicators). Considering that the rates of smoking and drinking among the Filipino youth are relatively high (21.0% and 41.4%, respectively) [ 25 ], these twin behaviors, specifically their frequencies, need closer examination vis-à-vis depressive symptoms.

The association between not living in the household with both biological parents and having more serious levels of depressive symptoms has ample empirical support [ 14 , 26 ]. Across the country, many Filipino students do not reside with both parents while pursuing their university education, because they live away from home in dormitories and/or their biological parents are single, separated, or are working abroad. Either as a permanent or a temporary condition, not living with both biological parents may induce depressive symptoms, primarily in cognitive-emotive terms as this study revealed, probably as a result of having restricted access to parental presence and support.

Satisfaction or dissatisfaction with one’s financial condition is well-confirmed in several other investigations for its significant role in mental health [ 27 ]. It is usually expensive to study in a private Philippine university compared to studying in the country’s state colleges and universities. Students in private universities would generally belong to higher levels of socioeconomic status and may influence a peer culture that promotes greater awareness of a person’s socioeconomic standing in society. Such an educational environment is, in turn, likely to enhance sensitivities about one’s own social status in comparison to one’s peers. Those who perceive themselves as higher in status also have higher levels of optimism and perceived control, and therefore, are also likely to exhibit lower levels of depressive symptoms [ 28 , 29 ].

The current study findings on the significant associations between the levels of closeness with parents and peers and depressive symptoms are to be expected; these are within the realm of the evidence widely reported in other investigations [ 7 , 30 ]. That most of the Filipino university students who participated in this study had high closeness levels with their parents and peers is hardly unexpected. Parents and friends are basic yet very significant primary groups for Filipino adolescents. Their provisions, including the immediate care, security and support that they bestow and the secure attachments that they consequently foster, are effective protectors and buffers of university students against depressive symptoms [ 31 , 32 ].

In the absence of high level of closeness of Filipino students with parents, in which the parent-child relationship would be characterized by communication problems, excessive parental control, low levels of cohesion, and high levels of conflict in the families, adolescents are bound to experience depressive symptoms [ 33 , 34 ]. Without high level of closeness with peers, local students are also predisposed to be at risk. Students are in a stage when they mostly need their peers for emotional support. Peer acceptance is important to the growing individual and is therefore associated with depressive symptoms [ 35 ]. Compared to the association of the lack of parental warmth and acceptance with adolescents’ depressive symptoms, which is largely unidirectional, the association between depressive symptoms and peer-relational problems tends to be bidirectional [ 36 ]. Filipino students exhibiting depressive symptoms are likely to be spending less time interacting with their peers and are prone to relate with them aggressively. This interaction pattern, in turn, is likely to cultivate further peer rejection and neglect.

Sex, age category, course category, year level and religion were not statistically significant factors as our analyses revealed. As a general rule, females show higher rates of depression than males [ 37 , 38 ] due to their tendency to be more expressive and more sensitive to the support provided by their social networks [ 39 ]. However, this normative rule on gender differences does not seem to hold true for university students [ 37 ]. The exception may be accounted for by the homogeneous university life experiences, similarities in parental education, or common socio-demographic conditions among the youth in general [ 37 , 39 ]. The lack of significant associations of age category, course category and year level among Filipino students could be due to this homogeneity factor as well, particularly that most of them were young, freshmen and completing general education rather than major subjects at the time of their interview. Religion was not significantly associated with depressive symptoms and this is to be expected: the Filipino youth, including university students, are largely nominal Catholics who seldom practice their faith [ 40 ]. Elsewhere, one’s religiousness rather than religious affiliation per se has been observed to be significantly related with lower levels of depressive symptoms in students [ 41 ].

The survey has some limitations. Since the study’s respondents were from general education classes with mostly first year students from middle- and high-income backgrounds, the findings cannot be generalized to the entire student population of the university surveyed or student populations from other universities in the Philippines. Another limitation of the survey is that it did not include other factors that may have potential relationships with higher levels of depressive symptoms. For instance, since completing a university degree is culturally valued among Filipinos, the academic performance of students could be a critical factor for assessing depressive symptoms. Also, the study is cross-sectional, and as such, its conclusions only refer to associations rather than causal relationships between the independent and dependent variables. Moreover, the level of depressive symptoms measured through the USDI pertains not to the sequence of the occurrence of high levels of depressive symptoms, but to the amount of depressive symptoms weighted by frequency of occurrence students experienced in the past fortnight.

More surveys using the USDI are needed in the Philippines. Future studies have to involve representative samples of Filipino university students from other socio-economic backgrounds. If feasible, longitudinal studies, which will provide repeated observations of the levels and associated factors of depressive symptoms, are a better alternative. Variables related to students’ academic performance should be included as well. Some variable measures (e.g., frequency of smoking) need to capture more nuanced dimensions of the social and demographic conditions of students at greater risk, For example, variables related to smoking and drinking should ask follow-up questions regarding the specific quantities of cigarettes and alcohol consumed by students in a given period. In addition, the association of religion with depressive symptoms will be better understood by a follow-up question on religiousness.

The present survey is a pioneering large-scale research on the social and demographic factors of higher levels of depressive symptoms among Filipino university students. These initial findings can help guide the development of a campus-based prevention program at the university surveyed. Towards addressing depressive symptoms and depression in students, lifestyle and factors related to financial condition and parental and peer relationships are important considerations for identifying those at greater risk. More research is needed towards building additional local knowledge on the topic.

Author Contributions

Conceived and designed the experiments: RBL MS SE CR. Analyzed the data: RBL MS SE CR. Wrote the manuscript: RBL MS SE CR.

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