66 JPAIR Multidisciplinary Research Issues and Challenges on the Mental Health Services of a Selected Municipality in Metro Manila: A Case Study WILLIAM JO SE M. BILLOTE 0000-0002-4762-7551 williamjosebillote@gmail.com Batanes State College Basco, Batanes, Philippines RYAN G. PONCE 0000-0002-7615-5194 ryangutierrezponce@gmail.com Saint Dominic College of Batanes Inc. Basco, Batanes, Philippines Originality: 100% • Grammar Check: 100% • Plagiarism: 0% ABSTRACT Mental health problem is one of the leading causes of disability worldwide. It makes up one-third of the world population. With the increasing number of individuals with mental health problems and difficulties worldwide, countries such as the Philippines are still on the process of addressing the issue of providing quality mental health care services. This study aimed to identify and evaluate the existing mental health services offered in a selected Municipality in Metro Manila, Philippines. Moreover, this sought to increase knowledge and awareness about mental health services to help solve the issues and challenges identified in this study. The study employed an initial semi-structured interview that can lead to a case study, which is qualitative research design. The study was conducted in one of the City Health Offices in Metro Manila. Insufficient budget, lack of Vol. 39 · January 2020 DOI: https://doi.org/10.7719/jpair.v39i1.761 Print ISSN 2012-3981 Online ISSN 2244-0445 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. mailto:williamjosebillote@gmail.com mailto:ryangutierrezponce@gmail.com https://doi.org/10.7719/jpair.v39i1.761 https://creativecommons.org/licenses/by-nc/4.0/ https://creativecommons.org/licenses/by-nc/4.0/ 67 International Peer Reviewed Journal trained professionals and mental health workers, lack of mental health system framework, not fully implemented mental health law, and lack of collaboration and integration were the problems identified in providing quality mental health services. Although the Philippine government exerts effort on filling in the gaps in providing treatment and care to those individuals with mental health difficulties, access to mental health institutions in the Philippines favors those near the National Capital Region. Keywords — Psychology, mental health, mental illness, mental health problem, mental health services, qualitative research, Metro Manila, Philippines INTRODUCTION Mental health is defined by the World Health Organization (2003) as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It includes concepts of well-being, self-efficacy, competence, autonomy, dependence, and recognition of the ability to realize one’s intellectual and emotional capabilities. The World Health Organization also defines it as a state of well-being where individuals can recognize their abilities, work fruitfully, and make contributions to their communities despite the normal stresses of life. Although mental health is defined universally, the symptoms of these disorders vary by discipline, and some of them show up as a reaction to culture. In oriental cultures, the symptoms of mental disorders are expressed physically, while this is rarely observed in Western cultures. The translation of mental disorders to physical expressions is thought to be a primitive behavior and is not welcome in Western societies. On the contrary, this somatization or conversion of emotions that are not freely expressible is an essential way for the social harmony of the individual (Çam & Uğuryol, 2018). Mental health problems and difficulties are growing issues worldwide. Thus, individuals who often have these problems and difficulties are misunderstood and discriminated. According to Vos and colleagues (2013), a new index of 301 diseases found mental health problems to be one of the leading causes of the overall disease burden worldwide. Common mental health problems include depression, generalized anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). These problems constitute the largest single source of world economic burden, with an estimated global cost of £1.6 trillion (or US$2.5 trillion) – higher than 68 JPAIR Multidisciplinary Research cardiovascular disease, chronic respiratory disease, cancer, and diabetes. With this, the second leading cause of disability worldwide is major depression. It has also been considered as a significant contributor to the burden of suicide (Whiteford et al., 2013). Additionally, Lozano and colleagues (2012) reported that the primary drivers of disability worldwide are mental health and behavioral problems. They cause over 40 million years of disability in 20 to 29-year-olds. Consequently, more than 100 million people suffer from mental disorders in the Western Pacific region, including the Philippines. According to the Department of Health Philippines, as reported by ASEAN Secretariat Jakarta (2016), there is an increasing rate of suicide and an increase in self-inflicted injuries. Death by suicide reached 2.2 per 100,000 population in 2005, increased from 0.5 and 2 in 1980 and 1996 respectively. Also, schizophrenia and other related disorders (71%) and mood disorders (18%) are the most frequent diagnoses among patients who are treated in mental hospitals. In contrast, substance abuse and neurotic disorders are more frequent diagnoses in out-patient facilities. Similarly, the ASEAN Secretariat Jakarta (2016) has compiled reports on mental health from its member states entitled ASEAN Mental Health Systems. It has found out that hospital out-patient and in-patient data shows that the leading mental health problems present in Brunei are psychotic disorders such as schizophrenia, followed by bipolar disorder and depression. On the other hand, mental health problems such as depression, anxiety, somatoform disorders, alcohol, and drug abuse are common in children. The Indonesia Basic Health Survey in 2013 estimated that 6% of the adult population have mental disorders. In Malaysia, a total of 8.6% of their population have mental disorders. It was also ranked fourth among the leading causes of the burden of disease. Mental health problems and difficulties developed complicatedly, and too often, there is no single or identifiable cause. Nonetheless, risk factors that may trigger mental health problems in certain people are heredity, adverse life events, certain medications, diseases or illnesses, and work-related stress (Gabriel & Liimatainen, 2000). Additionally, when an individual cannot manage the stress he or she is experiencing, he or she might have a mental health problem that can lead to mental illness. This would, therefore, affect the individual’s everyday functions and working conditions in numerous ways. Since this causes mild to severe disturbances in thought and, or behavior, this will result in an individual’s inability to cope with life’s ordinary demands and routines. Furthermore, mental health problems affect both the individual and the community. Individuals with mental health difficulties and problems are 69 International Peer Reviewed Journal excluded from their active role in the community. This often leads to losses in human potential and productivity. The costs of mental health problems, and other disabilities, include the direct cost of welfare services and treatment (e.g., costs of disability benefits, travel, access to services and medication), the indirect cost to those who are not directly affected such as caregivers, and the opportunity costs of income foregone due to incapacity (Gabriel & Liimatainen, 2000). With the escalating number of individuals with mental problems and difficulties worldwide, the Philippines, specifically, is still on the process of addressing the issue on providing quality mental health care services – from the lack of facilities, nonfunctional services due to insufficient human resources, budget constraints (Conde, 2004), and the implementation and integration of the mental health plan and services across the country. The World Health Organization has suggested effective strategies to prevent these problems and difficulties and provided ways to alleviate the suffering caused by such disorders. Effective strategies and techniques include mental health promotion and mental disorder prevention (Jané-Llopis & Anderson, 2005). Mental health promotion often refers to positive mental health and the process of enabling people to increase control over and to improve their health. Mental disorder prevention, on the other hand, is primarily concerned with avoiding the disease, its relapses and risks, and the other disabilities associated with it (World Health Organization, 2002). Other effective strategies include addressing risk and protective factors, strengthening community networks, improving access to education, promoting a healthy lifestyle, dealing with family disruptions, enhancing resilience, and reducing disruptive behaviors (World Health Organization, 2004). Thus, access to healthcare and social services capable of providing treatment and social support is the key. However, access to these healthcare facilities and services, insufficient budget allocation, and an inadequate number of skilled and trained workers for mental health remain as the gaps in providing treatment and care. It cannot be denied that the current treatments and strategies on mental health care do not sufficiently address the different complex challenges of mental illness. Suggested and existing models of care and available approaches for treatment often fail to address this increase in the global crisis of mental health care. Because mental illness accounts for about one-third of the world’s disability, then mental health care services call for a drastic change in its paradigm and practices. Such changes include improving standards of training, developing new research methods, and re-assessing current models of mental health care 70 JPAIR Multidisciplinary Research services. Additionally, based on the findings from the study conducted by Lally, Tully, and Samaniego (2019), they concluded that mental healthcare services in the Philippines face continued challenges. These include underinvestment, lack of mental health professionals, and underdeveloped community mental health services. The Department of Health (2018) reports that 17% of the population in the Philippines suffers from a major depressive disorder. Additionally, data from the Philippine General Hospital in 2014 show that epilepsy accounts for 33.44% of adult and 66.20% of pediatric neurologic out-patient visits per year and in 2011, WHO Global School-Based Health Survey showed that in the Philippines, 16% of students between 13-15 years old have ever seriously considered attempting suicide while 13% have actually attempted suicide one or more times. Since there are gaps in the increasing number of mental health problems in the Philippines, the researchers were interested in evaluating the existing mental health services in the Philippines, specifically in the National Capital Region. This study sought to identify the concerns or issues that should be addressed and will eventually lead to ways to helping professionals in the field of Psychology to offer accessible facilities and social services to people with mental health problems and provide skills training to workers for mental health. FRAMEWORK With the increasing trend of mental illness around the world, it is vital that health policy-makers and practitioners identify and support effective means to address issues on mental healthcare. It must be noted that the personal, social, and economic costs of mental illness are too significant to ignore. For this to happen, people concerned and responsible for programs and services on mental health must understand program sustainability. Sustainability remains a vague term in health promotion. Most definitions refer to a general notion of continuation (Health Communication Unit, 2001), and sustainability is often used interchangeably with the idea of the durability of effect, long-term viability, or long-term maintenance (O’Loughlin et al., 1998, as cited in World Health Organization, 2005). In the field of public health, program sustainability is defined as the capacity to be able to continue program services that will provide ongoing prevention and treatment for a particular health problem even after significant financial and managerial assistance have been terminated. With this, the entire service can be 71 International Peer Reviewed Journal continued with its original structure or even an alternate one, parts of the services may be continued, or some or all of services can be transferred to local service providers (LaPelle, Zapka, & Ockene, 2006). However, there can be many reasons why programs, services, or interventions might lose their effectiveness over time. They might also fail to transfer their benefits to their clients. Program sustainability must have the potential of an intervention or service to continue to deliver benefits or health gains beyond the initial stage. Even if such services are given limited resources, programs can still be sustainable if they continue to make an effort to achieve the benefits they have to offer. Unfortunately, in most parts of the world, services for mental health are not rendered anywhere the same importance as other areas of health, especially physical health. Instead, they have been largely ignored. Hence, the program sustainability of mental health services must maximize ongoing efforts to achieve the benefits of the services to its clients – people with mental illness, given limited resources. OBJECTIVES OF THE STUDY The study aimed to identify and evaluate the existing mental health services provided in a selected Municipality in Metro Manila, Philippines. Further, the study sought to increase knowledge and awareness about mental health services, which will help professionals to develop programs and interventions in solving the issues and concerns identified in this study. Thus, the researchers hope that the results of this study will lead to ways of helping professionals in the field of Psychology. METHODOLOGY Research Design The study employed an initial semi-structured interview that can lead to a case study, which is qualitative research design. The researchers used critical case sampling, which is a type of purposive sampling technique, in identifying the respondents of the study because this is deemed as most appropriate due to the characteristics of the study’s respondents. 72 JPAIR Multidisciplinary Research Research Site The study was conducted in one of the City Health Offices in Metro Manila. Participants The researchers were able to interview one (1) female respondent who was currently the Mental Health Department Head of the City Health Office and has worked with the institution for 20 years. Ethical Considerations This research undertaking was committed to the highest standard of professional conduct. To meet the ethical requirement established for this study, the researchers first sought approval from one of the City Health Offices in Manila. Upon their approval, the researchers conducted the interview. Before the interview, the researchers explained the purpose of the study, methodology, significance of the study, limitations of the study, and possible risks of the study to the participant. With this, the participant was allowed to express her concerns about the study and was informed of her right to refuse questions during the data collection process. The researchers also sought consent from the participant if they could take down notes and audio record the interview. After the interview, a token of appreciation was given to the participant for partaking in the study. When the data was transcribed, the researchers went back to the City Health Office and let the participant read the transcript, initial results, and the interpretation of her responses. Instrumentation The data gathering tool comprised of two parts which included the consent form and interview guide. Consent Form. The first part of the data gathering tool was attached to the front page of the interview guide. It provided a brief background of the researchers, the purpose and objectives of their study, and the respondent’s permission to participate in the study voluntarily. It also explained the significance of the results of the study. The respondent was given a copy that was signed to prove that she agreed to participate in the study. Interview Guide. The second part of the data gathering tool was used to gather information from the respondent. The questions in the interview guide that was used by the researchers were related to the demographics, competencies, 73 International Peer Reviewed Journal qualifications, services, programs, evaluations, problems encountered, and satisfaction of the respondent in the City Health Office. RESULTS AND DISCUSSION With the considerable lack of community mental health care in the Philippines, stated below are the issues and challenges being encountered and wished to be addressed. Insufficient Budget. WHO-AIMS (2007) reports 19 community- based psychiatric in-patient units and 15 community residential facilities. These accommodate 1.58 beds per 100,000 and 0.61 beds/place per 100,000, respectively. However, Jacob and colleagues (2007) report a lower estimate of 0.09 beds per 100,000. They further report that there are 46 out-patient mental health facilities and four day-treatment facilities— these cater to 124.3 users per 100,000 and 4.42 users per 100,000, respectively. In the Philippines, mental health remains poorly resourced. Only 3–5% of the total health budget is spent on mental health, and 70% of this is spent on hospital car. (World Health Organization, 2007; Department of Health, 2008). The abovementioned results, therefore, imply that mental health is not among the top priorities of the government. This was confirmed by the respondent when asked where they get their budget: “Wala. Puro lang kami trabaho. Work… Work… Work… but no budget.” (“None. We just work. Work… Work… Work… but no budget.”) However, it can be noted that there are times when they receive sponsorships: “Depende pag may mag-sponsor pero madalas wala kaming budget.” (It depends when we have sponsors but most of the time we do not have the budget.”) The sponsors helped them financially in providing mental health services to their patients but only for a period of time. Yet, the area of mental healthcare still remains an under-resourced and neglected aspect of healthcare in this part of Manila. Nevertheless, it is good to note that the Philippine Health Insurance Corporation (PhilHealth) added mental illness under its coverage in 2010 under 74 JPAIR Multidisciplinary Research PhilHealth Circular No. 09 s - 2010, but this is only for severe disorders, and confinement is for a short duration (Philippine Health Insurance Corporation, 2010). It can be deemed that the government is making efforts to offer funds for mental health care. However, in the other parts of the country, the availability of mental health resources and services is still severely lacking. To name a few, these parts of the country are Cavite, Laguna, Batangas, Rizal, and Quezon. According to WHO-AIMS Report on Mental Health System in The Philippines (2007), mental health facilities are sustained in public and private organizations, but access to these is uneven throughout the country. Most of the resources and facilities are located in the National Capital Region and major cities in the Philippines. Although there are 12 smaller satellite hospitals throughout the country that are affiliated with the National Center for Mental Health, overcrowding, poorly functioning units, and funding constraints are ongoing problems, particularly in peripheral facilities. Lack of Trained Professionals and Mental Health Workers. The mental health practitioners should be able to assess the needs of their patients, identify the possible concerns, and make diagnoses for underlying mental health problems. Thus, there is a need for proper orientation and training for these practitioners. In the mid-1990s, the National Mental Health Program integrated mental health services in community settings by providing training on the identification and management of specific psychiatric morbidities and psychosocial problems to the municipal health doctors and nurses. However, at present, it appears that the majority of those who have undergone mental health training is no longer available in their workplace, and the current primary health care staff lack training in mental health and interaction with mental health facilities is unusual (World Health Organization, 2007). Based on the interview, all the mental health workers were not adequately trained in terms of professional development: “Kulang! Kulang na kulang. They need more training.” (“Inadequate! It’s so inadequate. They need more training.”) When asked if their workers attend seminars, workshops, and trainings, only one (1) nurse was able to attend such: “Yes. Itong aking nurse ang pinakalast na training niya was last week sa Grand Opera Hotel from 6 to 9. Training ng mental health (mhGap Intervention).” 75 International Peer Reviewed Journal (“Yes, the nurse. She had her training last week at Grand Opera Hotel from 6 to 9. It was a training on mental health (mhGap Intervention.”) Also, there were no psychologists or psychometricians available in the City Health Office to help and provide psychological services to the patients, especially if a disaster happens. Furthermore, since the city mental health office offers consultation and counseling only, the mental health workers refer to the more advanced or specialized cases to trained psychiatrists: “We offer basic ones, such as assessment and counseling. Pag di kaya nirerefer namin sa psychiatrist.” (“We offer the basic ones such as assessment and counseling. If we can’t handle the case, we refer them to a psychiatrist.”) It appears that the current primary mental health workers seem to have inadequate training in providing mental health services. Their competencies are needed to be empowered and strengthened for them to provide better mental health services. When asked about the qualifications of a mental health worker: “Siguro ano, willingness. Dedicated.” (“Maybe willingness and dedication.”) Thus, there are no clear guidelines in the qualifications of a mental health worker in their area. Evidently, as reported by the World Health Organization (2007), 3.43 per 100,000 population is the rate of the total number of the workforce employed in mental health facilities or private practice. On the rate, 0.42 are psychiatrists, 0.17 are other medical doctors (not specialized in psychiatry), 0.91 are nurses, 0.14 are psychologists, 0.08 are social workers, 0.08 are occupational therapists, and 1.62 other health or mental health workers (e.g., auxiliary staff, non-doctor/ non-physician primary health care workers, health assistants, medical assistants, professional and paraprofessional psychosocial counselors). Lack of Mental Health System Framework. Based on the interview, it came out that the respondent and other mental health workers were not aware of the mental health framework provided by the Department of Health (DOH) when asked of their awareness regarding this: 76 JPAIR Multidisciplinary Research “No. Hindi naman kami binigyan ng DOH ng kopya ng framework.” (“No. We were not given a copy of the framework by DOH.”) This means that they are not adequately guided by the procedures in administering mental health services. They only provide basic mental health services such as assessment and counseling because there is a lack of information dissemination and implementation. However, it was observed that the government is taking action in developing good programs and guidelines to educate the mental health workers, specifically psychiatrists, psychologists, social workers, nurses, and allied mental health professionals. As reported by the World Health Organization (2007), almost all of the available mental health facilities and institutions are located in the National Capital Region. Hence, it seemed that access to these facilities favors those living near the main cities. Not Fully Implemented Mental Health Law. During the time of the interview, the initiatives of creating and fully implementing a mental health law are still ongoing, and mental health advocates are still  making an effort to establish it to make sure that proper guidelines are integrated into a comprehensive healthcare system. Because of this, the respondent was aware of the Mental Health Law, but she does not utilize the law yet as a guide in providing mental health services to her patients: “Ang meron ako dito ay yung kopya ng Mental Health Law pero di pa naman namin ito ini implement dito sa opisina namin.” (“What I have here is a copy of the Mental Health Law, but it is not yet implemented in our office.”) Additionally, prior to the implementation of the Mental Health Law, the respondent was asked about the guide they use in the delivery of mental health services: “No guide in the implementation. Bahala kami.” (“No guide in the implementation. It’s up to us.”) It is important to formulate and institutionalize national legislations, policies, program standards, and guidelines because these will emphasize the development of efficient and effective structures, systems and mechanisms that 77 International Peer Reviewed Journal will ensure equitably accessible, affordable and appropriate health services for the mentally ill patients, victims of disaster and other vulnerable groups (Department of Health, n.d.). It is then noted that on June 20, 2018, Republic Act No. 11036, otherwise known as the Mental Health Act has been signed into law and took effect of July 5, that same year by the Department of Health. Once the Philippine Mental Health Law’s regulations are successfully implemented, and the community has gathered its bearings, professionals, and advocates alike can collaborate to provide essential mental health services, integrate mental health programs and policies in the communities. Lack of Collaboration and Integration. The Department of Health needs to strengthen its organizational set-up for mental health in order to have a clearer structure, adequate human resources, and budget allocation to support its operation nationwide. Despite differences in approach and personal context, all mental health awareness groups aim for one thing, and that is, the recognition of mental health issues and to provide mental health services adequately. There are different strategies to promote mental health. This can be done through early interventions that target vulnerable groups, community development programs, and campaigns (Dogra, Parkin, Warner-Gale, & Frake, 2017). One potential strategy can be the use of the internet and social media. These are inexpensive ways to have conversations about mental health, impart information, and challenge stigma (Betton et al., 2015). Not only can it be used for help-seeking, but it could be used for universal mental health promotion (O’Reilly, Svirydzenka, Adams, & Dogra 2018). As seen in the interview conducted, the majority of patients who avail of mental health services were from the working class or professionals. These individuals may be the only ones who are more informed and has the financial capability of availing mental health services provided by the City Health Office. There is also the stigma that mental health conditions are for the rich only, which stems from a very real issue that only the middle to upper classes can afford mental healthcare. Thus, it is evident that there is a lack of human resources (e.g., psychologists and psychometricians) and budget to support the City Health Office in its operation in providing mental health services to patients. Since people spend significant time browsing through the internet and social media, then these strategies can be used by key stakeholders for mental health promotion. 78 JPAIR Multidisciplinary Research CONCLUSIONS For the Philippines to develop a structured mental health care program, the issues mentioned earlier should be addressed. Although the Philippine government exerts effort on filling in the gaps in providing treatment and care to those individuals with mental difficulties, access to mental health institutions in the Philippines favors those near the National Capital Region. The majority of the mental health professionals in the country also work in private institutions rather than in government facilities. Moreover, the government still provides insufficient budget allocation related to the various mental health programs and services that they offer and the costly amount to be paid by patients to avail the services they need add to the financial and emotional burden that they carry. TRANSLATIONAL RESEARCH The research can be used to assess mental health services in the country and plan for sustainable programs that will provide the necessary needs of people with mental illness. The research can also be used to give attention as to how the Department of Health, general health care, and mental health care can work together to improve access to health care services. National mental health policies should be concerned both with mental disorders and, with broader issues that promote mental health. With this, mental health awareness and promotion should be mainstreamed into governmental and non-governmental policies and programs. Programs and services can be provided to bridge the gap that exists between these systems. Such programs and services can include necessary training and resources to primary care providers on how to correctly treat mental health problems and have access to mental health specialists when it is necessary to make a referral. To address the increasing number of mental health issues in the Philippines, people and organizations concerned in this area can provide early childhood intervention programs that will provide a stable environment that is sensitive to children’s health, protection from threats, opportunities for learning, and interactions that are emotionally supportive and developmentally stimulating. Programs can also target vulnerable people (minorities, indigenous people, people affected b conflicts and disasters) and include community development programs to raise awareness of mental health. 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