Mental health services

The Philippines has recently passed its first Mental Health Act (Republic Act no. 11036). The Act seeks to establish access to comprehensive and integrated mental health services, while protecting the rights of people with mental disorders and their family members (Lally et al, Reference Lally, Samaniego and Tully2019). However, 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 care (WHO & Department of Health, 2006).

Accordingly, the majority of mental healthcare is provided in hospital settings and there are underdeveloped community mental health services. The National Center for Mental Health was previously estimated to account for 67% of the available psychiatric beds nationally (Conde, Reference Conde2004). More recent data indicate that there are 1.08 mental health beds in general hospitals and 4.95 beds in psychiatric hospitals per 100 000 of the population (WHO, 2014). There are 46 out-patient facilities (0.05/100 000 population) and 4 community residential facilities (0.02/100 000) (WHO, 2014). There are only two tertiary care psychiatric hospitals: the National Center for Mental Health in Mandaluyong City, Metro Manila (4200 beds) and the Mariveles Mental Hospital in Bataan, Luzon (500 beds). There are 12 smaller satellite hospitals affiliated with the National Center for Mental Health which are located throughout the country. Overcrowding, poorly functioning units, chronic staff shortages and funding constraints are ongoing problems, particularly in peripheral facilities. There are no dedicated forensic hospitals, although forensic beds are located at the National Center for Mental Health.

Mental health staff

There is 1 doctor for every 80 000 Filipinos (WHO & Department of Health, 2012); the emigration of trained specialists to other countries, particularly English-speaking countries, contributes to this scarcity. This shortage is magnified in psychiatry where, nationally, there are a little over 500 psychiatrists in practice. The ratio of mental health workers per population in the Philippines is low, at 2–3 per 100 000 population (WHO & Department of Health, 2006). This ratio is lower than in other Western Pacific Rim countries with similar economic status, for example Malaysia (4.9 mental health workers per 100 000 population) and Indonesia (3.1 per 100 000 population). Data indicate that there are 0.52 psychiatrists (Isaac et al, Reference Isaac, Ahmed and Chaturvedi2018) and 0.07 psychologists per 100 000 inhabitants, and 0.49 mental health nurses per 100 000 of the population (a reduction from 0.72 per 100 000 in 2011) (WHO, 2014).

Together, these figures equate to a severe shortage of mental health specialists in the Philippines. This is further illuminated when compared with the World Health Organization (WHO)-recommended global target of 10 psychiatrists per 100 000 population. Further, the majority of psychiatrists work in for-profit services or private practices and are mainly based in the major urban areas, particularly in the capital region known as Metro Manila.

The burden of mental disorders in the Philippines

There is little epidemiological evidence on mental disorders in the Philippines; however, some important data are available. For example, 14% of a population of 1.4 million Filipinos with disabilities were identified to have a mental disorder (Philippines Statistics Authority, 2010). The National Statistics Office identified that mental illness is the third most prevalent form of morbidity, however the finding that only 88 cases of mental health problems were reported for every 100 000 of the population (DOH, 2005) is likely an underestimate of the true extent of these issues.

The 2005 WHO World Health Survey in the Philippines identified that, of 10 075 participants, 0.4% had a diagnosis of schizophrenia and 14.5% had a diagnosis of depression. Of those with a diagnosis of schizophrenia, 33.2% had received treatment or screening in the past 2 weeks, compared with 14% of those with a diagnosis of depression. Recent data from the Philippine Health Information System on Mental Health identified that (from 14 public and private hospitals surveyed from 2014 to 2016) 42% of the 2562 surveyed patients were treated for schizophrenia.

Between 1984 and 2005, estimates for the incidence of suicide in the Philippines have increased from 0.23 to 3.59 per 100 000 in males, and from 0.12 to 1.09 per 100 000 in females (Redaniel et al, Reference Redaniel, Lebanan-Dalida and Gunnell2011). The most recent data from 2016 identified an overall suicide rate of 3.2/100 000, with a higher rate in males (4.3/100 000) than females (2.0/100 000) (WHO, 2018).

Access to treatment

Prohibitive economic conditions and the inaccessibility of mental health services limit access to mental healthcare in the Philippines. Further, perceived or internalised stigma has been shown to be a barrier to help-seeking behaviour in Filipinos (Tuliao & Velasquez, Reference Tuliao and Velasquez2014), just as is the case in Western populations (Lally et al, Reference Lally, ó Conghaile and Quigley2013). There is a cultural drive to ‘save face’ when there is a threat to or loss of one's social position, and as such Filipinos may have difficulty in admitting to mental health problems or seeking help. There is a strong sense of family in the Philippines and so, when problems are thought to be socially related, Filipinos will turn to family and peer networks before seeking medical help (Tuliao, Reference Tuliao2014).

There are little data on prescription rates and the use of psychotropic medications in treating mental disorders. The 2005 WHO Health Survey indicated that only a third of people with a diagnosis of schizophrenia were receiving treatment or screening (although antipsychotic medication was not specified as the treatment).

There is a national Department of Health Medication Access Program for Mental Health that carries a central list of essential medications, which are shown in Box 1. These medications are available at all service levels, but funding issues limit patient access, particularly access to newer medications. The most commonly used antipsychotics in clinical practice are chlorpromazine and haloperidol; escitalopram and fluoxetine are the most commonly used antidepressants.

Psychiatry training

There are currently 47 accredited medical schools in the Philippines. Psychiatry is a recognised core part of the medical curriculum, which is generally 4 years long. The average time allotted for the psychiatry module is 2 weeks, which incorporates teaching by lectures and clinical exposure. There are 13 postgraduate psychiatry training institutions, with 8 of them based in the Metro Manila region, including 1 based at the National Center for Mental Health. The others are generally located at regional or tertiary hospitals. Only two of the postgraduate training programmes offer 2-year fellowships in psychiatric subspecialties such as child and adolescent psychiatry, consultation–liaison psychiatry, community psychiatry and addiction psychiatry.

Postgraduate residency training is generally a 3- or 4-year programme, depending on the institution. The individual training institution is responsible for designing the training programme, with core competencies acquired in line with international standards. Trainees have the opportunity to spend 3 months in neurology and 2 months in an internal medicine department. All institutions conduct written examinations and Objective Structured Clinical Examinations (OSCEs). Upon completion of residency training, an exit examination is performed with written and OSCE components, following which the title Diplomate of the Specialty Board of Philippine Psychiatry is awarded to the candidates who qualify.

Despite these structures, psychiatry remains a less popular specialty for medical graduates in the Philippines, and the numbers being trained are inadequate to meet a growing need.