Community‐based mental health project in Davao Region

@#Mental health has profound effects on an individual’s quality of life, and it can also affect the families and the communities of persons with mental illness. In early 2020, the World Health Organization (WHO) Special Initiative for Mental Health in the Philippines recorded at least 3.6 million Filipinos suffering from a mental, neurological, or substance abuse disorder.1 In 2015, schizophrenia was the top mental disorder in the Philippines,2 and it is estimated that 1 million Filipinos (1% of the population) suffer from schizophrenia.3 Schizophrenia, a debilitating mental health condition, is characterized by both positive (e.g., hallucinations, delusions, confused thoughts, etc.) and negative (e.g., lack of pleasure, flattening, withdrawal, etc.) symptoms.4 5 6 The condition can affect the individual’s personal and social aspects of daily life, such as self-care, interpersonal relationships, education, and employment.7 8 9 10 Hospitalization is generally indicated for patients who are actively experiencing delusions/hallucinations, those who pose a serious threat of harm to themselves or others, or those who are unable to care for themselves and need constant supervision and support. Other possible indications for hospitalization include the presence of general medical or psychiatric problems that may render outpatient treatment unsafe or ineffective.11 12 Recent therapeutic advances, especially the introduction of atypical antipsychotic medications that have demonstrated better efficacy rates compared to older generation oral antipsychotic drugs, have allowed the reintegration of persons with mental health disorders (e.g., schizophrenia, other psychotic disorders, major depression, mood disorder, or bipolar disorder) into the society.13 14 15 Yet, despite the availability of such medications, there still exists substantial gaps in the delivery of mental health services. In the Philippines, mental health has remained poorly-resourced, with only 3-5% of the total health budget spent on mental health care.16 Mental health specialists have been in shortage, and a large proportion of these specialists work in urban for-profit services or private practices. 16 Mental health care services are delivered largely in hospital and private clinic settings,16 18 while community-based services remain underdeveloped.17 19 Prohibitive economic conditions and stigma on mental illness20 21 are some of the factors that contribute to low diagnosis and treatment rates. These factors, as well as funding issues that limit patient access, especially to newer innovative drugs, have rendered mental health care relatively inaccessible, leaving many patients undiagnosed and untreated or undertreated.17 In 2015, the Davao Center for Development (DCHD) Mental Health Program facilitated the establishment of Community-Based Mental Health Programs (CBMHPs) and the implementation of the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) in several municipalities in the region. Since their launching, CBMHPs in Davao Region documented annual increases ranging from 10 to 13% in the number of patients availing mental health services in primary and tertiary care facilities from 2016 to 2019. 22 During the program implementation review conducted by the National Mental Health Program in 2019, two Centers for Health Development (CHD)—those in Davao and in CaLaBaRZon—planned to implement a common project for patients with schizophrenia in some areas with CBMHPs in their respective regions.22 This is in accordance with the Republic Act 11036, also known as the Philippine Mental Health Act, which mandates that basic mental health services be provided in community settings.23 The Schizophrenia Project was designed to make mental health services accessible and antipsychotic medications readily available in municipalities with the highest burden of schizophrenia, the most common mental health condition in the region. The project involves community-level assessment, management, and follow up of patients with schizophrenia through the process described in the mhGAP-IG. In Davao, the ongoing Schizophrenia Project implementation has been made possible by the collaboration of primary care providers in rural health units (RHU) with psychiatrist consultants. Johnson & Johnson Philippines, the marketing authorization holder of paliperidone palmitate in the country, conducts training of health care workers involved in the project. DCHD finances the project and provides technical assistance to the RHUs. A pilot phase of the project was planned to run for one year in four implementation sites—Boston in Davao Oriental, Santo Tomas in Davao del Norte, Sta. Cruz in Davao del Sur, and Jose Abad Santos in Davao Occidental—which have been identified by DOH DCHD as having the highest numbers of patients diagnosed with schizophrenia in Davao Region. DCHD purchased paliperidone palmitate needed for project implementation in December 2019. In March 2020, Johnson & Johnson conducted the first training for health workers. Patient enrollment into the pilot phase started in July 2020 and was completed in October 2020. RHUs in the four implementation sites identified patients with probable schizophrenia through a community-based case-finding and referral strategy patterned after the mhGAP-IG. Among the four municipalities, a total of 49 patients—9 from Boston, 10 from Santo Tomas, 11 from Sta. Cruz, and 19 from Jose Abad Santos—were enrolled into the program. The enrolled patients were diagnosed, treated, and monitored at least every six months by the collaborating psychiatrists and RHU physicians. The RHUs were also tasked with setting-up communication lines for emergency consultations with the collaborating psychiatrists during crisis, providing counseling to the patients’ families, and conducting health promotion events to raise awareness on schizophrenia. After the one-year implementation of the pilot phase, health care providers were highly satisfied with the project. After initiation of treatment, most of the patients demonstrated improved symptoms, and some of them were able to perform household chores or return to work within a few months. None of the patients experienced hospitalization or relapse during the pilot phase. Health workers involved in drug dispensing and patient monitoring observed that the intravenous preparation of paliperidone palmitate used in this project facilitates easier supply inventory and patient tracking. DCHD also noted cost savings in expenditure on antipsychotic drugs when paliperidone palmitate was used in this project instead of the oral and conventional depot antipsychotic drugs used in the past. Health workers involved in the project also encountered some challenges during implementation. Many caregivers and families of patients in the project were not very cooperative in complying with the demands of the treatment sessions and social reintegration. After initiation of antipsychotic treatment, many patients could not comply with the regular follow up sessions, mostly because they live very far from the RHUs and could not afford the transportation costs of the visits. The Schizophrenia Project did not have a structured reintegration program, so many patients who were already in remission after a few months of treatment could not be properly reintegrated into their respective families and communities. During the project review after the pilot phase, stakeholders pointed out several good practices of individual municipalities that can possibly be scaled up or replicated by other CBMHPs implementing similar projects in the future. In Boston, the municipal health officer conducted a series of lectures on the social dimensions of mental health disorders to the caregivers and families of patients in the project. Those who attended the lectures have expressed an increased understanding of the nature of their patients’ condition. In Sta. Cruz, the RHU provided food (rice and snacks) and fare reimbursements to the families of patients who came during follow up checkups. The RHUs of Santo Tomas and Sta. Cruz involved the social welfare service units of their respective municipalities in the process of family and community reintegration of patients on remission. The pilot phase implementation of the Schizophrenia Project in the four municipalities in Davao has demonstrated that it is highly possible to integrate mental health services at the primary care and community settings, and achieve positive outcomes for patients, caregivers, health care providers, and the health system.

The design and outputs of the pilot implementation of the “Enhancing skills in screening and assessment for physicians and rehabilitation practitioners level 2 course”, Philippines, 2014

@#<p style="text-align: justify;"><strong>Background and Objectives:</strong> The Philippine Department of Health (DOH) is mandated by law to, among others, develop capacities and accredit physicians and rehabilitation practitioners across the country on the assessment and management of drug dependence. This paper describes the design and presents the outputs of an advanced course on screening and assessment of drug dependence developed by DOH in partnership with the College of Public Health of the University of the Philippines Manila, Philippine College of Addiction Medicine, and the Group for Addiction Psychiatry of the Philippines.</p><p style="text-align: justify;"><strong>Methodology:</strong> Review, abstraction and synthesis of data from training-related documents and records for the training activities implemented in 2014.</p><p style="text-align: justify;"><strong>Results:</strong> The Level 2a course is a five-day program that focuses on enhancing the skills of physicians and rehabilitation practitioners on the screening and assessment of drug dependence using team-based and practical learning approaches, and builds on learnings from the basic accreditation course. A total of 36 participants from ten Drug Abuse Treatment and Rehabilitation Centers (DATRCs) in nine regions completed the pilot implementation of the course in 2014. In general, the overall participant feedback on the training was mainly favorable based on data from 47% of participants who agreed or strongly agreed to statements on the relevance and attainment of the course aims (mean rating of 1.10±0.31, 1 = Strongly agree, 5 = Strongly disagree), and the appropriateness of its content (1.24±0.43) and design (1.18±0.39). A paired-samples t-test comparing scores for 44% of participants showed that there was a highly statistically significant difference in the pre-test (54%±13%) and post-test scores (69%±10%); t(16)=6.4240, p <0.0001.</p><p style="text-align: justify;"><strong>Conclusion:</strong> Development and design of capability-building initiatives in the field of drug rehabilitation will necessitate alignment with practice standards, grounding in the real-world setting in which professionals work, and orientation towards practical learning.</p>

Recovery in schizophrenia: Perspectives from psychiatrists in the Philippines

BACKGROUND@#A reliable and socially validated definition of recovery in schizophrenia is essential to decrease stigma associated with the illness. This study aimed to define recovery in schizophrenia in the Philippine context, determine its specific elements, and describe methods of assessment in clinical practice.@*METHODS@#We invited a group of purposively selected Filipino psychiatrists to participate in six simultaneous roundtable discussions to gather their opinions and perspectives on recovery in schizophrenia. Transcripts of the discussions were then subjected to framework analysis.@*RESULTS AND CONCLUSION@#Most Filipino psychiatrists were of the considered opinion that recovery in schizophrenia is possible, and their vision of a recovered patient resembles a combination of psychological and medical models. The mini-FROGS tool was deemed generally applicable in the Philippine setting except for self-esteem and sense of independence primarily because it is difficult to evaluate. The SWN was received with mixed reactions among the psychiatrists. Spirituality as an element of recovery and the family-oriented culture of the Filipinos were emphasized as important considerations in assessing patients. Other suggestions were given to tailor-fit these tools to the Philippine context.