The PHILIPPINE JOURNAL of

PSYCHIATRY
Official Journal of the Philippine Psychiatric Association

NYDIA FERMO

Depression Among Physicians in a Government Designated COVID-Center

Hospital During Coronavirus Disease-19 Pandemic

Factors Associated with Suicide Attempt Among Youth: A Retrospective

Review of Psychiatric Inpatients 15-24 Years Old Admitted for Suicidal
Ideation and Behavior at The Medical City (TMC) from 2013-2017

Validation Study of the Distress Thermometer: Psychosocial Distress

Screening Among Head and Neck Cancer Patients

Estimated Range of Cost of Treatment of Adult Schizophrenia Patients at a

Tertiary Government Hospital as of October 2015

Left Out - Persistent Pediatric Depression in Panhypopituitarism: A Case Report

VOLUME 2 (1-2) ANNUAL ISSUE
ISSN 2980-4884
2021
 PHILIPPINE PSYCHIATRIC
PHILIPPINE JOURNAL OF PSYCHIATRY
ASSOCIATION

BOARD OF OFFICERS 2022 EDITORIAL BOARD 2021

ANTONIO C. SISON, MD, FPPA (LIFE), FPDS GEORGINA GOZO- OLIVER, MD, DPBP, FPPA (LIFE) , FPSCAP
PRESIDENT EDITOR-IN-CHIEF
ANNA JOSEFINA VAZQUEZ-GENUINO, MD, MPH, DPBP,
ROBERT D. BUENAVENTURA, MD, FPPA (LIFE) FPPA (LIFE), FPSCAP
HECIL A. CRUZ, MD, DSBPP
VICE PRESIDENT MANUSCRIPT EDITORS
NINA KRISTY OSORIO - GRAPILON, MD, DSBPP
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MANAGING EDITOR
SECRETARY
NORIETA CALMA- BALDERRAMA MD, DPBP, FPPA
(LIFE), FPSCAP
ARNOLD ANGELO M. PINEDA, MD, FPPA, FPNA ALMA LUCINDO JIMENEZ, MD, FPPA (LIFE)
TREASURER CHRISTI ANNAH V. HIPONA, MD
ASSOCIATE EDITORS
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PUBLIC RELATIONS OFFICER EVANGELINE BASCARA DELA FUENTE, MD, MHA, MHPED, FPPA
TOMAS D. BAUTISTA, MD, MSC, FPPA
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ANGELO JESUS VECENTE V. ARIAS, MD, FPPA CARMINA G. BERNARDO, MD, FPPA, FPCPSYCH
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ANN PRINCESS P. GRANA-NESPRAL, MD, FPPA
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ENCARNITA RAYA-AMPIL, MD, FPNA, FPPA
IMMEDIATE PAST PRESIDENT PIA NATALYA T. REYES-SIA, MD, FPPA
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2021 · VOLUME 2 (1-2)

 PJP TABLE OF CONTENTS

ORIGINAL RESEARCHES PAGE

Depression Among Physicians in a Government-Designated COVID-Center Hospital during the 1

Coronavirus Disease-19 Pandemic
Nueva Joy A. Perucho, MD, PhD, MPM & Abegail Lozada-Laganao, MD, FPPA, FPSCAP

Factors Associated with Suicide Attempt Among Youth: A Retrospective Review of Psychiatric Inpatients
15-24 years old Admitted for Suicidal Ideation and Behavior at The Medical City (TMC) from 2013-2017 12
Anna Margarita G. Cruz, MD, DSBPP

Validation Study of the Distress Thermometer: Psychosocial Distress Screening among Head and Neck
Cancer Patients
22
Amor Joanna Indab, MD, FPPA

Estimated Range of Cost of Treatment of Adult Schizophrenia Patients at a Tertiary Government Hospital
as of October 2015 32
Anthony T. Abala, MD & Tomas Bautista, MD, FPPA

CASE REPORT

Left Out - Persistent Pediatric Depression in Panhypopituitarism: A Case Report

Jose Lorenzo A. Galan, MD 48
Jocelyn Nieva Yatco-Bautista, MD, FPPA, FPSCAP

ORIGINAL ABSTRACTS

Methods of Self-Injurious Behavior and Related Psychiatric Disorders Among Patients Seen at Baguio
General Hospital and Medical Center 58
Jennifer Espino, MD

A Descriptive Study of Stress as indicated by Perceived Stress Scale Scores Among the Neuropsychiatry
Unit Staff of the Makati Medical Center over a One Month Period in 2015 59
Alexandra A. Palis, MD

Comparison of C-reactive Protein Serum Levels Among In-patients with Acute Exacerbation of
Schizophrenia at the Veterans Memorial Medical Center (VMMC) Department of Psychiatry from August 60
2013 – July 2015.
Hannah Martella Maddatu Pajarillo, MD

SINAG: ART IN SCIENCE

Beach
61
Christmas Hope
The World in Painting 62
The Road of Life 63
INFORMATION FOR
64
CONTRIBUTORS
 PJP ORIGINAL RESEARCH

DEPRESSION AMONG PHYSICIANS IN A GOVERNMENT

DESIGNATED COVID-CENTER HOSPITAL DURING
CORONAVIRUS DISEASE-19 PANDEMIC *
NUEVA JOY A. PERUCHO, MD, PHD, MPM,
ABEGAIL LOZADA-LAGANAO, MD, FPPA, FPSCAP

ABSTRACT
ABSTRACT
OBJECTIVES: This study aimed to determine the prevalence, most common symptoms and
OBJECTIVES: THIS STUDY AIMED TO DETERMINE THE PREVALENCE, MOST
sociodemographic factors associated with depression among physicians in a government
COMMON SYMPTOMS AND SOCIODEMOGRAPHIC FACTORS ASSOCIATED
COVID-Center i.e. Southern Philippines Medical Center-Institute of Psychiatry & Behavioral
WITH DEPRESSION AMONG PHYSICIANS IN A GOVERNMENT COVID-
Medicine
C E N TinE Bajada,
R I . E . Davao
S O U TCity.
HERN PHILIPPINES MEDICAL CENTER-INSTITUTE OF
PSYCHIATRY & BEHAVIORAL MEDICINE IN BAJADA, DAVAO CITY.
METHODOLOGY:
M E T H O D OThis L O Gcross-sectional,
Y : T H I S C R Osurvey-based
S S - S E C T I Ostudy
N A L ,collected
SURVEY socio-demographic
- B A S E D S T U D Ydata
and COPHQ-9
L L E Cscores
T E D Susing
OCIO Google
- D E MForms,
O G R AfromP H I Cresident
D A T A physicians
A N D P H Qfrom - 9 SJulyC O 1R EtoS August
U S I N G31,
2020.
G O OMultinomial
GLE FORM logistics
S, FRO regression
M R E S I analysis
D E N T Pwas HYS used
ICIA toNidentify
S F R Orisk M Jfactors
U L Y 1 ofT O depression.
AUGUST
31, 2020. MULTINOMIAL LOGISTICS REGRESSION ANALYSIS WAS USED TO
RESULTS: Two hundred I D E Nfifty-one
T I F Y R I(251)
S K FoutA C TofO376
RS O F D E P R Eresponded
physicians S S I O N . (68.39% response
R EThe
rate). S U average
LTS: TW ageO was
H U N30 D Ryears
E D Fold,
I F T majority
Y - O N E were
( 2 5 1 female
) O U T (58.57%,
O F 3 7 6147), PHY S I C I(78.88%,
single ANS
R198),
ESPO N D E D ( 6(77.29%,
frontliners 8 . 3 9 % 194),
R E S Pwith
O N Saverage
E R A T Ehospital
). THE A V E R A G E ofA G
experience E years.
2.0 W A S 3Ninety0 Y E Asix
RS
O L D ,were
(38.26%) M A Jassigned
ORITY W inEsurgical
R E F E Mdepartments
A L E ( 5 8 . 5 7while
% , 1 41557 ) , (61.75%)
S I N G L Eworked
( 7 8 . 8 in
8 %nonsurgical
, 198),
Fdepartments.
R O N T L I N E RThere
S ( 7 7were
. 2 9 %twelve
, 1 9 4 respondents
) , W I T H A V(4.78%)
E R A G Ewho H OhadS P aI Thistory
A L E X of P Epsychiatric
R I E N C E Oillness
F 2.0
Yand
E A R31S .(12.35%)
NINETY had S I previous
X ( 3 8 . 2 psychiatric
6 % ) W E R Eintervention,
A S S I G N E DwhileI N S66 U R(26.29%)
G I C A L had D E PaA history
R T M E Nof
TS
Wmedical
HILE 15 5 ( 6 1 .Eighty-five
illness. 7 5 % ) W O(33.86%)
R K E D I Nhad N Odepression
N S U R G I Cusing
AL DE PARTM
PHQ-9; 57E (22.71%)
N T S . T Has E Rmild,
E W E19RE
TWELVE RESPONDENTS (4.78%) WHO HAD A HISTORY OF PSYCHIATRIC
(7.57%) moderate, 7 (2.79%) moderately severe and 2 (0.8%) severe. Out of 85 residents who
ILLNESS AND 31 (12.35%) HAD PREVIOUS PSYCHIATRIC INTERVENTION,
were depressed, the most common symptoms were: low energy (81, 95.29%); anhedonia (76,
WHILE 66 (26.29%) HAD A HISTORY OF MEDICAL ILLNESS. EIGHTY-FIVE
89.41%); and feeling depressed (72, 84.70%). Medical illness was associated with higher levels
(33.86%) HAD DEPRESSION USING PHQ-9; 57 (22.71%) AS MILD, 19 (7.57%)
of depression. Physicians with a history of psychiatric illness, psychiatric intervention and
MODERATE, 7 (2.79%) MODERATELY SEVERE AND 2 (0.8%) SEVERE. OUT
medical Oillness
F 8 5 hadR E Ssignificantly
I D E N T S WhigherH O WlevelsE R E ofD Edepression.
PRESSED, THE MOST COMMON
SYMPTOMS WERE: LOW ENERGY (81, 95.29%); ANHEDONIA (76, 89.41%);
CONCLUSION:
A N D F EMore ELING thanD EaPthird
R E S S(33.86%)
E D ( 7 2 of, 8physicians
4.70%). M screened
E D I C A Lpositive
ILLNES forS depression.
WAS
Current
A S S O Cmental
I A T E Dhealth
W I T Hprograms
H I G H E Rmust L E Vbe
ELS strengthened
O F D E P R Eand S S Imade
O N . Pspecific,
H Y S I Cto IAN prevent
S W I T HandA
address
HISTO depression
R Y O F Pespecially
S Y C H I A Tamong
R I C I Lthose
L N E S who
S , P have
SYCH a Ihistory
A T R I C ofI Npsychiatric
T E R V E N T Iand
O N medical
AND
illness.
MEDICAL ILLNESS HAD SIGNIFICANTLY HIGHER LEVELS OF DEPRESSION.
CONCLUSION: MORE THAN A THIRD (33.86%) OF PHYSICIANS SCREENED
P O S I T I V E Depression,
KEYWORDS: F O R D E P RMedical
E S S I OIllness,
N . C UResident
R R E N T Physicians,
MENTAL H EALTH
PHQ-9, P R O G RPandemic
COVID-19 AMS MUST
BE STRENGTHENED AND MADE SPECIFIC, TO PREVENT AND ADDRESS
D E P R E SatSthe
* Presented ION E S P E CPsychiatric
Philippine I A L L Y A MAssociation
O N G T H ONational
S E W H Awards
O H A Vfor E A H I S T OJanuary
Research R Y O F 21,
2020 PSYCHIATRIC AND MEDICAL ILLNESS.

1 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

INTRODUCTION
Coronavirus Disease-19 is a global infectious
disease that has been elevated to a pandemic
status by the World Health Organization on
March 12, 2020, with a case-fatality ratio
reported to be about 3.4-5.8%. (1)
The Philippines had its first confirmed case on
January 30, 2020 and reported its first local
transmission on March 7, 2020. (1) The city of
interest had its first case on March 15, 2020. By
March 31, the tertiary hospital wherein the study
was conducted became a Government-
Designated COVID-19 Center Hospital. (2)
A review of psychological impact of epidemic
outbreaks showed that depression rates could be
as high as 27.5% to 50.7% (3) among health care
workers (HCW), with much higher rates during
the current pandemic at 50.4 to 50.7%. (4,5)
Depressive symptoms in HCWs can be sustained
(6,7), and rates may vary when screening is
done at different time points - during and after
outbreaks. (5,8) Furthermore, depression
amongst physicians has been shown to increase
the risk of medical errors (9) and can translate
into poor quality of care, desired outcomes in
terms of morbidity and mortality rates, and
patient experience. (10)
The Patient Health Questionnaire-9 (PHQ-9) is a
9-item self-rating instrument and is based on the
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM IV) criteria for
Major Depressive Disorder. Aside from ease of
completion, scoring and interpretation, publicly
available; the questionnaire could be used
among diverse populations. Respondents rated
the items from 0-3 according to the frequency of
their experience over the previous two weeks.
The items were summed up to give a total score
for depression severity. Theoretical score range
was 0-27. The standardization of the total score
was: 1-4 for Minimal Depression; 5-9 for Mild
Depression; 10-14 for Moderate Depression; 15-19
for Moderately Severe Depression; and 20-27
for Severe Depression. A score of 10 or more
had a sensitivity and specificity of more than
88% for Major Depressive Disorder. (11)
The unprecedented nature of the COVID-19
outbreak has caused psychological stresses for
HCWs. (3)
Mental health measures should be available to
identify and limit psychological morbidity
among HCWs as a high-risk group. (4, 6,12)
However, local data on the psychological impact
of the COVID-19 pandemic was scarce.
Information regarding the prevalence of
depression, its common manifestations and risk
factors would facilitate integration of
psychosocial responses to administrative
policies for the current outbreak and guide
preparedness planning for future infectious
disease outbreaks as well.
This study aimed to assess the prevalence of
depression among physicians in a government-
designated COVID-Center Hospital during
COVID-19 Pandemic. Specifically, the study
determined the 1) socio-demographic profile of
resident physicians in terms of their age, sex,
marital status, hospital experience in years, area
of assignment, department of assignment,
history of psychiatric illness, previous
psychiatric intervention and history of medical
illness; 2) prevalence of depression; 3) most
common symptoms of depression; and 4)
predictors of depression using multinomial
logistic regression analysis.
METHODOLOGY
This study was a descriptive-analytical, cross-
sectional, hospital-based survey using the
screening tool PHQ-9, conducted online using
Google Forms, amongst all resident physicians
in a tertiary hospital.
This research underwent evaluation from the
Institutional Review Board and was approved
for conduct in May 2020. Data was gathered
from July 1 to August 31, 2020.
All resident physicians were invited to
participate in the study. A written request to
individual departments was sent to obtain
mobile numbers and e-mail addresses of the
residents. A text message and an e-mail with
individually assigned codes were sent to the
intended respondents, along with a link that
would lead to an online survey. To ensure
anonymity and confidentiality, respondents
were required to input their identifying code
when answering the online survey. Only the
author of this research knew the names and
codes of the respondents.
2 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
The online survey required the respondents’
consent to proceed. The consent form included
information on the study objectives, significance,
risks, benefits and confidentiality measures. The
respondents were also informed of their right to
refuse or withdraw from the study and were
given an option to receive feedback of their
results as well as to consent to receive a referral
form from the author should their PHQ-9 scores
be ≥10.
Sociodemographic data was reported by the
participants themselves that included age, sex,
marital status, hospital experience in years
(defined as number of years spent working in a
hospital setting from the time license was
obtained to practice as a medical doctor), area
of assignment (frontline vs second-line),
department of assignment (surgical vs non-
surgical), history of psychiatric illness, previous
psychiatric intervention (interventions included
any psychosocial or psychiatric intervention that
included pharmacotherapy, psychotherapy and
psychological first aid), and history of medical
illness. Upon completion of the socio-
demographic survey, the respondents then
answered the PHQ-9 tool.
In this study, frontline physicians were
physicians who were directly engaged in clinical
activities of diagnosing, treating, or providing
care to patients who were probable, possible or
confirmed COVID-19 cases; while second-line
physicians referred to physicians who were not
directly engaged in clinical activities of
diagnosing, treating, or providing care to
patients who are probable, possible or
confirmed COVID-19 cases.
Considering that this study was conducted at the
height of the Corona Virus Pandemic, residents
from all departments were required to rotate in
the COVID Wards. It has also been noted in a
study by Bianco et al, that health care providers
assigned to surgical departments may have
more stressful environments with increased risk
of COVID-19 infection due to aerosol-generating
medical procedures thus the department of
assignment, was categorized as surgical or non-
surgical. (13)
Data was processed using Statistical Package for
Social Sciences SPSS statistical software version
19.0 (IBM Corp).
3 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
The significance level was set at alpha = 0.05.
The ranked data, which were derived from the
count of each level for symptoms of depression
were presented as frequencies and percentages.
Means were used to determine individual
average PHQ-9 scores.
The nonparametric Mann-Whitney U test and
Kruskal-Wallis test was applied to compare the
severity of each symptom between two or more
groups, respectively.
Multinomial logistic regression analysis was
performed to determine factors associated with
symptoms of depression in participants.
RESULTS
Two hundred fifty-one (251) out of 376 resident
physicians responded (response rate of 68.39%).
The average age of respondents was 30 years
old.
The majority were female (58.57%, 147), single
(78.88%, 198), with average hospital experience
of 2.0 years. The majority were front liners
(77.29%, 194), with 96 (38.26%) assigned in
surgical departments and 155 (61.75%) assigned
in nonsurgical departments.
There were 12 (5%) who had a history of
psychiatric illness; while there were 31 (12%)
who had undergone previous psychiatric
intervention.
Of the twelve (12) respondents who had a
history of psychiatric illness, only two (2/251,
0.80%) indicated that they had received
psychiatric intervention and only three (3/125,
1.2%) of them had scores of ten or higher, who
were subsequently referred for psychiatric
evaluation and management. There were 66
(26%) who had a medical illness. (Table 1)
Eighty-five (33.9%) of the respondents had
depression according to PHQ-9, with 57 (22.71%)
classified as mild, 19 (7.57%) as moderate, 7
(2.79%) as moderately severe and 2 (0.8%) as
severe. (Figure 1)
Among the 85 residents who were depressed,
the most common symptoms were: low energy
(81, 95.29%); anhedonia (76, 89.41%); and feeling
depressed (72, 84.70%) (Figure 2)
 TABLE 1. SOCIODEMOGRAPHIC CHARACTERISTICS & PHQ-9 SCORES OF RESIDENT
PHYSICIANS

Severity of Depression (PHQ-9 Scores)

Sociodemographic Profile Total (N=251)
1-4 (n=166) 5-9 (n=57) 10-14 (n=19) 15-19 (n=7) 20-27(n=2)

Age in Years (Median) 30 29 30 31 31 30

# % # % # % # % # % # %

<26 3 1.8 1 1.75 0 0 0 0 0 0 4 1.59

26-30 94 56.63 42 73.68 13 68.42 3 42.86 1 50 153 60.96

31-40 66 39.76 14 24.56 6 31.57 4 57.14 1 50 91 36.25

>40 3 1.8 0 0 0 0 0 0 0 0 3 1.2

Sex

Female 98 59.04 36 63.16 8 42.11 4 57.14 1 50 147 58.57

Male 68 40.96 21 36.84 11 57.89 4 57.14 1 50 104 41.43

Civil Status

Single 124 74.7 52 91.22 15 78.95 6 85.71 1 50 198 78.88

Married 40 24.1 5 8.77 4 21.05 1 14.29 1 50 51 20.32

Separated 2 1.2 0 0 0 0 0 0 0 0 2 0.8

Widowed 0 0 0 0 0 0 0 0 0 0 0 0

Divorced 0 0 0 0 0 0 0 0 0 0 0 0

Hospital Experience in Years

82 2 2 1 1.5 2
(Median)

1 year and below 52 31.33 27 47.37 8 42.11 4 57.14 1 50 92 36.65

2 years 35 21.08 12 21.05 4 21.05 2 28.57 1 50 54 21.51

3 years 48 28.92 12 21.05 2 10.53 1 14.29 0 0 63 25.1

4 years and above 31 18.67 6 10.53 5 26.32 0 0 0 0 42 16.73

Area of Assignment

Frontline 128 77.11 45 78.95 14 73.68 6 85.71 1 50 194 77.29

Second line 38 22.89 12 21.05 5 26.32 1 14.29 1 50 57 22.71

Department of Assignment

Surgical 63 37.95 20 35 11 58 2 28 0 0 96 38.26

Non-surgical 103 62.05 37 65 8 42 5 72 2 100 155 61.75

History of Psychiatric Illness
Yes 4 2.41 5 8.77 1 5.26 1 14.29 1 50 12 4.78

No 162 97.59 52 91.23 18 94.74 6 85.71 1 50 239 95.23

Previous Psychiatric Intervention

Yes 14 8.43 8 14.04 6 31.58 2 28.57 1 50 31 12.35

No 152 91.57 49 85.96 13 68.42 5 71.43 1 50 220 87.65

History of Medical
Illness

Yes 34 20.48 19 33.33 9 47.37 3 42.86 1 50 66 26.29

No 132 79.52 38 66.67 10 52.63 4 57.14 1 50 185 73.71

4 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

 FIGURE 1. PREVALENCE AND SEVERITY OF DEPRESSION BASED ON PHQ-9 (N= 251)
Among the 85 residents who were depressed, the
most common symptoms were: low energy (81,
95.29%); anhedonia (76, 89.41%); and feeling
depressed (72, 84.70%)
(Figure 2)
Significant results were found among physicians
with a history of medical Illness (p-value 0.006),
history of psychiatric illness (p-value 0.00)d and
history of psychiatric intervention (p-value
0.00).
Specifically, physicians who had these histories
had significantly higher levels of depression
compared to their counterpart group (p<0.05).
No significant results were found across other
variables. (Table 2)
Furthermore, history of medical illness is
associated with higher levels of depression
5 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
(OR=0.438 [CI: 0.230 - 0.834], p-value=.012,
Wald=6.305). (Table 3)
DISCUSSION
Sociodemographic Characteristics
Age
Average age of the participants was 30 years
old. In this study, age does not appear to be
associated with depression. Of note, the majority
of the respondents in this study (244/ 251 =
97.21%) belong to the age group of 26-40 years
old. Findings agree with review of researches
pre-pandemic by Joules et al. in 2014 wherein
age of participants is not associated with rates
and severity of depression. (14)
Sex
Of the 85 (33.86%) who screened positive for
depression, 49 (57.65%) are females and 36
TABLE 3. RISK FACTORS FOR HIGHER LEVELS OF DEPRESSION IDENTIFIED BY MULTINOMIAL LOGISTIC REGRESSION ANALYSIS

CI (95%)
Variables Wald p-value Odds ratio
LU UB

Age

30 years old and

.175 .676 .863 .433 1.721
below

Above 30 years old Reference group

Sex

Female .005 .944 .980 .553 1.735

Male Reference group

Civil Status

Single 2.751 .097 .494 .215 1.137

Marriedc Reference group

Hospital Experience

1 year and below 2.689 .101 .464 .185 1.162

2 years .965 .326 .604 .221 1.652

3 years .126 .723 1.194 .447 3.189

4 years and above Reference group

Area of Assignment

Frontline .027 .870 1.061 .524 2.146

Second-line Reference group

Department of Assignment

Surgical 1.004 .316 .737 .405 1.340

Non-Surgical Reference group

History of Psychiatric Illness

Yes 1.149 .284 .410 .080 2.093

No Reference group

Previous Psychiatric Intervention

Yes .585 .444 .668 .238 1.878

No Reference group

*History of Medical Illness

Yes 6.305 .012* .438 .230 .834

No Reference group

CMARRIED CATEGORY INCLUDED DIVORCED PARTICIPANTS. UB - UPPER BOUND LB - LOWER BOUND

6 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

(42.35%) are males. There was no gender-
differences in terms of depression and gender
was not associated with depressive symptoms in
this study.
In other studies however, female gender has
been shown to be associated with increased risk
of depression in resident physicians (14) and
with increased suicide rates compared to males.
(15) During the current pandemic, females were
found to have higher rates both in the general
population (16, 17) and among HCWs. (4,18)
Higher rates in women, as suggested by
Hammerberg et al., may be due to the
disproportionate burden of unpaid caregiving.
(16)
Civil Status
In this study, there were no differences in the
levels of depression across single and married
resident physicians, and civil status was likewise
not associated with depression. Findings coincide
with a study from Joules et al. where marital
status and social support was not predictive of
screening positive for depression. (14)
Hospital Experience
Hospital experience was not associated with
depressive symptoms in this study. Findings
during the SARS outbreak however, found that
HCW with less experience had new onset
psychiatric disorders (8), while Joules et al. (14)
reported higher rates of depression amongst
resident physicians during the early years of
training. Our findings may be due to perceived
adequacy of training, and feelings of
preparedness among resident physicians, that
were purported to be protective of mental
health. (19) These factors can be strengthened
with training and education programs prior to
outbreaks. (20)
Area of Assignment
There was no significant difference in PHQ-9
scores between frontline and second line
physicians. Area of assignment in this study was
not predictive of depressive symptoms.
This study finding may be attributed to resident
physicians’ strong sense of altruism (21) and
hardiness (being able to adapt better in a crisis)
that may have mitigated the psychological
impact. (22)
A study among physicians and nurses in China,
however, found that HCWs who were assigned in
the frontlines were at higher risk of symptoms of
depression. (4)
Assigned Department
This study found no significant associations
between department assigned and rates of
depression. Likewise, there was no significant
difference in rates of depression between
surgical and nonsurgical departments. These
agree with a previous study by Mata et al. where
there was no statistically significant difference
observed between cross-sectional vs longitudinal
studies in studies comparing surgical and
nonsurgical residents. (23)
History of Psychiatric Illness
In this study, respondents with a history of
psychiatric illness and psychiatric intervention
showed significantly higher levels of depression
compared to those who had none.
Studies, which examined prevalence of
psychiatric morbidity among HCWs after the
SARS outbreak (8, 24), as well as studies
conducted during the COVID-19 pandemic (3,
25) showed that previous history of psychiatric
illness was a predictor of developing depression.
Moreover, a study among HCWs in a low
resource setting in Nepal, found that history of
taking medications for mental health problems
were associated with higher likelihood of
developing depression. (25)
Depression among physicians has been linked to
occupational distress and stressful working
conditions (26) and was more likely to develop
among those with a history of the disorder. (14)
This finding underlines the importance of
awareness of physicians of their personal risk in
order to respond to emergent symptoms of
depression (8), and caution in placing physicians
with a history of psychiatric illness in highly
stressful situations. (24)
History of Medical Illness
History of medical illness in this study was a risk
factor for developing higher levels of
depression. Likewise, those who had medical
illness had significantly higher levels of
depression compared to those who had none.
7 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
A study among at-risk groups in the United
Kingdom (27) and among HCWs in China
during the COVID-19 pandemic (28), identified
existing physical illness as a factor for
developing depression. Similarly, a hospital
survey comparing rates of depression before
and during COVID-19 pandemic (29), found
increased rates of depression among those who
were medically ill. This may be due to common
comorbidities that have been associated with
severity and increased mortality in COVID-19
infection such as hypertension, diabetes,
cardiovascular diseases, chronic obstructive
pulmonary disease, chronic kidney disease and
cancer. (30, 31)
Rates of Depression
Among the 251 resident physicians who
participated in the study, 33.86% screened
positive for depression rates using PHQ-9 scale.
This finding is lower than depression rates in
studies found on HCWs by Lai et al. and Liu et al.
in China with depression rates 50.4-50.7%, using
PHQ-9 score of equal and greater than five. (4,5)
The city in study had a relatively lower number
of cases compared to the regions where the
studies in comparison were conducted. (32) Also,
the data was gathered relatively early in the
course of the outbreak i.e. four months after the
start of the outbreak.
Although Psychological First Aid (PFA) was
initiated by the Institute of Psychiatry and
Behavioral Medicine among residents in the
hospital of study, only 31 (12.35%) received any
form of psychiatric intervention at the time data
were gathered.
Studies have shown that psychological support to
HCWs (33) along with training in novel tasks and
personal protection (8) may improve
adaptability and coping during pandemic even
among HCWs who are at high risk of developing
depression.
Chen et al. further advised that psychiatric
interventions should be specific to the needs of
the medical staff, otherwise, reluctance may be
encountered. (34) In their study, provision of a
place for rest, isolated from the staff’s family;
food and daily living supplies; detailed rules on
the use and management of PPEs; leisure
8 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
activities and relaxation training; and regular
psychological counsellors were instrumental in
mitigating psychological impact.
Chen et al. further advised that psychiatric
interventions should be specific to the needs of
the medical staff, otherwise, reluctance may be
encountered. (34) In their study, provision of a
place for rest, isolated from the staff’s family;
food and daily living supplies; detailed rules on
the use and management of PPEs; leisure
activities and relaxation training; and regular
psychological counsellors were instrumental in
mitigating psychological impact.
Symptoms of Depression
The most common depressive symptoms among
the 85 residents who were depressed in this
study were low energy low energy (81, 95.29%);
anhedonia (76, 89.41%); and feeling depressed
(72, 84.70%).
High percentages of low energy may be from
physical exhaustion from high work demands in
an outbreak. Dimitriu et al. explained that
physical fatigue in the context of the pandemic
could add to the mental stress among resident
physicians. (35) Prolonged use of personal
protective equipment and its physical effects
(36), modification of shifts and work schedule
and difficulty in interactions due to PPE use,
could contribute to physical fatigue. (35)
Anhedonia was one of the most treatment-
resistant symptoms in depression and could be
related to severity of depressive
psychopathology, dysfunctional impulsivity and
recurrent suicidal ideation. (37)
Concurrent with this study’s findings,
Hacimusalar et al., in 2020 found that
hopelessness was increased among HCWs
compared to non-HCWs during the COVID
pandemic. (38) Hopelessness has also been
shown to increase suicidal ideation. (39,40)
LIMITATIONS & RECOMMENDATIONS
Only resident physicians in one tertiary hospital
were the respondents of the study and therefore
this study cannot make generalizations to other
resident physicians from other hospitals. Data
was gathered during the early phase of the
outbreak and lacked longitudinal follow up. The resident physicians in a tertiary hospital
cross-sectional nature of the study did not allow screened positive for mild to severe depression
for determination of temporality. using PHQ-9.

This study was unable to distinguish if the
symptoms of depression were associated with
being a physician or with living in a city with a
viral outbreak since there was no comparator
group. This study was unable to differentiate if
the depressive symptoms were from a pre-
existing psychiatric illness or were new-onset
symptoms. Collection of data from multiple
centers, longitudinal follow-up and having a
comparator group are recommended for future
studies.
Although the study asked for participants’
history of psychiatric intervention, the study did
not specify which psychiatric interventions
(pharmacologic or nonpharmacologic) the
participants availed. Specifying the treatment
received will provide a clearer data.
Measures to reduce work related physical
exhaustion and to promptly identify significant
depressive symptoms, particularly those that
increase risk of suicide, was necessary. Current
mental health support programs must be
strengthened and made specific, to prevent and
address depression especially among those who
have a history of psychiatric and medical illness.
ACKNOWLEDGMENTS
The authors are grateful for all the participants
who contributed to our work. The authors
acknowledge the aid of Ms. Arnie Joy Vallejo for
her expertise in statistical analysis.

Despite the response rate being 68%, response

bias was still present if the non-responders were
either not interested in the survey or too stressed
to participate. Extending the sampling period
may have provided ample time for participants
to answer the online questionnaire.

Although the absence of face-to-face interviews

would have allowed respondents to feel more
comfortable in reporting their symptoms, it also
prevented the tracing and investigation of
nonresponders and follow-up of staff members
who needed help.

Longitudinal studies on the same population

may be conducted to investigate depressive
symptoms during the different phases of the
pandemic.

Furthermore, this study did not investigate on

other mental health issues that could arise in a
pandemic such as anxiety, stress, resilience, etc.
Studies investigating these responses are
suggested.

CONCLUSION

Four months after the outbreak of the COVID-19

pandemic, more than a third (33.86%) of

9 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

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11 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

 PJP ORIGINAL RESEARCH

FACTORS ASSOCIATED WITH SUICIDE ATTEMPT AMONG YOUTH:

A RETROSPECTIVE REVIEW OF PSYCHIATRIC INPATIENTS 15-24
YEARS OLD ADMITTED FOR SUICIDAL IDEATION AND BEHAVIOR
AT THE MEDICAL CITY (TMC) FROM 2013-2017
ANNA MARGARITA G. CRUZ, MD, DSBPP

ABSTRACT

OBJECTIVES: This study aimed to determine the factors associated with suicide attempt among
psychiatry inpatients aged 15 to 24 years old, admitted for suicidal ideations or behavior at The
Medical City during a five-year study period, January 2013 to December 2017; to describe the
demographic and clinical profile of these patients; and to determine if there was an association
between demographic and clinical factors as well as suicidal attempt in this population.

METHODOLOGY: This retrospective chart review, investigated the association between

demographic and clinical variables, and suicide attempt in a sample of suicidal psychiatry
inpatients aged 15-24 years old, during a 5-year study period. The sample was subdivided into
two subsets according to the presence or absence of suicide attempts in their lifetime. The
demographic and clinical variables were then collected, analyzed, and compared between the
two groups.

RESULTS: The present study reviewed 199 charts of suicidal psychiatry inpatients aged 15-24
years old hospitalized from 2013 to 2017 at The Medical City. The present study found an
increasing trend in the number of psychiatric inpatients aged 15 to 24 who were confined for
suicidal ideation and/or behavior over the course of the study period. Of the 199 subjects
included in the study, 119 (59.8%) had attempted suicide, while 80 (40.2%) had not.

CONCLUSION: On comparison of the demographic and clinical factors among patients with a
suicide attempt versus without an attempt, sex was found to be significantly associated with an
attempt (p-value = 0.01). Specifically, the odds of a suicide attempt was twice higher among
females (odds ratio = 2.27). Among the other demographic and clinical variables studied, no
sufficient statistical evidence was found to declare significant statistical association with
suicide attempt. This suggests that etiological factors related to suicide attempts for male and
females may differ, hence such nuances need to be taken into account in the clinical
assessment and design of interventions to prevent suicide.

KEYWORDS: Suicide Attempt, Suicidal Behavior, Youth

12 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

INTRODUCTION
Suicide is emerging as a significant health
concern among Filipino youth, but few local
studies have investigated possible precursors of
the act.
According to a Philippine time trend analysis
study, rates of suicide has consistently increased
from 1984 onwards. (1) Suicide incidence
increased from 0.23 to 3.59 per 100,000 in males
and 0.12 to 1.09 per 100,000 in females between
1984 and 2005. (1) More significantly, for most
of the yearly periods studied in the time trend
analysis, suicide rates were highest among those
aged 15-24 years of age. (1)
The Young Adult Fertility and Sexuality survey,
which is representative both at the national and
regional level, also highlights the increasing
threat of suicide among the Filipino youth. (2)
The survey indicated that 8.7% of respondents
reported to have thought of committing suicide,
while 3.2%, reported to have attempted suicide at
least once. (2)
Despite the rising suicide rates among Filipino
youth however, substantive local studies on
suicidal behavior and its precursors remain
sparse. The current study aims to expand the
present literature on suicide in the young by
providing a descriptive profile of Filipino
suicidal youth, as well as shed some light on the
possible risk factors for suicide attempts. The
seriousness of suicide among youth is
undisputed, as it is the third leading cause of
death among adolescents world-wide. (3)
According to the Center for Disease Prevention
and Control, suicide accounts for 20% of all
deaths among 15 to 24 -year-olds annually. (4)
The World Health Organization defines “youth”
as individuals in the 15 to 24- year age group. (5)
This time period, which bridges childhood to
adulthood, is a critical period characterized by
changes in the body and brain, as well as by the
need to face unique developmental and
psychological challenges and tasks.
An American study showed, that suicide ideation
is very low (1%) from birth to 10 years of age,
then increases slowly through 12 years of age,
and then more rapidly from 12 and 17 years of
age. (6).
The prevalence of attempts, in comparison,
remains very low (1%) until 12 years of age, then
increases in a roughly linear fashion starting 15
years of age. (6) Several studies have reported a
similar peak of hazard age of suicidal behaviors
around 15 years old. (7-8)
Suicide attempts are comparatively high among
youth compared to the older population. The
Center for Disease Control and Prevention
found that among 15 to 24- year-olds; there were
approximately 100-200 attempts for every
completed suicide. This is in contrast to the data
among the older adults and the elderly, wherein
there is 1 completed suicide for every 25
attempts. (4) Although the majority of these
attempts were of low medical lethality, having
made a past suicide attempt was the strongest
predictor of both future suicide attempts and
completions. (9)
In the country, 8.7% of Filipino youth reported to
have thought of committing suicide, while 3.2%,
reported to have attempted suicide at least once.
(2) In the survey conducted, no suicide
attempter reported negatively for suicide
ideation, which means that all cases of suicide
attempts followed the typical flow of thinking of
suicide first before attempting the act. (10) The
top 3 methods used for suicide attempt among
Filipino youth were: slashing of wrist, 48.4%;
ingesting substances, 26.9%; and hanging 12.2%.
(2) Other means of suicide attempt included
stabbing of oneself, jumping into a river,
throwing oneself under a vehicle, jumping from
a building, and starving oneself. (2)
Given the prevalence of suicide attempts among
youth, numerous studies have tried to
understand suicidal behavior and its predictors
in more developed countries, however literature
in the local setting is still limited.
Locally, the most extensive study exploring
suicidal behavior among youth found significant
relationships between integration in the family
and suicide. (10) The study revealed that family
problems, 69.8%, were cited as the most common
reason behind suicide ideations among Filipino
youth. This was followed by personal problems,
which included economic loss and academic
failure at 17.7%, and romantic problems at 7.5%.
(10) Other possible correlates of suicidal
ideation and
13 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
behavior, such as presence of a psychiatric
disorder, chronicity of suicidal ideation, history
of substance use prior to attempt, history of
adverse childhood experiences (ACE), presence
of psychiatric illnesses/suicide in the family,
were not explored however.
Internationally, several researches have
explored the link between demographic and
clinical factors, and suicidal behavior in this
critical phase of life. In a study conducted
among South Korean adolescents, perceived low
socio-economic status was associated with both
increased rates of suicidal ideation and attempt.
(11) Self-reported levels of academic
performance that were fair or poor were also
associated with an increased prevalence of
suicidal behaviors. (11) Adverse family
circumstances, such as low satisfaction with the
family environment, low parental monitoring,
and parental history of psychiatric disorder,
were significantly associated with suicidal
ideation and behavior among the adolescent
population. (9)
Studies also showed that ACE, such as emotional
abuse, physical abuse, sexual abuse, battered
mother, household alcohol/drug abuse, mental
illness in the household, parental separation or
divorce, incarcerated household member,
increased the risk of attempting suicide from 2-
to 5-fold. With this, it is crucial to note that the
risk of attempting suicide, increased
dramatically, the more ACE a person was
exposed. (12)
In terms of psychiatric co--morbodity, current
research showed that majority of adolescents
with a history of suicide ideation (89.3%) and
attempts (96.1%) met the criteria for at least 1
psychiatric diagnosis. (6) Interestingly, most
psychiatric disorders (major depressive
disorder, dysthymic disorder, generalized
anxiety disorder, panic disorder, attention-
deficit/hyperactivity disorder, conduct disorder,
and substance use disorder) were related to
increased risk of attempts among the adolescent
population. (13) This is an important finding, as
it emphasized that although many suicide
attempts occur in the context of depressive
disorders, almost all psychiatric morbidity
among young people is associated with
increased risk for suicidal behavior. (13)
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The current study was guided by an ideation-to-
action framework as suggested by a Western
study differentiating suicide attempters from
suicide “ideators”. (14) The study by Klonsky and
May, revealed that close examination of the
various suicide literature available revealed a
key knowledge gap. (14) Specifically, often cited
risk factors for suicide were, in actuality, risk
factors for suicide ideation, and not for
progression from suicide ideation to attempts.
(14)
According to the study, many significant risk
factors for suicide in literature were more
strongly related to ideation than to progression
from ideation to a plan or an attempt. (14) For
example, depression, and hopelessness has long
been emphasized as an important suicide risk
factor. (15) However, careful examination of the
literature indicated that, while elevated among
suicide ideators relative to non-suicidal controls,
these two factors failed to discriminate between
suicide ideators and attempters. (14)
Considering the high rates of suicide attempts
among youth and the fact that 40% of youth
suicides had made a prior attempt, making it a
strong risk factor for completed suicide. (16)
Information regarding possible precursors of
suicide attempt is critical to develop effective
suicide prevention programs in the country. It is
with this notion in mind, that the present study
was developed.
General Objectives
Determine the factors associated with suicide
attempt among psychiatry inpatients aged 15 to
24 -years old, admitted for suicidal ideations or
behavior at The Medical City during a five-year
study period, January 2013 to December 2017.
Specific Objectives
1. Describe the demographic (age, gender,
marital status, religion, educational
attainment, work status, living arrangement)
and clinical (inciting event, previous
psychiatric consult, chronicity of suicidal
ideation, substance use prior to current
admission, history of suicide of an
acquaintance or family, history of
psychiatric illness in the family, history of
non-suicidal self-injury, exposure to adverse
childhood experiences, psychiatric
diagnosis) profile of patients aged 15-24 years
old admitted for suicidal ideations or behavior
at The Medical City from 2012 to 2017.
2. Determine if there is an association between
demographic and clinical factors, and suicidal
attempt, among psychiatry patients aged 15-24
years old admitted for suicidal ideations or
behavior.
METHODOLOGY
Study Population
The medical records of all patients aged 15 to 24
years old admitted under or referred to
psychiatry at The Medical City for suicidal
ideations and/or behavior from January 2013
and December 2017 were reviewed.
Sample Size Computation
Using Epi Info version 7, the minimum sample
size requirement was at least 159 based on the
percentage of youth with suicidal ideations who
attempted suicide = 36.78% (DRDF & UPPI, 2014)
with a margin of error= 7.5% and confidence
level= 95%.
Inclusion criteria
Patients aged 15 to 24 years old admitted or
referred to psychiatry at The Medical City for
suicidal ideations and/or behavior from January
2013 and December 2017.
Exclusion criteria
The following were excluded from the study:
- Patients below 15 and above 24 years old
- Foreign / non-Filipino patients
- Incomplete medical records/chart
- Patients admitted for suicidal behavior but not
referred to psychiatry service
Sampling Method
A list of all patients aged 15 to 24 years old
admitted under or referred to the psychiatry
service from January 2013 to December 2017,
were taken from the records section of The
Medical City. The researcher reviewed these
charts and included those that fulfilled the
inclusion criteria.
The sample was subdivided into two subsets
according to the presence or absence of suicide
attempts in their lifetime. Those patients with a
history of suicide attempt were assigned to the
test group, while those patients without suicide
attempt, to the control group.
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For this study, the test group included those with
a history of: an actual attempt (a potentially self-
injurious act committed with at least some wish
to die, as a result of act. There does not have to
be any injury or harm, just the potential for
injury or harm), an interrupted attempt (when
the patient is interrupted by an outside
circumstance from starting the potentially self-
injurious act), and/or an aborted attempt (when
a patient begins to take steps toward attempting
suicide attempt but stopped themselves before
they actually engaged in any self-destructive
behavior).
On the other hand, the control group included
those patients with: a wish to be dead, suicidal
thoughts (thoughts of wanting to end one’s
life/commit suicide even without thoughts of
ways to kill oneself/associated methods, intent,
or plan during the assessment period), and
suicidal thoughts with plan and intent (thoughts
of killing oneself with details of plan fully or
partially worked out and subject has some intent
to carry it out).
Data Collection & Monitoring
Data was collected using data collection forms
and tabulated using Microsoft Excel. (Appendix
1)
The researcher was the only one who had
access to the records, as permitted by the
Medical Records Department. The researcher
ensured the safe-keeping of data gathered and
only the details needed for the study were
collected and recorded.
The patient’s names were not recorded on the
data collection forms. A number (P001 to XXX)
was used for each subject to ensure patient
confidentiality. No other information was
obtained except for the ones previously
mentioned.
Statistical analysis
Demographic data gathered from the medical
records included: age, gender, marital status,
religion, educational attainment, work status,
living arrangement. Clinical data gathered from
the database and history included: inciting event,
previous psychiatric consult, chronicity of
suicidal ideation, substance use prior to current
admission, history of suicide of an acquaintance
or family, history of psychiatric illness in the
family, history of non- suicidal self-injury,
exposure to adverse childhood experiences
(ACE), psychiatric diagnosis.
Data analysis was performed using SPSS
version 23. Quantitative variables were be
summarized as mean and standard deviation,
while qualitative variables will be tabulated as
frequency and percentage. The significance of
factors associated with suicide attempt among
patients were analyzed using t-test for age, chi-
square test. Odds ratio was used to measure the
strength of association between exposure and
outcome.
Ethical Considerations
The research was approved by the Institutional
Review Board of The Medical City prior to data
collection and conducted in accordance to the
International Conference on Harmonization –
Good Clinical Practice (ICH-GCP) ethical
principles of respect, beneficence, non-
maleficence, and justice. A letter for permission
to access medical records of inpatients was
submitted to the head of the Medical Information
Department of the hospital. Once obtained, all
electronic medical records of the subjects
selected were reviewed at The Medical City
Records Section. No physical medical records
were taken out of the department.
The study was done by reviewing the patient’s
electronic medical records/charts. There was no
direct contact or interaction with the patients,
hence a transfer criteria was not applicable.
The study employed a review of patient’s
electronic medical records/charts and did not
involve actual patients or patient interventions,
hence adverse events reporting was not
applicable.
RESULTS
A total of 209 of the 507 psychiatric inpatients
aged 15 to 24 years old from January 2013 to
December 2017, were included. Of the 209 charts
reviewed, 10 charts were excluded from the
study due to incomplete data (8 charts) and the
nationality of the patient (2 charts), thus only 199
were analyzed. (Table 1)
There was an increasing trend in the number of
youth psychiatric inpatients confined for suicidal
16 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
ideation and/or behavior during the five-year
study period. In 2013, only 18% of youth
psychiatric inpatients were confined for suicidal
ideation and/or behavior, but this further
increased to 29% in 2014, 31% in 2015, 52% in
2016, and 55% in 2017. (Table 1)
For the demographic characteristics, most of the
patients were female (70.35%), and all were
single. The mean age of the study population
was 19.25. Majority were students (81.91%), and in
college (70.85%) but a few were out of school
(3.02%). There were the same number of
employed (7.54%) and (7.54%) unemployed
patients. The top religious affiliations, were
Catholic, 78.89% and Born Again Christian,
12.06%. For living condition, 83.92% were living
with family, while 12.06% were with non-family
(friends, roommates, partners), and 3.52% were
living alone (Table 2).
For the clinical data, the more common inciting
event leading to confinement was
academic/work related issues (35.18%), closely
followed by family related problems (32.16%),
peer related problems (25.63%) and romantic
relationship problems (25.13%).
Most of the patients had prior psychiatric
consultation prior to confinement (70.85%), and
had presented with suicidal ideations of more
than one year (55.78%). Almost half (49.25%)
had a history of psychiatric illness in the family,
and 37.69% had a history of non- suicidal self-
injury.
A quarter (25.13%) of the study population had
exposure to adverse childhood experiences
(ACE). Among those with exposure to ACE,
about a third experienced parental separation
(38%), one fourth were victims of sexual abuse
(24%) and a fifth suffered physical abuse (20%).
The most common discharge diagnoses were
Bipolar Disorder (46.23%), and Major
Depressive Disorder (31.16%). (Table 3)
Of the 199 subjects included in the study, 119
(59.80%) had attempted suicide at least once,
while 80 (40.20%) had never attempted suicide.
Notably, of those who attempted suicide, the
most common methods were ingestion of
substances (62.19%), followed by jumping from
higher ground, (19.33%) and cutting (14.29%).
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19 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 Among females, the most common methods
were ingestion (64.13%), jumping (21.74%) and
cutting (15.22%); while for males, ingestion
(55.56%) and hanging (29.63%). (Table 4)
The significance of factors associated with
suicide attempt was analyzed using t-test for age,
and chi-square test for the rest of the categorical
variables. Among the demographic factors
studied, only sex was significantly associated
with suicide attempt, with a p-value = 0.011
(Table 4). Odds ratio was used to measure the
strength of association between patient sex and
suicide attempt. It was found that the odds of
suicide attempt doubled among female patients
(odds ratio = 2.27). No significant association
was noted between suicide attempt and the other
demographic factors studied, such as age,
educational attainment, work status, religion,
and living arrangement. Among the clinical
variables and psychiatric diagnoses studied, no
sufficient statistical evidence was found to
declare significant statistical association with
suicide attempt.
DISCUSSION
All over the world, suicide among the young has
emerged as a significant health issue, and the
present study further emphasizes this problem.
The findings of this study confirmed the rising
trend of suicidal ideations and behavior among
youth patients confined at The Medical City
from 2013 to 2017.
The study also found that the most common
diagnoses upon discharge among the study
population were Bipolar Disorder and Major
Depressive Disorder. This finding is similar to an
earlier study which found that the most common
psychiatric diagnoses among adolescents
included were mood, disruptive, and substance
abuse disorders (17);; although this study
population had low rates of substance use
(6.03%) and disruptive disorders (4.02%).
Notably, earlier studies estimate a lifetime
suicide attempt rate of 20% to 47% among youth
with bipolar disorder, and psychological
autopsy studies indicate that of all psychiatric
diagnoses, bipolar disorder poses the greatest
risk for completed suicide among youth. (18)
Among the study population, a quarter of
patients (25.13%) had exposure to adverse
childhood experiences (ACE).
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Of the adverse childhood experiences, parental
separation (38%), sexual abuse (24%), and
physical abuse (20%) were the most common. It
is well studied that ACE is a significant risk
factor for suicidal ideation and attempt. An
American study conducted among a nationally
representative population, found that ACE
increased the risk of attempted suicide by 2-to 5-
fold. (12)
Several explanations for this “gender paradox”
have been proposed, including gender
differences in the lethality of suicide attempt
methods, accuracy and openness in reporting of
past suicidal behavior, frequency of depression,
and socialization regarding culturally
acceptable forms of self- destructive behavior;
but no single explanation appears to adequately
account for these differences. (19)
CONCLUSION
The present study demonstrates the incessant
rise of suicidal ideation and attempt among the
population studied, especially in the last 5 years.
Every year the number of young patients
hospitalized for suicidal ideation and behavior
doubled. This suggests a call to action to enhance
suicide prevention in the country.
The study was able to achieve its objective to
give a descriptive profile of Filipino suicidal
youth, as well as identify the female gender as a
significant risk factor for suicide attempt in this
population. The odds of a suicide attempt was
twice higher among females in the population
studied. This suggests that etiological factors
related to suicide attempts for male and females
differ, and such nuances need to be taken into
account in the clinical assessment and design of
interventions to prevent suicide.
LIMITATION & RECOMMENDATIONS
While the present study was able to achieve its
objectives it holds some limitations. Being a
retrospective research design, the study was
limited by the data recorded on the patients’
charts. The information gathered in this
research was lifted from the patient’s admitting
database, referral notes, and daily progress
notes, which are mainly accomplished by
psychiatry residents-in-training.
Hence, individual differences in history taking,
record keeping styles, and assessment, may have
affected the results of the study. It is possible that
some risk factors present in these patients were
either not reported by the informants providing
the history, or not documented by the
documenter. With this, some caution is
warranted in terms of drawing negative
conclusions concerning the demographic and
clinical variables not found to be a statistically
significant in the present study. It is postulated
that due to the inherent limitations of a chart
review, some risk factors were not found to be
statistically significant. It may be fair to conclude
however, that the variables not found to be
statistically significant in this study, are not
among the strongest predictors of suicide
attempt among the sample population.
It may also be noted that the study population
was limited to in-patients, taken from a private
tertiary hospital with a particular clientele. As
such, the study may provide a skewed profile of
the Filipino suicidal youth. It is therefore
recommended to have future studies conducted
n a larger population to increase the study’s
generalizability. Perhaps expanding the study
population to youth seen on an outpatient basis,
as well as other institutions or clinics, both public
and private. It is further recommended that the
demographic and clinical profile of youth
patients with suicidal ideation and/or behavior
presented in this paper may be used to develop
and enhance suicide prevention programs for
the Filipino youth population.
21 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
REFERENCES
1. Redaniel MT, Lebanan-Dalida MA, Gunnell D. Suicide in the
Philippines: time trend analysis (1974-2005) and literature review.
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2. Demographic Research and Development Foundation (DRDF) and
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3. World Health Organization. Towards evidence-based suicide
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6. Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA,
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7. Borges G, Benjet C, Medina-Mora ME, Orozco R, Nock M. Suicide
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8. Husky MM, Olfson M, He JP, Nock MK, Swanson SA, Merikangas KR.
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9. King RA, Schwab-Stone M, Flisher AJ, Greenwald S, Kramer RA,
Goodman SH, Lahey BB, Shaffer D, Gould MS. Psychosocial and risk
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10. Quintos MA. Prevalence of suicide ideation and suicide attempts
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Asia Pacific Journal of Multidisciplinary Research. 2017 May
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11. Kang EH, Hyun MK, Choi SM, Kim JM, Kim GM, Woo JM. Twelve-
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and suicide attempt among Korean adolescents in a web-based
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12. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH.
Childhood abuse, household dysfunction, and the risk of attempted
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PH, Treadway SL. Psychiatric diagnoses as contemporaneous risk
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 PJP ORIGINAL RESEARCH

VALIDATION STUDY OF THE DISTRESS THERMOMETER:

PSYCHOSOCIAL DISTRESS SCREENING AMONG HEAD AND NECK
CANCER PATIENTS
AMOR JOANNA INDAB, MD, FPPA

ABSTRACT

OBJECTIVES: This study aims to validate the Distress Thermometer Filipino version, (DT-F) in
head and neck cancer patients and identify the cut off score of DT-F for psychosocial distress
at which to make referrals for clinical intervention.

METHODOLOGY: After obtaining permission from the National Comprehensive Cancer

Network (NCCN), translation and back-translation of the Distress Thermometer (DT) were
done. One hundred ninety- two patients who fit the inclusion criteria were included in the
study. They were from the outpatient clinic and ward of both the Cancer Institute and
Otorhinolaryngology Department and each participant accomplished a socio-demographic
form, the DT-F and Problem List, The Hospital Anxiety and Depression Scale-Pilipino (HADS P)
and had a brief psychiatric interview.

RESULTS: Receiver Operating Characteristic (ROC) curve analyses generated area under the
curve (AUC) of 0.7506, suggesting good discrimination using the HADS P cut off score of 11.
The optimal cut off score in DT-F is 4, with a sensitivity of 77% and specificity of 58%. Hence,
using this cut off score, head and neck cancer patients who score 4 and above in the DT-F were
identified to experience clinically relevant psychosocial distress than those who score below
the cut off.

CONCLUSION: The Filipino version of DT is a valid tool for screening psychosocial distress in
head and neck cancer patients. Using a cut off score of 4 is recommended for appropriate and
timely referral for further evaluation.

KEYWORDS: Distress Thermometer, Psychosocial Distress, Head & Neck Cancer

INTRODUCTION cases, while breast cancer (for women only) and

Cancer is a leading cause of morbidity and
mortality worldwide. Data show that there are
approximately 14 million new cancer cases, 8.2
million cancer deaths and 32. 6 million people
live with the consequences of cancer in 2012,
worldwide. (1) For both sexes, lung cancer was
the most common cancer worldwide
contributing 13% of the total number of new
colorectal cancer, the second and third most
common respectively, diagnosed in 2012. (2)
Jemal and colleagues reported that head and
neck squamous cell carcinomas (HNSCC) is the
sixth leading cancer worldwide and that there
are more than 550,000 new cases of head and
neck cancers (of which, 90% are HNSCC)
diagnosed each year with a male to female ratio

22 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

hat ranges from 2:1 to 4:1. (3)
In developing countries, head and neck cancers
are highly prevalent and one of the most
common forms of cancer, particularly in
Southeast Asia. Head and neck cancer is
considered to be one of the most “traumatic”
forms of cancer owing to its effects on the
patients’ breathing, swallowing, speech and
hearing (4).
In the Philippines, malignant neoplasms are the
third cause of mortality, with 98, 200 new cancer
cases diagnosed each year; with breast cancer
and lung cancer as the most prevalent in women
and men, respectively. (5) The report estimated
that oral cavity cancer will be the 15th most
common site when both sexes are combined
(2%) (6).
The risk factors for cancer worldwide are
tobacco use, alcohol use, unhealthy diet and
physical inactivity which are all modifiable.
Similarly, these risk factors account for the
continued increasing incidence and prevalence
of cancers in the Philippines. Given the
continued advances in early cancer detection
and treatment, and in spite of the awareness
campaigns conducted by public and private
sectors done in the Philippines, the reality is that
a large percentage of cancers are still not
diagnosed and treated at an earlier, and more
curable stage in the country.It has long been
perceived that lack of cancer awareness and
education account for the continued increase of
cancer incidence, however, it could also be that
socioeconomic reasons limit Filipinos in availing
the necessary cancer care and treatment. (7)
The chronic nature of cancer, the psychological,
its emotional and financial burden on the patient
and the family greatly impact the survivorship
of patients, and vice versa. Mehnert and
colleagues reported emotional distress is
common after a cancer diagnosis and is often a
result of a variety of problems that can affect
every aspect of life according to different stages
of the disease. The authors reported that most of
the concerns of patients relate to the physical
symptoms such as pain, fatigue and problems
with functional impairments and burden on the
family as well as social, financial and
occupational problems (6).
The National Comprehensive Cancer Network
(NCCN) in the United States has recognized the
lack of integration of psychosocial care into
routine cancer care and believed that physician
and patient attitudes contribute to this.
A multidisciplinary panel of the NCCN,
responsible for making pain the fifth vital sign
by using simple pain scale of zero to ten,
modelled and recommended a similar and
simple question to ask patients about their
psychosocial concerns and believed that distress
was the best umbrella term to represent and de-
stigmatize the emotional concerns that cancer
patients experience ranging from normal fears,
worry and sadness to clinical depression,
generalized anxiety, panic, isolation or a
spiritual or existential crisis. The NCCN panel
acknowledged the importance of incorporating
the assessment of psychosocial distress as part of
routine cancer care and considered distress as
the sixth vital sign. (7)
The high prevalence of psychosocial distress in
patients with head and neck cancer had been
noted in various literatures. In a review done by
Frampton, he reported that psychological
morbidity is often under diagnosed and
undertreated due to a range of factors that
include a normal reaction to the diagnosis of
cancer, the reluctance of patients to confide
openly to their doctor, the patients’ tendency to
minimize the severity of their symptoms and the
overlap of symptoms of physical and emotional
distress (4).
In a prospective observational study of
outpatients with head and neck cancers, Neilson
and colleagues assessed symptoms of depression
and anxiety before and after the patients
underwent radiotherapy using HADS and
Functional Assessment of Cancer Therapy-Head
& Neck (FACT -H & N). Their findings indicated
that there are significant changes in symptoms
of depression and anxiety in relation to timing of
radiotherapy, with a third of patients reporting
mild to severe depressive symptoms after
radiotherapy, emphasizing the need of ongoing
monitoring to identify patients at risk. (8)
Similarly, Lydiatt and colleagues stated in their
review that head and neck cancer patients
experience higher rates of major depressive
disorder of all oncology patients. (9)
23 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
A study by De Leeuw and coworkers cited in the
article enumerated factors that place head and
cancer patients at risk of developing depression;
these include lack of emotional support, a lack of
a social network, avoidant style of coping,
advanced tumor stage, gender (women), and a
lack of openness to discuss cancer in the family.
(10) The preceding studies mentioned have
highlighted the high prevalence of psychological
distress experienced by head and neck cancer
patients. Most of these emphasized the need for
appropriate and timely screening to detect and
address distress as part of the multidisciplinary
care of the cancer patient.
Multiple researches have been done to ascertain
the prevalence of psychosocial distress using
diverse methods to measure distress among
different cancer populations. Based on these
studies, there is a wide range of prevalence rates
of psychological distress, and it can be safely
assumed that one-third to two-thirds of cancer
patients experience distress. Norton and
colleagues identified the prevalence of
psychological distress among 143 patients with
ovarian cancer using the Beck Depression
Inventory, the Mental Health Inventory, the
Impact of Events Scale and a questionnaire
regarding mental health service use and found
out that about one fifth of women experienced
moderate to severe level of distress and more
than half reported high stress responses to their
cancer and its treatment. (11) Using the Hospital
and Depression Scale (HADS) among one
hundred cancer patients, Santre and colleagues
reported a rate of 42% cases experiencing
emotional distress. (12) Other researchers used
different methods and reported 77% prevalence
rate of psychological distress (13), 33% of
sarcoma patients experienced distress (14) while
prevalence of anxiety ranged between 21.5 and
27.4%, and prevalence of depression was 21.1%
(15), and 38% of cancer patients in the outpatient
reported experiencing psychological distress.
(16) In 1998, Roth and colleagues used the
Distress Thermometer in 97 prostate cancer
patients and reported 28.6% experienced
psychosocial distress based on the designated
cutoff. (17)
Studies among head and neck cancer patients
similarly showed a wide range of psychological
distress, from 12% as the lowest to as high as 46%
Pandey and colleagues cited in their study that
up to 20% of patients may show severe
depression, grief, lack of control, personality
changes and anxiety. (18) Other studies showed
higher ranges of psychological distress such as
in the study by Riblet and colleagues quoted that
35% of head and neck cancer patients
experience psychological distress (19), while 25%
to 30% was quoted initially by Krebber and
colleagues and reported after their study a
staggering 29% rate of psychological distress
experienced by patients in this population. (20)
In a cross-sectional study of 436 patients
attending a head and neck oncology
multidisciplinary clinic in New England, Maher
and colleagues stated in their study that 34% of
patients reported having pain, while 13% had
clinically significant distress. (21) In their
research, pain was assessed using a Numerical
Rating Scale, while distress was measured using
the PSYCH-6 and the Distress Thermometer
(DT) scales. (21)
The Distress Thermometer (DT) is a single-item
rating scale which the patient is asked to rate the
rate of their level of distress. Since its
development, the National Comprehensive
Cancer Network (NCCN) incorporated it as part
of the Clinical Practice Guidelines for Distress
Management. The NCCN suggested that as part
of a multidisciplinary approach on
incorporating psychosocial care into routine
cancer care, the Problem List be incorporated
with the Distress Thermometer.
The Problem List is used to determine the nature
and source of the patient’s distress and help
identify to which discipline the patient needs to
be referred. The initial cut off score was 4, and
was the basis of referral to appropriate service
for psychosocial support. (22) NCCN has since
then implemented the DT and the problem list as
the initial screening tool to assess distress in
cancer patients and those needing appropriate
psychosocial support (22).25
Administering to prostate carcinoma patients, a
pilot study using the DT by Roth and colleagues
in 1998 proved that DT, along with the Hospital
Anxiety and Depression Scale (HADS), can be a
rapid screening measure that allowed
oncologists determine patients with significant
distress.
24 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
They however suggested that further testing was
needed for the DT as well as the identification of
barriers that impede the detection of the most
distressed patients. (17) Since its introduction
and NCCN’s incorporation to the Clinical
Practice Guidelines for Distress Management, the
DT has been used, translated and validated in
numerous researches worldwide. (22)
Using the DT, detection of psychosocial distress
will impact the survivorship of cancer patients.
Providing psychosocial support to patients
diagnosed with cancer at key time points of their
cancer journey has the potential to reduce the
development of psychiatric morbidity and to
help patients be able to manage better the effect
of treatment and return to fully functional lives
and survivorship after treatment. (23) The DT
and problem list along with the Brief Symptom
Inventory (BSI) were used by Lee and colleagues
to describe the outcomes and clinical experience
of routine distress screening of newly admitted
patients to hematology and oncology ward. They
reported that 47% of 51% of clinically distressed
patients did not receive psychosocial support
before screening. Referrals to appropriate
discipline were done during the study and
witnessed the positive attitude of staff towards
the ability to routinely screen for distress. The
authors concluded that there was significant
improvement in the capacity of staff to offer
psychosocial care through routine distress
screening. (24)
In 2011, the evidence review conducted by the
McMillan Cancer Support Care in the United
Kingdom revealed that cancer affects patients
physically, emotionally and financially, however,
the emotional effects are the most neglected and
last the longest even after treatment is finished.
By using the four-tier model for cancer patients
and their families, as recommended by NICE, the
professionals were able to provide the necessary
psychological support needed by patients.
At level two of the model of the four -tier model,
staff including nurses, doctors, and allied health
professionals be proficient at screening for
psychological distress and intervening with
techniques such as psycho-education and
problem solving.
Timely provision of psychological support
resulted to improvement of the health and
wellbeing of people affected by cancer,
reduction of the work load of other health and
social care professionals and showed potential
efficiency gains for health and social care.
However, despite the growing knowledge and
national guidelines recommending active
management of distress, implementation in
routine practice remains a challenge.
Ging-Long Wang and colleagues screened for
psychosocial distress in Taiwan using both DT
and HADS as screening tools. They noted that
both tools were efficacious for screening anxiety
and depression for cancer patients, however
comparing both tools, DT appeared to have
higher sensitivity and specificity (25)
At present, there are no existing data in the
Philippines investigating the incidence and
prevalence of psychological and emotional
aspects of patients diagnosed with cancer as well
as any systemized referral process for
psychosocial support of patients with
psychological distress. Focus group discussion
done with Otorhinolaryngology residents
brought into light some key reasons for referral
of their patients for psychosocial support. Based
on their clinical assessment, patients who will
undergo disfiguring surgery, those with previous
psychiatric morbidity, patients whom they
consider to be a possible long-term burden to
the family and as part of the holistic
management are the patients the residents refer
for psychosocial support. (26)
This study aims to validate the Distress
Thermometer, Filipino version (DT-F) in head
and neck cancer patients, by using the translated
and validated HADS-P, which is an established
measure of distress. The optimal cut off score
for DT-F will be determined to identify patients
with clinically relevant psychosocial distress.
And in doing so, a valid screening tool that is
quickly administered may be made available for
psychosocial distress detection and timely
referral.
METHODOLOGY
This cross -sectional study was reviewed and
approved by Research Ethics Board. Permission
for translation and validation was requested and
granted by the National Comprehensive Cancer
25 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
Network.
The NCCN DT was translated into Filipino by
Sentrong Wikang Filipino, which is one of the
coordinating arms of the Manila that monitor,
facilitate, and conduct university policy and
programs on language. Back translation was
performed by a consultant and resident
physicians of the Department of Psychiatry and
Behavioral Medicine who speak English and
have never used the DT. The reviewing panel
suggested changes in a few terms in the Problem
list accompanying the DT. These changes were
incorporated and the Filipino version of the
Distress Thermometer (DT-F) was finalized.
Likewise, permission to use the HADS-P, the gold
standard used in this study, was obtained from
Dr X. Proper coordination with the head of both
the Department of Otorhinolaryngology and
Cancer Institute were done and permission to
conduct research on both departments was
obtained.
Using the general computation for estimation of
prevalence of psychosocial distress among head
and neck cancer patients, the sample size was
computed.
In the cross-sectional study of 436 patients
attending a head and neck oncology
multidisciplinary clinic in New England, Maher
and colleagues stated in their study that 13% had
clinically significant distress. In the study, pain
was assessed using a Numerical Rating Scale,
while distress was measured using the PSYCH-6
and the DT scales. (21) Using 13% prevalence
rate of psychosocial distress, the level of
confidence set at 95% and maximum tolerable
error of +/- 5 the sample size computed, the
formula revealed a sample size of 192, taking
into consideration an initial 10% drop-out rate.
One hundred ninety -two participants were
recruited using convenience sampling from
August 2016 to November 2016. Participants of
this study were patients seen at the outpatient
clinic or admitted at the wards of the
Otorhinolaryngology department and the
Cancer Institute.
Eligible participants were Filipinos aged 19
years old and above, diagnosed with head and
neck cancer, understood their diagnoses, able to
understand Filipino, not previously diagnosed
with any psychiatric disorder and were able to
give their informed consent.
After explaining the objectives, risks and benefits
of the study, informed consent was obtained
from each participant. They were given the
socio-demographic form, DT-F and HADS P. For
patients who had physical difficulties in reading
and those who were illiterate, the research
assistant read and helped complete the
screening tools. A brief psychiatric interview was
then done by the investigator. Participants
answered the questionnaires and interviewed by
the investigator in the waiting area prior to their
consultation at the OPD, while those admitted
accomplished the forms and were interviewed in
their respective beds at the ward. Data gathered
from the participants were kept confidential.
Recommendations for referral to the
Consultation Liaison section were given to the
attending physicians of participants who were
assigned with a psychiatric diagnosis on
interview.
Socio-demographic data
The following demographic data was collected
from participants and their medical records at
baseline: name, age, sex, marital status,
educational attainment, religion, living
conditions, employment status, length of time
since diagnosis was known, modes of treatment,
and history of psychiatric consultation.
Distress Thermometer and Problem List, Filipino
version (DT-F)
The Distress Thermometer has been
recommended by the National Comprehensive
Cancer Network (NCCN) as part of the
multidisciplinary care for cancer patients as a
screening tool to detect clinically significant
distress. (27). It is a one item, self-report
measure of psychological distress developed for
cancer patients who are asked to rate their
distress in the past week. It is a visual analogue
scale that range from 0 (no distress) to 10
(extreme distress). Afterwards, patients are
asked to fill in the problem list that accompanies
the DT. This is used to aid in the determination
of nature and source of the patient’s distress.
The translated Filipino versions of both the
distress thermometer and problem list were used
on head and neck cancer patients.
26 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
Hospital and Anxiety Depression Scale - Pilipino
(HADS-P)
The Hospital Anxiety and Depression Scale
(HADS) developed in 1983 by Zigmond and
Snaith, is a brief, self-administered questionnaire
designed for use with people who are medically
ill to detect anxiety and depressive disorders.
The HADS has 14 items, of which seven questions
are related to anxiety and the other seven,
related to depression. The HADS has different
cut-off scores in various studies to indicate
significant anxiety and depressive symptoms.
(28) In 2013, de Guzman determined the
reliability and validity of the HADS and its
Filipino translation (HADS-P). She reported that
the optimal cut off score was 11, with sensitivity,
specificity and a positive predictive value of
75%, 70%, 75%, respectively. (29) The HADS P
has been used in multiple studies since its
The area under the ROC curve (AUC)
represents the overall accuracy of a test. It takes
values from 0 to1 in which a value of 0 indicates
an inaccurate test while a value approaching 1.0
indicate high sensitivity and specificity. The
general guideline for interpretation of AUC
values were 0.50-0.60 as indication for no
discrimination, 0.60-0.70 for poor
discrimination, 0.70-0.80 indicates acceptable
discrimination, 0.80-0.90 has good
discrimination while 0.90-1 means excellent
discrimination. (33)
In this study, the discriminative accuracy of the
established DT-F cut off score using the cut off
score of HADS P which was 11 was estimated
using the Area Under the Curve (AUC).
TABLE 1. SOCIO-DEMOGRAPHIC PROFILE OF PARTICIPANTS. (N= 192)

validation in the Philippines and used as a gold

standard in this study.

Psychiatric Interview
A brief psychiatric interview of the participants
was done by the investigator after completion of
the DT-F and HADS P. This was to ensure that
questions pertaining to the questionnaires were
answered and that participants necessitating
intervention, and gave consent for referral, were
immediately referred to the Department.

Accomplished forms were checked and data

collected were encoded using Microsoft EXCEL.
Statistical analyses of the data were performed
using STATA for Windows (Version 12.0)
software program.

The participants’ characteristics were analyzed

using descriptive statistics. Analysis of Receiver
Operating Characteristics (ROC) curves was
used to determine the ability of the DT- F in
detecting psychosocial distress in participants.
ROC curves are a plot of (1-specificity) of a test
on the x-axis, HADS P in this study, against its
sensitivity on the y-axis for all the possible cut off
scores; (30) they are a graphical representation
of true positives versus false-positives across a
range of cut off scores and aid in the selection of
the optimal cut off score (31)

ROC curve analysis is used to quantify the

accuracy of tests in discriminating patients who
have the condition or the disease from those who
does not have the condition. (32)

27 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

RESULTS
FIGURE 1. RECEIVER OPERATING CHARACTERISTIC CURVE ANALYSIS OF
DISTRESS THERMOMETER FILIPINO VERSION SCORES VERSUS HOSPITAL
ANXIETY AND DEPRESSION SCALE PILIPINO CUT OFF SCORE.
A total of 192 patients were invited for this study
from the outpatient clinics and charity wards of
with clinically relevant psychosocial distress
the Otorhinolaryngology department and
using the HADS P cut off score of 11.
Cancer Institute of the Philippine General
Hospital. One hundred percent finished the
Figure 1 shows the Receiver Operating
questionnaires and were included in the analysis.
Characteristic (ROC) Curve analysis obtained
an Area Under the Curve of 0.7506, which
The distribution of patients according to their
showed good discrimination based on the gold
socio-demographic profile is shown in Table 1.
standard used. Each DT-F score was used as
This includes the age, gender, educational
potential cut off and the sensitivities and
attainment, living conditions, employment status,
specificities of each were computed.
length of time since diagnosis was known, and
treatment history. Most of the participants
The sensitivity, specificity, likelihood ratio
diagnosed with head and neck cancer were
positive and negative computed for each DT-F
aged 44 years old and above (139/192 – 72.40%).
cut off score are shown on Table 3. For the DT-F,
For gender, there were more male participants
a cut off score of 4 identified 77.06% of the
than females (110 or 57.29% males and 82 or
HADS P cases (sensitivity) and 57.83% of the
42.71% females). As for educational attainment,
HADS P non cases (specificity) while a cut off
majority of the participants were able to attain
score of 3 has 88.07% sensitivity and 51.81%
high school and higher education (137 or 71.35%)
specificity.
yet most of them were unemployed (57.29%),
which included housewives and retirees. More
DISCUSSION
than half of the participants were currently
living with their spouses and children (64.58%).
The validity of the Filipino version of the DT as
The mean number of months since diagnosis
a screening tool for psychosocial distress among
was 27.4 (SD = 15.5; range = 1- 120 months). Most
head and neck cancer patients examined in this
of the participants were seen within the first 18
study. HADS P used as a gold standard
months since they were diagnosed (124 or
identified 109 (56%) participants with
64.58%). More than half (50.52%) of the
psychosocial distress. Analyses of data showed
participants had not had received any form of
that a cut off score of 4 for the DT-F generated
treatment while 20.31% underwent surgery.
sensitivity of 77% and a specificity of 58% using
the HADS P cut off score of 11. Using this cut off
Out of the 192 participants, 31 (15.63%) were
score, the DT-F identified 119 (62%) participants
diagnosed with major depressive disorder,
with psychosocial distress.
generalized anxiety disorder and adjustment
disorder during the psychiatric interview.
Cut off scores from other literatures ranged
(Table 2). The 31 participants were informed of
from 3 to 6 for detecting psychosocial distress
their diagnosis and advised referral for further
while the optimal cut off set by NCCN Guidelines
evaluation and of these, 25 of the 31 (80.65%)
was 4 and above, and indicated the need for
patients gave consent for referral and were
further evaluation and referral to the proper
referred to the Department of Behavioral
psychosocial or supportive care service. (27) In
Medicine, while 6 (19.35%) of them refused
a study by Donovan and colleagues, the
referral. Fifty six percent of participants were
translation and validation of DT in different
identified

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countries were studied. Their research revealed
that DT had been translated from English to 21
non-English languages and 18 were validated.
Determination of cut off scores were done with
different screening tools used in ROC curve
analysis and were found to have variations in
different countries, however majority of them
have a cut off score of 4 that has optimum
sensitivity and specificity. (34) The result of this
study showed comparable results to studies done
in different countries, with majority of them
having a cut off of 4.
The ROC curve analysis of DT-F scores
compared with the established cut off of gold
standard used, HADS P, obtained an AUC of
0.7506. The AUC value indicates good
discrimination using the HADS P as a gold
standard. With each DT-F score used as
potential cut off and their sensitivities and
specificities computed, cut off scores of 3 and 4
were considered. DT-F cut off score are of 3 has
88% sensitivity and 52% specificity while the cut
off score of 4 identified 77% and 58%. Taking
into account the result of other validation studies
of the DT, in which majority revealed and
recommended a cut off of 4, in as much as the
recommended cut off of the NCN guidelines,
similarly, that is 4, the cut off score of 4 was set.
More importantly, the cut off score of had
optimum sensitivity and smaller percentage of
participants being incorrectly classified as
having psychosocial distress, as compared to the
cut off score of 3. Using the cut off score of 4 also
takes into consideration a patient’s response
when incorrectly classified as having
psychosocial distress. Incorrectly classified
patients may experience additional burden of
having to undergo further screening procedures
on top of their foremost priority of addressing
their cancer treatment. Lastly, the limitation of
manpower and financial costs of increased
umber of incorrectly classified patients are
taken into consideration. Hence, in using the DT-
F as a screening tool for psychosocial distress, it
is recommended that the cut off score of 4 is
used, which best parallels to other validation
studies and takes into account the important
physician and patient factors.
This is the first validation study of the DT to be
conducted in the Filipino population. In this
study, head and neck cancer patients were used
as the population sample.
Patients with head and neck cancer are known
to develop high degree of psychosocial distress.
Humphris and Ozakinci reported that patients
diagnosed with head and neck cancer are prone
to development of psychological distress after
disclosure of cancer diagnosis and tend to
extend during treatment phase. They further
noted that the variety of reaction depend on a
number of factors including fears of recurrence,
health beliefs, personality type, coping, and the
availability of support. (35)
Their review introduced a number of key
factors that allowed surgeons and clinicians to
be more mindful of a more complete
management of the patient with head and neck
cancer; that is to include psychological
interventions. A substantial number of literature
have further underscored the psychological
distress experienced by patients with head and
neck cancer. Pandey et al investigated the effect
of distress on the quality of life in head and neck
cancer patients in India where head and neck
cancer is the most common cancer in males and
third most common in females and concluded
that high amounts of stress led to poor quality of
life of patients. (18)
Krebber and colleagues investigated the
screening in follow up care to identify head and
neck cancer patients with untreated
psychological distress using Onco Quest (a touch
screen computer system to monitor
psychological distress, Hospital Anxiety and
Depression Scale (HADS) and quality of life
(HRQOL; EORTC QLQ-C30 and H&N35 module)
and concluded that screening for psychological
distress among head and neck cancer patients is
beneficial to identify patients with psychological
distress who do not yet receive treatment. (20)
Riblet and colleagues did a study to improve the
29 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
mental health care of patients with head and
neck cancers by identifying and managing
psychological distress using the Distress
Thermometer and an evidenced-based
treatment decision algorithm. This was done in
Norris Cotton Cancer Center in Northern New
England where the investigators conveyed that
though patients were treated in a 4. Frampton M. Psychological distress in patients with head and
multidisciplinary approach, the institution
lacked a policy for distress screening leading to
possible missed diagnoses of stress. (19)
A subset of head and neck cancer patients, oral
cancer survivors, and their supportive care
needs were determined by Lee et al. The result
of the study showed the substantial unmet needs
of this population, with many of the unmet needs
falling in the emotional domain and that the
survivors have high rates of interest in several
supportive care services including support
groups and various forms of informational
support. (36)
Patients with different types of cancer yield
different levels of distress. Similarly, with the
study was conducted, hence majority of the
participants belong to the middle to low socio-
economic class. Another limitation is the venue of
the study, particularly those seen in the
outpatient department, where patients may have
experienced discomfort waiting in line and
sometimes in a hurry to be seen by their
attending physician that may have affected the
manner of answering the screening tools.
Hence, it would be ideal that the DT-F may be
considered to be used in patients with other
types of cancer in future studies. It is also
recommended that multi-center studies with a
larger and more diverse population be done for
the DT-F.
Conclusion
The Filipino version of DT is a valid tool for
screening psychosocial distress in head and neck
cancer patients. Using a cut off score of 4 is
recommended for appropriate and timely
referral. The results of the study can help initiate
the regular implementation of the DT-F on all
cancer patients, eventual nationwide
implementation with the goal of psychosocial
support provision as part of the holistic care of
the cancer patient.
30 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
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PMC4476305. doi:10.1186/s12888-014-0354-0.
29. De Guzman MLR. A Validation of the Hospital Anxiety and
Depression Scale (HADS) in the Medically-Ill. Acta Medica Philippina.
[Internet]. 2013 Sep; 47(3):1-10. doi:
https://doi.org/10/47895/amp.v47i3.1318.
30. Abdul Ghaaliq Lalkhen, McCluskey A. Clinical tests: sensitivity
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doi:https://doi.org/10.1093/bjaceaccp/mkn041.
31. Florkowski CM. Sensitivity, Specificity, Receiver-Operating
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32. Hajian-Tilaki K. Receiver Operating Characteristic (ROC) Curve
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PMC3755824.
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34. Donovan K, Grassi L, McGinthy HL, Jacobsen PB. Validation of
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31 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

 PJP ORIGINAL RESEARCH

ESTIMATED RANGE OF COST OF TREATMENT OF ADULT

SCHIZOPHRENIA PATIENTS AT A TERTIARY GOVERNMENT
HOSPITAL AS OF OCTOBER 2015
ANTHONY T. ABALA, MD
TOMAS BAUTISTA, MD, FPPA

ABSTRACT

OBJECTIVES: Using the patient’s perspective, the study’s objective was to estimate the economic
cost of treatment for adult schizophrenia patients in a tertiary hospital using key informant
interviews.

METHODS: A guided structured key informant interview was done to determine key practices in
the treatment of adult schizophrenic patients in the charity and pay in-patient and out-patient
settings of the tertiary hospital. Cost of treatment included direct (medication, room and board,
professional fees, ancillaries) and indirect costs (productivity losses of both patient and caregiver)
and was computed based on 1 to 4 week length of stay for inpatients and varying intervals of
follow-up for outpatients. Total costs were computed depending on the treatment setting.

RESULTS: Twenty nine members of the Department of Psychiatry, involving 5 psychiatric nursing
staff, 13 residents-in-training, 4 fellows-in-training and 7 consultants were interviewed. The cost,
for charity inpatient care, may range from PhP 2332.00 to PhP 44,861.00 (USD 50.88 to 978.86).
For charity outpatient care, this may range from PhP 2892.00 to PhP 21,3612.00 (USD 63.10 to
4660.96) annually. For pay patients, costs were estimated to range from PhP15347.00 to PhP
24,6831.00 (USD 334.87 to 5385.80) for inpatient care and PhP 17,292.00 to PhP 1,125,600.00
(USD 377.31 to 25681.04) for outpatient care. The factor that influenced costs the most was the
choice of medication. As of October 15, 2015, 1 USD = 45.83 PhP.

CONCLUSION: Schizophrenia is a chronic psychiatric illness that places a significant financial

burden on patients and their caregivers. Based on the data gathered, patients’ and their families
could spend from as low as 2332 to as high as 1,125,600 pesos depending on the treatment
setting.

KEYWORDS: Cost of Treatment, Adult Schizophrenia, Tertiary Government Hospital

32 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

INTRODUCTION
Global health care systems involve several
entities to defray the cost of health care.
Depending on the viewpoint of this particular
system, 3 major perspectives (1) are referred to
when noting the economic evaluation of
healthcare. These are: society’s perspective
(socialized health care systems or services from
the public sector), health care services (private
health care providers and organizations), and
the patients themselves (out-of-pocket expenses,
as well as other non-financial costs such as
emotional burden of caregiving) (1, 2). When
evaluating healthcare from a health economics
standpoint, a study must choose which
perspective to take into account.
In the Philippines, majority of expenditures are
paid for from out-of-pocket by patients and
families. In 2005, 48.4% of health care expenses
were paid by patients (3). On the other hand, the
national health insurance program (PhilHealth)
provides coverage for inpatient treatment of
mental illnesses. As of 2013, the publicly posted
Philhealth case rates for psychiatric disorders
had (4), the same rate despite the variety of
treatments and medications needed for each
psychiatric disorder, including schizophrenia.
This uniformity of case rates can be attributed to
the absence of reliable local baseline
information on the cost of care for psychiatric
disorders, which are often chronic or lifelong
and require constant financial expenses.
Schizophrenia, in particular, is a chronic mental
illness requiring chronic medication, inpatient
care, regular outpatient follow up and large
amounts of money spent by patients and their
caregivers. Given this situation, this study was
done to estimate the cost for treatment of adult
schizophrenia inpatients and outpatients at a
tertiary hospital from the patients perspective. In
line with this, cost of treatment referred to the
financial costs incurred and sourced out-of-
pocket from either the patient or his family as
well as productivity losses of the patient, the
caregiver or both. Due to the absence of local
health economic data on schizophrenia, this
study would not compare any particular
treatment or intervention nor would
consequences of any treatment be examined.
Therefore this study served as a cost of illness
study.
Rationale
The need for a baseline cost of illness of
schizophrenia acted as the impetus for the
creation of this study; data gathered may be
used for higher order economic evaluations such
as cost analyses or cost outcome descriptions.
Additionally, data may also be presented to
Philhealth to attempt to request for more
accurate case rates for schizophrenia.
Disclosure
This study was done as a requirement for
research as a 3rd year Psychiatry resident in the
Department of Psychiatry of a tertiary hospital.
The researcher did not have any financial
benefit from this study and the expenses were
financed by the researcher. The results of this
study were presented to the Department of
Psychiatry.
General Objective
With the patient’s perspective in mind, this study
determined the estimated economic cost of
treatment for adult schizophrenia patients in the
tertiary hospital using information gathered
from guided interviews of key informants.
Specific Objectives
The specific objectives of this study were to
estimate the range of economic costs involved in
inpatient or outpatient treatment of an adult
schizophrenia patient using the following
indicators: range of costs of charity inpatient
and outpatient care as well as cost of pay
inpatient and outpatient care for the treatment
of an adult schizophrenia patient.
Review of Related Literature
Given the long-term nature of schizophrenia, it
poses a long-term burden on the patient, health
care systems and caregivers. De Silva, Hanwell,
and de Silva (5) broadly divided the financial
cost of illness into direct and indirect costs
(Figure 1). The former involves an actual
exchange of monies for different services. This
includes expenses paid for by a health care
system as well as out-of-pocket payments made
by the patient or carers. In studies conducted in
Sri Lanka, India, and France (5,6,7), majority of
these payments involved medications. Other
direct costs are: transport costs, food expenses,
as well as accommodations.
33 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
Sri Lankan (5) direct costs in 2012 per outpatient
visit was found to be about US$ 37.30 (travel,
meals, medication, and routine laboratories
were factored in); however this data was
significantly skewed due to the much cheaper
price of medications purchased directly from
Indian manufacturers vs data obtained in
industrialized nations. In France (7), for
example, mean total cost for inpatient and
outpatient care are US$1,540.00 and US$1,473.00,
respectively, per patient; annually this is roughly
US$ 69 million for inpatient care vs US$65
million for outpatient care. Indirect costs, on the
other hand, is lost productivity from either the
patient or the patient’s caregiver. It may also
include: personal suffering, premature mortality
costs, criminal justice system costs, private
informal alternative therapy costs. In
comparison of inpatient and outpatient
treatment, Chinese (8) data found significant
differences in cost. Total costs were US$ 2,008.00
(outpatient) vs US$ 3,116.00 (inpatient), with
larger direct and indirect costs for inpatient
treatment (direct and indirect US$ 1,281.00 and
US$ 1,835.00 vs US$ 406.00 and US$ 1,601.00).
One noted difference in studies involving the
costs of schizophrenia: in a developed country
such as France, direct costs far outstripped
indirect costs (7) while the opposite was found in
less developed countries (5). Nonetheless,
medications still accounted for the majority of
direct costs in any setting followed by costs
incurred in inpatient and then outpatient
settings. In addition, one possible reason for the
discrepancy between the proportion of direct
and indirect costs could be the greater use of
informal rather than state-provided care in less
developed nations.
Out-of-pocket expenditures are known to
precipitate and worsen poverty; however these
expenses have been found to be larger in in-
patient rather than out-patient settings in terms
of medication costs (6) and indirect costs (5).
Measurement of direct and indirect costs vary,
with the latter not having a uniform method of
measurement. Sarlon’s prospective study
measured indirect costs’ loss of productivity in
terms of monetary value by computing a
nation’s average monthly or daily income and
multiplying it by the number of days spent in
inpatient care. Ideally, as part of the human
capital, time and psychological costs of
schizophrenia--especially for caregivers--should
be included as a computed cost yet there has
been no reliable or standardized means of doing
so (7).
Due to the chronicity of schizophrenia, relapse is
another pertinent factor influencing the cost of
treatment. Ascher, et al (9) identified predictors
for relapse and its cost in 2010 in the United
States. Costs for patients with relapse redounded
into higher direct and indirect cost in either
inpatient or outpatient setting. Predictors for
relapse were: younger onset of illness, poor
medication adherence, more severe symptoms,
comorbid substance use disorder, and worse
functional status; inpatient costs were found to
be 5 times higher for patients who experienced
relapse.
Published literature regarding the financial cost
of schizophrenia in the Philippines was not
discovered during this review of related
literature. Additionally, there was no existing
local clinical guideline or consensus statement
regarding the management of schizophrenia;
thus the difficulty in further making rational and
adequately designed economic studies. Faced
with the absence of data, several methods of
filling in this gap in information can be made,
especially with direct costs. This can be done by
evaluation of medical records, pharmacies, etc.
Indirect costs can be measured using lost
productivity of both patient and caregiver,
typically quantified as lost wages (6,8). In that
regard, the absence of uniformity in patients’
experience (and subsequent variations in
management noted in medical records) makes
the use of patient records problematic--there is
the need to at least homogenize the treatments
used in the current setting. Unlike evaluation of
treatment for other medical specialties, the
absence of generally followed algorithm for
treatment makes it difficult to assess costs
relative to length of time for treatment (3).
Hence in consultation with a specialist in health
economics, there is a need to collect this data
using key informants involved in the decision-
making when it comes to treatment.
METHODOLOGY
Definition of Terms
Rather than a full economic evaluation, a cost of
34 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
illness study identified the expenses involved in
treatment of a particular clinical disorder. For
this study, a cost description of treatment of
adult schizophrenia patients was the focus.
Based on the health economics approach, the
patient’s perspective referred to the finances
spent out-of-pocket from either the patient or
his/her family. This could have been determined
by either the actual or theoretical perspective.
Instead of expounding on the direct experience
of the patient, this perspective instead focused on
financial or monetary values involved in
healthcare. Hence this cost may be either
financial or economic in nature. Financial costs
(FC) referred to the amount of money spent on
a good or service traded. Economic costs (EC)
related to the wider concept of resource
consumption, e.g. time spent by patients or
caregivers, while it did not involve a direct out-
of-pocket expense, were a real cost due to the
loss of possible income or earnings. The
economic cost referred to in this study involve
both financial expenses or direct costs that came
out-of-pocket, as well as a singular indirect cost
(10). The economic cost of this study referred to
the direct and indirect cost incurred by the
patient and his or her family for the treatment of
schizophrenia over a 1,2,3, or 4 week period of
time for inpatients, 1-4x/month consult for
outpatients, per annum costs, and estimated
annual cost plus one week of inpatient care due
to relapse.
Direct costs (DC) were defined as those expenses
directly related to the treatment of
schizophrenia. For this study, direct costs
included: the cost of medication, the cost of
laboratories and ancillaries, the cost of other
expenses incurred for care for the patient and
caregiver while as an in- or outpatient.
Due to the non-uniformity in measuring indirect
costs (IC) especially for caregiver burden,
emotional costs, and other related costs, for the
purpose of this study this was limited to the
productivity loss incurred by the patient, the
caregiver, or both due to treatment of
schizophrenia.
For inpatient care, productivity loss (PL) was
measured using the most recently posted
minimum daily wage for non-agricultural
workers in the Philippines (PhP 481.00).
This was done multiplied by the number of days
spent confined and again multiplied by a factor
of two if both patient and caregiver were
employed. If they were both unemployed then
this was not factored into the total costs. For
outpatients, this was computed by the
assumption that consult would only involve a
half-day’s absence from work. Hence the
productivity loss was assumed to be half the
daily minimum wage which could also be
multiplied if both parties were employed or was
disregarded if both were unemployed.
Healthcare Expenditure Model assumes that
treatment of schizophrenia followed a strictly
linear model wherein medications were not
combined, shifted, or altered in dose.
Medications considered also focused strictly on
oral antipsychotics and not on other medications
used during the course of treatment. Second, it
assumed ancillary procedures were either done
once or none at all. Third, other expenses were
assumed to have also been spent on a linear,
unchanging model. Hence any possible spikes or
variations were not taken into account. The
rationale for this model was in line with the
objectives of the study, which were to obtain the
range (from lowest possible to highest). Thus,
the model provides a basic formulation for costs
over a specified period of time.
Study Design
The study is an economic evaluation, specifically
a cost description of the cost of treatment of
schizophrenia in either inpatient (and influenced
by length of admission/hospital stay) or
outpatient settings and the added costs incurred
by patients and his/her family and/or relatives
for episodes of relapse. (Figure 1)
Setting
The study was conducted at the Charity and Pay
patient services of the Department of Psychiatry
of the tertiary hospital. The Charity in-patient
service only requires that patients’ pay for their
medication, and greatly reduced prices on
laboratory and other ancillary services.
Meanwhile, doctor’s fees, inpatient fees
(including room and board) are waived. The
Charity out-patient service covers free doctor’s
consultations with resident trainees of the
Department of Psychiatry. Patients, however, are
expected to pay for their own medications,
35· PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
laboratories, and ancillaries.
Definition of Population
For the purposes of this study, adult
schizophrenia patients are those age 19 to 65,
who fulfill the Diagnostic and Statistical Manual
5th Edition criteria for schizophrenia (13).
Patients must also have no known medical co-
morbidities (13).
Informants
The study aimed to determine the costs incurred
from the patient’s perspective yet the informants
were medical workers and physicians rather
than the patients themselves. The rationale for
this was as follows. Two factors were taken into
account: first, the absence of uniformly accepted
Filipino local practice guidelines for
schizophrenia and second, the study’s aim to
estimate rather than provide a distinct and
specific value for the cost. Therefore only
common practices as noted by physicians and
staff members were the required data to be
gathered. Informants for the charity inpatient
service were psychiatry residents and staff of
the psychiatric ward (nurses, nursing aides)
while charity outpatient service informants were
psychiatry residents and nurses. Informants for
both in- and out-patient pay services were the
consultants of the department of Psychiatry.
The key informants for this study were present
members of the Department of Psychiatry.
Modeled after the studies of Sarlon (7), de Silva
(5), healthcare workers were chosen as the key
informants as the study seeks to estimate the cost
based on ideal management based on their
clinical judgment, as opposed to based on non-
existent clinical practice guidelines. For costs
incurred by charity patients, key informants
were the current trainees of the department due
to their actual hands-on contact with charity
patients to be able to relate information about
the patients cost. Additional informants for
inpatients were ward staff who are exposed to
the other materials bought by patients during
the stay in the hospital. For costs incurred by pay
patients, all active consultants with experience
managing adult schizophrenia patients in the
pay wards of the tertiary hospital were
interviewed.
Inclusion & Exclusion Criteria
Resident and consultant psychiatrists, as well as
ward workers, of the Department of Psychiatry
who provided consent were interviewed. Only
those with experience with the treatment of
patients with schizophrenia within the study
setting were included in the study. While
informants who refused to be interviewed were
excluded.
36 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 Informants who refused to divulge their
professional fee were also excluded.
Ethical Considerations
This proposal was submitted for review to the
Ethics Review Board for review and approval
prior to data collection. The same panel
provided approval for the study to be
performed within the setting. Names and other
identifying information of the key informants
were collected; however years of
training/practice will be recorded. The study
was funded by the primary investigator, who has
no conflicts of interest to disclose. There were no
anticipated risks for the informants. There was
no compensation provided to the informants.
Truthfulness of informants was not anticipated
to be an issue in this study due to the absence of
any risks or possible punitive actions for
participating or not participating. No coercion of
informants was done. This study was presented
to the Department of Psychiatry. The informed
consent form was modeled after the Key
Interview Consent form by the public health
department of Los Angeles, USA (12).
Instruments
A structured interview guide was used while
interviewing the informants. (Appendix 1) The
interview determined the length of experience of
the interviewee as well as questions on the costs
of treatment. For costs in the inpatient setting,
respondents reported on: medication, usual
dosing range, requested laboratories and
ancillaries, professional fees, room and board
fee, PHIC enrollment, other expenses needed or
purchased for the hospital stay (including food,
transportation, additional supplies).
Multiplication of medication expenditure was by
the length of stay as provided by the informants.
For indirect cost: length of stay (as estimated by
informants) multiplied by average salary or the
national minimum wage similar to Sarlon’s
method of computation was done. (7) For the
outpatient setting costs, similar items were
factored in. (Figure 1)
Cost Estimate Plan
Addition of computed cost estimates will be done
and presented as such (Table 1). The most
recent prices of the medications reported by
informants were gathered from the hospital
pharmacy. For medications used that are not
available in the inpatient pharmacy, prices of
the cheapest available drug in Mercury Drug,
the largest national pharmacy chain were used.
The latest daily room rates was obtained from
the pay admitting services of the hospital and
this will be multiplied against the length of stay
of inpatients.
Limitations of the Study
Inherent limitations, as in other studies involving
interviews, were recall biases from the
interviewees. Additionally, the data of this study
is time bound and may be affected by inflation.
Generalizability to the national situation will be
limited due to the single center setting of the
study.
RESULTS
Key informants for this research were: 13
residents-in-training of the Department of
Psychiatry (ranging from 1 to 3 years of
experience), 4 fellows-in-training (4-5 years) 5
nursing staff (1 to 9 years of experience), and 7
consultants (6-over 30 years of experience).
Interviews were conducted in person after
written consent was obtained. Each interview
lasted from 10 to 15 minutes and were done in
private. Data from the responses were written
down on the same interview guide sheet of each
respondent.
For inpatient treatment of schizophrenia,
patients were admitted from a minimum of 1 to 4
weeks, whether in the pay or charity settings of
the hospital. For outpatient treatment, patients
were seen in varying intervals depending on the
severity and/or control of the patient’s
symptoms; the shortest interval was weekly while
the longest interval was every 3 months. The
aforementioned time periods were necessary in
the subsequent results.
Medications used in either treatment settings
were largely unchanged with the dosage range
37 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
remaining similar whether for pay or charity
patients. If a patient was being seen as an
outpatient, dosage ranges were typically lower
compared to inpatients, though once the best
dosage had been identified, this was maintained
throughout the patient’s consults. One notable
difference between either pay or charity
patients’ medications was the continued use of
the first- generation antipsychotic
chlorpromazine for charity patients which was
not given as a preferred medication for pay
patients. (Table 2)
Most medications were available in the
pharmacy; prices for Amisulpride and
Aripiprazole were based on the cheapest
available generic brand of pharmacies in the
perimeter of the hospital. For medications
available within the tertiary hospital, prices were
uniform regardless of the patient’s
socioeconomic status. For dosage ranges with no
applicable single tablet available, the closest
drug was used and the tablet’s price was either
halved or multiplied based on the dosage range.
For example, Quetiapine has no 800 mg
preparation and while both the 200 and 300 mg
preparations were available, the dosage cost was
approximated using four 200 mg tablets. Long -
acting antipsychotics namely Paliperidone,
Risperidone, and Fluphenazine were also noted
but only Fluphenazine was the most commonly
used LAI especially in charity outpatients. Other
medications used, especially for inpatient
treatment, were benzodiazepines however these
were not included in the computation of costs.
Benzodiazepines, while commonly used in the
management of schizophrenia, were excluded as
they are often used on an as needed basis. There
is no standardized frequency on it’s provision to
patients hence making it difficult to place an
appropriate estimate.
Informants identified several laboratories and
ancillaries requested. For inpatient care, as
much as possible, all of the laboratories listed in
Table 3, were requested. If, however, the patient
has financial constraints, electrolytes and
thyroid function tests were not included. Hence
the range for costs for labs and ancillaries
would be that involving all those listed below
and that which excludes electrolytes and thyroid
function tests. The most recent prices were
obtained from the central cashier’s database for
expenses and were accurate as of October 2015.
Costs for room and board and professional fees
were non-existent for charity patients while pay
patients expenses depended on the type of room
they chose. Most informants reported a
preference for a private room, though some
were amenable to the patient being placed in a
semi-private room. Hence the cost for room and
board could range from PhP 950.00/day to PhP
3500.00/day.
Room rates as of October 2015 are listed in
Appendix 2.Professional fees (PF) for inpatients
were computed based on the daily room rate
multiplied by the number of days confined with
the largest PF rate adding another PhP 1000.00.
Professional fees for outpatients ranged from
PhP1100.00 to PhP1800.00 and this depended on
whether the patient was a new patient or for
follow-up. However it was also emphasized by
informants that the professional fee could be
negotiated and subject to discounts - taking into
consideration the socioeconomic status of the
patient and the difficulty of the case; sometimes
even the waiving the fee altogether if necessary.
For the purpose of this study, however, the cost
estimate was based on the standard formula for
computation of the professional fee.
Other out-of-pocket expenses for both in and out
patients were taken into account. For inpatients,
the most common identified expenses were:
additional food, toiletries, and water for both
patient and caregiver, and cellphone load for
the caregiver. Food costs were computed based
on the prices of rice meals in the hospital
cooperative.
The cheapest and most expensive meals were
PhP 35.00 and PhP 50.00, respectively. The
former was assumed to be the meal of choice of
charity patients while the latter was the meal of
choice of pay patients. Cost for toiletries were
assumed to be the same for both pay and
charity patients. Water was also based on the
cost of 5 gallons at the hospital cooperative store
(15 pesos) and calculated that both patient and
caregiver would consume 1 gallon/day.
Finally, the cheapest cellphone load for a brief
phone call and several texts was obtained from
the same store.
Outpatient expenses were assumed to involve
both food and transport expenses. The cheapest
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TABLE 2 MEDICATION COST AS OF OCTOBER 2015

possible food cost for two people was assumed.

(cheapest possible sandwich at the outpatient
cafeteria: PhP 25.00, average price of rice meal:
PhP 50.00) Table 4& 5 lists these other expenses
below.

Transport expenses were reported based on the

assumption that majority the hospital’s patients
are from the immediate Metro Manila area
hence the cheapest fare for public
transportation extending about 2 kilometers was
used and multiplied for 2 (jeepney base fare of
8.5x2). Relapse for known patients was reported
to occur from a minimum of 0/year to about
4/year, especially for charity patients who were
reported to be non-compliant to their
medication.

39 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

TABLE 3. COST (PHP) OF LABORATORIES AND ANCILLARIES AS OF OCT 2015 excluded due to the fact that dosage intervals
may vary depending on the clinical status of the
patient. Also, the variation in the tables listed
below take into account whether laboratories
and ancillaries requested were all versus the
least number desired. The second line for every
dose of each medication lists the cost estimate
assuming both patient and caregiver are
employed.

Finally, all cost estimates assume that a

theoretical patient maintains the same dosage
throughout the particular time period eg. 2 mg
for all 4 weeks, which is not reflective of actual
clinical practice hence the need for, again, the
cost estimate between highest and lowest possible
monetary values. For tables 6 to 10, all values in
the upper row indicate cost based on medication
alone while the lower row adds other costs as
indicated in the first column, these costs include
indirect costs, laboratories, and other expenses.

TABLE 4. OTHER INPATIENT EXPENSES (PHP)

Indirect costs were found to vary depending on
the employment status of the patient and the
caregiver during either inpatient or outpatient
care. Productivity losses were computed based
on the assumption that most patients are based
in Metro Manila hence the minimum daily wage
for non-agricultural workers was used. In
computing for indirect cost, the range of
productivity losses could be as low as 0 if both
patient and caregiver are unemployed to twice
the daily minimum daily wage if both are
employed.

Several notes about the general inpatient cost

estimates: regardless of setting, intramuscular
haloperidol was the medication of choice for
acute agitation though there was no recalled
number of times it was necessary to be given to
patients hence the estimates do not reflect any
administration of haloperidol.Additional
administration of benzodiazepines and any long
acting antipsychotics were not taken into
account.

As mentioned earlier, frequency of

benzodiazepine use could vary greatly
depending on the need of the patient hence it’s
exclusion. Long acting antipsychotics were also

40 · PJP 2021 · Volume 2 (1-2) · ISSN


The above values displayed conservative
estimates erring on higher possible costs. The
cheapest possible course of charity inpatient
treatment was PhP 2332.00 (Risperidone 2 mg
with the least laboratories, both patient and
caregiver unemployed) while the most expensive
possible course was PhP 44,861.00 (Quetiapine
800 mg, all laboratories, both patient and
caregiver employed). (Table 6)
Table 7 lists the cost estimates for charity
outpatient treatment in PGH. While interviewees
reported variable periods of follow-up for their
patients, the most often was on a weekly basis
while the longest period was 3 months. All listed
values do not take into account any laboratories.
Values listed below include the purchase of one
week’s supply of medication from the hospital
pharmacy. The cheapest outpatient drug,
Risperidone 2 mg comes in at a cost of PhP
241.00 for monthly visits (this includes one
month’s supply of the drug and one outpatient
consult for patient and caregiver both docked
half a day’s wages) while the most expensive was
Quetiapine 800 mg/day with a cost of PhP
17,801.00. Extrapolated on an annual basis,
outpatient costs would range from PhP 2892.00
(Risperidone with monthly consults) to PhP
21,3612. 00.Again, this estimate does not include
costs for laboratories requested during the
course of the year. If laboratories may be
necessary, this can add an additional Php 1330 if
the physician requests for all the standard
baseline laboratories.
Should at least one 1 week readmission occur,
additional cost would range from PhP 3312.00
(Risperidone) to PhP 17,320.00 (Quetiapine) to
the annual cost of treatment. (Table 7)
For pay patients, the range was based on the
cheapest possible to the most expensive room
rate. Hence Table 8 illustrates cost estimates for
a patient admitted at a semi-private room while
Table 9 shows cost estimates for admission to a
private deluxe room. Note that these estimates do
not include the cost of possible administration of
intramuscular haloperidol, benzodiazepines, or
long -acting agents. Professional fees were also
added to these estimates. Also, charges for
laboratories and ancillaries were
As in the charity inpatient, Risperidone (PhP
15,347.00) and Quetiapine Php 89, 031 were the
cheapest and most expensive treatments,
respectively.Note that if Haloperidol +
Diphenhydramine had to be given, Php 277 would
be added per administration of this rescue
medication. (Table 8)
As in the charity inpatient, Risperidone (PhP
55,547.00) and Quetiapine (PhP 246,831.00) were
the cheapest and most expensive treatments,
respectively.(Table 9)
Finally, outpatient pay treatment were identified in
Table 10. Again, the cheapest out patient treatment
involves the use of Risperidone (PhP 1441.00,
1/month visit) and the most expensive is Quetiapine
(PhP 93,800.00 weekly visits, highest PF).
Extrapolated on an annual basis, the cheapest
possible course of pay outpatient treatment, with
Risperidone and Quetiapine, respectively, amounts
to PhP 17,292.00 to PhP 1,125,600.00.
The high cost estimate of Php 1,125,600, however, is
based on a weekly visit for 52 weeks with high
dosage and professional fees. Hence 93, 800 per
month amounts to 1,125,600 assuming the patient
follows up every week and maintains the high dose
Quetiapine. Should relapse occur, minimum added
additional cost would range from at least PhP 15,347
.00 (Risperidone 2 mg with cheapest room, PF, and
only 1 week stay) to PhP 244,906.00 (Quetiapine 800
mg, most expensive room and PF rate, and 4 week
stay).
The cost estimates in the table below do not include
additional possible costs incurred if laboratories
are requested. An additional Php 2325 to 4455 may
be added depending on if the physician requests
for only the most important tests versus all
appropriate tests. Note that the table is divided
based on the lowest versus highest professional fee
charged by the physician.
If a patient visits a physician charging the lowest
fees monthly then this cost is 1,100 while biweekly
visits cost 2,200 and weekly visits cost 4,400
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TABLE 6. COST (PHP) OF CHARITY INPATIENT CARE

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TABLE 7. CHARITY OUTPATIENT EXPENSES (PHP) TABLE 8 PAY INPATIENT-LOWEST ROOM RATE AND LABS/ANCILLARIES - LOWEST PF

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TABLE 9. PAY INPATIENT - HIGHEST ROOM RATE AND LABS/ANCILLARIES - HIGHEST PF

44 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

Should the patient consult with the physician TABLE 10. PAY OUTPATIENT EXPENSES (PHP)

charging the highest fees costs incurred are Php

1,800 (monthly visits), 3,600 (biweekly visits),
and 7,200 (weekly visits). Further computational
breakdowns may be found in Appendix 2.

In summary, the most influential factor on cost of

treatment was the type of medication used:
Risperidone and Quetiapine were the
medication for the cheapest and most expensive
course of treatment, respectively.

DISCUSSION
The study showed a range of costs for
hospitalization and outpatient treatment for
schizophrenia using information provided by
key informants. The study’s model, however,
makes for several key assumptions erring more
on the lowest and highest possible estimates. In
comparison to studies done in Sri Lanka (5),
Europe (6, 7), China (8), and the United States
(9), the estimated of cost of treatment for
schizophrenia in the Philippines are higher,
especially in the pay service setting.

As a study based on key informant interviews

and prospective costs, the data provides a linear
estimated model and does not take into account
possible decreases in the cost based on the
clinical picture of a patient. Nonetheless, the cost
involved in treating patients with schizophrenia,
based on these estimates, will significantly affect
the economic burden on the patient and their
caregivers.

The study’s focus is on the patient’s and family’s

estimated costs to be incurred in the treatment of
schizophrenia.. The perspective that represented
the viewpoint of the analysis was important since
it affected what types of costs were included and
how they were measured and valued. In
addition, the viewpoint allowed for the analysis
to lead to a decision-making context, namely the
national health insurance program (or the
PhilHealth). The government has tried to
alleviate the cost of healthcare by packages
provided for inpatient coverage of mental
illnesses. However, PhilHealth only covers two
weeks of inpatient care as well as a uniform case
rate regardless of the type of mental illness.
Specifically, PhilHealth provides a total of PhP
7800.00 (PhP 2340.00 for Professional Fee and
PhP 5460.00 for HealthCare Institution Fee). (4)
Depending on the medication used, it appears
that PhilHealth coverage would be enough for
inpatient charity care; however the above
model was unable to take into account other
possible sources of indirect costs. On the other
hand, application of this model shows the case
rate to only be able to cover approximately 30-
40% of the total expense. Thus this coverage may
be deemed lacking, especially for treatment on
the lower end of length of time (2 weeks).
However the model, especially on the 3rd and
4th weeks of treatment can be considered to be
highly excessive due to the large amount
contributed by professional fees that may be
decreased or socialized. The possibility that the
listed costs may be overestimations are also an
inherent limitation of the linearity of the model.

45 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

Another additional item to be considered would
be other financial sources. The hospital’s
patients, particularly charity patients, often opt
to request additional funding assistance from
other agencies such as the Philippine Charity
Sweepstakes Office, Philippine Gaming
Corporation, and the Department of Health.
inpatient charity care; however the above model
was unable to take into account other possible
sources of indirect costs. On the other hand,
application of this model shows the case rate to
only be able to cover approximately 30-40% of
the total expense. Thus this coverage may be
deemed lacking, especially for treatment on the
lower end of length of time (2 weeks). However
the model, especially on the 3rd and 4th weeks
of treatment can be considered to be highly
excessive due to the large amount contributed by
professional fees that may be decreased or
socialized. The possibility that the listed costs
may be overestimations are also an inherent
limitation of the linearity of the model.
Another additional item to be considered would
be other financial sources. The hospital’s
patients, particularly charity patients, often opt
to request additional funding assistance from
other agencies such as the Philippine Charity
Sweepstakes Office, Philippine Gaming
Corporation, and the Department of Health.
These agencies typically provide financial
subsidies for medications of patients; however
there are no publicly posted standard amounts
given for these subsidies. With this study, the
appropriate amounts could be requested--one
key caveat of this model is that drug prices are
based on the hospital pharmacy, which heavily
subsidizes the price of medication. For example,
private pharmacies price Risperidone 2 mg at
PhP 30.00 (the cheapest generic brand) versus
PhP 8.00 in the tertiary hospital.
Conclusions, Limitations & Recommendations
The study determined the cost of treatment for
pay and charity inpatient and outpatient care at
a government tertiary hospital. The cost, for
charity inpatient care, may ranged from PhP
2332.00 to PhP 44,861.00. For charity outpatient
care, this may range from PhP 2892.00 to PhP
213,612.00 annually. For pay patients, costs were
estimated to range from PhP 15,347.00 to PhP
246,831.00. The above costs prove that
schizophrenia is a significant healthcare burden
or patients in the Philippines. Though the study’s
model errs on the higher end of estimates, this
may prove to be obsolete as prices and costs
increase over time.
As mentioned earlier, the study had several
limitations. First, several medications (long
acting antipsychotics, as needed intramuscular
Haloperidol, benzodiazepines) were not taken
into account due to their variability in
administration. Secondly, the cost estimates did
not factor the possibility of patients being
PhilHealth members that may have decreased
the out-of-pocket expenditure. Thirdly, the
model assumes a linear use of medication--it
assumes patients use the same dose over the
same period of time, which is not true of actual
clinical practice where variation of dosages may
occur. Fourthly, the use of a single center setting
with highly subsidized costs may also skew data
towards lower values compared to other private
institutions. Finally, valuation of productivity
costs continue to be difficult to define and
uniform hence the indirect cost (assuming 0
cost) is unlikely.
The chief recommendation for this study is that
it may be used in further future studies,
especially in a multi-center study. The same
model may also be used for rough estimates of
other psychiatric disorders. The data obtained
should also help justify the increase of benefits
and financial support provided to the patient
and his/her family.
46 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
REFERENCES
1.Drummond M et al, Editors. Methods for the economic
evaluation of health care programmes. United Kingdom: Oxford
University Press; 2005.

2.Lam H et al,. Editors. Clinical economics primer: A self-

instructional module. International Clinical Epidemiology Trust:
2007.

3.Tumanan-Mendoza, B., Mendoza, V., Morales, D. Cost analysis

for the management of acute coronary syndrome using different
quality of care indicators. Acta Medica Philippina 2009 43, 4: 33-
38.

4.“List of Medical Case Rates” PhilHealth Official Website, 2013.

Web. 12 August 2015.
http://www.philhealth.gov.ph/circulars/2013/annexes/circ35_20
13/Annex1_ListOfMedicalCaseRates.pdf

5. de Silva, J., Hanwella, R., de Silva, V. Direct and indirect cost

of schizophrenia in outpatients treated in a tertiary care
psychiatry unit. Ceylon Medical Journal 2012 57:1, 14-18.

6.Marcus, S., and Olfson, M. Outpatient antipsychotic treatment

and inpatient costs of schizophrenia. Schizophrenia Bulletin
2008 34:1, 173–180.

7. Sarlon et al. A prospective study of health care resource

utilisation and selected costs of schizophrenia in France. BMC
Health Services Research 2012 12:269.

8. Zhai, J., Guo, X., Chen, M., Zhao, J., and Zhongua S. An
investigation of economic costs of schizophrenia in China.
International Journal of Mental Health Systems. 2013 7:26.

9.Ascher-Svanum, et al. The cost of relapse and predictors of

relapse in the treatment of schizophrenia. BioMed Central
Psychiatry 2010 10:2-14.

10.Haycox, A. What is health economics? (2nd ed). Hayward

Medical Communications: 2009, retrieved from:
http://www.medicine.ox.ac.uk/bandolier/painres/download/wha
tis/what_is_health_econ.pdf on November 5, 2015.

11.WHO-AIMS Report on Mental Health System in The

Philippines, WHO and Department of Health, Manila, The
Philippines, 2006.

12. Key Informant Interview Consent form obtained at

http://webcache.googleusercontent.com/search?
q=cache:Wymk7X-
DorIJ:publichealth.lacounty.gov/sapc/prevention/PV/Attachme
ntP_KeyInformantInterviewFocusGroupSupplementalDocument
s/KeyInformantFocusGroupConsentForms.pdf+&cd=7&hl=en&ct
=clnk&gl=ph on 12 August 2015.

13.Diagnostic and Statistical Manual of Mental Disorders, 5th ed.

American Psychiatric Publishing, 2013.

47· PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

 PJP CASE REPORT

LEFT OUT - PERSISTENT PEDIATRIC DEPRESSION IN

PANHYPOPITUITARISM: A CASE REPORT

JOSE LORENZO A. GALAN, MD

JOCELYN NIEVA YATCO-BAUTISTA, MD, FPPA, FPSCAP

ABSTRACT

This is a case of a 15-year-old Filipino male with a history of craniopharyngioma who

underwent trans-sphenoidal surgery with panhypopituitarism as its sequelae. The biological
factors of the patient's disease contributed to his persistent depression and were perpetuated
by psychosocial and cognitive factors. A biopsychosocial approach was used in understanding
this case to arrive at individualized treatment and management.

KEYWORDS: Craniopharyngioma, Depression, Biopsychosocial approach

INTRODUCTION depression and anxiety, and they feel impaired

Craniopharyngiomas (CP) are rare intracranial
tumors of low histological malignancy, derived
from malformation of embryonal tissue and
most frequently located in the sellar and
parasellar region of the brain. Due to their
proximity to the pituitary gland and the
hypothalamus, CPs often cause hypothalamic
dysfunction, including endocrine deficiencies
and obesity, resulting in neurocognitive
impairments and behavioral changes as well as
impairments in social-emotional functions. (1)
Its incidence is 1.5 per million per year. The age
distribution is bimodal, with the first peak in
childhood at the age of 5 to 14 years and the
second peak at 65 to 74 years. The most common
symptoms of craniopharyngioma are:
headaches, temporal visual field defects,
decreased growth rate, polydipsia/polyuria, and
excessive weight loss or weight gain. After tumor
removal as in our case, patients often suffer
from chronic disease due to hypothalamic injury
or hypopituitarism, which may have a severe
impact on daily life. Patients with early-onset
craniopharyngioma have increased rates of
in their social and professional integration as an
effect of the disease. (2)
In children with depression due to a medical
condition, there are some atypical presentations
of depression. In DSM – V TR, atypical
manifestation includes mood reactivity and two
of the following four symptoms or features also
must be present: 1) hyperphagia or weight gain,
2) hypersomnia, 3) leaden paralysis, and 4)
interpersonal rejection sensitivity. Although this
is mostly best understood in adults, it has been
found out to have a different pathophysiology,
presentation, prognosis, and response to
pharmacologic treatments. (3)
Another contributing factor in the case was the
absent parent particularly the father is seen in
this case. It has been found out that there was
evidence for a main effect of father absence in
early childhood on depressive symptoms at age
14 years old. The interaction between gender
and father absence in early childhood,
indicating that the association between father
absence and depressive symptoms was stronger

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in girls than in boys. The mechanisms linking
early father absence to an increased risk of
depressive symptoms in girls remain unclear. It
has been previously suggested that biological
and psychosocial effects of advancing puberty
may be implicated which complicates that this
patient had problems in his hormones that
affected his puberty. (4)
In this case report, it has been shown that not
only the biological factors of sequelae of
craniopharyngioma contributed to the
depression of the patient. It is a complex
interaction between the biological, psychosocial,
and cognitive factors that contribute to the
patient's persistent depression.
CLINICAL HISTORY
The patient is a 15-year-old male, single, right-
handed, Roman Catholic, junior high school
student, an only child, from a city in Rizal. This is
his first psychiatric consult. He was brought to
our institution due to suicidality, sadness, and
withdrawal as an outpatient pediatric neurology
referral. The patient is known to be jolly,
obedient, extrovert, frank premorbid but
became irritable, easily angered, and suicidal.
In 2008, when the patient was three years of age,
he started to complain of episodic headaches,
around 1-2x/week, uncharacterized. He was
brought to a pediatrician and was advised to
lessen gadget use. In the interim, there was the
persistence of headaches with increasing
frequency but no vomiting. He was brought for
follow-up but advised to consult with a pediatric
neurologist. There was no note of behavioral
changes such as depressed mood or irritability.
In October 2011 (aged 5, Grade 1), his headaches
became more frequent and intense
accompanied with vomiting. He subsequently
had loss of consciousness and was brought to a
nearby hospital. Cranial CT scan showed acute
hemorrhage, suprasellar cistern with intra-
ventricular extension, and mild obstructive
hydrocephalus; cranial MRI was then done,
which showed vertically oriented peripherally
enhancing suprasellar mass (2.1x 1.8 x 4.1cm),
which was consistent with craniopharyngioma.
The patient underwent trans-sphenoidal surgery
for resection of the tumor. Post- operatively,
there were endocrinologic complications—
hypothyroidism and central diabetes insipidus;
hence he was given hormonal supplementation.
He was then discharged after a month with
residual bi-temporal hemianopsia, but he
recovered functionally. The mother became
protective of her son due to his condition and
prevented him from doing strenuous physical
activities. The mother would even say that he
"special" and "not normal" unlike other kids
because of his illness. When he returned to
school, the patient had difficulty adjusting to the
school work due to the one-month delay. He was
noted to become more extrovert and frank in
expressing his feelings.
The mother disclosed to all of her son's teachers
and classmates that he needed special help in all
activities due to the deficits that he had after the
surgery (bi-temporal hemianopsia). His
classmates treated him as & "special"; because
they were afraid that they would get in trouble
should the patient get hurt. They excluded him
from group activities (academic group work
and play), which made him feel isolated and
sad. Due to his deficits and the inculcation that
he was different, the patient began to feel
incompetent, thus would always ask for
clarifications from his classmates and teachers
about assignments and group projects they had
in school. When the patient told his mother, she
perceived that her son was considered a burden
to other students—making the group slower and
the dynamics of their group complicated. But
instead of consoling the patient, patient’s mother
would often tell him that maybe he makes his
classmates angry by irritating them; which led to
more frustrations and worsening of patient’s
sadness. Nevertheless, the patient was able to
finish Grade 1 without failing grades but was
below average.
In 2012 (aged 6, Grade 2), the patient continued
to be excluded by his classmates in some
activities but was less problematic as there were
less group activities at this time. Although he was
able to develop a couple of friends that he
frequently played with, he still felt sad and
unwanted about not being included in group
work.
This pattern of behavior towards the patient
continued up to 2015 when he was 9 years old,
(Grade 4) that teachers would have to be the
ones to assign him to a group. Much as he
wanted to be a leader, he was never chosen as
such.
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Although he had some friends, they still didn’t
invite him to their outings (e.g., swimming) and
would sometimes eat lunch alone in school. He
was noted to cry more often and was no longer
interested in doing his hobbies such as
basketball. He also over ate when he was
stressed. He told his mother that his classmates
would say that they didn't want to play with him
because they might get into trouble when he got
hurt. The mother consoled him yet would often
say he did something wrong to his classmates
thus they don't want to be with him; this just
intensified his frustration and began to blame
himself and his disease. Despite this, the patient
was able to perform in school with no academic
performance problems and obtain average
grades.
In late 2015, the patient became a picky eater—
preferring to eat certain foods such as pasta and
instant noodles. He was also noted to drink 20
glasses of water per day. He gained more weight
(compared to his pre-medical condition). Due to
his health condition, his mother frequently
reminded him to have a healthy diet and to lose
weight. He felt unwanted because of his weight.
His mother often compared him to his cousins,
telling him that his cousins were obedient with
their mothers and he wasn't (e.g., regarding food
intake and diet), which would often lead to
arguments between the two. The patient would
often feel unwanted and sad, and at times would
hit his head using his fist out of frustration.
Whenever he would hurt himself, he was often
physically restrained and verbally
reprimanded, thus increasing his agitation. He
would only stop whenever he was tired, and
subsequently, would get what he wanted. They
followed up with his pediatrician, and he was
advised to consult with a psychiatrist but could
not comply due to the mother's schedule. These
symptoms persisted until 2016.
In June 2016 (aged 10, Grade 5), the patient and
his mother transferred to their new house in
Antipolo, Rizal, where his aunt and two cousins
(11-year-old boy and 12-year-old girl) stayed
with him for several months. His symptoms were
noted to have declined initially—no crying
episodes were reported, and he was seen
enjoying the company of his cousins. However,
when he attended his new school, his
expectations of a different environment were not
met. At school, his classmates would often
exclude him once again in their group activities,
and often his schoolmates would ask him if he
was a boy or a girl because he looked and
sounded like a girl. He also had difficulty
gaining friends.
This, on top of repeated arguments with his
mother, led to worsening feelings of sadness. He
was easily irritated and seemed to be wallowing
in self-pity. His behavior of hitting his head with
his fist recurred. He would often verbalize that
he wanted to die. Again, they consulted with his
pediatrician, and he was advised to seek
consultation with a psychiatrist but did not
comply. The symptoms persisted until the
following year.
In 2017 (aged 11, Grade 6), the patient was seen
crying during their recognition day because his
mother could not attend the awarding due to her
work. He was angry with his mother because he
expected her to be there for him when he would
receive his first academic award for being an
achiever. He felt sad that he was not that
important to his mother. Upon arriving home
after his mother fetched him, he went straight to
his room and locked the door. His mother heard
loud noises, so she forced her way into the room
and saw her son strangling himself with a belt.
Due to this incident, he was brought to his
pediatrician, who again advised consultation
with a child psychiatrist. Instead of consulting
with a psychiatrist, his mother resigned from her
work and set up a home business selling jewelry
and clothing so she could spend more time with
her son. After knowing what their son did, the
father scolded him, saying that he did this to
himself without thinking of his parents' feelings,
which further convinced him that he was
insignificant to his parents. Much as patient
wanted to die, there were no other suicidal
attempts.
In 2018 (aged 12, Grade 7), the patient had
frequent arguments with his cousins who were
supposed to keep him company but preferred to
focus on their gadgets than on him. He was
heard questioning himself, "Why doesn’t
anybody like me?". This just made his cousins
avoid him even more. The patient would have
crying episodes, became more irritable, and
frequently quarreled with his mother, especially
regarding household chores. In 2019 (aged 13,
Grade 8), the patient's feelings of sadness, self-
50 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
pity, and being unwanted persisted, and his self-
harming behavior became more alarming. In
one instance, his mother stopped him from
stabbing himself in the kitchen after they argued
about his food choices.
He was again reprimanded for this behavior,
and his father once more told him why he
should not do it again. In an attempt to help her
son recover, the mother asked some of his
classmates to befriend him. Some of his
classmates invited the patient to join them when
they went to malls, played online games, and
joined their group chats. However, the patient
was told that there was a limit to how he would
be involved in their conversations, and they will
exclude the patient in some activities such as
swimming and outings. He labeled his classmates
as "fake friends" because he assumed they only
liked him when he treated them out to eat. His
relationship with his "fake friends" faltered, and
he thought he was just being used. This resulted
in him having no friends at all.
In March 2020, at the start of the pandemic
(aged 14, Grade 9), because of the shift to online
classes, the patient and his mother were able to
spend more time together, they would often
watch movies on Netflix together, and they
considered each other's best friend because they
shared their problems and supported each
other. However, they still argued about his food
preferences and his excessive water intake of 6
liters per day. He became more irritable
argumentative and verbalized that he was
unwanted, useless, and burdened by his parents.
He thought that his parents were better off
without him. He was more often seen by his
mother hitting his head with his fists and
repeatedly saying that he was a burden to this
family. This time, due to the limitations set by the
pandemic, they were again unable to seek
psychiatric consult.
In June 2020 (aged 14, Grade 9), the patient
started having difficulty with school projects
because his classmates refused to help him, so he
had to do them all by himself. The crying
episodes and increased irritability recurred. He
also complained of generalized headaches, 7/10
in intensity, squeezing in character, aggravated
by stresses and emotions, and was relieved by
rest. This prompted a consult with his
pediatrician, and he was advised to undergo
repeat cranial neuroimaging.
In the interim, there was the persistence of the
previous symptoms and behavior. In July 2021,
the patient's follow-up cranial neuroimaging
showed a nodule in the suprasellar-sellar region
measuring 1.5x1.7x1.7cm, indents the optic chiasm
and adhered to the pituitary stalk, but with intact
pituitary gland.
The patient's parents decided to postpone his
education, and just focus on his medical
condition, which patient initially accepted even if
deep down he wanted to continue with his
education. In September 2021, his headache
worsened, becoming more frequent. Hence, he
consulted with his pediatrician, who attributed
the symptom to the craniopharyngioma. Repeat
cranial neuroimaging was requested, and
advised that patient undergo repeat excision of
the mass or radiation therapy. But due to
financial constraints, their family could not
proceed with the management and instead
followed through on the psychiatric tele-
consultation.
The patient's past medical history revealed
primary hypothyroidism, central diabetes
insipidus, and primary hypogonadism due to his
craniopharyngioma. Family and personal social
history were non- contributory. Developmental
history was at par with age but delayed sexual
maturity Tanner Stage I.
The patient lived with his parents until he was 3
years old when his father went to work in Dubai
and was the primary disciplinarian. He would
return to the Philippines yearly for about 2
weeks. The patient considered his interactions
with his father insufficient, and he wanted to be
with his father most of the time. He had thoughts
of being inadequate and a burden to his family,
believing that his illness was the reason why his
dad had to work abroad. Because of this, the
patient would always cry whenever his father
would leave the country.
The patient grew up with his mother who usually
gave in to all of patient's requests since she was
afraid that if he was stressed his headaches
would worsen. The mother described her son as
easy to take care of when he was a baby.
Whenever the mother had to go to work, her
sister (a maternal aunt) would take care of
patient. The patient was breastfed for six
months, then later shifted to bottle feeding for
51 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
another six months. Whenever the patient would
cry, his mother would immediately attend to
him. He was weaned off from bottle feeding at
the age of 2 years old. There was no note of
thumb-sucking or further use of soothers. His
developmental milestones were at par with age.
At the age of two, toilet training was initiated.
The training was strict, guided primarily by her
mother, and was completed at three years of
age.
PHYSICAL & MENTAL STATUS EXAM
The patient was overweight with a BMI of 30.3
(z-score= +2) and a height of 160cm (z score =
-1). Physical exam revealed Tanner Stage I, and
in the neurological exam, the patient had
bilateral temporal hemianopsia.
The patient was seen sitting on a chair in front of
a laptop during the online interview.
examination. He had short hair, was well-kempt,
wearing a white shirt and shorts. He had good
eye contact. He spoke in a low and soft tone of
voice with an average rate of speech. He claimed
to be depressed and affect was appropriate. He
would repeatedly say, "Am I evil? Did I do
something wrong to them? Why doesn’t anybody
love me?" He claimed he frequently thought it
was better if he were gone. He verbalized that he
did not know why he felt this way. There was no
tangentiality and circumstantiality. He denied
hallucinations or delusions. No impairments in
abstract thinking and planning were observed
by asking similarities of two words and using the
Montreal Cognitive Assessment - Philippines. The
patient was successful in identifying train and
bicycle as “transportation” and weighing scale
and ruler as “sukatan”. He had partial insight as
he did not understand his illness or why he feels
this way but is willing to be helped and
cooperate in therapy. The patient was
considered to have only fair judgment as he was
not remorseful of his suicidal attempts. When
asked, why he attempted suicide; he would just
ignore the questions and remained silent.
TREATMENT AND MANAGEMENT
The patient was started on low-dose
Escitalopram 10mg ½ tab at night. He was
advised to have a neuropsychological
examination to assess cognitive capacity and
explore personality traits, but was not done due
to financial constraints.
The patient's differential diagnosis was
persistent depressive disorder, as the patient
fulfilled the criteria of depression for more than
one year. Still, due to the multifactorial
consideration of the robust findings of
panhypopituitarism, depression secondary to a
general medical condition was considered.
Overeating, could be attributable to the medical
condition while low self-esteem and
hopelessness, were considered an effect of
psychosocial and socio-cognitive factors.
The patient also responded well with cognitive
behavioral therapy for three sessions that
identified his thoughts, emotions, and actions.
Later his sessions were focused on identifying his
cognitive distortions such as negative mental
filtering and polarized thinking that resulted in
decreased irritability, euthymic mood, and
reduced arguments at home. In the last follow-
up, the mother reported improvement in the
patient's mood, which was not euthymic, and he
did not argue as much with his mother. He often
could control his urges to drink and eat more
than his usual serving.
Cognitive behavioral therapy was used in this
case because of the common change and
mechanisms specifically targeted for pediatric
depression. Particularly behavioral activation
and cognitive restructuring have been most
consistently correlated with improvements in
depression among adolescents. Behavioral
activation includes bringing positive
reinforcements, specifically physical and social
activities, leads to increased engagement in
activities. Cognitive restructuring includes
generation of realistic and positive perspective
in patients thru challenging negative thoughts.
(5) Family therapy was conducted to teach his
parents proper behavior modification, such as
being consistent on how they would discipline
and improve family dynamics thru better
communication. The patient was referred back
to pediatric neurology and endocrinology for
close follow-up. Repeat hormonal assay, such as
testosterone, follicle-stimulating hormone,
luteinizing hormone, thyroid function tests, and
metabolic workup were scheduled.
DISCUSSION
The predominant symptoms in this case were
sadness, self-harming behavior, self-blame, and
worthlessness, which are constitutional signs of
52 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
depression. There are four main pillars that
significantly contribute to the development of
depression in this case: psychological, cognitive,
social, and biological. Both social and cognitive
factors greatly influence the psychological
factor. The social factor also affects cognition.
(Figure 1). Additional dwelling on the biological
origins of depression is the psychoendocrinology
of behavior. A discussion of the hypothalamus-
pituitary-gonadal axis is warranted to correlate
the symptoms of the patient's case with biological
underpinnings.

Like the other hormones governed by the

hypothalamus and pituitary, the cascade of
hormonal reactions in the HPG axis starts with
the release of hypothalamus and pituitary, the
cascade of hormonal reactions in the HPG axis
starts with the release of the GnRH or
gonadotropin-releasing hormone by the
hypothalamus, leading to the activation of the
pituitary gland leading to the release of the
luteinizing hormone and follicular stimulating
hormone. The LH and FSH activate the
conversion of precursor substance to
testosterone. Essential to take note in this is that
testosterone is the sole precursor of estradiol in is due to its activation of the dopaminergic
males. HPA controls secretion of corticotropin- system leading to reward regulation and positive
releasing hormone (CRH), which in turn controls affectivity. Testosterone also influences the
glucocorticoid secretion and may affect prefrontal cortex via the dopaminergic system
depressed mood. (Figure 2) (6)(7) leading to motivational regulation. (Figure 3) (9)

A neurobiological reason for the reduced
psychological status of individuals with
craniopharyngioma is the lack of hormones due
to an impaired HPA axis. Involvement of the
hypothalamus is neurobiological explanation of
impaired quality of life. In this patient, his
condition led to reduced self-confidence and
coping skills thru his feelings of being inferior
due to his physical illness.
There are two ways of involvement of
testosterone in behavior and, most importantly,
depression. The addictive effect of testosterone
The patient’s levels of testosterone as correlated
in the year April 2019 (35.6 ng/dL) and August
2019 (26.9ng/dL) as normal values should be
208.08-496.58 ng/dL. This low testosterone level
concurrently coincides with the patient's
depressed mood and suicidality. The
testosterone level of the patient was consistently
low.
The diagram below notes that testosterone is the
sole origin of estradiol in males, which increases
the conversion of tryptophan to serotonin in the
CNS serotonin system.

53· PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

Estradiol also inhibits the monoamine oxidase A,
which decreases the degradation of serotonin.
Cumulatively the effect of estradiol increases
theeffect of estradiol increases the CNS serotonin
levels, which is essential for cognition and mood
regulation. (Figure 3) (6)
Thyroid hormone application may desensitize
presynaptic 5-HT1A raphe autoreceptors, and
thus increase cortical serotonin release. In
addition, thyroid hormone-induced increases in
5-HT2 receptor sensitivity might potentiate the
effects of antidepressant drugs on the 5- HT2
receptors (Figure 4) (10)

For the Hypothalamus-Pituitary-Thyroid axis,

the hypothalamus releases thyrotropin-releasing
hormone, activating the release of the thyroid-
stimulating hormone by the pituitary. The
thyroid-stimulating hormone then stimulates
multiple reactions and cascades, leading to the
production and release of thyroid hormones -T4
and T3. Far more critical is its effect on mood
regulation, as deficits of thyroid hormone leads
to depression. (Figure 4)

The patient was hypothyroid with TSH levels of

0.49mU/L (normal value: 0.7 – 6.6 mU/L) last
October 2011 at age 5. This coincided with the
start of the depressed mood after patient’s trans-
sphenoidal surgery.

The thyroid hormone has direct effects on the

synthesis and release of serotonin as well as
increasing receptor sensitivity of the
hippocampus and cortex leading to mood
regulation. On the other hand, hypothyroid
states result in an increase in 5-HT turnover in
the brainstem. Increased 5-HT turnover in
For the Hypothalamus-Pituitary-Adrenal (HPA)
hypothyroid states may lead to an increase in
axis, elevation in glucocorticoids, either primary
raphe 5-HT1A autoreceptor activity and a
or secondary, can cause depression or psychosis
decrease in cortical 5-HT concentrations leading
when stressed. The hypothalamus releases the
to depression. The inverse effect of the thyroid
corticotropin-releasing hormone, which
hormone at the 5HT1A receptor, a presynaptic
activates the release of the pro-
inhibitory at the raphe nucleus, leads to
opiomelanocortin (POMC) precursor peptide
decreased serotonin reuptake.

54 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

prior to its cleavage to form
adrenocorticotropin releasing hormone. Part of
the POMC peptide is the endogenous opioid B-
endorphin that is vital in the modulation of stress
and pain. In conditions that decrease the
functionality of the pituitary hormone, the
production of endogenous B-endorphin peptides
is reduced. (8)
The patient was also worked up with cortisol
assay last December 2011 with normal results of
8.32 ug/dL with normal values of 6.2-19.4 ug/dL.
The neuropeptides, oxytocin, and vasopressin,
may also be involved in hypopituitarism when
the posterior pituitary is involved since our
patient was worked up for Diabetes Insipidus last
2011. Both oxytocin and vasopressin promote
social cognition; males have androgen-
dependent vasopressin receptors in the lateral
septal nucleus. The hippocampus is involved in
mechanisms of learning and memory
consolidation whereas the lateral septal nucleus
is important for social recognition and related
social behaviors. Vasopressin and oxytocin
activate both pyramidal neurons and
GABAergic interneurons in the hippocampus
and could facilitate memory consolidation by
potentiating synaptic transmission. At the same
time, both hormones promote social cognition.
Oxytocin has parasympathetic activation leading
to anti-anxiety and antidepressant effects, while
vasopressin activates sympathetic response
resulting in stress response activation and
regulation. (13)
Lastly, another important factor in this case is
the effect of obesity on depression. In normal
individuals, the anorexigenic substance leptin
produced by adipocytes decreases appetite,
while its counterpart, ghrelin, increases appetite.
In obesity, due to other factors such as diabetes,
hypothyroidism, or hypercortisolism, there is a
significant effect on the appetite overriding the
leptin-ghrelin control of appetite. The
overriding of this system leads to increased
macronutrient accumulation, increasing and
enlarging the abdominal adipocytes.
This leads to a further increase in leptin instead
of further decreasing appetite, which results in
leptin resistance. Elevated leptin levels cause an
inflammatory response in the CNS. Leptin
inhibits the conversion of tryptophan to
serotonin, adding to the development of
depression. (14) Relating this to the patient's case,
his obesity could be reflective of abnormal leptin
levels causing subsequent depressive symptoms.
Aside from the biological causes of depression
in this case, we need to analyze the other pillars
mentioned earlier. Elaborating on the
psychosocial domain, we utilize the Erik
Erikson's theory of psychosocial development. At
the age 3 -6 years old in Erik Eriksons’s
psychosocial development, children encounter
the crisis of initiative vs guilt. The child’s
expanding initiative forms the basis of
subsequent development of realistic ambition
and the virtue of purpose. The patient was able
to resolve this conflict as he has been an active
student in his early pre-school years. By the age
of 7-12-years old, children are met with a crisis
of industry versus inferiority. This stage is
influenced by both peers and family, and which
was the particular stage of conflict for the
patient. (15)
At the age of 5, even up to the recent events, the
patient had significant peer rejection and social
exclusion i.e. bullying experience. He wasn't able
to establish and evaluate himself in the context of
a group. His attempts to acquire peer
encouragement and acknowledgment were in
vain regardless of his initiatives. While at home,
the absence of his father and the lack of siblings
led to the focus of acquiring confidence from his
mother. However, his attempts of confiding with
his mother were met with subtle invalidating
responses, such as questioning his behavior in
school and towards his peers. His significant
acknowledgment in academics was met with
disappointment. The cumulative lack of positive
peer and familial influence caused him to see
himself as inferior leading to a psychological
malignancy called inertia. He lacked self-esteem,
often blamed himself and filled with self-doubt,
considered himself worthless. Every complaint
against him and his complaint about others was
ignored, which led to his maladaptation. (15)
(Figure 5)
He was bullied by his classmates and was
considered a burden by his classmates due to his
physical illness. The patient confided to his
mother but she felt the patient might have been
55 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
the problem and that he should be the one to
change his behavior. The patient felt his feelings
were invalidated, which led to his feeling
depressed and helplessness to the point he
considered himself a burden to everyone
including his family.
Currently at the age of 15 years old, the patient
has a new crisis of Identity versus Role
confusion. It will be a challenge for him in
adapting to the new changes of his adolescent
stage and is still in the process of figuring out
who he is. (15)
In the socio-cognitive domain, the main
prerequisite, of social interaction, proved to be
deficient in the patient's case. Social interaction is
essential in developing perspective-taking and
cognitive flexibility, to be able to set limits to
one's point of view, and to shy away from
egocentric thoughts. However, in this case, every
advice and attempt to correct his mistakes by his
parents, such as his diet, and even assuming the
point of view of his parents when he would
attempt to hurt himself, was met with resistance.
He further developed vast cognitive distortions,
only assuming his point of view in every
endeavor and conflict and learned helplessness
(Figure 6)
CONCLUSION
Biopsychosocial approach was the main
framework used to treat this patient with
panhypopituitarism. This framework enabled
the doctors to comprehend a multifaceted
disease and identify the patient’s problem. Due
to the multiple deficiencies in the patient’s
hormones particularly testosterone, the
depression of the patient could be considered as
having biological causes. The psychosocial
factors such as bullying and social exclusion by
his classmates contributed to the low self-esteem
and feelings of inferiority. From the cognitive
perspective, deficient peer interaction led to
being egocentric with multiple cognitive
distortions. Understanding all of the biological,
psychosocial, and cognitive factors that
contributed to a child's depression; it is
imperative to create a tailor-fit treatment and
management for this patient.
ETHICAL CONSIDERATIONS
This study was conducted according to the
accepted ethical research practice of the CARE
guidelines. Informed consent was obtained using
Informed Consent for Case Reports as Part I
then Certificate of Consent to Participate as Part
II in English, as the patient uses English as the
medium of communication and the mother is a
college graduate. Documents of the patient in
making this case report will be stored for 3
years and will be deleted accordingly. A written
consent form was obtained from the patient and
parent.
The consent was explained to the patient and
parent and co-signed by both as required by
our review board. This study was approved by
the Research Ethics Committee (REC) of our
institution.
56 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
CONFLICT OF INTERESTS
This study was investigator-initiated and not
industry-funded or company-sponsored. The
attending physician and the principal
investigator were directly handling the patient.
PATIENT ANONYMITY, INFORMED CONSENT
AND CONFIDENTIALITY
The patient's identity and personal data were
not be included in this study, and identifiers
were removed from the manuscript. Patient’s
anonymity and confidentiality was secured by
non-disclosure of any personal information that
may determine the patient's identity. Data was
accessed securely by the principal investigator
and protected from illegal or inadvertent access
by other people. The written informed consent
was directly obtained by the principal
investigator from the patient and parent.
RISKS
There were no risks for physical, psychological,
social, or economic harm on the subjects due to
this case report since the methodology only
involved the description of the case itself. No
active interventions were done, and no
discomfort or injury inflicted on the study
patient.
BENEFITS
Since the study was a case report, there was no
direct benefit for the patient. All the information
gathered about this case will be of great benefit
for the welfare of all future patients with this
similar presentation.
REFERENCES
1. Mehren A, Özyurt J, Svenja K, Christiane B, Müller HL. Self- and
informant-rated apathy in patients with childhood-onset
craniopharyngioma. J Neurooncol [Internet]. 2018;0(0):0. Available
from: http://dx.doi.org/10.1007/s11060-018-2936-z
2. Memmesheimer RM, Lange K, Dolle M, Heger S, Mueller I.
Psychological well-being and independent living of young adults with
childhood-onset craniopharyngioma. Dev Med Child Neurol. 2017
Aug; 59(8): 829-836.doi:10.1111/dmcn.13444. Epub 2017 May 9.
3. Paing WW, Weller RA, Brennan L, Weller EB. Atypical Depression in
Children and Adolescents. Curr Psych Rep. 2008 Apr;10(2):130-133.
doi:10.1007/s11920-008-0023-4.
4. Culpin I, Heron J, Araya R, Melotti R, Joinson C. Father absence
and depressive symptoms in adolescence : fi ndings from a UK
cohort. Psychol Med. 2013 Dec;43 (12):2615–26.
doi:10.1017/S0033291713000603. Epub 2013 May 14.
5. Gulley LD, Shomaker LB, Kelly NR, Chen KY, Olsen CH, Tanofsky-
kraff M, et al. Examining Cognitive-Behavioral Therapy Change
Mechanisms for Decreasing Depression, Weight, and Insulin
Resistance in Adolescent Girls at Risk for Type 2 Diabetes.J
Psychosom Res. 2022 Jun; 157:110781.
doi:10.1016/j.jpsychores.2022.110781. Epub 2022 Mar 10.
6. Janowsky JS. Thinking with your gonads : testosterone and
cognition. Trends Cogn Sci. 2006 Feb;10(2):77-82.
doi:10.1016/j.tics.2005.12.010.Epub 2006 Jan 4.
7. Zarrouf FA, Artz S, Griffith J, Sirbu C, Kommor M. Testosterone and
depression: Systematic review and meta-analysis. J Psychiatr Pract.
2009 Jul;15(4):289–305. doi:10/1097/01.pra0000358315-88931.fc
8. Huhtaniemi IT, Howard S, Dunkel L, Anderson RA. The Gonadal
Axis : A Life Perspective [Internet]. Third Edit. Vol. 4, Hormones, Brain
and Behavior. Elsevier; 2017. 3–58 p. Available from:
http://dx.doi.org/10.1016/B978-0-12-803592-4.00066-3
9. Welker KM, Gruber J, Mehta PH. A positive affective
neuroendocrinology approach to reward and behavioral
dysregulation. Front.Psychiatry. 2015 Jul 2;6:93.
https://doi:org/10.3389/fpsyt.2015.00093.
10. Bauer M, Heinz A, Whybrow PC. Thyroid hormones , serotonin
and mood : of synergy and significance in the adult brain. Mol
Psychiatry.2002; 7(2):140–56. doi:10.1038/sj.mp.4000963
11. Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Homeostatic
Control of the Thyroid – Pituitary Axis : Perspectives for Diagnosis
and Treatment. Front Endocrinol (Lausanne). 2015 Nov 20;6: 177. doi:
10.3389/fendo.2015.00177. eCollection 2015.
12. Sassone-Corsi P, Christen Y, editors. A Time for Metabolism and
Hormones [Internet]. Cham (CH): Springer; 2016. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK453176/ doi:10.1007/978-3-
319-27069-2.
57 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
CONFLICT OF INTERESTS
This study was investigator-initiated and not
industry-funded or company-sponsored. The
attending physician and the principal
investigator were directly handling the patient.
PATIENT ANONYMITY, INFORMED CONSENT
AND CONFIDENTIALITY
The patient's identity and personal data were
not be included in this study, and identifiers
were removed from the manuscript. Patient’s
anonymity and confidentiality was secured by
non-disclosure of any personal information that
may determine the patient's identity. Data was
accessed securely by the principal investigator
and protected from illegal or inadvertent access
by other people. The written informed consent
was directly obtained by the principal
investigator from the patient and parent.
RISKS
There were no risks for physical, psychological,
social, or economic harm on the subjects due to
this case report since the methodology only
involved the description of the case itself. No
active interventions were done, and no
discomfort or injury inflicted on the study
patient.
BENEFITS
Since the study was a case report, there was no
direct benefit for the patient. All the information
gathered about this case will be of great benefit
for the welfare of all future patients with this
similar presentation.
REFERENCES
1. Mehren A, Özyurt J, Svenja K, Christiane B, Müller HL. Self- and
informant-rated apathy in patients with childhood-onset
craniopharyngioma. J Neurooncol [Internet]. 2018;0(0):0. Available
from: http://dx.doi.org/10.1007/s11060-018-2936-z
2. Memmesheimer RM, Lange K, Dolle M, Heger S, Mueller I.
Psychological well-being and independent living of young adults with
childhood-onset craniopharyngioma. Dev Med Child Neurol. 2017
Aug; 59(8): 829-836.doi:10.1111/dmcn.13444. Epub 2017 May 9.
3. Paing WW, Weller RA, Brennan L, Weller EB. Atypical Depression in
Children and Adolescents. Curr Psych Rep. 2008 Apr;10(2):130-133.
doi:10.1007/s11920-008-0023-4.
4. Culpin I, Heron J, Araya R, Melotti R, Joinson C. Father absence
and depressive symptoms in adolescence : fi ndings from a UK
cohort. Psychol Med. 2013 Dec;43 (12):2615–26.
doi:10.1017/S0033291713000603. Epub 2013 May 14.
5. Gulley LD, Shomaker LB, Kelly NR, Chen KY, Olsen CH, Tanofsky-
kraff M, et al. Examining Cognitive-Behavioral Therapy Change
Mechanisms for Decreasing Depression, Weight, and Insulin
Resistance in Adolescent Girls at Risk for Type 2 Diabetes.J
Psychosom Res. 2022 Jun; 157:110781.
doi:10.1016/j.jpsychores.2022.110781. Epub 2022 Mar 10.
6. Janowsky JS. Thinking with your gonads : testosterone and
cognition. Trends Cogn Sci. 2006 Feb;10(2):77-82.
doi:10.1016/j.tics.2005.12.010.Epub 2006 Jan 4.
7. Zarrouf FA, Artz S, Griffith J, Sirbu C, Kommor M. Testosterone and
depression: Systematic review and meta-analysis. J Psychiatr Pract.
2009 Jul;15(4):289–305. doi:10/1097/01.pra0000358315-88931.fc
8. Huhtaniemi IT, Howard S, Dunkel L, Anderson RA. The Gonadal
Axis : A Life Perspective [Internet]. Third Edit. Vol. 4, Hormones, Brain
and Behavior. Elsevier; 2017. 3–58 p. Available from:
http://dx.doi.org/10.1016/B978-0-12-803592-4.00066-3
9. Welker KM, Gruber J, Mehta PH. A positive affective
neuroendocrinology approach to reward and behavioral
dysregulation. Front.Psychiatry. 2015 Jul 2;6:93.
https://doi:org/10.3389/fpsyt.2015.00093.
10. Bauer M, Heinz A, Whybrow PC. Thyroid hormones , serotonin
and mood : of synergy and significance in the adult brain. Mol
Psychiatry.2002; 7(2):140–56. doi:10.1038/sj.mp.4000963
11. Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Homeostatic
Control of the Thyroid – Pituitary Axis : Perspectives for Diagnosis
and Treatment. Front Endocrinol (Lausanne). 2015 Nov 20;6: 177. doi:
10.3389/fendo.2015.00177. eCollection 2015.
12. Sassone-Corsi P, Christen Y, editors. A Time for Metabolism and
Hormones [Internet]. Cham (CH): Springer; 2016. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK453176/ doi:10.1007/978-3-
319-27069-2.
57 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP ORIGINAL ABSTRACT

METHODS OF SELF-INJURIOUS BEHAVIOR AND RELATED

PSYCHIATRIC DISORDERS AMONG PATIENTS SEEN AT BAGUIO
GENERAL HOSPITAL AND MEDICAL CENTER

JENNIFER P. ESPINO, MD

ABSTRACT

OBJECTIVE: This study aimed to determine the methods of self-injurious behavior and related
psychiatric disorder among patients seen at Baguio General Hospital and Medical Center.

METHODS: This was a cross-sectional study which used convenience sampling. It involved 53
patients with self-injurious behavior brought to Baguio General Hospital and Medical Center
and assessed by the Department of Psychiatry. Data was gathered through a Psychiatric
interview done by a co-investigator to eliminate interviewer’s bias. Statistical analyses used
were both descriptive (percentages, mean, and frequency) and inferential in the form of chi-
square test.

RESULTS: Socio-demographic profile of patients showed that the mean age of patients with
self-injurious behavior was 26-27 (26.8), predominantly female, single and high school
graduate. For the factors leading to self-injury, it showed that self-injurious patients had a
family history of psychiatric disorder and a previous history of self-injury. The predominant
method used by the patients in the study was ingestion. The major psychiatric disorder found
among patients was Depressive Disorder. There was no association noted between the method
of self-injurious behavior employed and the specific psychiatric disorder.

CONCLUSION: Patients brought to the hospital due to self-injury commonly had an ongoing
psychiatric pathology, majority of whom had a Depressive Disorder. Since the method used for
self-injury was not found to be associated with the type of psychiatric disorder, it would be too
risky to conclude that patients with minor methods of self-injury ( e.g. scratching) would only
have a minor psychiatric disturbance. It is, therefore, recommended that a comprehensive
psychiatric assessment should be conducted for all patients with self-injurious behavior
irrespective of the level of lethality of their method self-injury.

KEYWORDS: Self injurious behavior, Psychiatric Disorder

58 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

 PJP ORIGINAL ABSTRACT

A DESCRIPTIVE STUDY OF STRESS AS INDICATED BY PERCEIVED

STRESS SCALE SCORES AMONG THE NEUROPSYCHIATRY UNIT
STAFF OF THE MAKATI MEDICAL CENTER OVER A ONE MONTH
PERIOD IN 2015
ALEXANDRA A. PALIS, MD

ABSTRACT

OBJECTIVE: The aim of this study was to describe the degree of stress experienced among
staff of a high-risk unit in Makati Medical Center - the Neuropsychiatry Unit.

METHODOLOGY: The Perceived Stress Scale developed by Cohen in 1983 was the tool used. It
is a ten-item, self-administered questionnaire that measures perceived stress levels of
respondents. Perceived stress levels may be lower than average, slightly lower than average,
average, slightly higher than average or much higher than average. Demographic
characteristics of respondents were likewise determined. Respondents were members of the
Neuropsychiatry unit staff.

RESULTS: The Neuropsychiatry unit staff generally presented with perceived stress levels of
slightly higher than average. Most of the staff were female, aged thirty years old and below,
single, with at least college level education. Birth order, the presence of night shifts, eight-hour
shifts, length of service in years, and varying job designation in the unit were also identified.
Majority of the respondents had not had any previous consultation with a mental health
professional, and viewed having a support group in the workplace to be beneficial.

CONCLUSION: The staff members of the Neuropsychiatry unit perceived stress to be slightly
higher than average.

KEYWORDS: Stress, Perceived Stress Scale, Neuropsychiatry Unit

59 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884

 PJP ORIGINAL ABSTRACT

COMPARISON OF C-REACTIVE PROTEIN SERUM LEVELS AMONG

IN-PATIENTS WITH ACUTE EXACERBATION OF SCHIZOPHRENIA AT
THE VETERANS MEMORIAL MEDICAL CENTER (VMMC)
DEPARTMENT OF PSYCHIATRY FROM AUGUST 2013 – JULY 2015.

HANNAH MARTELLA M. MADDATU- PAJARILLO, MD

ABSTRACT

BACKGROUND: Several immunological abnormalities, such as decreased T-cell interleukin-2

production and abnormal cellular and humoral reactivity to neurons, had been associated with
patients who have schizophrenia. Several researches have been conducted to study the
correlation of elevated inflammatory markers with the symptomatology of schizophrenia.

OBJECTIVES: The aim of this study is to determine the levels of C-reactive protein, which is a
general marker for infection and inflammation, in patients with Schizophrenia in acute
exacerbation and compare these to the levels of C-reactive protein in patients with
Schizophrenia in remission.

METHODS: A cross-sectional study was carried out on in-patients at the Veterans Memorial
Medical Center Department of Psychiatry. Serum levels of C-reactive protein in adult patients
were determined during an acute exacerbation of Schizophrenia. These were compared to C-
reactive protein levels of patients with Schizophrenia in remission. PASW Statistics 18 (SPSS)
was used for data management, tabulation and analysis.

RESULTS: Cases of eighty-six (86) patients, seen by the principal investigator during OPD
consults were reviewed, 43 of which had Schizophrenia in Acute Exacerbation and also 43 of
patients were in Remission. The mean CRP level of patients in acute exacerbation was 7.05
mg/L (SD=0.23), which was higher than the mean CRP level of patients in remission at 5.30
mg/L (SD=0.30).

CONCLUSION: This study demonstrated that a stronger association exists between an acute
exacerbation of Schizophrenia and elevated C-Reactive protein, in the absence of another
systemic inflammatory disease when compared to the association between levels of C-
reactive protein in patients with Schizophrenia, in remission. This finding could pave the way
for initiation of studies examining whether adjunct treatment of anti-inflammatory drugs with
anti-psychotics will improve disease outcome.

KEYWORDS: C-Reactive Protein, Schizophrenia

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 PJP
SinAg
ART IN SCIENCE

SinAg is a portmanteau of the Filipino words for Art ("Sining")

and Science ("Agham"). Taken together, they form the word
"Sinag" (Ray) as in "rays of light". This corner is intended to
shine rays of light onto the creative works of Filipino mental
health professionals, thus providing glimpses into their minds,
hearts, and souls.

Hope in the beach

Babes

The sun rising

The children frolicking
The lovers hugging
The family enjoying
The visions of hope instilled
The content of life redirected
the ties strongly bonded
with the love connected.

Christmas Hope
Anna Vazquez

Little girl eager to open her Xmas

gift
Slides down the banister and
scrambles to look
Under the pine tree with capis
angels and abaca star on top
A giant box wrapped in Santa
Claus paper
Tore it open to see
A walking doll dressed in powder
blue lace and ribbons

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 PJP
SinAgART IN SCIENCE

SinAg is a portmanteau of the Filipino words for Art ("Sining")

and Science ("Agham"). Taken together, they form the word
"Sinag" (Ray) as in "rays of light". This corner is intended to
shine rays of light onto the creative works of Filipino mental
health professionals, thus providing glimpses into their minds,
hearts, and souls.

The World in Painting

Rhodora Andrea M. Concepcion, MD

I see clouds stain the blue skies white

And flowers coloring the world red
I never waste a single breath
Chasing every beauty there is on earth.
As I have my back gently laid
On grass as green as emerald
Reflections come rushing downward
Calmly touching my heart and mind.
I’ve stood by the wind, watching the birds in flight
They forcefully soar the heights
As I sail through the boundless oceans in its
immeasurable depth
I see aquatic life with the wave’s gentle touch.
In the window of colors and designs
The world is brushed by different hands
With every shade and every hue
A MASTERPIECE COMES INTO VIEW.

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 PJP
SinAg
ART IN SCIENCE

SinAg is a portmanteau of the Filipino words for Art ("Sining")

and Science ("Agham"). Taken together, they form the word
"Sinag" (Ray) as in "rays of light". This corner is intended to
shine rays of light onto the creative works of Filipino mental
health professionals, thus providing glimpses into their minds,
hearts, and souls.

THE ROAD OF LIFE

Rhodora Andrea M. Concepcion, MD

Life is a long and winding road

One never knows when it will end.
It may bring us to the shining light
Or deep down the lightless night.
The roads of life that we go forth
Have different paths so rough.
Going through it is really tough
We need not mind it.
Instead we laugh.

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 PJP
INFORMATION FOR CONTRIBUTORS TO THE PHILIPPINE JOURNAL
OF PSYCHIATRY 2017
The Philippine Journal of Psychiatry is a
referred journal designed to meet the
continuing education needs of practicing
psychiatrists in the Philippines. It is published
under the auspices of the Philippine
Psychiatric Association. The Philippine Journal
of Psychiatry accepts only original and
unpublished articles on psychology,
psychiatry and other behavioral sciences with
the understanding that that they have not
been published previously, nor being reviewed
or considered for publication elsewhere,
either as a whole or any substantial part.
The corresponding author should inform the
editor in chief about all submissions to other
publications and any previous reports that
might be considered prior or duplicate
publications- including data or observations
already reported or patients already
described- and should include copies of such
material for the editor to examine.
Manuscripts must be accompanied by a cover
letter, which should include the ff information:
1) A full statement to the editor about all
submissions and previous reports that might
be regarded as redundant publication of the
same or very similar work. Any such work
should be referred to specifically and
referenced in the new paper. Copies of such
material should be included with the
submitted paper to help the editor address
the situation.
FOR CONTRIBUTORS
2) A statement of financial or other
relationships that might lead to a conflict of
interest, if that information is not included in
the manuscript itself or in an authors’ form.
3) A statement that the manuscript has been
read and approved by all the authors, that the
requirements for authorship as stated earlier
in this document have been met, and that
each author believes that the manuscript
represents honest work.
4) The full name, postal & email address, cell
phone and telephone number of the
corresponding author, who is responsible for
communicating with the other authors about
revisions and final approval of the proofs as
well as with the editorial board of the PJP.
SUBMISSION OF MANUSCRIPTS
Hard copy of manuscripts may be submitted
in duplicate, typewritten using Times New
Roman font 11, double spaced with a minimum
of 1.5” for margins on 8” x 11” (letter or short)
bond paper. All pages should be numbered. An
electronic form of the manuscript should be
stored in a document file- CD ReWritable disk
using Microsoft Word Program and submitted
along with the duplicate hard copy. Send all
copies of manuscript to the Editor- in -Chief or
to the PPA office. Please include all contact
numbers (residence & office telephone #, fax
#, cell phone # and addresses (email,
residence/ office/ clinic) of the corresponding
64 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
author as well as the email & office/ clinic
address and cell phone & landline telephone
numbers of ALL authors on the envelope
containing the manuscripts and disk.
REVIEW PROCESS
Manuscripts submitted to the PJP are sent for
blind review to at least 3 reviewers within a
week from date of receipt. The reviewers are
given 2-4 weeks to review the manuscript. The
suggestions for revision are summarized and
sent to the author for revision. A second or
third blind review may ensue until the paper is
deemed publishable by the editorial board.
The paper is then edited and shown to
corresponding author prior to publication.The
corresponding author is encouraged to check
the edited manuscript for any errors, to answer
any queries of the manuscript editor or clarify
some details in the manuscript. Manuscripts
are accepted with the understanding that they
will be edited for clarity, elimination of
redundancy and conformity with the PJP
standards.
DISCLOSURE & COPYRIGHT POLICY
When paper is accepted, the Editor will send
the corresponding author an agreement and
authorization from that states in essence that
the material is original, legal and has not been
previously published; that consent from all the
authors, when required, for permission to
publish has been obtained; that both the
Philippine Journal of Psychiatry and the
Philippine Psychiatric Association are harmless
against any suit arising out of any alleged
breach of these warranties; that each of the
authors has full responsibility for the content
of the manuscript; and that the author
authorizes the Philippine Psychiatric
Association to publish the article and have the
copyright.
FOR CONTRIBUTORS
All forms of financial support, including drug
company support, are listed in the
acknowledgments section of the paper.
Any affiliations or financial interests related to
subjects or services described in the paper- such
as employment, consultancies, stock ownership, or
honoraria- or any financial relationships that may
suggest conflict of interest, are described. Such
interests do not mean automatic rejection of the
manuscript however they must be disclosed for
the editor’s information and for possible
disclosure to reviewers.
PREPARATION OF MANUSCRIPTS FOR RESEARCH
PAPERS, BRIEF REPORTS, LITERATURE REVIEWS &
SPECIAL ARTICLES
Types of articles that can be submitted for
publication to the Philippine Journal of Psychiatry
are research reports, brief reports, literature
reviews, special articles, case reports,
commentaries, book reviews, monographs, letters
and others.
Manuscript may be submitted in English or
Pilipino, type written using New Times Roman font
of 11 single spaced and with 1” margins on all sides
of 8” x 11” sized paper. Number the pages
consecutively, placing the page number at the
lower right hand corner of each page, beginning
with the title page. The manuscript should be
arranged as the ff: 1) Title, 2) Structured Abstract,
3) Text, 4) Acknowledgments, 5) References, 6)
Tables & 7) Appendices. Enclose disclosure and
transfer of copyright duly signed by all the authors
and keep copies of everything submitted. The
manuscript must be accompanied by copies of any
permission to reproduce published material, to
use illustrations or report information about
identifiable people or to name people for their
contributions.
65 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
Manuscripts may be sent through email to the
PPA office, the Editor in Chief and/or the
Manuscript Editor.
I. Title Page should include a concise and
informative title, author’s name with highest
academic degree as well as the name of
institution to which work can be attributed or
where research study was conducted. The title
should include the study design especially for
randomized controlled trials i.e. any research
project that prospectively assigns human
subjects to intervention or concurrent
comparison or control groups to study the
cause and effect relationship between a
medical intervention and a health outcome.
Include the name, telephone & cell phone
numbers, mailing & email addresses of the
author responsible for correspondence about
the manuscript and the author to whom
requests for reprints should be addressed.
Sources of support in the form of grants,
equipment, drugs or all these should also be
included. If paper was presented at a national
or international meeting, full details of the
meetings should be stated such as title, place
and date.
II. Structured ABSTRACT should include:
OBJECTIVES- purpose of the study or research
question; METHODOLOGY- study design,
selection process, setting, subjects,
observational and analytical methods,
intervention(s) if any and main outcome
measure(s); RESULTS- main findings of
research in relation to objectives stated and
give the statistical significance of
observations; & CONCLUSION- primary
conclusions with emphasis on new and
important aspects
FOR CONTRIBUTORS
of the study or observations and funding
sources. The abstract should not exceed 250
words and list up to 5 key words under which
article will be indexed.
III. Text should consist of Introduction,
Methods, Results and Discussion.
A. The INTRODUCTION should provide the
context and rationale or the study i.e. nature
of the problem and its significance. State the
specific purpose or research objectives of or
hypothesis being tested by the study. The
research objective may be stated as a
question.
B. The METHODOLOGY section should
describe how and why the study was done in a
particular way in as much detail about the
Study Design and with enough Technical
Information that would allow others to
reproduce the results.
Methods for Selection of study population i.e.
inclusion & exclusion criteria, data collection,
and data analysis procedure should be
concisely yet easily understandable to the
readers.
Description of Study Participants should
include the Source Population, explain
relevance of inclusion / exclusion criteria and
demographic variables chosen e.g. why choose
to study only women from 40- 60 years old.
How variables were measured may also be
important to specify.
Describe the Statistical Methods with enough
detail to enable knowledgeable reader with
access to the original data to verify the
reported results. When possible, quantify
findings and present them with appropriate
66 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
indicators of measurement error or
uncertainty i.e. confidence intervals. Define
statistical terms, abbreviations and symbols
used as well as specify the computer software
used.
Ethical Considerations for the protection of
human subjects and animals in the research
should be indicated as when informed consent
was obtained and if the procedures followed
were in accordance with the ethical standards
of the responsible committee on human
experimentation (institutional and national) as
well as with the Helsinki Declaration of 1975 as
revised in 2008. Do not use patient’s names,
initials, or hospital numbers, especially in
illustrative material.
C. The RESULTS should report only the
findings related directly to the research
objectives. Give numeric results as absolute
numbers and as percentages as well as how
they were statistically analyzed. Use metric or
S.I. units of measurement and specify all units
of measurement clearly. Use only standard
abbreviations.
Include Tables & Figures only if they present
relevant numerical data more clearly than
could be done in the text. Do not repeat all the
data in tables, graphs or illustrations in the
text, where only the most important
observations are summarized. Label tables &
figures appropriately and number
consecutively in order of their first citation in
the text using Arabic numerals. Be sure that
each table and figure is cited in the text
otherwise don’t include it.
Cell alignment of Tables should be to top left,
single spaced or autofitted to contents of cell
with all grid lines visible. Place a heading for
FOR CONTRIBUTORS
each table column and brief title for each
table above the table.Explanation or
discussion of results in the table should be
placed before the Table and place Table
number referred to after paragraph where it is
mentioned e.g. (Table 1).
Figures should be as self explanatory as
possible. Figures accepted for publication
must be clear, uncluttered, and two-
dimensional. Figure number and title should
be placed below the figure. Explanations for
the Figures are placed after the Figure and
indicate in parenthesis which Figure was being
described e.g. (Figure 2)
For x-ray films, scans and other diagnostic
images as well as pictures of pathology
specimens or photomicrographs, send sharp,
glossy, black and white or color photographic
prints 5 x 7 inches or 127 x 173 mm in camera
ready form. The names of the authors should
be written at the back of each plate.
Photomicrographs should have internal scale
markers. Titles and detailed explanations
should be placed in the legends not on the
illustrations themselves. Explain the internal
scale and identify the method of staining in
photomicrographs.
When symbols, arrows, numbers or letters are
used to identify parts of the illustrations,
identify
and explain each one clearly in the legend.
Please list on a separate page, values for the
data points shown on graphs, in case the
reviewers/editors of the journal has to
recreate some figures. When reporting
statistically significant results, always report
the observed test statistic value, degrees of
freedom, probability level, and for t & F tests,
67 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
whether repeated measures were used.
Supplementary materials and technical detail
can be placed in an APPENDIX where they will
be accessible but do not interrupt the flow of
the text. Appendices are numbered in
sequence of how they are referred to in the
text e.g. (Appendix 3). Checklists and
questionnaires are generally not published.
D. The DISCUSSION should emphasize the new
and important aspects of the study and the
conclusions that follow from them. Link the
conclusions with the goals of the study but
avoid unqualified statement or conclusions
not supported by your data.
Recommendations when appropriate may be
included. Do not repeat study results in the
discussion but rather give explanations for the
findings, compare and contrast the results
with other relevant studies and state the
limitations of the study. Explore the
implications of the findings for future research
and for clinical practice.
E. ACKNOWLEDGMENTS. Disclosure
statements of sponsoring body may be
required for studies promoting products or
services described in the paper. One or more
statements should specify contributions that
need acknowledging but do not justify
authorship such as emotional, financial,
material or technical support. The
corresponding author should submit the
written permission to be acknowledged from
all acknowledged individuals before printing.
F. REERENCES: Only relevant references,
preferably from original researches should be
cited in the text and listed according to their
order of appearance in the text using Arabic
numerals in parenthesis or superscript. Limit
FOR CONTRIBUTORS
these to material that has already been
published, accepted for publication or
presented at a major national meeting.
Citations of material in press must include
journal or publisher’s name followed by “in
press” or forthcoming”. If unpublished
material is cited indicate source and year in
parenthesis in the text or written as a
footnote.
Avoid citing a “personal communication“
unless it provides essential information
unavailable from a public source, in which
case the name of the person and date of
communication should be cited in
parentheses in the text. For scientific articles,
obtain written permission and confirmation of
accuracy from the source of a personal
communication.
Avoid using abstracts as references. Accuracy
of the citation is the author’s responsibility.
Abbreviations of journal names should
conform to those used in Index Medicus.
Examples:
Articles in Journals (see also #36. Journal
article on the Internet)
1. Standard journal article
List All authors if 6 or less: Surname and
initials of all authors, tile of article, name of
journal, year, volume & first and last pages.
Halpern SD, Ubel PA, Caplan AL. Solid-organ
transplantation in HIV-infected patients. N
Engl J Med. 2002 Jul 25;347(4):284-7.
68 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
If more than six authors, list only the first 6
authors and add “et al”:
Rose ME, Huerbin MB, Melick J, Marion DW,
Palmer AM, Schiding JK, et al. Regulation of
interstitial excitatory amino acid
concentrations after cortical contusion injury.
Brain Res. 2002;935(1-2):40-6.
Optional addition of a database's unique
identifier for the citation:
Forooghian F, Yeh S, Faia LJ, Nussenblatt RB.
Uveitic foveal atrophy: clinical features and
associations. Arch Ophthalmol. 2009
Feb;127(2):179-86. PubMed PMID: 19204236;
PubMed Central PMCID: PMC2653214.
Optional addition of a clinical trial registration
number:
Trachtenberg F, Maserejian NN, Soncini JA,
Hayes C, Tavares M. Does fluoride in
toothpaste prevent future caries in children? J
Dent Res. 2009 Mar;88(3):276-9. PubMed
PMID: 19329464. ClinicalTrials.gov registration
number: NCT00065988.
2. Organization as author
Diabetes Prevention Program Research Group.
Hypertension, insulin, and proinsulin in
participants with impaired glucose tolerance.
Hypertension. 2002;40(5):679-86.
3. Both personal authors and organization as
author (List all as they appear in the byline.)
Vallancien G, Emberton M, Harving N, van
Moorselaar RJ; Alf-One Study Group. Sexual
dysfunction in 1,274 European men suffering
from lower urinary tract symptoms. J Urol.
2003;169(6):2257-61.
Margulies EH, Blanchette M; NISC
Comparative Sequencing Program, Haussler D,
Green ED. Identification and characterization
FOR CONTRIBUTORS
of multi-species conserved sequences.
Genome Res. 2003 Dec;13(12):2507-18.
4. No author given
21st century heart solution may have a sting in
the tail. BMJ. 2002;325(7357):184.
5. Article not in English
Ellingsen AE, Wilhelmsen I. Sykdomsangst
blant medisin- og jusstudenter. Tidsskr Nor
Laegeforen. 2002;122(8):785-7. Norwegian.
Optional translation of article title
(MEDLINE/PubMed practice):
Ellingsen AE, Wilhelmsen I. [Disease anxiety
among medical students and law students].
Tidsskr Nor Laegeforen. 2002 Mar
20;122(8):785-7. Norwegian.
6. Volume with supplement
Geraud G, Spierings EL, Keywood C.
Tolerability and safety of frovatriptan with
short- and long-term use for treatment of
migraine and in comparison with sumatriptan.
Headache. 2002;42 Suppl 2:S93-9.
7. Issue with supplement
Glauser TA. Integrating clinical trial data into
clinical practice. Neurology. 2002;58(12 Suppl
7):S6-12.
8. Volume with part
Abend SM, Kulish N. The psychoanalytic
method from an epistemological viewpoint. Int
J Psychoanal. 2002; 83(Pt 2):491-5.
9. Issue with part
Ahrar K, Madoff DC, Gupta S, Wallace MJ, Price
RE, Wright KC. Development of a large animal
model for lung tumors. J Vasc Interv Radiol.
2002;13(9 Pt 1):923-8.
69 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
10. Issue with no volume
Banit DM, Kaufer H, Hartford JM.
Intraoperative frozen section analysis in
revision total joint arthroplasty. Clin Orthop.
2002;(401):230-8.
11. No volume or issue
Outreach: bringing HIV-positive individuals
into care. HRSA Careaction. 2002 Jun:1-6.
12. Pagination in roman numerals
Chadwick R, Schuklenk U. The politics of
ethical consensus finding. Bioethics.
2002;16(2):iii-v.
13. Type of article indicated as needed
Tor M, Turker H. International approaches to
the prescription of long-term oxygen therapy
[letter]. Eur Respir J. 2002;20(1):242.
Lofwall MR, Strain EC, Brooner RK, Kindbom
KA, Bigelow GE. Characteristics of older
methadone maintenance (MM) patients
[abstract]. Drug Alcohol Depend. 2002;66
Suppl 1:S105.
14. Article containing retraction
Feifel D, Moutier CY, Perry W. Safety and
tolerability of a rapidly escalating dose-
loading regimen for risperidone. J Clin
Psychiatry. 2002;63(2):169. Retraction of:
Feifel D, Moutier CY, Perry W. J Clin
Psychiatry. 2000;61(12):909-11.
Article partially retracted:
Starkman JS, Wolter C, Gomelsky A, Scarpero
HM, Dmochowski RR. Voiding dysfunction
following removal of eroded synthetic mid
urethral slings. J Urol. 2006 Sep;176(3):1040-
4. Partial retraction in: Starkman JS, Wolder
CE, Gomelsky A, Scarpero HM, Dmochowski
RR. J Urol. 2006 Dec;176(6 Pt 1):2749.
FOR CONTRIBUTORS
15. Article retracted
Feifel D, Moutier CY, Perry W. Safety and
tolerability of a rapidly escalating dose-
loading regimen for risperidone. J Clin
Psychiatry. 2000;61(12):909-11. Retraction in:
Feifel D, Moutier CY, Perry W. J Clin
Psychiatry. 2002;63(2):169.
16. Article republished with corrections
Mansharamani M, Chilton BS. The
reproductive importance of P-type ATPases.
Mol Cell Endocrinol. 2002;188(1-2):22-5.
Corrected and republished from: Mol Cell
Endocrinol. 2001;183(1-2):123-6.
17. Article with published erratum
Malinowski JM, Bolesta S. Rosiglitazone in the
treatment of type 2 diabetes mellitus: a critical
review. Clin Ther. 2000;22(10):1151-68;
discussion 1149-50. Erratum in: Clin Ther.
2001;23(2):309.
18. Article published electronically ahead of
the print version
Yu WM, Hawley TS, Hawley RG, Qu CK.
Immortalization of yolk sac-derived precursor
cells. Blood. 2002 Nov 15;100(10):3828-31.
Epub 2002 Jul 5.
Books and Other Monographs
19. Personal author(s)
Murray PR, Rosenthal KS, Kobayashi GS,
Pfaller MA. Medical microbiology. 4th ed. St.
Louis: Mosby; 2002.
20. Editor(s), compiler(s) as author
Gilstrap LC 3rd, Cunningham FG, VanDorsten
JP, editors. Operative obstetrics. 2nd ed. New
York: McGraw-Hill; 2002.
70 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
10. Issue with no volume
Banit DM, Kaufer H, Hartford JM.
Intraoperative frozen section analysis in
revision total joint arthroplasty. Clin Orthop.
2002;(401):230-8.
11. No volume or issue
Outreach: bringing HIV-positive individuals
into care. HRSA Careaction. 2002 Jun:1-6.
12. Pagination in roman numerals
Chadwick R, Schuklenk U. The politics of
ethical consensus finding. Bioethics.
2002;16(2):iii-v.
13. Type of article indicated as needed
Tor M, Turker H. International approaches to
the prescription of long-term oxygen therapy
[letter]. Eur Respir J. 2002;20(1):242.
Lofwall MR, Strain EC, Brooner RK, Kindbom
KA, Bigelow GE. Characteristics of older
methadone maintenance (MM) patients
[abstract]. Drug Alcohol Depend. 2002;66
Suppl 1:S105.
14. Article containing retraction
Feifel D, Moutier CY, Perry W. Safety and
tolerability of a rapidly escalating dose-
loading regimen for risperidone. J Clin
Psychiatry. 2002;63(2):169. Retraction of:
Feifel D, Moutier CY, Perry W. J Clin
Psychiatry. 2000;61(12):909-11.
Article partially retracted:
Starkman JS, Wolter C, Gomelsky A, Scarpero
HM, Dmochowski RR. Voiding dysfunction
following removal of eroded synthetic mid
urethral slings. J Urol. 2006 Sep;176(3):1040-
4. Partial retraction in: Starkman JS, Wolder
CE, Gomelsky A, Scarpero HM, Dmochowski
RR. J Urol. 2006 Dec;176(6 Pt 1):2749.
FOR CONTRIBUTORS
15. Article retracted
Feifel D, Moutier CY, Perry W. Safety and
tolerability of a rapidly escalating dose-
loading regimen for risperidone. J Clin
Psychiatry. 2000;61(12):909-11. Retraction in:
Feifel D, Moutier CY, Perry W. J Clin
Psychiatry. 2002;63(2):169.
16. Article republished with corrections
Mansharamani M, Chilton BS. The
reproductive importance of P-type ATPases.
Mol Cell Endocrinol. 2002;188(1-2):22-5.
Corrected and republished from: Mol Cell
Endocrinol. 2001;183(1-2):123-6.
17. Article with published erratum
Malinowski JM, Bolesta S. Rosiglitazone in the
treatment of type 2 diabetes mellitus: a critical
review. Clin Ther. 2000;22(10):1151-68;
discussion 1149-50. Erratum in: Clin Ther.
2001;23(2):309.
18. Article published electronically ahead of
the print version
Yu WM, Hawley TS, Hawley RG, Qu CK.
Immortalization of yolk sac-derived precursor
cells. Blood. 2002 Nov 15;100(10):3828-31.
Epub 2002 Jul 5.
Books and Other Monographs
19. Personal author(s)
Murray PR, Rosenthal KS, Kobayashi GS,
Pfaller MA. Medical microbiology. 4th ed. St.
Louis: Mosby; 2002.
20. Editor(s), compiler(s) as author
Gilstrap LC 3rd, Cunningham FG, VanDorsten
JP, editors. Operative obstetrics. 2nd ed. New
York: McGraw-Hill; 2002.
71 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
21. Author(s) and editor(s)
Breedlove GK, Schorfheide AM. Adolescent
pregnancy. 2nd ed. Wieczorek RR, editor.
White Plains (NY): March of Dimes Education
Services; 2001.
22. Organization(s) as author
Advanced Life Support Group. Acute medical
emergencies: the practical approach. London:
BMJ Books; 2001. 454 p.
American Occupational Therapy Association,
Ad Hoc Committee on Occupational Therapy
Manpower. Occupational therapy manpower:
a plan for progress. Rockville (MD): The
Association; 1985 Apr. 84 p.
National Lawyers’ Guild AIDs Network (US);
National Gay Rights Advocates (US). AIDS
practice manual: a legal and educational guide.
2nd ed. San Francisco: The Network; 1988.
23. Chapter in a book
Meltzer PS, Kallioniemi A, Trent JM.
Chromosome alterations in human solid
tumors. In: Vogelstein B, Kinzler KW, editors.
The genetic basis of human cancer. New York:
McGraw-Hill; 2002. p. 93-113.
24. Conference proceedings
Harnden P, Joffe JK, Jones WG, editors. Germ
cell tumours V. Proceedings of the 5th Germ
Cell Tumour Conference; 2001 Sep 13-15;
Leeds, UK. New York: Springer; 2002.
25. Conference paper
Christensen S, Oppacher F. An analysis of
Koza's computational effort statistic for
genetic programming. In: Foster JA, Lutton E,
Miller J, Ryan C, Tettamanzi AG, editors.
Genetic programming. Euro GP 2002:
Proceedings of the 5th European Conference
FOR CONTRIBUTORS
on Genetic Programming; 2002 Apr 3-5;
Kinsdale, Ireland. Berlin: Springer; 2002. p.
182-91.
26. Scientific or technical report
Issued by funding/sponsoring agency:
Yen GG (Oklahoma State University, School of
Electrical and Computer Engineering,
Stillwater, OK). Health monitoring on vibration
signatures. Final report. Arlington (VA): Air
Force Office of Scientific Research (US), Air
Force Research Laboratory; 2002 Feb. Report
No.: AFRLSRBLTR020123. Contract No.:
F496209810049.
Issued by performing agency:
Russell ML, Goth-Goldstein R, Apte MG, Fisk
WJ. Method for measuring the size distribution
of airborne Rhinovirus. Berkeley (CA):
Lawrence Berkeley National Laboratory,
Environmental Energy Technologies Division;
2002 Jan. Report No.: LBNL49574. Contract
No.: DEAC0376SF00098. Sponsored by the
Department of Energy.
27. Dissertation
Borkowski MM. Infant sleep and feeding: a
telephone survey of Hispanic Americans
[dissertation]. Mount Pleasant (MI): Central
Michigan University; 2002.
28. Patent
Pagedas AC, inventor; Ancel Surgical R&D Inc.,
assignee. Flexible endoscopic grasping and
cutting device and positioning tool assembly.
United States patent US 20020103498. 2002
Aug 1.
Other Published Material
29. Newspaper article
Tynan T. Medical improvements lower
72 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884
 PJP
homicide rate: study sees drop in assault rate.
The Washington Post. 2002 Aug 12;Sect. A:2
(col. 4).
30. Audiovisual material
Chason KW, Sallustio S. Hospital preparedness
for bioterrorism [videocassette]. Secaucus
(NJ): Network for Continuing Medical
Education; 2002.
31. Legal Material
Public law:
Veterans Hearing Loss Compensation Act of
2002, Pub. L. No. 107-9, 115 Stat. 11 (May 24,
2001).
Unenacted bill:
Healthy Children Learn Act, S. 1012, 107th
Cong., 1st Sess. (2001).
Code of Federal Regulations:
Cardiopulmonary Bypass Intracardiac Suction
Control, 21 C.F.R. Sect. 870.4430 (2002).
Hearing:
Arsenic in Drinking Water: An Update on the
Science, Benefits and Cost: Hearing Before the
Subcomm. on Environment, Technology and
Standards of the House Comm. on Science,
107th Cong., 1st Sess. (Oct. 4, 2001).
32. Map
Pratt B, Flick P, Vynne C, cartographers.
Biodiversity hotspots [map]. Washington:
Conservation International; 2000.
33. Dictionary and similar references
Dorland's illustrated medical dictionary. 29th
ed. Philadelphia: W.B. Saunders; 2000.
Filamin; p. 675.
Unpublished Material
34. In press or Forthcoming
FOR CONTRIBUTORS
Tian D, Araki H, Stahl E, Bergelson J, Kreitman
M. Signature of balancing selection in
Arabidopsis. Proc Natl Acad Sci U S A.
Forthcoming 2002.
Electronic Material
35. CD-ROM
Anderson SC, Poulsen KB. Anderson's
electronic atlas of hematology [CD-ROM].
Philadelphia: Lippincott Williams & Wilkins;
2002.
36. Journal article on the Internet
Abood S. Quality improvement initiative in
nursing homes: the ANA acts in an advisory
role. Am J Nurs [Internet]. 2002 Jun [cited
2002 Aug 12];102(6):[about 1 p.]. Available
from:http://www.nursingworld.org/AJN/2002/j
une/Wawatch.htmArticle
Optional presentation (omits bracketed
phrase that qualifies the journal title
abbreviation):
Abood S. Quality improvement initiative in
nursing homes: the ANA acts in an advisory
role. Am J Nurs. 2002 Jun [cited 2002 Aug
12];102(6):[about 1 p.]. Available
from:http://www.nursingworld.org/AJN/2002/j
une/Wawatch.htmArticle
Article published on the Internet ahead of the
print version:
See # 18.
Optional formats used by NLM in
MEDLINE/PubMed:
Article with document number in place of
traditional pagination:
Williams JS, Brown SM, Conlin PR. Videos in
clinical medicine. Blood-pressure
measurement. N Engl J Med. 2009 Jan
29;360(5):e6. PubMed PMID: 19179309.
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 PJP
Article with a Digital Object Identifier (DOI):
Zhang M, Holman CD, Price SD, Sanfilippo FM,
Preen DB, Bulsara MK. Comorbidity and repeat
admission to hospital for adverse drug
reactions in older adults: retrospective cohort
study. BMJ. 2009 Jan 7;338:a2752. doi:
10.1136/bmj.a2752. PubMed PMID: 19129307;
PubMed Central PMCID: PMC2615549.
Article with unique publisher item identifier
(pii) in place of traditional pagination or DOI:
Tegnell A, Dillner J, Andrae B. Introduction of
human papillomavirus (HPV) vaccination in
Sweden. Euro Surveill. 2009 Feb 12;14(6). pii:
19119. PubMed PMID: 19215721.
37. Monograph on the Internet
Foley KM, Gelband H, editors. Improving
palliative care for cancer [Internet].
Washington: National Academy Press; 2001
[cited 2002 Jul 9]. Available from:
http://www.nap.edu/books/0309074029/html
/.
38. Homepage/Web site
Cancer-Pain.org [Internet]. New York:
Association of Cancer Online Resources, Inc.;
c2000-01 [updated 2002 May 16; cited 2002
Jul 9]. Available from: http://www.cancer-
pain.org/.
39. Part of a homepage/Web site
American Medical Association [Internet].
Chicago: The Association; c1995-2002
[updated 2001 Aug 23; cited 2002 Aug 12].
AMA Office of Group Practice Liaison; [about 2
screens]. Available from: http://www.ama-
assn.org/ama/pub/category/1736.html
40. Database on the Internet
Open database:
Who's Certified [Internet]. Evanston (IL): The
FOR CONTRIBUTORS
American Board of Medical Specialists. c2000
- [cited 2001 Mar 8]. Available from:
http://www.abms.org/newsearch.asp
Closed database:
Jablonski S. Online Multiple Congenital
Anomaly/Mental Retardation (MCA/MR)
Syndromes [Internet]. Bethesda (MD): National
Library of Medicine (US); c1999 [updated 2001
Nov 20; cited 2002 Aug 12]. Available from:
http://www.nlm.nih.gov/archive//20061212/m
esh/jablonski/syndrome_title.html
41. Part of a database on the Internet
MeSH Browser [Internet]. Bethesda (MD):
National Library of Medicine (US); 2002 - .
Meta-analysis [cited 2008 Jul 24]; [about 2 p.].
Available from:
http://www.nlm.nih.gov/cgi/mesh/2008/MB_cg
i?mode=&index=16408&view=concept MeSH
Unique ID: D017418.
42. Blogs
Holt M. The Health Care Blog [Internet]. San
Francisco: Matthew Holt. 2003 Oct - [cited
2009 Feb 13]. Available
from:http://www.thehealthcareblog.com/the_
health_care_blog/.
KidneyNotes.com [Internet]. New York:
KidneyNotes. c2006 - [cited 2009 Feb 13].
Available from: http://www.kidneynotes.com/.
Wall Street Journal. HEALTH BLOG: WSJ's blog
on health and the business of health
[Internet]. Hensley S, editor. New York: Dow
Jones & Company, Inc. c2007 - [cited 2009
Feb 13]. Available from:
http://blogs.wsj.com/health/.
Contribution to a blog:
Mantone J. Head trauma haunts many,
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 PJP
researchers say. 2008 Jan 29 [cited 2009 Feb
13]. In: Wall Street Journal. HEALTH BLOG
[Internet]. New York: Dow Jones & Company,
Inc. c2008 - . [about 1 screen]. Available from:
http://blogs.wsj.com/health/2008/01/29/head
-trauma-haunts-many-researchers-say/.
Campbell A. Diabetes and alcohol: do the two
mix? (Part 2). 2008 Jan 28 [cited 2009 Feb 13].
In: Diabetes Self-Management Blog [Internet].
New York: Diabetes Self-Management. [2006
Aug 14] - . 2 p. Available from:
http://www.diabetesselfmanagement.com/blo
g/Amy_Campbell/Diabetes_and_Alcohol_Do_th
e_Two_Mix_Part_2
Reider J. Docnotes: Health, Technology,
Family Medicine and other observations
[Internet]. [place unknown]: Jacob Reider.
1999 - . CRP again ...; 2004 Apr 2 [cited 2009
Feb 13]; [about 1 screen]. Available from:
http://www.docnotes.com/2004/04/crp-
again.html
More detailed information on how to cite
references can be found in Citing Medicine.
Note Appendix F which covers how citations in
MEDLINE/PubMed differ from the advice
inCiting Medicine.
PREPARATION OF MANUSCRIPTS FOR CASE
REPORTS, COMMENTARIES, BOOK REVIEWS,
MONOGRAPHS &LETTERS TO THE EDITOR:
Case Reports may adapt either of the 2
formats: 1) Clinical Case Conference-
Introduction based on Literature Review,
Initial Symptoms of the patient, Family &
Developmental History, Pre morbid Medical
History, Initial Examination, Treatment and
course of Illness and Discussion.
& 2) Case Report – Abstract, Introduction
which includes a Literature Review, Initial
FOR CONTRIBUTORS
Initial Symptoms of the patient, Family &
Developmental History, Pre morbid Medical
History, Initial Examination, Treatment and
course of Illness and Discussion.
& 2) Case Report – Abstract, Introduction
which includes a Literature Review, Case
description in terms of history, Mental Status
Exam, Diagnosis and Discussion of the case.
But in either format the ff: must be included:
an unstructured Abstract of a maximum of
100 words, brief Literature Review,
description of the case, its treatment/
management and discussion of analysis
(psychodynamics) and at least 10 references.
Authors must protect patient anonymity and
disguise their identifying information.
Commentaries may be up to a maximum of
1200 words, and include at least 10
references. Authors may be asked for source
material to support factual statements in
opinion pieces.
Book Reviews may be on books dealing with
any topic or issue related to or of interest to
psychiatry, psychology or mental health.
Indicate book title, authors/ editors, city
where it was published, year published,
publisher, total number of pages and sale
price of book reviewed. References are
optional.
Letters are published at the editor’s discretion
and should not exceed 500 words, with at
least 5 references. Letters related to material
published in PJP may be sent to the author
themselves for possible reply.
REFERENCES:
International Committee of Medical Journal
Editors. [home page on the internet].
Recommendations for the conduct,
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 PJP FOR CONTRIBUTORS

Reporting, Editing and Publication of Scholarly

Work in Medical Journals [cited 2016 Dec 24]
Available from: http;//www.ICMJE.org.

2.World Medical Association. World Medical

Association Declaration of Helsinki: Ethical
Principles for Medical Research Involving
Human Subjects. JAMA.2013;310 (20):2191-
94.doi.10.1001/jama.20132810

76 · PJP 2021 · Volume 2 (1-2) · ISSN 2980-4884