The PHILIPPINE JOURNAL of

PSYCHIATRY
Official Journal of the Philippine Psychiatric Association

NEW REQUIREMENTS FOR

PSYCHIATRY RESIDENCY
TRAINING PROGRAMS
(PRTPs) IN THE PHILIPPINES
VILLANUEVA, RUTH T., LOPEZ- ROCES, MYRA DEE,
DELLA, CONSTANTINE D.,
GATLABAYAN-CLETO, JANNEL, & GOZO-OLIVER,
GEORGINA M.

SUPPORTING MEDICAL
EDUCATORS TO ENSURE
WELLNESS OF MEDICAL
STUDENTS
DELLA, CONSTANTINE D.

PRACTICE AND PERCEPTIONS OF

PEDIATRIC RESIDENTS IN A
TERTIARY GOVERNMENT
HOSPITAL ON MENTAL
HEALTHCARE AS PART OF
GENERAL PRACTICE
YU-CHUA, CONSTANTINE L. & ELMA, LORELEI MELANIE K

Jewelyn Ann Carpio, MD A CROSS-SECTIONAL STUDY ON

Glessa Francesa Garibay, MD THE PREVALENCE AND SEVERITY
OF SUICIDAL IDEATIONS AND
VOLUME 4 (2) BEHAVIORS OF SENIOR HIGH
ISSN 2980-4884 SCHOOL STUDENTS USING THE
JULY-DECEMBER 2023 COLUMBIA-SUICIDE SEVERITY
RATING SCALE (C-SSRS)
REYES, JOHN MICHAEL L.

EXAMINATION OF THE RIGHT

TO CONFIDENTIALITY
OSORIO-GRAPILON, NINA KRISTY A.
 PHILIPPINE PSYCHIATRIC
PHILIPPINE JOURNAL OF PSYCHIATRY
ASSOCIATION

BOARD OF OFFICERS 2023 EDITORIAL BOARD 2023

Georgina Gozo- Oliver, MD, DPBP, FPPA (Life), FPSCAP
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PRESIDENT
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FPSCAP
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artist

2023 · VOLUME 4 (2-1)

 PJP TABLE OF CONTENTS

SPECIAL ARTICLES PAGE

New Requirements for Psychiatry Residency Training Programs (PRTPs)

in the Philippines
1
Villanueva, Ruth T., Lopez- Roces, Myra Dee, Della, Constantine D.,
Gatlabayan-Cleto, Jannel, & Gozo-Oliver, Georgina M.

Supporting Medical Educators to Ensure Wellness of Medical Students

Della, Constantine D.
16

ORIGINAL RESEARCH
Practice and Perceptions of Pediatric Residents in a Tertiary Government 21
Hospital on Mental Healthcare as Part of General Practice
Yu-Chua, Constantine L. & Elma, Lorelei Melanie K

A Cross-Sectional Study on the Prevalence and Severity of Suicidal ideations

and Behaviors of Senior High School Students using the Columbia-Suicide 33
Severity Rating Scale (C-SSRS)
Reyes, John Michael L.

CASE REPORT
Examination of the Right to Confidentiality
Osorio-Grapilon, Nina Kristy A.
42

ABSTRACTS

Major Depressive Disorder Among Patients Receiving Antiretroviral Treatment 51

in a Social Hygiene Clinic: Prevalence, Associated Factors and Effects on Quality
of Life
Bumatay, Leonides Jr., E., Paccial, Rodelen, Cruzada, Joeffrey & Sevilleja, Emmanuela

Determining the Prevalence of Depressive and Anxiety Synptoms Among

Seleced Pregnant Patients in Some Parts of Luzon During the COVID-19
52
Pandemic: A Cross-Sectional Study
Paggadu, Marie Cresanne R.

Resilience Levels Among Filipino Non-Medical Personnel at a Tertiary 53

Government Hospital in Metro Manial during the COVID-19 Pandemic - July
2021
Legaspi, Rafael E. & Della, Constantine D.

Comorbid Sleep Disorders among Patients Presenting with Insomnia Who 54

Underwent Polysomnography
Hernandez, April Fatima & Dela Eva, Roland

INFORMATION FOR CONTRIBUTORS 55

 PJP
NEW REQUIREMENTS FOR PSYCHIATRY RESIDENCY
TRAINING PROGRAMS (PRTPs) IN THE PHILIPPINES
THE BOARD OF ACCREDITATION OF THE SPECIALTY
BOARD OF PHILIPPINE PSYCHIATRY
Villanueva, Ruth T., Lopez- Roces, Myra Dee, Della, Constantine D.,
Gatlabayan-Cleto, Jannel, & Gozo-Oliver, Georgina M.
INTRODUCTION
It has been more than a decade since the Com-
mittee on Standardization and Accreditation of
Residency Training was renamed Board of
Accreditation of the Specialty Board of
Philippine Psychiatry (SBPP). The SBPP is
composed of two bodies namely the Boards of
Accreditation and Certification. These bodies are
mandated to uphold the highest standards of
accrediting psychiatry residency training
programs (Board of Accreditation) and granting
diplomate status to graduates of these programs
(Board of Certification). Guided by the
biopsychosocial and spiritual model of health,
the Board of Accreditation remains steadfast in
ensuring that psychiatry residency training
programs continue to be relevant to current
demands of mental health and psychiatric care
in the country. In addition, it sees to it that these
programs are in harmony with global standards.
As psychiatry faces new challenges in the third
millennium, certain innovations and iterations in
the manner by which mental illnesses are
diagnosed, treated, and prevented must be set
in place. Through its Millennium Developmental
Goals, the United Nations has declared that the
achievement of gender equality is an effective
way of combating disease. Mental health
problems and psychiatric disorders are closely
linked with gender-related issues. Yet, many
residency training programs in the Philippines
have not formally and systematically integrated
gender sensitivity into their curricula. The same
can be said of the concepts of religion and
spirituality. Numerous researches have estab-
lished the positive link between religion and
spirituality and mental health.
SPECIAL ARTICLE
Filipinos take pride in the fact that religion and
spirituality occupy a focal point in their mental
health. Yet, the relevance of religion and
spirituality to mental health and psychiatric care
is barely tackled by residency training programs
in the country. In this light, the Board of
Accreditation recognizes the need for psychiatry
residents to apply the principles of gender
sensitivity and religion and spirituality to the
care of patients with mental health and
psychiatric problems. In the same vein,
improving the quality of mental health and
psychiatric care by residents must be given
paramount attention by all training programs.
The Board of Accreditation strongly believes
that promoting the wellness of psychiatry
trainees and arming them with the necessary
tools to succeed in their careers are effective
and efficient ways to ensure that they are able
to provide the highest quality of mental health
and psychiatric care for their patients.
Upon the approval of the Board of Directors of
the Philippine Psychiatric Association, the Board
of Accreditation now requires the inclusion of
the following in the psychiatry residency training
programs of all accredited institutions.
1. Wellness program for residents
2. Mentoring program for residents
3. Course on gender and psychiatry
4. Course on religion and spirituality and
psychiatry
In the spirit of learning outcomes/competency-
based/outcome-based education and in consi-
deration of the particular contexts and missions
of PRTPs, the Board provides flexibility for the
1 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
coordinators of PRTPs to innovate their cur-
riculum on the courses on gender and psy-
chiatry and religion and spirituality and psy-
chiatry. The same flexibility applies to the
development and implementation of the
wellness and mentoring programs. The PRTPs
must design their curricula and programs to suit
their own contexts and missions but these must
achieve the required minimum set of outcomes.
In addition, PRTPs have freedom in curriculum
delivery and in specification and deployment of
human and physical resources. The PRTPs must
show that the alternative route they propose
effectively fulfills the program outcomes and
satisfies program educational objectives. The
program outcomes that the Board prescribes are
described in Table 1.
This paper provides conceptual frameworks on
the courses on gender and psychiatry and
religion and spirituality and psychiatry and the
programs on wellness and mentoring. The
general and specific objectives for establishing
these courses and programs are described.
Furthermore, it also discusses current evidence
on the relevance of these courses and programs
in psychiatry residency training.
I. Wellness Program
Residency training is a formative and intense
period that has its own set of challenges that
affect the well-being of trainees. (2, 3)
The COVID-19 pandemic highlighted the
complex challenges faced by residents.
Mendonça and colleagues found that the
COVID-19 pandemic contributed to symptoms
of depression, anxiety, and burnout in majority
of medical residents. (4) This pandemic may bear
a long-lasting impact on residents who may need
psychological support for a wide range of
personal and professional concerns. (5)
It has been proposed that medical education
may select for individuals who are prone to
psychological distress because of their high
levels of ambition and competition. (6) Medical
students bring these stress-inducing qualities
with them to residency making them vulnerable
to burnout because of disappointment and
frustration. In addition, residents may adopt
maladaptive perfectionism or develop imposter
syndrome. Maladaptive perfectionism involves
unreasonable self-expectation, negative reac-
tions to failure, and constant dissatisfaction with
one’s performance. Maladaptive perfectionism
hinders trainees from being aware of their
vulnerabilities and limitations. Imposter syn-
drome is characterized by lack of self-
confidence and fear of being discovered as un-
derserving despite one’s achievements. Mal-
adaptive perfectionism and imposter syndrome
predispose to psychological distress or patho-
logy. Closely linked with perfectionism and the
imposter syndrome is shame. Shame may arise
from internal and external factors and it may
lead to isolation, distress, or disruption in self-
esteem and self-identity. Intrinsic qualities of
residents such as the lack of resiliency may not
be the sole drivers of diminished well-being.
Studies show that multiple factors associated
with the training environment contribute to lack
or absence of wellness. Experts believe that
systemic factors such as organizational
pressures and work stressors and not personal
resilience contribute to burnout among
healthcare professionals. (7)
Although self-directed strategies such as
mindfulness practice help reduce stress, anxiety,
and burnout, systemic factors that lead to such
consequences must also be addressed.
Providing interventions geared towards equip-
ping administration and the trainers with the
capacity to optimize their roles as educators and
role models for residents is an example. This
strategy will facilitate a top-down approach
aimed at increasing resident wellness. (6)
2 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
Alkatan pointed out the phenomenon of
“generational gap” that training faculty need to
appreciate in order to ensure the success of a
wellness program. (8) The current set of trainers
belong to the baby boomer and X generations
while the current trainees belong to the
millennial or Y generation. The latter is
characterized by being confident, team-
oriented, achievement-oriented, pressured, and
conventional. In dealing with this generational
difference, trainers are urged to be guided by
certain strategies some of which are described
in Table 2.
The Philippine government has recognized the
value of wellness programs thus the Department
of Health in cooperation with the World Health
Organization and the Australian government,
launched The Wellness Movement on 16 January
2023. This is an initiative that aims to improve
the mental health and well-being of Filipino
healthcare workers. (9, 10)
Literature shows that burnout is prevalent
among residents across all specialties. (11, 12,
13) In fact, it is believed to be a growing endemic
with at least 60% of residents reporting it. (7).
Locally, one study showed an average to
moderate degree of burnout among residents of
a private tertiary hospital in Metro Manila with
single females and those belonging to major or
non-surgical departments having higher burnout
levels. (13) Another study conducted post-
COVID pandemic, showed that a significant
number of Internal Medicine residents at a
government tertiary hospital were at risk for
burnout. (14) There is a dearth of research on
stress or burnout among Filipino psychiatry
residents. A study conducted at a government
tertiary psychiatric facility in Metro Manila
measured the occupational stress levels of psy-
-chiatry residents and showed that burnout was
not evident. The number of participants of this
study, however, was too small (N=18) to be able
to generate substantial conclusions. (15)
As residency training progresses the risk of
burnout increases as exhaustion, sleep
deprivation, adjustment difficulties, inter-
personal conflicts, demanding workload, disen-
chantment, detachment, and cynicism increase.
Burnout may contribute to the spectrum of
stress conditions and/or clinical health issues of
trainees such as suicide, depression, and
substance use. Burnout has also been
associated with physician attrition and poor
quality of patient care. On the contrary,
physician wellness has been linked with
increased patient satisfaction and improved
treatment adherence. (3, 16) Traditionally, the
Maslach Burnout Inventory is used to diagnose
burnout. This scale assesses emotional
exhaustion (feeling overworked and losing com-
passion), depersonalization (detachment from
colleagues and/or patients), and personal
accomplishment (feelings of competence and
professional satisfaction). (6) Other scales for
burnout include the Copenhagen Burnout
Inventory and Symptom Checklist 90 (SCL 90).
Studying the factors that contribute to burnout
is crucial in understanding the factors that
ensure patient safety and influence the career
trajectory of residents. (6) It was hypothesized
that burnout resulted from excessive duty
hours. Studies in the US, Canada, and Europe,
however, did not show that shortening duty
hours improved sleep, work efficiency, or
depression. In fact, this strategy potentially
lessened the time for residents to learn and
compromised patient care. (3) Lu & Ratnapalan
conducted a scoping review of resident burnout
interventions and found that longitudinal
wellness training, physical activities, healthy
dietary habits, social activities, formal mentor-
ship programs, and health checkups were
effective in reducing burnout. (17)
Psychiatry residency training adds another layer
of burden that may aggravate stress or lead to
burnout. These include vicarious traumatization,
patient suicide and violence, and stigma of the
profession. International studies showed that
31% to 69% of residents experience patient
death by suicide. This results in significant
psychosocial stress as residents deal with
feelings of helplessness and guilt that may have
3 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
lingering effects. (18) The stigma existing within
the medical community also poses an additional
stressor that has been unaddressed and has a
negative impact on the morale of residents.
Numerous studies have proven that physician
burnout is correlated with consequences
beyond the self, such as negative impact on
patient care and the health care system. These
include medical errors, increased risk of
malpractice, and reduced patient satisfaction,
quality of care and patient outcomes. (19)
The term “wellness” implies a multidimensional
and dynamic state of optimal well-being that
may be generally defined as one’s personal
recipe for thriving and not just surviving. (20, 21)
Specifically, the World Health Organization
defines it as “the realization of the fullest
potential of an individual physically, psy-
chologically, socially, spiritually and eco-
nomically and the fulfillment of [the] individual’s
roles in family, workplace and community
settings.” (20) The American Medical Association
defines it as being composed of six important
markers namely, nutrition, fitness, emotional
health, preventative care, financial health, and
mindset and behavior adaptability. (16, 22)
Another model of wellness describes eight
dimensions: professional (occupation, voc-
ational), social (family, community), emotional
(mental), spiritual (values), intellectual, physical
(fitness, nutrition), environmental, and financial.
(20)
The individual must strive to achieve wellness
because it does not come naturally. Further-
more, its inherent multidimensional nature
makes quantitative research challenging. The
Gallup-Healthways Well-Being Index Composite
Score is one attempt in quantifying wellness. It
emphasizes the presence of health rather than
the absence of disease. In addition, it describes
well-being across the following domains: life
evaluation, emotional health, physical health,
healthy behavior, work environment, and basic
access. (6)
Significant features that contribute to the
success of wellness programs for medical
students have been identified. (6) These features
may also be applicable to residents. These
include the presence of a wellness committee
that coordinates with administration, con-
sultants, and residents and strategies that are
designed to decrease the training burdens of
residents.
The wellness committee must conduct a needs
assessment among residents which includes
quantitative and qualitative evaluations of the
degree of resident stress or burnout. This will
identify those trainees who may need certain
support or intervention. Ultimately, a wellness
program must be responsive to the specific
needs of the residents. In order to optimize
success, the wellness committee must work
closely with the mentoring program and training
program committees.
Embedding a culture of wellness should be an
end goal of every psychiatry residency training
program. While working on wellness on an
individual level is a given, a systems approach is
essential in providing the necessary envi-
ronment where care for oneself is nurtured and
accepted as the norm. In North America, medical
education accreditation bodies now consider
wellness as a core competency. (7) In the US, the
Accreditation Council for Graduate Medical
Education (ACGME) mandated residency pro-
grams to address trainee wellness within the
Common Program Requirements. In 2017, a
Resident Wellness Consensus Summit (RWCS)
was inaugurated in the US. Part of this summit’s
output was a proposal for an evidence-based
wellness curriculum that contained seventeen
modules that focus on the spectrum of wellness
and burnout. A study showed that running small
group discussions on these topics significantly
increased empowerment and work engagement
and decreased rates of burnout, emotional
exhaustion, and depersonalization. (21) Table 3
describes these topics. The psychiatry
department of McMaster University in Canada
launched its well-being program for residents in
2018. This program provided an electronic
curriculum on resident resilience, a wellness
newsletter, and peer groups as infrastructural
supports for residents. (7) Table 4 describes this
wellness program.
A wellness program possesses a multidi-
mensional approach that integrates individual
needs, institutional and cultural barriers to
wellness, and systemic issues that contribute to
stress. (2) At an individual level, wellness is
achieved when residents practice healthy habits
on a daily basis allowing a balance in the
physical, emotional, intellectual, social, spiritual,
environmental, and occupational aspects of
being. Activities and/or interventions through-
out the academic year include, but are not
limited to, retreats, mental health leaves, recrea-
4 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
5 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
-tional and leisure activities, exercise, conducive
workspaces, retreat zones or quiet spaces,
respite spaces with relaxation apps, open air
sitting areas, a simple gym area, a
snack/hydration station, self-care workshops,
and communication and stress management
trainings. Avenues for psychosocial support
include, but are not limited to, check-ins with
mentors or with each other, group peer support
(structured group sharing), buddy systems, and
therapy sessions. Residents must be made
aware of such interventions using multiple
channels of communication such as regular
emails, fliers posted in work areas, a wellness
website, and announcements in team meetings.
Ultimately, these programs must be able to
reduce the barriers to accessing wellness
services. Studies have identified several barriers
that include concerns about confidentiality,
stigma and stoicism, fears about reporting to
credentialing or licensure boards, financial
concerns, demanding clinical schedules, and
identifying therapists experienced in working
with physicians. (5, 16)
Wellness programs should foster a culture that
allows open exchange of ideas and flexibility in
responding to issues as they emerge. Wellness
programs must allow residents to become an
integral part of program policy changes and to
participate in program improvements.
Consequently, wellness programs become more
successful and leadership and communication
skills are enhanced among residents. The
differences in experiences of the learning envi-
ronment among subgroups of residents does not
permit a singular approach to wellness. Under-
standing such diversity will guide whatever
changes to the learning environment are made.
(2, 3, 8, 16) The concept of the learning
environment (LE) is defined by two main
dimensions namely, psychosocial and socio-
material dimensions. Individual characteristics
that contribute to or respond to the LE, inter-
personal interactions, and institutional policies,
culture, and regulation constitute the layers of
the psychosocial dimension. The sociomaterial
dimension defines how residents interact with
the physical and virtual worlds that they learn in.
(20) Incorporating web-based and other digital
resources into residency training will contribute
to the success of wellness programs because
this provides the residents the opportunity to
learn at their own pace. (7)
6 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
Figure 1 depicts a model of the learning
environment. At present, the relationship
between wellness and LE is not well understood
and needs to be studied using high quality
research. (20)
Objectives
General: To develop a program that will enhance
the wellbeing of psychiatry residents.
Specific: The wellness program must aim to
1. Increase the awareness of psychiatry
residents of the factors and resources that
contribute to well-being.
2. Provide information, activities, and services
designed to support healthy lifestyle choices
among psychiatry residents.
3. Encourage habits of wellness among
psychiatry residents.
4. Empower psychiatry residents to take
responsibility for their own health.
5. Address the physical, emotional, intellectual,
social, spiritual, environmental, and
occupational needs of psychiatry residents.
6. Improve the quality of life of psychiatry
residents.
7. Promote the resiliency of psychiatry
residents.
8. Recognize the early signs of psychological
distress among psychiatry residents.
9. Prevent burnout and other psychiatric
sequelae of residency training.
10. Facilitate access to medical and
psychosocial services to trainees with health
concerns.
11. Combat stigma to encourage residents to
share their experiences with chronic stress
and burnout.
12. Engage residents in program policy making.
13. Evaluate its effectiveness.
14. Produce and/or publish research outputs
about wellness of psychiatry residents.
Bibliography of Recommended Resource
Materials for Wellness Programs
1.AMA STEPS Forward
https://edhub.ama-assn.org/steps-
forward/module/2702511
2. APA Toolkit for Well-Being Ambassadors: A
Manual
(https://www.psychiatry.org/psychiatrists/practi
ce/well-being-and-burnout/well-being-
resources#:~:text=Download%20the-,Toolkit%20
for%20Well%2Dbeing%20Ambassadors,-
Download%20the%C2%A0)
3. Nasirzadeh Y., Chertkow L., Smith S. et al.
(2021). What do residents want from wellness? A
needs assessment of Psychiatry residents to
inform a residency wellness strategy. Academic
Psychiatry.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
8782672/pdf/40596_2021_Article_1578.pdf
4. Resident Wellness Toolkit (John Hopkins
Medicine)
https://christianacare.org/documents/medical-
dental%20staff/ResidencyWellnessToolkit-
Prototype-Dec17.pdf
5. Resilience in the Era of Sustainable Physicians:
An International Training Endeavour
https://respite.machealth.ca
In summary, the following steps in developing a
wellness program for psychiatry residents are
recommended by the Board. First, a wellness
committee must be formed. Second, the
committee conducts a baseline needs
assessment and burnout inventory profile of the
residents. Although not validated locally, the
Maslach Burnout Inventory may be used as this
is considered the gold standard. Alternatively,
the Copenhagen Burnout Inventory and
screening scales for depression and/or anxiety
may also be utilized. Third, the committee
creates a module (see Table 3 for an example) to
introduce stress, burnout and wellness. These
topics are introduced not as a formal lecture but
embedded in various activities (small group dis-
7 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
-cussion or sharing) or in spaces within the
wellness program structure. Flexibility, creativity
and resourcefulness is important in this area.
Fourth, review existing wellness resources within
the workplace and improve when able and
necessary. These include safe/quiet spaces such
as residents’ quarters or working spaces,
hydration stations, access to healthcare, among
others. Fifth, the wellness committee must work
closely with the training and mentoring
committees. This will address the stressors that
come from the learning environment. Simple
examples of these may be honoring protected
time or schedules that have been set
beforehand and improving avenues of
communication to allow open exchange of ideas.
In conclusion, data on burnout among
psychiatry residents in the Philippines is scanty.
This must not hinder initiatives to introduce
wellness programs among the training centers.
Worldwide data shows an upward trend in
burnout and depression and anxiety in the
medical profession. In order to generate
baseline data, the accredited training centers of
PPA must collaborate to develop a working
system that is relevant, dynamic, and adaptable.
II. Mentoring Program
A study of 229 Psychiatry chief residents
participating in the American Psychiatric
Association National Chief Residents Leadership
Program in 2004 and 2005 showed that half of
them reported a lack of clearly defined career
development mentors. These trainees believed
that they were less prepared to practice
psychiatry after graduation. This showed the
need for psychiatric residency training programs
to clarify and implement effective mentorship
programs. (23)
The Standing Committee on Postgraduate
Medical and Dental Education (24), defined
mentoring as, “guiding another individual in the
development and re-examination of their own
ideas, learning and personal and professional
development.” Since the transitions in the
journey from medical student to consultant can
be complicated, mentoring can help residents
cope and adjust to the challenges.
Many graduate medical education programs
internationally have mandated the inclusion of
mentoring in postgraduate training.
Citing the importance of mentorship in the
continuum of academic medicine, the Office for
Diversity Inclusion and Community Partnership
of the Harvard Medical School, for instance,
offers mentoring for junior faculty, trainees and
students. They offer varied mentor trainings and
provide online resources for mentors and
mentees in order to ensure the quality of the
program. (25) A study of successful physicians
showed that medical career success was
determined by the acquisition during training of
core competencies such as patient care, medical
knowledge, interpersonal and communication
skills, professionalism, practice-based learning
and improvement, and systems-based practice.
(26) Mentoring programs should therefore be
designed in line with the core competencies set
by training or accrediting bodies in the specialty.
The perceived benefits of mentoring may cross
the personal-professional interface and may
override organizational differences. (27) The
diagram below highlights the complex
relationships which exist between the three
areas of professional practice, personal well-
being, and personal and professional
development. This can be a guide for the
mentoring process for both mentors and
mentees.
Figure 2. The Personal-Professional Overlap: Areas of Benefit
and Underlying Processes
Mentors can provide support and
encouragement for a resident’s personal
development, usually with a professional focus,
that also factors in work-life balance (22).
Mentoring involves the long-term development
of residents who are helped to manage their
training and improve their skills. In addition,
mentoring provides a venue for the residents to
discuss their personal issues in confidence and a
8 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
way of achieving both individual and
organizational goals. (28)
Mentoring programs during residency training
can increase the satisfaction, well-being,
positive work, and career attitudes of trainees. It
can help them realize their full potential in
Psychiatry and achieve the results they value by
allowing them to take charge of their own
development. (29) Additionally, the benefits of
mentoring apply not only to residents but to the
wider system they are in. Since their personal
and professional developments are enhanced,
these may lead to increased trainee retention in
training programs, enhanced team relationships,
improve competence in patient care and elevate
over-all improvement in the quality of mental
healthcare services. (30)
De Souza asserts that mentoring must not be
confused with direct work-related supervision
and therapy or counseling. (31) Hameed and
colleagues point out that mentoring can mean
different things to different people and there
may be a confusion between mentoring and
other formal structures of support such as
supervision, coaching, consultation, befriending,
and even counseling. (32) Mentoring is none of
the above but at the same time a combination of
them. Mentoring may overlap with coaching,
which is viewed as building particular skills and
focusing on a narrowly defined task or goal. The
difference is that mentors, who have more
experience in the profession, convey and instill
the standards, norms and values of the
profession with a holistic broader view (33).
Since there will be investment in time, effort,
and resources for mentoring programs, this
demands evaluation that may include any of the
following: mentee empowerment and training,
mentor training, aligning expectations, mentor
self-reflection, and mentee evaluation of
mentor. It is also important in the long run to
evaluate the sustainability of the program. (34)
Mentoring relationships last for varying lengths
of time but they can continue after the training
stages in order to include guidance in the early
stages of practice. (24) It is a formative and
developmental relationship that can
significantly impact the personal and profes-
sional life of an individual.
What is the state of mentoring in Psychiatry
training in the Philippines at present?
Informal mentoring between consultants
(mentor) and residents (mentee) is being
conducted in some training programs. These
programs, however, must be formalized,
structured, and standardized in order to ensure
the quality and consistency of its benefits.
Mentoring programs must be embedded in all
Psychiatry residency training programs in the
Philippines and must essentially be part of the
evaluation of training programs for accre-
ditation.
Training on how to design, run, and evaluate a
mentoring program is a significant activity that
ensures the success of the mentoring endeavor.
Collaboration among the different training
institutions is highly encouraged and supported
by the Board because this will guarantee that
the program outcomes are uniformly aspired for
and achieved.
Objectives
General: The mentoring program must empower
and support Psychiatry residents in their
training and future career development in order
to increase their professional satisfaction, well-
being, positive work experiences, and career
attitudes.
Specific: The mentoring program must:
1. Provide resources and support to ensure
that mentors and mentees have productive,
fulfilling, and sustainable interactions.
2. Help the trainees realize their full potential
by helping them take charge of their own
development.
3. Provide a nurturing learning environment
where networking between mentors and
mentees are facilitated.
4. Provide mentors with opportunities to
develop their skills, knowledge, and attitudes
related to their mentoring roles.
5. Provide mentors with opportunities to share
their wisdom and experience to mentees.
6. Support and guide mentees in order to
ensure trainee retention, enhanced team
relationships, and improvement in the
quality of mental healthcare services.
7. Evaluate its effectiveness.
8. Produce and/or publish research outputs on
mentorship of psychiatry residents.
Proposed Methodologies
A. Training of mentors
B. Matching/selection of mentees/mentors
9 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
C. Orientation sessions
D. Mentorship sessions
E. Collaboration among the training institutions
in developing mentoring programs
III. Gender Sensitivity
Gender and gender role orientation increasingly
assume salient functions in mental health and
illness both on the individual and community
levels. A study of young adolescents showed
that perceived gender role influences one’s
expression of empathy. (35) Another study
showed that adolescents who possessed both
positive masculine and feminine qualities in their
self-concept had optimal levels of school-
related well-being. (36) The rapid increase in
transgender and gender diverse people seeking
medical help has created a transgender
healthcare system that is evolving into an
interdisciplinary field. (37) Gender may be a
factor that contributes to poor mental health
because of stigma, social inequality, and
discrimination. For instance, mental health
conditions such as anxiety, depression, and low
levels of well-being are more common among
women. (38). Gender and gender roles may also
influence the prevalence, symptom profile, age
of onset, comorbidities, functional impairment,
and prognosis of mental disorders. Furthermore,
gender-related factors have important impli-
cations to treatment response. (39) The major
systems of classification of mental disorders,
namely DSM 5 and ICD 11, contain stand-alone
chapters for gender-related mental disorders.
(40, 41, 42).
It is imperative that psychiatrists possess a firm
and thorough understanding of the concepts of
gender and gender role orientation because this
has serious implications on the diagnosis and
management of mental disorders and the
establishment of a therapeutic relationship and
the quality of patient care. (43) The Philippine
Psychiatric Association, through the Board of
Accreditation of the Specialty Board of
Philippine Psychiatry therefore require the
incorporation of learning activities on gender
sensitivity in all psychiatric residency training
programs in the country.
Objectives
General: At the end of the course, the
psychiatric resident must be able to integrate
the principles of gender sensitivity to clinical
practice.
Specific: At the end of the course, the
psychiatric resident must be able to
1. Illustrate how the theoretical foundations of
gender and gender role orientation are
applied in medicine and psychiatry.
2. Compose biopsychosocial formulations of
patients that integrate gender and gender
role concepts.
3. Design and implement gender sensitive
interventions for patients and their families.
4. Propose and/or researches on gender and
gender role orientations.
Proposed Methodologies
1. Didactics
2. Seminars
3. Workshops
4. Focus group discussions
5. Case conferences
6. Clinical supervision
Ideally, this learning exercise should be
accomplished during the resident’s second year
of residency training.
Proposed Topics
Learning activities include, but are not limited
to, the following topics.
1. Key concepts on gender
2. Sex and gender differences in health
3. Guidelines on anti-sexual harassment
4. Gender sensitive healthcare
5. Gender sensitive language
6. Gender sensitive clinical practice
7. Gender aspects in psychiatry, psycho-
dynamics, and psychotherapy
IV. Religion and Spirituality (R/S) and Psychiatry
In recent time, the relevance of R/S to health
issues has been increasingly studied. Literature
abounds with empirical researches that
demonstrate the relationship between R/S and
health. The concepts of religion and spirituality
(R/S) have been used synonymously because of
the lack of a universally agreed definition. (44) At
present, religion and spirituality are viewed as
distinct yet overlapping concepts. Spirituality is
a broad concept that involves a dimension of
subjective, embodied, and emotional exper-
iences of closeness and connection with the
sacred or transcendent or to ultimate reality.
10 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
Spirituality is intimately linked with values,
meaning and purpose and it develops
individually or in communities and traditions. In
contrast, religion is the institutional aspect of
spirituality. It involves a search for importance
in the context of adhering to established and
organized beliefs, behaviors, and practices that
are part of a particular faith tradition,
community, or social group. (44, 45, 46, 47, 48)
Spirituality is more popular than religion
because it is self-defined and inclusive. Religion,
on the other hand, may be unpopular because of
its potential to be divisive.
The growing interest in the role of R/S in health
care in general and in mental health care in
particular has led to studies that show that
patients want their R/S concerns addressed by
health care providers. (44) In fact, the World
Health Organization considers R/S as an
essential quality of life element (49). A meta-
analysis of 48 longitudinal studies showed
evidence for a positive effect of R/S on mental
health (50). The association of R/S with mental
health has an even greater implication for global
public health because more than 84% of the
world’s population has some religious affiliation.
(51). Specifically, attendance in religious services
has been significantly asso-ciated with greater
longevity, less depression, less suicide, less
smoking, less substance abuse, better cancer
and cardiovascular disease sur-vival, less
divorce, greater social support, greater meaning
and purpose in life, greater life satisfaction,
greater wellbeing, more charitable giving, more
volunteering, and greater civic engagement (44,
52, 53). King and Bushwick found that 94% of
patients believed spiritual health was as
important as physical wellbeing. Although 77% of
the patients wanted spiritual matters to be
considered in their care, only 10-20% had
conversations with their physician on the topic.
(54)
R/S has significant implications on the
prevalence, diagnosis, outcomes, and
prevention of mental disorders (44). Fitchett and
colleagues reported that 80% of psychiatric
patients expressed the need for prayer and 65%
of them needed a visit from a chaplain to pray
with them. (55) Studies also suggest that R/S is
related to greater subjective well-being, life
satisfaction, and marital satisfaction, as well as
to decreases in mental health problems such as
depression, suicide, delinquency, and alcohol
and drug use. (56).
On the other hand, R/S may be associated with
negative health outcomes, such as depression,
obesity, poor compliance to treatment and even
oppression and violence (57). Religious crises
may lead to distress or be symptoms of
psychopathology (e.g., delusions or
hallucinations). Religion may also become a
problem when it is used to avoid making changes
in attitude or behavior or when religious
teachings are rigidly and inflexibly applied. (52)
The integration of R/S in psychotherapy has
been shown to result in greater improvement in
psychological and spiritual functioning
compared with no treatment and non-R/S
psychotherapies. R/S-adapted psychotherapy
influences treatment through case formulation,
treatment goals, interventions, and
interpersonal processes. (47) Despite this
evidence, most psychotherapists receive little or
no training in R/S issues. One possible
explanation to this problem is the absence of an
agreed-upon R/S competencies or training
guidelines. (48)
R/S contributes to the psychological wellbeing
of residents which, in turn, is associated with
greater sense of work accomplishment, overall
self-rated health, lesser burnout and depressive
symptoms, and better therapeutic relationship.
These redound to better treatment adherence
and coping among patients. (46)
In the Philippines, the Philippine Council for
Mental Health (created through Republic Act
11036) calls for a reorientation of the concept of
mental health. It advocates for the integration of
the spiritual dimension of health in the extant
biopsychosocial model of health. This
movement is also being pursued in government
sectors apart from the health sector. (58) In
other parts of the world, psychiatrists –
regardless of their religious, spiritual, or
philosophical orientations – are urged to include
R/S in the evaluation and management of
patients. Studies show, however, that mental
health professionals fail to integrate R/S in
clinical practice because of several reasons. A
major impediment is the lack of formal training.
Many psychiatry residency training coordinators
and faculty have an insufficient knowledge of
the subject and a lack of time to include it in
training. In addition, they are apprehensive
about proselytizing or introducing an
unscientific approach and adding another topic
to an already full curriculum. (57) There are few
psychiatry training programs that integrate R/S
11 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
in research and clinical practice.
The World Psychiatric Association (WPA) and
national psychiatric organizations from Brazil,
India, South Africa, UK, and USA created
organizational sections on R/S. In addition, WPA
has included R/S in the core training curriculum
for psychiatry. (44, 57) Courses in psychiatry
residency programs in North America are being
developed to address this important aspect of
life. The American Accreditation Council for
Graduate Medical Education and the American
Psychiatric Association (APA) emphasize the
importance of addressing spiritual issues in
psychiatry training. The APA has started to
establish R/S competencies for psychiatrists. In
addition, the American Association of Medical
Colleges and the Joint Commission on the
Accreditation of Healthcare Organizations in the
US, require the incorporation of R/S in patient
care. (47) In Canada, psychiatric residency
training programs are increasingly mandating
training in R/S (59, 60). De Oliveira and
colleagues developed a comprehensive R/S
curriculum based on a review of prevalent
strategies of training and recommendations
from psychiatric associations. This curriculum
consists of a 12-hour course for psychiatry
residents that is easily implementable even if
the faculty does not have expertise in R/S and
there is little time to learn it. (57)
R/S is woven into the fabric of the core beliefs,
values, and experiences of many Filipinos. These
constructs should therefore play a central role
in academic, clinical, and investigative
psychiatry in the Philippines. At present, the
Philippine Council for Health Research and
Development is working on identifying aspects
of R/S that are relevant to mental health
research in the country. (61) In the Philippines,
most psychiatry residency training programs do
not incorporate formal and systematic courses
on R/S. The Board of Accreditation therefore
requires inclusion of this course in psychiatry
residency training because of its benefit to
resident trainees and, ultimately, patients.
Objectives
General: At the end of the course, the psychiatry
resident must be able to apply the concepts and
principles of R/S in mental health care.
Specific: At the end of the course, the psychiatry
resident must be able to:
1. Conceptualize R/S as an important aspect of
human diversity along with factors such as
race, ethnicity, sexual orientation,
socioeconomic status, disability, gender, and
age.
2. Discuss how R/S are distinct yet overlapping
constructs.
3. Compare the diverse forms of R/S.
4. Discuss the positive and negative ways by
which R/S affects mental health.
5. Discuss how patients’ R/S develops and
changes over the lifespan.
6. Construct a complete R/S history as a
routine part of psychiatric practice.
7. Integrate the bio-psycho-socio-spiritual
elements of a case in the diagnostic process
and the treatment plan.
8. Demonstrate the psychodynamic aspects
involving R/S issues in psychotherapy (e.g.,
transference, countertransference).
9. Disseminate information about the
relationship of R/S and mental health to the
wider community as a way of helping
promote the health and wellbeing of
individuals.
10. Formulate ways by which his/her patients
may access their R/S strengths and
resources.
11. Apply evidence-based strategies or
interventions in addressing the mental
health issues and mental disorders of
patients with diverse R/S backgrounds.
12. Contrast the experiences of patients that are
consistent with their R/S and those that are
part of psychopathological processes.
13. Examine legal and ethical issues related to
R/S that may arise when working with
patients.
14. Demonstrate empathy, respect, and
appreciation for patients from diverse
spiritual, religious, or secular backgrounds
and affiliations.
15. Examine how his/her own R/S background
and beliefs influence his/her clinical practice
and his/her attitudes, perceptions, and
assumptions about the nature of mental
processes.
16. Assess his/her R/S competence continuously.
17. Demonstrate the willingness to collaborate
with leaders or members of faith
communities, chaplains, pastoral workers,
clergy, and other qualified individuals and
groups in support of the wellbeing of their
patients.
12 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
18. Analyze current research on the relationship
of R/S to clinical practice.
19. Propose and/or publish researches on the
relationship between R/S and physical and
mental health.
Proposed Pedagogical Strategies
1. Blended and hybrid learning
2. Didactics
3. Seminars
4. Workshops
5. Focus Group Discussions
6. Case conferences
7. Supervision
8. Feedback
9. Reflective practice
10. Faculty and peer support
This course is recommended during second year
of residency training. In developing this course,
the training program committee must be
cognizant of the following caveats: (1) R/S is not
more important than other core areas of mental
health; (2) residents are not required to gain in-
depth knowledge of theologies or R/S concepts
and traditions around the world; and (3) R/S
does not apply only when working with highly
religious or spiritual patients. The residency
training program committee must be able to
identify hindrances to R/S-related training and
assess the outcomes of R/S-related curriculum
including how they affect the wellbeing of
patients and residents through time. (46)
AUTHOR INFORMATION AND CONTACT DETAILS:
Ruth T. Villanueva, M.D.
Department of Neurosciences and Behavioral Medicine
University of Santo Tomas Hospital
villanueva.ruth@yahoo.com
Myra Dee Lopez-Roces, M.D.
Department of Psychiatry
Batangas Medical Center
myradee.lopez@gmail.com
Constantine D. Della, M.D.
Department of Psychiatry and Behavioral Medicine
College of Medicine and Philippine General Hospital
University of the Philippines Manila
cddella@up.edu.ph
Jannel Gatlabayan-Cleto, M.D.
Department of Psychiatry
Institute of the Neurosciences
The Medical City
jannelgatlabayancleto@gmail.com
Georgina M. Gozo-Oliver, M.D.
Department of Psychiatry
Veterans Memorial Medical Center
ggozooliver@yahoo.com
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35. Andrews K, Lariccia L, Talwar V, Bosacki S. Empathetic concern
in emerging adolescents: the role of theory of mind and gender
roles. Journal of Early Adolescence, 2021; 41(9): 1394–1424.
36. Korlat S, Holzer J, Schultes M., Buerger S, Schober B, Spiel C et
al. Benefits of psychological androgyny in adolescence: the role of
gender role self-concept in school-related well-being. Frontiers in
Psychology. 2022; 13: 856758, doi: 10.3389/fpsyg.2022.856758.
37. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC,
Deutsch MB et al. Standards of care for the health of transgender
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38. Kelmendi K, Jemini-Gashi J. An exploratory study of gender role
stress and psychological distress of women in Kosovo. Women’s
Health. 2022; 18: 1–15.
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39. Christiansen DM, McCarthy MM, Seeman MV. Where sex meets
gender: how sex and gender come together to cause sex differences
in mental illness. Frontiers in Psychiatry. 2022; 13: 856436, doi:
10.3389/fpsyt.2022.856436.
40. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition. 2013; Arlington, VA:
American Psychiatric Association.
41. International Classification of Diseases 11th Revision, World
Health Organization, Available from: https://icd.who.int/en.
42. Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB
et al. Disorders related to sexuality and gender identity in the ICD-11:
revising the ICD-10 classification based on current scientific
evidence, best clinical practices, and human rights considerations.
World Psychiatry. 2016; 15: 205–221.
43. Yu Chua C. Gender Liaison Program of the Section of
Consultation-Liaison Psychiatry, Department of Psychiatry &
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44. Moreira-Almeida, A., Sharma, A., Bernard van Rensburg, B.J.,
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45. Christopher C.H. Cook, C.C.H. (2016). WPA position statement on
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AW, Hamilton C. Integrating positive psychology and the psychology
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Religiosity and spirituality in psychiatry residency programs: Why,
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60. Roth B, Grabovac A. Spirituality and religion in Canadian
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61. Grabovac AD, Ganesan S. Spirituality and religion in Canadian
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62. Department of Science and Technology – Philippine Council for
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series-of-rtds/

15 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

 PJP SPECIAL ARTICLE

SUPPORTING MEDICAL EDUCATORS TO ENSURE

WELLNESS OF MEDICAL STUDENTS

CONSTANTINE DELLA, MD, FPPA

Most medical faculty members assume various In addition, it describes well-being across the
roles such as educator, administrator, clinician, following domains: life evaluation, emotional
and researcher. (1) Furthermore, they act as role health, physical health, healthy behavior, work
models for students and instruments to improve environment, and basic access. (2)
student wellness. Strategies geared towards the
faculty can therefore promote a top-down In the Philippines, wellness activities are being
approach to enhancing student wellness. (2) conducted for medical faculty but these are not
Unfortunately, there is a dearth of data about organized, systematized, and institutionalized.
this. If we expect the faculty to take care of This presentation will discuss how wellness
students’ wellness, then we must ascertain the initiatives for medical faculty are designed and
faculty’s wellness as well. implemented abroad. It will highlight the critical
role that medical school leadership possesses in
“Wellness” refers to a multidimensional and making faculty wellness a priority.
dynamic state of optimal wellbeing. (3,4)
Specifically, the World Health Organization Medical schools currently face difficulty
defines it as “the realization of the fullest attracting and retaining faculty. Many factors
potential of an individual physically, have been identified to explain this problem.
psychologically, socially, spiritually and These include the income gap between private
economically and the fulfillment of [the] practice and academia, available time for family
individual’s roles in family, workplace and and personal life, quality of departments,
community settings.” (3) The American Medical teaching load, and rigorous and inflexible work
Association defines it as being composed of six schedule. (7,8) Studies have also shown that
important markers namely, nutrition, fitness, many physicians continue to experience high
emotional health, preventative care, financial rates of burnout and decreased wellbeing. (9)
health, and mindset and behavior adaptability.
(5,6) Another model of wellness describes eight Research shows that the rate of burnout is
dimensions: professional (occupation, similar for academic medical faculty and
vocational), social (family, community), physicians in general. Among the different types
emotional (mental), spiritual (values), of medical faculty, the rates of burnout are
intellectual, physical (fitness, nutrition), similar, whether they belong to clinical
environmental, and financial. (3) The individual departments involved in patient care, clinical
must strive to achieve wellness because it does departments not involved in patient care, or
not come naturally. The inherently basic science departments. What varies are the
multidimensional nature of wellness makes factors that contribute to burnout. (1) The high
quantitative research challenging. The Gallup- prevalence of burnout among medical faculty in
Healthways Well-Being Index Composite Score is the West is reflected in the first nationwide
one attempt in quantifying it. It emphasizes the study on medical faculty burnout in South
presence of health rather than the absence of Korea. Faculty members from 40 medical
disease. schools participated in the study. Using the

16 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

Maslach Burnout Inventory, the following rates
for burnout parameters were obtained: 34%
experienced emotional exhaustion, 66.3%
experienced depersonalization, and 92.4%
experienced reduced personal accomplishment.
(10)
(Paper was delivered on 15 June 2023 at the
55th Annual Convention of the Association of
Philippine Medical Colleges)
Burnout among medical faculty has been
associated with work-life conflict, lack of
acknowledgement and appreciation, decreased
number of faculty, inadequate resources,
ambiguity about future growth in the academe,
job demands, long working hours, and excessive
regulation by the government or university.
(10,11,12) Burnout has been closely linked with
personal and professional repercussions among
physicians. Personal consequences include
broken relationships, alcohol and substance use,
depression, and suicide. Professional
repercussions include decreased quality of care
and increased medical errors, decreased patient
satisfaction, decreased productivity and
professional effort, and physician turnover. (13)
Physician burnout has become more
pronounced during the COVID-19 pandemic.
Prior to the pandemic, more than 45% of
physicians were vulnerable to burnout.
Compared to the general population, physicians
were more likely to experience burnout and to
be dissatisfied with work-life balance. (14)
During the pandemic, burnout rate steadily
increased such that in the US, one in five
physicians intended to leave practice. (15) What
about academic physicians in particular?
A study among Canadian medical faculty
revealed a burnout rate of almost 76%. Rates
were higher among women and early career
faculty members, an observation that was also
noted in South Korea. (10, 16)
How then can medical schools foster faculty
engagement in academia while acknowledging
the challenges and uncertainty of our time?
Experts believe that instituting interventions
that improve physician wellness and reduce
burnout have been shown to decrease physician
turnover. The mistaken notion that physicians
themselves are solely responsible for burnout
and professional satisfaction lead organizations
or administrations to focus on strategies
(e.g., stress management workshops,
mindfulness training, resilience training) that are
insufficient to produce meaningful outcomes. (2)
Experts believe that systemic factors such as
organizational pressures and work stressors and
not personal resilience contribute to burnout
among healthcare professionals. (9)
Although self-directed strategies such as
mindfulness practice help reduce stress, anxiety,
and burnout, systemic factors that lead to such
consequences must also be addressed. (2) Self-
directed strategies disregard organization-
centric or administration-centric factors that are
primary drivers of burnout. Framing the issue as
a personal problem may push physicians to look
for solutions that are personally beneficial but
disadvantageous to the organization such as
reducing professional work effort. (13) Providing
interventions geared towards equipping
administration and the faculty with the capacity
to optimize their roles as educators and role
models is an example. This strategy will facilitate
a top-down approach aimed at increasing
medical student wellness. (2) Strategies
addressing organizational issues have not been
effectively developed because of two main
reasons. First, it is believed that steps geared
towards achieving physician wellbeing will
conflict with organizational goals. Second, all
wellness initiatives are costly. In reality,
physician wellness is critical to achieving
organizational objectives and many effective
wellness strategies are not cost prohibitive. It is
imperative that system-level strategies should
be implemented in order to ensure medical
faculty wellness. The Mayo Clinic in the US has
evolved the following nine evidence-based
organizational strategies to promote physician
wellness: 1) acknowledge and assess problems
related to wellbeing; 2) harness the power of
leadership; 3) develop and implement targeted
interventions; 4) cultivate a sense of community
at work; 5) use rewards and incentives wisely; 6)
align values and strengthen culture; 7) promote
flexibility and work-life integration; 8) provide
resources to promote resilience and self-care;
and 9) facilitate and fund organizational science.
(13)
Organizations are urged to promote meaningful
interaction among faculty members and provide
protected time for faculty for their wellness
activities. (17) The New York University Long
Island School of Medicine in the US executed a
wellness initiative that was created primarily for
17 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
medical faculty. (18)
They formed the Committee for Professional
Health and Wellbeing that systematically
addressed occupational hazards of burnout.
They invited members who were highly
passionate and persistent in the field of
wellbeing. In order to develop a multi-
disciplinary approach, this committee created
an Executive Committee that, in turn, crafted a
wellness ambassador program. This program
ensured that the wellness initiatives were rolled
out departmentally throughout the medical
school. The ambassadors had to participate in
50% of committee meetings and document
wellness activities for their departments. The
ambassadors were also tasked to ensure that
their interventions promoted connection with
colleagues and reinvigorated a sense of meaning
in work. This committee paved the way for
sharing and discussing ideas among the various
departments. The initiatives that were designed
by certain departments created a ripple effect
such that other departments replicated wellness
strategies that they learned from others. For
instance, the departments of Obstetrics and
Gynecology and Surgery implemented an Annual
Wellness Week that focused on different
emotional, physical, environmental, and mental
components of wellness each day. In order to
promote faculty engagement, the departments
of Pathology and Obstetrics and Gynecology ran
structured annual retreats and social gatherings
that focused on stress reduction and
mindfulness. In order to promote camaraderie,
the department of Foundations of Medicine
conducted monthly department walks (called
Infinity walks) at a local park. The department of
Radiology implemented a “Wellness Wednesday”
that comprised of outdoor activities, financial
planning, and summer socials. The divisions of
Maternal-Fetal Medicine and Gynecologic
Oncology carried out weekly “check ins” and
debriefings during division meetings and an
activity entitled “Three Good Things Exercise.”
The department of Pediatrics led a wellness
activity called “Gratitude Month” that entailed
the posting of thank-you notes at “Appreciation
Stations” and “Gratitude Calendar” that involved
hanging daily prompts at workstations. The
committee also developed structured
educational Wellbeing Grand Rounds that aimed
to discuss topics such as work-life balance,
resiliency, and mindfulness. In order to
encourage participation, faculty members who
attended the lectures were granted CME credits.
Ultimately, the departments were given the
autonomy to design programs that served them
best given the differences among specialties and
work units. (18)
The virtual platform enabled faculty across
departments or divisions to conveniently and
effectively share significant life roles and events.
This process was a motivating force for faculty
to pursue their academic and personal growth.
The committee promoted their own internal
faculty as keynote speakers in faculty
development events. They ensured that their
wellness initiatives were shaped by locally
generated data from surveys or studies. For
instance, the departmental wellness
ambassadors used the responses to wellness-
oriented questions from an employee
engagement survey in designing wellness
programs. Furthermore, this survey was
redistributed annually in order to document
change and progress. (18)
The committee provided the following general
guidelines for institutions that are looking for
ways to reengage their faculty: 1) offer flexible
learning environments for faculty development
events in order to accommodate different time
schedules and geographical locations; 2) provide
opportunities that foster conversations about
life roles and hobbies; 3) obtain support from
institutional leadership that advocates for
faculty wellness; 4) organize committees and
task forces that will promote faculty wellness
through departmental activities; and 5) accept
and adapt faculty feedback. The critical need for
medical school leadership to make faculty
wellness a priority was consistently highlighted
by their dean who was highly supportive of their
wellness initiatives. (18) Other authors affirmed
that harnessing the power of leadership can set
the tone of institutional culture and make
wellness efforts even more effective. (13) This
leadership must gradually enact organizational
or system-level changes the impact of which
would be felt over time. (5)
In 2017, a Resident Wellness Consensus Summit
was inaugurated in the US. Part of this summit’s
output was a proposal for an evidence-based
wellness curriculum that contained modules
that focus on the spectrum of wellness and
burnout. A study showed that running small
group discussions on these topics significantly
increased empowerment and work engagement
and decreased rates of burnout, emotional
18 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
exhaustion, and depersonalization. This
curriculum may also be applicable to medical
faculty. The following topics may be included in
these wellness initiatives: 1) introduction to
wellness (introduction to physician wellness and
burnout and the wellness curriculum); 2) why
wellness matters (building awareness on
burnout, depression, and mental health issues in
medical faculty; wellness is not the absence of
distress); 3) wellness activities of physicians
(how physicians stay well through relationships,
religion and spirituality, self-care, work, and
approach to life); 4) sleep (education on sleep
hygiene and scheduling); 5) nutrition (education
on the basics of nutrition and how to eat a
healthy, balanced diet, particularly for people
with busy lifestyles); 6) physical fitness
(education on the basics and scientifically
proven benefits of physical fitness, as well as
how to get started on an exercise program); 7)
financial health (overview of the basics of
budgeting and living within your means); 8)
mindfulness and reflection (overview of the
concept, scientifically-proven benefits,
unwarranted stigma, and practice of
mindfulness for the busy faculty); 9) building
support network (discussion about the
importance of a support network for the faculty
in promoting wellness and building
resiliency);10) physician suicide (education on
risk factors for depression and suicide specific
for physicians, and how to recognize them in
oneself);11) “I Need Help” (education on how to
get mental health help for oneself, with a focus
on systems that ensure confidentiality); 12)
wellness in the workplace (discussion about how
individual wellness depends on the supportive
workplace wellness culture). (4)
A wellness program possesses a and institutional policies, culture, and regulation
multidimensional approach that integrates
individual needs, institutional and cultural
barriers to wellness, and systemic issues that
contribute to stress. (8) At an individual level,
wellness is achieved when the faculty practice
healthy habits on a daily basis allowing a balance
in the physical, emotional, intellectual, social,
spiritual, environmental, and occupational
aspects of being.
Activities and strategies throughout the
academic year include retreats, mental health
leaves, recreational and leisure activities,
exercise, conducive workspaces, retreat zones or
quiet spaces with relaxation apps, open air
sitting areas, a simple gym area, a
snack/hydration station, self-care workshops,
and communication and stress management
trainings. Avenues for psychosocial support
include check-ins with each other, group peer
support (structured group sharing), and therapy
sessions. The faculty must be made aware of
such interventions using multiple channels of
communication such as regular emails, fliers
posted in work areas, a wellness website, and
announcements in team meetings. Ultimately,
these programs must be able to reduce the
barriers to accessing wellness services. Studies
have identified several barriers that include
concerns about confidentiality, stigma and
stoicism, demanding clinical schedules, and
identifying therapists experienced in working
with physicians. (5,19)
Wellness programs should foster a culture that
allows open exchange of ideas and flexibility in
responding to issues as they emerge. Wellness
programs must allow the medical faculty to
become an integral part of program policy
changes and to participate in program
improvements. Consequently, wellness
programs become more successful and
leadership and communication skills are
enhanced among the faculty. The differences in
experiences of the learning environment among
subgroups of faculty does not permit a singular
approach to wellness. Understanding such
diversity will guide whatever changes to the
learning environment are made. (5, 7, 8, 17, 20)
The concept of the learning environment (LE) is
defined by two main dimensions namely,
psychosocial and socio-material dimensions.
Individual characteristics that contribute to or
respond to the LE, interpersonal interactions,
constitute the layers of the psychosocial
dimension. The socio-material dimension defines
how the faculty interacts with the physical and
virtual worlds that they operate in. (3)
Incorporating web-based and other digital
resources will contribute to the success of
wellness programs because this provides the
faculty and students the opportunity to learn at
their own pace. (9) At present, the relationship
between wellness and LE is not well understood
and needs to be studied using high quality
research. (3)
As medical education continues to adapt to
technology and the challenges of a post-
19 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
pandemic landscape, faculty and administration
will continue to play pivotal roles in student
wellness. (2) It is essential that we understand
the diversity of medical faculty because a one-
size-fits-all approach to wellness initiatives may
not be effective. (8) Institutions must take into
account the impact of workplace culture on
faculty wellness. By identifying and addressing
issues arising from day-to-day experiences,
institutional and departmental leaders can help
build faculty resilience. Further research is
essential in studying factors that contribute to
wellness among groups of academic medical
faculty. (1) Ultimately, embedding a culture of
wellness that is openly and intently supported
by administration should be a goal of every
medical school.
In conclusion, academic medical faculty assume
various roles and this predisposes them to
burnout. In order for a wellness program for
medical students to succeed, the faculty should
also be recipients of wellness strategies or
interventions themselves and not just
implementers of the program. Strategies that
ensure medical faculty wellness should not only
be individual-centric but also organization-
centric. Finally, no wellness program will
succeed unless the power of leadership is
harnessed.
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20 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
 PJP ORIGINAL RESEARCH

PRACTICE AND PERCEPTIONS OF PEDIATRIC RESIDENTS

IN A TERTIARY GOVERNMENT HOSPITAL ON MENTAL
HEALTHCARE AS PART OF GENERAL PRACTICE

CONSTANTINE L. YU CHUA
LORELEI MELANIE K. ELMA

ABSTRACT

OBJECTIVE: This study aimed to describe mental health practice patterns, perceptions,
perceived responsibility, confidence, barriers, and supports of pediatric residents in a tertiary
government hospital to arrive at recommendations in enhancing their mental health
competencies.

METHODOLOGY: As part of needs and baseline assessment within an existing collaboration,

written self-administered questionnaires were distributed among pediatric residents of the
hospital. Frequency of answers were tallied to see clustering and trends. RESULTS: Most of the
37 Pediatric residents had positive perceptions i.e. 78.83% - 83.78% and planned to incorporate
all aspects mental healthcare in their future practice as consultants i.e. 89.19 %- 97.29 %.
However, they did not get to practice or apply it as much during training. All respondents
perceived that diagnosing the neurodevelopmental disorders of Autism Spectrum, Attention
Deficit and Hyperactivity, Intellectual Disability and Learning was their responsibility. When it
came to confidence in diagnosing other psychiatric disorders less than half to 3/5 (45.9%-
64/9%) were confident or very confident in doing so. Approximately three fifths (56.75%
-67.56%) of them were confident in managing neurodevelopmental disorders. There was an even
lower proportion i.e. one fourth (16.21% - 32.43%) of pediatric residents who were confident in
managing other psychiatric disorders. Time was the most often perceived barrier while more
exposure and training were the supportive factors for integrating mental healthcare into
practice.

CONCLUSION: With such positive perceptions already in place, programs to improve knowledge
and skills can be developed to increase confidence, focusing on diagnosing and managing
psychiatric conditions. Target areas as guided by this research can be on how to use screening
tools and psychotropics, diagnosing anxiety and behavioral addictions, and managing psychosis
and trauma. These should be incorporated in a time-efficient manner into usual patient
interviews. Training and added exposure can be utilized in the short-term as well as
institutionalization of collaboration, liaison, and feedback systems in the future.

KEYWORDS: Pediatric Residents, primary mental healthcare, mental health competency

21 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

INTRODUCTION
Integrating mental health (MH) into pediatric
practice is seen as an effective way to maximize
access, especially in developing countries. This
utilizes the pediatricians’ long-standing
relationship with the patient and family, as well
as the family-friendly nature of their practice. It
is more cost effective and has been linked with
better outcomes compared to a tertiary care
model alone. (1) Among child and adolescent
populations, pediatricians are considered the
gatekeepers of care and current trends have
shown the expansion of their roles to include the
MH dimension. (2) This is especially important in
the Philippines where there are very few child
and adolescent psychiatrists to address a
growing “mental health crisis” in the youth. The
recently enacted National Mental Health Law (3)
articulates MH as part of primary care.
In the Western setting, pediatricians were asked
in a survey by the American Academy of
Pediatrics (AAP) regarding their perceived
responsibility to identify, manage, and refer
various MH conditions. More than 80% of the
surveyed pediatric consultants believed they
should identify ADHD, depression, behavior
management problems, anxiety disorder,
substance abuse, and eating disorders. However,
while 70% believed they should manage ADHD,
which approximately coincided with the rate of
perceived responsibility for its identification,
only around 30% or less believed they should
manage the other abovementioned concerns.
Around 80% believed instead that they should
just refer for those. (4) The discrepancy between
ADHD and the other disorders was not explained
but may perhaps be due to pediatricians’
discomfort with matters that have strong socio-
emotional components and are traditionally
labeled as part of psychiatry and psychology.
In another study also by the AAP, only 13% of
general pediatricians felt confident overall in
their capability to manage depression. Almost
80% recalled referral to a MH professional as
their “management” in their most recent case of
depression. In the AAP study, the greatest
perceived barriers were inadequate time to
provide counseling and conduct adequate
history, plus inadequate training. Other factors
implicated included: insurance and financial
issues, authorization and paperwork problems,
patient or parent reluctance, or medical prob-
-lems being more pressing. (5) A “referral
mindset” predominates, which may be affected
by perceptions, perceived responsibility,
confidence, barriers, and supports.
In the Philippines and among Filipino
respondents that also include trainees, a 1994
study by Manapat and Ramos-Leynes showed
that in a local tertiary children’s hospital, none
of the pediatric residents and consultants would
ignore various emotional or behavioral
complaints in consultations and very few would
opt to just observe. However, few would opt to
manage independently as well. Majority would
“handle and refer” cases like bedwetting beyond
five years, poor school performance,
nervousness or fearfulness, and school phobia.
On the other hand, problems like psychotic
behavior, drug abuse or dependence, stealing,
and truancy would be “referred immediately”.
Collectively, the study showed that in this
population of Filipino pediatricians, the model
was to “handle and refer” or “refer immediately”
for emotional and behavioral concerns and not
be the primary care provider. (6) This parallels
American practice patterns in 2008 where
primary care pediatricians (PCP) and also child
psychiatrists believe that PCPs should identify
and refer but not necessarily treat children with
MH concerns. (7)
While the “referral model” has understandable
basis, it is important to note that not all areas in
the Philippines have access to child and
adolescent psychiatrists for referral. Moreover,
pediatricians have a big opportunity for
promotive and preventive interventions not
available to psychiatrists who usually see
patients already needing treatment. Effective
referral is also not a singular step but also
assumes that the pediatrician is adept in
identifying a MH concern, explaining it to the
patient and family, forming a trusting
therapeutic relationship with them, and
performing psychoeducation and supportive
maneuvers. This is especially true where MH
stigma is rampant.
What supports the engagement of pediatricians
in MH? It was found by the AAP that those who
completed at least four weeks of
developmental-behavioral pediatrics training
had 1.8 times increased odds of co-management
and those who had prior MH training had 1.4
times increased odds.
22 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
The factor which mattered most was the simple
fact of having strong interest in the subject
matter, which led to an increase of 2.75 times. (8)
This highlights that both training and personal
factors such as interest or personality of the
physician influence their willingness to tackle
MH issues of their patients. Related to this,
another area of effort was not just to integrate
MH practice in pediatrics but to increase
pediatricians who themselves were MH
practitioners. In the United States, the “Post
Pediatric Portal Project” is a program which
enables pediatricians to train and be licensed in
general psychiatry and child & adolescent
psychiatry within a span of three years as a
fellowship program. (9) No such program exists
in the Philippines as of now, but this could very
well be a way of increasing pediatricians who
could manage psychiatric disorders.
Have MH practice patterns in pediatrics changed
in the Filipino setting after nearly thirty years?
What are the factors that influence this? In the
current Filipino context, it is hypothesized that
perceived responsibility and confidence levels
may be lower than Western counterparts
because standardized MH integration in
pediatric residency curricula has not yet been
established. Variations in workload, culture, and
education may also cause practice patterns to
differ.
The primary objective of this study was to
describe the baseline practice and perceptions
of pediatric residents at the University of the
Philippines-Philippine General Hospital (UP-
PGH) on MH practice. The focus on residents
was given that practice and perceptions as
consultants may be rooted and modified during
formative years in residency training and it may
be valuable to focus on this stage. Specific
objectives are to describe the following among
pediatric residents: 1) MH practice patterns and
plans; 2) perceptions about MH practice; 3)
perceived responsibility in diagnosing and
treating various psychiatric conditions; 4)
confidence in diagnosing and treating various
psychiatric conditions; and 5) perceived barriers
and supports in integrating MH into pediatric
practice. The study was done in the context of
gathering data to guide a capacity building
program in MH between the UP-PGH Pediatrics
and Child and Adolescent Psychiatry
departments. Beyond the program, it is hoped
the study could also guide pediatric residency
program of other hospitals in the future in colla-
boration with the professional societies in-
volved.
METHODOLOGY
Participants / Methods for Selection
The study involved pediatric residents of UP-
PGH, from first to third year level, who were
recruited by the principal investigator during
their weekly conferences via convenience
sampling. This was permitted as part of the
existing collaborative program between Pedia-
trics and Psychiatry to improve MH com-
petencies among pediatric residents. Within May
to July 2019, a total of 37 out of a total of
seventy residents were recruited – those were
present in the conference. Collection was done
in three conferences (once per month) to reach
those who did not attend before. However, not
all residents were able to answer despite this
effort due to leaves or duties in critical posts.
Sample size was not computed. As the study was
within the context of a program, the goal was to
collect data from as many residents as possible
but at the same time without disrupting their
work. All residents who were present were in-
cluded but medical interns, rotators from other
institutions, and fellows already in subspecialty
training were excluded.
Data Collection
The study followed a cross-sectional, descriptive
design. A written questionnaire was formulated
based on the review of literature, which included
various factors that would influence the MH
practice of pediatricians. This was expanded and
modified based on focus group discussions with
the pediatric residency training officer, chief
resident of pediatrics, head of the division of
child psychiatry, and chief fellow of child psy-
chiatry. The questionnaire, phrased in English,
which is the standard language of education and
training in the country, was directly admi-
nistered. No validation study was done as it was
done in the context of guiding a time-bound
program. It was divided into five parts, as
follows. Part one included questions on patterns
for current MH practice as a resident and for
planned clinical engagement as a consultant.
Part two included questions on perceptions
regarding MH practice in pediatrics. Part three
included questions on perceived responsibility
23 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
in diagnosing and managing specific conditions
as a pediatrician. Part four included questions
on confidence in diagnosing and managing
specific conditions as a pediatrician. These were
all in the form of Likert scales corresponding to
the degree of frequency or agreement to
statements. Part five included two open-ended
questions on problems encountered and
possible supports when it comes to MH
integration in practice. (Appendix 1)
Data Analysis
Percentages of total answers per choice of each
item, calculated using Microsoft Excel, were
presented for parts 1 to 4. For part 5, common
answers were grouped together by themes and
tallied.
This was a purely descriptive study and no
statistical correlations were analyzed.
Ethical Considerations
The study was approved by the institution’s
research ethics board, part of which required
that researchers have undergone good clinical
practice training. Participants underwent due
informed consent process with their confi-
dentiality upheld in all steps of the process.
Joining the study did not impact participation in
the abovementioned competency building
workshop in any manner. There were no
conflicts of interest that required disclosure.
Results were presented as a whole without indi-
vidual or sub-group identifying data to the De-
partment of Pediatrics as part of the colla-
boration.
RESULTS
Demographic data
There was a total of 37 pediatric residents. Most
(29 or 78.38%) of them were female. The mean
age was 28.3 years old. The respondents were
distributed relatively equally among the year
levels: 11 first-years, 10 second-years, and 16
third-years. Around one-third (62.16%) of them
graduated from the medical school partnered
with the study hospital (UP-PGH). Undergrad-
uate courses taken were: biology (28.73%),
seven-year direct MD program (13.51%), nursing
(13.51%), psychology (13.51%), other allied
health courses (8.1%), and others/did not specify
(21.62%).
Approximately half had their rotation in the var-
-ious MH-related rotations: child protection unit
(48.65%), developmental pediatrics (54.05%),
and adolescent medicine (48.65%). Notably,
these rotations were randomly assigned at any
year level. Due to time constraints, not all
residents were able to go through all three ro-
tations within the duration of their training.
Practice Patterns of Pediatric Residents & Future
Clinical Practice
Majority of residents (greater than 75%) would
explore and detect MH concerns, discuss MH
promotion or prevention, diagnose specific psy-
chiatric conditions, and perform counseling so-
metimes, often, or almost always in their cur-
rent clinical engagements. On the other hand,
many residents (greater than 50%) would almost
24 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
 never handle basic MH cases on their own.
(Table 1). In contrast to their residency practice
patterns, most of the participants planned to
conduct all aspects of mental healthcare
sometimes, often, or always as future
consultants – even the use of screening tools
(97.29%), initiation of psychotropics (89.19%),
and independently handling MH cases (91.9%).
This indicated that most of them plan to
integrate mental healthcare in their practice,
even if they did not do it as much when they
were residents.
Highlighting an example of a discrepancy
between current practice in training and future
plan, 56.76% planned to initiate psychotropics
often or almost always as future consultants,
while only 5.12% actually did so during their
residency. (Table 2)
Perceptions on Mental Health Practice
Results revealed that pediatric residents had a
positive overall perception toward MH practice.
25 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
As pediatricians-in-training, majority (83.78%)
felt that patients were open to discuss and
78.38% would take MH directives. Many (81.08%)
were interested in psychiatry as a topic and
86.49% were interested in MH concerns of their
patients. Most (83.78%) of them agreed that
dealing with MH problems would be adequately
reimbursed. Notably, all of the respondents
agreed that psychosocial concerns have an
impact on health.
However, it was notable that around one fourth
(24.32%) believed that medical concerns are
more pressing than MH concerns and another
one fourth (27.03% were ambivalent. Around
one-third (35,84%) also believed that their role
as pediatrician was more for medical than MH
concerns. (Table 3) Pediatric residents all
wanted to have a MH clinic as part of the
pediatric services in the hospital.
26 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
Generally, 86.48% expressed willingness to
rotate in child and adolescent psychiatry. All the
respondents felt that the child protection unit
rotation and 94.4% said that their rotation in
adolescent medicine helped them integrate MH
in their pediatric rotations. To a significant but
lesser extent (69%), developmental pediatrics
rotation was also seen to be helpful. The
discrepancy in developmental pediatrics may
reflect mindsets about development being a
separate construct from MH. (Table 4)
For around half of respondents (48.65%),
premedical studies helped them in MH aspects
of pediatric care while 64.87% mentioned that it
was in medical school that they learned to
attend to mental health of patients. This showed
a possibility that not all pediatric residents were
equipped in addressing mental health concerns.
Around one-third (37.84%) of respondents
expressed some interest in possibly specializing
in child and adolescent psychiatry if there was
such a program from a background of pediatrics.
(Table 4)
Perceived Responsibilities
All respondents perceived that diagnosing the
neurodevelopmental disorders (ASD, ADHD, ID,
and LD) was their responsibility. Almost all
perceived diagnosing substance use problems
(94.59%) and behavioral addictions (91.88%) to
also be their responsibility.
There was more hesitation with regard
conditions that were “traditionally psychiatric”;
given answers of “undecided” and even “not
responsible” for cases such as depression (8.1%),
anxiety (10.8%), psychosis (18.9%), conduct
disorders (10.8%), and trauma (10.8%);
nonetheless, for these conditions, still a great
majority (80% or more) felt they should be able
to diagnose. (Table 5)
For neurodevelopmental disorders, a significant
majority of residents felt the perceived
responsibility to manage, ranging from 86.49%
to 89.19%, which corresponds well to the 100%
perceived responsibility to diagnose those
disorders. This was not the case for the
psychiatric disorders. Less respondents felt
responsible to manage, ranging from 56.76% to
78.38%, despite a lot of them feeling responsible
to diagnose (above 80%). On the other hand,
only 67.56% felt responsible for diagnosing
anxiety and 56.75% felt the same about
diagnosing psychosis. This downward drift
possibly illustrates where the “referral mindset”
starts to manifest. (Table 6)
Confidence in Mental Health Practice
Similar to the pattern in perceived
responsibility, there was greater confidence in
the diagnosis of neurodevelopmental disorders,
wherein 78.4%-89.2% reported being confident
or very confident. In contrast, only approximate-
27 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
 -ly half (45.9%- 64.9%) of respondents were
confident in diagnosing the other psychiatric
conditions. The least number of residents were
confident in diagnosing behavioral addictions
(45.9%) and anxiety (48.6%). (Table 7)
Approximately three-fifths (56.75 % to 67.56%)
of pediatric residents were confident or very
confident in managing the neurodevelopmental
disorders. On the other hand, only around one-
fourth were confident or very confident in
managing depression, (24.32%), anxiety (29.73%),
substance problems (29.73%), and behavioral
addictions (24.32%). The least number of
respondents were confident in managing
psychosis (16.21%) and traumatic disorders
(21.62%), where the approximate ratio falls to
approximately one out of five. This may possibly
reflect their perceived complexity or risk with
these conditions or stricter delegation of these
as purely within psychiatry. For psychosis, this
may also correlate with the lack of experience in
using psychotropics as seen earlier in practice
patterns. (Table 8)
frequent suggestion (9 respondents), followed by
having more time (3 respondents) and even having
a child and adolescent psychiatry rotation (3
respondents). (Table 10)
DISCUSSION
The study was able to highlight important gaps or
discrepancies. First, there were positive
perceptions about MH with residents planning to
integrate mental health care as consultants, but
there was hardly any chance to so during pediatric
residency. Second, many recognized that
diagnosing and treating MH problems was their
responsibility, but were not so confident in doing
so.
Barriers and supports
For the questions regarding barriers and
supports, these were open-ended questions to
which not all respondents answered. There were
answers which recurred in many answered
questionnaires. The greatest perceived barrier
to practicing MH in pediatric residency was the
lack of time (13/ 33 respondents or 39.39%). Lack
of training was the second biggest barrier (8/ 33
respondents or 24.24%). The lack of space or
venue was also identified as a barrier (3 /33
respondents or 9.09%). This may point to issues
about conduciveness of environment and
privacy. The “referral mindset” was also
mentioned, wherein the accessibility of
psychiatry services led residents to just refer
and focus their efforts on medical illnesses.
(Table 9)
The most relevant support was to have more
training or education opportunities in MH, as
identified by 12 respondents (36.36%). This may
be related to the lack of training mentioned
earlier. More exposure was the next most
These reflect a concern that their pediatric
residency training might not be adequately
preparing them for something they actually
consider as important and hope to get involved
with in their future clinical practice. It was noted
that the questionnaire did not ask if the
participant planned to take further training or a
fellowship program related to MH to close the
gap. Requiring fellowship to achieve MH
competency seems counterintuitive to the
concept of primary care integration. Residents
felt responsible and confident in diagnosing but
not so much in managing psychiatric conditions,
which may reflect that their training may have
focused only on detection of such illnesses
28 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
rather than on treatment. The “handle and refer”
or “refer immediately” mindset parallel to the
Manapat and Ramos-Leynes study done in
another Filipino tertiary hospital almost thirty
years ago in 1994 can be gleaned from this. (6)
Given the results in perceptions, one possible
contributor to this includes role confusion –
should they prioritize physical or MH? This
conceptual divide may be influenced first by the
high workload that limits time. Second is the
presence of dedicated MH service (i.e.,
psychiatry) in the current hospital setting that
makes referral more practical and perhaps the
pressure to avoid overlaps and infringements in
roles.
On the more positive side, the results reflect
that efforts to integrate MH in pediatric practice
are likely to be perceived as relevant and fruitful
by the residents should it be established. There
is no need to work from the very bottom to
address misconception and resistances
anymore, and institutional efforts are not likely
to be left ignored. The residents may benefit
from capacity building in MH practice. Results
show that many are open to having avenues of
learning and practicing, but also, that it is
difficult to find additional time. A balance has to
be created between providing experience
without further adding to their workload.
Drawing from the information generated from
the focused group discussions surrounding the
capacity building program, making MH a
convenient part of the usual consult may be
helpful, akin to the HEADSSS (Home, Education,
Activities, Drugs, Suicidality, Sexuality, and
Safety) in adolescents. The utility of cascading it
down to the level of medical students, similar to
the adolescent interview, was also emphasized.
This agrees with literature that integrating MH in
pediatrics requires exposure in medical school
and residency, as well as the availability of back-
up and consultation from child and adolescent
psychiatry. (10)
It is also significant to note that only around
two-thirds of the pediatric residents felt that
medical school helped them with the MH
dimension of clinical practice, so there is still
much to be improved in the medical curriculum.
The advantage of this would be that MH would
become part of primary care, rather than “yet
another subspecialty” that pediatric trainees
must learn in addition to their myriad of
rotations. This strengthens views that MH is part
of primary pediatric care. For interventions, it
was discussed that it may be more practical to
start application of MH practice into special
populations integrally encountered in various
subspecialties such as abused children,
chronically ill children, emergency consults for
suicide attempts, and in the adolescent clinic.
Although not necessarily a long-term solution,
workshops were also deemed feasible at this
time, strengthening the hands-on application of
clinical skills in handling patients with
psychiatric conditions as well as mechanisms for
feedback from psychiatry. Ideally these
programs can be integrated in the clinics. In the
US, one model involved hiring a dually-trained
pediatrician and child psychiatrist who initially
educated the pediatricians, performed patient
consultations with them in a once-every-two-
weeks MH clinic, and eventually allowed the
pediatricians to do the consultations alone while
being available for questions as needed. This
yielded to 11% to 37% increase in MH diagnoses
made by pediatricians. (11)
There are however no programs that train such
dually-trained specialists in the Philippines.
Another model used standard patient
encounters with trained actors who simulated
behavioral concerns, which were simultaneously
interviewed by pediatric trainees and behavioral
health trainees, to facilitate exposure to and
exchange of differing techniques. This was also
found to improve awareness of behavioral
29 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
health resources, confidence in using screening
tools, and willingness to adjust future practice
orientations. (12) Such methods of learning
through actual clinical experience could guide
future MH capacity building efforts.
In the focused group discussions, it was
discussed that there were no MH competencies
articulated in the professional association of
pediatricians as of now. Also, it was not yet part
of the residency curriculum of the hospital, but
rather incorporated in relevant rotations.
Moving forward, these efforts can ideally be
institutionalized by professional policy for
uniformity, sustainability, and continuity.
Limitations and Recommendations
The limitations of the study were that
convenience sampling was used and the turn-
out was only around 50%. There may have been
selection bias in such that participants were
those who were more inclined toward MH
practice. Results may also not be directly
applicable to other pediatric residency
programs in the country; the unique factors of
the hospital of study were the availability of
child psychiatry services, being a major
subspecialty referral center, and its location in
the urban center. Findings are expected to
change in non-specialty rural hospitals without
proximate access to child psychiatry services. It
is recommended that the study be expanded to
multiple centers in the Philippines, using formal
sampling methodology and validated
instruments.
Future studies can also go beyond descriptive
methodology by comparing changes pre- and
post- intervention (e.g., a workshop or liaison
program) using statistical analysis. Factors that
increase or decrease actual engagement or
outcomes like psychiatric diagnoses,
psychotropic prescription, and the like could
then be determined and explored.
Therefore, for the hospital of study, the
collaboration may go directly to knowledge and
skills enhancement, rather than focusing on
baseline attitudes. To close the gap and bridge
the above discrepancy, specific
recommendations can include the following:
1. Knowledge and skills regarding diagnosing
and managing non-neurodevelopmental
psychiatric conditions can be enhanced
through various means, with emphasis on
going beyond detection as a point of
emphasis.
2. The following can be focused on in training,
as they attained the lowest ratings: using
screening tools, basic psychotropic
prescription, diagnosing anxiety and
behavioral addictions, and managing
psychosis and trauma.
3. Mental health can be incorporated in routine
health interviews in a time-efficient manner
as time constraint was the most common
limiting factor. This can be initiated earlier in
general medical education.
4. Child protection and adolescent medicine
rotations for all pediatric residents can be
maximized as they were deemed very helpful
in learning MH. A child and adolescent
psychiatry rotation can be offered for those
who are interested.
5. A capacity building project for MH practice
can be initiated since more training was most
identified as a possible support.
6. Further collaborations beyond workshops
and seminars such as having a shared
pediatric MH clinic and integrating principles
of mental health in pediatric training
curricula.
REFERENCES
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6. Manapat RC, Ramos-Leynes MCJ. Attitudes of pediatricians at
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Szilagyi M, et al. Which pediatricians comanage mental health
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31 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

 PJP ORIGINAL RESEARCH

A CROSS-SECTIONAL STUDY ON THE PREVALENCE AND

SEVERITY OF SUICIDAL IDEATIONS AND BEHAVIORS OF SENIOR
HIGH SCHOOL STUDENTS USING THE COLUMBIA-SUICIDE
SEVERITY RATING SCALE (C-SSRS)

JOHN MICHAEL L. REYES, MD

ABSTRACT

OBJECTIVES: In the light of increased suicide risk among adolescents, this research aimed at determining
the prevalence and severity of suicidal ideations and behaviors of senior high school students in a public
secondary school in Metro Manila using the Columbia-Suicide Severity Rating Scale (C-SSRS).

METHODOLOGY: This is a descriptive cross-sectional school-based study, conducted on 236 senior high
school students, 18 years old and above, in San Juan National High School (SJNHS) in San Juan, Metro
Manila. The study employed convenience sampling. Upon selection, the C-SSRS was administered. Data
on four constructs of suicide were gathered: 1) suicidal ideation severity; 2) intensity, which was
quantified in terms of frequency, duration, control, deterrents and reasons for suicidal ideation; 3)
suicidal behavior rated on a nominal subscale as actual, aborted, interrupted, preparatory behavior and
non-suicidal injurious behavior; and lastly 4) lethality of actual suicide attempts on a 6-point ordinal scale,
and if actual lethality was zero, potential lethality was further rated on a 3-point ordinal scale.

RESULTS: The majority (67.8%) had mild suicidal ideations; 37.71% had active suicidal ideations with intent
but not necessarily a specific plan and only 13.98% had active suicidal ideation with intent to act and a
specific plan. The intensity of suicidal ideation was not that frequent in 35.59% of the respondents
i.e.18.64% 1x/ week and 16.95% less than 1x/ week. About a third (30.07%) had very short duration of
suicidal ideations i.e. fleetingly (19.92%) or less than an hour/ day (11.02%). A third (32.62%) were able to
easily control (18.64%) or control with minimal difficulty (13.98%). Reason for suicidal ideation were either
to get attention (10.59%) or to end the emotional pain (11.02%). A third (30.93%) had actual attempts
(15.25%) and Non -Suicidal Self Injury (NSSI) (15.68%); while another 35.06 % had interrupted (16.53%) or
aborted (19.07%) attempts. Those who had actual attempts, 41.67% had no physical injury while 50 %
incurred minor injuries. Thirty- two (88.89%) had suicidal attempt that was likely to result in injury but not
likely to cause death.

CONCLUSION: In light of these relatively high prevalence rates for suicidal ideation and behaviors, school-
wide intervention on education or awareness programs, gatekeeper training, peer leadership, skills
training and screening or assessment may have to be instituted to curb the increased suicide risk of the
senior high school students and further prevent suicide attempts.

KEYWORDS: Prevalence, Suicidal Ideations, Suicidal Behavior, High School Students, Columbia- Suicide
Severity Rating Scale (C-SSRS)

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INTRODUCTION
Background of the Study
According to the World Health Organization
Global Estimates, among the people ages 10-29
years old, 27% had committed suicide. 27% of
suicides were attempted by adolescents (10-19
years old). (1) Suicide was the second leading
cause of death among young people aged 15-29
globally. (2) In the Western Pacific Region,
suicide was also the second leading cause of
death among young people aged 15-29, eclipsed
only by road accidents.
In the Philippine setting, a time-trend study
showed that rates of suicide peaked at the age
range of 15-24. In a study in 2000, exploring the
trend of suicide rates among adolescents and
young adults in the United States, it was found
out that adolescents 15 to 19 years old had a
suicide rate of 8 per 100 000, with no change in
trend from 2000 to 2007. However, an
increasing trend from 2007 to 2014 was noted
with an annual percentage change (APC) of 3.1%
followed by a steep uptrend from 2014 to 2017,
with an APC of 10.0%. (3) The father of child and
adolescent psychiatry in the Philippines, Dr.
Cornelio Banaag has sounded the alarm that
young Filipinos are in the midst of a mental
health crisis. (4)
It is projected by the Philippine Statistics
Authority that adolescents (10-19) will comprise
19% of the Philippines by year 2020. (5)
Adolescents can be vulnerable since they are in
one of the most rapid and formative phases of
human development with distinct physical,
cognitive, social, emotional and sexual
development, simultaneously occurring during
this phase, it is also characterized by a widening
gap between biological maturity and social
transition to adulthood accompanied by an
emerging need for autonomy yet still requiring
adult supervision and guidance. (6)
In Erik Erikson’s Eight Stages of Psychosocial
Development he states that adolescents had the
task of Identity vs Role Confusion. This is the
stage wherein a sense of self is developed by
testing roles then integrating these roles to form
a sense of identity. Social and environmental
factors also play a role, such as bullying,
impaired parent-child relationship, living outside
of the home, getting out of school, social
isolation, romantic difficulties. (6) Therefore,
adolescence can also be accompanied by an
increased incidence of depression and suicidal
behavior. (7)
In light of the increased risk and trend of suicide
among adolescents (8) this study aimed to
determine the prevalence and severity of
suicidal ideations and behaviors among senior
high school students using the Columbia-Suicide
Severity Rating Scale (C-SSRS) in San Juan
National High School, in San Juan, Metro Manila.
METHODOLOGY
Study Design
This is a descriptive cross-sectional school-
based study, conducted on 236 senior high
school students, 18 to 20 years old, in San Juan
National High School (SJNHS) in San Juan, Metro
Manila. Permission to conduct the research in
SJNHS was granted by the Assistant Schools
Division Superintendent.
Sampling
The study employed convenience sampling,
recruiting 236 participants from San Juan
National High School (SJNHS) in San Juan in
Metro Manila, who fulfilled the inclusion and
exclusion criteria of the study as follows:
Inclusion criteria: Subjects aged 18 to 20 years
enrolled in senior high school in a public
secondary school in San Juan, Metro Manila,
who expressed willingness and gave consent to
participate in the study.
Exclusion criteria: Inability to understand English
or Filipino; students with diagnoses of
intellectual disability, previously diagnosed with
a psychiatric condition or any condition that
would preclude a participant from answering the
questionnaire.
The minimum required sample size was 216
based on the 17% prevalence of suicidal
ideations in the youth (9), a level of confidence
of 95% and a margin of error of 5%.
Instrument
Permission was obtained from the Columbia
Lighthouse Project to use the Columbia Suicide
Severity Rating Scale (C-SSRS) Tagalog version.
The translation and linguistic validation to
Tagalog was carried out by Fernandez et al. (10)
Training in the use of the C-SSRS was done by
watching a prerecorded 20 -minute educational
course offered by the Columbia Lighthouse
34 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
Project. A certificate of learning was obtained.
The CSSRS was designed to provide definitions
of suicidal ideation and behavior and non-
suicidal self-injurious behavior and
corresponding probes; to quantify the full
spectrum of suicidal ideation and suicidal
behavior and gauge their severity over specified
periods. The CSSRS also distinguished suicidal
behavior and non-suicidal self-injurious
behavior. (11)
The C-SSRS dwells on the four constructs of
suicide. The first is on severity, rated on a 5-
point ordinal scale wherein 1 = wish to be dead, 2
= non-specific active suicidal thoughts, 3 =
suicidal thoughts with methods, 4 = suicidal
intent, and 5 = suicidal intent with plan. Second
construct is on intensity, which has 5 items that
are each rated on a 5- point ordinal scale:
frequency, duration, controllability, deterrents
and reason for ideation. The third is on behavior,
rated on a nominal subscale: actual, aborted,
interrupted, preparatory behavior and non-
suicidal injurious behavior. The fourth is the
lethality subscale, which assesses actual
attempts; actual lethality rated on a 6-point
ordinal scale, and if actual lethality is zero,
potential lethality is rated on a 3-point ordinal
scale. The assessment of lethality is done by the
assessor. (11)
As for the validity and reliability, in a study by
Posner et al (11), the internal consistency of the
intensity subscale was high, with a Cronbach’s
alpha of 0.937 for the last visit and 0.946 for the
past week. In the C-SSRS compilation of
supporting evidence, a study of the
psychometric properties of the CSSRS (12), the
inter-rater reliability for the most severe
ideation scores in the last month and lifetime
were good (Lifetime Cohen’s kappa at 0.91 and
recent Cohen’s kappa at 0.76). (13)
Data Collection
Due to the large sample size needed for senior
high school students, and the proximity of
SJNHS, it was chosen to be the school where the
study was conducted. The setting for
administering the questionnaires was in their
classrooms during their vacant periods in the
afternoon. Students who were present in certain
classrooms were chosen as participants, and
once with their consent, they were given a brief
backgrounder on what the study was and what it
aimed to find out.
35 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
They were given instructions on how to answer
the C-SSRS. Participants were then screened
using the inclusion and exclusion criteria cited
above. Upon selection, consent from the
participants was obtained for the study.
Thereafter, the researcher administered the
CSRSS to the students with advanced
coordination with the principal and teachers of
SJNHS. A room for the one -on- one data
collection was provided and the administration
took only about 3 – 5 minutes per subject.
Demographic information: such as age, sex, and
educational attainment were obtained. Names
and Contact details were taken for appropriate
referral to the OPD telepsychiatry service for
those who scored high on the severity of suicide
risk.
Statistical Analysis
Suicidal ideation was separated into a 5 -point
ordinal severity scale in which 1=wish to be
dead, 2=nonspecific active suicidal thoughts,
3=suicidal thoughts with methods, 4=suicidal
intent, and 5=suicidal intent with plan. Previous
studies predicting suicide attempts showed that
severity increased relative to method, intent,
and plan, respectively. (11) For the intensity of
suicidal ideation, a 5 -point ordinal severity scale
was used. The suicide risk was greater when
thoughts were more frequent, of longer
duration, less controllable, fewer deterrents and
if stopping the pain was the reason. (14)
For suicidal behaviors, interrupted attempts,
aborted attempts and preparatory behavior
were equally predictive of an attempt, and those
with multiple behaviors had greater risk. Non-
suicidal self -injury was associated with suicidal
thoughts that also increased the risk for suicide.
(15) For the lethality, suicidal intent correlated
highly with medical lethality when the attempter
had sufficient knowledge to assess properly the
probable outcome of his/her attempt.
Descriptive measures such as frequencies and
proportions were applied for all the data
obtained in the research.
This study was limited since it was administered
in only one national high school, hence no
generalizations were made on the findings of this
study. The study was also limited by the age
group since most of the participants were
mostly in their late adolescence.
Ethical Considerations
The study protocol was reviewed and approved
by the Research Institute of Health Science
(RIHS) Ethics Review Committee of the
University of the East – Ramon Magsaysay
Memorial Medical Center Inc. (UERMMCI) in
Quezon City.
Informed consent was obtained for all
participants to be included in this study. They
were allowed to withdraw from the study at any
point in time if they preferred to do so. A brief
background and explanation of the purpose of
the study was done to ensure that they were
able to understand the objectives of the
research. The risk and benefits of participation
were also explained. The researcher had no
conflict of interest in conducting this study.
The participants of this study were assured of
anonymity in accordance with the Data Privacy
Act provisions. (16) Their personal and interview
data were kept in a private safe in the office of
the researcher and only the researcher could
gain access to their data for further analysis. The
researcher also considered the stigma attached
to mental health conditions and the impact it
could have in the community thus the data
privacy of the participants were safely guarded.
The duration of the participants involvement in
the study lasted up until the CSSRS had been
administered and the informed consent duly
signed, this lasted about 3-5 minutes.
Follow up assessment of suicide severity was
done using the CSSRS.
There were no monetary costs in participating in
this study. Likewise, no monetary nor material
benefits were gained in participating. The only
benefit that the participants received was to get
an earlier referral to a psychiatrist if they had
suicidal ideations or behaviors. The findings
from this study will be shared with SJNHS.
RESULTS
A total of 236 senior high school students
grade11 and 12, aged 18-19 years old consented
to participate and were administered the
Columbia Suicide Severity Rating Scale. The
majority were 18 -year -olds but grade level and
sex were more or less evenly distributed. (Table
1)
Seventy -four patients out of 236 (31.36%)
wished to be dead but an even higher number of
respondents at 86 (36.44%) answered that they
had had non-specific active suicidal ideation i.e.
they had thoughts of wanting to end their life
but had not thought of a specific plan yet. For
this part of the questionnaire, the structure of
the CSSRS gives the patients a chance to answer
numbers 3,4 and 5 only if they answer question 1
and 2 with yes; respondents may have multiple
responses. (Table 2)

Possible risks that may be experienced while

undergoing this research may include a
recollection of stressors that led to the subject
having suicidal ideations. Should a patient be
noted to have severe suicidality in terms of
ideations and behaviors, he/she was referred to
the Telepsychiatry Outpatient Department
(OPD) for further assessment and management.
It was also explained that there would be a
corresponding fee of 150 PhP for an online OPD
consult. No actively distressed participants were
encountered during the administration of the
survey. Participants who had mild distress due
to remembering their previous suicidal attempts
were asked to do deep breathing exercises and
their expressed feelings and emotions were
supported, acknowledged and validated. The
option of going through further consult was also
given.

36 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

Those who answered yes to 1 or 2 or 3, 4 and 5
questions in the suicidal ideations get to answer
the intensity of suicidal ideations subscale that
follows. Due to these multiple options of
answering provided by the CSSRS, the intensity
subscale as well as the other subscales may not
show a consistent tally with the total number of
236 respondents. (Table 3)

There were 109 who admitted to having suicidal

ideation. For the intensity of suicidal ideation,
responses on the subscale of frequency of
suicidal ideations, 44 respondents (18.64%) had
suicidal thoughts once a week and 40 (16.95%)
had suicidal thoughts less than once a week. In
the duration subscale, 47 (19.92%) noted they
had fleeting thoughts of suicide, lasting a few
seconds or minutes and 26 (11.02%) said that the
suicidal thoughts lasted less than an hour. On
the controllability subscale, majority at 44
(18.64%) said they were easily able to control
thoughts, 33 (13.98%) said they were able to
control their thoughts with little difficulty. For
the deterrents, i.e. anyone or anything that has
stopped the respondent from wanting to die or
carrying out the suicidal thoughts, 63 or 26.69%
said that deterrents definitely stopped them
from committing suicide. When it came to the
reasons for the suicidal ideation, there was a
similar proportion of those who said they were
merely trying to get attention, revenge or a
reaction from others (25 or 10.59%), and those
who answered that it was to end or stop the pain
26 (11.01%). The mean scores are displayed to
show the average of the group responses. (Table
3)

For the suicidal behaviors, the more common

description was that their suicidal attempt was
aborted (19.07%) i.e. they had planned to carry
out the suicidal act, but stopped it themselves;
while 16.53% had their attempts interrupted.
Interrupted suicide attempts occur when
individuals initiate action to end their lives but
are stopped by someone or something external
to the individual before actually carrying out the
act. Aborted suicide attempts occur when
individuals start to do something to try to end
their lives but stop themselves before actually
harming themselves. The average number of
attempts for the 36 respondents was 2 but with
a range of 1-3 times. Those who did manifest
suicidal behaviors could have several types and
thus account for the multiple responses. (11)
(Table 4)

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For the suicidal behaviors, the more common
description was that their suicidal attempt was
aborted (19.07%) i.e. they had planned to carry
out the suicidal act, but stopped it themselves;
while 16.53% had their attempts interrupted.
Interrupted suicide attempts occur when
individuals initiate action to end their lives but
are stopped by someone or something external
to the individual before actually carrying out the
act. Aborted suicide attempts occur when
individuals start to do something to try to end
their lives but stop themselves before actually
harming themselves. The average number of
attempts for the 36 respondents was 2 but with
a range of 1-3 times. Those who did manifest
suicidal behaviors could have several types and
thus account for the multiple responses. (11)
(Table 4)
Of the 36 respondents who said they had actual
suicide attempts, 18 respondents reported
suffering only minor physical injury. Minor
physical injury was defined as having sustained
injury to the body but not needing medical
attention. (Table 5)
DISCUSSION
Suicidal Ideation
In this study the prevalence of suicidal ideation
severity was at 36.44%, which was described as
nonspecific active suicidal thoughts.
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This was higher compared to the 17% suicidal
ideation prevalence rate taken from the Youth
Risk Behavior Survey (YRBS). (9) The YRBS was
administered yearly by the Centers for Disease
Control and Prevention’s (CDC) Division of
Adolescent and School Health (DASH), which
routinely monitored adolescent health
behaviors and experiences; and collaborates
with education agencies in the United States to
provide the most recent surveillance data on
health behaviors and experiences among high
school students across the country, among
these are mental health and suicide.
The prevalence of suicidal ideation was also in
stark contrast to local data on suicidal ideation
as collected in the 2013 Young Adult Fertility
and Sexuality Survey 4 (YAFS 4). (17) The YAFS 4
is a series of surveys about young adults aged 15
to 24, which tracked some core indicators of
youth status, well-being, risk and non-risk
behaviors and other outcomes and the
determinants of such outcomes. The YAFS 4
survey put the national prevalence of suicidal
ideation at 8.7%. The large disparity of this
research’s results with that of other surveys may
be due to the fact that the C-SSRS referred to a
whole life time, while the YRBS only asked about
the past 12 months and the YAFS 4 was unclear
regarding its time frame.
On the other hand, this relatively high
prevalence of suicidal ideation was consistent
with a study by Estrada et al (18), wherein they
used the CSSRS to document suicidal ideation
and behaviors among adolescent learners
enrolled in the Alternative Learning System
(ALS) in Manila, Philippines. They showed that
the lifetime prevalence of suicidal ideation – the
wish to be dead and non-specific active suicidal
thoughts were at 40.4% and 40.9% respectively,
which were approximated the numbers in this
study. The high prevalence of suicidal ideation,
using the CSSRS may be heralding an upward
trend in suicidal ideation, yet may be overlooked
and undetected due to lack of a standardized
method of inquiring regarding suicide.
This high prevalence rate may reflect the higher
suicide attempts among adolescents and young
adults. It may also be indicative of changing
sociocultural attitudes towards suicide i.e. that
the government has mandated a National
Suicide Prevention Strategy of the Department
of Health in partnership with the WHO. (19)
This includes a multisectoral approach to mental
health that has set up programs and
interventions in schools.
Usage of social media has become a primary
forum for interpersonal engagement among
teens, which is a period when social contact is
important in maintaining their well-being but at
the same time may have a negative influence
when exposed to other cultures and suicidality.
Another key feature of social media is the
amount of time adolescents spend engaged with
it and the fact that it makes social contact
available almost without limits. (20)
The rise in suicide rages parallels the rise of
social media usage. The percentage of American
adults who used social media increased from 5%
in 2005 to 79% in 2019. (21) This steep rise in
social media use is fairly recent and may have
just been unfolding when the YAFS 4 was
conducted in 2013. (17) Thus, this increased
prevalence may be heralding an uptrend in
suicidal ideation and behaviors in adolescents.
The other items (Items 3, 4 and 5) on the severity
ordinal scale of suicidal ideations highlight the
importance of asking not just about ideation, but
also about ideation relative to method, intent
and plan. These need to be asked for these other
items were based on previous studies predicting
suicide attempts. Asking about these other items
could also be important in reducing access to
means, an area of strategic action proposed by
the WHO for suicide prevention. (19)
Intensity of Ideation
The intensity of ideation subscale, comprises 5
items, each rated on a 5-point ordinal scale:
frequency, duration, controllability, deterrents,
and reason for ideation. The intensity subscale
scores were significant predictors of suicide
attempts at return psychiatric emergency (PE)
visits across the 1-year study period for
predictors of suicide attempts among ado-
lescents in psychiatric emergency (PE) settings
in a study by Gipson et al (22). These five
variables examined independently resulted in
the duration item being the only significant in-
dependent predictor of return PE visits or
suicide attempts at return visit. For this
research, the mean duration score was at 2.12
(<1 hr/day) compared to 2.32 for the study by
Gipson et al (22).
39 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
For the frequency subscale, the mean score was
2 (once a week). In this light, a promising
development has turned up with Chang et al.
(23) who developed a Frequency of Suicidal
Ideation Inventory (FSII). Frequency of suicidal
thoughts in participants over the past year were
measured using a 5-point Likert-type scale,
ranging from 1 (never) to 5 (almost every day).
Higher scores on the FSII were indicative of
greater suicidal ideation (SI) frequency. This
could be used in future studies wherein a
reliable and validated tool for measuring the
impact of the frequency of suicidal ideations
may be required.
For the deterrents subscale, 26.69% answered
that deterrents definitely stopped them. This
relatively high rate of suicide attempts that have
been deterred, highlights that suicide risk is
often short term and situation specific, and
therefore preventable. The examples of
deterrents listed in the CSSRS were family, fear
of pain and religion, which could be expected
considering the Philippines is a predominantly
Catholic or Christian nation.
In a recent review by Lawrence et al (24), they
found that many studies indicated that religious
affiliation was protective against suicide
attempts and suicide, but not suicidal ideation.
Torgler and Schaltegger found that in the 20-
year period (1981–2001) in Switzerland, a strong
negative correlation between Catholicism and
the number of suicides per capita was noted.
(25)
In terms of sex, 58 (68%) of those who had
suicidal ideations in this study were females.
Thus, the role of gender may also play a role in
the higher prevalence of suicidal ideations, as
demonstrated by Lie et al. who showed that
Female Filipino junior high school students
showed higher suicidal ideations. (26)
Suicidal Behaviors
A history of suicide attempts was regarded as
one of the strongest predictors of future suicide
according to Suominen et al. (27) This study’s
prevalence rate of 15.25% was similar compared
to the local study using the CSSRS by Estrada et
al. (18), which showed that the prevalence of
suicide attempts was12.9% but was higher when
compared with the YRBS, which found that the
prevalence of suicide attempts was 7.4% (9) and
that of the YAFS 4 local data that reported a
prevalence of 3.2%. (17)
The stark difference in rates of the C-SSRS vis a
vis the YRBS and YAFS 4 may be due to a more
elaborated, and specified way of asking about
suicide attempt. An actual attempt was defined
in the CSSRS to be a potentially self-injurious act
committed with at least some wish to die, as a
result of the act. Behavior was in part thought of
as method to kill oneself. Intent does not have to
be 100%. If there is any intent/desire to die
associated with the act, then it can be
considered an actual suicide attempt. There
does not have to be any injury or harm, just the
potential for injury or harm. For example, if
person pulls the trigger while a gun is in his/ her
mouth but the gun broke without any resulting
injury, this would be considered an attempt.
The prevalence of Non-Suicidal Self Injury (NSSI)
was 15.68% was relatively lower compared to
the 20% prevalence of NSSI described by
Masana et al. in their local study with college
students examining the relationship of adverse
childhood experiences, NSSI and pathological
personality traits. (28)
In a study by Cyzy et al (29), NSSI was noted to
be a means of coping with suicidal thoughts and
considered to be a particularly high-risk group in
need of more intensive support.
The proportion of interrupted (16.53%) and
aborted suicide attempts (19.07%) of this study
were surprisingly higher than the actual suicide
attempts (15.25%). Compared to the findings
with Estrada et al., they found the prevalence of
interrupted attempts to be at 6.4% and for
aborted attempts to be at 16.4%. (18)
Examining the associations between interrupted,
aborted, and actual suicide attempts among
adolescent inpatients, Burke et al (30), found
that both interrupted attempts and aborted
attempts were significantly associated with the
frequency of actual attempts after co-varying
for suicidal ideation and demographic
characteristics. These results suggested that a
failure to integrate interrupted and aborted
attempts into suicide risk assessments may
result in underestimating adolescent suicide risk.
Twelve (5.08%) of the 236 respondents had
preparatory behavior. In a study by Mundt et al
(31) wherein C-SSRS was administered to
depressed subjects, interrupted attempts,
aborted attempts and preparatory behavior
40 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
were equally predictive of actual attempts, and
those with multiple behaviors had greater risk.
In a retrospective study by Mckean et al wherein
they reviewed first suicide attempt outcomes.
They found that despite composing only 31.7%
of the cohort, male subjects composed most
completed suicides. (32)
CONCLUSION AND RECOMMENDATIONS
For the respondents of this particular National
High School, about one third (36.44%) had non -
specific suicidal ideations and only 13.98% had
active suicidal ideas with intent to carry out a
suicidal plan coupled with 15.25% of actual
suicide attempts; both of which are higher than
international data. The severity of the ideations
and behavior on the other hand were not as
alarming since majority of the ideations were low
in frequency and duration while high in
controllability. The suicidal behaviors on the
other hand mostly resulted in minor physical
injury. In light of these relatively high prevalence
rates, school-wide intervention on education or
awareness programs, gatekeeper training, peer
leadership, skills training and screening or
assessment should be instituted to curb the
suicide risk of senior high school students.
In a systematic review by Surgenor et al (33),
they identified key issues with the said school-
wide interventions. In this light, they had ten
recommendations, which would also be the
recommendations for this school and other
schools in the Philippines: 1) employ longer term
strategies; 2) be aware of contextual factors, in
which suicide prevention programs are
delivered; 3) clearly define learning outcomes
when it comes to suicide prevention programs;
4) start with a preparatory phase; 5) create a
flexible design and delivery, 6) tap external
expert facilitators instead of staff; 8) Not to be
restrictive; 9) Not to overemphasize risk factors;
10) implement a varied, interactive and engaging
manner of delivery; and lastly 10) re-evaluate
programs regularly.
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 PJP CASE REPORT

EXAMINATION OF THE RIGHT TO CONFIDENTIALITY

NINA KRISTY A. OSORIO-GRAPILON, MD, DSBPP

ABSTRACT

With the establishment of the Republic Act No. 11036, more popularly known as the
Mental Health Act, improvement in the mental, neurologic, and psychosocial health took a
step forward in the Philippines. This law, which was signed on June 2018, gave specific
provisions in different aspects of delivery of mental health services to Filipinos. This law
proved very useful in the dilemma faced in the following case where a potential problem
in confidentiality was encountered.

CASE PRESENTATION
Chief Complaint
N.O. is a 15-year-old, Filipino Catholic
adolescent female, an only child of her parents’
union but the youngest among 4 children on her
father’s side and the youngest of 10 children on
her mother’s side, presently residing with her
parents. N.O. was brought for consult by her
mother due to persistent headaches and
difficulty in sleeping.
History of Present Illness
Two years prior to consult, when N.O. was 12
years old, she was allegedly raped by her 22-
year-old neighbor. They were chatting online for
a few weeks until she was invited over to his
house because he said he would give her a
surprise gift. Intrigued, she sneaked out one
night and went over to her neighbor’s house. She
was led inside his room, forced to lie down on
the bed, disrobed, and was under the control of
her neighbor. During that time, the patient felt
helpless and scared. She did not know what to
do and even failed to fight her neighbor. When it
was over, she was warned not to tell anybody of
the incident or else she would be harmed.
Fearing for her life, she went back to her house
without saying anything to her family. She
blamed herself. She felt alone. Since then, she
was noted to be more quiet than usual and was
easily startled, prompting her half-brother
(A.O.), who came to visit their parents several
days after the alleged incident happened, to ask
the patient what was happening to her. She con-
fided to A.O. but pleaded with him not to say or
do anything. He promised and instead, helped
her out in determining if she got pregnant by u-
sing a pregnancy test. Negative results were
noted, and the 2 siblings decided to be quiet
about it for the meantime. She went about her
usual activities. She attended her classes
without fail and consistently garnered high
grades. However, she would occasionally have
difficulty in concentrating at school. At home,
she was terrified at the possibility of encoun-
tering her neighbor. She was able to take com-
fort in the fact that she was not allowed to go
outside the house without being accompanied
by either one of her parents and so she stayed
home most of the time. She would have frequent
dreams about her neighbor and the alleged inci-
dent. She would distance herself from her half-
brother because she would remember the alle-

42 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

-ged incident. No problems were noted until a
few weeks after when she was fed up with a
classmate teasing her and so tried to choke him.
She felt it was unfair when she was reprimanded.
Despite this, N.O. was still able to maintain high
grades and was at the top of her class but later
the patient was dropped from the 1st rank of the
class due to her English subject. She felt
betrayed because she was usually the favorite in
her class. In secret, N.O. would scratch her arms
or would think of hurting herself because she
felt that she was humiliated. She attempted to
slash her wrist but was prevented by her half-
brother. She was then transferred to another
school after her parents’ unsuccessful attempts
to plead with the patient’s teacher to give her
some consideration.
N.O. was initially faring well academically in her
new school but 1 year prior to consult she
punched a classmate due to his relentless
teasing. She felt ill-used when she was
reprimanded. She was obedient and well-liked
by her teachers, but she was blamed for the
incident regardless of the teasing by her
classmate. Since then, the patient again felt that
she did not belong in her school because they
seemed afraid of her. Still, her grades were not
affected even if she would have some difficulty
in concentrating while in class.
At another time, the patient informed her
parents that she would be a little late in coming
home from school because of a school project
with her classmates. However, her parents found
out that she and her classmates went to a mall
near their school. Her parents, most especially
her father, got very mad and scolded the patient
and her classmates. She had a big fight with her
father and wanted to die because no one really
understood her, not even her father. She took 2-
3 tablets of Trimetazidine (her father’s
medication) when she was stopped by her
mother and brought to the hospital. She was
observed and was sent home with no
complications. She promised her parents that
she would not hurt herself again. She went back
to her usual activities, but was more closely
monitored by her parents. Her feelings of
loneliness and isolation persisted but she tried
to divert her feelings.
About 2 months prior to consult, she was told
hat she would be transferred to her old school
because of financial constraints.
She did not want to return but she had no
choice but to agree despite being very
apprehensive about it. With the prospect of
going back to her old school, she started to have
more frequent dreams about her alleged sexual
assault 2 years ago, though unable to recall
some parts of the alleged incident. During this
time, N.O. would see her parents frequently
fighting about their financial problems. She
feared that they would separate and leave her.
Since then, the patient was noted to be easily
irritated and quieter. She would scratch her
forearms to relieve stress and release her
tension. She would occasionally think of what it
was like to die but at the same time was afraid
to try killing herself.
One month prior to consult, N.O.’s father
underwent a major surgery. She was very
worried about her father as they were very
close. She felt guilty that she burdened him with
her problems. She started thinking about what
happened to her 2 years prior. Her dreams
about the alleged incident became more
frequent. She wanted to tell her father but she
was too afraid of his reaction. She felt ashamed
and guilty of not having told her father of what
happened. N.O. started to have frequent
headaches and difficulty in sleeping. She had
difficulty concentrating. Her mother noted that
N.O. had frequent blank stares. The patient
would get distressed about feeling that she did
not belong in her family and in her community
as if she was a ghost.
Two weeks prior to consult, headaches became
more frequent and persistent, with pain scores
of 6-7/10, prompting her to seek consult in the
emergency section of the Pediatrics
department, where she was prescribed with
Mefenamic acid 500mg/tab, 1 tab every 6 hours
and Vitamin B complex 1 tab once a day. No
relief of symptoms were noted with the
medications. She was very frustrated up to the
point that she wanted to die. She was referred
to Psychiatry in the ER due to her difficulty in
sleeping. At that time, she was noted to be
depressed with congruent affect. She was
anxious and was hesitant to relate her feelings.
She denied any history of trauma or abuse.
Initial impression was Persistent Depressive
Disorder; with Borderline Personality Traits and
Suicide Risk. She was prescribed with Sertraline
50mg/tab ½ tab ODHS and Alprazolam
500mg/tab ½ tab PRN for insomnia. They were
advised to follow-up after 1 week.
43 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
Family and Social History
There were no known psychiatric illnesses in the
family. There was hypertension and heart
disease on her paternal side, while dyslipidemia
and kidney problems on her maternal side. She
was a non-smoker and never used illicit drugs.
She occasionally drank wine (1-2 times a year,
half a glass) with her last intake a year prior to
consult.
Family Genogram
Father: R.O., 68 years old
He was a retired military pilot, who eventually
worked in the real estate sector. Before he
became ill, he was involved with real estate that
occasionally entailed going abroad to work on
projects. One month prior to the patient’s
consult, he was admitted due to hemothorax
and underwent bullectomy and lobectomy.
He had 3 children from his former common-law
wife who all live in the United States, thus have
a strained relationship with R.O. With his 3
children, he was very strict and authoritarian,
especially when he was still in the military. He
was easily angered and used corporal
punishment in disciplining his children. He
separated with his common-law wife when she
went to work abroad.
He allegedly and impulsively shot a person
point-blank while the said person was drinking
with his friends immediately after discovering
that his daughter (the patient’s half-sister) was
bullied by that person. Patient’s father then
went to the police station because the person
that he killed reportedly had a cousin who was a
police officer and also shot the police officer.
44 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
The matter was smoothed over because R.O. had
money at that time, thus he was not arrested or
jailed. He met his wife, the patient’s mother,
when he was still in the military. When the
patient was born, he was observed to have
apparently changed. Athough still short-
tempered, he could be pacified by his wife.
He doted on the patient and not once did he hit
her. Lately, patient’s parents would be heard
bickering mostly about money, which would
alarm the patient, thinking that her parents
were going to separate.
Mother: D.O., 50 years old
She was a real estate agent who had a previous
common-law husband with whom she had 9
children; 2 of whom are close to the patient
(J.O. and A.O.). She separated from her first
husband due to undisclosed reasons.
She was described as talkative, frank and short-
tempered. She also allegedly stabbed a person
who attempted to pick a fight with her. Like her
husband, she doted on the patient and gave her
whatever she asked for and was the one more
easily swayed by the patient.
Half-Siblings on the Paternal side:
1. G.O., 45 years old, married and currently
living abroad. He has no relationship with the
patient and has a strained relationship with his
father.
2. J.O., 41 years old, married and currently living
abroad. She has no relationship with the patient
and also has a strained relationship with her
father.
3. S.O., 38 years old, married and currently living
abroad. She would come and visit every year,
bring gifts to the patient and allowed the patient
to have a sip of wine with her during dinner.
Half- Siblings on the Maternal side
All of the patient’s siblings with her mother are
living with their father in the province. They do
not visit their mother in Quezon City due to the
strained relationship between their father and
the patient’s mother. Only J.O. and A.O. would
come by and stay for a few days with N.O. and
her parents.
1. L.A., 29 years old, currently working in the
province. He has no relationship with the
patient.
2. R.A., 28 years old, currently working with his
brother, L.O. in the province. He has no
relationship with the patient.
3. J.A., 27 years old, employed in Quezon City,
currently living in an apartment. He would
sometimes visit his mother and half -sister for a
few days. He would play and talk with the
patient and was like one of the patient’s close
friends.
4. K.A., 26 years old, working in the province. He
has no relationship with the patient.
5. L.A.A., 25 years old, married and lives in the
province. She has no relationship with the
patient.
6. T.A., 24 years old, working in the province. She
has no relationship with the patient.
7. A.A., 23 years old, employed in Quezon City,
currently living in an apartment. He would
occasionally visit his mother and half -sister for
a few days where he would play and talk with the
patient and also considered as one of the
patient’s close friends. Patient is closer to A.0.
as he was the first one to know of her alleged
rape 2 years ago.
8. F.A., 22 years old, currently working in the
province. He has no relationship with the
patient.
9. W.A., 21 years old, working in the province.
She has no relationship with the patient.
Developmental & Social History
N.O. was born term and without complications
to her then 35 -year-old G10P9 (9009) mother
via Normal Spontaneous Delivery at a private
hospital. Her mother had regular prenatal
check-ups. She took Ferrous Sulfate during the
2nd trimester of pregnancy. The pregnancy was
planned and wanted. Mother’s emotional and
physical states were unremarkable, with no
history of trauma, substance abuse, and intake
of teratogenic drugs. She reported bleeding
during the 3rd trimester of pregnancy which
turned out to be due to placenta previa, which
resolved eventually. No other complications
were noted throughout pregnancy. N.O. was
immediately mixed fed with breastmilk and
formula milk until 3 months because of
decreased maternal milk output. She was fed
immediately as per demand. No eating
problems were noted. The mother was the
primary caregiver. Developmental milestones
were noted to be at par with her age. She was
attached to her mother and would cry when
another person would carry her away from her
mother. However, she would calm down after a
few minutes and would respond happily to the
person carrying her.
Moderately strict toilet training was enforced
by the father, who would wake her up at night to
go to the toilet. Accidents were dealt with
verbal reprimands by the father most of the
time and embraces and kisses from the mother
whenever she would pee accidentally. Toys
were bought almost always. She would throw a
fit when her wants were not met, and she would
calm down with the reassurances of her
parents. She was shy towards neighbors but
active at home. She often played alone or with
her half-brothers, because her parents did not
allow her to play outside.
The first memory of N.O. was when she was 5 -
years-old happily eating together with her
parents. She was enrolled in a preparatory class
near her home. She was an active and smart
child, and got along with her peers. On the 1st
day of 1st grade, she was anxious to be left
alone by her mother that she had to be
reassured of mother returning after class. She
was a top student during her grade school and
45 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
was tutored by both parents who encouraged
her to get high grades. Many of her classmates
were her friends but was not open to share her
feelings with them. Her activities were limited to
school and home because her parents did not
want her to play outside the house.
At home, she would play with 2 of her half-
brothers. The rest of her siblings were away and
had little to no interaction with her. She would
ask about them, but she would be told not to
mind them because she was their priority.
Discipline was enforced by both parents, but lax.
The father was firmer in his decisions with
regards to the patient. However, both would
waver and give in to the patient most of the
time. She transferred to another school after
finishing Grade 7 then returned for Grade 9. She
was more at ease in her 2nd school but she was
transferred back due to financial constraints.
She was more of a follower than a leader. N.O.
was one of her teachers’ favorites thus often
given special errands. She was not allowed to go
out on her own with her friends and needed
supervision by her parents. She spent most of
her time at home, watching Korean movies or
television series and spending time with her
family. She liked to apply make-up and dress up.
Past Medical and Psychiatric History
There was no history of psychiatric
consultations or hospitalizations. She was
admitted twice for Dengue Fever and once for
Urinary Tract Infection with no complications
noted. She had an early menarche at 10, like her
mother. Menstruation was irregular, consuming
2-3 pads/day, moderately-soaked, 3-4 days
duration. She was nulligravid but with 1st sexual
contact at 12 years old. No contraception was
used.
Mental Status Examination
She was seen and examined as an adolescent
female, medium built, dressed older for her age
with tight-fitting top and leggings, and with
slightly heavy make-up; fairly kempt and
groomed. No behavioral oddities were noted,
with fair eye contact. She was cooperative and
fairly conversant. Mood was depressed, with
appropriate affect. She had normo-productive
speech, slightly slow rate and decreased tone of
voice. She related that she was hearing buzzing
sounds beside her ears. She admitted to feeling
depressed but related that the difference this
time was that she will get the help she needed.
She denied suicidal or homicidal ideations.
Responses were linear and goal-directed. She
was oriented to 3 spheres, with intact memory;
good concentration, calculation, fund of
knowledge, abstract thinking, impulse control,
and judgement. Insight level was III. She believed
that she needed help because of what happened
to her in the past.
Physical and Neurologic Examinations
Both physical and neurologic examinations
revealed unremarkable findings.
Diagnosis & Differential Diagnoses
Diagnostic work-up was done to rule out a
DEPRESSIVE DISORDER DUE TO ANOTHER
MEDICAL CONDITION [293.83 (F06.31)], given
that a general medical condition could cause
behavioral changes must always be considered.
The patient’s symptomatology was able to fulfill
Criteria A, D, E of the disorder: i.e. there was a
prominent and persistent depressed mood
(Criteria A); that the disturbance did not occur
exclusively during the course of the delirium
(Criteria D) as there was no report of
fluctuations of attention and consciousness; and
the disturbance caused clinically significant
distress and impairment in her social functioning
(Criteria E). However, she was not able to fulfill
Criteria B and C i.e. there was no evidence that
the disturbance was the direct
pathophysiological consequence of another
medical condition (Criteria B), as all laboratory
work-ups done upon initial encounter were
normal and she was cleared medically by the
Pediatrics Department. Thyroid function tests
were also done in her OPD consult, with normal
results. In addition, EEG was done with
unremarkable results. And for criteria C i.e. The
disturbance could be explained by another
mental disorder; thus this diagnosis was ruled
out.
Thorough review of the patient’s substance or
drug use history was done, as well as a spot
urine drug test, to rule out a
SUBSTANCE-/MEDICATION-INDUCED
DEPRESSIVE DISORDER [292.84 (F19.94)]. The
patient belonged to an age-group with high
potential for illicit drug use. The patient fulfilled
Criteria A, D, and E. There was a prominent and
46 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
persistent depressed mood (Criteria A). The
disturbance did not occur exclusively during the
course of the delirium (Criteria D). The
disturbance caused clinically significant distress
to the patient and impairment in her social
functioning (Criteria E). However, she was not
able to fulfill Criteria B and C i.e., there was no
evidence that the symptoms developed during
or soon after exposure to a drug (Criteria B), as
urine drug test was done with negative results.
No other medications were taken by the patient
that could possibly produce her symptoms and
the disturbance could be explained by another
mental disorder (Criteria C); thus, this condition
was also ruled out.
Despite the depressive symptoms noted from
the history, the patient was unable to fulfill
Criterion A for MAJOR DEPRESSIVE DISORDER
[296.24 (F32.3)]. She was only able to fulfill 4 out
of the 9 symptoms: depressed mood, insomnia,
diminished ability to think or concentration, and
recurrent thoughts of death. Still, depressive
symptoms could not be overlooked. A
PERSISTENT DEPRESSIVE DISORDER
(Dysthymia) [300.4 (F34.1)] was also initially
considered but ruled out. Despite the symptoms
of the patient, these were not apparent to have
occurred for more days than not, as specified in
Criterion A of the disorder. In any patient
presenting with depression, it is important to
probe for possible manic or hypomanic episodes
(BIPOLAR I OR II DISORDER [296.40 (F31.9] /
296.89 [F31.81)]) in the past. In the case of the
patient, no manic episode was noted.
First follow-up revealed hallucinatory behavior
and a history of trauma. A trauma-related
disorder was then considered. With the exposure
of the patient to a traumatic event, as well the
pattern of the patient upon longitudinal review
of her history, a diagnosis of POST-TRAUMATIC
STRESS DISORDER [309.81 (F43.10)] was highly
considered and eventually made. The patient
had a 2-month long history of intrusive symp-
toms (Criterion B), specifically recurrent distres-
sing dreams about her attack, as well as intense
psychological distress upon exposure to
external cues reminiscent of her attack. She was
also able to fulfill Criterion C in which she would
avoid ex-ternal reminders of her attack. Criterion
D was also fulfilled. She had dissociative
amnesia as well as feelings of detachment and
estrangement from others. Criterion E was also
47 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
fulfilled. She had irritable behavior and angry
outbursts at school and she also had problems
with concentration and sleep disturbances. Her
recurrent experiences of unreality of her
surroundings necessitated the specifier of
dissociative symptoms. This was ruled in.
BORDERLINE PERSONALITY TRAITS were also
highly considered. Unstable sense of self,
parasuicidal behavior, feelings of emptiness,
episodes of physical violence, dissociative
symptoms were noted. Although the patient
presented with these manifestations, she could
not yet be diagnosed with a personality disorder
because these traits were not yet inflexible as
required in the diagnosis of personality disorder
1. Despite this, it is important to be aware and to
take noted of this because the stability of the
personality traits needs to be assessed over
time and across different situations. Borderline
personality traits have been shown to develop
to borderline personality disorder in time 2,3.
Course in the Clinic
N.O. revealed her alleged sexual assault on the
1st follow-up. She was started on Olanzapine
5mg/day due to disturbed and hallucinatory
behavior. Dissociative amnesia was noted. She
related her desire to tell her father, but her
mother refused out of fear that he would kill the
perpetrator. Subsequent follow-ups showed
fluctuations between improvement and
disturbed behavior, warranting increase in doses
of Sertraline to 50mg/day and Olanzapine to
10mg/day. Improvement in symptoms were
noted and Cognitive Behavior Therapy (CBT) was
initiated with promising results. Olanzapine was
discontinued in her last follow-up, with
preparations for the patient to return to school.
DISCUSSION
Psychodynamic Formulation
Absence of delayed gratification is a common
theme throughout the N.O.’s life as all her wants
and needs were readily given by her parents. In
addition, she was not exposed to relationships
outside the family. Her parents both had prob-
lems in controlling their anger, thus were poor
role models on handling emotions. This lack of
“practice” for social interaction could be the
reason for her apparent lack of close rela-
tionships. She did not know how to act or ad-just
accordingly, leading to feelings of being bullied.
-Ultimately, when the time came that the family
became financially challenged, she was unable
accept or cope with the need to be deprived of
her material wishes or frustrated of her
demands. These restrictions were internalized
by N.O. as a negative experience and became
angry at her parents for not giving her what she
wanted.
Aggressive feelings led to conflicting and
confusing feelings within N.O. There was a clash
between opposing pairs of internal object
relations, that is, between having a good parent
or having a bad parent. Prior to this, her alleged
sexual assault took a toll on her. She blamed
herself for what happened because she was the
one who decided to sneak off to her neighbor’
house. She was raped and humiliated. She was
overpowered. She had no control of the
situation. This humiliation might have devalued
the patient as an individual, resulting to loss of
self-esteem and self-worth. She might have been
pushed over the edge when her father got sick
since she had to take care of him. N.O. noticed
how her father was transformed from being very
functional and even aggressive to being weak
and useless. Having introjected her father also,
this loss of function and purpose reverberated
within her. She was both angry and sad that her
father was now helpless (loss of the father image
as a constant pillar of strength and provision)
while she now had to be burdened with taking
care of him and giving up material benefits and
her preferred school. Unconsciously, she may
have also blamed herself for his condition. The
guilt feelings that were with her for being
sexually assaulted, for being angry at her
parents because of their financial problems, all
led to her blaming herself. Being subjected to
the taunts of her classmates, to her perceived
unjustified low grade that cost her top rank in
class, her father’s illness and recurrent financial
troubles, reactivated that same sense of lack of
control when she was sexually assaulted. She
was helpless. The old trauma was reawakened by
her recent troubles. Dissociative defenses came
into play, trying to keep her intense and painful
affects unconscious.
However, the prominence of the traumatic
memories caused them to be maintained at a
high state of cognitive activation. These factors
led to N.O.’s memory intrusion alternating with
48 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
memory failure. Instead of working through the
painful memories, N.O. somatized her affects i.e.
headaches, difficulty sleeping in order to avoid
the powerful emotions, which were viewed as
threats to her. That lack of control led to
dissociation, which represented N.O.’s failure to
integrate aspects of her perception, memory,
identity, and consciousness. It gave her a sense
or illusion of psychological control.
Management
Biological: The possibility of admission was
discussed with the mother if the patient’s
behavior would escalate at home. She was
thoroughly informed, and her decision was to
keep a close watch on the patient instead. The
patient was maintained on the following: (1)
Sertraline 50mg/tab 1 tablet ODHS-
Antidepressants have been used as adjuncts to
psychosocial treatments and Sertraline is
approved by the FDA 4,5 in the treatment of
PTSD in adults, but with scant evidence to
support the use in the youth. Still, several
studies 6,7,8 would show that SSRIs have
moderate effects in PTSD. (2) Olanzapine
5mg/tab 1 tablet ODHS. An antipsychotic was
given and eventually discontinued to address
the hallucinatory behavior of the patient as
reported in the course of her follow-ups. (3)
Alprazolam 500mcg/tab 1 tablet as needed for
anxiety and difficulty sleeping.
Psychological: Cognitive Behavioral Therapy i.e.
psychoeducation was conducted for the parents
and the patient. Knowing the low frustration
tolerance of the patient, parents were guided on
their parenting skills, e.g. on when to say no to
the patient, not giving in to demands and wants
all the time. The patient was encouraged to do
relaxation techniques, and to identify her
feelings and talk about it.
Social: Safety of the patient was the most
important consideration. Given that the alleged
perpetrator was still living nearby, it was
discussed with the mother on how to ensure the
safety of the patient and whether patient could
live physically far from the alleged perpetrator.
However, it was not possible at the time for the
family to transfer residence. The mother made
the initiative to talk to the perpetrator and his
family, warning against any interaction with the
patient. A threat of filing a case or a police
report was discussed with the perpetrator and
his family. For the patient, the mother was
contemplating on having her on close watch by
herself or, if she could hire a nanny, to watch the
patient while she was away. Strong community
support was also discussed. The reputation of
the parents in the community could also be
harmful to the patient. Outside school, the
patient also had limited social interactions in the
community. Both issues were thoroughly
discussed, and steps were taken to start to
expose the patient to the community. Although
the patient was not able to identify any friends
in her school, she admitted that she had a few
friends before in the neighborhood and she
verbalized the desire to rekindle the
relationships.
Dilemma on Confidentiality
Establishing rapport could not be over-
emphasized in this case. The first encounter
proved that several meetings were needed to
fully establish the trust between a doctor and a
patient. With N.O. opening about the trauma she
experienced; it was decided that on her sub-
sequent follow-ups, a more focused and guided
approach would be utilized.
In addition to her medications, the need for N.O.
to work through her trauma was deemed of
utmost importance. And one step identified, as
volunteered by N.O., was to inform her father of
what happened. However, her mother was
against the idea out of fear that he would kill the
alleged perpetrator as well as his entire family,
given his history. The father, when hypo-
thetically asked what he would do if such
incident would happen to his daughter, admitted
that he would hunt and kill the perpetrator
without any regard for what will happen to him.
Given such a situation, what should a reasonable
psychiatrist do? We turn to the Mental Health
Act (Republic Act No. 11036) 9. In Chapter II,
Section 5 (Rights of Service Users), one of the
rights identified was: (l) “Confidentiality of all
information, communications, and records…shall
not be disclosed to third parties without the
written consent of the service user concerned or
the service user’s legal representative, except in
the following circumstances:…(3) A life-threaten-
ing emergency exists, and such disclosure is ne-
49 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
cessary to prevent harm or injury to the service
user or to other persons.” With the examination
of this provision, it was N.O.’s decision herself to
disclose the information to her father. However,
being a minor, her mother served as her legal
guardian who was against the N.O.’s wishes.
Ideally, the patient should be encouraged to
inform her father with the intent of relieving N.O.
of her guilt. Yet if the patient would tell her
father, there was a chance of assault towards
the alleged perpetrator.
Furthermore, examination of the Mental Health
Act showed that informing the father would
serve as a breach of confidentiality as specified
in Section 5l and the psychiatrist may be held
criminally liable as stated in Section 44 9:
“Penalty clause: Any person who commits any of
the following acts shall… be punished by
imprisonment… or a fine…, or both, at the
discretion of the court..”
The mother can file for a criminal case of breach
of confidentiality against the doctor, since she
specifically told the doctor not to tell the father
anything about the rape incident. Should this
happen, the burden would be for the doctor to
prove his or her own innocence in court. Given
that there is that chance of harm to the alleged
perpetrator, is it warranted to warn him? One
case comes to mind: Tarasoff v. Regents of the
University of California (1974) 10. In this case, it
was held that mental health professionals did
have a duty to protect individuals who were
being threatened with bodily harm by a patient.
However, the father was the one who made the
threat. Despite the father’s statement, the
threat was not in absolute terms. Also, the
patient’s father was not the patient. The
psychiatrist has no technical responsibility in
preventing him from enacting his threat. There is
no provision in the Act stating an explicit duty to
inform another person of a threat of harm (in
contrast to the Tarasoff case). It rather only
creates an exception to the patient’s right to
confidentiality and thus, the only obligation to
the patient’s right to confidentiality under it, was
to not violate that confidentiality. In
consideration of N.O., the need to inform the
father was examined. If the father would be
informed of the rape incident, the guilt feelings
of N.O. would possibly be unloaded.
At the same time, if the father indeed would kill
the neighbor and his family, a crime would be
committed, and the patient might suffer more
with the burden of death of several people. N.O.
ultimately has the right to inform her father or
not. The role of the psychiatrist was not to
influence or force the patient.
CONCLUSION
Physicians, in general, sometimes have the
difficult task of balancing a decision that will be
beneficial for the patient or to the family or even
the public. Now with legal implications for every
decision in a patient, the Mental Health Act will
serve as a guide for physicians in considering the
welfare of their patients and the community. In
N.O.’s case, the decision to give out or withhold
the information rests on the patient. The role of
the psychiatrist is to discuss the pros and cons
of such “telling”, providing support for the
patient and letting her decide for herself without
undue influence from the doctor.
ACKNOWLEDGEMENTS
The author thanks the 2019 consultant and
resident staff of Veterans Memorial Medical
Center for their support during the development
of this case report.
50 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders Fifth Edition. Arlington, VA:
American Psychiatric Association; 2013. 647 p.
2. Warner MB, Morey LC, Finch JF, Gunderson JG, Skodol AE,
Sanislow CA, et al. The Longitudinal Relationship of Personality
Traits and Disorders. Focus (Am Psychiatr Publ). 2005;3(3):465-
477.
3. Trull TJ, Widiger TA, Lynam DR, Costa PTJ. Borderline
Personality Disorder from the Perspective of General
Personality Functioning. Focus (Am Psychiatr Publ).
2005;3(3):453-464.
4. Henney JE. Sertraline Approved for Posttraumatic Stress
Disorder. [Abstract]. JAMA. 2000;283(5):596.
5. Schoenfeld FB, Marmar CR, Neylan TC. Current Concepts in
Pharmacotherapy for Posttraumatic Stress Disorder. Psychiatric
Services. 2004;55(5):519-531.
6. Gearson R, Rappaport N. Traumatic Stress and Posttraumatic
Stress Disorder in Youth: Recent Research Findings on Clinical
Impact, Assessment, and Treatment. J Adolesc Health.
2013;52(2):137-143.
7. American Academy of Child and Adolescent Psychiatry.
Practice Parameter for the Assessment and Treatment of
Children and Adolescents with Posttraumatic Stress Disorder. J
Am Acad Child Adoles. Psychiatiry. 2010;49(4):414-430.
8. Stamatako M, Campo JV. Psychopharmacologic Treatment of
Traumatized Youth. Opinion in Pediatrics. 2010;22(5) 599-604.
9. Public Law: Mental Health Act. Republic Act No. 11036.
(Approved June 20, 2018).
10. Supreme Court of California. Tarasoff v. Regents of
University of Californian 1974 [Internet]. Available from:
https://caselaw.findlaw.com/court/ca-supreme-
court/1829929.html
 PJP ABSTRACT

MAJOR DEPRESSIVE DISORDER AMONG PATIENTS RECEIVING

ANTIRETROVIRAL TREATMENT IN A SOCIAL HYGIENE CLINIC:
PREVALENCE, ASSOCIATED FACTORS AND EFFECTS ON QUALITY OF LIFE
LEONIDES E. BUMATAY, JR., MD, DSBPP
RODELEN PACCIAL, MD, DSBPP
JOEFFREY CRUZADA, MD, FPPA
EMMANUEL SEVILLEJA, MD

ABSTRACT

OBJECTIVES: The current study aimed to determine the prevalence of depression among
patients who received antiretroviral treatment; describe the sociodemographic and
clinical factors associated with Major Depressive Disorder; as well as compare the quality
of life among those with and without the co morbid psychiatric illness.
METHODOLOGY: A descriptive study was performed at a local hygiene clinic.
Sociodemographic and clinical data were gathered, using the Patient Health
Questionnaire 9 (PHQ-9) for screening depression and confirmed by Mental Status Exam
(MSE). Quality of life assessment was done through WHOQOL-HIV BREF questionnaire.
RESULTS: Of the 130 respondents, 31 (23.85%) subjects were assessed to have
depression. Among the different sociodemographic and clinical factors, younger age (p
value = .0174) was associated with depression. Though the quality of life of a Person Living
with HIV (PLHIV) fell in the acceptable category, those who had depression had poorer
quality of life in all subdomains especially in the psychological and social domains and
these were all highly statistically significant (p value <.0001).
CONCLUSION: The study revealed that Major Depressive Disorder (MDD) was prevalent in
almost one fourth (23.85%) of HIV patients who were mostly of a younger age i.e. less than
45 years old; with 90.32 % of the 31 noted to have MDD were less than 35 years old.
Patients with concomitant depression had a poorer quality of life not only psychologically
but in all subdomains compared to those who were not depressed.

Key Words: Depression, Antiretroviral Treatment, HIV, Person Living with HIV, Quality of
Life

51 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

 PJP ABSTRACT

DETERMINING THE PREVALENCE OF DEPRESSIVE AND ANXIETY

SYMPTOMS AMONG SELECTED PREGNANT PATIENTS IN SOME PARTS OF
LUZON DURING THE COVID-19 PANDEMIC: A CROSS- SECTIONAL STUDY
MARIE CRESANNE R. PAGADDU, M.D.

ABSTRACT

OBJECTIVES: This study explored the prevalence of depressive and anxiety symptoms
during the COVID-19 pandemic as well as the relationship between certain
sociodemographic factors these depressive and anxiety symptoms among the
participants.
METHODOLOGY: This research used a quantitative cross sectional study design. The
participants were selected through convenience and snowball sampling. They answered a
Sociodemographic Survey, Hamilton Anxiety Rating Scale and Hamilton Depression Rating
Scale. Frequency and Percentage were used to describe the sociodemographic
characteristics and to tabulate the prevalence of anxiety and depressive symptoms.
Ordinal Logistic Regression Analysis was used to determine the relationship between
certain sociodemographic factors and depressive and anxiety symptoms among the
participants.
RESULTS: Of the 212 women in this sample, 96.2% showed anxiety and 43.9% manifested
depressive symptoms during the COVID-19 Pandemic. Younger participants and those in
post- partum experienced higher levels of anxiety while those with lower educational
attainment had lower levels of anxiety as well as that of depression. Those with more
pregnancies were more likely to have higher levels of depression and those at 2nd and 3rd
Trimester of their pregnancy were less likely to develop higher levels of depression than
those during their postpartum period.
CONCLUSION: This study demonstrated that certain concerns during the pandemic
represented a significant risk factor for mental distress among pregnant women as well as
those who had just given birth. Screening of patients for possible psychiatric symptoms
and common concerns should be prioritized upon their routine ante-natal care. Support
measures must be considered for women during pregnancy or perinatal period to
safeguard this susceptible population.

KEYWORDS: Depression, Anxiety, Pregnancy, Postpartum Women, Covid 19 pandemic

52 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

 PJP ABSTRACT

RESILIENCE LEVELS AMONG FILIPINO NON-MEDICAL PERSONNEL AT A

TERTIARY GOVERNMENT HOSPITAL IN METRO MANILA DURING THE
COVID-19 PANDEMIC – JULY 2021
RAFAEL E. LEGASPI, MD,
CONSTANTINE D. DELLA, MD

ABSTRACT

OBJECTIVES: This study aimed to measure the resilience level of non-medical personnel
of the University of the Philippines Manila – Philippine General Hospital (UP-PGH) and
determine whether this was associated with sociodemographic factors such as gender,
length of service and job position.
METHODOLOGY: A cross-sectional study that included non-medical personnel using
convenience sampling via email was done. Data was obtained through the 14-item
Resilience Scale (RS-14) as well as a sociodemographic factors questionnaire. Descriptive
and non-parametric correlational analysis of data was used.
RESULTS: One hundred twenty five of the 153 respondents (81.70%) garnered a resilience
score of 74-98 or moderate to high resilience level, while 28 or 18.30% had a resilience
score corresponding to very low and on the low end. The mean resilience score was 81.8,
corresponding to a moderate resilience level. More women than men had a resilience level
of moderate to high. Respondents with greater than 5 years of work experience within the
hospital had higher resilience levels than those who were less experienced. Moderate to
high resilience levels were found in more administrative than non-administrative
personnel. No significant association was found between resilience level and the factors
analyzed. In terms of Resilience Core Characteristics, all comparisons between
demographic factors of interest and Self-reliance, Purpose, Equanimity, Perseverance and
Authenticity yielded insignificant results except for Self-reliance versus length of service,
which showed a weak but significant relationship. Exploratory factor analysis found that
the unidimensionality of the RS-14 Scale (US Version) still applied when administered to
Filipinos in this particular population.
CONCLUSION: Majority of the non- medical personnel of the UP -PGH had moderate level
of resilience. There was a lack of significant association between resilience level and
demographic characteristics like age, length of service, and position in the study sample.
In terms of Resilience Core Characteristics, comparison between length of service and
self -reliance showed a weak but significant relationship.

KEYWORDS: Resilience, Non- medical Hospital Personnel, Tertiary Government Hospital,

COVID -19 Pandemic

53 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

 PJP ABSTRACT

COMORBID SLEEP DISORDERS AMONG PATIENTS PRESENTING WITH

INSOMNIA WHO UNDERWENT
POLYSOMNOGRAPHY
APRIL FATIMA HERNANDEZ MD, FPPA, FPSSM
ROLAND DELA EVA MD, FPPS, FPAPP, FPSSM

ABSTRACT
OBJECTIVE: The aim of this study was to determine the comorbid sleep disorders on
Polysomnography (PSG) of patients complaining of insomnia symptoms.
METHODOLOGY: This is a retrospective study among patients who underwent diagnostic
and split-night polysomnography from April 2014 to February 2019. Those who had at
least one of the following insomnia symptoms of difficulty initiating sleep, difficulty
maintaining sleep and early morning awakening with or without a history of sleep aide use
were identified as patients with insomnia. Polysomnography sleep parameters and
outcome were tabulated and statistical analysis was done using SPSS v 20.0.
RESULTS: Out of the 302 patients who were included in the study, 34.4% of subjects had a
family history of sleep disorder and 70.4% had a history of sleep aide use. Among the
medical comorbidities, 47.7% of the subjects were diagnosed with hypertension while
10.65% were diagnosed with psychiatric disorder. Most of the patients complained of
both difficulty initiating sleep and early morning awakening. PSG sleep parameters
showed that patients did not experience excessive daytime sleepiness or delayed sleep
latency. On the other hand, poor sleep efficiency could be due to increased arousal index.
Half of the patients turned out to have severe obstructive sleep apnea (52%) while 2.3% of
the patients had periodic limb movement disorder. Among those diagnosed with severe
OSA, 53.3% had a history of sleep aide use.
CONCLUSION: The study showed the importance of screening patients with insomnia for
underlying comorbid sleep disorders. The American Academy of Sleep Medicine (AASM)
treatment guidelines for chronic insomnia emphasized the need to have a high index of
suspicion for this population in order to recommend diagnostic procedures such as
polysomnography. Diagnosing a patient with insomnia to have an underlying sleep apnea
and/or periodic limb movement disorder would change the course of management among
patients with chronic insomnia and eventually avoid prescribing medications that could
actually worsen the patient’s condition.

KEYWORDS: Insomnia, Sleep Disorders, Comorbidity in Sleep Problems,

Polysomnography

54 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884

 PJP
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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
57 · PJP 2023 · Volume 4 (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,
58 · PJP 2023 · Volume 4 (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.
59 · PJP 2023 · Volume 4 (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.
60 · PJP 2023 · Volume 4 (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.
61 · PJP 2023 · Volume 4 (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.
62 · PJP 2023 · Volume 4 (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
63 · PJP 2023 · Volume 4 (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.
64 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
 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,
65 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
 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,
66 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884
 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

67 · PJP 2023 · Volume 4 (2) · ISSN 2980-4884