COVID-19-related mental health challenges and opportunities perceived by mental health providers in the Philippines

This paper outlines the psychosocial impacts of the COVID-19 pandemic as reported by 145 licensed mental health providers in the Philippines in an online survey. Respondents perceived an increase in observed mental health disorders in their beneficiaries and an overall decrease in stigma associated with receiving mental health care services during the pandemic. Respondents further identified specific stigma-related help-seeking barriers during the pandemic. Positive impacts of telehealth and importance of increased public education of mental health were highlighted, with implications for improving the landscape of mental health care for Philippines post-pandemic.


Introduction
The unprecedented COVID-19 pandemic was also a mental health crisis, with rates of anxiety and depression increasing globally by 25 % during the first year (World Health Organization (WHO), 2022). Studies from Asia in early 2020 highlighted some initial mental health symptoms associated with the outbreak of COVID-19 (see Wang et al., 2020;Ahmed et al., 2020;and Zandifar and Badrfam, 2020, for examples). A systematic review and meta-analysis of mental health symptoms during the pandemic in Southeast Asia found that the prevalence of anxiety and depression in the region was 27 % in the general population (Pappa et al., 2022). In the Philippines, a country that experienced one of the world's strictest lockdowns, close to 25 % of respondents reported moderate-to-severe anxiety and 17 % reported moderate-to-severe depression and psychological impact in a study examining the prevalence of psychiatric symptoms and factors contributing to the psychological impact of COVID-19 (Tee et al., 2020).
The COVID-19 pandemic's containment and mitigation measures also created social isolation, job insecurity, and barriers to normal health and mental health care services, among other impacts that have long-term consequences on people's mental health (Narvaez, 2022). While the pandemic may be ending, its long-term consequences and remaining uncertainty are still being addressed (Tandon, 2022). Additional research is needed to fully understand the pandemic's effects on mental health as well as mental health care in Southeast Asia and to inform strategies to reduce the negative mental health outcomes of COVID-19 and future disease outbreaks. This study aimed to gather perceptions of COVID-19-related mental health challenges, and perceived barriers and facilitators to mental health care from mental health care providers in the Philippines.

Method
Data for this cross-sectional survey study were collected between February 1, 2022, and April 30, 2022, using an online self-report, English-language survey of adults who were practicing or providing mental health services in the Philippines. The survey was disseminated by the Philippines Psychiatric Association (PPA) and Psychological Association of the Philippines (PAP). Developed with local experts from PPA and PAP, the survey consisted of demographic questions, original Likert scale questions that assessed providers' perspectives of changes in mental health needs in the help-seeking population, and open-ended questions about innovations and recommendations for mental health services since COVID-19 began. The survey further assessed perceived barriers to accessing mental health care using the 30-item Barriers to Care Evaluation scale (BACE-3;Clements et al., 2012), a validated instrument measuring the extent to which accessibility, attitudinal, and stigma-related barriers were perceived to be experienced by treatmentseekers on a 4-point Likert scale (0 = 'Not at all' to 3 = 'A lot'), with higher scores indicating a greater barrier. Mean response scores, percentage reporting experiencing the barrier to any degree (i.e., endorsing 1, 2, or 3), and percentage experiencing barriers as a major barrier (i.e., endorsing 3) for each barrier were calculated. The mean score of all stigma-related barriers were also reported. Qualitative data from openended questions were coded using content analysis, and frequency of responses with similar content codes were calculated.
The study was approved by the Harvard Longwood Campus Institutional Review Board and the Philippines Social Science Council-Social Science Ethics Review Board and conforms with the United States Federal Policy for the Protection of Human Subjects.

Perceived mental health concerns during COVID-19
The majority of respondents (97.9 %) perceived an increase in mental health concerns in the help-seeking population in the Philippines since the advent of the COVID-19 pandemic. Respondents observed an increase primarily in anxiety (97.9 %) and depressive disorders (97.2 %), followed by bipolar and related disorders (49.0 %), trauma-related disorders (46.2 %), and suicide risk behaviors (e.g., suicidal ideation and suicide attempts) (44.1 %). Increases in schizophrenia spectrum and other psychotic disorders (24.8 %), substance-related and addictive disorders (16.6 %), and obsessive-compulsive related disorders (13.1 %) were less frequently reported.

Perceived barriers and facilitators of mental health care
Table 1 ranks barriers to mental health care perceived as major barriers in ascending order. Besides the top-ranked major barrier being high financial costs of mental health care (40.0 %), the other top five barriers were stigma-related, such as feeling embarrassed or ashamed (35.9 %), concern that they might be perceived as 'crazy' (31.0 %) or weak (30.3 %), and concern about family (23.4 %) and other people's reactions (22.1 %). On average, stigma-related barriers were experienced as a moderate to major barrier (M = 1.8, SD = 0.3).
The majority of respondents (65.0 %) perceived that barriers to access and treatment stigma has decreased since COVID-19 began. Respondent testimonials of success related to mental health service provision provided explanation and elaboration on decreased accessibility and stigma-related barriers during the pandemic. Most provider testimonials (62.6 %) emphasized that the transition to teletherapy ensured care continuity. In some cases, switching to teletherapy allowed for the expansion of services and service areas. 26.1 % of testimonials endorsed successes in increasing the availability of mental health services and increasing awareness of the importance of mental health through public and community education during the pandemic.

Recommendations for improvement in mental health services
Survey respondents recommended increasing training for mental health providers or staff (82.5 %), more mental health service providers (75.5 %), better internet connectivity (72 %); more government funding for mental health (69.9 %); and greater awareness-raising for services (66.4 %) to better reach communities in need.

Discussion
Perceptions of mental health providers gathered in this study supported the increased global incidence of mental health concerns (WHO, 2022), as well as underscored barriers to mental health care in the Philippines and factors that accelerated ways of overcoming them during the pandemic. Notably, barriers to access and stigma-related treatment barriers were perceived to be reduced during the pandemic. As qualitative findings suggested, many providers perceived that this may have been due to the benefits of teletherapy, and increased awareness and education around mental health. While teletherapy can facilitate greater access to mental health care, it can also pose challenges related to technological disparities in accessibility (Leochico et al., 2020), as providers also advocated for better internet connectivity to facilitate the shift to teletherapy during and after pandemic times.
While the study was limited by the representativeness of its sample and potential recall bias on providers' perception of a general trend over the course of the pandemic rather than an epidemiological survey of mental health needs in the Philippines, the findings provide a valuable snapshot of the mental health needs and context in a difficult to access and under-resourced setting from providers' perspectives. More robust epidemiological surveys are needed to understand the mental health needs in the general population, and the impact and pitfalls of teletherapy on mental health care access and stigma reduction in the Philippines.

Financial disclosure
The authors acknowledge that no outside funding was used to support this study.

Declaration of Competing Interest
The authors have no known conflicts of interest to disclose.