Discussion

As the Philippines is known to be hit by at least 20 typhoons every year, ⁷ delayed mental health effects have been noticed more often than immediate effects. The worst typhoon in the Philippines’ natural disaster history recorded before the recent Super Typhoon Goni was Super Typhoon Haiyan (locally known as Super Typhoon Yolanda) that hit in November 2013. ^{Reference Madarang17,Reference McPherson, Counahan and Hall26} Studies reported that the mental health of Filipinos after Super Typhoon Haiyan has reasoned out the delay in manifestations of mental instability. At the time of disaster, surviving the worst and escaping the worst occupy the victims. Post-rescue, when a safe space is reached, which is after a period of 3 to 6 months, is when the mental component enters. Posttraumatic stress disorder (PTSD), depression, and anxiety were reported after Super Typhoon Haiyan, and the same could be expected now. ^{Reference Geronimo27}

With the added pandemic, adjustment problems and irrational fears, shock, and hopelessness are worse this time, compared with previous disasters in the Philippines. A constant state of despair is also seen in the victims, which is stirring the mental health of the population. The burden of losing a loved one and the effect of realizing it later, displacement of family, socio-economic loss, environmental loss, and lack of mental preparedness and social support with negative coping skills, such as substance abuse, may induce psychological stress. ^{Reference Makwana25} One important cause of this is the non-availability of medications for people who were already on drugs for pre-existing mental health problems, which aggravates their condition. ^{Reference Geronimo27}

Moreover, the effect of pandemics on mental health has also been studied frequently during the COVID-19 pandemic. It was stated in a study conducted within the early portion of 2020 that a minimum of 3.6 million Filipinos suffer from a type of mental, neurological, and substance use disorder. ²⁸ Thus, one can conclude that the COVID-19 pandemic has had a very detrimental effect on mental health, leading to depression, anxiety, severe stress, and high suicidal tendencies in the general population all over the world. ^{Reference Cleofas and Rocha29,Reference Xiong, Lipsitz and Nasri30}

In the Philippines, many studies were conducted to assess the correlation between the pandemic and mental health of Filipinos. One study concluded that around 17% have moderate-to-severe depressive symptoms, whereas around 30% reported to have moderate-to-severe anxiety levels, and around 14% had moderate-to-severe stress levels. ^{Reference Tee, Tee and Anlacan31} Cases for mental health conditions, especially depression, anxiety, and severe stress significantly spiked up. A rise in suicide rates, increased by 25.7% in 2020, was a major concern. ^{Reference Rivas32} Although the Philippines has consistently ranked in the top 5 of a worldwide optimism index, the National Center for Mental Health (NCMH) has revealed a huge rise in monthly hotline calls about depression, with numbers increasing from just 80 calls before lockdown to about 400. ³³

Many factors having an adverse effect on mental health during the pandemic were identified, which include younger than age 30, female gender, well-educated, unmarried or separated, prolonged home stay, excessive worries about COVID-19, and association with people who have already contracted the disease. Protective factors, on the other hand, included male gender, staying within a joint family especially with children, having confidence in one’s own ability to make it through the pandemic as well as one’s health care professionals, having employment, and hand hygiene. ^{Reference Tee, Tee and Anlacan31,Reference Wang, Tee and Roy34}

Since the passing of the country’s Mental Health Act, the comprehensive and integrated approach has been practiced. ^{Reference Lally, Tully and Samaniego35} To incorporate community involvement and provide a holistic approach, 3 main ideas have been highlighted, such as incorporation of culture in intervention program by ensuring audience appropriate language usage for the material and methodology used, participatory approaches by implying the utilization of community for both the delivery as well as the reception of the intervention, and evolving role of competent community psychologists who will empower the community by understanding and managing the stakeholders. ^{Reference Lally, Tully and Samaniego35} The importance of community-based intervention is felt since mental health is still stigmatized in the Philippines. Thus, involving the community in designing, delivering, and training would be a more agreeable approach.

Realizing this, the government of the Philippines introduced a multi-sectoral approach for mental health in a variety of settings, such as in offices, colleges, schools, and hospitals. ³⁶ These include National Suicide Prevention Strategy, NCMH’s 24/7 hotline, and World Suicide Prevention Day to raise awareness. Collaborating with the government, the World Health Organization urges Filipinos to have conversations about mental health and highlights the need for empathy by listening to those affected. ³³ Moreover, US $12 billion will be allocated to the purchase and distribution of COVID-19 vaccines in developing countries, including the Philippines, by the World Bank Group. ³⁷ The Office of Civil Defense and the National Disaster Risk Reduction and Management Council are also working to build preparedness within residents by encouraging sanitation and social distancing during the disaster to help improve safety within temporary shelters. ^{Reference Mendoza38}

At the communal level, local initiatives are working to address mental health needs of the general population through training programs and requests to build more mental health facilities. A scarcity of well-trained psychiatrists exists in communal settings, which allows locals to find alternatives to training workers in identifying and managing mental health concerns, especially trauma. ^{Reference Estrada, Usami and Satake39} One such example is the initiative by the regional office of the Department of Health (DOH) in Bicol which aims to train workers in rural and city areas to manage mental health concerns within their communities. The DOH has also requested the local government units to increase mental health institutes like Don Susano Rodriguez Memorial Mental Hospital in Pili as such institutes are few in number in the region and in the country. ^{Reference Toledo40} In addition, the local government units in Bicol, with the assistance of the Department of Education, conducted therapeutic sessions on psychological well-being and mental support programs to assist the locals in recovering from trauma and anxiety caused by the recurrent catastrophic typhoons and current pandemic. ^{Reference Balala41} Teachers were also identified as key players in addressing mental health issues of children and hence initiatives to provide psychological first aid training to them are helping address their mental health needs. ^{Reference Estrada, Usami and Satake39}

Other suggestions include the use of telemedicine to help navigate the burden of mental health issues, and implementation of disaster risk reduction management and psychological interventions to Filipinos who were greatly affected by both natural disasters and the COVID-19 pandemic. ^{Reference Ćosić, Popović, Šarlija and Kesedžić42,43} Psychological interventions include coping strategies, psychological first aid, debriefing, cognitive behavioral therapy, psychosocial support, and community-based interventions. ^{44,Reference Math, Nirmala, Moirangthem and Kumar45} In addition, it is necessary that primary health care services, which constitute the most frequent contact of a greater part of the population, integrate aspects of mental health care, with a focus on previous diagnosis, prevention, and treatment of mental disorders in the community, as well as in the development of educational and awareness campaigns on the topic. Such integration is also necessary, because during the pandemic and in situations of public emergency, such services are the main form of care for patients with psychiatric diseases, due to the difficulty of accessing some services. In this scenario, more substantial financing by the government is also needed, with the objective of expanding and giving greater autonomy to primary care services, through the training of professionals to work in the initial management of mental disorders. Strategies like these can assist not only in the treatment of pre-existing mental illnesses, but also in reducing the incidence of new psychiatric disorders.