CEBU INSTITUTE OF MEDICINE

Department of Family and Community Medicine

Community Medico-Social Services
Primary Care and Family Health Center
Paknaan, Mandaue City
Tel. No. (032) 253 3124

Monte - Aribal Family

Zone Monggos, Barangay Paknaan, Mandaue City

A Clinico-Sociological Case Presentation

“Dan-ag”
gleam (n.); glow (v.); illuminate (v.)
n. (state) ~ good health, healthiness, the state of being vigorous and free from bodily or mental
disease.

Submitted by:

Amobi, Gabriel C.
Ballesteros, Christine Faith A.
Barolo, Mary Dianne Louise A.
Benitez, Marie Bernice P.
Cubelo, Murielle R.
Fuentes, Bianca Louise U.
Lam, Justin Riley Y.
Lozada, Michel Marilouis H.
Sanoy, Kristine Mae P.
Tan, Arvin T.
Tan, Frances Gabrielle D.
Torrenueva, Lesly Marie P.
Ureta, Paul Martin P.
Varela, Vera Maxine S.

December 2021
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TABLE OF CONTENTS
INTRODUCTION 3

BURDEN OF THE DISEASE 4

GENERAL OBJECTIVES 7

SPECIFIC OBJECTIVES 7

SCOPE AND LIMITATIONS 7

MEDICAL SCENARIO (PATIENT-CENTERED) 8

PATIENT PROFILE 8
HISTORY OF PRESENT ILLNESS 13
REVIEW OF SYSTEMS 15
Mental Status Examination 15
Physical Examination 17
Clinical Formulation 19

CASE DISCUSSION 23
Definition 23
Epidemiology and Incidence 23
Etiology and Pathophysiology 23
DSM-V Diagnostic Criteria for Major Depressive Disorder 25
Therapeutic Interventions 27
Pharmacotherapy 27
Psychotherapy 29
Supportive therapy 29
Complications 29
Prognosis 30

FAMILY FOCUSED 31
FAMILY PROFILE 31
FAMILY LIFELINE 33
FAMILY AND HOME ENVIRONMENT 34
FAMILY GENOGRAM 38
FAMILY LIFE CYCLE 38
APGAR I 40
APGAR II 41
FAMILY DYNAMICS 42
FAMILY MAP 44
FAMILY CIRCLE 45
FAMILY ILLNESS TRAJECTORY 45
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Stage I: Onset of Illness 45

Stage II: Impact Phase - Reaction to Diagnosis 46
Stage III: Major Therapeutic Efforts 46
SMILKSTEIN’S CYCLE OF FAMILY FUNCTION 47

COMMUNITY-ORIENTED 48
SCREEM-RES 48
SCREEM ANALYSIS 49
FAMILY ECOMAP OF MONTE-ARIBAL FAMILY 50
MENTAL HEALTH PROGRAMS IN THE COMMUNITY 51
ROOT CAUSE ANALYSIS 56

PROBLEM PRIORITIZATION 58

PROGRAM PLANS 59

FAMILY WELLNESS PLAN 61

INTERVENTIONS 69

RECOMMENDATIONS 72

FINAL DIAGNOSES 73

REFERENCES 74

APPENDICES 75
Appendix A. Mini Mental Status Exam (MMSE) 75
Appendix B: PHQ-9 Depression Questionnaire 76
Appendix C. Columbia-Suicide Severity Rating Scale (C-SSRS) 77
Appendix D: Malnutrition Universal Screening Tool 78
Appendix E: Family Home and Environment 79
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INTRODUCTION

Mental illness is a leading cause of disability. Mental health disorders remain a poorly
understood concept in the Philippines that warrants immediate attention especially during the
advent of the COVID-19 pandemic where there is complete transformation of the psychosocial
environment. Stressful life events such as enforced lockdowns, physical and social isolation,
unemployment, and death of loved ones have become the norm. Untreated mental illness can
cause severe emotional, behavioral, and physical health problems. This is amplified in those
who already are affected with mental illnesses.

These trying times have taken a toll on our mental health. The unprecedented mental
health crises unfolded simultaneously with the pandemic. It suffices to say that while we are
fighting a battle against the COVID-19 virus, we are also struggling an internal battle, a war that
we have long suppressed.

The National Center for Mental Health (NCMH) crisis hotline has shown an increasing
number of calls since the pandemic started. Just in 2021, they have recorded an average call of
76 a day in the month of September alone and a monthly average of 2,000 calls since the start
of the year. They have received a total of 14,987 calls with 34% being suicide-related since
January to September 2021. As shown in Figure 1, there is a noticeable increase in the
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percentage of both suicide-related and other mental health-related calls. Among these calls, the
top 3 reasons they have identified are (1) anxiety and depressive symptoms, (2) asking for a
referral to a psychiatrist/psychologist, and (3) love/relationship problems (DOH, 2021). In 2020,
suicide is the 27th leading cause of death in the Philippines coming from the 31st in the year
2019 (PSA, 2021).

This is the case of A.A., an 18-year-old female suffering from Major Depressive Disorder.
This paper will discuss the course of her disease, the misperceptions and downplaying of her
family regarding her mental illness, her symptomatology, the dynamics among the family
members as well as their health and identified resources and pathology. We will unfold the
arduous journey of A.A. who was once lost in the midst of darkness, with only a sliver of light as
a guiding lamp towards reclaiming her “dan-ag”.

BURDEN OF THE DISEASE

Major Depressive Disorder (MDD) is one of the most burdensome illnesses globally, with
significant negative impacts on activities of daily living, quality of life, cognitive function, and
employment status and work productivity. Researchers studying MDD are challenged by the
complex nature of the disease, which often co-occurs with other chronic and acute conditions,
including both physical and psychiatric disorders. In particular, the treatment pathway for
patients with MDD is remarkably complicated, with extensive variability in disease presentation,
uncertainty of diagnoses, and heterogeneity of treatment effects.

With the severe impact of the COVID-19 pandemic on mental health, much new
research and analysis will be needed to assess the growing burden of MDD. Starting in early
2020, the pandemic resulted in new, stressful, and at times overwhelming worries about the
health effects of the virus itself, heightened concerns about potential loss of employment, and
prolonged social isolation involving greatly reduced interaction with family and friends. Actions
taken to reduce the risk of COVID transmission, such as quarantining and social distancing,
may have intensified feelings of loneliness, anxiety, and depression for many people.

Another alarming finding concerns the financial burden of the medical conditions that
commonly occur alongside depression. Only 38% of the total costs of MDD were attributable to
the disorder itself; the remaining 62% were incurred from direct and indirect costs from
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co-occurring disorders, such as anxiety disorders; adjustment disorder; posttraumatic stress

disorder; and non-psychiatric medical conditions, including chronic pain and sleep disturbance.
Clearly, the concern for depression in the workplace should extend beyond that of the disorder
itself to its associated conditions that often require medical treatment, produce disability, and
interfere with occupational functioning. This raises important considerations about secondary
benefits of treating depression by potentially mitigating the effects of concurrent disorders, which
could be impactful given their prominent contribution to depression’s economic footprint.

Mental health issues can substantially influence many aspects of an individual’s life. The
stigma around mental illnesses has been going on for centuries. Dating back to the 16th century
when mental illnesses are usually associated with magic, witchcraft and evil doings, people with
mental illnesses were ridiculed and maltreated. Over time, we have slowly understood the
science behind mental disorders but stigma still emanates to which culture has been playing a
big role.

In the Philippines, our understanding of mental health is inextricably bound to our

culture. Our cultural beliefs have made depression and anxiety non-existent and that these facts
are to be ashamed of. Offensive terms like “abnoy”, “kulang sa pansin” and “baliw” are often
incorporated in casual conversations when people with mental health issues try to open up.
Social stigma and discrimination around mental health is a public health issue that needs to be
addressed and we find it a good opportunity to do this through this clinico-sociological case
presentation.

According to the American Psychiatric Association (APA), stigma stems from lack of
understanding and fear. It has 3 distinct elements: (1) people living with mental issues are
negatively stereotyped, (2) an emotional reaction to that stereotype is prejudice and (3) a
behavioral manifestation of prejudice is discrimination which can either be subtle or obvious.
Types of stigma can either be public, self or institutional. Public stigma involves discriminatory
attitudes towards mental illnesses; self-stigma refers to negative attitudes like shame that
people with mental illness have about their condition and; institutional stigma involves
government and private policies that may limit opportunities for people with mental illness.

It is sad to know that stigma often starts within the family. Mental health problems are
perceived as problems of the family which is why family shame is a significant contributor of
treatment avoidance. This case aims to emphasize that the family must be educated about
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mental health. They should be encouraged to participate in and contribute to development of

policies and guidelines. Maravilla and Tan in 2021 even highlighted how family group
conferencing skills must be included in the training and practice of psychiatry. This is just one of
the efforts that can help us create a mentally healthy Filipino population.
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GENERAL OBJECTIVES
To present a case of an 18-year-old female who presented with Major Depressive
Disorder (MDD) and to discuss the family dynamics of the Monte-Aribal family.

SPECIFIC OBJECTIVES
1. To present a patient-centered approach to a person with Major Depressive Disorder.
2. To discuss the family structure through situational analysis and genogram of the Monte-
Aribal family.
3. To discuss the family function and dynamics of the Monte-Aribal family through
appropriate tools of family assessment.
4. To present a holistic management plan by using the patient-centered, family-focused,
and community oriented (PFC) matrix for the patient’s case.
5. To discuss community interventions for people with mental health issues.

SCOPE AND LIMITATIONS

The case study is limited to the Monte-Aribal family and was conducted through a series
of phone calls and face-to-face interviews. The case study relied on the recall capability of the
patient, her family members, and her present laboratory results. The paper focuses on the
specific mental disorder of the patient and would not cover mental health disorders in general.
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MEDICAL SCENARIO (PATIENT-CENTERED)

PATIENT PROFILE

Date: November 19, 2021

Informant: Patient
Reliability: 90%

A.A., an 18 year-old female, single, Filipino, Roman Catholic, Grade 12 student, from
Zone Monggos, Paknaan, Mandaue City, Cebu was consulted for her “feelings of emptiness”.

Patient is non-hypertensive, nondiabetic, and non-asthmatic as claimed. Patient has a

history of chicken pox at 9 years of age, no other childhood illnesses. The patient has
completed childhood vaccinations as claimed. Patient had a recent upper left maxillary 3rd
molar tooth removal in the first week of November, the patient completed Amoxicillin 500 mg
every 8 hours for 7 days. No previous hospitalizations or surgeries. No history of trauma to the
head, stroke or seizures. Patient has food allergies to crustaceans and seafood. Patient has no
known drug allergies. Patient is fully vaccinated with Astrazeneca vaccine for COVID-19 last
November 24, 2021.

Patient had no previous psychiatric consultations, hospitalizations, or treatments. The

patient has prior signs and symptoms of other psychiatric illnesses such as depression. No
other signs of psychosis or manic and hypomanic symptoms. She has a history of past suicidal
ideations and non-suicidal self-injurious behavior. No history of violent intent.

Menarche was at 14 years of age, with regular intervals until recently lasting 3 days with
no dysmenorrhea, using 1 pad per day which are mildly soaked. Patient noticed an irregular
pattern 2 months ago; she had her period last September and missed her period last October;
PMP: first week of November; LMP: November 16 lasting 2-3 days. Patient claims to have no
history of any sexual contact.

Patient is a non-smoker, occasional alcoholic drinker, patient drinks on occasion around

1-2x per month during festivities, drinking a few glasses of wine. No history of any illicit drug
use. She is currently a Grade 12 student in the Mandaue School for the Arts, currently on a pure
online platform. Patient was from Cagayan de Oro, and was struck by Typhoon Sendong. The
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family then decided to move to Cebu around 2015. Patient lives in a 2-storey house made of
wood and concrete owned by her auntie. Patient is the youngest child and she lives with her
parents and 3 siblings for a total of 6 in the household. Patient eats 3x a day and the diet mainly
consists of meat and rice. Patient drinks water around 4-6 cups daily and drinks carbonated
drinks around once every 2 days on average. Patient did not note any changes in bowel or
bladder habits.

HEADSS FIRST

Home. The patient lives with both her parents and 3 other siblings in their home. The house is
owned by their aunt, the father’s younger sister and they have been living in the house since
2015. Patient claims that there are times that she wants to run away whenever she gets scolded
and whenever she gets the feeling of wanting to be free.

Education.The patient is currently a grade 12 student, enrolled in the Mandaue School for the
arts. She currently has 10 subjects and does modules for each subject weekly. She is in her 2nd
quarter for the school year. She claims that there are plenty of people who want to be friends
with her but she finds it difficult to make friends with them because she gets tired of getting to
know them. Patient claims to use social media such as Facebook all the time due to the shift of
online platforms of education brought about by the pandemic, but lately, deactivates it whenever
she feels down. Patient plays volleyball and has joined a few competitions such as the Mayor’s
Cup. Patient feels nervous going to school ever since Grade School/elementary school until
High School. She claims to be absent from school because she gets scared of her classmates
and teachers. Patient started school at the age of 7 in Grade 1. She claims to not have
experienced kindergarten and missed the experiences a child should have experienced during
that time. “Diba lingaw man na kay magduwa2x pirmi dili skwela dayun jud” (Wouldn't it be fun if
we just play all the time rather than go to school as soon as possible) Patient learned how to
read late in grade 2 because she did not want to be taught before and only wanted to play.
Patient was bullied in Grade school/elementary school. Patient transferred schools twice in
grade school/elementary school. It was hard for her to adjust. She gets tired whenever her new
classmates ask her about the reason why she transferred schools. In Cagayan De Oro: City
Central School: Grade 1-3, Balulang Elementary School: Grade 4-5, Ibabao-Estancia
Elementary School: Grade 6 She said that her classmates would follow her around and tease
her about something that she no longer recalls. She would get annoyed and would just ignore
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them. Patient claims that she did not make any close friends in grade school/elementary school
and only sees them as her acquaintances. Patient found it hard to adjust in the new schools she
attended; “lisod kaayo mag adjust” (It is very hard to adjust). In Grade 9, patient claims to have
made 2 close friends and considered only one of them as her best friend who understands her.
In Grade 10, patient no longer experienced any form of bullying from her classmates and
claimed that they wanted to be friends with her but she herself did not want to.

Eating and Exercise. Patient has not been eating well due to loss of appetite noting that even
though she eats 3 times a day, she only eats 2-3 spoonfuls of rice per meal and as low as only 1
spoonful occasionally as she has no appetite. She claims that she is not currently on a diet, nor
does she want to lose weight. The patient used to play volleyball but since the pandemic has
not played any sport.

Activities. Due to the pandemic, the patient's activities with her friends include video calling each
other once or twice a week. Patient thinks that a lot of people know her. Patient was anxious in
high school and she got nervous upon waking up before going to school. She socializes with her
classmates by joking around with them and considers herself as the “joker” in the group. The
patient usually draws and sketches during times in which she can concentrate, but notes that it
takes her a long time to finish her drawings because she has a hard time concentrating. Patient
fears clowns, mannequin and porcelain dolls.

Drug Use, Cigarettes, Alcohol. Patient is an occasional alcoholic drinker. The patient drinks wine
during festivities around 1-2 times a month. Patient drinks around 1-2 glasses during these
occasions, and not to the point of intoxication. Patient is a non-smoker, no history of illicit drug
use.

Sexual Behavior. Patient claimed that she explored her genitals once out of curiosity but she
couldn’t remember how old she was. She claims to have learned sexual knowledge from her
classmates who talk about lewd jokes and conversations. Patient has no sexual contact. She
also doesn't know about her parents’ point of view regarding sex. Patient did not experience any
form of sexual abuse. Patient claims that her older sisters have informed her about the process
of puberty such as menstruation and expected changes in her body. Patient is currently talking
to a guy friend and claims that she likes the attention given to her. They play mobile legends
together and talk every other day. She feels validated by this guy friend as he gives her
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compliments and she claims that this boosts her confidence. Patient is not interested in dating,
however she wants someone to talk to. She also likes the compliments other people say to her
such as:“Luh maayoha nimo mo mu drawing” (Wow, you are so good at drawing) and “Gwapa
bisad gi bugas” (You still look pretty even with the pimples). She claims that she wants to know
what other people think of her and it doesn't bother her if she hears negative feedback. Patient
claims to be shy around people she isn’t close to. She claims to “bogal-bogal” (joke around),
“roasts” or teases a guy if she likes him.

Family and Friends. Patient plays with her sister 3 all the time while growing up. Patient claims
that in elementary school, she doesn’t play with her classmates. She just sits and seldom talks
to her seatmates and classmates during their recess. Patient claims that she can’t seem to
relate with girls and that she is closer to boys. She doesn't understand girls’ way of thinking, and
she thinks that they are too “girly”, talking about topics she can’t relate to such as makeup. She
claims to be good at socializing if there’s a need but she doesn't like doing it because she finds
it tiresome and energy-consuming. Patient has 2 close friends and considers only one of them
as her best friend. She claims to be the leader in their friendship because she always initiates
the conversations first. Patient has a feeling of inferiority towards her classmates because she
can’t seem to relate with them. She also feels inferior towards her parents because they value
their opinion more rather than the patient’s opinions.

Image. The patient sees herself as tired and depressed all the time. She is sometimes
self-conscious with the way she looks and dresses, especially when she goes out. Patients
sometimes would also not care because she would be too tired or disinterested and wouldn’t
care how she looks. Patient noticed some weight loss but shrugged it off because she was also
thin before.

Recreation. The patient spends most of her time finishing her modules for class, the patient
watches anime and movies during her spare time, and may on occasion sketch these
characters.

Spirituality. The patient is a Roman Catholic and continues to pray even though she thinks her
situation is very difficult. The patient does not join her family during Sunday masses because
when the priest will try and make a point during the homily, the mother would glare at her and
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accuse her of such. Her faith has stayed the same and does not blame God for these feelings
these past 4 years.

Threat. The patient notes that she is almost always in a depressed mood, noting that she has
no interest in doing her activities. Patient also notes that she has thoughts regarding taking her
own life.

Developmental History

Point of view of mother. Mother was a G4P3(3003) at the time of pregnancy, mother had
complete prenatal check-ups as claimed, the patient was delivered without any complications.
The father was not present during the birth due to being away as a seaman. The grandmother
helped in taking care of the children while the mother was in labor. The patient was breastfed
until about 8 months where soft food was given, at around 2 years of age when solid food was
given. There was no developmental delay during growth and growth was at par with age as
claimed. The child was noted to be jolly during her childhood and sings along in the house.
Patient had a few childhood friends back in Cagayan de Oro City. The patient had always
transferred schools during her childhood, from grade 1-3 the patient went to school in the city
central, this is because her sister was also enrolled there, the patient was noted to be absent a
few times during grades 1-3 because the school was really far, and the mother also was
sometimes tired to bring her to school. After the patient's sister graduated from this school, the
patient was transferred to a school near her house from grade 4-5. During grade 6, the patient
then transferred to Cebu and was enrolled in Ibabao School in Mandaue City, where she was
noted to cut classes because she was bullied by her classmates because she was a transferee.
She stayed there until the patient graduated grade 10. Sometime in her junior high, the patient
was a fan of playing volleyball during her spare time, but due to always coming home late for
practices, the mother did not allow the patient to play volleyball again, at this point the mother
noted that this was the only time she felt that the patient was angry at her. During this time, her
grades were enough to pass.The mother did not know any of the patient's friends, in contrast
with that of her siblings where the mother knows their friends. After graduating grade 10, the
patient then transferred to the school of the arts in mandaue.

Heredofamilial disease includes hypertension on the paternal side. No familial history of

any psychiatric disorder.
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HISTORY OF PRESENT ILLNESS

Problem #1: “I feel empty”

Four years PTC, the patient suddenly noted a feeling of emptiness; she did not have any
recent stressors nor any significant life events. She had lost interest in her daily activities and
lost motivation due to always thinking “mamatay raman gyapun tang tanan” (We will all die
anyway); she still had no suicidal ideations then. Patient did not think of the feeling as
pathologic, but thought of it as “phase raman siguru nako ni.”(This might just be a phase).
Patient was unable to share nor express these feelings to anyone else and had kept it to
herself. Patient had friends but opted not to share due to the fear of being judged, the patient
claims that it has not affected her educational performance.

Three years PTC patient noted worsened feelings of emptiness, and continue to have
no interest in her daily activities. She claims to be absent in school more often, due to feeling
“kapuy” (tired) no significant stressors were noted during these episodes, the mother was not
pressuring the patient to go to school and let her be. Patient had her 1st suicidal ideation and
had thought of hanging herself using a rope but did not pursue the action due to the
repercussions to her other family members, and did not want to burden them with the effect.
Patient did not also talk to her friends about her feelings due to the fear of them judging her.
Patient tried to open up to one of her friends at this time but was told that it was “OA”(Over
acting). She continued to keep it to herself and still thought that this was a phase of sadness.
Patient found out that she had talents in the arts and pursued it for her senior high school.

In the interim, the patient still continued to have these thoughts and feelings of
emptiness and noted worsening of her sadness, with loss of appetite noting that she only eats
2-3 spoonfuls of rice per meal and as low as only 1 spoonful occasionally as she has no
appetite. She claims that she is not currently on a diet, nor does she want to lose weight.
Patient claims to be around 40 kilograms. The patient has irregular sleeping patterns even
sleeping as late as 6 am in the morning. The patient also continued to think that “maypa
mamatay nalang ko” (I’d rather just die) very frequently. Patient claims to try and keep herself
busy to avoid these empty feelings. Patient could not recall when but also slashed her wrist.
 14

One year PTC, the patient had tried to open up her feelings to her parents and
mentioned that “ako gi pagawas tanan” (I let it all out) to her parents but the parents mentioned
that these are just lifestyle changes and did not acknowledge the issue at hand. Patient was
devastated and thought again to take her life, but did not pursue due to the burden left to the
family if she proceeded.

Patient claims to have thoughts of taking her own life when cleaning the dishes
especially when wielding a knife. Patient also started to drown herself when taking a shower on
multiple occasions. Patient claims to still have the feeling of emptiness, loss interest in life, was
always forgetting and was unable to concentrate, had trouble sleeping, was always fatigued,
was always depressed and had a feeling of worthlessness, and still continued to think that
nothing was important because “mamatay ra gihapon ta” (We are going to die anyway). Patient
noted that this was her lowest moment in her life when she tried to open up and was shut down
by her parents. Around this time, the patient claims to have now known about the struggles and
legitimacy of mental health illnesses due to the increased awareness in her school, and before
this patient just thought of it as a phase.

In the interim, symptoms continued to persist and patient mentioned that even her older
sister, rank 2/4 in the family, also reiterated to her that these are just “OA” (Over Acting)and
that her losing weight are just lifestyle changes, and patient mentioned that “wa man sila
kahibaw na in-ani ako lifestyle tungud ani akong feelings” (They do not know that this is my
lifestyle because of my feelings)

Six months PTC around her birthday, patient prepared her rope again to try and take
her life, she had no significant stressors then and mentioned that “wala lang, ni gawas lang
gyud” during this time but she did not opt to continue again due to the fact that it will be a
burden to the family. Patient had continued to keep to herself due to the fact that she feels no
one understands her. Patient continued to try and drown regularly herself but knew that she
would be a burden so did not opt to continue.

In the interim, symptoms continued to persist and the patient just kept to herself.

On the day of Consult, the patient sought consultation at CIM CMSS Paknaan for
medical clearance for enrollment. During the consultation, she was noted to be severely
underweight with a BMI of 13, patient was assessed to a possible major depressive disorder,
 15

patient was given laboratory tests such as CBC, Chest Xray, Thyroid panel (TSH, FT3, FT4),
Serum albumin, Serum electrolytes (Phosphorus, Potassium, Sodium, Chloride), Fasting
Blood Sugar, AST, ALT and Lipid panel and was appropriately referred to a psychiatrist and
clinical psychologist patient was also given Dibencozide (Heraclene) 1mg/cap take 2 caps
orally 1x a day.

Problem #2: Loss of appetite, Severely underweight

The patient had a loss of appetite 3 years PTC and was not able to eat as much food as
she wanted. Patient noted that she was a bit smaller, and around 2 years PTC weighed at
around 40kg. Patient still noted continued loss of appetite due to the feelings of emptiness, the
patient was only eating 2-3 tablespoons of rice and meat per meal, eating 3x a day. On the day
of consultation the patient was weight to be 35kg with a BMI of 14.5, noted to be severely
underweight. Patient claims that this was unintentional and that she really wants to eat a lot and
gain weight but can’t due to the loss of appetite. Patient was given Dibencozide (Heraclene)
1mg/cap take 2 caps orally 1x a day and advised to increase intake of food.

REVIEW OF SYSTEMS

Mental Status Examination

Appearance and Behavior

Patient was seen sitting with good posture. She appears to be her stated age and is
well-groomed with proper hygiene. She was cooperative and attentive. Her gait was normal by
observation. Patient started was not open to talking when her parents were nearby.

Motor Activity
Patient had good eye contact. Motor activity is normal but her hands were fidgety.

Speech
Her speech rate and volume are normal. The patient tends to talk fast but claims that is
her normal way of speaking. The patient can fluently speak and understand Cebuano dialect
and English.
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Mood
Patient is comfortable during the interview. However, the patient claimed she still felt
empty inside and was sad.

Affect
The patient's affect was full and appropriate. She was seen crying when talking about a
sensitive topic regarding her past experiences.

Thought Content
The patient's thoughts consist mainly of the purpose of living, claiming that there is no
point in living since we are all going to die anyway. As she is currently enrolled in Grade 12,
patient constantly thinks of school, given modules to work on. Thoughts also include her
immediate future regarding the possibility of choosing a major for college.

Thought Process
Patient’s thought process is linear, organized and direct. No formal thought disorders
such as circumstantiality, derailment, flight of ideas, neologism and tangentiality.

Perceptual Disturbances
There were no noted hallucinations or delusions as well as any perceptual disturbance
as claimed.

Cognition
She is oriented to time, place and person. She was able to concentrate well, enumerate
the months of the year backwards, and compute basic calculations.

Abstract Reasoning
Patient has good abstract thinking. She was able to identify the similarities between fruits
and vegetables. Patient was asked to interpret “walay aso nga makomkom” and interpreted the
smoke as a problem, and that there is no problem that can be solved without discussing it or
confronting it.

Insight
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Patient has insight as she is aware and understands that she has a mental health
illness. Patient also notes that she might need outside help in order to overcome this obstacle.

Judgment
Patient has good judgement. She was able to make the right decision when given a
situation with a dilemma. She understands the consequence or outcome of the decision she
made.

Scales and Questionnaires

Mini Mental State Exam

Score: 30/30 No Cognitive Impairment
(See Appendix A)

PHQ Depression Questionnaire

Score: 17 Moderately Severe Depression
(See Appendix B)

Columbia Suicide Severity Rating Scale (C-SSRS) Risk Assessment

Moderate Risk
(See Appendix C)

Malnutrition Universal Screening Tool (MUST)

Score 3 points - High Risk
(See Appendix D)

Physical Examination

Examined an alert, coherent, cooperative, afebrile patient not in respiratory distress with
the following vital signs:
Temp: 37.2 ℃
RR: 25 cpm
PR: 92 bpm
BP: 110/80 mmHg
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O2 sat: 98%
Height: 155 cm
Weight: 35 kg
BMI: 14.5 kg/m²

Skin: warm, moist, good turgor and mobility, no rashes

HEENT: pink palpebral conjunctivae, no gross deformities, no tenderness, no lesions, no alar
flaring, no naso-aural discharge, moist lips
Neck: supple, trachea at midline, no lymphadenopathy, blood vessels not engorged
Cardiovascular System: Adynamic praecordium, no heaves and thrills, cardiac area of dullness
not enlarged, distinct heart sounds, regular rhythm, no murmurs
Chest and Lungs: equal chest expansion, no retractions, no tenderness, equal tactile fremitus,
resonant both lung fields, equal vesicular breath sounds both lungs, no rales or wheezes
Abdomen: flat, soft, normoactive bowel sounds (15 clicks/min), tympanitic except over area of
liver dullness (6 cm at MCL, 4 cm at MSL), no palpable masses
Extremities: no deformities, no limitation of movements, no edema, strong peripheral pulses
(bilateral radial, dorsalis pedis and posterior tibial arteries), CRT < 2 seconds, no lesions

Neurological Examination:
Cerebral: conscious, coherent, oriented to person, time and place

Cranial nerves:
CN 1: able to recognize the scent of coffee
CN 2, 3: equal pupillary light reflex, direct and consensual, both eyes
CN 3, 4, 6: full range of extraocular muscle movement by Finger Following test
CN 5: facial sensations intact, strong muscles of mastication
CN 7: facial symmetry, good facial expressions
CN 8: able to hear Spoken Voice test
CN 9, 10: uvula at midline, able to swallow
CN 11: able to turn head and shrug shoulders against resistance
CN 12: tongue at midline upon rest and protrusion, no atrophy or fasciculations

Cerebellar Function: well-coordinated movements by Finger-to-Nose Test and Heel-to-Shin Test

 19

Motor system: good muscle strength and tone; no atrophy, fasciculations, nor tremors
5/5 5/5
5/5 5/5

Reflexes:

Clinical Formulation

Problem #1: Feeling of Emptiness

Primary Impression: Major Depressive Disorder, Moderate

The patient is a young female, in her teens, and is in school which is the most common
demographic for a patient with MDD. The patient also fulfilled the DSM criteria which includes:
a. Depressed mood
b. Markedly diminished interest or pleasure
c. Significant weight loss
d. Insomnia and Hypersomnia
e. Psychomotor retardation
f. Fatigue or loss of energy
g. Feelings of worthlessness
h. Diminished ability to think or concentrate
i. Recurrent thoughts of death and recurrent ideation.
 20

The patient has 8/9 of these symptoms for more than 2 weeks. The patient also has a
moderate severity because the disorder has affected her function, which includes her social and
day to day activities, leading to moderate functional impairment.
The patient did not also present with manic or hypomanic symptoms, the patient also
does not have any delusions or hallucinations, nor any significant stressor or life event the past
3 months. Patient also has no history of any purging or binge eating episodes, the patient does
not eat only because she has no interest at all, the patient wants to gain weight.

Differential Diagnosis:

1. Persistent Depressive Disorder (PDD)

The patient fulfills the criteria for PDD with the presence of poor appetite,
insomnia, low energy, low self esteem, impaired concentration, and feelings of
hopelessness, these has been on most days for 2 years or longer and has not had
absence of these symptoms for more than 2 months, however, in patients with this
disorder, patients do not usually have suicidal thoughts and patients also do not have
any or only mild functional impairment.
2. Bipolar disorder
Due to the fact that bipolar disorder and major depressive disorder have a lot of
overlapping signs and symptoms, what would differentiate each is the presence or
absence of hypomanic or manic symptoms. The patient fulfills the depressive criteria for
bipolar disorder but this diagnosis is less likely because the patient does not have any
history of manic or hypomanic symptoms such as inflated self-esteem, decreased need
for sleep, excess pleasurable or risky activity, racing thoughts or pressured speech.
3. Anorexia nervosa
This is due to the fact that the patient has a very low BMI at 13. This is less likely
because according to the DSM 5 criteria the patient must have all of the criteria which
includes persistent restriction of energy intake, intense fear if gaining weight and lack of
recognition of the seriousness of the current body weight, the patient only presents with
2 out of the 3 which includes the lack of recognition of the seriousness of the current low
body weight and persistent restriction of energy intake, the patients does not have an
intense fear of gaining weight or becoming fat.
4. Mood disorder secondary to a thyroid disorder
 21

The patient is a young female who presents with weight loss, this is less likely
because the consistency of symptoms for a specific thyroid disorder such as
hyperthyroidism or hypothyroidism is not found in the patients, the patient has signs of
hyperthyroidism such as weight loss but also signs of hypothyroidism such as depressed
mood and loss of interest.
5. Mood disorder secondary to Tuberculosis
The patient is a Filipina who lives in an endemic country and presents with weight
loss. This is less likely because the patient does not present with night sweats, cough,
unexplained weight loss, and unexplained fever. The patient has weight loss but can be
explained by the significant lack of appetite and decreased intake of food.

Problem #2: Severe Underweight BMI 14.5

Primary Impression: Chronic Malnutrition Secondary to Major Depressive Disorder

The patient has not been eating enough food the past 3 years due to her feelings of
emptiness, based on the Malnutrition universal screening tool, with a score of 3 she is at high
risk for malnutrition.The patient was also weighed at 35kg with a BMI of 14.5, noted to be
severely underweight.

Diagnostic Plans:

Definitive Plans: Psychiatric History and Mental Status exam according to the DSM-5 criteria

Supportive Plans: (Cater the supportive labs in ruling out the differentials)
1. Depression Questionnaire - monitor the severity of the depression Score:17
2. Suicidal Risk Assessment- this can be done through the Columbia- Suicide Severity
Rating Scale (C-SSRS). Moderate Risk
3. Mini Nutritional Status Assessment Scale: Score 4: Malnourished
4. CBC - to check for hemodynamic status and signs of inflammation
5. UA - to check for a possible focus of infection and screen for organ disorders
6. Serum Na, K, Ca, Phosphorus - to check for possibility of imbalances due to the chronic
decrease in appetite.
7. Serum albumin - to check for the possibility of disorders secondary to the decreased
food intake
 22

8. Stool Exam - to screen for possible gastrointestinal diseases or parasites that may also
affect the diet and weight loss
9. Creatinine and BUN - to check for baseline renal function status
10. ALT and AST - to check for baseline liver function
11. FBS - to screen for a metabolic disorder
12. Lipid Panel - To screen for possible metabolic disorders
13. Thyroid Panel - To screen and rule out a possible thyroid disorder
14. Chest X-ray - to screen for the possibility of tuberculosis

Therapeutic Plans:
Definitive Plans:
1. Psychotherapy with a psychiatrist and clinical psychologist such as cognitive behavioral
therapy and interpersonal therapy
2. Serotonin-Selective Reuptake inhibitors- is the first line treatment for patients with MDD
who need pharmacotherapy

Supportive Plans:
1. Adjunctive therapy with a second generation antipsychotic, Risperidone 2mg/tab ½ tab
once daily, to increase appetite and allow weight gain
2. Reassured the patient that we are here to support the patient in these difficult times
3. Reassured the patient that this is a condition that is legitimate and can be treated
4. Psychoeducation of the patient about the etiology, treatment and prognosis
5. Psychoeducation of the family about the etiology, treatment and prognosis
6. Advised the patient to increase meal intake and eat a well balanced diet when appetite
increase
 23

CASE DISCUSSION

Definition

Major depressive disorder (MDD), simply also known as depression, is a mental

disorder, lasting at least for two weeks, characterized by a pervasive low mood and/or
anhedonia, and other depressed symptoms like unintentional weight loss, insomnia, fatigue,
feeling of worthlessness, etc. (Sadock et al., 2015; Jameson et al., 2018). This is a chronic and
relapsing disease, and is diagnosed through a thorough history, physical examination and
depression inventory tools. In DSM-5, there is a distinction between grief and major depressive
episode (MDE). In the former, the predominant affect is feelings of emptiness and loss, while in
the latter it is persistent depressed mood and the inability to anticipate happiness or pleasure.
The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves,
while the depressed mood of MDE is more persistent and not tied to specific thoughts or
preoccupations.

Epidemiology and Incidence

In the most recent surveys, major depressive disorder has the highest lifetime
prevalence (almost 17 percent) of any psychiatric disorder. An almost universal observation,
independent of country or culture, is the twofold greater prevalence of major depressive disorder
in women than in men. The reasons for the difference are hypothesized to involve hormonal
differences, the effects of childbirth, differing psychosocial stressors for women and for men,
and behavioral models of learned helplessness. The mean age of onset for major depressive
disorder is about 40 years, with 50 percent of all patients having an onset between the ages of
20 and 50 years. Major depressive disorder can also begin in childhood or in old age. Major
depressive disorder occurs most often in persons without close interpersonal relationships and
in those who are divorced or separated. No correlation has been found between socioeconomic
status and major depressive disorder.

Etiology and Pathophysiology

The specific cause of MDD is not known; however, according to Kaplan and Sadocks’s
Synopsis of Psychiatry 11th Edition, there are biological, genetic and psychosocial factors, in
 24

addition to other causal theories. Of the biogenic amines, norepinephrine and serotonin are the
two neurotransmitters most implicated in the pathophysiology of mood disorders. The
correlation suggested by basic science studies between the downregulation or decreased
sensitivity of beta-adrenergic receptors and clinical antidepressant responses is probably the
single most compelling piece of data indicating a direct role for the noradrenergic system in
depression. Other evidence has also implicated the presynaptic b2-receptors in depression
because activation of these receptors results in a decrease of the amount of norepinephrine
released. With the huge effect that the selective serotonin reuptake inhibitors (SSRIs) -- for
example, fluoxetine (Prozac) have made on the treatment of depression, serotonin has become
the biogenic amine neurotransmitter most commonly associated with depression. The
identification of multiple serotonin receptor subtypes has also increased the excitement within
the research community about the development of even more specific treatments for
depression. Besides that SSRIs and other serotonergic antidepressants are effective in the
treatment of depression, other data indicate that serotonin is involved in the pathophysiology of
depression. Depletion of serotonin may precipitate depression, and some patients with suicidal
impulses have low cerebrospinal fluid (CSF) concentrations of serotonin metabolites and low
concentrations of serotonin uptake sites on platelets.
Family studies address the question of whether a disorder is familial. More specifically, is
the rate of illness in the family members of someone with the disorder greater than that of the
general population? Family data indicate that if one parent has a mood disorder, a child will
have a risk of between 10 and 25 percent for mood disorder. If both parents are affected, this
risk roughly doubles. The more members of the family who are affected, the greater the risk is to
a child. The risk is greater if the affected family members are first-degree relatives rather than
more distant relatives. Twin studies provide the most powerful approach to separating genetics
from environmental factors, or "nature" from "nurture." The twin data provide compelling
evidence that genes explain only 50 to 70 percent of the etiology of mood disorders.
Environment or other non-heritable factors must explain the remainder. Therefore, it is a
predisposition or susceptibility to disease that is inherited.
A long-standing clinical observation is that stressful life events more often precede first,
rather than subsequent, episodes of mood disorders. This association has been reported for
both patients with major depressive disorder and patients with bipolar I disorder. One theory
proposed to explain this observation is that the stress accompanying the first episode results in
long-lasting changes in the brain's biology. These long-lasting changes may alter the functional
 25

states of various neurotransmitter and intraneuronal signaling systems, changes that may even
include the loss of neurons and an excessive reduction in synaptic contacts. As a result, a
person has a high risk of undergoing subsequent episodes of a mood disorder, even without an
external stressor.

DSM-V Diagnostic Criteria for Major Depressive Disorder

A. Five (or more) of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms is either
(1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report
(e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note:
In children and adolescents, they can be in an irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change or more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children,
consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings or restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)

nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by

subjective account or as observed by others).
 26

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to

another medical condition.

Note: Criteria A to C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which
may resemble a depressive episode. Although such symptoms may be understandable or
considered appropriate to the loss, the presence of a major depressive episode in addition to
the normal response to a significant loss should also be considered. This decision inevitably
requires the exercise of clinical judgment based on the individual's history and the cultural
norms for the expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and
unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are
substance-induced or are attributable to the physiological effects of another medical condition.

Depression may occur as a single episode or may be recurrent. Patients who are
experiencing at least a second episode of depression are classified as having major depressive
disorder, recurrent. For an episode to be considered recurrent, there must be an interval of at
least 2 consecutive months between separate episodes in which criteria are not met for a major
depressive episode.

Specify current severity:

 27

Severity is based on the number of criterion symptoms, the severity of those symptoms, and the
degree of functional disability.

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the
intensity of the symptoms is distressing but manageable, and the symptoms result in minor
impairment in social or occupational functioning.

Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are
between those specified for "mild" and "severe."

Severe: The number of symptoms is substantially in excess of that required to make the
diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the
symptoms markedly interfere with social and occupational functioning.

Therapeutic Interventions

Treatment of patients with mood disorders should be directed toward several goals.
First, the patient's safety must be guaranteed. Second, a complete diagnostic evaluation of the
patient is necessary. Third, a treatment plan that addresses not only the immediate symptoms
but also the patient's prospective well being should be initiated. Although current treatment
emphasizes pharmacotherapy and psychotherapy addressed to the individual patient, stressful
life events are also associated with increases in relapse rates. Thus, treatment should address
the number and severity of stressors in patients' lives. The treatment considerations to be made
include: the need for hospitalization, psychosocial therapy, vagal nerve stimulation, transcranial
magnetic stimulation, sleep deprivation, phototherapy and pharmacotherapy.

Pharmacotherapy

With respect to pharmacotherapy, the objective of pharmacologic treatment is symptom

remission, not just symptom reduction. Patients with residual symptoms, as opposed to full
remission, are more likely to experience a relapse or recurrence of mood episodes and to
experience ongoing impairment of daily functioning. The use of specific pharmacotherapy
approximately doubles the chances that a depressed patient will recover in 1 month. All
currently available anti depressants may take up to 3 to 4 weeks to exert significant therapeutic
effects, although they may begin to show their effects earlier. Choice of antidepressants is
 28

determined by the side effect profile least objectionable to a given patient's physical status,
temperament, and lifestyle.
The most common clinical mistake leading to an unsuccessful trial of an antidepressant
drug is the use of too low a dosage for too short a time. Unless adverse events prevent it, the
dosage of an antidepressant should be raised to the maximum recommended level and
maintained at that level for at least 4 or 5 weeks before a drug trial is considered unsuccessful.
Alternatively, if a patient is improving clinically on a low dosage of the drug, this dosage should
not be raised unless clinical improvement stops before maximal benefit is obtained. When a
patient does not begin to respond to appropriate dosages of a drug after 2 or 3 weeks, clinicians
may decide to obtain a plasma concentration of the drug if the test is available for the particular
drug being used. The test may indicate either noncompliance or particularly unusual pharma
cokinetic disposition of the drug and may thereby suggest an alternative dosage.
Antidepressant treatment should be maintained for at least 6 months or the length of a
previous episode, whichever is greater. Prophylactic treatment with antidepressants is effective
in reducing the number and severity of recurrences. Another factor suggesting prophylactic
treatment is the seriousness of previous depressive episodes. Episodes that have involved
significant suicidal ideation or impairment of psychosocial functioning may indicate that
clinicians should consider prophylactic treatment. When antidepressant treatment is stopped,
the drug dose should be tapered gradually over 1 to 2 weeks, depending on the half-life of the
particular compound. Several studies indicate that maintenance antidepressant medication
appears to be safe and effective for the treatment of chronic depression. Prevention of new
mood episodes (i.e. recurrences) is the aim of the maintenance phase of treatment. Only
patients with recurrent or chronic depressions are candidates for maintenance treatment.
The patient was prescribed Escitalopram 10 mg/tab and Risperidone 2mg/tab. Below are
the prices of the drugs in pharmacies in Metro Cebu.

Prices (Php)
Medicine Brand name
Rose Pharmacy Mercury Drugs

Escivex 26.32 21.25

Escitalopram 10 mg Jovia 57.96 50.50

Lexapro - 128.50
 29

Aspidon - 124.60
Risperidone 2 mg
Renuvie 116.20 98.25

Risdine 60.76 53.50

Ritemed 75.05 -

Psychotherapy

Based on the American Psychiatric Association (APA), the initial treatment

recommended is Cognitive-Behavioral Therapy (CBT) and Interpersonal Psychotherapy
adapted for Adolescents (IPT-A).
Actually, these guidelines recommend fluoxetine as first-line medication for adolescents. The
guidelines also provided a list of medications not recommended for adolescents. This includes
clomipramine, imipramine, mirtazapine, paroxetine, venlafaxine. However, when there are no
other options are not available, effective or acceptable to the patient, it is recommended that
shared decision-making between the patient and clinician. When the aforementioned
medications are to be considered, the guidelines recommend paroxetine over clomipramine and
paroxetine over imipramine.

Supportive therapy
Complementary and alternative treatments suggested by the guidelines include Exercise
monotherapy and St. John Wort’s monotherapy. Bright light therapy and yoga can also be
considered. However, there is insufficient evidence to recommend Tai Chi, Acupuncture
monotherapy, combination of 2nd-generation antidepressants and omega-3 fatty acids,
5-adenosyl methionine monotherapy and combination of 2nd-generation antidepressant and
exercise.

Complications

About 5 to 10 percent of patients with an initial diagnosis of major depressive disorder

have a manic episode 6 to 10 years after the first depressive episode. The mean age for this
switch is 32 years, and it often occurs after two to four depressive episodes.
 30

An untreated depressive episode lasts 6 to 13 months; most treated episodes last about 3
months. The withdrawal of antidepressants before 3 months has elapsed almost always results
in the return of the symptoms. As the course of the disorder progresses, patients tend to have
more frequent episodes that last longer. Over a 20-year period, the mean number of episodes is
five or six.

Prognosis

Major depressive disorder is not a benign disorder. It tends to be chronic, and patients
tend to relapse. Patients who have been hospitalized for a first episode of major depressive
disorder have about a 50 percent chance of recovering in the first year. The percentage of
patients recovering after repeated hospitalization decreases with passing time. About 25
percent of patients experience a recurrence of major depressive disorder in the first 6 months
after release from a hospital, about 30 to 50 percent in the following 2 years, and about 50 to 75
percent in 5 years. The incidence of relapse is lower than these figures in patients who continue
prophylactic psychopharmacological treatment and in patients who have had only one or two
depressive episodes. Generally, as a patient experiences more and more depressive episodes,
the time between the episodes decreases, and the severity of each episode increases.
 31

FAMILY FOCUSED

FAMILY PROFILE

The Monte-Aribal Family is composed of the patient, Alayanah, her parents Simeon and
Amelita, her brother Brett, and her sisters Shaira and Sachie. The patient is the youngest of four
children.

Alyanah Aribal is an 18 year old, female, Filipino, Roman Catholic, grade 12 student
from Paknaan, Mandaue City. She is non-hypertensive, non-diabetic, non-asthmatic. Patient has
food allergies to crustaceans and seafood. Patient has no known drug allergies. Patient is fully
vaccinated with Astrazeneca vaccine for COVID-19 last November 24, 2021. Patient is a
non-smoker, occasional alcoholic drinker, patient drinks on occasion around 1-2x per month
during festivities, and a few glasses of wine. No history of any illicit drug use. Patient was from
Cagayan de Oro, and was struck by typhoon sendong. The family then decided to move to
Cebu around 2015. Patient lives with her parents and 3 siblings for a total of 6 in the house. No
history of any heredofamilial disease as claimed.

Simeon Aribal Jr., a 61 year old male, Filipino, Roman Catholic, is the father of the
patient. He is a graduate of Marine Technology and previously worked as a seaman for 23
years. Patient was is not a known hypertensive, diabetic, and asthmatic. No previous
hospitalization and surgeries as claimed. Patient has completed the COVID-19 Vaccine. Patient
is an alcoholic beverage drinker, drinking 1-2 drinks per day, patient claims to frequently drink
“hard drinks”. Patient is a non-smoker and has no history of illicit drug use. He has no known
food and drug allergies.

Amelita Aribal, a 58 year-old, female, Filipino, Roman Catholic, is the mother of the
patient. She is a graduate of midwifery and previously worked in a pharmacy after giving birth to
her first child. She is asthmatic since 27 years old. Maintenance medications include Ventolin,
once or twice daily with relief. She has no previous hospitalizations or surgeries, and was fully
vaccinated with Pfizer for COVID-19. She is a non-smoker, non-alcoholic beverage drinker and
denies illicit drug use. She has no food and drug allergies.
 32

Brett Aribal, 26 years old, male, Filipino, Roman Catholic, is the eldest of the four
siblings. He is a business management graduate and currently works as a call center agent. He
earns a starting salary of PHP 12,000/month and gives the remaining to the family. He is
non-hypertensive, non-diabetic, and non-asthmatic. He also has no prior hospitalizations nor
surgeries. However, he had measles in 2004 and had pulmonary tuberculosis in 2015, he was
given Rifampicin for 9 months. At the end of treatment, his chest radiograph showed clear and
normal lung findings. He has no food and drug allergies. He claimed to have completed
childhood vaccination at their local barangay health center in Cagayan de Oro. He also claimed
to be fully vaccinated with Sinovac for COVID-19. Patient is an occasional alcoholic-beverage
drinker and non-smoker. He denies illicit drug use. Patient has a BMI of 24.16 which is
considered overweight in Asian-Pacific BMI classification.

Shaira Aribal, a 25 years old, female, Filipino, Roman Catholic, is the eldest sister of the
patient. She is a graduate of BS in Development Communication. She is currently working as a
BPO agent and also runs a small business called Amie’s Balloons and Party Prints. She earns
around Php 29, 000 a month working as a BPO agent and Php 5,000 - 10,000 a month from her
small business. She is non-hypertensive, non-diabetic and non-asthmatic. Past illnesses
include pulmonary tuberculosis in 2016. She was prescribed Rifampicin and was on treatment
from June 2019 to January 2020. Upon follow-up, she had a Chest X-ray which showed a
normal result. She also had Chickenpox last 2015. She claimed to have completed childhood
immunization at their local barangay health center in Cagayan de Oro. She is fully vaccinated
with Sinovac for COVID-19. She claims to be allergic to dust. Patient is a non-smoker and
non-alcoholic drinker. She denies illicit drug use.

Sachie Aribal, a 20 year old female, Roman Catholic is the 2nd elder sister of the patient.
She is currently a 3rd year medical biology student. She is non hypertensive, non diabetic and
non-asthmatic. No maintenance medications, no previous history of illness or hospitalization.
She is fully vaccinated with astrazeneca for COVID-19. She is a non-smoker, non alcoholic
drinker and denies illicit drug use.
 33

FAMILY LIFELINE

Monte - Aribal Family

Family Lifeline is a very significant tool that summarizes the important events in the
history of a family. It focuses on the individual’s or family’s significant life events over a period of
time in a chronologically-sequenced manner. The interpretation is based on the most significant
event that probably affected the health of each member of the family.
Alyanah’s parents, Simeon Jr. and Amelita, got married in 1992. Two years after their
marriage, their eldest child, Brett, was born, followed by Shaira in 1996. Four years later, in
2000, Sachie was born. Lastly, our patient, Alyanah, was born in 2003.
When the typhoon Sendong happened in the year 2011, it severely damaged their
properties and caused distress in their family, especially to his dad. The dad’s sister, her aunt,
helped their family to rise up again and gave his father a job in Cebu manning her business in
the year 2012. This probed her dad to stop working as a seaman.
In the year 2013-2015, Alyanah was bullied in her grade school. In the same year of
2015, their whole family transferred permanently to Cebu and Brett was diagnosed with
Tuberculosis. And the following year, Shaira was diagnosed also with Tuberculosis. In the
interim of 2016 to 2019, Alyanah was bullied again in her high school.
 34

In the year 2017, Alyanah started to feel empty accompanied with anhedonia. A year
after that, in 2018, she now started to think of committing suicide without any attempts. In 2019,
she began to lose her appetite thus resulting in her body to become malnourished and
underweight.
In the year 2020, Alyanah attempted to disclose her feelings and emotions to her family
but she got dismissed immediately and blamed her social network activities as the cause of her
negative emotions.
In the year 2021, Alyanah had weight loss and sought consultation in CIM-CMSS
Paknaan for a well-being check-up.

FAMILY AND HOME ENVIRONMENT

The Monte-Aribal Family lives in an approximately 400 sq. meter area, with a two-storey,
bungalow type of house with 4 bedrooms and 1 bathroom in Paknaan, owned by the patient’s
aunt. The house is made up of mixed materials of concrete and plywood (Appendix E). The area
is not prone to flooding. They have access to improved sanitation and waste disposal. Their
water source is from water pipes. Type of toilet used is a flush-type toilet. Upon exiting
CIM-CMSS Paknaan, turn right and drive approximately fifty (50) meters. Stop at the
intersection and turn left. About fifty (50) meters in, to your right you will see a large, open field,
with a nearby sign saying F2 Logistics. Keep following the main road. A hundred (100) meters
from the previous landmark, and following the curve of the road, note Paknaan’s Barangay
Hall, situated on your right. Drive for another two hundred (200) meters. You will pass by the
Paknaan National High School, and continue driving towards the rightward curve of the road,
fifty (50) meters from the previous landmark. Drive about another hundred (100) meters,
keeping watch for the entrance to the barangay’s church, Sto. Nino Parish, which you will see
on your left. Continue driving straight about two hundred eighty-two (282) meters until you see
an intersection of the road. You will find a row of stalls on your right which is the Paknaan Mini
Market. From there, turn left and continue following the road about one hundred fifty-eight (158)
meters from the intersection, you will pass by Golden Bark on your left. Drive for another two
hundred eighty-four (284) meters, you will find St. Therese Chapel on your right. Follow the
curve of the road and drive for another one hundred eighty-eight (188) meters, following Jayme
Street and you will find to your right the entrance of Sto. Nino Village at Zone Sikwa, Road 1.
To your right, you will find a neighborhood sundry store named Bogo store. Right beside the
 35

previous landmark, you will find a two-story home made of wood and concrete with a black
colored gate. This is the home of our CSC patient.

Fig. X Floor plan of the Monte-Aribal Family

 36

Figure X.

Spot Map of Monte-Aribal Family

 37

Fig. X Monte-Aribal Family Genogram

 38

FAMILY GENOGRAM

The Monte-Aribal Family Genogram shows three generations and depicts a nuclear
family with adolescents living in the same household as the patient, delineated by a dashed line.
The patient, Alyanah (18), is indicated by the black arrow and has been diagnosed with Major
Depressive Disorder on November 23, 2021. She lives with her parents and 3 siblings in Zone
Monggos, Barangay Paknaan, Mandaue City.
The patient’s parents, Simeon Aribal, Jr. (61) and Amelita Monte Ariba (58), have been
married since 1992. Simeon Jr. is the family breadwinner and primary decision maker. He has
no vices but was diagnosed with Primary Hypertension, Stage II, Newly Diagnosed on
November 20, 2021. Amelita is the primary caretaker. She was diagnosed with adult bronchial
asthma in 1991, currently it is not well-controlled. The couple has 4 children together: Brett (28),
Shaira Marie (25), Sachie (20), and Alyanah (18). Brett and Shaira Marie had pulmonary
tuberculosis in 2014 and 2016, respectively.

FAMILY LIFE CYCLE

Figure X. Family Life Cycle of the Monte-Aribal Family

 39

The Family Life Cycle is a description of family dynamics through six clearly defined
stages of development. The patient’s family is currently in Stage 4, Family with Adolescents,
which begins when the first child of the family reaches adolescent age. Although the first three
children of the family, Brett (28), Shaira Marie (25), and Sachie (20), are not considered
adolescents by WHO’s definition (individuals aged 10-19 years old), the family is not considered
as a Launching family (Stage 5) because the launching years start only when the first child
leaves home. The children in the family are not currently re-examining their living arrangement
with their own parents and there is development of adult-to-adult relationships between the
parents and the first two children, which are first and second order changes in the launching
family stage, respectively. However, they still live with their parents and the fifth stage only
begins when the first child leaves home.
First order changes are changes that the family must do to develop their current life
stage. Examples of first order changes during this stage include working out money matters with
teenagers, sharing the tasks of responsibilities of family living, putting the marriage relationship
into focus, keeping the communication system open, maintaining contacts with the extended
family, growing into the world as a family and as a person, and reworking and maintaining a
philosophy of life. The parents give allowances to Sachie and Alyanah and they don’t demand
money from their parents. Amelita usually does the chores in the house but the children also
help out when they are free. Amelita claims to have a good relationship with her husband and
rarely argue with each other. Amelita also claims that the family is able to talk to each other
openly. The family still maintains contact with their relatives, however, seldomly.
There are three developmental tasks, or second order changes, that must be
accomplished during this stage: (1) a shifting of parent-child relationships to permit the
adolescents to move in and out of the system, (2) a refocusing on midlife marital and career
issues, and (3) beginning a shift towards joint caring for the older generation. Amelita claims
that her first child is in a relationship and her second child is engaged. She is ready to let them
leave their home when they are ready. Amelita understands that she is approaching her senior
years.
For the Monte-Aribal Family, the medical problems encountered by the adolescents
include menstrual irregularities and seafood allergy, especially to shrimps. The
emotional/psychosocial problems encountered by the adolescents include identity crisis, conflict
with parents, and suicide tendencies. Alyanah said that she is confused about her identity and
that she is attracted to both men and women. Alyanah feels that her mother frequently nags at
 40

her and blames her lifestyle for the issues she has. Amelita downplays her daughter’s concerns
and just tells her that it’s just in your head. Amelita also decides on what Alyanah wears.
Alyanah still has thoughts of hanging herself using a rope and taking her own life when cleaning
the dishes especially when wielding a knife. Alyanah also attempted to drown herself when
taking a shower on multiple occasions. The medical problems encountered by the parents
include asthma, hypertension, and alcoholism.

APGAR I

PART I-C: FAMILY FUNCTIONALITY – FAMILY APGAR

ITEMS Name
Place the name/s of the family member/s who will answer and score each
item as follows per family member:
0: Hardly ever (Wala gayud), Index Mother
Father
1: Some of the time (Pipila ka panahon)
2: Almost always (Halos kanunay)

ADAPTATION – I am satisfied I can turn to my family for help

when something is troubling me. 1 2 2

PARTNERSHIP – I am satisfied with the way my family talks

over things with me and shares problems with me. 1 2 2

GROWTH – I am satisfied that my family accepts and

supports my wishes to take on new activities or directions. 1 2 2

AFFECTION – I am satisfied with the way my family expresses

affection and responds to my emotions, such as anger,
0 2 2
sorrow or love.

RESOLVE – I am satisfied with the way my family and I share

time together. 1 2 2

4 (Moderately 10 (Highly 10 (Highly

TOTAL SCORE AND INTERPRETATION *:
Dysfunctional) functional) functional)

The family APGAR I is a family tool used to assess family function. The patient gave a
score of 0-1 for each parameter, with a total score of 4 which indicates that she sees her family
as moderately dysfunctional. According to her, she gets nervous whenever she tries to turn to
 41

her family in times of need and asking for help. Patient is not satisfied with the way her family
talks to her with her problems. Patient also feels distant from her father and she claims to have
a gap with him. She also feels that she is responsible for initiating reconciliation with her mother
whenever they are not on good terms. Patient feels that both her mother and father support and
do not support her endeavors and activities at the same time. Patient also claims that her family
members are unable to share and express their emotions and feelings to one another. She also
claims her siblings are busy and they don’t get to spend much time together.

For the father and the mother of the patient, they gave a score of 2 for each parameter
with a total score of 10. They are satisfied with how their family can turn into each other
whenever they have problems and support each other's decisions. When the father decided to
work for his younger sister in Cebu, the family followed him after 3 years with no hesitations.
The family gives time to each other whenever they express emotions such as anger. They also
enjoy their time together whenever their second child suggests family outings. For the parent’s
APGAR score, it shows a highly functional family.

APGAR II

INFORMANT: PATIENT

APGAR II

Who lives in your home? How do you get along?

Name Relationship Age Sex Well Fairly Poor

Simeon Jr. Father 61 M ✔

Amelita Mother 57 F ✔

Brett Older Brother 28 M ✔

Shaira Older Sister 25 F ✔

Sachie Older Sister 20 F ✔

The Family APGAR II delineates relationships with other members and identifies people
who can give assistance and indicate conflicts not revealed in APGAR I. The patient’s APGAR II
 42

shows that the patient gets along well with all the family members in the household and claims
that she has no conflicts within the family.

FAMILY DYNAMICS

Point of view of the patient. The patient feels she is different from her other siblings and
describes herself as more “badlungon”. Patient feels distant from her father. She feels like there
is a “gap” between them. Patient is disappointed at her father’s vices of drinking alcohol. Patient
thinks her mother is overprotective of her. She feels that her mother decides too much on what
she needs to do. She also feels like her mother thinks of her as healthy and has no problems.
Patient feels that she is responsible for initiating reconciliation with her mother whenever they
are not on good terms. Patient feels that both her mother and father support and do not support
her endeavors and activities at the same time. Patient claims that she is close with her sister 3
and that they used to be able to share and do things together before. She also thinks her
siblings are busy and they don’t get to spend time together. Patient also mentioned that she
doesn’t have any close friends in the neighborhood and she only has 3 close friends from high
school. Patient also claims that her family members are unable to share and express how they
feel to one another.

Point of view of the father. The father was a previous seaman for 20+ years, and claimed that he
would be away from home around 9 months a year and come back for a few months during a
break. The father mentioned that when the patient was still a child, he was away for 2 straight
years and was unable to see, and when he came back the patient was surprised to see her
father, and did not recognize her father. The father does not see anything wrong in the patient,
he just sees it as a lifestyle choice when asked regarding the weight loss and the loss of
appetite. Even continuing to scold the patient when the patient is not eating properly, thinking of
her health. The father says that he would give anything to the patient if he has the means. The
father mentioned that he does not support the pursuit of the patient in the fine arts. He wants
her to get a “practical” course, because fine arts is a rich family’s job. He does not see any
problems with anyone in the family nor any problems in their relationship with each other. Father
does not seem to understand the problems of mental health. 10 years prior, father and the
family were hit by Typhoon Sendong, and they lost everything in the flood. Father claimed he
 43

was depressed but sees it not as a problem but rather as an obstacle that he had to overcome
in order to stand up again.

Point of view of the mother. The mother was a graduate of midwifery but worked in a pharmacy
for 10 years. She is the primary caregiver of the family. She is worried about the patient's health
and scolds the patient when not eating on time because she wants her to have good health,
however she also thinks that this is only influenced by lifestyle. She focuses on the patient more
than her other children because she thinks that Alyanah is not capable of going out on her own.
She is not supportive of the patient's pursuit of fine arts. She restricts the patient's activities
because she doesn't trust the patient's friends and worries about her going out alone. She
believes that everything she's doing is the best for her children. She thinks that her child has no
problem or is just focused on her studies.

Point of view of Sister 1. Sister 1 is 2nd in rank among the four siblings and is the most
responsible of the four. She is one of the financial providers of the family. She is a college
graduate and finished a degree in BS Developmental communication and is currently working in
a business process outsourcing. She is currently engaged and has plans to get married next
year, already with the consent of her parents. Sister 1 is the one in the family who tries to initiate
family outings/family gatherings, one recent example is that she was the one who pushed their
parents to have a celebration for the patient’s 18th birthday and presented to pay for the
expenses. She is protective of the patient, she is the one who tells their mom to stop scolding
the patient. The sister thinks that the patient is not yet mature enough, as she is hard-headed
and is a bit distant to the family. Sister 1 agrees that the patient should not be allowed to go out
alone or with her friends, as she claims that their family doesn’t know who these friends are..
The patient occasionally shares problems with the sister, the sister would try her best to console
her but in a way that the patient wouldn’t think that something is wrong with her. Sister 1
believes in mental health and claims to have a close friend who has an anxiety disorder,
however, she does not know that there is something wrong with her sister.

Point of view of Sister 2. The sister is currently a 3rd year BS medical biology major in the
University of San Jose-Recoletos (USJR). She mentions that she and the patient are the most
close in the family, that they live and share the same room. She mentioned that she and the
patient used to share personal things with each other, but did not mention the possible mood
disorder of the patient. She does not see anything wrong with the patient when asked who in the
 44

family has problems. She even thinks that out of everyone in the family, sister 1 is the person
with the most likely mental health problem. She believes in mental health and the possibility of
problems with mental health. She also thinks that the patient's changes in weight is a lifestyle
choice, she mentions that she noticed the changes when the pandemic started and could be the
reason why. Does not see any problems in the family, just a few petty fights owing to the fact
that they are all cooped up in the house. She also wants to be a doctor in the future.

FAMILY MAP

For the family map, we have Alyannah, the patient, Simeon, her father, Amelita, her mother and
her siblings, Shaira, Sachi and Bret. The patient’s relationship with the mother is enmeshed
since the mother stopped the patient from joining the volleyball varsity. The patient is bound by
the rules established by her parents and lacks the freedom of fulfilling her wants and having her
own life choices. The remaining persons in the family share functional relationships with each
other. The patient and the mother have rigid boundaries because the patient does not have the
freedom to do or decide as she pleases. The family also has a lack of reaction to the problems
 45

shared by the patient. The patient claims that she feels the love from her parents but she feels
that they are overprotective.

FAMILY CIRCLE

Figure X. Family Circle by Alayanah Aribal

The Family Circle is a schematic diagram drawn by a person that represents their own
view of their family system, illustrating the patterns of closeness and distance, family alliances
and boundaries. The patient identifies Sachie as the individual closest to her followed by Shaira
and Bret. The patient has a good relationship with siblings. The patient feels distant to her
parents. She describes that there is a wall between her and her mother and that her father is
an absentee. All of the members have equal influences in her life.

FAMILY ILLNESS TRAJECTORY

Stage I: Onset of Illness

In the first stage, the onset of illness was gradual as the patient started questioning the
purpose of doing things when all of us will just die. This thought started last 2017 and has been
 46

repeating in her mind since then. This thought was associated with a feeling of emptiness and
anhedonia. In 2018, the patient had suicidal ideations, such as hanging herself with a rope.
Anhedonia and feeling of emptiness also worsened. The patient shared her thoughts and
feelings to her friend but was not comforted as her friend told her that she was just “OA”. In
2019, the patient still had anhedonia and felt really empty. She also had suicidal ideation. The
patient also started to lose her appetite at this time, consuming only 1-3 spoons per meal. In
2020, the patient’s anhedonia, feeling of emptiness and suicidal ideations persisted. Her parents
noticed how she had been losing weight and got scolded about it. The patient opened up about
her feelings to her parents but felt rejected as she was told that she was just “OA” and her
weight loss is just due to her lifestyle. In 2021, the patient visited CIM-CMSS for a medical
check up as a requirement for a scholarship program and was able to share her feeling of
emptiness, anhedonia and suicidal ideations to the attending physician and was referred to a
psychiatrist.

Stage II: Impact Phase - Reaction to Diagnosis

When the patient was brought to CIM-CMSS, the patient cried when privately assessed
by the attending physician. She shared her feeling of emptiness, anhedonia and suicidal
ideations was referred to a psychiatrist. Although the patient is underweight, the laboratory tests
and imaging taken at Maayo Medical revealed unremarkable results. The patient was then
brought to a psychiatrist and was diagnosed with Major Depressive Disorder. The patient was
initially confused with her condition but eventually understood what Major Depressive Disorder
is and that it is not only an illness of thought but there is also a physical component to it.
Alyanah’s condition was also explained to the mother and father at their level of understanding.
Her parents showed full support towards her condition.

Stage III: Major Therapeutic Efforts

The patient was prescribed pharmacologic treatment with Escitalopram 10 mg/tablet, to

be taken ½ tablet after breakfast and Risperidone 2 mg/tablet, to be taken ½ tablet before sleep.
The patient was also referred to a clinical psychologist with sessions advised for an hour every
2 weeks or monthly. The patient is currently compliant with her medications and already had her
first session with a clinical psychologist. The parents were educated on how to support the
patient on her condition such as listening to her when she shares her feelings and talking to her
 47

instead of scolding her. The patient had noticed that she had regained her appetite and had an
adequate sleep since taking her medication.

SMILKSTEIN’S CYCLE OF FAMILY FUNCTION

The Smilkstein’s cycle of family function is a conceptual framework that presents an

empirical view of the responses that may result when a family experiences a stressful life event.
The family was initially in in equilibrium when suddenly the patient felt empty for 4 years, this
was associated with anhedonia, loss of appetite, weight loss, and suicide ideation. This places
the family in disequilibrium. The patient tried to open up to her parents about her problems but
her family who is part of the intrafamilial resource didn't understand her and told her that she
was just exaggerating. The family was then placed in crisis.
Patient’s family wasn’t able to understand what she has been going through for the past
4 years, and assumed that she has been fine the whole time. Currently, not all members of the
family know the diagnosis of the patient.
 48

COMMUNITY-ORIENTED

SCREEM-RES

PART I-D: FAMILY RESOURCES – SCREEM-RES

AVERAGE PER
3– 0–
2– 1– ASPECT
QUESTIONS Strongly
Agree Disagree
Strongly
(Total per aspect /
Agree Disagree
2)

We help each other in our family. ✓

1. SOCIAL
1.5
We are helped by friends and other members of
the community.
✓

Our culture gives our family strength. ✓

2. CULTURAL 0
A culture of helping and cooperation in our
community helps our family.
✓

Our faith and religion help our family. ✓

3. RELIGIOUS 1.5
We are helped by members of our church or other
religious groups.
✓

Our family’s savings are adequate for our needs. ✓

4. ECONOMIC
3
Our family’s income is adequate for our needs. ✓
Our education/knowledge is adequate to
understand information about the illness.
✓
5. EDUCATIONAL 2
Our education/knowledge is adequate to care for
the patient.
✓
It is easy to access medical help in our
community.
✓
6. MEDICAL 3
We are helped by doctors, nurses, and health
workers.
✓

TOTAL SCORE (SUM OF AVERAGES) AND INTERPRETATION*: 11

*INTERPRETATION: 0-6 = severely inadequate resources; 7-12 = moderately inadequate; 13-18 = adequate family resources

SCREEM ANALYSIS
RESOURCES
SOCIAL The mother has an open
relationship with family and claims
that they do not have any conflicts.
They help each other at times of
need.
The family has friends within the
neighborhood and claims to have
no conflicts with them.
CULTURAL Deeply ingrained respect for their
parents made the patient hesitant
to execute suicidal ideations.
RELIGIOUS Deep faith in God gives the family
strength to overcome their current
crisis
ECONOMIC Three members of the family are
earning. The father is able to
sustain daily needs with his income.
The first and second child in the
family also contributes to the
family’s income.
The second child is wise in
investing her money through
sideline businesses.
49
PATHOLOGY
The patient feels like her family
does not help each other.
The parents invalidate the patient’s
feelings, assuming that what she is
feeling is just a phase whenever she
encounters a problem.
The mother and the older sister of
the patient have trust issues with
the patient’s friends as she doesn’t
introduce much of her friends, and
had experienced bullying since
elementary.
They don’t interact much with their
neighbors.
The patient thinks family gatherings
don't give strength to their family.
The family doesn't participate in
community activities.
The patient believes in God but has
stopped practicing her faith because
her parents criticize her during the
homily.
None
 50

The father receives a monthly

pension which they keep as
savings.

The family can turn to their relatives

in times of need.

EDUCATION Everyone in the household values Parents do not support the patient’s
education. The father, mother, 1st aspirations on a particular degree
and 2nd child are college preference and decide for the
graduates. patient's future academic path.

Sister is a B.S. Biology Major who

can understand the patient's
condition.

MEDICAL The family is aware of health Family has poor understanding and
facilities and services available for awareness about mental health.
them in times of need.
Family has poor healthcare seeking
Some members of the family are behavior.
Philhealth members and have
company insurance.

FAMILY ECOMAP OF MONTE-ARIBAL FAMILY

Zone Monggos, Barangay Paknaan, Mandaue City
 51

Simeon, Shaira and Bret are paying members of PAG-IBIG but have not availed of their
services yet. For the SSS, the patient’s father paid for his SSS and is currently receiving his
monthly pension and is using it for Alyanah’s expenses in school. Shaira and Bret are currently
paying for their SSS and currently do not receive any benefits. Sachie is a scholar from DOST
and studies in USJR, she does not pay for her tuition fee. Since Alyanah’s school is a public
school, she does not pay for tuition. Alyanah learns a lot from the school and in return she joins
art competitions representing the school. For the company, Shaira works as a call center agent
in a BPO company. The company includes health insurance that she actively pays monthly.
Her mother is under the beneficiary of Shaira’s health insurance and was able to use this
insurance last year when she had an asthma attack. She had no medical expenses and the
insurance gives free medical services. All of them are already members and paying for
Philhealth except for Sachie and Alyanah. They haven’t used their Philhealth insurance since
none of them have been recently hospitalized.
For their relatives, her mother mentioned that their current business is from the sister of
the father, Simeon. She said that her sister, Merna, helped them a lot especially last 2011 when
they got hit by Bagyong Sendong and also extended help for the studies of their children. As for
their other relatives, the mother claimed that they sometimes extend help when they really need
it and vice versa. The CIM clerks and doctors CIM-CMSS Paknaan is helping the patient by
handling her case and in turn we learn a lot from them. We went to Maayo clinic to have the
patient’s labs done and Hospitaller Sister’s of the Sacred Heart of Jesus Maria Josefa Recio
Therapeutic Center for consultation. Untapped resources include NCMH (National Center for
Mental Health) and KAUBAN mental health group.

MENTAL HEALTH PROGRAMS IN THE COMMUNITY

The National Mental Health Program by the Department of Health, the overall head
program for Mental Health in the country, is a program that includes a wide range of promotive,
preventive, treatment and rehabilitative services. The National Mental Health Program has the
following specific objectives:
1. To promote participatory governance and leadership in mental health
 52

2. To strengthen coverage of mental health services through multi-sectoral partnership to

provide high quality service aiming at best patient experience in a responsive service
delivery network
3. To harness capacities of LGUs and organized groups to implement promotive and
preventive interventions on mental health
4. To leverage quality data and research evidence for mental health
5. To set standards for compliance in different aspects of services

The National Mental Health Program has the following components:

1. Wellness of Daily Living which aims to promote, attain and maintain the mental health
and well-being of all persons across the life course (from pregnancy to old age) and in
different settings (such as schools, workplace, communities) through healthy and
effective coping as well as the prevention of suicide
2. Extreme Life Experience with emphasizes the development and enhancement of
resiliency and address the mental health and psychosocial needs and consequences of
persons, families and communities that experience critical incidents and events (such as
trauma, domestic violence and disasters)
3. Mental Disorder which focuses on the promotion of mental health and well-being;
prevention of mental disorders; assessing, diagnosing and treating of mental disorders;
and improving of the quality of life of persons with psychosocial disability through
rehabilitation, and community integration
4. Neurologic Disorders with the specific goal of promoting neurologic health and
preventing common neurologic disorders such as, but not limited to epilepsy, dementia,
and developmental disorders; assessing, diagnosing and treating neurologic disorders;
and improving the quality of life of persons with neurologic disorders
5. Substance Abuse and other Forms of Addiction with the primary objective of promoting
protective factors, reducing risk factors and preventing the development of substance
abuse and other forms of addiction in different settings (family, school, workplace,
community and industry)
These program implementations were governed by the following policies and laws,
namely, the National Mental Health Policy (DOH Administrative Order No. 8 series of 2001)
signed by the former DOH Secretary Manuel Dayrit in which it puts emphasis on the pursuance
of the creation of a national mental health policy and address its core issues which are the lack
 53

of conscious awareness of mental health as an integral component of total health care and of
the general health care system and the lack of political will to implement a comprehensive
national mental health program. It also mandates the integration of mental health into general
health care programs and services, and systems of hospitals, health centers and other health
units of the government and private sectors. The essential treatment and drugs for substance
abuse and brain disorders such as epilepsy, dementia and cerebral palsy were also given
prioritization in this policy.
Secondly, we have the Revised Operational Framework for a Comprehensive National
Mental Health Program (DOH administrative order no. 2016- 0039) signed by DOH Secretary
Paulyn Jean Ubial last October 28, 2016 which highlights the need to reduce by one-third (⅓)
the premature mortality due to non-communicable diseases through the prevention and
promotion of mental health and well-being, and to strengthen the prevention of substance abuse
and treatment of mental disorders by 2030 in line with the United Nations Sustainable
Development Goals
Lastly, we have the Republic Act 11036 or otherwise known as the Mental Health Act
which was signed last June 20, 2018 by President Rodrigo Duterte. This law was promulgated
to enhance and integrate mental health service delivery to Universal Health Care through the
promotion and protection of the rights of persons using psychosocial health services and
increasing investments in mental health. This was principally authored by Senator Risa
Hontiveros in the context that mental health remains a grossly misunderstood topic in the
Philippines and most people who suffer from mental illnesses are often discriminated, and in
turn, this stigma translates to poor statistics and underestimation of the disease severity. She
also emphasized that accessibility remains uneven throughout the country since most facilities
are situated in the NCR.

Mental Health Free Counseling Hotlines

● In Touch: Crisis Line
○ Landline: (02) 893-7603
○ Globe: 0917-800-1123
○ Sun Double Unlimited: 0922-893-8944
● NCMH Crisis Hotline​(National Center for Mental Health)
○ Globe/TM Subscribers:
■ 0917-899-USAP (8727)
 54

■ 0966-351-4518
○ Smart/Sun/TNT Subscribers
■ 0908-639-2672
○ Nationwide Landline toll-free
■ 1553
● VSMMC Center for Behavioural Sciences Teleconsult
○ Landline: 253-4423
○ Mobile: 09292873688
● Thomasian Mental Health Responders
○ text/Viber through +639171521817
● Hopeline (by ​Natasha Goulbourn Foundation​)
○ Landline: (02) 804-HOPE (4673)
○ Globe: (0917) 558-HOPE (4673)
○ Globe and TM: 2919
● Tawag Paglaum-Centro Bisaya
○ Smart/Sun: 0939-9375433 / 0939-9365433
○ Globe/TM: 0927-6541629
● Philippine Mental Health Association, Inc.
○ (02) 921-4958 / (02) 921-4959
Mental Health Support Groups and Organizations in Cebu
● KAUBAN
● Tawag Paglaum-Centro Bisaya
● VSMMC-Center for Behavioral Science Tele-consultation
● Mental Health for Millennial (MH4M)
● Cebu Anxiety and Depression Support Group
Mental Health Support Groups and Organizations in the Philippines
● Anxiety and Depression Support Philippines
● Be Healed Foundation
● Bipolar Support PH
● Boxless Society
● Buhay Movement
● Crisis Line
● Coalescent Foundation
 55

● Mental Health and Psychosocial Support, Philippines

● Mental Health Matters by Kylie Verzosa
● Mental Health PH
● National Center for Mental Health
● No To Mental Health Stigma PH
● Philippine Mental Health Association, Inc.
● Philippine Psychiatric Association
● Psychological Association of the Philippines
● PRISM
● Schizophrenia and Bipolar Philippines Support Group
● Social Anxiety Support Philippines
● SOS Philippines
● Tala Mental Wellness
● Talang Dalisay
● The Julia Buencamino Project
● Tibok
● Youth For Mental Health Coalition
 56

ROOT CAUSE ANALYSIS

Several factors were identified that contributed to the lack of mental health awareness.
The primary factor identified is mental health stigma in the Philippines. This, in turn, leads to
prejudice and hostility towards people with mental illness and discrimination and bullying of
people with mental illness. This stigma in the local setting only shows that a lot of Filipinos lack
proper information about mental health.
A second factor identified is poor mental health literacy. Good mental health literacy in
young people and their key helpers may lead to better outcomes for those with mental
disorders, either by facilitating early help-seeking by young people themselves, or by helping
adults to identify early signs of mental disorders and seek help on their behalf. This is due to
lack of research and poor insight on mental health.
 57

A third factor identified is the lack of mental health services accessibility. In the
Philippines, most facilities are situated within the National Capital Region and the country’s
major cities that make accessibility a challenge for people who live far from these areas. There
is also a lack of mental health experts and facilities. One psychiatrist handles 250,000 mentally
ill patients and the ideal ratio is 1:50,000. Only 5% of the total DOH budget is allocated for
mental health. 95% of the 5% are spent on the operation, maintenance, and salary of personnel
of mental hospitals. There is also a shortage of medication for those affected with mental illness.
There is also a lack of appreciation of the field and also it is expensive to enter that field.
The fourth factor identified is poor health-seeking behavior. Because of the stigma, the
people would rather hide their problem. The shame and stereotyping also pushes those affected
to hide and struggle on their own; these would lead to pathologic coping mechanisms and poor
quality of life.
The fifth factor identified is toxic positivity. Because of a lack of belief about mental
health, people would think it’s just a phase or just attention-seeking behavior. This is worsened
due to the generation gap, in which the older generation has little or no knowledge about mental
health and illnesses.
The sixth factor identified is reduced social networks. Poor social support has been
linked to depression and loneliness and has been shown to alter brain function. Factors that
contribute to the reduced social networks include low-self esteem and poor self-efficacy,
overprotective parents, and detachment from friends and family.
 58

PROBLEM PRIORITIZATION

Problems Urgency Capability to Resources Total

Respond

Prejudice and 4 2 3 9
hostility towards
people with
mental illness

Misperceptions 4 2 3 9
of people with
mental illness

Poor insight on 5 4 5 14
mental health

Mental health 4 3 4 11
awareness not
promoted or
talked about in
school

Lack of mental 4 3 4 11
health education
campaigns

Lack of Mental 3 2 3 8
health experts
and facilities

Patients don’t 4 2 2 8
really go to
psychiatrists

Psychiatric 2 2 3 7
consults are
expensive

Unawareness of 4 3 3 10
Mental Health
Policies

Pathologic 5 5 5 15
coping
mechanisms
 59

Fear of 5 4 5 14
discrimination to
self (self-stigma)

Fear of 4 2 3 9
discrimination
towards family
(family shame)

Unrealistic 4 2 3 9
optimism about
disease severity

Differences of 3 2 2 7
perspective due
to Generational
gap

Low self-esteem 5 4 4 13
and poor
self-efficacy

Overprotective 4 3 3 10
parents

Isolation from 5 3 3 11
friends and
family

PROGRAM PLANS

GOAL: Let the patient, family and community acknowledge that mental health is a
growing pandemic and a pressing issue that needs to be dealt with immediately.

Objectives Outputs Component Activities

GO 1: To employ a Do major therapeutic efforts

biopsychosocial approach to
manage the patient’s mental
health condition.

SO 1: To educate the patient Refer the patient to a The patient will undergo
on healthy coping strategies. psychiatrist. psychotherapy and
pharmacotherapy.
 60

SO 2: To encourage selective The patient will learn from Introduce the patient to
disclosure and to empower others with similar mental health support groups
the patient to reduce experiences.
self-stigma.

SO 3: To provide avenues to Refer the patient to a clinical The patient will undergo
further improve and utilize her psychologist art-based therapy
strengths and talents to open
her social network.

GO 2: To involve the family in Provide emotional support

the patient’s plans of care. (Level 3 of physician
involvement)

SO 1: To correct the family’s
emotionally critical
misperceptions on the
patient’s condition.
Family will acknowledge and
understand the patient’s
condition.
Elaborate the explanatory
model of the patient’s illness
to the family through the CEA
method during the family
meeting.

SO 2: To educate the family The family will know their Consult an adolescent
regarding adolescent limitations on the patient’s pediatrics/psychologist.
development. decisions in life.

GO 3: To raise public Do a CSC Webinar and make

awareness on mental health. an infographic

SO 1: To increase awareness Talk about the social issues

on how discrimination,
bullying, prejudice and
hostility affect people with
mental illnesses
SO 2: To encourage equality
between physical and mental
illnesses.
like bullying that could be risk
Share an infographic about
factors that can predispose MDD. Invite mental
someone to mental health healthcare professionals
illnesses. (psychologist, psychiatrist,
adolescent pediatrics, mental
Emphasize the need for a health support group) during
holistic approach in managing the webinar that can
patients in the community. enlighten the general public
about mental health.

With our primary goal to bring to light the issue of mental health, our general objectives
are outlined using the patient-family-community (PFC) matrix. For patient-centered
interventions, our plans are geared toward pharmacotherapeutic and psychotherapeutic
management of our patient. For family-focused, we aim more on educating her family about her
condition. With the help of an adolescent pediatrician, we can understand better the relationship
 61

between an adolescent and her parents. For our community-oriented goal, we aim to be able to
increase the awareness on risk factors of mental illnesses.

FAMILY WELLNESS PLAN

Monte - Aribal Family

Family Diagnosis Primary Intervention Secondary Tertiary

Member Intervention Intervention

Alyanah Aribal, Major Pharmacotherapy

18/F Depressive - Escitalopram
(Patient) Disorder 10mg/tab ½ tab
after breakfast
- Risperidone
2mg/tab ½ tab
before sleep
Monitoring
- Monitoring of
common side
effects of
escitalopram
include diarrhea,
drowsiness,
headache,
insomnia,
nausea
- Monitoring of
common side
effects of
risperidone
include agitation,
akathisia,
anxiety,
constipation,
dizziness,
drowsiness,
dystonia,
extrapyramidal
reaction, nausea,
rhinitis, weight
gain
Psychotherapy
 62

- Psychotherapy
sessions twice a
month
- Cognitive
behavioral
therapy
- Interpersonal
Therapy for
Adolescent\
Monitoring
- Monitoring of
life-threatening or
dangerous
behavior such as
acting recklessly
or engaging in
risky activities or
self injurious
behaviour, and
stopping
life-saving
medical
medications.

Chronic Addressing underlying cause:

Malnutrition - Major Depressive
Disorder (MDD),
Moderate
Monitoring
- Periodic measurement of
weight
Lifestyle Modification
- Offer nutritional
counselling and build up
achieving healthy weight
appropriate for age and
height
- Adequate diet, containing
all essential macro- and
micronutrients
- Advice to lessen
sedentary behaviours and
increase the routine daily
physical activity of at least
150 minutes
moderate-intensity
aerobic physical activity
throughout the week, or
do at least 75 minutes of
vigorous-intensity aerobic
 63

physical activity
throughout the week, or
an equivalent combination
of moderate- and
vigorous-intensity activity
- Reduced intake of free
sugars throughout the life
course to less than 10%
of total energy intake

General Periodic Health Exam:

Wellness - Medical history
- Complete PE: Periodic
height and weight
measurements, BMI
Immunizations
- Booster for Tdap every 10
years
- Influenza annually
- HPV Vaccine
- JE Vaccine
- COVID-19 vaccine
booster after 6 months
from the second dose
Screening
- Latent TB infection
screening with Mantoux
test
Psychosocial and Lifestyle:
- Unhealthy alcohol use
screening and behavioral
interventions
- Unhealthy drug use
screening
- Healthy eating habits
- 150 minutes
moderate-intensity
aerobic physical activity
throughout the week, or
do at least 75 minutes of
vigorous-intensity aerobic
physical activity
throughout the week, or
an equivalent combination
of moderate- and
vigorous-intensity activity
- Follow COVID-19
protocols

Simeon Jr. T/C Primary Work-up

Aribal, 61/M Hypertension - Blood tests: Na, K, serum
(Father) creatinine, eGFR, lipid
panel (Cholesterol, LDL,
 64

TAG, VLDL, HDL), fasting

glucose
- Urine Test: Dipstick urine
test
- 12-Lead ECG
Pharmacotherapy
- Losartan 50mg/tab, 1
tablet PO once per day
- Amlodipine 10mg/tab, 1
tablet PO once per day
Monitoring
- Annual health exam
(urinalysis, ECG, lipid
panel, creatinine, BUN)
- Daily BP home monitoring
- BMI monitoring
Lifestyle Modification
- Diet: DASH diet
- Exercise: At least 90 to
180 minutes of moderate
intensity exercise per
week
- Lower alcoholic intake

General Periodic Health Exam:

Wellness - Medical history
- Complete PE: Periodic
height and weight
measurements, BMI
Immunizations
- Booster for Tdap every 10
years
- Influenza annually
- Pneumococcal Vaccine
- COVID-19 vaccine
booster after 6 months
from the second does
Screening:
- Osteoporosis screening
with DEXA scan
- Latent TB infection
screening with Mantoux
test
Psychosocial and Lifestyle:
- Unhealthy alcohol use
screening and behavioral
interventions
- Falls prevention
interventions
- Dietary counseling:
Reduce saturated fats,
sodium, and
sweets/sugars and
 65

increased consumption of
fruits, vegetables, and
whole grains.
- Physical activity: 90 to
180 minutes per week of
moderate to vigorous
activity
- Follow COVID-19
protocols

Amelita Aribal, Bronchial Non-Pharmacotherapy

58/F Asthma, - Consult
(Mother) Uncontrolled, physician for
not in Acute medication
Exacerbation
adjustment
Lifestyle Modification:
- Avoidance of
allergens
- Breathing
exercises
- Healthy diet

T/C Primary Work-up

Hypertension - Blood tests: Na, K, serum
creatinine, eGFR, lipid panel
(Cholesterol, LDL, TAG, VLDL,
HDL), fasting glucose
- Urine Test: Dipstick urine
test
- 12-Lead ECG
Pharmacotherapy
- Losartan 50mg/tab, 1
tablet PO once per day
- Amlodipine 10mg/tab, 1
tablet PO once per day
Monitoring
- Annual health exam
(urinalysis, ECG, lipid
panel, creatinine, BUN)
- Daily BP home monitoring
- BMI monitoring
Lifestyle Modification
- Diet: DASH diet
- Exercise: At least 90 to
180 minutes of moderate
intensity exercise per
week

General Periodic Health Exam:

Wellness - Medical history
- Complete PE: Periodic
 66

height and weight

measurements, BMI
Immunizations
- Booster for Tdap every 10
years
- Influenza annually
- JE vaccine
- Pneumococcal Vaccine
- COVID-19 vaccine
booster after 6 months
from the second does
Screening:
- Osteoporosis screening
with DEXA scan
- Breast cancer:
Mammography every 2
years
- Cervical Cancer
screening: every 3 years
with cervical cytology
alone, every 5 years with
high-risk human
papillomavirus (hrHPV)
testing alone, or every 5
years with hrHPV testing
in combination with
cytology (cotesting)
- Latent TB infection
screening with Mantoux
test
Psychosocial and Lifestyle:
- Unhealthy alcohol use
screening and behavioral
interventions
- Falls prevention
interventions
- Dietary counseling:
Reduce saturated fats,
sodium, and
sweets/sugars and
increased consumption of
fruits, vegetables, and
whole grains.
- Physical activity: 90 to
180 minutes per week of
moderate to vigorous
activity
- Follow COVID-19
protocols

Brett Aribal, S/P Pulmonary Post treatment follow-up

26/M Tuberculosis, - Clinical evaluation of TB
 67

(Older Brother) treatment signs and symptoms

completed - Chest X-ray
(2016) - SM and culture

Essentially Well Periodic Health Exam:

- Medical history
- Complete PE: Periodic
height and weight
measurements,BMI
Immunizations:
- Influenza annually
- HPV (quadrivalent or
nonavalent)
- Booster for Hepatitis B,
Tdap and MMR
- JE vaccine
- COVID-19 booster 6
months after 2nd dose
Screening:
- Hypertension
- Diabetes Mellitus
- Hepatitis B and C, and
HIV
- Cervical CA
- Skin CA
- Chlamydia & Gonorrhea,
if sexually active
- Breast Self-Exam
- Depression
- Alcohol and Drug use
Counseling:
- Physical Activity: Exercise
30 minutes per day
- Nutrition/Diet: 3 full meals
per day
- Safety Measures: Alcohol
limit
- Follow COVID-19
protocols

Shaira Aribal, S/P Pulmonary Post treatment follow-up at 6

25/M (Older Tuberculosis, and 12 months after treatment
Sister) treatment completion (cured or
completed completed)
(2020) - Clinical evaluation of TB
signs and symptoms
- Chest X-ray
- SM and culture

Essentially Well Periodic Health Exam:

- Medical history
- Complete PE: Periodic
height and weight
 68

measurements,BMI
Immunizations:
- Influenza annually
- HPV vaccine (Bivalent,
Quadrivalent, or
Nonavalent)
- Booster for Hepatitis B,
Tdap and MMR
- JE vaccine
- COVID-19 Booster 6
months after 2nd dose
Screening:
- Hypertension
- Breast Self-Exam
- Depression
- Alcohol and Drug use
- Skin CA
STD Screening:
- Behavioral Counseling
- Hepatitis B and C, and
HIV - HBsAg, Anti-HCV,
HIV-1 NAT
- Chlamydia & Gonorrhea -
Nucleic acid amplification
tests
- Syphilis exam -
nontreponemal and
treponemal Ab tests
- Cervical CA - Screening
every 3 years
Counseling:
- Physical Activity: Exercise
30 minutes per day
- Nutrition/Diet: 3 full meals
per day
- Safety Measures: Alcohol
limit
- Follow COVID-19 health
protocols

Sachie Aribal, Essentially Well Periodic Health Exam:

20/F (Older - Medical history
Sister) - Complete PE: Every one
to two years
measurement of height,
weight, and BMI
measurements
Immunizations:
- Influenza annually
- HPV vaccine (Bivalent,
Quadrivalent, or
Nonavalent)
- Booster for Hepatitis B,
 69

Tdap and MMR

- JE vaccine
- COVID-19 Booster 6
months after 2nd dose
Screening:
- TST as screening for TB
- Hypertension
- Breast Self-Exam
- Depression
- Alcohol and Drug use
STI Screening: (if sexually
active)
- Behavioral Counseling
- Hepatitis B and C, and
HIV - HBsAg, Anti-HCV,
HIV-1 NAT
- Chlamydia & Gonorrhea -
Nucleic acid amplification
tests
- Syphilis exam -
nontreponemal and
treponemal Ab tests
Counseling:
- Physical Activity: Exercise
30 minutes per day
- Nutrition/Diet: 3 full meals
per day
- Safety Measures: Alcohol
limit
- Follow COVID-19 health
protocols

INTERVENTIONS

Patient-centered
A. Clinical Management of the Patient’s Condition
a. General Objective: To diagnose and treat the patient’s condition
b. Specific Objectives:
i. To utilize the data obtained from history, physical examination, scales,
questionnaires and laboratory work-ups to establish the diagnosis of
Major Depressive Disorder (MDD).
ii. To refer the patient to a psychiatrist and clinical psychologist.
iii. To educate the patient on her misconceptions regarding her condition.
 70

c. Methodology:
i. Diagnostics
1. Definitive: Psychiatric History and Mental Status exam according
to the DSM-5 criteria
2. Supportive:
a. Depression Questionnaire
b. Suicidal Risk Assessment
c. Mini Nutritional Status Assessment Scale
d. Complete Blood Count
e. Urinalysis
f. Serum Na, K, Ca, Phosphorus
g. Serum Albumin
h. Stool Exam
i. Serum Creatinine and BUN
j. AST and ALT
k. FBS
l. Lipid Panel
m. Thyroid Panel
n. Chest X-ray PA and Lateral views

ii. Management
1. Definitive
a. Psychotherapy with a psychiatrist and clinical psychologist
such as cognitive behavioral therapy and interpersonal
therapy
b. Escitalopram 10 mg/tablet, to be taken ½ tablet after
breakfast
2. Supportive Plans:
a. Adjunctive therapy with a second generation antipsychotic,
Risperidone 2mg/tab ½ tab once daily, to increase appetite
and allow weight gain
b. Reassured the patient that we are here to support the
patient in these difficult times
 71

c. Reassured the patient that this is a condition that is

legitimate and can be treated
d. Psychoeducation of the patient about the etiology,
treatment and prognosis
e. Psychoeducation of the family about the etiology, treatment
and prognosis
f. Advised the patient to increase meal intake and eat a well
balanced diet when appetite increase

Family-focused
I. Family Health Education
A. General Objective: To educate the family regarding Major Depressive Disorder
B. Specific Objectives: To hold a family meeting:
1. To utilize the Catharsis-Education-Action (CEA) method to gauge their
thoughts, feelings, explanatory models, and plans regarding the disease
activity.
2. To discuss the role of each family member in the medical interventions for
the index patient.
3. To set clear expectations for the
4. To educated about Major Depressive Disorder
a) Etiology
b) Risk factors
c) Pathogenesis
d) Diagnostics
e) Treatment
f) Follow-up
g) Prognosis
5. To inform the family on the Family Wellness Plan
6. Educated on COVID-19 misconceptions and anticipatory guidance

Community-oriented
I. Community Education
 72

A. General Objective: To educate the community on mental health and mental

illness, especially Major Depressive Disorder, and to increase awareness through
the use of different government agencies and organizations
B. Specific objectives:
1. Spreading awareness on Major Depressive Disorder
2. Increase awareness on available and affordable health services and
financial assistance programs from different government and
non-government agencies and organizations
a) CIM-CMSS
b) National Center for Mental Health USAP Crisis Hotline
(1553-Toll-free)
c) Philhealth
d) Maayo Medical Center
e) KAUBAN Mental Health Support Group
C. Methodology
1. Social Media Publication Materials
a) Infographic on Major Depressive Disorder
2. CSC Presentation on Facebook Live

RECOMMENDATIONS
The presenting clinical clerks propose the following recommendations:

For the patient:

1. To continue taking her medications:
a. Escitalopram 10 mg/tablet, to be taken ½ tablet after breakfast.
b. Risperidone 2 mg/tablet, to be taken ½ tablet before sleep.
2. To be followed-up with the clinical psychologist with sessions advised for an hour every 2
weeks or monthly.
3. To apply alternative therapeutic approaches such as exercise, meditation, mindfulness
and other stress-reduction techniques.
4. To continue to nurture her hobbies and talents as a form of expression and relaxation
technique.
 73

For the family:

1. To continue reminding her of her medications and psychotherapeutic sessions.
2. To continue supporting and assisting the patient on her way to recovery.

For the incoming Family Medicine Intern-in-charge:

1. To monitor the patient’s response to her medications and check compliance with
psychotherapy sessions.
2. To evaluate family’s monthly expenses

FINAL DIAGNOSES
● Medical Diagnosis:
1. Major Depressive Disorder, Moderate
2. Chronic Malnutrition secondary to number 1

● Family Diagnosis:
1. Family Structure and Cycle: Nuclear family with adolescents
2. APGAR 1: Moderately Dysfunctional
3. Smilkstein’s Cycle of Family Function: Family in Crisis
4. Family Illness Trajectory: Stage II: Impact Phase- Reaction to Diagnosis and
Stage III Major Therapeutic Efforts
 74

REFERENCES

Abdullah, T., & Brown, T. (2011). Mental Illness Stigma and Ethnocultural Beliefs, Values
& Norms: An Integrative Review. Clin Psychol Rev, 31, 934-948.

American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of

Psychiatric Disorders, 5th edition.

American Psychological Association. (2019). APA Clinical Practice Guideline for the
Treatment of Depression Across Three Age Cohorts.
https://www.apa.org/depression-guideline

Borenstein, J. (n.d.). Stigma and Discrimination. American Psychiatric Association.

Retrieved November 19, 2021, from
https://www.psychiatry.org/patients-families/stigma-and-discrimination

Jameson, J., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (2018).
Harrison's Principles of Internal Medicine, 20th edition (Vol. 2). McGraw Hill.

Maravilla, N. M. A. T., & Tan, M. J. T. (2021). Philippine Mental Health Act: Just An Act?
A Call to Look into the Bi-directionality of Mental Health and Economy. Front. Psychol.,
12.
Rivera, A. K., & Antonio, C. A. (2017). Mental Health Stigma Among Filipinos: Time for a
Paradigm Shift. Phil J Health Res Dev, 21(2), 20-24.

https://mhfa.com.au/sites/default/files/Suicide-Guidelines-Phillipines-CURRENT.pdf
 75

APPENDICES

Appendix A. Mini Mental Status Exam (MMSE)

 76

Appendix B: PHQ-9 Depression Questionnaire

 77

Appendix C. Columbia-Suicide Severity Rating Scale (C-SSRS)

 78

Appendix D: Malnutrition Universal Screening Tool

 79

Appendix E: Family Home and Environment

PART I-B: FAMILY HOME AND ENVIRONMENT**

Indicated with an (X) the applicable classification for each item. Take note the number of yellow items marked.

x Not Crowded x Good Condition

Overcrowding index Crowded Basic Household Equipment Fair Condition

Overcrowded Poor Condition

Permanency of Structure Self-owned

Security of Tenure /
x Permanent Paying rent
Ownership of House

Non-permanent X None / Informal ownership

Location
Housing Durability

x Non-hazardous x Formal collection

No Collection / Other
Hazardous (flood-prone,
disposal methods:
landslide-prone, polluted
areas)
Burned

Concrete / Steel / Glass Composting

Access to Improved Sanitation
Housing Materials Utilized x Mixed Facilities – Solid Waste Disposal Buried in pit

Light Materials Thrown anywhere /

outside
X

x With access (specify): Others (specify):

x MCWD / Water Pipes

Artesian Well / Pump

Deep Well (Hand X Owned

Access to Improved Water
Source – Daily Water Source
Pump) Not owned / Common toilet

Deep Well (Electric Access to Improved Sanitation

Facilities – Sanitation / Toilet
Pump) facilities Pit latrine

No access Antipolo

x Water-sealed / flush-type
 80

Chlorine Others (specify): Pour-Flush

Toilet
Boiling of water

Access to Improved Water

x Mineral / Distilled Water None / No access
Source – Potable Water Source /
Water Purification Method
Others (specify):

None / Directly from daily

NUMBER OF YELLOW ITEMS MARKED: 0 OUT OF 9
water source