Journal of Affective Disorders Reports 3 (2021) 100073

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Journal of Affective Disorders Reports

journal homepage: www.elsevier.com/locate/jadr

Research Paper

Depressive symptoms among young adults in the Philippines: Results from

a nationwide cross-sectional survey
Joseph H. Puyat a,b,∗, Ma. Cecilia Gastardo-Conaco c, Josefina Natividad d, Mariah Allyson Banal b
a
Centre for Health Evaluation and Outcome Sciences, Providence Health Care, 588 - 1081 Burrard St (Room 583A), St. Paul’s Hospital, Vancouver, BC V6Z 1Y6,
Canada
b
School of Population & Public Health, University of British Columbia, Vancouver, Canada
c
Department of Psychology, College of Social Sciences and Philosophy, University of the Philippines Diliman, Quezon City, Metro Manila, Philippines
d
Population Institute, College of Social Sciences and Philosophy, University of the Philippines Diliman, Quezon City, Metro Manila, Philippines

a r t i c l e i n f o a b s t r a c t

Keywords: Background: This study aims to estimate the proportion of young adults in the Philippines who experience mod-
Depressive symptoms erate to severe depressive symptoms, identify the most frequently reported depressive symptoms, and, examine
Young adults factors associated with depressive symptoms.
Philippines
Epidemiology Methods: Data were from a 2013 nationwide probability survey of 19,017 respondents, age 15–24. Depressive
CES-D symptoms were assessed using a 12-item version of the Center for Epidemiological Studies Depression (CES-D)
scale. The distribution of depressive symptoms was examined using descriptive statistics and the adjusted and
unadjusted association between sociodemographic factors, suicidal ideation, and moderate to severe depressive
symptoms were estimated using log-binomial regression.
Results: Up to 8.9% (95% CI=8.3–9.6) of young Filipino adults experience moderate to severe depressive symp-
toms and the prevalence is higher in females (10.2%) than males (7.6%). The symptom most often experienced in
the general population was “not enjoying life”, while “loneliness” was the most frequently reported symptom in
those with moderate to severe depressive symptoms. The prevalence of moderate to severe depressive symptoms
was higher in those with less education, persons who were separated/widowed/divorced, and residents in urban
areas. Those with moderate to severe depressive symptoms are about twice more likely to experience suicidal
ideation.
Limitations: The version of CES-D included in the survey has not been validated for use among young Filipino
adults.
Conclusions: Close to 1 in 10 young adults (8.9%) in the Philippines experience moderate to severe depressive
symptoms. Policies and mental health resources are needed to support young adults who are experiencing mod-
erate to severe depressive symptoms.

1. Introduction
Depression has recently become the leading cause of disability
worldwide (World Health Organization, 2017). In high-income coun-
tries, such as the US, UK and Canada, its economic impact is stagger-
ing, both in terms of productivity losses and direct health care costs
(Greenberg et al., 2015; Conference Board of Canada, 2016; Thomas and
Morris, 2003). Left untreated, the condition can cause significant suf-
fering to individuals and their families. In many high-income countries,
such as in the US and Canada, evidence-based treatments are largely
available; but, gaps in the quality of care persists as a large proportion
of people with depression receive mental health care that do not meet
the most basic criteria for treatment adequacy (Thornicroft et al., 2017;
Puyat et al., 2016).
In low income countries, such as the Philippines, depression is also a
leading cause of disability. A report released by the World Health Orga-
nization has estimated that the overall prevalence of depression in the
Philippines is 3.3%, (World Health Organization, 2017) suggesting that
about 3.3 million Filipinos are experiencing depressive symptoms based
on the 2015 population estimate (Philippine Statistics Authority, 2016).
Depression was also ranked as the 8th single largest cause of disability
in the country (Institute for Health Metrics and Evaluation, 2017). The
large number of individuals and families affected by depression raises

∗
Corresponding author.
E-mail address: jpuyat@cheos.ubc.ca (J.H. Puyat).

https://doi.org/10.1016/j.jadr.2020.100073
Received 13 December 2020; Received in revised form 21 December 2020; Accepted 31 December 2020
Available online 2 January 2021
2666-9153/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
J.H. Puyat, Ma.C. Gastardo-Conaco, J. Natividad et al.
serious concerns about the state of mental health care in the country
given the limited availability of tertiary care facilities, severe shortage
of mental health professionals, and the inadequate capacity of the pri-
mary health care system to manage mental health issues (Lally et al.,
2019b; WHO and Department of Health, 2006).
It is likely that the issues associated with depression and its conse-
quences are even greater in the young adult Filipino population since
depression has been reported elsewhere to have the highest prevalence
among individuals who are between the ages of 15 to 25 (Hedden et al.,
2015; Statistics Canada, Health Statistics Division, 2014). The sever-
ity of the problem, however, is largely unknown, as there is currently
no estimate, based on large epidemiological data, of the prevalence of
depression on this segment of the Philippine population. Identifying
who in this age group are experiencing moderate to severe depressive
symptoms and understanding their characteristics are particularly im-
portant as they are the group more likely to have persistent symptoms
(Gustavson et al., 2018; Rushton et al., 2002) and consequently more
likely to require ongoing treatment, support and other related services.
This study was conducted to help address current gaps in knowl-
edge about depressive symptoms among young adults in the Philippines.
The specific objectives of this study are to: 1) estimate the prevalence
of moderate to severe depressive symptoms; 2) identify the most fre-
quently reported depressive symptoms in those with moderate to severe
depressive symptoms; 3) examine the socio-demographic characteristics
associated with moderate to severe depressive symptoms; and, 4) esti-
mate the association between moderate to severe depressive symptoms
and suicide ideation.
2. Methods
2.1. Study population
Data for this study were from a survey conducted in the Philippines,
which is a democratic country in Southeast Asia with a presidential form
of government. The country has an estimated population of about 100
million as of 2015 (Philippine Statistics Authority, 2016) and is classi-
fied as a lower middle-income country with gross national income per
capita of US$3,830 in 2018 (World Bank, 2020). The majority of the
republic’s citizens practice Roman Catholicism with a small proportion
of the population practicing Islam.
The data analyzed for this study came from the 2013 Young Adult
Fertility and Sexuality Study (YAFS2013), which is a cross-sectional sur-
vey of individuals age 15 to 24 in the Philippines (Demographic Re-
search and Development Foundation and University of the Philippines
Population Institute, 2014). Conducted by the Demographic Research
and Development Foundation and the University of the Philippines Pop-
ulation Institute, with funding support from the Australian Government
through the United Nations Population Fund and the Philippine Depart-
ment of Health, YAFS2013 is the fourth round in the series of YAFS
surveys done on a representative sample of the Filipino young adult
population (Demographic Research and Development Foundation and
University of the Philippines Population Institute, 2014). As of 2013,
10.2 and 9 million Filipinos were estimated to be in the 15 to 19 and
20 to 24 age groups, respectively (Demographic Research and Devel-
opment Foundation and University of the Philippines Population Insti-
tute, 2014).
YAFS2013 collected 19,178 survey responses (9,353 males and 9,825
females) from a nationally and regionally representative sample of the
Filipino young adult population (Demographic Research and Develop-
ment Foundation and University of the Philippines Population Insti-
tute, 2014). Data collection took place between December 2012 and
May 2013. The complex, multi-stage sampling strategy employed a com-
bination of stratified and cluster sampling techniques and was designed
around 17 large geographic regions and 1,141 barangays (smallest ad-
ministrative region in the Philippines). A detailed description of the
sampling strategy is available elsewhere (Demographic Research and
2
Journal of Affective Disorders Reports 3 (2021) 100073
Development Foundation and University of the Philippines Population
Institute, 2014).
2.2. Survey questionnaire
YAFS2013 collected data on various domains. In this study, only
the data on depression, socio-demographic characteristics and suicidal
ideation were used in the analyses.
Data on depressive symptoms were collected using a modified ver-
sion of the original 20-item CES-D scale (Radloff, 1977). The modified
version (CES-D-12) contains 12 items and uses three response categories
(0 – rarely/not at all; 1 – sometimes, 2 – often) instead of the original
four (rarely or none of the time; some or a little of the time; occasion-
ally or a moderate amount of time; most or all of the time). Responses to
the scale items were coded as 0, 1, and 2 and summed for each respon-
dent, resulting in a total score ranging from zero (absence of depressive
symptoms) to 24 (presence of all depressive symptoms all the time).
2.3. Statistical analysis
We used descriptive statistics to describe the sample and to exam-
ine the distribution of the CES-D-12 scores. We calculated the mean and
standard deviation of the CES-D-12 to identify a cutpoint for moderate
to severe depressive symptoms. Cutpoints used to define high depres-
sive symptoms in previous studies vary depending on the version of the
CES-D scale used. In earlier studies, including the one conducted by the
original CES-D developer (Radloff, 1977), the cutpoint was set to a score
that is just above the mean, resulting in a larger estimate of individuals
with moderate to severe depression. Later studies have recommended
and used higher cut points, ranging from 0.5 to 1 SD above the mean
(Roberts et al., 1991, 1990; Yang, 2004; Lin et al., 2008; Gao et al.,
2020; Pietsch et al., 2013). In this study, we used a cutpoint that corre-
sponds to a score that was greater than one SD above the mean as the
threshold for moderate to severe depressive symptoms (Roberts et al.,
1990; Rushton et al., 2002).
Using the cutpoint derived from the data, we estimated the preva-
lence of young adults with moderate to severe depressive symptoms by
sociodemographic characteristics, with 95% confidence intervals. We
also examined the most frequently reported depressive symptoms, using
the cutpoint as reference, among those with moderate to severe depres-
sive symptoms compared to the general population, and among females
versus males.
We estimated the association between moderate to severe depres-
sive symptoms and various sociodemographic characteristics using log-
binomial regression, which is a regression model from the binomial fam-
ily with log link function. We chose this type of regression model to
generate results that are interpretable as prevalence ratios. Unadjusted
prevalence ratios (PR) were calculated to determine the apparent associ-
ation that can be observed from the data, such as, for example the ratio
of the prevalence of moderate to severe depressive symptoms among
males relative to females. We also calculated adjusted prevalence ratios
(aPR) to examine the association between various factors and moderate
to severe depressive symptoms, independent of the potential influence
of other factors in the model.
All data with missing values were dropped from analysis as the pro-
portion of data with missing values in this study is very low, and is
therefore unlikely to affect the results (Schafer, 2016; Bennett, 2001).
All statistical analyses were performed with survey sampling weights on
to account for the survey’s complex, multi-stage sampling design. Anal-
yses were conducted using the Survey Data Analysis Module of Stata
V16 (StataCorp, 2019).
This study involves the secondary analysis of publicly available
data and does not require institutional ethics review or approval
(Canadian Institutes of Health Research, 2018).
J.H. Puyat, Ma.C. Gastardo-Conaco, J. Natividad et al. Journal of Affective Disorders Reports 3 (2021) 100073

Table 1 ple as unfriendly were most common among those with moderate to
Sample and Population characteristics. severe depressive symptoms. Among females, the top three symptoms
Sample Weighted Proportion reported were “feeling lonely”, having restless sleep, and feeling de-
pressed. Among males, the top three symptoms reported were feeling
% 95% CI
that people were unfriendly, not enjoying life, and “feeling lonely”.
Sex Table 2 shows the prevalence of moderate to severe depressive symp-
male 9,267 48.9 48.1 49.6
toms by socio-demographic characteristics. Up to 8.9% (95% CI: 8.3 –
female 9,740 51.1 50.4 51.9
Age 9.6) of young adults in the Philippines reported experiencing moderate
15–19 11,374 59.6 58.6 60.6 to severe depressive symptoms (CES-D-12 > 12), with prevalence no-
20–24 7,633 40.4 39.4 41.4 tably higher in females (10.2%) than males (7.6%), and among those
Education who were separated, widowed, or divorced (17.8%).
no schooling/elementary 2,831 13.8 12.7 14.9
Table 2 also shows the results of the log-binomial regression models
high school undergraduate 7,221 36.7 35.6 37.9
high school graduate/vocational 5,101 28.5 27.3 29.7 that estimated the unadjusted and adjusted association between moder-
college or higher 3,851 21.0 19.6 22.5 ate to severe depressive symptoms and socio-demographic characteris-
Marital Status tics. The associations are expressed as prevalence ratios and were calcu-
never married 14,481 76.7 75.7 77.6
lated for each variable in the table using one of the categories for each
living-in 1,746 8.5 7.8 9.2
formally married 2,595 13.8 12.9 14.7
variable as reference or comparison group. The results suggest that the
separated/widowed/divorced 185 1.1 0.9 1.3 prevalence of moderate to severe depressive symptoms is 40% higher
Place of Residence among females than males (aPR = 1.40, 95% CI: 1.20 – 1.63). Individ-
mrban 4,100 27.3 23.7 31.2 uals with less education, particularly those with no schooling or those
rural 14,907 72.7 68.8 76.3
who had completed elementary education only (aPR = 1.44, 95% CI:
Wealth Index (quintile)
poorest 4,545 19.9 18.3 21.6 1.14 – 1.81), also, have higher prevalence of moderate to severe depres-
second 4,362 20.5 19.2 22.0 sive symptoms compared to those with more education. Similarly, the
middle 4,109 21.7 20.5 23.1 prevalence of moderate to severe depressive symptoms is higher among
fourth 3,439 20.9 19.4 22.6
those who were separated, divorced or widowed (aPR = 1.66, 95% CI:
wealthiest 2,552 16.8 15.1 18.8
1.11 – 2.46) and among residents of urban areas (aPR = 1.23, 95% CI:
1.04 – 1.45). These relative differences persisted even after accounting
for various confounders. No significant differences in the prevalence of
3. Results moderate to severe depressive symptoms were found across age groups
and socioeconomic status as measured by the wealth index (Rutstein and
Of the total 19,178 responses, 171 (0.9%) were dropped from anal- Johnson, 2004).
yses due to missing data on the outcome measure, resulting in an ana- In the overall sample, which represents the general youth popula-
lytic sample consisting of 19,007 respondents. Table 1 summarizes the tion, 8.7% (95% CI: 8.1 – 9.3) have thought about taking their own lives.
socio-demographic characteristics of the analytic sample. There were Among those with moderate to severe depressive symptoms, 17.9%
slightly more females (n = 9,740) than males (n = 9,267) and around (95% CI: 14.7 – 21.5) have thought of committing suicide compared to
60% of the participants were between the ages of 15–19 years old. 7.8% (95% CI: 7.2 – 8.4) in those without moderate to severe depressive
There were slightly more individuals who did not finish high school symptoms. This represents a prevalence ratio of about 2.3 (95% CI: 1.9
compared to those who completed college or vocational training. About – 2.8), suggesting that suicide ideation is about twice more prevalent in
77% were never married and 73% lived in rural areas in the Philippines. those with moderate to severe depressive symptoms. The results of the
A relatively lower proportion of the respondents (17%) belonged to the log-binomial regression analysis indicate that the association between
wealthiest quintile. moderate to severe depressive symptoms and suicide ideation persists
Fig. 1 describes the distribution of CES-D-12 scores by socio- even after controlling for sex, age, education, marital status, place of
demographic characteristics. As indicated by the differences in the box- residence, and wealth index (aPR=2.07; 95% CI: 1.7 – 2.5).
plots, females had a higher median score than males. Those who had no
schooling or completed elementary school had a higher median score 4. Discussion
compared to those with higher educational backgrounds. Participants
who were separated, divorced or widowed also had a higher median This study addresses an important gap in knowledge about the preva-
score than those who were formally married or never married. Median lence of depressive symptoms in the Philippines by analyzing a large
scores of individuals who belong to the poorest and second quintiles dataset from a probability survey (n = 19,007) conducted among young
were higher than the median scores of the middle, fourth, and wealthi- adults. Study results suggest that 8.9% of young adults in the Philippines
est quintiles. live with moderate to severe depressive symptoms, with females having
Fig. 2 illustrates the overall distribution of the CES-D-12 scores. The a disproportionate share of the burden than males. The results also in-
mean CES-D-12 score was 7.9 (SD = 3.7) and the median was 8 (IQR dicate that the prevalence of moderate to severe depressive symptoms
= 5). CES-D-12′s Alpha Cronbach was 0.75 (0.74 in the unweighted are higher in individuals with less education, persons who are divorced,
sample). Using the sum of the mean and standard deviation, the em- separated or widowed, and residents of urban areas. No significant dif-
pirical cutpoint for moderate to severe depressive symptoms was de- ferences were found by age or wealth index. Lastly, thoughts of suicide
termined to be 11.6 or 12. Because responses to the CES-D-12 scale do not always occur among young adults who are experiencing moder-
add up to whole numbers only, all respondents with CES-D-12 scores ate to severe depressive symptoms; however, they are more than two
of over 12 were categorized as having moderate to severe depressive times more likely to think about taking their own lives compared with
symptoms. those who are not experiencing moderate to severe depressive symp-
Fig. 3 shows the most frequently reported depressive symptoms in toms.
the general population compared with those with moderate to severe Studies in Asia that have used the CES-D tool to examine the preva-
depressive symptoms, and among males and females with moderate lence of moderate to severe depressive symptoms have reported vary-
to severe depressive symptoms. The most common depressive symp- ing estimates. A 2020 study of children age 6–12 residing in rural ar-
toms experienced by the general population were “not enjoying life” eas of Taiwan, for example, reported an estimate of 8% based on a
and “sleep was restless”, whereas “feeling lonely” and perceiving peo- random sample of 1,655 fourth and fifth grade students (Gao et al.,

3
J.H. Puyat, Ma.C. Gastardo-Conaco, J. Natividad et al.
2020). Another study from Taiwan, using a representative sample of
9,586 students from junior and senior high schools, yielded a higher es-
timate of 12.3% (Lin et al., 2008). In various parts of China, prevalence
estimates ranging from 5.6 to 24% have been reported (Li et al., 2019).
These studies (Gao et al., 2020; Lin et al., 2008; Li et al., 2019) have
used the standard 20-item CES-D scale with a cutpoint ≥ 29 (about 1
SD above the mean) to estimate the prevalence of moderate to severe
depressive symptoms. Higher cut points are typically used to estimate
the proportion of people with major or clinical depression (Gao et al.,
2020; Lin et al., 2008; Roberts et al., 1990). In high resource countries,
such as the US and Canada, about 6% (US)(Hedden et al., 2015) to
7% (Canada)(Statistics Canada, Health Statistics Division, 2014) of peo-
4
Journal of Affective Disorders Reports 3 (2021) 100073
Fig. 1. Distribution of the CES-D-12 scores by
socio-demographic characteristics. Note: The
middle point of the boxplots represent median
scores; the boundaries of the box pertain to
the interquartile range (IQR) box or the middle
50% of the data; the left and right vertical lines
connected to the whiskers represent the min-
imum and maximum scores; data represented
by circles are outliers.
Fig. 2. Histogram of the CES-D-12 scores.
ple age 18–25 are estimated to be experiencing major depression every
year.
It is worth noting that among young adults with moderate to severe
depressive symptoms, the most frequently experienced depressive symp-
toms are those related to loneliness. Somatic symptoms like sleep prob-
lems and tiredness were also reported, which is consistent with previ-
ous studies that indicate that individuals with depression in low resource
countries often present with somatic symptoms (Patel et al., 2009). How-
ever, these symptoms do not appear to be as prominent as those per-
taining to affect and cognitions related to loneliness. This implies that
addressing depression among young adults in the Philippines requires
an understanding of what loneliness is, its determinants, and the inter-
J.H. Puyat, Ma.C. Gastardo-Conaco, J. Natividad et al.
ventions that can help reduce it. In the literature, loneliness is typically
associated with the subjective feeling of social isolation and is different
from the factual state of being alone (Hawkley and Cacioppo, 2010).
People can, therefore, be alone without feeling lonely, while anyone can
be lonely even if they are surrounded by other people, such is in school
or work settings. A likely determinant of this subjective feeling of so-
cial isolation is the lack of congruence between people’s expectations
and the actual satisfaction they derive from their social relationships
(Russell et al., 2012). The strategies that have been developed to reduce
loneliness have either focused on helping the individual improve social
skills and overcome maladaptive ways of thinking, or on enhancing so-
cial support and increasing opportunities for positive social interaction
(Masi et al., 2011).
Another finding worth noting is the lack of income-related differ-
ences in moderate to severe depressive symptoms. This is remarkable
particularly in light of the presence of significantly higher prevalence
of moderate to severe depressive symptoms in youth with lower educa-
tional achievement compared to those with more education. This pat-
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Journal of Affective Disorders Reports 3 (2021) 100073
Fig. 3. Depressive symptoms in A) the general population versus
those with moderate to severe depressive symptoms, and B) males
and females with moderate to severe depressive symptoms.
tern, which can be observed in both the unadjusted and adjusted regres-
sion results, indicates that socioeconomic disparities in mental health
outcomes among Filipino youth are probably associated more with dif-
ferences in educational achievement than differences in affluence. In the
literature, the link between socioeconomic status and mental health is
well-established (Hudson, 2005), although, there is still a great deal of
uncertainty regarding which aspect of socioeconomic status is reliably
associated with mental health disparities (McLaughlin et al., 2012). This
is mainly because societies and cultures ascribe different levels of impor-
tance to various dimensions of socioeconomic status. In the UK, for ex-
ample, occupation is an important measure of socioeconomic status (Ga-
lobardes et al., 2006) whereas in the US, income tends to be a much more
salient determinant (McGrail et al., 2009). Similarly, in Canada, educa-
tional achievement and income have been demonstrated to be robust
determinants of socioeconomic status and are consequently associated
with health-related outcomes (Bushnik et al., 2020). Given the impor-
tance of educational achievement in Philippine culture (Puyat, 2005),
it is very likely that the socioeconomic gradient usually associated with
J.H. Puyat, Ma.C. Gastardo-Conaco, J. Natividad et al. Journal of Affective Disorders Reports 3 (2021) 100073

Table 2
Prevalence and relative differences in the prevalence of moderate to severe depressive symptoms by sociodemographic characteristics.

Moderate to Severe Depressive Symptoms (CES-d-12 > 12)

Prevalence Prevalence Ratio

% 95% CI Unadjusted 95% CI Adjusted 95% CI

All 8.9 8.3 9.6 – – – – – –

Sex
male 7.6 6.8 8.4 Reference – – Reference – –
female 10.2 9.2 11.3 1.35 1.16 1.56 1.40 1.20 1.63
Age
15–19 8.9 8.2 9.7 Reference – – Reference – –
20–24 8.9 7.9 10 1.00 0.86 1.15 1.09 0.92 1.28
Education
no schooling/elementary 9.9 8.6 11.4 1.31 1.04 1.65 1.44 1.14 1.81
high school undergraduate 9.6 8.7 10.7 1.27 1.02 1.57 1.35 1.11 1.65
high school graduate/vocational 8.6 7.4 9.9 1.13 0.90 1.43 1.18 0.95 1.46
college or higher 7.6 6.3 9.1 Reference – – Reference – –
Marital Status
never married 8.8 8.1 9.5 Reference – – Reference – –
living-in 8.3 6.5 10.5 0.94 0.74 1.19 0.82 0.65 1.04
formally married 9.3 7.7 11.2 1.06 0.86 1.29 0.90 0.73 1.12
separated/widowed/divorced 17.8 12.1 25.4 2.02 1.38 2.96 1.66 1.11 2.46
Place of Residence
urban 9.9 8.6 11.4 1.16 0.99 1.36 1.23 1.04 1.45
rural 8.6 7.9 9.2 Reference – – Reference – –
Wealth Index (quintile)∗
poorest 9.8 8.8 10.9 1.12 0.95 1.33 1.11 0.93 1.31
second 9.1 7.9 10.4 1.04 0.87 1.24 1.04 0.88 1.23
middle 8.7 7.6 10.1 Reference – – Reference – –
fourth 7.9 6.8 9.2 0.90 0.73 1.11 0.89 0.72 1.10
wealthiest 9.3 7.5 11.3 1.06 0.82 1.37 1.05 0.82 1.34

Note: numbers in bold are statistically significant at p<0.05; wealth index was assessed via the DHS Wealth Index (Rutstein and Johnson, 2004);
high school undergraduate includes any year(s) in high school education, without earning a high school diploma; college or higher means completing
college/university or higher degrees.

moderate to severe depressive symptoms can more strongly be observed of the individual and that are also culturally appropriate. Important
across different levels of educational achievement. Future studies should challenges lay ahead as the country addresses issues pertaining to un-
help confirm this pattern. derinvestment, lack of mental health professionals, and underdeveloped
The finding about increased prevalence of moderate to severe de- community-based resources and services (Lally et al., 2019b). Epidemi-
pressive symptoms in youth with self-reported marital breakdowns ological insights, such as the ones this study provide can help inform
are consistent with previous findings about the strong association current and future efforts to address these challenges.
between marital separation and depressive symptoms (Sbarra and
Coan, 2017; Rotermann, 2007) or increased use of mental health ser-
4.1. Limitations
vices (Reneflot et al., 2020). This could either be due to untreated per-
sistent depressive symptoms causing marital breakdowns, or to break-
Although this study was based on a probability survey of a large sam-
downs in relationship causing stress and depressive symptoms. The
ple of respondents, there are limitations that need to be considered when
cross-sectional data used in this study cannot clearly identify which
interpreting the study results. First, the version of the CES-D tool used
causal direction is more likely, but, support for both explanations can be
in the study has not been validated in a sample of young Filipino adults.
found in the available literature (Braithwaite and Holt-Lunstad, 2017).
In this study, a cutpoint based on the mean and standard deviation was
Similarly, the results that indicate that moderate to severe depressive
used to reduce the chances of over or under estimating the proportion
symptoms are more prevalent in youth residing in urban areas than in
of those with moderate to severe depressive symptoms. Future surveys
youth in rural areas is consistent with previous studies that link urban-
that will use the same CES-D version tool would benefit from a valida-
icity and depression (Weaver et al., 2015; Romans et al., 2011). Several
tion study of the tool’s diagnostic properties using a sample of Filipino
aspects of the urban environment have been highlighted as potential
young adults. Another limitation pertains to the self-reported nature of
contributors to poor mental health, including amount of green space or
the tool used to assess depressive symptoms. Because of this and the
natural environments, walkability, land-use mix, traffic volume, level
status of mental illness, including depression, as a highly stigmatized
of industrial activity, pollution, and neighbourhood quality or extent of
condition in Philippine culture (Martinez et al., 2020; Rivera and Anto-
physical deterioration (Gong et al., 2016). Another plausible explana-
nio, 2017; Tuliao, 2014), it is possible that our study has underestimated
tion is that rural community residents have a higher sense of community
the actual proportion of young adults with depressive symptoms. The
and belongingness, which has been shown to be associated with lower
estimates of the prevalence and the relative differences in prevalence
depression prevalence (Romans et al., 2011).
(prevalence ratio) reported in this study should therefore be regarded
A significant milestone was achieved on June 21, 2018 with the
as conservative estimates.
enactment of the Philippine Mental Health Act of 2017. The legisla-
tion lays out a framework for the provision of a comprehensive mental
health care that respects human rights and that is comprehensive and Conclusions
integrated in its approach toward health service delivery (Lally et al.,
2019). It contains sections that underscore the importance of providing Close to 1 in 10 young adults (8.9%) in the Philippines experience
evidence-based mental health services that are responsive to the needs moderate to severe depressive symptoms and the prevalence is up to 40

6
J.H. Puyat, Ma.C. Gastardo-Conaco, J. Natividad et al.
times higher among females than males (aPR=1.40). Young adults expe-
riencing moderate to severe depressive symptoms are also more likely
to think of taking their own lives. There is an urgent need, therefore, for
policies and mental health resources to support young adults who are
experiencing depressive symptoms.
Author statement
Contributors
JHP contributed to the conceptualization, analysis, interpretation of
results and writing of the manuscript. MCGC contributed to the concep-
tualization, interpretation of results and drafting of the manuscript. JN
contributed to data collection, interpretation of results and drafting of
the manuscript. MAB managed the literature searches and contributed to
the interpretation and writing of the manuscript. All authors approved
the final version of the manuscript.
Funding
This study did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
JHP is supported by a Scholar Award from the British Columbia
Michael Smith Foundation for Health Research (MSFHR Grant ID#
18299).
The authors thank the Demographic Research and Development
Foundation (DRDF) and University of the Philippines Population Insti-
tute (UPPI) for sharing the survey data used in this study.
All inferences, opinions, and conclusions drawn in this study are
those of the authors, and do not reflect the opinions or policies of
MSFHR, DRDF or UPPI.
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