PHE Mental Health
PHE Mental Health
PHE Mental Health
GUIDELINES on
PERIODIC HEALTH
EXAMINATION
Screening for Mental
Health and Addiction
PERIODIC HEALTH EXAMINATION TASK FORCE 2021
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DISCLAIMER
This guideline is intended to be used by specialists, general practitioners, allied health
professionals who are primary care providers. Although adherence to this guideline is
encouraged, it should not restrict the healthcare providers in using their sound clinical
judgment in handling individual cases.
Payors and policymakers, including hospital administrators and employers, can also
utilize this CPG, but this document should not be the sole basis for evaluating insurance
claims. Recommendations from this guideline should not also be treated as strict rules on
which to base legal action.
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TABLE OF CONTENTS
DISCLAIMER ................................................................................................................................ 2
TABLE OF CONTENTS .............................................................................................................. 3
ABBREVIATIONS AND ACRONYMS....................................................................................... 5
EXECUTIVE SUMMARY ............................................................................................................ 8
SUMMARY OF RECOMMENDATIONS ................................................................................... 9
1. INTRODUCTION ................................................................................................................... 12
2. SCOPE & PURPOSE ............................................................................................................ 14
3. GUIDELINE DEVELOPMENT METHODOLOGY............................................................. 15
3.1 Organization of the Process 15
3.2 Creation of the Evidence Summaries 15
3.3 Composition of the CPG Panel 16
3.4 Formulation of the Recommendations 17
3.5 Managing Conflicts of Interest 17
3.6 External Review Process 18
3.7 Planning for Dissemination and Implementation 18
4. RECOMMENDATIONS AND PANEL DISCUSSION ....................................................... 19
4.1 Standardized Instruments in Screening for Dementia ................................................... 19
4.2 Standardized Drug Tests in Screening for Substance Use Disorders ........................ 29
4.3 Standardized Instruments in Screening for Substance Use Disorders....................... 37
4.4 Standardized Instruments in Screening for Depression among High-Risk Groups .. 45
4.5 Standardized Instruments in Screening for Anxiety ....................................................... 55
4.6 Standardized Instruments in Screening for Depression among Children and
Adolescents ................................................................................................................................. 62
4.7 Standardized Instruments in Screening for Anxiety among Adolescents................... 72
4.8 Standardized Instruments in Screening for Stress ......................................................... 79
4.9 Standardized Instruments in Screening for Sleep Disturbances/Problems ............... 88
5. RESEARCH IMPLICATIONS............................................................................................... 95
6. DISSEMINATION AND IMPLEMENTATION .................................................................... 96
7. APPLICABILITY ISSUES ..................................................................................................... 96
8. UPDATING OF THE GUIDELINES .................................................................................... 96
9. APPENDICES ........................................................................................................................ 97
1. Standardized Instruments in Screening for Dementia 98
2. Standardized Drug Tests in Screening for Substance Use Disorders 118
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3. Standardized Instruments in Screening for Substance Use Disorders 123
4. Standardized Instruments in Screening for Depression among High-Risk
Groups 138
5. Standardized Instruments in Screening for Anxiety 145
6. Standardized Instruments in Screening for Depression among Children and
Adolescents 154
7. Standardized Instruments in Screening for Anxiety among Adolescents 168
8. Standardized Instruments in Screening for Stress 180
9. Standardized Instruments in Screening for Sleep Disturbances/Problems 188
PERIODIC HEALTH EXAMINATION TASK FORCE ON MENTAL HEALTH AND
ADDICTION 2021..................................................................................................................... 198
PERIODIC HEALTH EXAMINATION PHASE 2 TASK FORCE 2021 ............................. 200
CONFLICT OF INTEREST DECLARATION ....................................................................... 201
EXTERNAL REVIEW............................................................................................................... 202
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ABBREVIATIONS AND ACRONYMS
AACAP American Academy of Child and Adolescent Psychiatry
AAFP American Academy of Family Physicians
AAP American Academy of Pediatrics
ACOG American College of Obstetrics and Gynecology
ADRD Alzheimer’s disease and related dementias
AIDS acquired immunodeficiency syndrome
AIS Athens Insomnia Scale
AD8 Eight-item informant interview to Differentiate Aging and Dementia
APCM American College of Preventive Medicine
BPI brief psychological intervention
CBT cognitive behavioral therapy
CDT Clock Drawing Test
CES-D Center for Epidemiologic Studies Depression Scale
CI confidence interval
CIDI Composite International Diagnostic Interview
CIS-R Clinical Interview Schedule Revised
CoE certainty of evidence
CP consensus panel
CPG clinical practice guidelines
CTFPHC Canadian Task Force for Preventive Health Care
DALY disability-adjusted life year
DASS-21 Depression, Anxiety, and Stress Scale
DISC-IV Child Diagnostic Interview Schedule
DOH Department of Health
DSM Diagnostic and Statistical Manual of Mental Disorders
ERE evidence review experts
EtD evidence to decision
FDA Food and Drug Administration
GAD generalized anxiety disorder
GDS Geriatric Depression Scale
GRADE Grading of Recommendations, Assessment, Development, and Evaluation
HAD-S Hospital Anxiety and Depression Rating Scale – Anxiety
HCP healthcare provider
HIV human immunodeficiency virus
HMO health maintenance organization
ICD International Statistical Classification of Diseases and Related Health Problems
ICSD International Classification of Sleep Disorders
ICSI Institute of Clinical Systems Improvement
IPT interpersonal therapy
ISI Insomnia Severity Index
MD mean difference
MDD major depressive disorder
MET motivational enhancement therapy
MCI mild cognitive impairment
MHSE Mental Health Status Exam
MINI Mini International Neuropsychiatric Interview
MIS Memory Impairment Scale
MMSE Mini-Mental State Exam
MoCA Montreal Cognitive Assessment
MQICG Michigan Quality Improvement Consortium Guideline
NCD non-communicable disease
NCMH National Center for Mental Health
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NCR National Capital Region
NDST non-directive supportive therapy
NGO non-government organization
NICE National Institute for Health and Care Excellence
NIH-ICE National Institutes of Health-Institute of Clinical Epidemiology
NNT number needed to treat
NPV negative predictive value
OECD Organization for Economic Cooperation and Development
OIS optimal information size
OPD outpatient department
OR odds ratio
PGH Philippine General Hospital
Php Philippine peso
PICO population, intervention, comparator, and outcome
PHEX periodic health examination
PHIC Philippine Health Insurance Corporation
PHQ-A Patient Health Questionnaire for Adolescents
PHQ-9 Patient Health Questionnaire-9
PPA Philippine Psychiatric Association
PPV positive predictive value
PSQI Pittsburgh Sleep Quality Index
PSS-10 Perceived Stress Scale
QALY quality-adjusted life year
QOL quality of life
RACGP Royal Australian College of General Practitioners
RCT randomized controlled trial
RR risk ratio/relative risk
SAMHSA Substance Abuse and Mental Health Services Administration
SBIRT screening, brief interventions, and referral to treatment
SC steering committee
SCARED Screen for Child Anxiety Related Emotional Disorders
SCAS Spence Children’s Anxiety Scale
SCID Structured Clinical Interview for DSM Disorders
SMD standardized mean difference
Sn sensitivity
Sp specificity
SR systematic review
STPP short-term psychoanalytic psychotherapy
SUD substance use disorder
SWS Social Weather Station
USPSTF United States Preventive Services Task Force
WHO World Health Organization
WSQ Work Stress Questionnaire
YLD years lived with disability
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ACKNOWLEDGMENT
This CPG on PHEX 2021 was prepared by the National Institutes of Health - Institute of
Clinical Epidemiology (NIH-ICE).
This project would not have been possible without the initiative and financial support from
the Department of Health (DOH). The DOH neither imposed any condition nor exerted
any influence on the operations and the final output formulation.
The NIH-ICE undertook extensive technical work in 1) searching and synthesizing the
evidence while ensuring objectivity in each stage of the process, 2) presenting the
evidence in the panel discussion, and 3) documenting and writing the final report. They
were also indispensable in carrying out the legwork, coordinating among various
individuals, groups, and committees, and facilitating the en banc meeting. The CPG
Central Steering Committee and the Task Forces Steering Committee were responsible
for overall organization and management and are accountable for the quality of the CPG.
The content of this CPG is an intellectual property of the Department of Health (DOH).
Kindly provide the proper citations when using any part of this document in lectures,
research papers, and any other format presented to the public. The electronic version of
this material can be accessed online on the DOH website.
Queries, suggestions, and other concerns regarding this CPG may be directed to the
DOH National Practice Guidelines Program office by email ([email protected]) or to
DOH-HPDPB and UP-NIH.
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EXECUTIVE SUMMARY
This Clinical Practice Guideline for the Periodic Health Examination on screening for
Mental Health and Addiction is an output from the joint undertaking of the Department of
Health and National Institutes of Health- Institute of Clinical Epidemiology.
Recommendations are based on the appraisal of the best available evidence on each of
the nine (9) identified clinical questions. The CPG is intended to be used by general
practitioners and specialists in the primary care setting, policy makers, employers and
administrators, allied health practitioners, and even patients. The guideline development
process followed the widely accepted Grading of Recommendations, Assessment,
Development, and Evaluation or the GRADE approach including GRADE Adolopment1 ,
a systematic process of adapting evidence summaries and the GRADE Evidence to
Decision (EtD)2 framework. It included 1) identification of critical questions and critical
outcomes, 2) retrieval of current evidence, 3) assessment and synthesis of the evidence
base for these critical questions, 4) formulation of draft recommendations, 5) convening
of a multi-sectoral stakeholder panel to discuss values and preferences and assess the
strength of the recommendations, and 6) planning for dissemination, implementation,
impact evaluation and updating.
The recommendations in this CPG shall hold and will be updated after 3 years or when
new evidence arises.
1 Schunemann H, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa R, Manja V. GRADE Evidence to Decision (EtD) frameworks for
adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol. 2017;81:101-
10.
2 Schunemann HJ, Mustafa R, Brozek J, Santesso N, Alonso-Coello P, Guyatt G, et al. GRADE Guidelines: 16. GRADE evidence to
decision frameworks for tests in clinical practice and public health. J Clin Epidemiol. 2016;76:89-98.
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SUMMARY OF RECOMMENDATIONS
Strength of Panel
Recommendation Certainty of Evidence
Recommendation
Question 1: Should screening for dementia among older adults be done using standardized instruments?
1.1 Among asymptomatic healthy adults aged 60 years and Very Low Weak
above, we suggest against screening for dementia.
Question 2: Should screening for substance use disorders among the general population be done using
standardized drug tests?
Question 3: Should screening for substance use disorders among the general population be done using
standardized instruments?
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Question 4: Should screening for depression be done among high-risk groups using standardized
instruments?
Question 5: Should screening for anxiety and symptoms of anxiety disorder among the general population
be done using standardized instruments?
Question 6: Should screening for depression among children and adolescents be done using standardized
instruments?
6.1 Among healthy asymptomatic children and adolescents (10- Low Strong
18 years old), we recommend screening for depression using
PHQ-9 twice a year.
Question 7: Should screening for symptoms of anxiety disorder among children and adolescents be done
using standardized instruments?
7.1 Among healthy asymptomatic adolescents (10-19 years old), Moderate Weak
we suggest screening for anxiety disorder using standardized
instruments twice a year.
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Question 8: Should screening for stress among the general population be done using standardized
instruments?
Question 9: Should screening for sleep disturbance/problems among the general population be done
using standardized instruments?
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1. INTRODUCTION
The Philippine Guidelines on Periodic Health Examination (PHEX) was first published in
2004.(1) It was a comprehensive appraisal and synthesis of evidence on screening
interventions committed to providing early prevention services among apparently healthy
Filipinos. It was a long-awaited publication and the first to offer evidence-based
recommendations for screening tests made possible through the concerted effort of
various medical and paramedical organizations composed of more than a hundred
experts, researchers, and stakeholders.(1) It was inspired by the Canadian and the US
Preventive Services Task Forces, but it was tailored to the Philippine setting.
Due to the evolving technology, scientific evidence, and health policies, there is a
pressing need to update this guideline. This 2021 Philippine Guidelines will support the
objectives stated in the Universal Health Care Act (2) that all Filipinos are given access
to quality and affordable medical services, including primary care benefits.
The evidence collated to answer the research questions on screening tests are used in
formulating the recommendations. They can be classified into two: 1) screening for a risk
factor and 2) screening for early disease. Screening for the former is directed towards
determining the effective management of the condition as a risk factor, and screening for
the latter is focused on the performance of the tests that will be used to detect and
subsequently treat that early disease and prevent it from progressing.
Health screening also carries potential harm, for example, mislabeling the person as
being ill. It can pose a threat to the psychological, social, or physical well-being and even
to the individual's financial stability. Because of these probable adverse effects of
screening, criteria are set to determine if screening for a particular condition can be
beneficial and pragmatic. The voting panel members used these criteria (5) aligned with
the EtD framework: 1) burden of illness must be high, 2) screening tests must be accurate
enough, 3) early treatment must be more effective than late treatment, 4) confirmatory
tests and early management must be safe and available, and 5) costs of screening must
be proportional with the potential benefit.
Aside from the regulatory agencies and policymakers in the national government, the
target users of this guideline on screening strategies include primary care providers,
general physicians, specialists, training institutions, payors, patients, the general public,
and industry partners.
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References
1. Dans A, Morales D. Philippine Guidelines on Periodic Health Examination (PHEX): Effective
Screening for Diseases among Apparently Healthy Filipinos. Manila: The Publications Program;
2004.
2. Duque F, Villaverde M, Morales R. Implementing Rules and Regulations of the Universal Health
Care Act (Republic Act No. 11223). In: Health Do, editor.: PhilHealth.
3. PhilHealth. Circular No. 2020-0022: Implementing Guidelines for the PhilHealth Konsultasyong Sulit
at Tama (PhilHealth Konsulta) Package. In: Corporation PHI, editor. Pasig City: PhilHealth; 2020.
4. Alonso-Coello P, Schünemann H, Moberg J, Brignardello-Petersen R, Davoli M, Treweek S, et al.
GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making
well informed healthcare choices. 1: Introduction. BMJ. 2016;353:i2016.
5. Schunemann H, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa R, Manja V. GRADE
Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of
trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol. 2017;81:101-10.
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2. SCOPE & PURPOSE
Screening for mental health and addiction disorders is a priority due to the rising
prevalence of these conditions. Screening for dementia in older adults (60 and above),
screening for depression in high-risk groups, screening for anxiety in adults, and
screening for substance use disorders in adults and adolescents are included in this CPG.
In addition, screening for depression and anxiety among children and adolescents are
also included. Screening for stress and sleep disturbances/problems as risk factors for
possible mental health or addiction disorders is also included.
General outcomes that were considered for the identified clinical questions included:
health-related quality of life, symptoms of the specific conditions, prevalence of the
specific conditions, hospital admissions, and remission rates
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3. GUIDELINE DEVELOPMENT METHODOLOGY
3.1 Organization of the Process
Following the international standards, the DOH (1) outlined the guideline development
process into four phases: 1) preparation and prioritization, 2) CPG generation, 3) CPG
appraisal, and 4) implementation in the Manual for CPG Development.(1)
In the preparation and prioritization phase, the Steering Committee set the CPG
objectives, scope, target audience, and clinical questions. They consulted different
stakeholders in prioritizing and developing the guideline questions. They identified and
formed the working groups involved in creating the evidence base and finalizing the
recommendations for each clinical question included.
The evidence review experts (ERE) or the technical working group were tasked to review
existing CPGs, appraise and summarize the evidence, and draft the initial
recommendations. The evidence summaries were then presented to the consensus panel
members to finalize the recommendations.
The results of the appraisal of existing CPGs and their evidence summaries determined
the need for a systematic search in electronic databases (MEDLINE via PubMed,
CENTRAL, Google Scholar) for the need to do de-novo systematic reviews and meta-
analysis for each question. All searches were done from May to Nov. of 2021. Details on
the time periods were discussed under the specific questions. Please see evidence
summaries in Appendices. Relevant local databases and websites of medical societies
were also utilized in the search. Keywords were based on PICO (MeSH and free text) set
for each question. The ERE also contacted authors of related articles to verify details and
identify other research studies for appraisal, if needed. Students from the Pamantasan
ng Lunsod ng Maynila (PLM) also assisted the evidence reviewers in the literature search
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(background research on prevalence, cost of tests and local programs) and review of
articles.
At least two reviewers worked on each PICO question. The search strategy and inclusion
criteria were based on the PICO question and are included in their respective evidence
summaries. Evidence reviewers appraised the directness, methodological validity,
results, and applicability of each relevant article included. RevMan, STATA, and
GRADEPro were used for the quantitative synthesis of important clinical outcomes for
each question. The ERE generated evidence summaries for each of the nine (9)
questions. Each evidence summary included evidence on the burden of the problem, and
diagnostic performance, benefits, harm, and social and economic impact of the screening
test/intervention. Evidence/information that will facilitate the decision (i.e. cost of
screening test, cost-effectiveness studies, qualitative studies) were also included in the
evidence summaries. The Quality of Evidence was assessed using the GRADE
approach.(2) See table 1.
Table 1. Basis for Assessing the Quality of the Evidence using GRADE Approach
Certainty of Evidence Interpretation
High We are very confident that the true effect lies close to that of the estimate of the effect
Moderate We are moderately confident in the effect estimate: The true effect is likely to be close to
the estimate of the effect, but there is a possibility that it is substantially different
Low Our confidence in the effect estimate is limited: The true effect may be substantially
different from the estimate of the effect
Very Low We have very little confidence in the effect estimate: The true effect is likely to be
substantially different from the estimate of effect
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3.4 Formulation of the Recommendations
Draft recommendations were formulated based on the quality of evidence, trade-offs
between benefit and harm, cost-effectiveness, applicability, feasibility, equity, resources
and uncertainty due to research gaps. Prior to the series of online consensus panel
meetings, the consensus panel received the draft recommendations together with
evidence summaries based on the EtD framework shown in Table 2. These
recommendations, together with the evidence summaries, were presented during the en
banc meeting.
The strength of each recommendation (i.e., strong or weak) was determined by the panel
considering all the factors mentioned above. Strong recommendation means that the
panel is “confident that the desirable effects of adherence to a recommendation outweigh
the undesirable effects” while weak recommendation means that the “desirable effects of
adherence to a recommendation probably outweigh the undesirable effect but is not
confident.”(4)
The recommendation for each question and its strength was determined through voting.
A consensus decision was reached if 75% of all CP members agreed.(2) If consensus
was not reached in the first voting, questions, and discussions were encouraged. Two
further rounds of voting on an issue were conducted. Evidence-based draft
recommendations were also revised based on input arrived at by consensus in the en
banc discussions.
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of OC conducted additional investigations with due diligence to ensure the integrity of the
CPG process and the final recommendations.
All task force members submitted a DCOI and their curriculum vitae (CV) prior to the
initiation of guideline development process. The disclosure included a 4-year period of
personal potential intellectual and/or financial conflicts of interest (COI).
Management of the COI of the Consensus Panel, Technical Coordinators, and Task
Force Steering Committees were deliberated and decided by the OC, using the pre-
agreed criteria. A full description of the methods can be found in the Final Technical
report.
Those with significant potential COI based on the decision of the Oversight Committee
were not allowed to vote during the en banc meeting but fully participated in the panel
discussions. See Conflict of Interest Declaration.
References
1. DOH, PHIC. Manual for Clinical Practice Guideline Development 2018.
2. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y,
Meerpohl J, Norris S, Guyatt GH. GRADE guidelines: 3. Rating the quality of evidence. J Clin
Epidemiol. 2011 Apr;64(4):401-6. doi: 10.1016/j.jclinepi.2010.07.015. Epub 2011 Jan 5. PMID:
21208779.
3. Schunemann H, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa R, Manja V. GRADE
Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of
trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol. 2017;81:101-10.
4. Guyatt, G. H., Oxman, A. D., Kunz, R., Falck-Ytter, Y., Vist, G. E., Liberati, A., Schünemann, H. J., &
GRADE Working Group (2008). Going from evidence to recommendations. BMJ (Clinical research
ed.), 336(7652), 1049–1051. https://doi.org/10.1136/bmj.39493.646875.AE
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4. RECOMMENDATIONS AND PANEL DISCUSSION
Among asymptomatic healthy adults aged 60 years and above, we suggest against
screening for dementia. (Very low certainty of evidence; Weak recommendation)
Considerations
The consensus panel considered the following when formulating this recommendation:
● Main considerations for recommending against screening for dementia was mainly
due to the cost-effectiveness and feasibility of screening.
● The potential harm of a false positive result may cause significant distress on the
patient and their family.
● The benefits placed on the outcomes that were rated as critical are not large
enough.
● Screening may not be beneficial for most Filipinos since most memory clinics are
concentrated in NCR, leaving uncertainty on what to do next for those patients who
test positive residing in rural areas or in areas where treatment may not be
available.
● Although there are screening tools that are already available, validated, and even
translated, the administration of these tools in the primary care setting may not be
feasible.
● Prevention and wellness programs may be more cost effective than mass
screening.
● Some members of the panel believe that screening should be done due the rising
prevalence of dementia and that early detection leads to early intervention, which
may have better outcomes and an improved quality of life for the patient and their
family. Early detection also facilitates preparation for the patient, their family, and
their community. In addition, the potential harms of screening may be mitigated by
referral to the appropriate specialists and facilities.
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increased risk for COVID-19 after adjusting for demographics and risk factors with higher
mortality and hospitalization risk.(5) Symptom-mediating medications such as
acetylcholinesterase inhibitors and memantine have not proven to reverse or stop the
progression of dementia. The most recently approved drug by the US FDA, aducanumab,
may have a clinical benefit as it targets pathologic amyloid beta plaques in patients with
Alzheimer’s disease (6) however, trials had conflicting outcomes.(7) Hence, public health
approaches are geared towards prevention by managing risk factors and providing
screening tools at the community level.(8)
The health-related quality of life after 12 months of those screened and not screened for
dementia both had a mean score of 0.68, with a mean difference of 0.002 (95% CI –0.017
to 0.021; p = 0.81).
All-cause mortality was assessed within 12 months. Those screened were less likely to
have mortality, although this was insignificant between the two groups (RR 0.83, 95% CI
0.46-1.47).
For hospital admissions, there was no significant difference between the groups (RR 0.99,
95% CI 0.87-1.13).
For depressive symptoms after 1 month, mean scores between the screened and
unscreened groups were within the pre-specified equivalence interval (MD −0.23, 95% CI
−0.42 to −0.04). This indicates that effects were not statistically meaningful.
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Anxiety Symptoms (1 randomized trial, N = 2,019; VERY LOW certainty of evidence,
IMPORTANT)
Likewise, anxiety symptom mean scores were also within the equivalence interval (MD
−0.087, 95% CI −0.246 to 0.072).
Advanced directives include advanced care planning, power of attorney for health care
and/or financial affairs, living will, and insurance policies. It was found that those who
were screened were likely to perform advanced directives, but were also not statistically
significant (RR 1.03, 95% CI 0.97-1.1).
For MIS, 5 studies with a cut-off ≤4 and <5 had a pooled sensitivity of 0.76 (0.63-0.86)
and a pooled specificity of 0.94 (0.89-0.96). The studies involved populations aged 65
years and above, all of which were from the United States and utilized the DSM III-R and
DSM IV as the reference standard (see Appendix I-B for GRADE Evidence Profile).
For Mini-cog, 6 studies with varying cut-offs (≤1, ≤2, ≤3) had a pooled sensitivity of 0.90
(0.72-0.97) and a pooled specificity of 0.83 (0.58-0.94). Cross-sectional studies involved
populations aged 65 years old and older from community and primary care settings with
majority including Caucasian subjects, while 2 studies were comprised of ethnic minorities
residing in the United States.(15,17) Reference tests include DSM-III-R, DSM-IV, and
CDR. The largest study (20) had a skewed specificity (Sp 0.20, 0.14-0.26) due to the
methodology of the research. They initially included only veterans who screened positive
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on the Mini-cog tool but later on added data from patients who screened negative but
requested further dementia assessment (see Appendix I-B for GRADE Evidence Profile).
For MMSE, 6 studies with a cut-off ≤23 or ≤24 had a pooled sensitivity of 0.87 (0.80-0.92)
and a pooled specificity of 0.87 (0.74-0.94). The studies involved populations aged 50
years and above, mostly from longitudinal community studies and primary care settings.
All the included studies utilized the DSM IV as the reference standard (see Appendix I-B
for GRADE Evidence Profile).
For MoCA, 7 studies with varying cut-offs (≤16, ≤20, ≤22, ≤23.5, ≤25) had a pooled
sensitivity of 0.91 (0.80-0.96) and pooled specificity of 0.77 (0.63-0.87). Cross-sectional
studies involved populations aged 60 years old and above from community and primary
care settings with the majority being Asian subjects. Studies utilized DSM-IV, CERAD,
NINCDS-ADRDA, and CDR as reference tests (see Appendix I-B for GRADE Evidence
Profile).
For AD-8, 5 studies with varying cut-offs (≥2, ≥3) had a pooled sensitivity of 0.89 (0.86-
0.91) and pooled specificity of 0.79 (0.70-0.86). Cross-sectional studies involved
populations aged 60 years old and above from community and primary care settings with
the majority being Asian subjects. Studies utilized DSM-IV and NIA-AA as reference tests
(see Appendix I-B for GRADE Evidence Profile).
For CDT, 4 studies with varied scoring methods (Sunderland, Freedman, and Normal
patterns) had a pooled sensitivity of 0.87 (0.72 to 0.95) and pooled specificity of 0.86
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(0.79-0.91). Cross-sectional studies involved mostly Caucasians aged 60 years old and
above from community and primary care settings including 1 study with patients from a
geriatric OPD. Studies utilized DSM-III, DSM-IV, NINCDS-ADRDA, and a
neuropsychiatric assessment as reference tests (see Appendix I-B for GRADE Evidence
Profile).
A summary table comparing the different screening tests can be found in Appendix I-E.
PhilHealth also provides coverage for dementia-related conditions, which include case
rate reimbursements (contains diagnostic costs) (47), ranging from Php 7,800 to as much
as Php 22,200 (48) (see Appendix I-F).
Additionally, the IU CHOICE study noted that patients who screened positively and
proceeded to receive collaborative care had significantly decreased hospital admissions
as compared to those who were not screened but had evidence of cognitive impairment
(data was not shown).(9) The same Indiana clinic had previous data that illustrated how
a dementia collaborative care model implemented at their local memory clinic generated
an annual net cost savings of up to $2,856 per patient.(49)
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4.1.5 Equity, Acceptability, and Feasibility
An Asian study on community dwelling older adults showed that less than half (41%) were
willing to undergo regular dementia screening.(50) The most prominent reasons were
“bothersome to visit clinic” and “do not know which doctors can be consulted.” Another
study showed that most (92.7%) had a positive experience with screening, but those
whose results indicated cognitive deficits on MoCA were less likely to share the results
with their families (48.9% vs. 68.6%; p = 0.007).(51) Only a third (32%) shared screening
results with their healthcare provider (HCP); of this, only 51% reported their HCP seemed
interested but did not follow-up.(50)
From those who were screened, less than half (49%) reported that they did behavioral
changes, including diet, exercise, social engagement, cognitive stimulation, and
advanced care planning.(50) Of those who did not change, their reasons include: no need
for change (37.4%), things got in the way (26.4%), planning to change in the future
(13.2%), and not interested (12.1%).
There was also fear of Alzheimer’s disease and other related dementias among
community dwelling older adults that stems from its impact on memory loss, dreadfulness
and uncertainty, stress to family, and stigma.(52) A study on community stakeholders
found that willingness of a community for cognitive screening depends on the level of trust
they have on the proponents and the level of understanding on the condition.(53) The
people who perform the screening must be either from the community or engaged in the
community for an extended period of time to better understand the condition.
US Preventive Services Task Although screening tools can adequately detect cognitive
Force (2020) (44) impairment, there is no empirical evidence that screening for
such improves patient or caregiver outcomes nor causes harm.
None of the treatment trials cited were linked with a screening
program as recruited patients were at least diagnosed with mild
cognitive impairment. Interventions, both pharmacologic and
nonpharmacologic, were seen to have little benefit and uncertain
clinical importance.
National Institute for Health and Recommends an initial assessment and history from the patient
Care Excellence (2018) (56) and someone who knows the person well if dementia is
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suspected and should not be dismissed as “a part of ageing.”
The guidelines list validated cognitive instruments that can be
utilized in the primary care setting as well as when to refer to a
specialist (i.e., dementia is still suspected despite addressing
reversible causes and if symptoms are rapidly progressive).
The WHO published a toolkit for community workers in low- and middle-income countries
as part of their Mental Health Gap Action Programme (mhGAP) to guide community-
based management and care of people with dementia.(8) This document illustrates a
flowchart for the early detection of dementia through basic a screening question (“Have
you noticed a change in memory, behavior, or function in the last year?”), a checklist for
identifying people at risk if the answer is “yes” to the screening question, and the 8-item
informant interview if the person answers “no” (see Appendix I-G).
25
References
I. Burden of Dementia
1. Nichols E, Szoeke CEI, Vollset SE, Abbasi N, Abd-Allah F, Abdela J, et al. Global, regional, and national
burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global
Burden of Disease Study 2016. The Lancet Neurology. 2019 Jan;18(1):88–106.
2. De la Vega S. Focused Interventions for Frail Older Persons Research and Development Program:
Study 2 Final Report. Manila, Philippines; 2020 Nov.
3. Dominguez JC, Fowler KC, De Guzman MFP (2020). In support of a national dementia plan: A follow-up
study for dementia incidence and risk profiling in Filipino homes. Accessed from: https://alz-
journals.onlinelibrary.wiley.com/doi/pdf/10.1002/alz.043294 [Accessed 28th July 2021]
4. Dominguez J (2018). Prevalence of Dementia and Associated Risk Factors: A Population-Based Study
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2021]
5. Wang Q, Davis PB, Gurney ME, Xu R. COVID-19 and dementia: Analyses of risk, disparity, and
outcomes from electronic health records in the US. Alzheimers Dement. 2021 Aug;17(8):1297-1306.
doi: 10.1002/alz.12296. Epub 2021 Feb 9.
6. Sevigny J, Chiao P, Bussière T, Weinreb PH, Williams L, Maier M, et al. The antibody aducanumab
reduces Aβ plaques in Alzheimer’s disease. Nature. 2016 Sep 1;537(7618):50–6.
7. Knopman DS, Jones DT, Greicius MD. Failure to demonstrate efficacy of aducanumab: An analysis of
the EMERGE and ENGAGE trials as reported by Biogen, December 2019. Alzheimer’s &
Dementia. 2021 Apr;17(4):696–701.
8. World Health Organization. Dementia toolkit for community workers in low-and middle-income countries:
guide for community-based management and care of people with dementia [Internet]. Manila: WHO
Regional Office for the Western Pacific; 2018. Available from:
https://iris.wpro.who.int/handle/10665.1/14014
26
19. Holsinger T, Plassman, BL, Stechuchak KM, Burke JR, Coffman CJ, Williams Jr JW. Screening for
cognitive impairment: comparing the performance of four instruments in primary care. J Am Geriatr Soc.
2012 Jun;60(6):1027-36.
20. McCarten JR, Anderson P, Kuskowski MA, McPherson SE, Borson S, Dysken MW. Finding dementia in
primary care: the results of a clinical demonstration project. J Am Geriatr Soc. 2012 Feb;60(2):210-7.
21. Brodaty H, Pond D, Kemp NM, Luscombe G, Harding L, Berman K, et al. The GPCOG: A New
Screening Test for Dementia Designed for General Practice. J Am Geriatr Soc. 2002 Mar;50(3):530–4.
22. Kahle-Wrobleski K, Corrada MM, Li B, Kawas CH. Sensitivity and Specificity of the Mini-Mental State
Examination for Identifying Dementia in the Oldest-Old: The 90+ Study: SENSITIVITY AND
SPECIFICITY OF MMSE IN THOSE AGED 90 AND OLDER. J Am Geriatr Soc. 2007 Feb;55(2):284–9.
23.Ramlall S, Chipps J, Bhigjee AI, Pillay BJ. The Sensitivity and Specificity of Subjective Memory
Complaints and the Subjective Memory Rating Scale, Deterioration Cognitive Observee, Mini-Mental
State Examination, Six-Item Screener and Clock Drawing Test in Dementia Screening. Dement Geriatr
Cogn Disord. 2013;36(1–2):119–35.
24. Ranson JM, Kuźma E, Hamilton W, Muniz-Terrera G, Langa KM, Llewellyn DJ. Predictors of dementia
misclassification when using brief cognitive assessments. Neurol Clin Pract. 2019 Apr;9(2):109–17.
25. Stein J, Luppa M, Kaduszkiewicz H, Eisele M, Weyerer S, Werle J, et al. Is the Short Form of the Mini-
Mental State Examination (MMSE) a better screening instrument for dementia in older primary care
patients than the original MMSE? Results of the German study on ageing, cognition, and dementia in
primary care patients (AgeCoDe). Psychological Assessment. 2015 Sep;27(3):895–904.
26. Waite LM, Broe GA, Casey B, Bennett HP, Jorm AF, Creasey H, et al. Screening for Dementia Using
an Informant Interview. Aging, Neuropsychology, and Cognition. 1998 Sep;5(3):194–202.
27. Markwick A, Zamboni G, de Jager CA. Profiles of cognitive subtest impairment in the Montreal
Cognitive Assessment (MoCA) in a research cohort with normal Mini-Mental State Examination (MMSE)
scores. J Clin Exp Neuropsychol. 2012 Apr 3;34(7):750-7.
28. Lu J, Li D, Li F, Zhou A, Wang F, Zuo X, et al. Montreal cognitive assessment in detecting cognitive
impairment in Chinese elderly individuals: a population-based study. Journal of Geriatric Psychiatry and
Neurology. 2011 Dec;24(4):184-90.
29. Lee JY, Lee DW, Cho SJ, Na DL, Jeon HJ, Kim SK, et al. Brief screening for mild cognitive impairment
in elderly outpatient clinic: validation of the Korean version of the Montreal Cognitive Assessment.
Journal of Geriatric Psychiatry and Neurology. 2008 Jun;21(2):104-10.
30. Chan QL, Xu X, Shaik MA, Chong SS, Hui RJ, Chen, CL, et al. Clinical utility of the informant AD8 as a
dementia case finding instrument in primary healthcare. J Alzheimers Dis Rep. 2016;49(1):121-7.
31. Dominguez J, Soriano J, Magpantay C, Orquiza M, Solis W, Reandelar Jr. M, Joson M. Early Detection
of Mild Alzheimer’s Disease in Filipino Elderly: Validation of the Montreal Cognitive Assessment-
Philippines (MoCA-P). Advances in Alzheimer's Disease. 2014 Dec;3(4):160-7.
32. Kasai M, Nakamura K, Kato Y, Nakai M, Nakatsuka M, Ishikawa H, et al. A community-based study of
the Montreal Cognitive Assessment (MoCA) in Japan: The Kurihara project. In: Conference: Alzheimer's
Association International Conference, Paris France. Conference Start: 20110716 Conference End:
20110721. 2011.
33. Hsu JL, Fan YC, Huang YL, Wang J, Chen WH, Chiu HC, et al. Improved predictive ability of the
Montreal Cognitive Assessment for diagnosing dementia in a community-based study. Alzheimers Res
Ther. 2015 Nov 9;7(1):69.
34. Correia CC, Lima F, Junqueira F, Campos MS, Bastos O, Petribu K, et al. AD8-Brazil: Cross-cultural
validation of the Ascertaining Dementia Interview in Portuguese. Journal of Alzheimer’s Disease
2011;27(1):177–85.
35. Chan QL, Xu X, Shaik MA, Chong SS, Hui RJ, Chen, CL, et al. Clinical utility of the informant AD8 as a
dementia case finding instrument in primary healthcare. J Alzheimers Dis Rep. 2016;49(1):121-7.
36. Yang L, Yan J, Jin X, Jin Y, Yu W, Xu S, et al. Screening for dementia in older adults: comparison of
Mini-Mental State Examination, Mini-Cog, Clock Drawing Test and AD8. PLOS One 2016 Dec
22;12(11):e0168949.
37. Meguro K, Kasai M, Nakamura K. Reliability and validity of the Japanese version of the AD8. Nihon
Ronen Igakkai zasshi [Japanese Journal of Geriatrics]. 2015;52(1):61–70.
38. Mao HF, Chang LH, Tsai AY, Huang WN, Tang LY, Lee HJ, et al. Diagnostic accuracy of Instrumental
Activities of Daily Living for dementia in community-dwelling older adults. Age Ageing. 2018 Jul
1;47(4):551-7.
27
39. Del Ser T, Sanchez-Sanchez F, Garcia de Yebenes MJ, Otero A, Munoz DG. Validation of the seven-
minute screen neurocognitive battery for the diagnosis of dementia in a Spanish population-based
sample. Dement Geriatr Cogn Disord. 2006;22(5-6):454-64.
40. Fuchs A, Wiese B, Altiner A, Wollny A, Pentzek M. Cued Recall and Other Cognitive Tasks to Facilitate
Dementia Recognition in Primary Care. J Am Geriatr Soc. 2012 Jan;60(1):130-5.
41. Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The clock drawing test in primary care: sensitivity
in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry.
2001 Oct;16(10):935-40.
42. Wolf-Klein GP, Silverstone FA, Levy AP, Brod MS. Screening for Alzheimer's disease by clock drawing.
J Am Geriatr Soc. 1989 Aug ;37(8):730-4.
43. https://www.mims.com/philippines [Accessed 9/14/21]
44. Patnode CD, Perdue LA, Rossom RC, Rushkin MC, Redmond N, Thomas RG, et al. Screening for
cognitive impairment in older adults: updated evidence report and systematic review for the US
Preventive Services Task Force. JAMA. 2020 Feb 25;323(8):764–85. doi:10.1001/jama.2019.22258
28
4.2 Standardized Drug Tests in Screening for Substance Use
Disorders
RECOMMENDATION
Among the general adult population, we recommend against screening for substance
use disorders using standardized drug tests. (Low certainty of evidence; Strong
recommendation)
Considerations
The consensus panel considered the following when formulating this recommendation:
● Recommended against the use of standardized drug tests for screening of
substance use disorders due to the poor evidence and questionable accuracy of
these tests.
● Most of the evidence presented were mainly on cannabis use.
● Social impact of drug testing, risk for stigmatization, and possible unemployment
for those that may test positive.
● The harm of screening with these drug tests outweigh the benefits.
● Although the panel recognizes that substance use disorders are a priority and that
early intervention can prevent escalation into a full blown drug disorder,
standardized drug testing (urine or blood) may not be cost-effective and readily
acceptable.
● The benefits of screening may help in promoting the medicalization rather than
criminalization of drug use with the use of alternative methods aside from
standardized drug tests.
In the Philippines, around 1.67 million Filipinos, aged 10 to 69 years, are current users of
drugs, which equates to a prevalence rate of 2.05%.(2) Cannabis is the most commonly
abused substance (57%), followed by methamphetamine hydrochloride (35%).(2) Not all
persons who use drugs have a SUD. Those who do have a disorder, established after a
more definitive assessment, often get referred to an inpatient rehabilitation program. The
majority of those admitted into facilities are abusers of methamphetamine (93.72%),
followed by marijuana (22.59%), with a small percent of contact cement or Rugby users
(0.73%).(3) Most cases are mono drug users.
Immediate effects may cause physiologic derangement and psychosis. With excessive
intake, abusers may suffer an overdose, and possible death.(4) Persons with substance
29
use problems also have higher rates of risk taking behavior, which leads to driving
accidents, increased rates of sexually transmitted diseases, as well as increased risk
transmitting blood-borne disease due to needle sharing. Other medical problems add to
the burden, with higher risk for heart disease, stroke, and liver problems.(4)
Once misuse or abuse is identified, counselling interventions are done to prevent further
use and screening for SUD may be done. If a disorder is identified, treatment may begin,
usually in the form of a rehabilitation program, which may be done in the outpatient, or
inpatient setting. Treatment consists mainly of psychosocial interventions, with the
inclusion of select pharmacologic interventions, depending on the substance abused.(5)
A review of psychosocial interventions for cannabis use disorders by Gates et al., (8)
showed that the use of a psychosocial intervention, in addition to standard treatment, was
shown to potentially reduce the frequency of use and severity of dependence, in the short
term. Effects were not maintained in the long term upon follow-up months after the end
of treatment. The most supported approach was a combination of motivational
enhancement therapy (MET), cognitive-behavioral therapy (CBT), and abstinence-based
incentives.(8) There was no report of any adverse events resulting from the interventions.
(See Appendix II-B for Evidence Summary Table)
30
4.2.3 Diagnostic Performance of Screening Tests
Currently, there are no studies that determine the accuracy of laboratory drug testing in
diagnosing substance use disorders.
Test performance of laboratory drug tests is usually evaluated in the context of accurately
detecting recent substance use.(9) The most common specimen for testing is urine.(10)
Initially, a screening test is done, with a predetermined threshold for detection of a
substance or metabolite. The initial screen is an immunoassay, with results that are
qualitative in nature (may be positive or negative for the substance of interest). Positive
screens are then sent for confirmatory testing to quantify the amount of substance by
means of Chromatography and Mass Spectrometry.(10)
Medical detoxification:
Mandatory Services
31
Urine pH
Serum Na, K, Cl
Creatinine
BUN
ECG
Chest x-ray
Medicines
As indicated only:
Activated charcoal
Sodium sulfate
Vitamin B complex
Benzodiazepine
Antipsychotic medicines
DS0-50
Private Institutions:
Variable: Php 50,000 -
100,000
32
conditions for testing would be tests that are scheduled and done in a setting where a
positive result would warrant a health care referral, rather than termination of
employment.(17) There is no literature that examines attitudes toward drug testing in the
local context.
33
The AAP recommends screening for alcohol and other
drug use at adolescent health supervision visits and
appropriate acute-care visits.
The American
Academy of Testing for evidence of drug use can be particularly None stated
Pediatrics (20) helpful for monitoring compliance with SUD treatment
and in cases of acute intoxication where identification
of specific substances guides acute medical
management. It is not a routine part of substance use
screening and is not necessary to initiate substance
use treatment; a thorough history is most important.
34
References
35
17. Stone, D. L., & Kotch, D. A. (1989). Individuals' attitudes toward organizational drug testing policies
and practices. Journal of Applied Psychology, 74(3), 518–521. https://doi.org/10.1037/0021-
9010.74.3.518
36
4.3 Standardized Instruments in Screening for Substance Use
Disorders
RECOMMENDATIONS
Considerations
The consensus panel considered the following when formulating this recommendation:
● Unanimous with their decision to recommend screening for both asymptomatic
healthy adults and adolescents with the use of standardized screening tools.
● Substance use disorders are a priority and early intervention can prevent
escalation into a full blown drug disorder.
● Standardized tools such as questionnaires are cost-effective, easy to administer,
and more acceptable.
● Screening was recommended by the panel to be done at least once a year to
minimize costs.
● Screening for substance use disorders can be incorporated into annual check-ups
for adults and school check-ups for adolescents.
Patients with drug use disorder suffer from poor prognosis of associated health disorders,
either caused by their substance abuse, such as liver disease and organic brain disorders
or exacerbated by the neglect of health and lack of preventive health care. In addition,
diseases such as HIV/AIDS, strains of hepatitis, and tuberculosis may be transmitted by
substance abuse.(3) Depending on the type of substance use, pharmacologic and
cognitive behavioral therapy for specific drug abuse disorder is the first-line treatment.
37
Current studies suggest that best practices in addiction treatment should include the
combination of both.(4)
Psychosocial Interventions
There were few trials on psychosocial interventions that focused on adolescents aged 12
to 17 years. USPSTF evidence synthesis concluded that evidence was limited and results
were inconclusive. In addition, these studies did not report the effect of psychosocial
interventions on drugs other than cannabis.(5)
Greater decrease versus control conditions in the number of drug use days (19 trials; MD
-0.49 day in the last 7 days, 95% CI -0.85 to -0.13) and a small but statistically significant
greater decrease in drug use severity (16 trials; SMD -0.18, 95% CI -0.32 to -0.05) at 3
to 4 month follow-up.(5)
Small but statistically significant decrease in drug use severity versus controls at 3 to 4
months (17 trials, SMD -0.18, 95% CI -0.32 to -0.05; I2 = 73%) but not at 6 to 12 months
(13 trials, SMD -0.10, 95% CI -0.24 to 0.02; I2 = 65%).(5)
Table 1. Effect of psychological Interventions among adults with substance abuse disorder in adults
Duration of follow
Outcomes No. of Studies RR (95% CI) Level of Certainty
up
3-4 Months 15 1.60 (1.24 to 2.13) Moderate
Abstinence
6-12 Months 14 1.25 (1.11 to 1.52) Moderate
3-4 Months 19 -0.49 (-0.85 to 0.13) Moderate
Drug Use Days
6-12 Months 15 -0.08 (-0.30 to 0.11) Moderate
Drug Use -0.18 (-0.32 to -
3-4 Months 17 Moderate
Severity 0.05)
38
6-12 Months 13 -0.10 (-0.24 to 0.02) Moderate
No reported significant effects on drug use or health, social, or legal outcomes of drug
use at 3 to 6 months after the start of the interventions.(5)
Harm (4 Randomized Control Trials, N = 1,198; Low Certainty of Evidence)
In treatment-seeking populations with opioid use disorder, naltrexone (12 trials; RR 0.73,
95% CI 0.62-0.85; NNT 5.3) and opioid agonist therapy with methadone or buprenorphine
(4 trials; RR 0.75, 95% CI 0.59-0.82; NNT 2.9) were associated with decreased risk of
drug use relapse compared with placebo or no pharmacotherapy.(5)
39
Adolescent (11 studies, N = 13,330; Low Certainty of Evidence)
Most studies focus on the detection of cannabis use. The USPSTF determined the
evidence on the accuracy of screening in adolescents to be inadequate given the limited
number of studies on individual tools and the lack of information on the accuracy of tools
for detecting use of drugs other than cannabis.(6)
Sensitivity for detecting any cannabis use or unhealthy use ranged from 0.68 to 0.98 (95%
CI 0.64-0.99) and specificity ranged from 0.82 to 1.00 (95% CI 0.80-1.00). Sensitivity for
detecting cannabis use disorders ranged from 0.71 to 0.98 (95% CI 0.41-1.00) and
specificity ranged from 0.79 to 0.95 (95% CI 0.77-0.98).(6)
The sensitivity of direct tools for detecting unhealthy use of “any drug” (including illicit
drugs and nonmedical use of prescription drugs) in the past month or year ranged from
0.71 to 0.94 (95%CI, 0.62-0.97), and specificity ranged from 0.87 to 0.97 (95% CI, 0.83-
0.98). Direct tool sensitivity for detecting abuse or dependence or a use disorder related
to “any drug” ranged from 0.85 to 1.00 (95% CI, 0.75-1.00) and specificity ranged from
0.67 to 0.93 (95% CI, 0.58-0.95).
Screening tools had higher sensitivity for detecting unhealthy drug use and drug use
disorders related to “any drug” (most of which was cannabis), cannabis, heroin, and
stimulants than for detecting unhealthy drug use or drug use disorders related to
nonmedical use of prescription drugs, including opioids or sedatives (range 0.38-0.96,
95% CI 0.29-0.99) but specificity was comparable (range 0.79-1.00, 95% CI 0.71-
1.00).(6)
The detection of any prenatal use of drugs using direct tools ranged from 0.37 to 0.76
(95% CI 0.24-0.86) and specificity ranged from 0.68 to 0.83 (95% CI 0.55-0.91). The
indirect tool Parents Partner Past Pregnancy reported high sensitivity 0.87 (95% CI 0.71-
0.95) and high specificity 0.76 (95% CI 0.70-0.82) for detecting the combined outcome of
any prenatal use of drugs or alcohol.(6)
Table 3. Diagnostic Performance of screening tests by interview questions for substance abuse.
No. of Level of
Subgroup Outcomes Sensitivity Specificity
Studies Certainty
0.68 to 0.98 0.82 to 1.00
Cannabis use
(0.64-0.99) (0.80-1.00)
Adolescent 11 Low
Cannabis use 0.71 to 0.98 0.79 to 0.95
Disorder (0.41-1.00) (0.77-0.98)
0.71 to 0.94 0.87 to 0.97
Drug Use
(0.62-0.97) (0.83-0.98) Moderate
Adults 12
0.85 to 1.00 0.67 to 0.93
Drug Use Disorder
(0.75-1.00) (0.58-0.95)
40
Prenatal Drug Use 0.37 to 0.76 0.68 to 0.83
Pregnant and (Direct tools) (0.24-0.86) (0.55-0.91)
5 Low
Postpartum Prenatal Drug Use 0.87 0.76
(Indirect Tools) (0.71-0.95) (0.70-0.82)
Table 4: Resource Table for Substance Abuse Screening and Confirmatory Tests
Screening intervention Confirmatory Tests
Unit cost of
screening
0b - 10, 000c
intervention Free Free 250-450
Philippine Peso
(PHP)
a: AUDIT, DAST-10 test and manuals used by Department of Health Dangerous Drugs Abuse Prevention and
Treatment Program are downloadable and free
b: Free DDE from programs of Bridges of Hope Inc.
c: Range is based on psychologists’ and psychiatrists’ quotation rates
One study (13) found that patients, primary care providers, and medical assistants
unanimously agreed that identifying and addressing substance use in primary care was
important due to its negative impact on overall health, co-occurring conditions, and
treatment adherence. For patients, barriers to screening centered around a perceived
lack of rapport with providers, which contributed to concerns about trust, judgment, and
41
privacy. For primary care providers and medical assistants, barriers included lack of
comfort, training, and preparedness to address screening results and offer treatment.(13)
A study on Philippine programs and policies that aims to improve the assessment and
management of drug dependence in the country concluded that there is a need to
develop a bigger pool of health professionals that can manage drug use disorders.(14)
No local studies were found on equity regarding substance abuse screening.
Substance Abuse and Mental Recommends universal screening for substance use
Health Services Administration (including alcohol), brief intervention, and/or referral to
(SAMHSA) (15) treatment (known as SBIRT) as part of routine health care,
including during pregnancy.
42
References
43
Providers and Patients. J Gen Intern Med. 2019 Dec;34(12):2824-2832. doi: 10.1007/s11606-019-
05232-y. PMID: 31414355; PMCID: PMC6854168.
14. Antonio CT, Guevarra JP, Cavinta LL, Gloriani NG, Peralta JT, Reyes-Sare M. Lessons learned from
government-academe-civil society partnership to improve the assessment and management of drug
dependence in the Philippines. Acta Medica Philippina, 2018, 52(3), 277-280
44
4.4 Standardized Instruments in Screening for Depression
among High-Risk Groups
RECOMMENDATION
Among high-risk healthy asymptomatic adults, we recommend screening for depression
using:
PHQ-9 for medical students, and healthcare workers
CES-D among caregivers and ill adults
GDS-15 among older persons
Considerations
The consensus panel considered the following when formulating this recommendation:
● Unanimous with the decision to recommend screening for depression among high-
risk asymptomatic groups.
● Despite the low certainty of evidence, the panel strongly recommended screening
since the harm is little to none and the benefits far outweigh the harm or risks.
● Acceptability of screening seems to vary among patients, especially in relation with
socioeconomic status
● The panel also identified research gaps such as the lack of local data on the
preferences and acceptability of Filipino patients with regards to depression
screening
● Another research gap identified was the inclusion of other high-risk groups such
as those from the LGBTQ+ community.
● The panel was unable to reach a consensus vote on the frequency of screening.
● Some members voted for screening at least once a year as part of annual check-
ups.
● However, other members voted for screening more than once a year since these
are high risk groups that are more vulnerable to developing depression.
● More frequent screening may also aid in early detection and also as a way to
monitor any progression of depressive symptoms.
45
increased by 14.3% in 2017.(2) Globally, mortality due to suicide is over 700,000 with
low- and middle-income countries accounting for 77%.(3) In 2017, WHO cited that the
prevalence of depressive disorders in the Philippine population was 3,298,652 or 3.3%.(4)
The estimated suicide mortality rate in the Philippines is 3.2 per 100,000 population in
2017.(5)
Depressive disorder rates vary across different subgroups, therefore certain populations
are at higher risk for depression. Medical students seem to have increased rates of
depression. Among medical students in a Philippine private medical school, the
prevalence of positive screens for moderate to severe depression was 19.1%.(6)
According to a systematic review among medical students in China, the prevalence of
positive screens for depression was 29% (95% CI 0.15-0.44).(7)
Older persons are at a higher risk of depressive disorders. In 2012, 44% of Filipino older
persons living in an institution had positive screens for moderate to severe depression.(8)
These results are comparable to other systematic reviews (SRs), including one done in
South Asian Countries, which reported a 42% (95% CI 0.38-0.46) prevalence for positive
screens for depression among older persons.(9) According to the SR in Nepal, the
prevalence of positive depression screens varies in the community setting (25.5-60.6%),
care facilities (17.3-89.1%), and hospital settings (53.2-57.1%).(10) In India, there is a
34.4% (95% CI 0.29-0.40) prevalence of positive screens for depression among older
persons.(11) Other studies investigated the prevalence of diagnosed major depressive
disorders (MDD) among older persons. The Philippine FITforFRAIL study cited a 19.8%
prevalence of diagnosed depression among older persons.(12) Among Chinese older
persons, 2.7% (95% CI 0.02-0.03) suffered from MDD.(13) A meta-analysis among
nursing home residents reports an 18.9% (95% CI 0.15-0.24) pooled prevalence rate of
MDD.(14)
Informal caregivers have an increased risk for depression. According to three meta-
analysis, the prevalence of positive screens for depression among informal caregivers of
patients with Alzheimer’s disease was 34% (15), 40.2% (95% CI 0.30-0.51) among
caregivers of stroke survivors (16), and 42.30% (95% CI 0.33-0.51) among caregivers of
cancer patients.(17)
Individuals with diseases are at a higher risk for depression than the general population.
According to three systematic reviews on patients with bowel diseases, the prevalence of
positive screens for depression was 21.6-25.2% for those suffering from inflammatory
bowel disease (20,21), and 39.1% among those with irritable bowel syndrome.(22)
Among people with osteoarthritis, the pooled prevalence of positive screens for
depression was 19.9% (95% CI 0.16-0.25).(23) A meta-analysis investigated the
46
prevalence of positive depression screens among patients months after a critical illness.
The cited prevalence of depression in their review was 29% (95% CI 0.22-0.36) at 2 to 3
months, 34% (95% CI 0.24-0.43) at 6 months, and 29% (95% CI 0.23-0.34) at 12-14
months.(24)
The prevalence rates of positive screens for depression are comparable to the rates of
diagnosed MDD among diseased individuals. Two meta-analysis report a 17.9% (95% CI
0.13-0.23) (25) and 26.8% (95% CI 0.22-0.32) (26) prevalence of diagnosed depressive
disorders among people with hypertension. Based on a meta-analysis on HIV-infected
adults, the prevalence of diagnosed depression was 15.3% (95% CI 12.5-17.1).(27)
Depression screening has small to no harms in the adult population. The USPSTF reports
finding no evidence on the harms of depression screening.(30)
According to a meta-analysis in 2019, at a cut off score of 10, the Patient Health
Questionnaire 9 (PHQ-9) had a sensitivity of 0.88 (95% CI 0.83-0.92) and a specificity
0.85 (95% CI 0.82-0.88).(31)
A meta-analysis was done in 2016, to assess the diagnostic accuracy of the Center for
Epidemiologic Studies Depression Scale (CES-D) among the general population. They
reported that the CES-D (cut off score of 16) had a sensitivity of 0.87 (95% CI 0.82-0.92)
and a specificity of 0.70 (95% CI 0.65-0.75).(32)
47
sensitivity was 0.86 (95% CI 0.81 – 0.90) and the pooled specificity was 0.85 (95% CI
0.78–0.91). The cut off scores for psychiatric patients was 24 or higher and the pooled
sensitivity and specificity was 0.84 (95% CI 0.79–0.88) and 0.86 (95% CI 0.78–0.91)
respectively.(33)
Center for
Parameter Patient Health Geriatric
Epidemiologic Studies
Questionnaire 9 Depression Scale
Depression Scale
(PHQ-9) (GDS)
(CES-D)
Unit cost of
screening Free Free Free
intervention
Values based test costs
A study done among older adults in primary care showed that most patients were willing
to complete screening and most found the process to be valuable for health. Receiving
an informative pamphlet prior to screening made patients more willing to undergo
screening.(36)
48
Another study, with semi-structured in-depth interviews, was carried out among patients
with positive screening results for depression. All patients appreciated the active
approach to screening.[37] Most recognized that they had symptoms, but more than half
did not accept the diagnosis of depression. The reasons for non-acceptance were fear of
stigmatization and skepticism about the usefulness of labelling, belief that depressive
symptoms were a normal, transitory reaction to adversity, and doubts about the necessity
and effectiveness of treatment.(37)
Perspectives in the local context must also be considered. A systematic review of Filipino
attitudes toward mental health and service seeking showed low utilization of mental health
services among Filipinos, with mental health stigma as a primary barrier, while resilience
and self-reliance as coping strategies were cited in qualitative studies.(38) Social support
and severity of symptoms were cited as prominent facilitators for mental health service
seeking.(38) A survey of barangay residents showed that respondents were generally
knowledgeable about mental health illness.(39) There was a general acceptance and less
stigmatizing attitude, and willingness to interact with people with mental illness, but there
were reservations toward working with persons with mental illness.
Canadian Task CTFPHC does not recommend routine Certainty of evidence: Very
Force on screening for depression in the general Low Quality of Evidence
Preventive Health population or in subgroups with
Strength of recommendation:
Care (40) increased risk.
Weak
49
Services Task same time, it indicates the need to Strength of recommendation:
Force (42) provide coordinated treatment. Strong
Institute of Clinical ICSI recommends routine screening for Certainty of evidence: Low
Systems depression in the adult population using
Strength of recommendation:
Improvement (46) PHQ-2 and/or PHQ-9 especially if they
are suspected based on risk factors or Strong
presentation.
50
References
I. Burden of Depression
1. World Health Organization. Depression. 30 January 2020. https://www.who.int/news-room/fact-
sheets/detail/depression. Accessed August 30, 2021.
2. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national
incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries
and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.
Lancet. 2018 Nov 10;392(10159):1789-1858. doi: 10.1016/S0140-6736(18)32279-7. Epub 2018 Nov
8. Erratum in: Lancet. 2019 Jun 22;393(10190):e44. PMID: 30496104; PMCID: PMC6227754.
3. World Health Organization. Depression. 17 June 2021. https://www.who.int/news-room/fact-
sheets/detail/suicide
4. World Health Organization. Depression and Other Common Mental Disorders: Global Health
Estimates. 2017. Licence: CC BY-NC-SA 3.0 IGO.
5. World Health Organization. Mental Health ATLAS 2017 Member State Profile.
https://www.who.int/mental_health/evidence/atlas/profiles-2017/PHL.pdf?ua=1. Accessed August 30,
2021.
6. Vitocruz, PG, Vivar, AG, Whang, GR, Wonglue, NM, Wu, Y, Yadao, LP, Prevalence of depression
among medical students in a private medical school: A cross-sectional study. The Health Sciences
Journal. 2019; 8(2), 122-126
7. Zeng W, Chen R, Wang X, Zhang Q, Deng W. Prevalence of mental health problems among medical
students in China: A meta-analysis. Medicine (Baltimore). 2019 May;98(18):e15337. doi:
10.1097/MD.0000000000015337. PMID: 31045774; PMCID: PMC6504335.
8. MJ T. Dela Cruz, J P. Dianzon, R B. Domingo, JM S. Engada, R L. Fajutag, R M. Gentica, D
C. Narag, D Quelete, B Sevilla, M D. Tolentino, R J. Sarmiento. Using the center for Epidemiologic
Studies Depression Scale (CES-D) in assessing depression among institutionalized elderly in the
Philippines: A survey research on demographic differences. March 2012.
9. Assariparambil AR, Noronha JA, Kamath A, Adhikari P, Nayak BS, Shankar R, George A. Depression
among older adults: a systematic review of South Asian countries. Psychogeriatrics. 2021
Mar;21(2):201-219. doi: 10.1111/psyg.12644. Epub 2020 Dec 15. Erratum in: Psychogeriatrics. 2021
Jul;21(4):693. PMID: 33319427.
10. Thapa DK, Visentin D, Kornhaber R, Cleary M. Prevalence of Mental Disorders among Older People
in Nepal: A Systematic Review. Kathmandu Univ Med J (KUMJ). 2018 Apr-Jun;16(62):181-190.
PMID: 30636762.
11. Pilania M, Yadav V, Bairwa M, Behera P, Gupta SD, Khurana H, Mohan V, Baniya G, Poongothai S.
Prevalence of depression among the elderly (60 years and above) population in India, 1997-2016: a
systematic review and meta-analysis. BMC Public Health. 2019 Jun 27;19(1):832. doi:
10.1186/s12889-019-7136-z. PMID: 31248394; PMCID: PMC6598256.
12. Pellejo H, Guzman KL, Lopez MRJ, Ladia MA, Giron MaS, Ong K, De la Vega, SA. Mental Health
Matters: The Need for Mental Health Services for Older Persons at the Barangay Level. 2020. Wang
F, Zhang QE, Zhang L, Ng CH, Ungvari GS, Yuan Z, Zhang J, Zhang L, Xiang YT. Prevalence of
major depressive disorder in older adults in China: A systematic review and meta-analysis. J Affect
Disord. 2018 Dec 1;241:297-304. doi: 10.1016/j.jad.2018.07.061. Epub 2018 Jul 27. PMID:
30142588.
13. Fornaro M, Solmi M, Stubbs B, Veronese N, Monaco F, Novello S, Fusco A, Anastasia A, De
Berardis D, Carvalho AF, de Bartolomeis A, Vieta E. Prevalence and correlates of major depressive
disorder, bipolar disorder and schizophrenia among nursing home residents without dementia:
systematic review and meta-analysis. Br J Psychiatry. 2020 Jan;216(1):6-15. doi: 10.1192/bjp.2019.5.
PMID: 30864533.
14. Sallim AB, Sayampanathan AA, Cuttilan A, Ho R. Prevalence of Mental Health Disorders Among
Caregivers of Patients With Alzheimer Disease. J Am Med Dir Assoc. 2015 Dec;16(12):1034-41. doi:
10.1016/j.jamda.2015.09.007. PMID: 26593303.
15. Loh AZ, Tan JS, Zhang MW, Ho RC. The Global Prevalence of Anxiety and Depressive Symptoms
Among Caregivers of Stroke Survivors. J Am Med Dir Assoc. 2017 Feb 1;18(2):111-116. doi:
10.1016/j.jamda.2016.08.014. Epub 2016 Oct 11. PMID: 27742585.
51
16. Geng HM, Chuang DM, Yang F, Yang Y, Liu WM, Liu LH, Tian HM. Prevalence and determinants of
depression in caregivers of cancer patients: A systematic review and meta-analysis. Medicine
(Baltimore). 2018 Sep;97(39):e11863. doi: 10.1097/MD.0000000000011863. PMID: 30278483;
PMCID: PMC6181540.
17. Salari N, Khazaie H, Hosseinian-Far A, Khaledi-Paveh B, Kazeminia M, Mohammadi M, Shohaimi S,
Daneshkhah A, Eskandari S. The prevalence of stress, anxiety and depression within front-line
healthcare workers caring for COVID-19 patients: a systematic review and meta-regression. Hum
Resour Health. 2020 Dec 17;18(1):100. doi: 10.1186/s12960-020-00544-1. PMID: 33334335; PMCID:
PMC7745176.
18. Krishnamoorthy Y, Nagarajan R, Saya GK, Menon V. Prevalence of psychological morbidities among
general population, healthcare workers and COVID-19 patients amidst the COVID-19 pandemic: A
systematic review and meta-analysis. Psychiatry Res. 2020 Nov;293:113382. doi:
10.1016/j.psychres.2020.113382. Epub 2020 Aug 11. PMID: 32829073; PMCID: PMC7417292.
19. Neuendorf R, Harding A, Stello N, Hanes D, Wahbeh H. Depression and anxiety in patients with
Inflammatory Bowel Disease: A systematic review. J Psychosom Res. 2016 Aug;87:70-80. doi:
10.1016/j.jpsychores.2016.06.001. Epub 2016 Jun 6. PMID: 27411754.
20. Barberio B, Zamani M, Black CJ, Savarino EV, Ford AC. Prevalence of symptoms of anxiety and
depression in patients with inflammatory bowel disease: a systematic review and meta-analysis.
Lancet Gastroenterol Hepatol. 2021 May;6(5):359-370. doi: 10.1016/S2468-1253(21)00014-5. Epub
2021 Mar 12. PMID: 33721557.
21. Zamani M, Alizadeh-Tabari S, Zamani V. Systematic review with meta-analysis: the prevalence of
anxiety and depression in patients with irritable bowel syndrome. Aliment Pharmacol Ther. 2019
Jul;50(2):132-143. doi: 10.1111/apt.15325. Epub 2019 Jun 3. PMID: 31157418.
22. Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in
osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016 Mar;45(2):228-35. doi:
10.1093/ageing/afw001. Epub 2016 Jan 20. PMID: 26795974.
23. Rabiee A, Nikayin S, Hashem MD, Huang M, Dinglas VD, Bienvenu OJ, Turnbull AE, Needham DM.
Depressive Symptoms After Critical Illness: A Systematic Review and Meta-Analysis. Crit Care Med.
2016 Sep;44(9):1744-53. doi: 10.1097/CCM.0000000000001811. PMID: 27153046; PMCID:
PMC7418220.
24. Endomba FT, Mazou TN, Bigna JJ. Epidemiology of depressive disorders in people living with
hypertension in Africa: a systematic review and meta-analysis. BMJ Open. 2020 Dec
10;10(12):e037975. doi: 10.1136/bmjopen-2020-037975. PMID: 33303433; PMCID: PMC7733170.
25. Li Z, Li Y, Chen L, Chen P, Hu Y. Prevalence of Depression in Patients With Hypertension: A
Systematic Review and Meta-Analysis. Medicine (Baltimore). 2015 Aug;94(31):e1317. doi:
10.1097/MD.0000000000001317. Erratum in: Medicine (Baltimore). 2018 Jun;97(22):e11059. PMID:
26252317; PMCID: PMC4616591.
26. Lofgren SM, Bond DJ, Nakasujja N, Boulware DR. Burden of Depression in Outpatient HIV-Infected
adults in Sub-Saharan Africa; Systematic Review and Meta-analysis. AIDS Behav. 2020
Jun;24(6):1752-1764. doi: 10.1007/s10461-019-02706-2. PMID: 31720956; PMCID: PMC7478178.
27. National Institute for Health and Care Excellence. Depression in adults: recognition and management.
2009 October 28. Available at: https://www.nice.org.uk/guidance/cg90/resources/depression-in-
adults-recognition-and-management-pdf-975742636741
28. O'Connor E, Rossom RC, Henninger M, et al. Screening for Depression in Adults: An Updated
Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD):
Agency for Healthcare Research and Quality (US); 2016 Jan. (Evidence Syntheses, No. 128.) 4,
Discussion. Available from: https://www.ncbi.nlm.nih.gov/books/NBK349025/
52
individual participant data meta-analysis. BMJ. 2019 Apr 9;365:l1476. doi: 10.1136/bmj.l1476.
Erratum in: BMJ. 2019 Apr 12;365:l1781. PMID: 30967483; PMCID: PMC6454318.
53
improvement-consortium-guideline-primary-4a789e.html. Access: September 2, 2021.
45. Trangle M, Gursky J, Haight R, et al. Depression in primary care: health care guidelines, 17th ed.
Bloomington, MN: Institute of Clinical Systems Improvement, 2016.
54
4.5 Standardized Instruments in Screening for Anxiety
RECOMMENDATION
Among healthy asymptomatic adults, we recommend screening for anxiety and anxiety
disorders using a standardized instrument at least once a year. (Moderate certainty of
evidence; Strong recommendation)
Considerations
The consensus panel considered the following when formulating this recommendation:
● Unanimous with their decision to recommend screening for anxiety and anxiety
disorders due to the prevalence of these problems, especially during the
pandemic.
● The benefits outweigh the potential harms such as over diagnosis and
stigmatization.
● The harms can be mitigated with the use of validated and acceptable screening
tools.
● The panel voted on screening at least once a year and may be incorporated into
annual check-ups.
Screening tools for anxiety have a cut-off score that would warrant further examination,
usually with a physician to diagnose the anxiety disorder at hand. There are several tools
used for diagnosis such as the Composite International Diagnostic Interview (CIDI),
Clinical Interview Schedule Revised (CIS-R), Structured Clinical Interview for DSM
Disorders (SCID), or Mini International Neuropsychiatric Interview (MINI). Further
management depends on the type of anxiety disorder, ranging from behavioral therapy
to pharmacologic management.
55
No direct studies were found on the benefits and harm of screening for anxiety and anxiety
disorders. A study done in 2020 (6) was not able to find any supporting evidence as to
effectiveness of screening for anxiety, and harms of screening.
Studies done (7-10) on patients diagnosed with an anxiety disorder show that there is an
increased risk for health outcomes as described in Table 1. With regard to the
effectiveness of treatment (11), there was an improved outcome in patients with anxiety
disorders who were treated with cognitive behavioral therapy, as shown in Table 2.
Table 1. Health-related Outcomes of those with Anxiety and Anxiety Disorders
No. of Studies Rate
Outcomes Level of Certainty
(no. of participants) (95% CI)
36 studies included
All-cause Mortality HR 0.99 (0.96–1.02) Moderate
(n = 127,552)
8 studies included
Stroke OR 1.24 (1.09 to 1.41) High
(n = 950,759)
14 studies included
Diabetes OR 1.47 (1.23 to 1.75) Very Low
(n = 1,760,800)
Clinically important
12 studies included
improvement in anxiety RR 3.75 (2.51 to 5.60) Low
(n = 866)
at post-treatment
Disorder-specific
anxiety symptom 28 studies included 1.06 standard deviations Low
severity at post- (n = 2,147) lower
treatment
General anxiety
28 studies included 0.75 standard deviations
symptom severity at Low
(n = 1,496) lower
post-treatment
56
No. of Studies
Outcomes Effect Estimate Level of Certainty
(no. of participants)
The GAD-7 is a recently developed, easy to use, 7-item scale based on the Diagnostic
and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria, for identifying likely cases
of GAD. It has been found to have great psychometric properties and is short and easy
to administer. This allows the GAD-7 to be used in remote health surveys, epidemiologic
studies, and also in primary care settings.(12) Most studies use a cut-off score of 10 to
warrant further investigation.
Based on a systematic review (13) comprising 9 studies with moderate quality studies,
with the cut-off score of 8 (N = 4,479), sensitivity was 0.83 (95% CI 0.71-0.91) and
specificity was 0.84 (95% CI 0.70-0.92). With a cut-off score of 10 (N = 4642), the
sensitivity was 0.74 (95% CI 0.61-0.84) and specificity was 0.83 (95% CI 0.66-0.95). The
study used SICI, MINI, and CIS as the gold standard for the tool. No subgroups by age,
sex, race, or ethnicity were reported.
Table 3. Sensitivity and Specificity of GAD-7 with cut-off scores of 8> and 10>
GAD-7 Sensitivity (95% CI) Specificity (95% CI)
Cut-off Score 8> 0.83 (0.78 to 0.87) 0.84 (0.83 to 0.85)
Cut-off Score 10> 0.74 (0.69 to 0.79) 0.83 (0.82 to 0.84)
The GAD-2 is an ultra-quick version of the 7-item scale that incorporates the first two
questions of the GAD-7, which represents the core anxiety symptoms. A score of 3 or
more warrants further investigation for anxiety disorders.
A systematic review in 2017 (14) with 11 moderate to high quality studies (N = 3,176), the
sensitivity and specificity were at 0.80 (95% CI 0.67-0.89) and 0.82 (95% CI 0.72-0.90)
respectively. The study included adults in the general population along with subjects from
primary care. No subgroups by age, sex, race, or ethnicity were reported. However, when
removing 2 studies with outliers, the sensitivity and specificity changes to 0.78 (95% CI
0.61-0.89) and 0.83 (95% CI 0.71-0.91) but reducing the heterogeneity significantly, from
I2 = 62.8 to I2 = 37.0 (see Appendix V-B for the GRADE Evidence Profile).
Table 4. Sensitivity and Specificity of GAD-2 (11 studies) vs. with outliers removed (9 studies)
GAD-2 Sensitivity (95% CI) Specificity (95% CI) Heterogeneity (I2)
Complete (11 studies) 0.80 (0.74 to 0.85) 0.82 (0.81 to 0.83) 62.8
57
Removed Outliers (9 37.0
0.78 (0.71 to 0.84) 0.83 (0.82 to 0.84)
studies)
The HADS-A is widely used as a brief self-rating instrument for both dimensional and
categorical aspects of anxiety and depression in both epidemiology and specialist care.
Although used mainly in the hospital setting, there are few studies that have used it in the
general population.
Based on one systematic review done in 2016 (15) consisting of 8 studies (N = 1,383),
with low quality studies, the sensitivity was 0.90 (95% CI 0.85-0.94) while specificity was
0.85 (95% CI 0.83-87). These studies used varying tools as gold standards ranging from
the PSE, CIS-R, DSM, and MINI. No subgroups by age, sex, race, or ethnicity were
reported (see Appendix V-B for GRADE Evidence Profile)
Table 5. Sensitivity and Specificity of HADS-A and HADS-P
Sensitivity (95% CI) Specificity (95% CI)
HADS-A (cut-off score ≥7) 0.90 (0.85 to 0.94) 0.85 (0.83 to 0.94)
58
4.5.6 Recommendations from Other Groups
In the United Kingdom, the National Institute for Health and Care Excellence (NICE)
Common Mental Health Problems: Identification and Pathways to Care Guidelines last
updated on February 2021 (20) recommends screening for those who may have anxiety
using the 2-item Generalized Anxiety Disorder (GAD-2) Scale. Having a significant score
warrants further assessment by a physician. They recommend this for people with a
history of anxiety disorder and possible somatic symptoms or those who answer yes to
the question “Do you find yourself avoiding places or activities and does this cause you
problems?”
59
References
I. Burden of Anxiety
1. World Health Organization. Depression and Other Common Mental Disorders: Global Health
Estimates [Internet]. World Health Organization; 2017. Available from:
https://www.who.int/publications/i/item/depression-global-health-estimates
2. Flores JL, Hernandez MA, Leyva EW, Cacciata M, Tuazon J, Evangelista L. Prevalence and
correlates of depression, anxiety, and distress among Filipinos from low-income communities in the
Philippines. Philipp J Nurs. 2018;88(2):8–13.
3. Yatham S, Sivathasan S, Yoon R, da Silva TL, Ravindran AV. Depression, anxiety, and post-traumatic
stress disorder among youth in low and middle income countries: A review of prevalence and
treatment interventions. Asian J Psychiatr. 2018;38:78–91.
4. Généreux M, Schluter PJ, Hung KK, Wong CS, Pui Yin Mok C, O’Sullivan T, et al. One virus, four
continents, eight countries: An interdisciplinary and international study on the psychosocial impacts of
the COVID-19 pandemic among adults. Int J Environ Res Public Health. 2020;17(22):8390.
5. Santabárbara J, Lasheras I, Lipnicki DM, Bueno-Notivol J, Pérez-Moreno M, López-Antón R, et al.
Prevalence of anxiety in the COVID-19 pandemic: An updated meta-analysis of community-based
studies. Prog Neuropsychopharmacol Biol Psychiatry. 2021;109(110207):110207.
60
17. Psychological Association of the Philippines. Free consultations from the Philippine Psychiatric
Association (PPA). They provide services even for non-frontliners. Please call 0918 942 4864 or email
them at [email protected]. Thank you PPA! [Internet]. 2020 May 2 [cited 2021 Aug 19];
Available from:
https://www.facebook.com/148851815387/photos/a.10150469570850388/10156646495015388/?type
=3&theaterhttp%3A%2F%2F.
18. Prescription Psychiatrists. Psychologist and Psychiatrist Services in Metro Manila [Internet]. Metro
Manila, Philippines: Prescription Psychiatrists; 2021 [cited 2021 Aug 19]. Available from:
https://prescriptionpsychiatrists.com.ph/.
61
4.6 Standardized Instruments in Screening for Depression
among Children and Adolescents
RECOMMENDATION
Considerations
The consensus panel considered the following when formulating this recommendation:
● Unanimous with their decision to recommend screening for depression among
children and adolescents due to the high prevalence of depression and the high
suicide rate among this age group.
● Despite the low level of evidence, this was a strong recommendation from the
panel due to the high prevalence of depression and the potential benefits.
● Potential harms such as the stigmatization and cultural acceptability of mental
health problems, especially among adolescents can be mitigated with proper
mental health education and awareness.
● Especially during the pandemic, there has been a rise in mental health awareness
programs and several government facilities and organizations already have
subsidies for putting mental health programs into place.
● Other issues raised were the potential costs for confirmatory testing or assessment
and treatment and the limited human resources or service providers available to
administer the screening, especially at the primary care level.
● The acceptability of screening both from the children, adolescents and their
parents may have issues, especially in terms of disclosure.
● The screening tools presented are mostly self-report questionnaires, which may
be favorable for the adolescent group.
● The timing of screening is also important, screening may be done in the middle of
the school year or semester, wherein students may be subjected to high stress,
which may make them vulnerable to developing mental health problems.
62
students (n = 311) showed a depression rate of 12.5%. Both studies reported higher rates
in females.(5)
Examples of negative prognosticating factors are: (a) lower baseline function, (b) stressful
life events, (c) childhood maltreatment, (d) psychiatric or physical comorbidities, and (e)
treatment resistance; while a shorter duration of untreated disease and early response to
treatment are linked to better long-term outcomes. This suggests that early recognition
and treatment are crucial.[6] Richardson et al., (7) also concluded that depression
symptom severity and continued symptoms on repeat screening after 6 weeks are the
strongest predictors of depression persistence. The worst outcome of depression is
suicide, which is the second leading cause of death in 15 to 29-year-olds.(8)
The National Institute for Health and Care Excellence (NICE) Guideline uses a stepped-
care model that recommends different management based on depression severity.
Watchful waiting, digital/group cognitive-behavioral therapy (CBT), group interpersonal
psychotherapy (IPT), or group non-directive supportive therapy (NDST) can be given for
those with mild depression. 5 to 11-year-olds with moderate to severe depression can be
given family-based IPT, individual CBT, or fluoxetine with the latter two also given to 12
to 18-year-olds presenting with the same depression severity.(9) Available psychotherapy
services in the National Center for Mental Health (NCMH) are CBT, IPT, and supportive
counseling.(10)
3 RCTs 2.15
Referral Very Low
(n = 749) (0.49 to 9.41)
1 RCT 1.14
Service uptake Low
(n = 3,961) (1.08 to 1.21)
63
For the main outcomes, studies on the effectiveness of treatment among those with
depression were found.
Eleven randomized controlled trials (RCTs) on two systematic reviews (11,18) evaluated
the effect of psychotherapy (i.e., CBT and IPT) on remission. Most of the trials included
adolescents aged 12 to 18 years old, with one study reporting on children aged 5 to 11
years old. Individual CBT has no difference in remission compared to placebo (RR 0.97,
95% CI 0.63-1.49) or non-directive supportive therapy (NDST) (RR 1.14, 95% CI 1.01-
1.30) at post-treatment and no difference at a longer follow-up (RR 0.95, 95% CI 0.69-
1.31). Between two studies, group CBT may increase remission rate compared to waitlist
control (RR 1.76, 95% CI 1.11-2.79) with one study greatly favoring the CBT group. The
only study in 5 to 11-year-olds showed no difference in remission between family
psychoeducation with CBT and placebo (RR 1.10, 95% CI 0.63-1.91).
Among three IPT studies, family-based IPT (RR 2.08, 95% CI 0.87-4.95) and IPT for
Adolescents (IPT-A) (RR 1.50, 95% CI 1.04-2.17) have higher remission rates; while one
study found no significant difference in remission between IPT and group IPT.
4 RCTs 1.14
Moderate
Remission (Individual CBT vs. (n = 403) (1.01 to 1.30)
Non-Directive Supportive
Therapy) 1 RCT 0.95
Low
(n = 56) (0.69 to 1.31)
● At > 6 to ≤ 18 months follow-
up 3 RCTs 1.15
Moderate
(n = 186) (0.96 to 1.38)
● Without comorbidity
● With comorbidity (IBS) 1 RCT 1.07
Moderate
(n = 217) (0.88 to 1.31)
2 RCTs 1.76
Remission (Group CBT) Low
(n = 102) (1.11 to 2.79)
1 RCT 2.08
Remission (Family-based IPT) Low
(n = 42) (0.87 to 4.95)
64
(n = 48) (1.04 to 2.17)
One study from a systematic review [11] did not find any difference between CBT and
placebo in improving the quality of life (SMD -0.08, 95% CI -0.34 to 0.19).
A fair-quality study (19) on Patient Health Questionnaire-9 (PHQ-9) using a cutoff score
≥ 11, with the Child Diagnostic Interview Schedule (DISC-IV) as a reference standard,
reported a sensitivity of 89.5% (95% CI 69-97), specificity of 77.5% (95% CI 73-81),
positive predictive value (PPV) of 15% (95% CI 10-23), and negative predictive value
(NPV) of 99% (95% CI, 98-100). One study (20) with a cutoff score of ≥ 5, against ICD-
10 diagnostic criteria as reference, reported a sensitivity of 87.1% (95% CI 82.2-90.8),
specificity of 79.7% (95% CI 74.2-84.5), PPV of 39.7% (95% CI 29-52), and NPV of
97.58% (95% CI 94-99). A cutoff score of ≥ 5.5 has a sensitivity of 78.4% (95% CI 69-85)
and specificity of 73.8% (95% CI 65-81).(21)
Based on a systematic review (11), the Patient Health Questionnaire for Adolescents
(PHQ-A) was reported to have a high sensitivity and specificity in detecting Major
Depressive Disorder (sensitivity 73%; specificity 94%).
65
Table 4. Summary of Diagnostic Performance of the Screening Tests
Positive Negative Certainty
Screening Sample Sensitivity Specificity
Predictive Value Predictive Value of
tool size (n) (95%CI) (95% CI)
(95% CI) (95% CI) Evidence
PHQ-9
78.4% 73.8%
≥ 5.5 121 N/A N/A Poor
(69-85) (65-81)
79.7%
87.1% 39.7% 97.58%
≥5 233 (74.2- Good
(82.2-90.8) (29-52) (94-99)
84.5)
73% 94%
PHQ-A 403 56% 97% Fair
(68-77) (91-96)
A proposed Php 29.2 billion for Priority 2 of the 2021 DOH health budget (23) covers
prevention and control of non-communicable diseases (NCD) among others. Php 370
million is allotted for mental health conditions. This amounts to 0.005% of the total health
budget proposed. WHO reported a 2.65% expenditure for mental health in 2020.(10)
No data was found on costs of specific screening instruments, but NCMH offers projective
tests for Php 2,500.[24] Initial consultation fees in different institutions range from free to
Php 2,500 in NCR, while individual practitioner fees can range from free to Php 5,000.(25)
Standard rates of private psychiatrists are Php 2,000 to 3,000 per hour with mid-range
fees at Php 1,500.(26) The Philippine General Hospital (PGH) has free psychiatric
consultation and counseling services, while NCMH offers free basic counseling and
referral.(27) There are also various non-government organizations, associations,
foundations, and facilities offering free online counseling.(26) Psychotherapy, such as
66
CBT is available in both urban and rural mental hospitals.(10) In school settings, a
guidance counselor can help in detecting and dealing with mental health problems but
there is a lack of them in public compared to private settings.(28)
Societal and treatment costs of clinically depressed adolescents are likely to be higher
than other adolescents, even those with psychological disorders.(29,30) Cost-effective
prevention and intervention programs may be warranted.(29) Out-patient costs also play
a major part in the total expenditures.(30) A systematic review (18) also found that CBT
was the most cost-effective when compared with a brief psychological intervention (BPI)
or short-term psychoanalytic psychotherapy (STPP).
One factor that may affect service equity is the unequal distribution of mental health
workers in the country. WHO stated that there are an estimated 548 psychiatrists, 133
psychologists, 516 psychiatric nurses, and 1,241 mental health social workers (0.5, 0.1,
0.5, and 1.2 / per 100,000 population, respectively).(10) There are only 60 child
psychiatrists, practicing mostly in urban areas like the National Capital Region.(28) The
migration of trained health workers also contributes to the lack of professionals in the
country.(10) Lack of time and confidence in their professional training, as well as
insufficient mental health experts to refer to in cases of positive screens are also possible
barriers.(32) In a simulation by Gardner (33), they reported that there are many points in
which a mental health care delivery can break, thus limiting the population effect of
screening.
Based on the 2017 Member Profile from the WHO (34), there are 11 out-patient and 11
in-patient facilities specifically for children and adolescents, which contrasts the
situational assessment (10) that there are no in-patient or out-patient child and adolescent
facilities available. Another possible factor for service equity is that most mental health
services are from private providers (10), which are paid mostly or entirely out-of-pocket
by patients.(28) With limited human and medical resources, health providers can use
predictors of depression persistence as guidance to determine the appropriate treatment
(35) or follow a similar quality improvement project by Mansour (36), which resulted in an
increased screening rate. Forging connections with the community, as well as providing
access to services in primary care and/or school, may aid in decreasing racial disparities
and help in tailor-fitting both screening and treatment to the target population.(37)
67
4.6.6 Recommendations from Other Groups
Table 5. Summary of Recommendations from Other Groups
Regulatory Agency Recommendation
68
References
I. Burden of Depression
1. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204
countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study
2019. The Lancet. 2020;396(10258): 1204-1222. Available from: https://doi.org/10.1016/S0140-
6736(20)30925-9.
2. Institute for Health Metrics Evaluation. GBD Compare Viz Hub. Available from:
https://vizhub.healthdata.org/gbd-compare/ [Accessed 19th August 2021].
3. Ngis-iban PL. The Prevalence of Depressive Features Among Students in a Secondary Public
School. Available from:
https://www.herdin.ph/index.php/component/herdin/?view=research&cid=72170#studyDetails
[Accessed 19th August 2021].
4. Puyat JH, Gastardo-Conaco MC, Natividad J, Banal MA. Depressive symptoms among young adults
in the Philippines: Results from a nationwide cross-sectional survey. Journal of Affective Disorders
Reports. 2021;3(100073): 1-8. Available from: https://doi.org/10.1016/j.jadr.2020.100073.
5. Acob, J. R. U., Arifin, H., & Dewi, Y. S. (2021). Depression, Anxiety and Stress among Students
amidst COVID-19 Pandemic: A Cross-Sectional Study in Philippines. Jurnal Keperawatan
Padjadjaran, 9(2), 103–110. https://doi.org/10.24198/jkp.v9i2.1673
6. Kraus C, Kadriu B, Lanzenberger R, Zarate Jr. CA, Kasper S. Prognosis and improved outcomes in
major depression: a review. Translational Psychiatry. 2019;9(127): 1-17. Available from:
https://doi.org/10.1038/s41398-019-0460-3.
7. Richardson LP, McCauley E, McCarty CA, Grossman DC, Myaing M, Zhou C, et al. Predictors of
Persistence After a Positive Depression Screen Among Adolescents. Pediatrics. 2012;130(6):
e1541-e1548. Available from: https://doi.org/10.1542/peds.2012-0450.
8. World Health Organization. Depression. Available from: https://www.who.int/news-room/fact-
sheets/detail/depression [Accessed 19th August 2021].
9. National Institute for Health and Care Excellence (NICE), Depression in children and young people:
identification and management: NICE guideline [NG134]. 2019. Available from:
https://www.nice.org.uk/guidance/ng134 [Accessed 20th August 2021].
69
visit processes. Journal of Adolescent Health. 2015;56(3): 267-273. Available from:
https://doi.org/10.1016/j.jadohealth.2014.11.011.
17. Chisolm DJ, Klima J, Gardner W, Kelleher KJ. Adolescent Behavioral Risk Screening and Use of
Health Services. Administration and Policy in Mental Health and Mental Health Services Research.
2009; 36: 374-380. Available from: https://doi.org/10.1007/s10488-009-0245-8.
18. National Institute for Health and Care Excellence. Depression in children and young people, 2019
evidence review. NICE guideline. 2019;NG134: 1-583. Available from:
https://www.nice.org.uk/guidance/ng134/evidence/a-psychological-interventions-for-the-treatment-of-
depression-pdf-6834544094.
70
Developmental and Behavioral Pediatrics. Promoting Optimal Development: Screening for
Behavioral and Emotional Problems. Pediatrics. 2015;135(2): 384-395. Available from:
https://doi.org/10.1542/peds.2014-3716.
33. Gardner W, Bevans K, Kelleher KJ. The Potential for Improving the Population Health Effectiveness
of Screening: A Simulation Study. Pediatrics. 2021;148(Supplement 1): s3-s10. Available from:
https://doi.org/10.1542/peds.2021-050693C.
34. World Health Organization. Mental Health Atlas 2017 Country Profile: Philippines. Available from:
https://www.who.int/publications/m/item/mental-health-atlas-2017-country-profile-philippines
[Accessed 24th August 2021].
35. Richardson LP, McCauley E, McCarty CA, Grossman DC, Myaing M, Zhou C, et al. Predictors of
Persistence After a Positive Depression Screen Among Adolescents. Pediatrics. 2012;130(6):
e1541-e1548. Available from: doi:10.1542/peds.2012-0450.
36. Mansour M, Krishnaprasadh D, Lichtenberger J, Teitelbaum J. Implementing the Patient Health
Questionnaire Modified for Adolescents to improve screening for depression among adolescents in a
Federally Qualified Health Centre. BMJ Open Quality. 2020;9: e000751. Available from: doi:
10.1136/bmjoq-2019-000751.
37. Costello LH, Suh C, Burnett B, Kelsay K, Bunik M, Talmi A. Addressing Adolescent Depression in
Primary Care: Building Capacity Through Psychologist and Pediatrician Partnership. Journal of
Clinical Psychology in Medical Settings. 2021;28: 53-66. Available from:
https://doi.org/10.1007/s10880-019-09680-w.
71
4.7 Standardized Instruments in Screening for Anxiety among
Adolescents
RECOMMENDATION
Among healthy asymptomatic adolescents (10-19 years old), we suggest screening for
anxiety disorder using standardized instruments twice a year. (Moderate certainty of
evidence; Weak recommendation)
Considerations
The consensus panel considered the following when formulating this recommendation:
● Unanimous with their decision to recommend screening for anxiety disorders
among adolescents due to the rising prevalence of anxiety, especially during the
pandemic.
● The panel also decided to recommend the screening for the adolescent (10-19
years old) age group since the population of the evidence reviewed were done
mostly on this age group.
● Potential benefits outweigh the potential harms such as overdiagnosis,
abnormalized behavior, and exaggeration of experiences or emotions.
● The strength of recommendation was weak due to limited instrumentation and
insufficient data, the screening tools presented are also not widely used in the
Philippines.
● There is a need for more studies on screening tools, especially for this population.
● Screening tools on anxiety disorders used on adults may be used on adolescents,
but this still needs more evidence and validation.
● The timing of screening is also important, screening may be done in the middle of
the school year or semester, wherein students may be subjected to high stress,
which may make them vulnerable to developing mental health problems.
Screening may also be done during general pediatric check-ups.
72
According to Mellick (5), experiential avoidance (EA) might be an important predictor of
GAD symptomatology persistence. Essau (6) reported that adolescent anxiety predicted
more adverse outcomes such as unemployment, maladjustment poor coping skills, poor
family relationships, less life satisfaction, more chronic stress, and other
psychopathologies like major depressive disorder (MDD), substance use disorder (SUD),
and alcohol abuse/dependence (AUD) at age 30. In a prospective study, Letcher (7) found
that despite a similar increase in the level of anxiety symptoms for both genders from
aged 11 to 15, girls reported higher anxiety scores.
In a systematic review with 39 studies (11) reported that CBT had increased remission of
primary anxiety diagnosis compared to waitlist control at post-treatment (OR 5.48, 95%
CI 3.91-7.68). In terms of delivery format, child-focused CBT had greater remission
compared to parent-focused or combined format (OR 10.61, 95% CI 5.86-19.21; I² =
52%). Individual or group CBT may increase remission compared to a waitlist control
(individual OR 4.60, 95% CI 2.55-8.28; group therapy OR 6.27, 4.44-8.85) but the review
did not find any differences between the two subgroups (Chi² = 0.80; df = 1 [p = 0.37]; I²
= 0%).
39 RCTs 5.48
Primary anxiety diagnosis Moderate
(n = 2,697) (3.91 to 7.68)
73
17 RCTs 4.60
Individual CBT Moderate
(n = 1,165) (2.55 to 8.28)
22 RCTs 6.27
Group CBT High
(n = 1,532) (4.44 to 8.85)
10 RCTs 2.28
Primary anxiety diagnosis Low
(n = 822) (1.33 to 3.90)
5 RCTs 2.04
Individual CBT Moderate
(n = 469) (1.06 to 3.91)
5 RCTs 3.14
Group CBT Low
(n = 353) (1.13 to 8.71)
38-item
341 72% 64% -- -- Fair
SCARED
74
41-item 331
36.36% 76.17% 14.46% 91.53% Fair
SCARED (children)
A proposed Php 29.2 billion for Priority 2 of the 2021 DOH health budget (14) covers
prevention and control of non-communicable diseases (NCD) among others. Php 370
million are allotted for mental health conditions. This amounts to 0.005% of the total health
budget proposed. WHO reported a 2.65% expenditure for mental health in 2020.(9)
No data was found on costs of specific screening instruments, but NCMH offers projective
tests for Php 2,500.(15) Initial consultation fees in different institutions range from free to
Php 2,500 in NCR, while individual practitioner fees can range from free to Php 5,000.(16)
Standard rates of private psychiatrists are Php 2,000 to 3,000 per hour with mid-range
fees at Php 1,500.(17) The Philippine General Hospital (PGH) has free psychiatric
consultation and counseling services, while NCMH offers free basic counseling and
referral.(18) There are also various non-government organizations, associations,
foundations, and facilities offering free online counseling.(17) Psychotherapy, such as
CBT is available in both urban and rural mental hospitals.(9) In school settings, a
guidance counselor can help in detecting and dealing with mental health problems but
there is a lack of them in public compared to private settings.(19)
One factor that may affect service equity is the unequal distribution of mental health
workers in the country. WHO stated that there are an estimated 548 psychiatrists, 133
psychologists, 516 psychiatric nurses, and 1,241 mental health social workers (0.5, 0.1,
0.5, and 1.2 / per 100,000 population, respectively).(9) There are only 60 child
psychiatrists, practicing mostly in urban areas like the National Capital Region.(19) The
migration of trained health workers also contributes to the lack of professionals in the
country.(9) Some of the possible barriers in screening as reported by primary care
practitioners are (a) lack of adequate professional training, (b) lack of time, (c) long waiting
time of patients, (d) insufficient mental health experts to refer to in case there’s a positive
screen, (e) concerns with reimbursement of health visits, and (f) time commitment from
the patients as well as the health care providers. (21). In a simulation by Gardner (22),
75
they reported that there are many points in which a mental health care delivery can break,
and thus limit the population effect of screening.
Based on the 2017 Member Profile from the WHO (23), there are 11 out-patient and 11
in-patient facilities specifically for children and adolescents, which contrasts the
situational assessment (9) that there are no in-patient or out-patient child and adolescent
facilities available. Another possible factor for service equity is that most mental health
services are from private providers (9), which are paid mostly or entirely out-of-pocket by
patients.(19) With limited resources, an early gathering of data on anxiety symptoms from
self-, parent-, and teacher reports might be best to identify youth who need
intervention.(7) Forging connections with the community, as well as providing access to
services in primary care and/or school, may aid in decreasing racial disparities and help
in tailor-fitting both screening and treatment to the target population.(24)
76
References
I. Burden of Anxiety
1. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204
countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study
2019. The Lancet. 2020;396(10258): 1204-1222. Available from: https://doi.org/10.1016/S0140-
6736(20)30925-9.
2. Institute for Health Metrics Evaluation. GBD Compare Viz Hub. Available from:
https://vizhub.healthdata.org/gbd-compare/ [Accessed 19th August 2021].
3. Chen F, Zheng D, Liu J, Gong Y, Guan Z, Lou D. Depression and anxiety among adolescents during
COVID-19: A cross-sectional study. Brain, Behavior, and Immunity. 2020;8: 36-38. Available from:
https://doi.org/10.1016/j.bbi.2020.05.061.
4. Chen YL, Chen WJ, Lin KC, Shen LJ, Gau SSF. Prevalence of DSM-5 mental disorders in a
nationally representative sample of children in Taiwan: methodology and main findings.
Epidemiology and Psychiatric Sciences. 2020;29(e15): 1-9. Available from:
https://doi.org/10.1017/S2045796018000793.
5. Mellick WH, Mills JA, Kroska EB, Calarge CA, Sharp C, Dindo LN. Experiential avoidance predicts
persistence of major depressive disorder and generalized anxiety disorder in late adolescence. The
Journal of Clinical Psychiatry. 2019;80(6): 1-17. Available from: doi:10.4088/JCP.18m12265.
6. Essau CA, Lewinsohn PM, Olaya B, Seeley JR. Anxiety disorders in adolescents and psychosocial
outcomes at age 30. Journal of Affective Disorders. 2014;163: 125-132. Available from:
https://doi.org/10.1016/j.jad.2013.12.033.
7. Letcher P, Sanson A, Smart D, Toumbourou JW. Precursors and Correlates of Anxiety Trajectories
From Late Childhood to Late Adolescence. Journal of Clinical Child & Adolescent Psychology.
2012;41(4): 417-432. Available from: https://doi.org/10.1080/15374416.2012.680189.
8. Walter HJ, Bukstein OG, Abright AR, Keable H, Ramtekkar U, Ripperger-Suhler J, et al. Clinical
Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety
Disorders. Journal of the American Academy of Child & Adolescent Psychiatry. 2020;59(10): 1107-
1124. Available from: https://doi.org/10.1016/j.jaac.2020.05.005.
9. World Health Organization. Philippines WHO Special Initiative for Mental Health Situational
Assessment. Available from: https://www.who.int/publications/m/item/philippines---who-special-
initiative-for-mental-health [Accessed 9th September 2021]
77
15. National Center for Mental Health. Hospital Rates. Available from:
http://www.ncmh.gov.ph/index.php/rates#psychological-services [Accessed 24th August 2021].
16. Sevilla I. For those seeking professional help. Available from:
https://docs.google.com/spreadsheets/d/1t9cCNOtSuIpo84OECOUPSUwjVKqdsD8aBhdnSrfVs1c/e
dit#gid=0 [Accessed 24th August 2021].
17. Alvarez K. Master List of Hotlines and Mental Health Resources in the Philippines. Available from:
https://katewashere.com/mentalhealthph/ [Accessed 24th August 2021].
18. Viernes F. 5 free counseling and psychiatric consultation services that are just a call away. Available
from: https://www.gmanetwork.com/news/lifestyle/healthandwellness/780655/5-free-counseling-and-
psychiatric-consultation-services-that-are-just-a-call-away/story/ [Accessed 24th August 2021].
19. Estrada CA, Usami M, Satake N, Gregorio Jr. E, Leynes C, Balderrama N, et al. Current situation
and challenges for mental health focused on treatment and care in Japan and the Philippines -
highlights of the training program by the National Center for Global Health and Medicine. BMC
Proceedings. 2020;14(Suppl 11): 1-9. Available from: https://doi.org/10.1186/s12919-020-00194-0.
78
4.8 Standardized Instruments in Screening for Stress
RECOMMENDATION
Considerations
The consensus panel considered the following when formulating this recommendation:
● Unanimous with their decision to screen for stress as a potential risk factor for
mental health problems.
● An issue raised was the challenge for different environments such as the
workplace and academic settings to deal with those who will have positive screens.
However, this may serve as a good opportunity to come up with and emphasize
preventive strategies.
● The decision on the strength of the recommendation took three rounds due to the
split decision of the panel.
● The recommendation was weak for some panel members due to the lack of a
validated tool and the low level of evidence presented in the review.
● Other panel members believed that this should be a strong recommendation due
to the high prevalence and the opportunity for prevention and possible early
intervention.
● One of the panelists also mentioned the DASS-21 (Depression, Anxiety, and
Stress Scale), which was widely used during the pandemic nationwide. This may
be a potential screening tool that can be used once more studies are done.
● Another panelist also mentioned that the DASS-21 tool has already been
translated but not yet validated.
● After three rounds of voting, the panel was unanimous with their decision to
strongly recommend screening for stress as a risk factor.
● The panel voted on screening at least once a year in order to minimize the cost
and it may be incorporated into annual check-ups.
The relations of mental and physical well-being may be explained by the allostatic load
theory. Allostatic load is defined as cumulative perturbations on the physiologic processes
brought about by stress. Over time, this could result in the “wear and tear” of the body
79
and the development of diseases.(4) Perceived stress is associated with increased risk
for cardiovascular diseases (5,6) (work stress OR 3.2, marital stress OR 2.28, economic
stress OR 1.30) (6), stroke (OR 1.09, 95% CI 0.94-1.26) (7), persistence of allergic rhinitis
(8), mental disorders (9), and other health outcomes (cognitive function, Body Mass
Index, blood pressure, and obesity).(10)
The World Health Organization (WHO) has suggested assessment and management
strategies for reducing stress. Stress reduction therapies include mindfulness-based
techniques, meditation, diaphragmatic breathing, and cognitive-behavioral
techniques.(16)
Three separate studies set in 7 primary healthcare centers in western Sweden aimed to
evaluate the use of the Work Stress Questionnaire (WSQ) in the primary care setting in
preventing sickness absence.(17-19) The studies included the same sample of 271
employed, non-sick listed participants, aged 18 to 64 years who were randomized to the
intervention group (N = 132) and usual care control group (N = 139). In the intervention,
the participants received feedback about their WSQ and measures for prevention of work
stress. The control group received the usual care and accomplished the WSQ without
feedback. The results of the studies are summarized in Table 1.
It is worth noting that a sick leave is a complex outcome measure as it may be an indicator
of ill health or a tool for the treatment of health.(17) In addition, the most prevalent types
of medication in the second RCT were anti-inflammatory and antirheumatic products (N
= 92), antidepressants (N = 91) and drugs for treatment of peptic ulcer disease (N =
58).(18)
80
Meditation and cardiovascular risk reduction (1 RCT, N = 85; Moderate certainty of
evidence)
A scientific statement from the American Heart Association in 2017 suggested that
meditation possibly reduces cardiovascular risk. However, most of the studies were
outdated, and the overall quality and quantity of study data were modest.(20) An RCT in
2019 tested stress reduction using transcendental meditation versus health education
among African Americans in reducing cardiovascular disease (CVD) risk.(21) The study
reported left ventricular mass index (LVMI), an independent risk factor for CVD, was
significantly lower among participants who received transcendental meditation (TM) than
those who received health education (HE) after 6 months. Other health outcomes were
significantly reduced within groups, but were not significantly different between the two
groups (Table 1). The GRADE Evidence profile may be found in Appendix VIII-B.
81
(p < 0.05)
Collaborative care measures: (23% vs 11%) (p <
0.05).
The TM group had significantly lower LVMI
compared with the HE group (-7.55gm/m2, 95% CI
1 RCT -14.78 to -.34 gm/m2; p = 0.040).
Left
(N = 85)
ventricular
Both interventions showed significant reductions in Moderate
hypertrop
Schneider, et al., blood pressure, (SBP/ DBP changes for TM: -5/ -3
hy
2019 mmHg, and for HE: -7/-6 mmHg; p = 0.028 to
<.001), but no significant difference between
groups.
TM - transcendental meditation, HE - health education, SBP - systolic blood pressure, DBP - diastolic blood
pressure
A local personal finance website collated the costs of consultation, therapy, and
medications for mental health in the Philippines. A session of therapy or consultation may
cost from Php 100 to 4,500.(26) Non-government organizations such as the Center for
82
Family Ministries Foundation of Ateneo de Manila and Don Bosco only ask to be paid
according to the patient’s capacity. PSS may be downloaded for free.
83
Table 5. Summary of Recommendations from NICE Guidelines
Group Recommendation Certainty of Evidence
Create a supportive environment that enables Moderate certainty of evidence,
employees to be proactive when and if unspecified level of
possible, to protect and enhance their own recommendation
health and wellbeing.
Develop policies to support the workplace
culture such as respect for work – life balance.
For example, in relation to stress,
organizations could refer to the principles of
the Health and Safety Executive's
Management standards for work related
stress. These cover the following 6 aspects of
work and the process for assessing and
managing these:
1. Demands (workload, work patterns
NICE (2015) and work environment)
2. Control (how much say the employee Moderate certainty of evidence,
has in the way they do their work) unspecified level of
recommendation
3. Support (from the organization, line
manager, and colleagues)
4. Relationships (promoting positive
working to avoid conflict and dealing
with unacceptable behavior)
5. Roles (if employees understand their
role within the organization and
whether the organization ensures that
they do not have conflicting roles)
6. Change (how change is managed and
communicated in the organization)
Recognizing that the COVID-19 pandemic has made workers more vulnerable to stress
or job stress, the Philippine College of Occupational Medicine suggested using the Mental
Health Status Exam (MHSE) to identify who needs additional support. They advised
seeking a comprehensive evaluation of mental health with psychologists, psychiatrists,
and psychometricians. No available evidence was provided in the released material.(31)
84
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of depression, anxiety, and distress among Filipinos from low-income communities in the Philippines.
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4. Epel ES, Crosswell AD, Mayer SE, Prather AA, Slavich GM, Puterman E, et al. More than a feeling:
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6. Lagraauw HM, Kuiper J, Bot I. Acute and chronic psychological stress as risk factors for
cardiovascular disease: Insights gained from epidemiological, clinical and experimental studies.
Brain, Behavior, and Immunity. 2015Aug5;50:18–30.
7. Fransson EI, Nyberg ST, Heikkilä K, Alfredsson L, Bjorner JB, Borritz M, et al. Job strain and the risk
of stroke. Stroke. 2015Feb;46(2):557–9.
8. El Hennawi DE, Ahmed MR, Farid AM. Psychological stress and its relationship with persistent
allergic rhinitis. European Archives of Oto-Rhino-Laryngology. 2015May8;273(4):899–904.
9. Seo EJ, Ahn J-A, Hayman LL, Kim C-J. The association between perceived stress and quality of life
in university students: The parallel mediating role of depressive symptoms and health-promoting
behaviors. Asian Nursing Research. 2018Aug;12(3):190–6.
10. Turner AI, Smyth N, Hall SJ, Torres SJ, Hussein M, Jayasinghe SU, et al. Psychological stress
reactivity and future health and disease outcomes: A systematic review of prospective evidence.
Psychoneuroendocrinology. 2020 Jan 29;114:104599.
11. Nater UM. The multidimensionality of stress and its assessment. Brain, Behavior, and Immunity.
2018Jul20;73:159–60.
12. Crosswell AD, Lockwood KG. Best practices for stress measurement: How to measure psychological
stress in Health Research. Health Psychology Open. 2020Dec;7(2):205510292093307.
13. Mayer S. Subjective stress [Internet]. UCSF SMN. 2017 [cited 2021Aug14]. Available from:
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87
4.9 Standardized Instruments in Screening for Sleep
Disturbances/Problems
RECOMMENDATION
Considerations
The consensus panel considered the following when formulating this recommendation:
● Unanimous with their recommendation to screen for sleep disturbances/problems
due to the prevalence of these problems, which are potential risk factors for
developing mental health disorders.
● Sleep problems are identified to be one of the first behavioral problems people
may experience and screening serves as an opportunity for prevention and
possible early intervention.
● Despite the low level of evidence, the panel still strongly recommended screening
due to its prevalence and potential benefits.
● However, there are no specific screening tools yet and this serves as a research
gap.
● Further studies on the effectiveness , acceptability, and feasibility of these
screening tools must be done.
● The panel voted on screening at least once a year in order to minimize the cost
and it may be incorporated into annual check-ups.
Sleep disorders are associated with increased productivity loss (3,4), risk of depression
(5,6), traffic accidents (7), and healthcare utilization.(8) Studies have also found sleep
disorders to be linked to a number of medical conditions such as musculoskeletal pain
(9), cancers, and cardiovascular diseases.(10) Insomnia remains an underdiagnosed
health problem (11) despite its high prevalence and substantial negative consequences.
An estimated $680-billion of economic output every year is lost each year across five
OECD Countries.(12) Direct cost analysis demonstrates significantly higher utilization of
emergency and office health care visits as well as greater cost for prescription drugs.(13)
Likewise, indirect costs in the form of work absenteeism, loss of productivity, and sleep
88
disorder-related accidents contribute significantly to the economic burden of the
disorder.(12-14)
The evidence synthesis for cognitive behavioral intervention had 6 studies for group CBTs
and 5 for internet CBTs. The selected studies were randomized controlled trials. The
methods for the search, selection, and quality assessments of the included studies are
presented in Appendix 1.
Group and Internet Cognitive Behavioral interventions are indicated to improve sleep in
adults and adolescents. The effect of ISI score was observed for group CBTs (mean = -
4.65; p = 0.0001) and internet CBTs (mean = -6.48; p = 0.00001) to favor the intervention.
However, because treatment protocols were heterogeneous and risk of bias was high,
results should be interpreted with caution. Large and rigorous trials are needed.
Internet
MD -6.48
CBT 5 Very Low Not Important
(-6.63 to -6.33)
(16,21-24)
A study on the cost-effectiveness on internet CBTs found that intervention costs of €200
(Php 13,918.13) results in a net benefit of €418 (95% CI -593.03 to 1,488.70) (Php
29,104.21) per participant and a return on investment of 208% (95% -296.52 to
744.35).(25) The reduction in costs was mainly driven by the effects of the intervention
on presenteeism and to a lesser degree by reduced absenteeism. These results were
similar to that of another study, which concluded that group- and Internet-delivered CBTs
are equally effective in improving adolescent sleep, but costs are lower in Internet-
CBTs.(26)
89
Classification of Sleep Disorders (ICSD). Two commonly used brief self-reported
questionnaires that use these standards as a basis are the Insomnia Severity Index (ISI)
and the Athens Insomnia Scale (AIS). The Pittsburgh Sleep Quality is another widely used
instrument that was recommended by an expert panel of sleep researchers.(26)
A total of 21 studies were found, with 8 studies using the ISI (27-35), 7 studies using the
AIS (36-41), and 8 studies using PSQI.(28,42-48) Seven studies used a case-control
study design. The ICSD-II and the DSM-IV were the most commonly used reference tests
for a sleep disorder diagnosis. The cut-off scores for the ISI ranged from 9 to 15.5; the
AIS was 6 to 6.5; and the PSQI was 5 to 8. For pre-test prevalence, we used a global
sleep disorder prevalence of 25.2% (1), a Philippines restless sleep prevalence of 35.2%
(2), and a sleep disorder prevalence of 22.1% as typically found in this study.
In terms of ISI, it had a pooled sensitivity of 0.87 (95% CI 0.79-0.92), a pooled specificity
of 83% (95% CI 0.72-0.90), a positive likelihood ratio of 4.25, a negative likelihood ratio
of 0.16, and a pooled diagnostic odds ratio of 20/31.75 (95% CI 13.40-75.20). See
Appendix IX-B for the GRADE Evidence Table and Appendix IX-C for the forest plots.
In terms of AIS, it had a pooled sensitivity of 0.87 (95% CI 0.79 -0.92), a pooled specificity
of 83% (95% CI 0.72-0.90), a positive likelihood ratio of 4.25, a negative likelihood ratio
of 0.16, and a pooled diagnostic odds ratio of 31.75 (95% CI 13.40-75.20). See Appendix
IX-B for the GRADE Evidence Table and Appendix IX-C for the forest plots.
With regard to the PSQI, it had a pooled sensitivity of 0.94 (95% CI 0.86-0.98), a pooled
specificity of 76% (95% CI 0.65-0.85), a positive likelihood ratio of 3.56, a negative
likelihood ratio of 0.08, and a pooled diagnostic odds ratio of 37.98 (95% CI 12.51-
115.31). See Appendix IX-B for the GRADE Evidence Table and Appendix IX-C for the
forest plots.
Test reliability values higher than 0.75 are considered strong, values from 0.40 to 0.75
are moderate, and values less than 0.40 are considered poor.(49) With all studies
reporting scores above the range defined as ‘poor’ at the least, the aforementioned
screening instruments were found to be reliable tools for screening for sleep disorders.
The PSQI is a 19-item questionnaire evaluating sleep quality and disturbances over the
past month. The PSQI uses a 0-3 Likert scale, which requires the completion of 7
90
components and will yield a global score. It will take five to ten minutes to complete. It is
now available in 56 languages.
Table 3. Costing data on sleep disorder screening using the Insomnia Severity Index (ISI), the
Athens Insomnia Scale (AIS), and the Pittsburgh Sleep Quality Index (PSQI)
Screening Intervention Confirmatory Test
Parameter
ISI AIS PSQI Sleep devices and Sleep studies
In the Philippines, there are sleep centers and sleep labs mostly in NCR: Manila Doctors
Hospital, Capitol Medical Center, Lung Center of the Philippines, St. Luke’s Hospital and
Medical Center, and Cebu City: Chong Hua Hospital. The Philippines also has dedicated
organizations to promote awareness on the importance of sleep health such as the
Philippine Society of Sleep Medicine.
91
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94
5. RESEARCH IMPLICATIONS
Many research questions from the identified clinical questions in this CPG were
unanswered in terms of benefits and harms of screening, equity, applicability, and
feasibility. Direct evidence is still lacking to aid in providing definite recommendations for
screening certain conditions using the tests. Screening for substance use disorders using
standardized drug tests and screening instruments, screening for anxiety among adults
and adolescents using standardized screening instruments, screening for stress using
standardized screening instruments, and screening for sleep disturbances/problems
using standardized screening instruments are screening strategies that lack direct
evidence to ascertain their benefits among the general population.
Generating direct evidence (screening vs. no screening) may be difficult. Because of this
challenge, in some instances, establishing the diagnostic performance of tests as indirect
evidence can be adequate. However, specific tests’ accuracy in detecting early diseases
and preventing them from developing into a chronic or more severe state is still not
investigated. The screening instruments available are not always available in the local
setting, with only a few instruments being validated and translated.
There have been cost-effectiveness studies available for screening the conditions
included in this CPG, but most of them are conducted in Western countries. For conditions
with a burden that has been recently increasing, such as depression, anxiety, and
substance abuse disorders, cost-effectiveness research is still not adequately
investigated in the local setting.
Examining needs and monitoring implementation of screening programs were also found
to be not well-established even if, in some conditions, guidelines and programs are
already in place. Perspectives and experiences of clinical practitioners and other
stakeholders directly involved in screening programs are rarely reported in studies.
Many research questions emerged from collating the evidence for this CPG and can be
explored further. Filling in these gaps can provide a clearer picture of the impact of
screening programs using previously mentioned tests and may influence the
recommendations for updating this guideline.
95
6. DISSEMINATION AND IMPLEMENTATION
A full copy of this document will be sent to the Department of Health for transmittal and
publication. The Disease Prevention and Control Bureau will transmit copies of this CPG
to the Philippine Health Insurance Corporation (PHIC) and health maintenance
organizations (HMOs) and NGOs involved in a periodic health examination. The
recommendations and the evidence summaries will be posted in the PHEX web based
application.
All strong recommendations in this guideline can be used for monitoring and auditing
practices in institutions. This can be converted to key performance indicators and it can
also be used in creating clinical pathways.
The DOH planned to develop a simplified version of this CPG and made it available in the
format that will be ready for reproduction and dissemination to the patients in different
health care settings. It will also be available for interested parties who might visit the DOH
website.
7. APPLICABILITY ISSUES
The PHEX Task Force accentuates some caveats of this CPG using equity and
applicability lenses. Comprehensive history taking, physical examination, and monitoring
are essential parts of evaluating risk factors and the probability of developing diseases.
This CPG does not necessarily supersede the consumers’ (i.e., health professionals,
hospital administrators, employers, payors, patients) values, settings, and circumstances.
Although this CPG intends to influence the direction of health policies for the general
population, it should not be the sole basis for recreating or abolishing practices that aim
to improve the health conditions of many Filipinos, particularly those part of the workforce.
96
9. APPENDICES
Search Strategy, Characteristics of Included Studies, Forest Plots, GRADE Evidence,
and Cost-effectiveness Studies for the Research Questions
97
1. Standardized Instruments in Screening for Dementia
ti: title
ab: abstract
kw: keyword
98
APPENDIX B: GRADE Profiles
Benefits and Harms of Screening GRADE Evidence Table
Certainty Assessment № of patients Effect
Certainty Importance
№ of Study Risk of Other Non- Relative Absolute
Inconsistency Indirectness Imprecision Screening
studies design bias considerations screening (95% CI) (95% CI)
Health-related Quality of Life (follow up: median 12 months; assessed with: Health Utility Index; Scale from: 0 (worst) to 1 (best))
MD 0.002 higher
1
Randomised
serious a not serious b not serious serious c none 993 976 - (0.017 lower to ⨁⨁◯◯ CRITICAL
trials LOW
0.021 higher)
Depressive Symptoms (follow up: median 1 month; assessed with: PHQ-9; Scale from: 0 (best) to 27 (worst))
MD 0.23 lower
1
Randomised
serious a not serious b not serious serious d none 996 1022 - (0.421 lower to ⨁⨁◯◯ IMPORTANT
trials
0.039 lower) LOW
Anxiety Symptoms (follow up: median 1 month; assessed with: GAD-7; Scale from: 0 (best) to 21 (worst))
MD 0.087 lower
1
Randomised
serious a not serious b not serious
very serious
e none 997 1022 - (0.246 lower to ⨁◯◯◯ IMPORTANT
trials
0.072 higher) VERY LOW
Emergency Department Visits (follow up: median 12 months; assessed with: Indiana Network for Patient Care)
Hospital Admissions (follow up: median 12 months; assessed with: Indiana Network for Patient Care)
Advanced directives (advanced care planning, power of attorney for health care and/or financial affairs, living will, insurance policies) (follow up: 12 months)
99
Explanations
a. Half of the participants were loss to follow up, or excluded due to the errors made by one staff member. Likewise, there was no mention if they will perform intention-to-treat analysis. However,
there was blinding, sequence generation and allocation concealment.
b. Only one study was included; there are no significant differences in the baseline characteristics of participants and they obtained similar screening and method of data collection.
c. A sample size of 3,951 was needed to achieve 80% power and only 1,969 were analyzed.
d. A sample size of 3,951 was needed to achieve 80% power and only 2,018 were analyzed; wide confidence intervals (–0.421 to –0.039)
e. A sample of 3,951 was needed to achieve 80% power and only 2,019 were analyzed; wide confidence interval that included the null (–0.246, 0.072)
f. A sample size of 3,951 was needed to achieve 80% power and 3,416 were analyzed. However, the CI crossed the null.
g. More participants were included and count was closer to the target sample (>85%); performed blinding, sequence generation and allocation concealment, but still no intention-to-treat analysis
h. A sample size of 3,951 was needed to achieve 80% power and only 2,000 were analyzed. Also, the CI crossed the null.
100
MIS Diagnostic Accuracy GRADE Evidence Table
Question: Should MIS be used to diagnose dementia in the general population?
Factors that may decrease certainty of evidence Effect per 100,000 patients tested
№ of
studies Study Test accuracy
Outcome Pre-test Pre-test Pre-test
(№ of design Risk of Publication CoE
Indirectness Inconsistency Imprecision probability probability probability of
patients) bias bias
of 13.9% of 10.6% 0.712%
True negatives
80504 83589
(patients 92834
(76371 to (79298 to
without (88068 to 95614)
82914) 86092)
dementia)
Cross-
5 studies sectional
False very ⨁◯◯◯
(2,060 (cohort type seriousa not serious very seriousb none
positives seriousc VERY LOW
patients) accuracy
(patients 5596 5811
study) 6454
incorrectly (3186 to (3308 to
(3674 to 11220)
classified as 9729) 10102)
having
dementia)
Explanations
a. Most of the studies have unclear risk of bias in terms of the index test, reference standard and flow and timing
b. Pooled estimates have high heterogeneity (100%)
c. Some of the included studies have wide confidence intervals for sensitivity (4 studies) and specificity (1 study)
Prevalence rates are [a] the average rate from the included studies, [b] the local crude prevalence rate (4), and [c] from gl obal estimates (1)
101
Mini-Cog Diagnostic Accuracy GRADE Evidence Table
Question: Should Mini-Cog be used to diagnose dementia in the general population?
Factors that may decrease certainty of evidence Effect per 100,000 patients tested
№ of
studies Study Test accuracy
Outcome Pre-test Pre-test Pre-test
(№ of design Risk of Publication CoE
Indirectness Inconsistency Imprecision probability of probability probability
patients) bias bias
30.6% of 10.6% of 0.712%
True
negatives 57602 74202 82409
(patients (40599 to (52299 to (58083 to
without 65583) 84483) 93827)
dementia) Cross-
6 studies sectional
⨁◯◯◯
False (2,569 (cohort type seriousa not serious seriousb seriousc none
positives VERY LOW
patients) accuracy
(patients study) 11798 15198 16879
incorrectly (3817 to (4917 to (5461 to
classified as 28801) 37101) 41205)
having
dementia)
Explanations
a. Unclear and high risk of bias in multiple studies pertaining to patient selection, index test, reference standard, and flow of timing
b. The studies varied significantly in terms of heterogeneity (cannot be pooled due to different covariates such as cut-offs, demographics, educational background, primary care vs community-
dwelling adults, etc)
c. The point estimates and confidence intervals of the studies' specificities are varied due to the largest study by McCarten et al (2012)
Prevalence rates are [a] the average rate from the included studies, [b] the local crude prevalence rate (4), and [c] from gl obal estimates (1)
102
MMSE Diagnostic Accuracy GRADE Evidence Table
Question: Should MMSE be used to diagnose dementia in the general population?
Factors that may decrease certainty of evidence Effect per 100,000 patients tested
№ of
studies Study Test accuracy
Outcome Pre-test Pre-test Pre-test
(№ of design Risk of Publication CoE
Indirectness Inconsistency Imprecision probability probability probability
patients) bias bias
of 22.98% of 10.6% of 0.712%
True negatives
67084 77867 86480
(patients
(56918 to (66067 to (73374 to
without
72476) 84125) 93430)
dementia)
Cross-
6 studies sectional
False ⨁⨁◯◯
(3,768 (cohort type seriousa not serious seriousb not seriousc none
positives LOW
patients) accuracy
(patients 9936 11533 12808
study)
incorrectly (4544 to (5275 to (5858 to
classified as 20102) 23333) 25914)
having
dementia)
Explanations
a. Several studies had unclear risk of bias in terms of how the index and reference standards were conducted, and the flow and timing.
b. The studies varied significantly in terms of heterogeneity (i.e., cannot be pooled)
c. One study has a sensitivity that has a lower range <0.50
Prevalence rates are [a] the average rate from the included studies, [b] the local crude prevalence rate (4), and [c] from global estimates (1)
103
MoCA Diagnostic Accuracy GRADE Evidence Table
Factors that may decrease certainty of evidence Effect per 100,000 patients tested
№ of
studies (№ Study Test accuracy
Outcome Pre-test Pre-test Pre-test
of design Risk of Publication CoE
Indirectness Inconsistency Imprecision probability of probability probability of
patients) bias bias
13% of 10.6% 0.712%
Explanations
a. Some of the studies had unclear or high risk of bias in terms of patient selection, how the index tests were conducted, an d the flow and timing
b. The studies varied significantly in terms of heterogeneity (cannot be pooled due to different covariates such as cut-off scores, demographics, educational background, etc)
c. Many studies (4/7) had less than 300 total patients analyzed
Prevalence rates are [a] the average rate from the included studies, [b] the local crude prevalence rate (4), and [c] from global estimates (1)
104
AD8 Diagnostic Accuracy GRADE Evidence Table
Factors that may decrease certainty of evidence Effect per 100,000 patients tested
№ of
studies Study Test accuracy
Outcome Pre-test Pre-test pre-test
(№ of design Risk of Publication CoE
Indirectness Inconsistency Imprecision probability probability probability
patients) bias bias
of14.18% of10.6% of0.712%
Explanations
a. Some of the studies had unclear risk of bias in terms of patient selection, how the index tests and reference standards were conducted, as well as the flow and timing.
b. The studies varied significantly in terms of heterogeneity (cannot be pooled due to different covariates such as cut-off scores, demographics, educational background, etc)
c. Two large community-based studies with overlapping sensitivities (Yang et al, 2016 & Mao et al, 2018)
Prevalence rates are [a] the average rate from the included studies, [b] the local crude prevalence rate (4), and [c] from gl obal estimates (1)
105
CDT Diagnostic Accuracy GRADE Evidence Table
Factors that may decrease certainty of evidence Effect per 100,000 patients tested
№ of
studies Study Test accuracy
Outcome Pre-test Pre-test Pre-test
(№ of design Risk of Publication CoE
Indirectness Inconsistency Imprecision probability probability probability
patients) bias bias
of 15.4% of 10.6% of 0.712%
Explanations
a. Some of the studies had unclear or high risk of bias in terms of patient selection, how the index tests were conducted, an d the flow and timing
b. The studies varied significantly in terms of heterogeneity (cannot be pooled due to different covariates such as scoring systems, demographics, educational background, primary care vs geriatric
OPD, etc)
Prevalence rates are [a] the average rate from the included studies, [b] the local crude prevalence rate (4), and [c] from gl obal estimates (1)
106
APPENDIX D: Risk of Bias Summary Tables
Figure 1. MIS Risk of bias and applicability concerns graph: Review authors' judgements about each domain presented as percentages across
included studies
Figure 2. MIS Risk of bias and applicability concerns summary: Review authors' judgements about each domain for each included study
107
Figure 3. Mini-Cog Risk of bias and applicability concerns graph: Review authors' judgements about each domain presented as percentages
across included studies
Figure 4. Mini-Cog Risk of bias and applicability concerns summary: Review authors' judgements about each domain for each included study
108
Figure 5. MMSE Risk of bias and applicability concerns graph: Review authors' judgements about each domain presented as percentages across
included studies
Figure 6. MMSE Risk of bias and applicability concerns summary: Review authors' judgements about each domain for each included study
109
Figure 7. MoCA Risk of bias and applicability concerns graph: Review authors' judgements about each domain presented as percentages across
included studies
Figure 8. MoCA Risk of bias and applicability concerns summary: Review authors' judgements about each domain for each included study
110
Figure 9. AD8 Risk of bias and applicability concerns graph: Review authors' judgements about each domain presented as percentages across
included studies
Figure 10. AD8 Risk of bias and applicability concerns summary: Review authors' judgements about each domain for each included study
111
Figure 11. CDT Risk of bias and applicability concerns graph: Review authors' judgements about each domain presented as percentages across
included studies
Figure 12. CDT Risk of bias and applicability concerns summary: Review authors' judgements about each domain for each included study
112
APPENDIX C: Forest Plots
Figure 1. MIS Forest plot of studies' sensitivity and specificity assessing MIS to determine dementia in the community
Figure 2. Mini-Cog Forest plot of studies' sensitivity and specificity assessing Mini-Cog to determine dementia in the community
Figure 3. MMSE Forest plot of studies' sensitivity and specificity assessing MMSE to determine dementia in the community
113
Figure 4. MoCA Forest plot of studies' sensitivity and specificity assessing MoCA to determine dementia in the community
Figure 5. CDT Forest plot of studies' sensitivity and specificity assessing AD8 to determine dementia in the community
Figure 6. AD8 Forest plot of studies' sensitivity and specificity assessing AD8 to determine dementia in the community
114
APPENDIX E: Summary of the 6 Screening Tests for Dementia
115
MIS Mini-Cog MMSE MoCA AD8 CDT
Simple and easy to
administer even to
Simple and easy to
Easy to administer, hearing impaired Can be administered
Most widely used in administer even to
simple, does not need and less educated More sensitive for over the phone; does
literature searches; hearing impaired and
Advantages ability to write, does individuals, no MCI and more not require patient to be
translated into many less educated
not require extensive training required, educated individuals present; requires
dialects individuals, no training
training to administer Better than CDT to minimal training
required
detect milder forms
of dementia
Inability to detect
subtle memory Does not assess
Inapplicable for people
losses; Age, memory; multiple
who cannot read
education, and scoring systems; less
(visual impairment or inapplicable for Takes time to
cultural background Requires competent sensitive in detecting
Disadvantages illiteracy), does not those with severe administer; requires
affect scores informant early-stage dementia,
evaluate executive sensory impairment some training; cost
inapplicable for those
functioning and
Takes time to with severe sensory
visuospatial ability
administer; requires impairment
some training; cost
Sensitivity 76.0 90.0 86.9 91.0 89.0 87.3
(%) (63 to 85.5) (72.1 to 96.9) (80.1 to 91.6) (80.0 to 96.2) (86.5 to 91.1) (72.0 to 94.8)
116
APPENDIX F: PhilHealth Reimbursement for dementia-related cases in Php
APPENDIX G: Screening flowchart to assess how people at risk for dementia can be screened and
detected in the community (Dementia toolkit for community workers in low-and middle-income countries:
guide for community- based management and care of people with dementia. Manila, Philippines. World
Health Organization Regional Office for the Western Pacific. 2018)
117
2. Standardized Drug Tests in Screening for Substance Use Disorders
119
all topics under
August 9, all articles, on title review, were on
"Tobacco, drugs & 183 0
2021, 1:00 pm interventions
alcohol" category
APA recommends (1C) that the initial
psychiatric evaluation of a patient include
assessment of the patient’s use of tobacco,
alcohol, and other substances (e.g.,
marijuana, cocaine, heroin, hallucinogens)
and any misuse of prescribed or over-the-
counter medications or supplements.
(Asking questions can be supplemented
with use of scales) Regarding lab testing:
In some circumstances, information from
American
substance use August 10, laboratory testing may be available that
Journal of 15 1
disorder 2021, 9:00 am provides clues to substance use. When a
Psychiatry
patient has evidence of tobacco, alcohol,
or other substance use in response to
screening measures, interview questions,
or laboratory testing, additional follow-up
questions will generally be needed. The
American Psychiatric Association Practice
Guidelines For The Psychiatric Evaluation
Of Adults, Third Edition
https://doi.org/10.1176/appi.books.978089
0426760
1) screening and treatment of substance
use disorders among adolescents
recommendation is screening with
U.S. standardized tool. No mention of laboratory
Department of drug testing (2) clinical drug testing in
Health & pramary care : Disclaimer, document was
Human all publications published in 2012, SUD criteria used at the
Services: under category of August 10, time was DSM-IV. Document outlines the
20 2
Substance "substance abuse 2021, 9:30 am role of drug testing in primary care (its
Abuse and screening" distinctions and similarities to workplace
Mental Health drug testing, which has developed
Services standards for drug testing). Document
Administration provided insight on the nature of
standardized drug tests, its uses,
limitations, and role in the primary care
setting
Philippine August 10,
Psychiatric all publications 2021, 10:00 20 0 no articles on drug testing
Association am
No articles on drug testing / screening as
Substance Abuse August 14, intervention (Most articles were therapeutic
Central 68 0
Detection (Mesh) 2021, 9:00 am interventions for populations with high risk
substance use, or established SUD)
Substance use August 14, No evidence available on drug testing or
Herdin 27 0
disorder 2021, 1:00 pm screening
120
Appendix B: GRADE Profiles
Summary of findings for the main comparison
Any psychosocial treatment compared to no intervention for psychostimulant misuse
Patient or population: Adults (18 years and older) with a diagnosis of psychostimulant misuse
Settings: Outpatients
Intervention: Any psychosocial treatment
Comparison: No intervention
* The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison
group and the relative effect of the intervention (and its 95%CI).
CI: confidence interval; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to chan ge the estimate.
Very low quality: We are very uncertain about the estimate.
a. High risk of selection bias in one study, unclear risk in the majority of the others.
b. Downgraded one level due to serious risk of bias (high risk for attrition bias for three studies).
c. Downgraded one level due to serious inconsistency (I 2 = 70%, p=0.001. Confidence intervals not overlapping).
d. Downgraded one level due to serious risk of bias (unclear risk of selection bias in all but one study, which is at high ri sk; high risk of attrition bias in one study; high risk of detection bias in one study).
e. Downgraded one level due to serious imprecision (optimal information size (OIS) not met, wide confidence interval).
Summary of findings for the main comparison
Psychosocial intervention compared with inactive control for cannabis use disorder
Patient or population: Adults with cannabis use disorder or frequent cannabis use
Settings: Out-patient treatment
Intervention: Psychosocial intervention
Comparison: Inactive control
123
Date and Results
Search Strategy/
Database Time of Remarks
Search Terms Yield Eligible
Search
NICE Substance AND abuse July 17,
16 0
AND screen 2021
U.S. Preventive Substance AND abuse July 17, Directly answers the research
Services Task AND screen 2021 question. Will use thispre-
8 1
Force (USPSTF) appraised guideline for evidence
review.
Canadian Task Substance AND abuse July 17,
Force for AND screen 2021
0 0
Preventive Health
Care (CTFPHC)
Cochrane Substance AND abuse July 30, Most articles that are possibly
64 0
2021 related to substance abuse
Cochrane Substance AND Abuse July 30, screening by interview does not
17 0
AND screening 2021 tackle benefit and harm
Cochrane Drug AND Abuse July 30,
680 too wide
2021
Cochrane Drug AND Abuse AND July 30,
532 0
Screening 2021
Pubmed Drug AND abuse August 01,
186,584 too wide
2021
Pubmed Drug AND abuse AND August 01,
634 0
screening AND harm 2021
Pubmed Drug AND abuse AND August 01,
screening AND harm 2021 80 0
AND benefit
MEDLINE Substance AND abuse August 03,
15,831 too wide
2021
MEDLINE Substance AND abuse August 03,
AND Screening AND 2021 287 0
harm
Pubmed ("drug abuse August 13, Additional literature search update
screening"[All Fields]) 2021 for years not covered by the
35 0
AND guideline (2020-2021)
(2020:2021[pdat])
Pubmed ("Substance August 13,
screening"[All Fields]) 2021
4 0
AND
(2020:2021[pdat])
Pubmed ("Substance abuse August 13,
screening"[All Fields]) 2021
5 1
AND
(2020:2021[pdat])
American ("Substance abuse August 13,
Psychiatry Journal screening"[All Fields]) 2021
143 0
of Psychiatry AND
(2020:2021[pdat])
HERDIN (Drug OR August 13,
Screening[All Fields]) 2021
0 0
AND
(2020:2021[pdat])
Dangerous Drug August 19, Local Prevalence rate for Drug
Board Website 2021 Abuse Disorder
124
United Nations August 19, Local Community Based guidelines
Office on Drug and 2021 on Drug Dependence Management
Crime
Institute of Health August 19,
Metrics and 2021
Evaluation
Substance Abuse August 20, Treatment/Management, Prognosis
and Mental Health 2021 Resource for different drug abuse
Services disorders.
Administration
(SAMHSA) -
Evidence Based
Practices Resource
Center
PubMed cost effectiveness August 25,
227 4
AND "drug abuse" 2021
PubMed "substance abuse" August 25,
AND qualitative AND 2021 209 3
screening AND patient
HERDIN Drug AND screening September
77 1
9, 2021
HERDIN Substance AND September
12 1
screening 9, 2021
125
Appendix B: GRADE Profiles
Benefits GRADE Table – Psychosocial Interventions
Drug Use Days (follow up: range 3 months to 4 months; assessed with: SD Days)
Drug Use Days (follow up: range 6 months to 12 months; assessed with: SD Days)
Drug Use Severity (follow up: range 3 months to 4 months; assessed with: SMD)
Drug Use Severity (follow up: range 6 months to 12 months; assessed with: SMD)
Explanations
a. Moderate to high attrition rate on some of the studies included.
b. Effects are generally stronger in trials that evaluated cannabis use than any other type of drug use.
c. Effects are generally stronger in trials with intensive intervention than brief interventions.
d. Effects present in trials of treatment-seeking but not screen-detected populations.
e. High statistical heterogeneity.
126
Benefits GRADE Table – Pharmacological Interventions
Naltrexone - Relapse
Explanations
a. Statistically high heterogeneity.
127
Harm GRADE Table – Naltrexone
Certainty Assessment Summary of Findings
Constipation
Diarrhea
Explanations
a. Too wide confidence interval
b. Unclear allocation concealment.
c. Unclear Randomization
d. Unclear blinding
128
Harm GRADE Table – Opioid Agonists
Certainty Assessment Summary of Findings
Constipation
Nausea
Diaphoresis
Explanations
a. Unclear randomization generation method.
b. Unclear allocation concealment
c. Wide confidence interval.
d. Missing data that may influence results
129
Harm GRADE Table – Psychosocial interventions
1198 ⨁⨁⨁◯
serious a,b not serious not serious not serious none 0/595 (0.0%) 0/603 (0.0%) not estimable 0 per 1,000
(4 RCTs) MODERATE
CI: Confidence interval; RR: Risk ratio
Explanations
a. Most of the studies have large drop off rate (17-34%)
b. Some studies have lower intervention adherence.
130
Diagnosis GRADE Table – Single Item Question: Drug Use
Factors that may decrease certainty of evidence Effect per 1,000 patients tested
№ of studies Test
Outcome (№ of Study design Pre-test Pre-test Pre-test accuracy
Risk of Publication
patients) Indirectness Inconsistency Imprecision probability of probability of probability of CoE
bias bias
1.57% 0% 0%
True positives
(patients with Drug 11 to 15 0 to 0 0 to 0
Use)
Cross-sectional
2 studies
(cohort type
not
not serious not serious not serious none ⨁⨁⨁⨁
False negatives (745 patients) serious HIGH
accuracy study)
(patients incorrectly
1 to 5 0 to 0 0 to 0
classified as not
having Drug Use)
True negatives
(patients without 846 to 945 860 to 960 860 to 960
Drug Use) Cross-sectional
2 studies
(cohort type
not
not serious not serious not serious none ⨁⨁⨁⨁
False positives (745 patients) serious HIGH
accuracy study)
(patients incorrectly
39 to 138 40 to 140 40 to 140
classified as having
Drug Use)
131
Diagnosis GRADE Table – Single Item Question: Drug Use Disorder
True positives
13 to 16
(patients with Drug Use Disorder)
Cross-sectional
2 studies
(cohort type accuracy
not
not serious not serious not serious none ⨁⨁⨁⨁
False negatives (745 patients) serious HIGH
study)
(patients incorrectly classified as 0 to 3
not having Drug Use Disorder)
True negatives
(patients without Drug Use 728 to 876
Disorder) Cross-sectional
2 studies
(cohort type accuracy
not
not serious not serious not serious none ⨁⨁⨁⨁
(745 patients) serious HIGH
False positives study)
(patients incorrectly classified as 108 to 256
having Drug Use Disorder)
132
Diagnosis GRADE Table – ASSIST: Drug Use
True positives
15 to 15
(patients with Drug Use)
True negatives
807 to 896
(patients without Drug Use)
False positives
2 studies Cross-sectional (cohort not
not serious not serious not serious none ⨁⨁⨁⨁
(924 patients) type accuracy study) serious HIGH
(patients incorrectly
88 to 177
classified as having Drug
Use)
133
Diagnosis GRADE Table – ASSIST: Drug Use Disorder
True positives
13 to 15
(patients with Drug Use Disorder)
Cross-sectional
2 studies
(cohort type accuracy
not
not serious not serious not serious none ⨁⨁⨁⨁
False negatives (924 patients) serious HIGH
study)
(patients incorrectly classified as 1 to 3
not having Drug Use Disorder)
True negatives
(patients without Drug Use 817 to 856
Disorder) Cross-sectional
2 studies
(cohort type accuracy
not
not serious not serious not serious none ⨁⨁⨁⨁
(924 patients) serious HIGH
False positives study)
(patients incorrectly classified as 128 to 167
having Drug Use Disorder)
134
Diagnosis GRADE Table – DAST-10 : Drug Use
Factors that may decrease certainty of evidence Effect per 1,000 patients tested
№ of studies
Test accuracy
Outcome (№ of Study design Pre-test Pre-test Pre-test
Risk of Publication CoE
patients) Indirectness Inconsistency Imprecision probability of probability of probability of
bias bias
1.57% 0% 0%
True positives
(patients with Drug 13 to 14 0 to 0 0 to 0
Use)
Cross-sectional
2 studies
(cohort type
not
not serious not serious not serious none ⨁⨁⨁⨁
False negatives (997 patients) serious HIGH
accuracy study)
(patients incorrectly
2 to 3 0 to 0 0 to 0
classified as not
having Drug Use)
True negatives
(patients without 925 to 945 940 to 960 940 to 960
Drug Use) Cross-sectional
2 studies
(cohort type
not
not serious not serious not serious none ⨁⨁⨁⨁
False positives (997 patients) serious HIGH
accuracy study)
(patients incorrectly
39 to 59 40 to 60 40 to 60
classified as having
Drug Use)
135
Diagnosis GRADE Table – DAST-10 : Drug Use Disorder
True positives 16
(patients with Drug Use Disorder) (14 to 16)
1 study
(286
Cross-sectional (cohort not
not serious not serious not serious none ⨁⨁⨁⨁
False negatives type accuracy study) serious HIGH
patients) 0
(patients incorrectly classified as
(0 to 2)
not having Drug Use Disorder)
True negatives
758
(patients without Drug Use
(699 to 807)
Disorder) 1 study
(286
Cross-sectional (cohort not
not serious not serious not serious none ⨁⨁⨁⨁
type accuracy study) serious HIGH
False positives patients) 226
(patients incorrectly classified as
(177 to 285)
having Drug Use Disorder)
136
Appendix C: Screening Tools Used
Adolescent:
Tools asked about general substance use including drugs and alcohol with or without
tobacco:
• ASSIST,
• BSTAD,
• CRAFFT,
• PESQ-PS,
• POSIT,
• POSIT-revised
Tools asked about cannabis use only
• ASSIST-LITE for cannabis,
• CAST,
• CPQ-A-S,
• single-item cannabis-frequency question,
• SDS
Indirect screening tool:
• AUDIT,
• AUDIT-C,
• NIAAA Youth Screen
Adults:
Direct Screening tool, Single-item drug frequency:
• SUBS [Substance Use Brief Screen]
• TAPS-1
• single-item drug frequency
Direct Screening tool, Frequency of drug use and risks associated with drug use:
• ASSIST
• ASSIST-Drug
• CAST [Cannabis Abuse Screening Test]
• 2-, 10-, and 28-DAST [Drug-Abuse Screening Test]
• PDUQp [Prescription Drug Use Questionnaire-Patient Version]
• PSQ [Parent Screening Questionnaire]
• SoDU [Screen of Drug Use]
• TAPS
• TICS [Two-Item Conjoint Screen]
Indirect screening tool:
• single-item heavy episode drinking frequency
137
4. Standardized Instruments in Screening for Depression among High-Risk Groups
138
4. Free Text Search
Search Strategy/Search Results
Database Remarks
terms Date of search Yield Eligible
National Institute
for Health and Care depression screening 08/03/2021 79 0 Outdated evidence
Excellence (NICE)
U.S. Preventive
Updated CPG that meets the
Services Task depression screening 08/03/2021 7 pages 1
eligibility criteria
Force (USPSTF)
Canadian Task
Force for
depression screening 08/03/2021 6 pages 0 Outdated evidence
Preventive Health
Care (CTFPHC)
Guidelines
CPG focuses on older adults
International depression screening 08/04/2021 6 1
specifically
Network (GIN)
Original Pubmed MeSH search did
not catch enough so needed broader
search terms. Retrieved CPGs
clinical practice guideline however, the AAFP and ICSI were
Pubmed 08/04/2021 321 4
depression screening based on the USPSTF CPG. Other
recommendations focused on
comparing existing and was not
based on their own data.
No local data on screening
Herdin depression screening 08/09/2021 43 0
guidelines
depression screening
Cochrane 08/09/2021 105 0 No CPGs obtained
filter: 2015-2021
TITLE-ABS-KEY (
depression AND screening
AND systematic AND
review ) AND ( LIMIT-TO (
PUBYEAR , 2021 ) OR
LIMIT-TO ( PUBYEAR ,
2020 ) OR LIMIT-TO (
Scopus 08/09/2021 1,113 3 No CPGs obtained
PUBYEAR , 2019 ) OR
LIMIT-TO ( PUBYEAR ,
2018 ) OR LIMIT-TO (
PUBYEAR , 2017 ) OR
LIMIT-TO ( PUBYEAR ,
2016 ) OR LIMIT-TO (
PUBYEAR , 2015 ) )
depression AND screening Ebsco’s system was glitching on
Ebsco AND primary care AND 08/10/2021 411 0 more than 5 occasions. Could not
systematic reviews review evidence
Few cross sectionals, some are
Herdin depression prevalence 08/26/2021 76 3
outdated.
psychometric property of
Searched specific screening tools for
Pubmed zung self-rating 09/13/2021 2 0
better yields.
depression scale
cost effectiveness Center
Limited cost effectiveness studies
Pubmed for Epidemiologic Studies 09/13/2021 18 0
using other screening tools
Depression Scale (CES-D)
Cochrane depression prevalence 09/15/2021 93 0 Evidence was unrelated
139
APPENDIX B: GRADE Profiles
PHQ-9
Question: Should PHQ-9 be used to screen for depressive disorders in the adult population?
Patient or Population: General adult population33
Setting: Community-based primary care practice, outpatient specialty, inpatient specialty care, non-medical care 33
New test: PHQ-9 | Cut-off value: 10 (range of score: 0 – 27)33
Pooled sensitivity: 0.88 (95% CI 0.83 to 0.92) | Pooled specificity: 0.85 (95% CI 0.82 to 0.88) 33
Sensitivity 0.88 (95% CI 0.83 to 0.92)
Prevalences 3.44% 14% 25%
Specificity 0.85 (95% CI 0.82 to 0.88)
Factors that may decrease certainty of evidence Effect per 1,000 patients tested
№ of
studies Test accuracy
Outcome Study design Pre-test Pre-test Pre-test
(№ of Risk of Publication CoE
patients) Indirectness Inconsistency Imprecision probability of probability of probability of
bias bias
3.44% 14% 25%
True positives
30 123 220
(patients with depressive 58
disorders) Cross-sectional Publication (29 to 32) (116 to 129) (208 to 230)
studies not ⨁⨁◯◯
(cohort type not serious serious a not serious bias strongly
(17,357 serious LOW
False negatives accuracy study) suspected b 4 17 30
(patients incorrectly classified as patients)
not having depressive disorders) (2 to 5) (11 to 24) (20 to 42)
True negatives
821 731 638
(patients without depressive 58
disorders) Cross-sectional Publication (792 to 850) (705 to 757) (615 to 660)
studies not ⨁⨁◯◯
(cohort type not serious serious a not serious bias strongly
(17,357 serious LOW
False positives accuracy study) suspected b 145 129 112
(patients incorrectly classified as patients)
having depressive disorders) (116 to 174) (103 to 155) (90 to 135)
Explanations
a. Analysis revealed moderate heterogeneity across included studies.
b. Did not investigate publication bias. Did not declare conflicts of interest. Funding came from multiple sources.
Prevalence 14%
Test results Typically seen in
this study
140
CES-D 1
Question: Should CES-D be used to screen for depressive disorders in adult population?
Patient or population: general adult population 31
Setting: community-based primary care practice, general population, residential, schools 31
New test: CES-D | Cut-off value: 16 (range of score: 0 – 60)31
31
Pooled sensitivity: 0.87 (95% CI: 0.82 to 0.92) | Pooled specificity: 0.70 (95% CI: 0.65 to 0.75)
Sensitivity 0.87 (95% CI: 0.82 to 0.92)
Prevalence 3.44% 8.8% 25%
Specificity 0.70 (95% CI: 0.65 to 0.75)
Factors that may decrease certainty of evidence Effect per 1,000 patients tested
№ of studies
Test accuracy
Outcome (№ of Study design Pre-test Pre-test Pre-test
Risk of CoE
patients) Indirectness Inconsistency Imprecision Publication bias probability of probability of probability of
bias
3.44% 8.8% 25%
True positives
30 77 218
(patients with
(28 to 32) (72 to 81) (205 to 230)
depressive disorders) 28 studies Cross-sectional Publication bias
(10,617 (cohort type
not
not serious serious a not serious strongly ⨁⨁◯◯
False negatives serious LOW
patients) accuracy study) suspected b
(patients incorrectly 4 11 32
classified as not having (2 to 6) (7 to 16) (20 to 45)
depressive disorders)
True negatives
676 638 525
(patients without
(628 to 724) (593 to 684) (488 to 563)
depressive disorders) 28 studies Cross-sectional Publication bias
(10,617 (cohort type
not
not serious serious a not serious strongly ⨁⨁◯◯
False positives serious LOW
patients) accuracy study) suspected b
(patients incorrectly 290 274 225
classified as having (242 to 338) (228 to 319) (187 to 262)
depressive disorders)
Explanations
a. The authors mentioned an assessment of possible sources of heterogeneity however found none to be statistically significant. The Source of heterogeneity was not resolved.
b. Each author was supported and funded by different sources. Additionally, they did not disclose any conflict of interest or discuss any declaration of no conflict of interest. They did not investigate publication bias.
Prevalence 8.8%
Test results Typically seen in
this study
141
CES-D 2a
Question: Should CES-D be used to screen for depressive disorders in adult population?
Patient or population: general adult population 32
Setting: community-based primary care practice, general population32
New test: CES-D | Cut-off value: 16 (range of score: 0 – 60)32
32
Pooled sensitivity: 0.84 (95% CI: 0.79 to 0.88) | Pooled specificity: 0.74 (95% CI: 0.68 to 0.81)
Sensitivity 0.84 (95% CI: 0.79 to 0.88)
Prevalence 3.44% 11% 25%
Specificity 0.74 (95% CI: 0.68 to 0.81)
Factors that may decrease certainty of evidence Effect per 1,000 patients tested
№ of studies
Outcome (№ of Study design Pre-test Pre-test Pre-test Test accuracy CoE
Risk of Publication
patients) Indirectness Inconsistency Imprecision probability of probability of probability of
bias bias
3.44% 11% 25%
True positives
29 92 210
(patients with depressive
disorders) (27 to 30) (87 to 97) (198 to 220)
8 studies Cross-sectional
(2,743 (cohort type
not
not serious serious a not serious none ⨁⨁⨁◯
False negatives serious MODERATE
(patients incorrectly patients) accuracy study) 5 18 40
classified as not having (4 to 7) (13 to 23) (30 to 52)
depressive disorders)
True negatives
715 659 555
(patients without depressive
disorders) (657 to 782) (605 to 721) (510 to 608)
8 studies Cross-sectional
(2,743 (cohort type
not
not serious serious a not serious none ⨁⨁⨁◯
False positives serious MODERATE
(patients incorrectly patients) accuracy study) 251 231 195
classified as having (184 to 309) (169 to 285) (142 to 240)
depressive disorders)
Explanations
a. Heterogeneity across studies for community-dwelling adults
Prevalence 11%
Test results Typically seen in
this study
142
CES-D 2b
Question: Should CES-D be used to screen for depressive disorders in chronically ill adults?
Patient or population: general adult population 32
Setting: chronically ill, out patient32
New test: CES-D | Cut-off value: 20-23 (range of score: 0 – 60)32
32
Pooled sensitivity: 0.86 (95% CI: 0.81 to 0.90) | Pooled specificity: 0.85 (95% CI: 0.78 to 0.91)
Sensitivity 0.86 (95% CI: 0.81 to 0.90)
Prevalence 3.44% 21% 25%
Specificity 0.85 (95% CI: 0.78 to 0.91)
Factors that may decrease certainty of evidence Effect per 1,000 patients tested
Test
№ of studies
Outcome Study design Pre-test Pre-test Pre-test accuracy
(№ of patients) Risk of Publication
Indirectness Inconsistency Imprecision probability of probability of probability of CoE
bias bias
3.44% 21% 25%
True positives
30 181 215
(patients with depressive
disorders) (28 to 31) (170 to 189) (203 to 225)
8 studies Cross-sectional
(1,868 (cohort type
not
not serious not serious not serious none ⨁⨁⨁⨁
False negatives serious HIGH
(patients incorrectly patients) accuracy study) 4 29 35
classified as not having (3 to 6) (21 to 40) (25 to 47)
depressive disorders)
True negatives
821 672 638
(patients without
depressive disorders) (753 to 879) (616 to 719) (585 to 683)
8 studies Cross-sectional
(1,868 (cohort type
not
not serious not serious not serious none ⨁⨁⨁⨁
False positives serious HIGH
(patients incorrectly patients) accuracy study) 145 118 112
classified as having (87 to 213) (71 to 174) (67 to 165)
depressive disorders)
Prevalence 21%
Test results Typically seen in
this study
143
GDS-15
Question: Should GDS-15 be used to screen for depressive disorders in older adult population?
Patient or population: older adult population 30
Setting: community-based, clinical setting30
New test: GDS-15 | Cut-off value: 5 (range of score: 0 – 15)30
30
Pooled sensitivity: 0.86 (95% CI: 0.82 to 0.89) | Pooled specificity: 0.79 (95% CI: 0.73 to 0.84)
Sensitivity 0.86 (95% CI: 0.82 to 0.89)
Prevalence 3.44% 42% 25%
Specificity 0.79 (95% CI: 0.73 to 0.84)
Factors that may decrease certainty of evidence Effect per 1,000 patients tested
№ of studies
Test accuracy
Outcome (№ of Study design Pre-test Pre-test Pre-test
Risk of Publication CoE
patients) Indirectness Inconsistency Imprecision probability of probability of probability of
bias bias
3.44% 42% 25%
True positives
30 361 215
(patients with depressive
disorders) (28 to 31) (344 to 374) (205 to 223)
30 studies Cross-sectional
(14,034 (cohort type
not
not serious serious a not serious none ⨁⨁⨁◯
False negatives serious MODERATE
(patients incorrectly patients) accuracy study) 4 59 35
classified as not having (3 to 6) (46 to 76) (27 to 45)
depressive disorders)
True negatives
763 458 593
(patients without
depressive disorders) (705 to 811) (423 to 487) (548 to 630)
30 studies Cross-sectional
(14,034 (cohort type
not
not serious serious a not serious none ⨁⨁⨁◯
False positives serious MODERATE
(patients incorrectly patients) accuracy study) 203 122 157
classified as having (155 to 261) (93 to 157) (120 to 202)
depressive disorders)
Explanations
a. Heterogeneity in results
Prevalence 42%
Test results Typically seen in
this study
False
5.9%
Negatives
144
5. Standardized Instruments in Screening for Anxiety
145
Appendix B: GRADE Profiles
GRADE Evidence Table: Health-related outcomes for adults with anxiety disorders compared to adults without anxiety disorders
Patient or population: Patients with diagnosed anxiety disorders
Settings: Admitted patients, outpatient care
Comparison: Adults with no anxiety disorders
All-cause Mortality
RR 1.41 ⊕⊕⊝⊝
28 Cohort studies Not serious Not serious Not serious Serious None IMPORTANT
(1.13 to 1.73) LOW 2
Stroke
OR 1.47 ⊕⊕⊕⊕
8 Prospective studies Not serious Not serious Not serious Not serious None IMPORTANT
(1.23 to 1.75) HIGH
Diabetes
OR 1.47 ⊕⊝⊝⊝
14 Prospective studies Serious Serious Not serious Serious None IMPORTANT
(1.23 to 1.75) VERY LOW 3
1 Downgraded for publication bias (-1) because results of Egger’s test (p<0.01) suggested a publication bias favoring small studies with large, positive associations.
2 Downgraded for inconsistency (-1) because the heterogeneity amongst the included studies was quite high. Downgraded for indirectness (-1) because of differences in the tool used to measure outcomes
3 Downgraded for risk of bias (-1) primarily because many of the studies included have self-reported anxiety symptoms as well as some studies not being generalizable. Downgraded for inconsistency (-1) due to the high heterogeneity of
the studies. Downgraded for publication bias (-1) because of the Egger’s test (P= 0.05) signifying high probability of publication bias.
146
GRADE Evidence Table: Anxiety Disorder Screening Tool Validation
Patient or population: Asymptomatic adults
Settings: General population, outpatient care
Intervention: Screening tool for anxiety
Comparison: “Reference standard”
Diagnostic test With 2 outlier studies Sen: 0.78 (0.71 to 0.84) ⊕⊕⊕⊕
9 Not serious Not serious Not serious Not serious CRITICAL
accuracy studies removed Spec: 0.83 (0.82 to 0.84) HIGH
for publication bias (-1) because due to the tendency to over-report positive findings.
147
GRADE Evidence Table: Therapist-Supported ICBT compared to waiting list, attention, information, or online discussion group only control for anxiety
disorders in adults
Patient or population: Patients with anxiety disorders
Settings: Outpatient care via Internet with e-mail or telephone support, or both
Intervention: Therapist-supported ICBT
Comparison: Waiting list, attention, information, or online discussion group only control
148
Study population
Participant satisfaction See comment See comment Studies reported high
Indexed by a mix of
overall treatment
qualitative and Not estimable 0 (13) See comment
Moderate satisfaction for therapist-
quantitative self-report
supported ICBT
measures
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assum ed risk in the comparison group and the relative
effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate
1 For clinically important improvement in anxiety, an event is indicative of a participant achieving clinically important improvement.
2 Downgraded for risk of bias (-1) primarily because four of the included studies did not blind their outcome assessors to participants' group assignment and due to lack of blinding of participants and study therapists. Downgraded
for publication bias (-1) because only 12 studies reported this outcome. Not downgraded for inconsistency (0) because heterogeneity was reduced followi ng subgroup analysis by anxiety disorder.
3 Downgraded for risk of bias (-1) primarily due to minor concerns with selective outcome reporting, incomplete outcome data, baseline imbalances in a few studies, and lack of blinding of participants and study ther apists.
4 Downgraded for inconsistency (-1) because the heterogeneity amongst the included studies was quite high. This may be explained by the variety of anxiety disorders investigated and differences in the treatment details;
however, the number of studies that could be included in subgroup analyses was not sufficient to provide useful reasons for this heterogeneity.
5 According to Cohen's (1969) interpretation of effect sizes.
6 Downgraded for risk of bias (-1) primarily because two studies included baseline imbalances in participant severity across study groups and due to lack of blinding of participants and study therapists.
149
Appendix C: Screening Tools
150
Figure 3. Hospitalized Anxiety and Depression Scale (HADS) Questionnaire
151
Appendix D: Diagnostic Tables
Table 7. 2x2 of GAD-2 (excluding 2 outlier studies) vs. Gold Standard, cut-off score of 3
Anxiety Present Anxiety Absent Total
Test Positive 143 455 598
Test Negative 40 2223 2263
Total 183 2678 2861
152
Table 8. Diagnostic Accuracy of GAD-2 (excluding 2 outlier studies) vs. Gold Standard, cut-off score of 3
Statistic Value 95% CI
Sensitivity 78.14% 71.45% to 83.90%
Specificity 83.01% 81.53% to 84.41%
Positive Likelihood Ratio 4.60 4.11 to 5.15
Negative Likelihood Ratio 0.26 0.20 to 0.35
Disease prevalence (*) 5.00%
Positive Predictive Value (*) 19.49% 17.77% to 21.33%
Negative Predictive Value (*) 98.63% 98.21% to 98.96%
Accuracy (*) 82.77% 81.33% to 84.13%
Heterogeneity i2 37.0
Studies Included 9
Table 9. 2x2 of GAD-2 (excluding 2 outlier studies) vs. Gold Standard, cut-off score of 3
Anxiety Present Anxiety Absent Total
Test Positive 143 455 598
Test Negative 40 2223 2263
Total 183 2678 2861
Table 10. Diagnostic Accuracy of GAD-2 (excluding 2 outlier studies) vs. Gold Standard, cut-off score of 3
Statistic Value 95% CI
Sensitivity 78.14% 71.45% to 83.90%
Specificity 83.01% 81.53% to 84.41%
Positive Likelihood Ratio 4.60 4.11 to 5.15
Negative Likelihood Ratio 0.26 0.20 to 0.35
Disease prevalence (*) 5.00%
Positive Predictive Value (*) 19.49% 17.77% to 21.33%
Negative Predictive Value (*) 98.63% 98.21% to 98.96%
Accuracy (*) 82.77% 81.33% to 84.13%
Heterogeneity i2 37.0
Studies Included 9
153
6. Standardized Instruments in Screening for Depression among Children and
Adolescents
154
(depression[MeSH Terms])) AND (depressive disorder[MeSH Terms]))
AND (children[MeSH Terms])) AND (adolescents[MeSH Terms])
6 (harm):ti,ab,kw 13,139
9 #7 AND #8 1
10 #7 AND #4 0
11 #7 AND #5 150
12 #7 AND #6 54
7 (accuracy):ti,ab,kw 23,677
8 #1 to #4 5,134
9 #5 to #7 2,548
10 #8 AND #9 5
11 #8 AND #5 279
12 #8 AND #6 109
13 #8 AND #7 80
15 #14 AND #9 13
155
17 #14 AND #6 46
3. Other databases
Results
Data and Time of
Database Search Terms Remarks
Search
Yield Eligible
Guidelines
August 26, 2021, 8:00 No studies on the
International depression 38 0
am relevant population
Network (GIN)
Philippine
Psychiatric August 26, 2021, 8:00 No studies on the
depression 14 0
Association am relevant population
(PPA)
American
depression AND August 26, 2021, 8:00 No studies relevant to
Journal of 130 0
screening am the question
Psychiatry (AJP)
depression AND
August 26, 2021, 8:00
Scopus screening AND 262 6
am
children
depression
August 26, 2021, 8:00 No studies relevant to
LILACS screening AND 40 0
am the question
children
depression AND
August 26, 2021, 8:00
TRIP database (child OR 47 19
am
adolescent)
156
APPENDIX B: GRADE Evidence Tables
Depression screening versus no screening
Identification of depression
Referral
Service uptake
Explanations
a. > 33% of the items have unclear bias
b. High I2 and low p-value with little overlap in their confidence intervals
c. Wide confidence interval
d. Comparator group is actually delayed feedback on screening but data on no screening was given
157
Remission: CBT versus placebo/NDST/waitlist
Certainty Assessment Summary of Findings
Explanations
a. > 33.3% of weighted data from studies at moderate or high risk of bias
b. Small sample size and confidence interval crossing the line of null effect
c. High I2 value
158
Remission: IPT versus NDST/waitlist/group IPT
Certainty Assessment Summary of Findings
Explanations
a. > 33% of the items have unclear or high risk of bias
b. Small sample size, wide confidence interval
c. Small sample size, no appreciable benefits/s or harm
159
Quality of life: CBT versus placebo
Quality of life (follow up: 12 weeks; assessed with PQ-LES-Q; Scale from 15 to 75)
SMD 0.08
223 ⨁⨁◯◯
seriousa not serious not serious seriousb none 112 111 - - SD lower
(1 RCT) LOW (0.34 lower to 0.19 higher)
CI: confidence interval; RR: risk ratio
Explanations
a. > 33.3% of weighted data from studies at moderate risk of bias
b. No appreciable benefit/s or harm
160
APPENDIX C: Forest Plots
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Figure 1. Identification of depression: screening versus no screening
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Figure 2. Referral rate: screening versus no screening
____________________________________________________________________________________________________________________
161
____________________________________________________________________________________________________________________
Figure 3. Service uptake: screening versus no screening
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Figure 4. Remission: Individual CBT versus placebo
Subgroup: CBT versus Family-based CBT
____________________________________________________________________________________________________________________
162
____________________________________________________________________________________________________________________
Figure 5. Remission: Individual CBT versus non-directive supportive therapy (NDST)
Subgroup: Without comorbidity versus with comorbidity
____________________________________________________________________________________________________________________
163
____________________________________________________________________________________________________________________
Figure 6. Remission: Group CBT versus waitlist control
___________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Figure 7. Remission: Family-based IPT versus NDST
____________________________________________________________________________________________________________________
164
____________________________________________________________________________________________________________________
Figure 8. Remission: IPT-A versus waitlist control
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Figure 9. Remission: Individual IPT versus Group IPT
____________________________________________________________________________________________________________________
165
Appendix D: Quality Rating of Studies on Diagnostic Accuracy of Screening Instruments
166
APPENDIX E: Screening for Depression Analytic Framework
167
7. Standardized Instruments in Screening for Anxiety among Adolescents
6 (harm):ti,ab,kw 13,139
168
9 #7 AND #8 1
10 #7 AND #4 9
11 #7 AND #5 136
12 #7 AND #6 41
7 (accuracy):ti,ab,kw 23,677
8 #1 to #4 4,420
9 #5 to #7 2,514
10 #8 AND #9 11
11 #8 AND #5 228
12 #8 AND #6 77
13 #8 AND #7 68
14 (screen for child anxiety related disorders):ti,ab,kw OR (scared near item):ti,ab,kw 205
15 #14 AND #9 3
16 #14 AND #5 29
17 #14 AND #6 9
18 #14 AND #7 9
169
3. Other databases
Results
Data and Time of
Database Search Terms Remarks
Search
Yield Eligible
Guidelines
August 26, 2021, 10:00 Studies are for adult
International anxiety 20 0
am populations
Network (GIN)
Philippine
August 26, 2021, 10:00 None found among
Psychiatric anxiety 0 0
am research titles listed
Association (PPA)
170
Appendix B: GRADE Evidence Tables
Remission: CBT versus waitlist
Explanations
e. Downgraded one level due to moderate heterogeneity (inconsistency)
171
Remission: CBT versus attention control
Explanations
a. Downgraded one level due to moderate heterogeneity (inconsistency)
b. At least moderate heterogeneity and large variation in treatment (inconsistency)
c. Small number of events (imprecision)
d. Wide confidence interval
172
Appendix C: Forest Plots
_________________________________________________________________________________
_________________________________________________________________________________
Figure 1. Remission of primary anxiety diagnosis: CBT versus waitlist control
173
_________________________________________________________________________________
_________________________________________________________________________________
Figure 2. Remission of primary anxiety diagnosis: CBT versus waitlist control
Subgroup: Individual CBT versus Group CBT
174
_________________________________________________________________________________
_________________________________________________________________________________
Figure 3. Remission of all anxiety diagnosis: CBT versus waitlist control
175
_________________________________________________________________________________
_________________________________________________________________________________
Figure 4. Remission of primary anxiety diagnosis: CBT versus attention control
_________________________________________________________________________________
_________________________________________________________________________________
Figure 5. Remission of primary anxiety diagnosis: CBT versus attention control
Subgroup: Individual CBT versus Group CBT
176
________________________________________________________________________________
_________________________________________________________________________________
Figure 6. Remission of all anxiety diagnosis: CBT versus attention control
177
Appendix D: Quality Rating of Studies on Diagnostic Accuracy of Screening Instruments
178
Appendix E: Screening for Depression Analytic Framework
10-14 15-19
Diagnosis Total
M F M F
179
8. Standardized Instruments in Screening for Stress
5 #1 AND #3 7,474
6 #2 AND #4 7,474
7 #2 AND #4 FILTERS: Adult, Young Adult, Aged, Middle Aged, 80+ 5,246
180
10
Query #9 AND filters: 2015, Systematic Review, Meta-analyss,
456
Randomized Controlled Trial
6. Cochrane
Step Query Results
7. Google Scholar
Step Query Results
Results
Date and Time
Database Search Strategy/ Search terms Remarks
of Search
Yield Eligible
Same article as
NICE adult AND Stress AND mental 8/2/21 2:00 PM 98 1
previous search
Canadian Task
adult stress screen 8/3/21 2:00 PM 1 0
Force
(((screening) OR (diagnosis) OR
(questionnaire) OR (Perceived
stress)) AND ((psychological
PubMed stress) OR (quality of life)) AND 9/7/21 3:00 PM 81 1
(worker) AND Asia Filters: from
2015, Adult age groups,
Systematic Review, RC
"stress, psychological"[MeSH
Terms] AND ("diagnosis"[MeSH
Subheading] OR "mass
10/12/21 10:00
PubMed screening"[MeSH Terms] OR 5,332
AM
"early detection of cancer"[MeSH
Terms] OR "screening"[Text
Word])
181
Appendix B: GRADE Evidence Profiles for Indirect Evidence
A. A brief preventive intervention on work-related stress compared to the usual care in determining sick leave among non-sick listed patients (18-64 years)
Bibliography: Hultén A-M, Bjerkeli P, Holmgren K. Self-reported sick leave following a brief preventive intervention on work-related stress: A randomised controlled trial in Primary Health Care. BMJ Open. 2021Mar22;11(3).
220 ⨁⨁⨁◯ 61/115 59/105 RR 1.059 530 per 31 more per 1,000
seriousa not serious not serious not serious none
(1 RCT) MODERATE (53.0%) (56.2%) 1,000
241 ⨁⨁⨁◯ 57/122 61/119 RR 1.097 467 per 45 more per 1,000
seriousa not serious not serious not serious none
(1 RCT) MODERATE (46.7%) (51.3%) 1,000
Explanations
a. The statistical power of study is low due to the lack of participants. The initial power calculation stipulated a need for 135 individuals per group in order to detect a 15% difference between the groups. There were
<135 individuals in all groups during the follow-up.
182
B. Early identification of high work-related stress compared to usual care in determining polypharmacy among employed individuals
Bibliography: Bjerkeli PJ, Skoglund I, Holmgren K. Does early identification of high work related stress affect pharmacological treatment of primary care patients? - analysis of Swedish pharmacy dispensing data in
a randomised control study. BMC Family Practice. 2020Apr25;21(1).
Polypharmacy: number of different medications used per individual (follow-up: 365 days; assessed with: pharmacy dispensing data)
The number of different medications used per individual did not differ
271
seriousa not serious not serious not serious none ⨁⨁⨁◯ significantly between the control group (median 4.0) and the intervention
(1 RCT) MODERATE group (median 4.0, p-value 0.076).
Polypharmacy: proportion of individuals who collected more than 10 different medications (follow -up: 365 days; assessed with: pharmacy dispensing data)
Polypharmacy: Proportion of individuals filling prescriptions issued from more than three different clinics (follow-up: 365 days; assessed with: pharmacy dispensing data )
Explanations
a. Measurement bias could be present because the study is based on pharmacy dispensing data. There is lack knowledge about the actual number of prescriptions that were issued to the patient including those that
were not on their database.
183
C. A work stress intervention compared to the usual care in determining healthcare use and treatment among stressed employees
Bibliography: Sandheimer C, Hedenrud T, Hensing G, Holmgren K. Effects of a work stress intervention on healthcare use and treatment compared to treatment as usual: A randomized controlled trial in Swedish Primary
Healthcare. BMC Family Practice. 2020Jul6;21(1).
Healthcare use and treatment (follow-up: 12 months; assessed with: Västra Götaland (VGR) VEGA Database)
Explanations
a. Selection bias could be present due to the lack of data from the occupational health care service. The investigators were able to use only the VEGA database in recruiting its target population. Other employed
patients were overlooked.
b. Despite significant differences observed, investigators cannot say with absolute certainty what caused the effect. The low power of the study could be due to a lack of participants and/or short follow-up.
184
D. Transcendental meditation compared to health education for reducing cardiovascular risk among African-Americans
Bibliography: Schneider RH, Myers HF, Marwaha K, Rainforth MA, Salerno JW, Nidich SI, et al. Stress reduction in the prevention of left ventricular hypertrophy: A randomized controlled trial of Transcendental
Meditation and health education in hypertensive African Americans. Ethnicity & Disease. 2019;29(4):577–86.
85 not ⨁⨁⨁◯ The TM group had significantly lower LVMI compared with the HE group (-7.55gm/m2,
not serious serious a not serious none
(1 RCT) serious MODERATE 95% CI -14.78 to -.34 gm/m2, p =. 040).
Blood pressure (follow-up: 6 months; assessed with: Critikon Dina- map 1846 SX/P version 0846)
Both interventions showed significant reductions in blood pressure, (SBP/ DBP changes for
85 not ⨁⨁⨁◯
not serious serious a not serious none TM: -5/ -3 mm Hg, and for HE: -7/-6 mm Hg, p =.028 to <.001), but not significant
(1 RCT) serious MODERATE
difference between groups.
85 not ⨁⨁⨁◯
not serious serious a not serious none Both groups showed significant reductions in anger (p = 0.002 to 0.001).
(1 RCT) serious MODERATE
185
GRADE Evidence Table for Performance of PSS-10
A. Psychometric Properties of PSS-10
Bibliography: Stryker SD, Andrew Yockey R, Rabin J, Vaughn LM, Jacquez F. How do we measure stress in Latinos in the United States? A systematic review. Health Equity. 2021May19;5(1):338–44.
Overall
Participants Risk of Inconsistenc Publication
Indirectness Imprecision certainty of Impact
(studies) bias y bias
evidence
Content validity
0 -
The three studies did not assess content validity
(Observational studies)
Criterion validity
0 -
The three studies did not assess content validity
(Observational studies)
Factor structure
6202 ⨁◯◯◯
serious a not serious not serious not serious none
(3 observational studies) VERY LOW
Construct validity
6202 ⨁◯◯◯
serious a not serious not serious not serious none
(3 observational studies) VERY LOW
CI: Confidence interval
Explanations
a. Search was not exhaustive, may have selection bias
b. excluded studies that involved Latinos in Latin America and studies that were not in English
186
B. The Association Between Perceived Stress and Mortality Among People with Multimorbidity: A Prospective Population-Based Cohort
Study
Bibliography: Prior A, Fenger-Grøn M, Larsen KK, Larsen FB, Robinson KM, Nielsen MG, et al. The association between perceived stress and mortality among pe ople with multimorbidity: A prospective population-
based cohort study. American Journal of Epidemiology. 2016Jul11;184(3):199–210.
Mortality among people with multimorbidity (assessed with: Danish National Health Survey 2010)
Explanations
a. Survey participation rate was only 56% percent. Selection bias may exist
187
9. Standardized Instruments in Screening for Sleep Disturbances/Problems
188
5. COCHRANE (August 20 2021 05:00 PM)
Step Query Results
(Sleep disorder or insomnia or sleep disturbance or sleep
1 20,566
problem):ti,ab,kw
2 #1 and (Intervention or therapy or medication or aid):ti,ab,kw 7,775
#1 and #2 not (apnea or apnoea or bruxism or disease or
4 syndrome or obstructive or chronic or cancer or depression or 1,689
anxiety or pregnant or children):ti,ab,kw
5 #4 and (quality of life):ti,ab,kw 449
6 #5 from Jan 2015 to Dec 2021 341
1 mesh:sleep 106
2 mesh:sleep disorder 26
3 mesh:sleep disturbance 0
4 mesh:sleep problem 0
5 mesh:insomnia 1
6 mesh:sleep AND mesh:screen 0
1 Sleep 49,271
2 ((sleep disorder) AND (screen)) 8,285
3 #2 and content I can access 1,475
4 #3 from 2015 to 2021 99
189
Results
Database Search Strategy/Search Terms Date and Time of
Search Yield Eligible
TOTAL 2370 89
190
Appendix B: GRADE Evidence Tables
Should the Insomnia Severity Index be used to screen for sleep disorders in asymptomatic apparently healthy adults and
adolescents?
Sensitivity 0.87 (95% Cl 0.81 to 0.92) Prevalences 23.9% 35.2% 22.1%
Outcome Factors that may decrease certainty of evidence Effect per 1.000 patients tested
No of
Outcome studies Test accuracy CoE
(No of Pre-test
Pre-test Pre-test
patients) Study Risk of Indirectnes Inconsisten Publicatio probabilit
Imprecision probability probability of
design bias s cy n bias y of
of 35.2% 22.1%
23.87%
True negatives
598
(patients 518 623
Cohort (434 to
without sleep (376 to 596) (452 to 717)
9 studies & case- 688)
disorders)
(3,257 control not serious not serious serious a serious b,c none LOW
False positives patients) type
(patients incorrectly studies 150 130 156
classified as having (60 to 314) (52 to 272) (62 to 327)
sleep disorders)
Explanations
a. Uses various reference standards, such as DSM-IV, ICD-10, and ICSD-II for identifying sleep disorders
b. Typically measures for insomnia and other specific sleep disorders as opposed to measuring sleep disorder as a whole.
c. Only a small number of studies were included in our meta-analysis
191
Should the Athens Insomnia Scale be used to screen for sleep disorders in asymptomatic apparently healthy adults and
adolescents?
Sensitivity 0.87 (95% CI 0.79 to 0.92) Prevalences 23.9% 35.2% 22.1%
Specificity 0.83 (95% CI 0.72 to 0.90)
Factors that may decrease certainty of evidence Effect per 1.000 patients tested
Outcome No of Test
Outcome studies accuracy
(No of patients) CoE
Pre-test Pre-test Pre-test
Inconsistenc Publicatio
Study design Risk of bias Indirectness Imprecision probability of probability of probability of
y n bias
23.87% 35.2% 22.1%
True positives
208 306 192
(patients with seen
Cohort (189 to 220) (278 to 324) (175 to 203)
disorders)
7 studies & case-control
False negatives serious a not serious serious b serious c,d none VERY LOW
(1,369 patients) type
(patients incorrectly studies 46 46 29
classified as nor having (19 to 50) (28 to 74) (18to 46)
sleep disorders)
True negatives
538 538 647
(patients
Cohort (467 to 583) (467 to 583) (561 to 701)
without sleep disorders)
7 studies & case-control
False positives serious a not serious serious b serious c,d none VERY LOW
(2,272 patients) type
(patients incorrectly studies 129 110 132
classified as having (76 to 213) (65 to 181) (78 to 218)
sleep disorders)
Explanations
a. Blinding and test reproducibility were not fully reported
b. Uses various reference standards, such as DSM-IV. ICD-10. and ICSD-Il for identifying sleep disorders
c. Typically measures for insomnia and other specific sleep disorders as opposed to measuring sleep disorder as a whole
d. Only a small number of studies were included in our meta-analysis
192
Should the Pittsburgh Sleep Quality Index be used to screen for sleep disorders in asymptomatic apparently healthy adults and
adolescents
Sensitivity 0.94 (95% CI 0.86 to 0.98) Prevalences 23.9% 35.2% 22.1%
Factors that may decrease certainty of evidence Effect per 1.000 patients tested
Outcome No
Test
of studies
Outcome Pre-test Pre-test Pre-test accuracy
(No of Inconsistenc Publication
Study design Risk of bias Indirectness Imprecision probability of probability of probability of CoE
patients) y bias
23.87% 35.2% 22.1%
Explanations
a. Blinding and test reproducibility were not fully reported,
b. Uses various reference standards, such as DSM-IV, ICD-10, and ICSD-ll for identifying sleep disorders
c. Typically measures for insomnia and other specific sleep dis orders as opposed to measuring sleep disorder as a whole.
d. Only a small number of studies were included in our meta-analysis
193
Cognitive Behavioral Therapy compared to no treatment for sleep disorders
Certainty Assessment No of patients Effect
Group Cognitive Behavioral Therapy Intervention (follow up: mean 6 months; assessed with: Insomnia Severity Index; Scale from: 0 to 28)
MD 4.65 lower
randomised NOT
6 not serious serious a not serious serious b none 145 147 (5.62 lower to LOW
trials IMPORTANT
0.71 lower)
Internet Cognitive Behavioral Therapy Intervention (follow up: range 1 months te months; assessed with: Insomnia Severity Index; Scale from: 0 to 28)
MD 6.48 lower
randomised NOT
5 not serious serious a not serious serious b,c none 815 1126 (6.63 lower to LOW
trials IMPORTANT
6.33 lower)
Explanations
a. Differences in population
b. recommended cut-off scores vary
c. One large study may skew the results
194
Appendix C: Forest Plots
Figure 1. Mean-difference of the intervention on cognitive behavioral therapy conducted through groups
as measured by the Insomnia Severity Index scores
Figure 2. Mean-difference of the intervention on cognitive behavioral therapy conducted through the
internet as measured by the Insomnia Severity Index scores
195
Figure 5. Diagnostic Odds Ratio of the Pittsburgh Sleep Quality Index
196
Figure 9. Negative Likelihood Ratio of the Insomnia Severity Index
Figure 11. Negative Likelihood Ratio of the Pittsburgh Sleep Quality Index
197
PERIODIC HEALTH EXAMINATION TASK FORCE
ON MENTAL HEALTH AND ADDICTION 2021
Task Force Steering Committee
Technical Coordinator
Consensus Panel
198
Viel D.S. Mendoza Alzheimers Disease Association of the
Philippines (ADAP)
Lia Palileo-Villanueva, MD
Technical Writer
Christine A. Dator, MD
Administrative Officer
Note: All members of the Task Force are based in the National Capital Region, Philippines
except for BM. Dimatatac (CALABARZON), MT. Jacalan & AG. Daga (Region VII), and
FR. Tan (Region III).
199
PERIODIC HEALTH EXAMINATION PHASE 2 TASK
FORCE 2021
Central Steering Committee
Oversight Committee
Project Leader
Co-Project Leader
Project Managers
Administrative Staff
200
CONFLICT OF INTEREST DECLARATION
COI based on
Panelist Oversight Remarks
Committee
Agnes Joy L. Casiño, MD Manageable B Speaker and trainor for private
(DOH-DPCB) companies
Alfon Guiller D. Daga, MAN, RN Manageable A Non-financial interest: Nurse II (Eastern
(PNA) Visayas Reginal Medical Center), board
member of advocacy group (Philippine
Nurses Association)
Emmanuel V. Hernani, PhD Manageable A & B Employment, research support,
(PAPO) commercial business interest, non-
financial interest (official function in a
government agency), public statements
and positions
Francisca Rosario E. Espino-Tan, Manageable A No conflict of interest declared.
MD (PCGM)
Jennifer Justice F. Manzano, MD Manageable A Employment, support as speaker, non-
(PNA) financial interest (Steering Committee
member, Board member)
Lourdes Carolina I. Dumlao, MD Manageable A Support as speaker, non-financial
(PCGM) interest (Board member of non-
government organization and an
advocacy group)
Maria Eliza Ruiz R. Aguila, PhD Manageable A Non-financial interest (official function in
(UP-CAMP) a government agency, outcome of CPG
may influence CAMP clinic
Robert D. Buenaventura, MD Manageable A Support as speaker, non-financial
(PPA) interest (co-author of published paper
related to CPG topic, Board member of
non-profit organization)
Salvador Benjamin D. Vista, MD Manageable B Employment and consulting (UPCM,
(Addiction Psychiatry) DOH), research support (WHO, USAID),
pharmaceutical lectures, commercial
business, CGP topic authorship, trainer,
and board member
Venus S. Arain, MD, DPBP, FPPA, Manageable A Non-financial interest (Board member of
(PMHA) non-profit organization)
Viel D.S. Mendoza (ADAP) Manageable A No conflict of interest declared.
201
EXTERNAL REVIEW
Methods
An external review was conducted to gather feedback on the draft recommendations,
assess equity, acceptability, applicability, and feasibility of these recommendations,
and to disseminate the collected evidence to the external members and stakeholders.
A Google form was used for evaluation, followed by an online meeting. The copy of the
manuscript with corresponding attachments was shared to the representatives of the
Philippine College of Geriatric Medicine (PCGM) and the Alzheimer’s Disease
Association of the Philippines (ADAP) via electronic mail. They were given enough time
to review the materials and provide feedback from May 27 to June 06, 2022 via an
online external review Google form (https://forms.gle/GN3AKbohkg8kYPnFA). They
assessed equity, acceptability, applicability, and feasibility of the recommendations and
quality of evidence using a 5-point rating scale (1 as the lowest and 5 as the highest).
After accomplishing the Google form, they were convened in an online meeting on
June 25, 2022 to present and discuss the external review results for additional
comments and suggestions.
Results
A. Google Survey
A total of 9 external reviewers from the 2 organizations accomplished the Google form.
Below is the summary of the initial external review findings based on the recorded
responses:
202
Table 2. Ratings of Screening Recommendations
Mean rating
Recommendation Equity Acceptability Applicability Feasibility Quality Overall
of
evidence
1.1.: Among
asymptomatic 3.11 3.33 3.11 3.22 3.11 3.18
healthy adults aged
60 years and above,
we suggest against
screening for
dementia.
2.1.: Among the
general population,
we recommend
against screening for 3.00 2.67 2.78 2.44 2.67 2.71
substance use
disorders using
standardized drug
tests.
3.1.: Among
asymptomatic
healthy adults, we
recommend
screening for 3.22 3.11 2.67 2.56 2.78 2.87
substance use
disorder using
standardized tools at
least once a year.
4.1.: Among high-risk
healthy
asymptomatic adults,
we recommend
screening for
depression* using:
PHQ-9 for medical 3.78 3.78 3.33 3.44 3.56 3.58
students, and
healthcare workers;
CES-D among
caregivers and ill
adults; GDS-15
among older persons
*no consensus for
frequency.
5.1.: Among healthy
3.11 3.11 2.89 2.67 3.11
asymptomatic adults, 3.02
203
we recommend
screening for anxiety
and anxiety disorders
using a standardized
instrument at least
once a year.
8.1.: Among healthy
asymptomatic adults,
we suggest
screening for stress 3.44 3.44 2.89 2.78 3.22 3.15
using standardized
stress scales once a
year.
9.1.: Among
asymptomatic
apparently healthy
adults, we suggest 3.44 3.22 2.78 2.67 2.89 3.00
screening for sleep
disturbance/problems
at least once a year.
Rating scale: 1 (lowest) to 5 (highest)
A total of 7 out of the 9 external reviewers attended the meeting. The Project Leader
presented the summary of the external review results per screening question and
recommendation. The external reviewers agreed with all the Task Force’s
recommendations except for the screening for substance use disorders using
standardized tools. This is due to the concerns on feasibility of using the screening tool,
definition, privacy, and stigma on drug use.
204