What caused the shortage of mental health medicine in PH?

I n March, my antidepressant Cymbalta (generic name: Duloxetine) was about to run out and so I whipped out my phone, expecting to do what I have done so many times before: message a nearby Mercury Drug on Viber, send my prescription and place an order, pay via GCash and have it picked up by Grab. But instead, I got this reply: “Wala po kami available na Cymbalta.”

Not a problem. I messaged a different Mercury branch.

“Yung Cymbalta not available po as of now.”

And another.

“Wala po kaming Cymbalta 60 mg.”

I messaged and called what felt like a hundred Mercury Drug branches and reached out to other drugstores, but none of them had stocks of my medicine.

I called the drugstores inside the biggest hospitals and they didn’t have it. I called the pharmacy of the Philippine Center for Mental Health—surely they’d have it, right? But they didn’t either. I took a deep breath, trying to quell the panic that was building inside of me, and turned to Facebook. Soon, I started receiving comments and messages.

Among the messages from friends who wanted to help were from people telling me that they or people they loved were facing the same issue.

Out of stock

“Pati Rivotril (generic name: Clonazepam) out of stock. Pahirapan these days ang psych meds,” someone else said, while another person commented about how impossible it’s been to get other medicines.

Friends reached out to Mercury Drug branches near them—Makati, Mandaluyong, Parañaque, Batangas, Quezon City—asking if they had my meds. Others—even those abroad—offered to try and see if they can find stocks and ship them to me. Many bugged their doctor and med rep friends. My mother started messaging everyone she knows. My aunt and even her boyfriend, who lives thousands of miles away, tried to find replenishment. I was touched by their kindness. But I was also livid. It shouldn’t take a village to buy your medicine. Refilling your prescription shouldn’t be this difficult.

Some people suggested other antidepressants, but switching meds isn’t that simple. It’s an involved process that shouldn’t be done without the guidance of your psychiatrist.

A friend gave me the number of Mercury’s hotline. They can check availability anywhere in the country, he said. I called the hotline and was told there were barely any stocks in Metro Manila—there were more in Visayas and Mindanao. “Nothing closer?” I asked. They found capsules for me in Novaliches. I quickly paid through GCash and booked a Grab.

I was good—at least for a few weeks. But I continued to receive messages from people who, like me, were unhappy about the fact that certain medicines have become difficult to access.

And it’s not just people I know.

A quick online search yields posts from people all over the country complaining about being unable to purchase their medicine, many of which were prescribed for mental health issues like depression and anxiety. You can sense the desperation from the posts.

Can you imagine having anxiety issues and getting even more anxious because you can’t get the medicines you need? It’s ridiculous.

Alternative medsThere were even posts about how the alternative meds their doctors have prescribed have also gone out of stock.

Some talked about the withdrawal symptoms they felt after going days without their prescription. Psych meds shouldn’t be stopped just like that—you’re supposed to taper your dose slowly (again, with the guidance of your doctor). Some even warned that they might harm themselves if they couldn’t get access to their meds.

It’s difficult enough to get people to commit to taking meds for mental health issues. There’s stigma around it, patients often feel ashamed and hate having to depend on medication just to feel as “normal” as possible. I should know—it took me a while to accept that these medicines were going to become a regular part of my life. If we need to keep jumping through hoops just to buy medicine, I can totally imagine some patients just shrugging and saying, “Wala pala eh, di ‘wag na.” And that could be a very dangerous thing.

“It is a problem,” said Dr. Corazon Angela Cuadro, a psychiatrist, back in March, telling Lifestyle that the shortage of medicines had been going on for some time. “There have been difficulties with medication stocks in the past, but especially over the past several months. I don’t know if this awareness is conditioned or magnified by the recent shortage of ADHD (attention deficit hyperactivity disorder) meds in particular. We encounter this as patients, as doctors, as hospital employees, as caregivers, as loved ones caring for loved ones panicking about missed medications.”

Dr. Cuadro explained that when they recommend pharmacologic treatment, the effectiveness of a particular medicine isn’t the only consideration. “As significant are pharmacoeconomics, side effects, which vary per individual, patients’ comorbid conditions, other medications being taken hence anticipated drug interactions, etc.,” she said. This meticulous process has also been affected by shortage issues.

Dr. Cuadro shared, “In my experience, if patient/family and I are planning for initiation of medications, I tell them about current difficulties with stocks, and that consequently, we admittedly are opting for second-line or third-line alternatives given the lack of stocks.”

Meanwhile, for patients who have already been taking meds and then find themselves unable to get access, “We plan for 1) alternative brands, 2) exploring drug stores branches, 3) coordinating with pharma company/distributor, 4) shifting to alternate meds. These are not exclusive of one another; almost always, we plan for these concurrently. We, of course, also discuss what to anticipate—possible discontinuation, initiation or reinitiation effects and timeline of these observed phenomena, how to shift from one medication to another, possible effects on the symptoms we have been trying to manage. We also discuss how the patient/family feels about our options.”

Wanting to understand what was causing the shortage and what could be done about it, I reached out to the Department of Health (DOH), the Food and Drug Administration and even the Department of Trade and Industry. While I received initial responses, when it came to really scheduling the interviews, I got nothing. For weeks, nothing. I tried following up, and nothing. DOH’s bakuna jingle kept blasting in my ears as I waited for someone to talk to me, and still, nothing.

In the meantime, my stocks of Cymbalta ran out again. This time, a friend from grade school came to my rescue—she had five capsules left in her pill box, she no longer needed them and so she gave them to me.

And when those ran out, I began the search again.

Solutions

“Paano pag wala talaga?” my mother, who had been worrying about this for weeks and weeks, kept asking.

I told her I had three choices: one, use the generic version Loxx; two, drink two 30-milligram capsules of Cymbalta instead of one 60-mg capsule every day; or three, talk to my doctor and switch to a different medication.

None of these solutions are ideal. I already tried another generic version of Cymbalta some years back but my doctor eventually switched me back to Cymbalta because it just didn’t work well for me.

One 60-mg capsule of Cymbalta costs P128.75. One 30-mg capsule of Cymbalta costs P128.75. Yes, they’re the same price, I don’t understand it either. That would mean my medicine budget would have to double.

The third option, switching to a new medication, will mean the possibility of dealing with withdrawal symptoms, new side effects and then waiting weeks for my body to adjust to the new meds.

A few months ago, Mercury Drug’s hotline operator told me that there were possible stocks of Cymbalta in Bacolod, Cagayan de Oro and Cebu. But they weren’t sure—I had to check with the branches. Then, they gave me a glimmer of hope: there was a box available in Greenhills!

I called the branch quickly but was told that I couldn’t buy it. The box of Cymbalta was someone else’s—in fact, they had sourced the medicine from Cebu for that regular customer. They said they’d try to find stocks for me, but I didn’t hear from them again.

I threw my hands up and bought Loxx. It will have to do, I told myself, it’s better than nothing. But then, in May, I decided to call Mercury’s hotline again. There were stocks in BGC, I was told. I bought several boxes—each one good for 28 days. It was a big bill, the most amount of money I’ve spent on my antidepressants in one go, but it’s the price I’ve had to pay for peace of mind. At least I wouldn’t have to worry about running out of meds for a few months.

I wondered—is this a global problem? Is this a Philippine problem? I reached out to Lilly, the international pharmaceutical company that manufactures Cymbalta.

Their associate director for media relations replied, “Lilly can confirm there are no shortages of Cymbalta in the Philippines. Patients who may have difficulty accessing the medication should contact their primary provider.”

So what was the problem?

Production delays

It might be a different case for Rivotril, as I’ve read online that patients in Ireland have had difficulty getting their hands on this medicine, too. This was an update on the website of Parkinson’s Association of Ireland: “We have received information that the shortages are due to production delays caused by the manufacturing site not receiving the packaging materials required to make the product.”

This month, I’m glad to report that Cymbalta and Rivotril seem to be available in our drugstores again. But I still wanted to understand the cause of the shortage in hopes of preventing it from happening again.

I tried reaching out to more experts about the shortage and heard from Dr. Diana M. Edralin, general manager of Roche who, along with Marian Pausanos, public affairs and communications director for the Pharmaceutical and Healthcare Association of the Philippines (PHAP), and PHAP members answered my questions.

Here’s what they said.

What factors have been contributing to the shortage of medicines particularly those prescribed to mental health patients?

A number of factors could contribute to the shortage of medicines in any country. Rapid changes in health, economic and geopolitical developments could result in drug shortages. Manufacturing concerns, supply chain disruptions, increased demand, and regulatory requirements could also affect medicine supply. Due to these multiple factors, PHAP members exert all efforts to minimize supply disruptions through close coordination with manufacturers located worldwide, regulatory agencies, healthcare professionals, and patient organizations.

Due to a shortage of the product in Spain, where the manufacturer of a specific brand of clonazepam is located, the health authority there had banned all export permits for this drug until the market was supplied with sufficient stocks. The low stock level in Spain had been caused by a lot of artwork changes due to the transfer of the product from one manufacturer to another, which implementation caused a backlog in the manufacturing campaigns scheduled for goods in Spanish livery. This situation has since been fully resolved and regular supply is ongoing since early 2023.

As for duloxetine, stock replenishment is ongoing for a brand of this drug, and that there are currently sufficient stocks for its 60 mg dosage form.

The PHAP Code of Practice prohibits direct-to-consumer communication of prescription drugs. Thus, we can only mention the generic name of these products for purposes of this media inquiry.

Who determines the inventory/orders of medicines that come into or become available in the country? The inventory or orders of medicines coming into the country is primarily determined or forecasted according to need—historical use and projected use. As the Philippine pharmaceutical system is majority a private market, determining supply is done by the pharmaceutical company, while the national government through the Department of Health and the individual local government unit conducts its own supply management for public facilities.

For highly in-demand medicines and limited supply, such as COVID-19 technologies, there is coordination among the government, private healthcare service providers, and those who administrate over treating patients with the manufacturers, distributors, or even the parts of government that regulate and enable bringing medicines and/or healthcare devices into the country.

Planning, policy, and coordination are proven ways to ensure the supply of medicines and other healthcare solutions. As with many countries with universal healthcare systems in place, or where the government takes a central role in bringing access to medicines to the people, PHAP strongly advocates for the national government to project the needs of the country for important medicines as well as to secure multi-year contracts with reliable, quality suppliers. In this strategy, which is already implemented in other countries, the government is able to secure supply for many years by contracting with reliable suppliers that are able to deliver quality medicines to the people. Also, the price of medicines are made lower as these manufacturers supply in volumes to different countries.

Has there been an unusual spike in the demand for these medications?We were informed that there was an unusual demand spike for duloxetine in February, but stock replenishment is ongoing. As mentioned, there are currently sufficient stocks for its 60 mg dosage form.

It is important to emphasize that when there is a multi-year forecast and adequate stockpiling for the near term, there would be less likelihood of a country being affected by unusual events.

In the field of mental health, or other relatively chronic diseases like diabetes, age-related conditions, or cancer, the country would have enough experts to be able to forecast the medical needs and plan correctly. These experts may be sitting currently in the private sector, academe, or in government. It is to the country’s advantage to establish a platform for greater public and private collaborations on medicine supply security. Also important is the need to contract for the medicines by securing sustainable funding through policies.

What would you like to tell patients who’ve been having difficulty getting access to the medicines they need in the past months?We understand the feelings of patients and their families whenever they have difficulties gaining access to needed medicines. Especially during the pandemic, even those employed in the pharmaceutical industry had to find ways to source the medicines that they needed.

Our communication lines remain open in providing additional information and concerns they have on their prescribed medicines. PHAP members are constantly working with both public and private stakeholders to provide immediate responses to these shortages to provide much-needed relief for patients in the near term but also support the government to achieve medicine security for the long term.

What can be done to ensure that people have a supply of the medications they need?PHAP is one of the stakeholders involved and consulted in the crafting of the DOH’s Philippine Medicines Policy (PMP) 2023-2030.

First, it is crucial to build health systems that can provide medicines to the people for the longer term by proper forecasting and contracting. Multi-year forecasting and contracting can help secure medicines in longer terms and at lower volume prices.

Second, it is important to provide needed medicines that respond to the real needs of the patients. These medicines must be made available through a faster registration process as the Food and Drug Administration provides now, inclusion in Philippine National Formulary, and covered by PhilHealth benefits or procured through DOH medicine access programs.

The Health Technology Assessment Council review processes must be expedited to allow the faster inclusion of life-saving medicines into the Philippine National Formulary, so that public facilities—like their private counterparts—can make these medicines available in their shelves, and provide access support for these—either for free or at lower prices—through PhilHealth or their own procurement.

Finally, there will be a need for constant communication and partnerships among the government, pharmaceutical industry, healthcare providers, and patient organizations among others in preparation for any sudden disruptions in medicine supply.