By JUSTIN BONCODIN, CAREESE CHONG, ALEX CULLA, and BEATRICE DAVID
Bulatlat.com

Kert Tandog, 35, wakes up before sunrise once a month to go to their doctor’s appointment. They travel from Kabacan, Cotabato to Davao City for four hours for their consultation with their psychiatrist that lasts for only an hour.

They would travel more than 100 kilometers and endure commuting just to meet their doctor.

Kert was diagnosed with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder. They were misdiagnosed with bipolar disorder for 13 years before consulting with their current psychiatrist, the ninth they have seen so far.

ADHD is a developmental disorder that causes people to have difficulties in focusing, controlling their energy or managing their impulses. It is commonly diagnosed in children, but recent studies have shown that prevalence of ADHD symptoms among adults is increasing globally.

In the Western Pacific Region, which includes the Philippines, symptoms of ADHD are common in 9.67 percent of adults. There is no national data yet for the number of Filipino adults diagnosed with ADHD, but the National Survey for Mental Health and Well-being (NSMHW) shows that it is prevalent in 1.29 percent of Filipino children.

ADHD symptoms can be treated with medications, behavioral and cognitive-behavioral therapies, computer-based cognitive training and neurofeedback, supplements, diet, and exercise. 

In Kert’s case, their treatment includes various medications since they are diagnosed with multiple mental health conditions.

However, Kert and other Filipino adults with ADHD currently struggle with uncertain access to their medications due to high prices and limited supply.

High-priced medications

Every month, Kert’s family would spend around P20,000 ($348.52) for their mental health medications only. A piece of 36 milligrams of Concerta (methylphenidate hydrochloride), which Kert takes for treatment of ADHD symptoms, already costs P279 ($4.86).

Concerta is one of the most available brands with the drug formulation of methylphenidate in the Philippines. This medication is classified as a central nervous system (CNS) stimulant, which works by increasing the activity of a person’s brain so they can stay awake and alert. 

Methylphenidate is a regulated drug in the Philippines closely monitored by the Dangerous Drugs Board (DDB), in compliance with the United Nations Single Convention on Psychotropic Substances. It is also approved by the Food and Drug Administration (FDA) as an ADHD medication. 

As of this writing, there are four FDA-registered brands in the Philippines, namely Ritalin (manufactured by Novartis), Ritalin LA (manufactured by Recro Gainesville), Concerta (manufactured by Janssen), and Medikinet (manufactured by MEDICE).

However, only the first three brands are available in the Philippines. There are also non-stimulants like atomoxetine, which help a person stay alert without a drastic increase in heart rate, but are no longer in the market.  

Kert was initially prescribed with 18 milligrams of Concerta, but they and their psychiatrist realized that this had no effect. Their dose was eventually increased to 27 milligrams.

However, the new dosage is unavailable in their area, resulting in their psychiatrist upping their dosage to 36 milligrams that required further observation in their symptoms and more money for their family to shell out.

“My mother pays the entire cost of my medicines. My income alone cannot cover for it because my earnings are not constant,” Kert said in Filipino.

Alu Tabije, 21, also shared that it is her mother who provides for her mental health medications, one of which is Ritalin to treat her ADHD symptoms.

Ritalin, another brand of methylphenidate hydrochloride, is available for P90 ($1.57) per piece.

“My mind is like a radio that keeps on changing channels. When I eventually took [methylphenidate], [my mind] became quiet. I now have more control with my thoughts,” Alu said.

However, Alu said that she cannot be consistent with the intake of her medications because of its high costs. 

She would sometimes hide the fact from her mother that she already ran out of medicine, especially when they need to wait for paydays.

Inaccessible medications

Before Kert and Alu can buy methylphenidate, the Philippine government requires them to have a “yellow prescription” that must be obtained from their psychiatrist with an S-2 license issued by the Philippine Drug Enforcement Agency (PDEA).

Republic Act No. 9165 or the Comprehensive Dangerous Drugs Act of 2002 mandates that purchases of controlled substances identified by DDB must be made with a special prescription from a physician licensed by PDEA.

In a special prescription pad, the licensed physician will write only one prescribed regulated medication and include their contact number, Professional Regulation Commission (PRC) license number, PDEA S-2 license number, and their professional tax receipt (PTR) number. 

Each prescription must have a triplicate copy reserved for the patient, prescribing practitioner, and the pharmacy.

Apart from the strict regulations, Filipino ADHD patients struggle to acquire methylphenidate due to limited stocks and branches of Mercury Drug selling the medications.

Kert said that they have scoured Mercury Drug branches in Cotabato, but they did not find one that sells Concerta. And so, every month, they have to travel to Davao City to buy the ADHD medications.

“Our dad would drive us from Kabacan to Kidapawan. Then, we commute from Kidapawan to Davao. Since I experience sensory overload during the commute, there is an added disability tax when we ride the taxi in the city,” Kert recalled.

When Alu was first prescribed Ritalin, her mother went to various Mercury Drug branches, from San Jose Del Monte in Bulacan to Quezon City and Caloocan City in the evening to find stocks of her medicine. Eventually, they were able to buy Ritalin in a branch in Malolos City, Bulacan, which is more than 20 kilometers from their home.

Alu said that she has now learned her lesson, and shared that she messages Mercury Drug branches near her to ask first if they have available stocks of Ritalin. 

Bulatlat reached out to the Mercury Drug Corporation on why only a limited number of their branches sell methylphenidate in the Philippines but they declined the interview request.

Global shortage

As of November 2024, both immediate release tablets and extended release capsules of methylphenidate were reported to have a shortage according to the American Society of Health-System Pharmacists (ASHP).

The ASHP drug shortage tracker showed that the shortage on the immediate release capsules happened due to the Ritalin tablets being “divested” to Sandoz by Novartis, in which Sandoz did not provide an explanation. Janssen has Concerta extended-release capsules available but, again, Sandoz did not provide any explanation on the shortage of methylphenidate extended-release capsules and Ritalin LA capsules.

In December 2024, the Pharmaceutical Management Agency of New Zealand released a medicine notice on the methylphenidate shortage. The notice indicated that the global demand for the medication was not increasing and that there were challenges in transportation, manufacturing constraints, and quota limits.

The US Drug Enforcement Administration ordered a revision on the 2023 Aggregation Production Quota for methylphenidate from 41,800 kg to 54,283 kg in September 2023. 

Pharmacist Jarvin Tan said that the so-called production quotas in the United States of America is one of the factors that affects the stocks of methylphenidate. 

Tan added that methylphenidate is not included in the World Health Organization’s (WHO) Essential Medicine List, which could be another reason for the global shortage. “If WHO will include that in their own essential medicines list, other governments will take that as a good basis to include it in theirs.”

The Philippine National Formulary includes methylphenidate as an essential medicine in the country. But it is not listed in the 2024 Drug Price Reference Index (DPRI) which protects consumers from excessive mark-ups. Controlled substances like benzodiazepines Alprazolam, Clonazepam, Diazepam, Midazolam, and barbiturate Phenobarbital are all part of the DPRI.

Some of the substances listed in the DPRI are also included in DOH’s Medicine Access Program for Mental Health (MAP-MH). Still, methylphenidate is not included.

Tan said that the controlled drug is not yet procured for free distribution because it is a dangerous drug. “Yes, I will not deny that there is a risk of addiction [for methylphenidate], but have [they] not considered also the risk of developing addiction behaviors for people with ADHD who do not take medicines?”

The World Federation of ADHD, in its 2020 petition to include methylphenidate in the WHO’s list, cited 208 evidence-based conclusions in support from 27 counties and 6 continents. It showed that use of methylphenidate in ADHD led to better academic performance, lower crime rates, decrease injury and accident rates, and reduced risk of depression and suicide.

However, this would mark the second attempt after being rejected by WHO in February 2022 “due to uncertainties in the estimates of benefit of the medication.”

Bulatlat asked the Food and Drug Administration (FDA) and the Bureau of Customs regarding the methylphenidate imported in the country and they have not yet replied as of writing.

Costs of no medications

The shortage problem poses another dilemma, forcing patients to either lessen their intake of prescribed medicine or not take it at all. 

Psychiatrist and public mental health expert Dinah Nadera warned about the possibility of experiencing a discontinuation syndrome when patients suddenly stop taking their maintenance medications. 

“The discontinuation syndrome will make this person experience more severe symptoms… That’s why others think that [the medications are] addicting. Because if you don’t have it, you cannot function, which is definitely not true,” Nadera said in a mix of English and Filipino.

Alu similarly experienced this when she put some of her medicine aside to save for days when it would be needed more. However, she felt the adverse effects of skipping the medicine on her body. 

“When I skip the medication, I can really feel the difference… It’s like I am a zombie,” Alu said in Filipino.

This is not the only effect patients should watch out for, Nadera said, as it also causes indirect mental distress for the patients. They may be more prone to developing anxiety when they are unable to purchase their medicine. 

“It’s really anxiety-inducing. You cannot get an appointment [instantly]. If you can get an appointment, you’ll pay for a 15-minute consultation to get that prescription and then you cannot buy the prescription,” Nadera said.

One of the goals set by the Philippine Council for Mental Health (PCMH) Strategic Framework for 2024 to 2028 is for the national government to provide available and affordable medicines for mental, neurological, and substance use (MNS) disorders.

While doctors who offer health services at the municipal level are being trained to assess and diagnose ADHD, treatment can only be done by specialists such as psychiatrists.

Treatment of ADHD symptoms is a “combination of behavioral therapy and medications”, but the high costs of mental health services leads many Filipinos to deny altogether that they are experiencing symptoms of a mental illness. 

The NSMHW also found poverty as one of the causes that Filipino adults are unable to access mental, neurological, and substance abuse (MNS) disorders medications, along with the lack of awareness, treatment facilities, and trained professionals.

Bulatlat asked the Department of Health for comments but there is no response as of press time.

For Kert who has to traverse mountains each month just to reach the nearest drug store that sells their medicine for ADHD, they often compromise. There would be instances they would ration the medicine just to get by. 

“I need to really assess whether I should do my work today. I need to plan. Since I have ADHD, I find it hard to make plans. Now I need to plan for my medications, especially when I think it is optimal to take it,” they said. (RTS, RVO)

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Help is available. If you or someone you know is in need of mental health assistance, please reach out to the National Center for Mental Health (NCMH). You may reach their crisis hotline by dialing 1553 (Luzon-wide, toll-free landline number), 0917-899-8727 or 0966-351-4518 (for Globe and TM subscribers), and 0908-639-2672 (for Smart and Sun subscribers).

The authors are journalism students from the University of the Philippines Diliman. An earlier version of this story was submitted for Journalism 105 (Investigative Reporting) class under Assistant Professor Karol Ilagan.

Consistent with our stand for inclusivity, Bulatlat uses the preferred pronouns of our sources, including the ‘they/them/their’ pronouns for those who do not identify within the gender binary.