When Ellen* decided she wanted to work abroad in Italy, she knew there would be plenty to prepare for. There was the normal stuff, like getting a job and sorting somewhere to live, but also another issue: how would she keep up her prescription of antidepressants? The idea of running out while living in Sicily or Treviso wasn't something the 21-year-old Liverpudlian wanted to deal with.
What Ellen didn't realise was that she might have to face exactly the same problem at home because of uncertainty around Brexit. "It's already something I'm worrying about," she tells me over the phone. "I can only get my prescription one month at a time. If it was to just stop, I wouldn't just be mildly unwell – it would be really bad."
Shortages for certain medicines are not unheard of, but Brexit has caused concerns over shortages because three-quarters of medicines come through the Channel Tunnel. This has affected the price of certain medications and can be seen in data from the Pharmaceutical Services Negotiating Committee (PSNC), an agency that applies to the government and negotiates price concessions when drugs are in short supply and become unavailable to purchase at or below the fixed monthly tariff price set by the government.
Exclusive VICE analysis of PSNC data found that 14 drugs used to treat common mental health conditions appeared on the price concession list over the period of ten months between January and October of 2019. This includes widely-used antidepressants, antipsychotics and anti-anxiety medications, such as Fluoxetine, Propranolol and Risperidone. Mental health drugs spent an average of four months on the list at a time.
Nine antidepressants showed up on the concession list over numerous months, with three medications – Citalopram, Dosulepin and Nortriptyline – appearing six times in a row between January and June. While Dosulepin and Nortriptyline are less commonly prescribed, Citalopram is one of the eight selective serotonin reuptake inhibitors (SSRIs) prescribed by the NHS to treat depression.
Other antidepressants also appear frequently on the list. Escitalopram, another SSRI, has been on the PSNC list for the last five months in a row, while the tricyclic antidepressant (TCA) Clomipramine appeared five times from January to May.
Both Lofepramine – another TCA – and Mirtazapine, an antidepressant also used to treat OCD and some anxiety disorders, showed up on the list for four months. Sertraline, another SSRI, appeared over three months.
Fluoxetine, popularly known by its brand name Prozac, appears once on the list in January, in a 20mg dosage. However, the PSNC reported a Fluoxetine shortage for 10mg, 30mg and 40mg capsules in September. The agency told VICE they're just not on the concession list – the PSNC might not grant a price concession if there is simply no product available to buy.
Three atypical antipsychotic drugs, Olanzapine, Risperidone and Quetiapine, appear on the concessions list over numerous months. Quetiapine – used to treat schizophrenia, bipolar disorder and major depressive disorders – is the mental health drug that shows up most frequently. It was on the list for seven consecutive months, up until July of this year.
Risperidone, also used for schizophrenia and bipolar disorder, appears from January to March this year. Olanzapine, a drug that can be used to treat the early stages of schizophrenia, as well as bipolar disorders, shows up twice on the list for March and April.
Two anti-anxiety meds also appear on the concessions list: Propranolol, a beta blocker used for anxiety, shows up twice, while Buspirone – used to treat general anxiety disorders – once. Although Propranolol is listed twice in a 80mg dosage, this specific dose is used to treat heart problems and is larger than that usually prescribed for anxiety. However, the PSNC told VICE that this may place additional pressure on other dosages of the drug. If pharmacists are unable to provide a certain dosage, they may suggest patients take pills containing a different dose, meaning other dosages may be in higher demand as a result.
Many drugs listed are only in short supply for certain dosages. While Fluoxetine is unavailable in 10mg, 30mg and 40mg capsules, it may be possible to still source 10mg tablets from a different manufacturer, according to the PSNC.
But there are many drugs where most – if not all – dosages were listed on the concessions list. All of the capsule dosages available for the antidepressant Escitalopram have appeared on the concession list for five months, from May to September.
Ellen's antidepressants and anti-anxiety medications have all appeared on the concessions list – a combination of drugs that have taken years for her to get right. "When I've changed medications in the past, I know the doctors can say it takes six weeks to get used to it, but for me it just takes months, and those months are the most serious depressive episodes."
In the past, Ellen has switched drugs by weaning herself off them. If her prescribed medication becomes unavailable, she’s worried at the prospect of having to abruptly move on to another drug. "I've not done that before, but what I can say from having being weaned off and then introduced to something… I can just imagine it would be a rollercoaster inside your body."
Changing your antidepressants and antipsychotics isn't straightforward. Doctors recommend "tapering off" a certain type while introducing another. A sudden shortage could come with dire side effects, even if other antidepressant medications are available. Experts also warn that switching off atypical antipsychotic drugs – the more recent type of antipsychotic drugs, developed in the 1990s – can be particularly dangerous and can intensify the symptoms of the mental health condition if not tapered off correctly.
"I read the news and listen to the news, and there's not a day that goes by where I don't think, 'Oh god, I could be left without this.' It could kill me."
"You can't just abruptly stop these types of medications," Ian Hamilton, a senior lecturer in addiction and mental health at the University of York, tells me over the phone. "You can't go from taking them daily to not having any. You need a slow reduction that can take weeks, if not months. The reason for that is that you can get a rebound of depression if it's antidepressants you're on, or psychosis if it's an atypical antipsychotics."
It can already be hard enough to get extremely vulnerable people to take the right medication in the first place. "Sometimes it takes a huge amount of work to get the person to agree to take it and take it the way they're meant to," says Hamilton. "So anything that jeopardises that – and particularly something that's avoidable, like Brexit – that's a real tragedy."
He adds: "We haven't got the infrastructure to cope with the fallout from this, because of austerity. Mental health services, despite what the government says, have been cut to the bone."
Ryan*, who grew up in Newcastle, has been on antidepressants since he was 15 and is aware of the difficult side effects associated with changing prescriptions. “I know what it's like to come off of the medication,” he tells me on the phone. “It makes me very depressed, suicidal, feeling like life's not worth it. I get very anxious and it frightens me to think [a shortage] could actually happen.”
He says he has bought up the issue with his GP and suggested stockpiling, but was told that it was not likely to be that bad. “But with all the news that has come out,” he tells me, “and I have seen that Sertraline is on shortage lists, I kind of feel like I’m being misled a bit.”
“I think about it quite a bit because Brexit is just a huge, never ending thing and it's been on the news all the time,” he adds. “I'm very politically aware and I read the news and listen to the news, and there's not a day that goes by where I don't think, ‘Oh god, I could be left without this.’ It could kill me.”
Earlier this year, PSNC chief executive Simon Dukes released a statement linking medicine shortages to Brexit. “Community pharmacies are facing significant problems sourcing a large number of medicines at the moment,” he said. “While medicines supply issues are not a new problem, uncertainty around Brexit and contingency planning may be compounding the issues.”
However, mental health charity Mind are reticent to definitively link shortages to Brexit. Stephen Buckley, the head of information at the charity, told VICE: “We know it can be really difficult to find the right treatment or combination of treatments to help manage a mental health problem, so we understand why people might be particularly concerned at the moment with so much discussion about supply shortage because of Brexit.”
“The supply of different medication to the UK is constantly fluctuating due to a range of reasons including increased global demand, the price of raw materials and new legal restrictions driving up prices,” he added. “We've been assured that medicine supply is a government priority and that everything is hand, but we will regularly seek updates from the Department of Health and Social Care as things progress.”
While many are worried about the potential for shortages, some taking matters into their own hands. Dannie, a first year uni student in Newcastle, has been stockpiling a small amount of their antidepressant, Sertraline, for the last year. “I don't want to mess the NHS around too much, so from each month's prescription amount I keep maybe a week's worth of tablets back,” they tell me. “I'm not convinced the country can cope in terms of medical supply; I know from my last experience [of switching medication] that it is a very rough experience.”
The pharmacy Dannie collects their medication from has a sign indicating that patients should expect some shortages towards the end of this month. “I read the [Operation Yellowhammer] report on the day it came out and that sort of confirmed my worst fears,” they add. “From that point, I stepped up my stockpiling because the deadline is getting closer and it's looking more and more likely to be no deal.”
While politicians go back and forth over progress motions and threaten a general election, the lives of young people struggling with mental health issues are at risk. Although MPs deny that this is down to Brexit, the UK government recently introduced a ban on certain drug exports to protect NHS patients from shortages, while Operation Yellowhammer, a leaked report on the consequences of leaving the EU on the 31st of October, details extensive medical shortages.
Tthis month, the Department of Health and Social Care also released the first ever serious shortage protocol to deal with medicine shortages, allowing pharmacists to prescribe alternate dosages if they run out of the patient’s prescribed amount. The first for the protocol to be applied to? Fluoxetine.
A spokesperson for the Department of Health and Social Care told VICE: “We fully understand the concerns some people have about the availability of medicines, however there is no evidence of any supply shortages being related to Brexit.”
“Patients should be reassured that we are doing everything we can to help ensure they can access the treatments they need when we leave the EU, whatever the circumstances,” they added. “The Department has been preparing extensively and has full plans in place for the supply of medicines and medical products after Brexit.’’
The Department of Health and Social Care claim that Brexit has nothing to do with shortages, but others disagree. They say the stakes are too high for Brexit to get in the way of people’s mental health. “These are serious conditions, particularly depression,” Hamilton, who worked as a mental health nurse before becoming an academic, tells me. “People who are depressed, some will be suicidal, so the worst thing you want is someone to be denied treatment or medication which is essentially keeping them alive and stopping them harming themselves.”
“The worst possible outcome is death.”
* Some names have been changed in this piece.
UPDATE 31/10/19: An earlier version of this article said that the Pharmaceutical Services Negotiating Committee was "an agency that grants price concessions." This has now been corrected to, "an agency that applies to the government and negotiates price concessions."