THE COST OF MENTAL HEALTH IN UKRAINE The Review of Privately and Publicly Procured Medicines and Dietary Supplements (2015–2019) Authors: Oleksii Sukhovii, Olga Khan, Olena Doroshenko, Vrishali Shekhar RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. © 2022 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. | 1 ACKNOWLEDGMENTS This study was prepared by a team led by Olena Doroshenko (Senior Economist, Health, HECHN). The core team members were Oleksii Sukhovii (Consultant, World Bank), Olga Khan (Consultant, World Bank), and Vrishali Shekar (Consultant, World Bank). The study was prepared under the oversight and management of Tania Dmytraczenko (Practice Manager, HECHN). The team bene ted from excellent comments from the peer reviewers, Moulay Driss Zine Eddine El Idrissi (Lead Economist, Health, HECHN) and Ana Mercado (Senior Health Specialist, Health, HECHN). The report was prepared with the support of the Swiss Agency for Development and Cooperation in the ‘Support to Reforms and Governance in the Health Sector’ project implemented by the World Bank and in partnership with the Safe, A ordable, and E ec- tive Medicines for Ukrainians (SAFEMed) Project, nanced by the United States Agency for International Development (USAID). The primary source of information was the data provided by Support in Market Development (SMD) company through its collaboration with the SAFEMed Project. 2 | ACKNOWLEDGMENTS TABLE OF CONTENTS Acronyms 14 Executive Summary 15 1. Introduction 18 2. Mental Health Situation in Ukraine 20 2.1 Legislation 20 2.2 Mental Health Indicators 20 2.2.1 Mental disorders due to alcohol use 21 2.2.2 Schizophrenia disorders 21 2.2.3 Mood (a ective) disorders 21 2.2.4 Neurotic disorders 22 2.2.5 Dementia 22 2.3 Financing and Cost of Mental Health 25 2.4 Service Delivery for Mental Health in Ukraine 27 2.5 Categorization of Psychotropic Medicines 28 2.6 Standardization of the use of medicines in the eld of mental health 29 2.6.1 Use of the State Formulary of Medicines 29 2.6.2 Use of other industry standards for medicines 30 2.6.3 National List of Essential Medicines 31 2.6.4 Involvement of PHC providers 31 2.7 Cost on Medicines for Mental Health 32 TABLE OF CONTENTS | 3 3. Methodology 34 4. Overview of the Results 35 5. Results and Discussion 36 5.1 Medicines Used Mainly for Treatment of Persons with Mental Disorders 36 5.1.1 Antipsychotic medicines (N05A according to ATC classi cation) 38 5.1.2 Antianxiety medicines (N05B according to ATC classi cation) 41 5.1.3 Antidepressants (N06A according to ATC classi cation) 42 5.1.4 Medicines used in the treatment of dementia (N06D according to ATC classi cation) 44 5.1.5 Medicines used in the treatment of alcohol addiction (N07BB according to ATC classi cation) 45 5.1.6 Medicines used in the treatment of opioid addiction (N07BC according to ATC classi cation) 47 5.1.7 Medicines used in the treatment of nicotine addiction (N07BA according to ATC classi cation) 48 5.2 Medicines That Can Be Used to Treat Persons with Mental Disorders 49 5.2.1 Nootropic and psychostimulant medicines (N06B according to ATC classi cation) 53 5.2.2 Hypnotics and sedatives (N05C according to ATC classi cation) 54 5.2.3 Antiepileptic medicines (N03 according to ATC classi cation) 56 5.2.4 Antiparkinsonian medicines (N04 according to ATC classi cation) 58 5.2.5 Other medicines that can be used in the treatment of persons with mental disorders 59 4 | TABLE OF CONTENTS 5.3 Dietary Supplements That May Be Associated with Mental Health Treatment 61 5.3.1 Dietary supplements that may be associated with CNS activity 63 5.3.2 Dietary supplements that may be used in connection with alcohol consumption 63 5.3.3 Dietary supplements that can be used in connection with smoking 63 6. Key Challenges 64 7. Recommendations 66 8. Conclusion 68 ANNEXES 69 Annex 1. Methodology 69 Annex 2. Financing of Mental Health System 71 Annex 3. Statistics with Regard to Mental Health Care Indicators 72 Annex 4. Medicines Used Mainly for Treatment of Persons with Mental Disorders 78 Annex 5. Medicines That Can Be Used to Treat Persons with Mental Disorders 121 Annex 6. Dietary Supplements That May Be Associated with Mental Health Treatment 165 Annex 7. Standardization of the Use of Medicines in the Field of Mental Health 176 TABLE OF CONTENTS | 5 LIST OF FIGURES Figure 1. Persons who started outpatient psychiatric care with a newly diagnosed mental disorder (2019) 23 Figure 2. Persons receiving outpatient psychiatric care as of the end of the year (2019) 23 Figure 3. Persons who received inpatient psychiatric care (2019) 24 Figure 4. Bed-days spent by patients per year in inpatient psychiatric care (2019) 24 Figure 5. Funding of psychiatric care facilities under the PMG in Q2–Q4 2020 26 Figure 6. Mental health expenditure in % of total health care funding 27 Figure 7. Signi cant di erences between groups of medicines in terms of their availability in the State Formulary of Medicines 30 Figure 8. Procurement of medicines among those analyzed in this study - in PHC facilities 32 Figure 9. Expenditures on medicines associated with mental health disorders in 2019 in Ukraine (UAH, billions) 33 Figure 10. The cost of mental health in Ukraine (direct costs) 33 Figure 11. Medicines used mainly for treatment of persons with mental disorders: pharmacy sales and public procurement of separate groups of medicines 39 Figure 12. Medicines that can be used to treat persons with mental disorders: pharmacy sales and public procurement of separate groups of medicines 52 Figure 13. Dietary supplements that may be associated with mental health treatment: pharmacy sales and public procurement of separate groups of dietary supplements 62 Figure 4.1. Pharmacy sales of medicines available in the State Formulary of Medicines (% of all medicines in the section used mainly for treatment of persons with mental disorders) 78 Figure 4.2. Public procurement of medicines available in the State Formulary of Medicines (% of all medicines in the section used mainly for treatment of persons with mental disorders) 78 Figure 4.3. Total volume of pharmacy sales and public procurement of medicines used mainly for treatment of persons with mental disorders 79 Figure 4.4. Volumes of pharmacy sales and public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (packages) 79 Figure 4.5. Volumes of pharmacy sales and public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (UAH) 80 Figure 4.6. Volumes of pharmacy sales and public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (USD) 80 6 | LIST OF FIGURES Figure 4.7. Volumes of pharmacy sales of medicines used mainly for treatment of persons with mental disorders 81 Figure 4.8. Volumes of pharmacy sales of separate groups of medicines used mainly for treatment of persons with mental disorders (packages) 81 Figure 4.9. Volumes of pharmacy sales of separate groups of medicines used mainly for treatment of persons with mental disorders (UAH) 82 Figure 4.10. Volumes of pharmacy sales of separate groups of medicines used mainly for treatment of persons with mental disorders (USD) 82 Figure 4.11. Volumes of public procurement of medicines used mainly for treatment of persons with mental disorders 83 Figure 4.12. Volumes of public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (packages) 83 Figure 4.13. Volumes of public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (UAH) 84 Figure 4.14. Volumes of public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (USD) 84 Figure 4.15. Aggregate indicators of pharmacy sales and public procurement of antipsychotic medicines 85 Figure 4.16. Sales volumes of antipsychotic medicines 85 Figure 4.17. Sales volumes of antipsychotic medicines, according to INN (packages) 86 Figure 4.18. Sales volumes of antipsychotic medicines, according to INN (UAH) 87 Figure 4.19. Sales volumes of antipsychotic medicines, according to INN (USD) 88 Figure 4.20. Volumes of public procurement of antipsychotic medicines 89 Figure 4.21. Volumes of public procurement of antipsychotic medicines according to INN (packages) 90 Figure 4.22. Volumes of public procurement of antipsychotic medicines according to INN (UAH) 91 Figure 4.23. Volumes of public procurement of antipsychotic medicines according to INN (USD) 92 Figure 4.24. Total indicators of pharmacy sales and public procurement of antianxiety medicines 93 Figure 4.25. Sales volumes of the group of antianxiety medicines 93 Figure 4.26. Sales volumes of antianxiety medicines according to INN (packages) 94 Figure 4.27. Sales volumes of antianxiety medicines according to INN (UAH) 95 Figure 4.28. Sales volumes of antianxiety medicines according to INN (USD) 95 Figure 4.29. Volumes of public procurement of antianxiety medicines 96 Figure 4.30. Volumes of public procurement of antianxiety medicines according to INN (packages) 96 LIST OF FIGURES | 7 Figure 4.31. Volumes of public procurement of antianxiety medicines according to INN (UAH) 97 Figure 4.32. Volumes of public procurement of antianxiety medicines according to INN (USD) 98 Figure 4.33. Total volume of pharmacy sales and public procurement of antidepressants 99 Figure 4.34. Sales volumes of the group of antidepressants 99 Figure 4.35. Sales volumes of antidepressants according to INN (packages) 100 Figure 4.36. Sales volumes of antidepressants according to INN (UAH) 101 Figure 4.37. Sales volumes of antidepressants according to INN (USD) 102 Figure 4.38. Volumes of public procurement of antidepressants 103 Figure 4.39. Volumes of public procurement of antidepressants according to INN (packages) 104 Figure 4.40. Volumes of public procurement of antidepressants according to INN (UAH) 105 Figure 4.41. Volumes of public procurement of antidepressants according to INN (USD) 106 Figure 4.42. Total volume of pharmacy sales and public procurement of medicines used in the treatment of dementia 107 Figure 4.43. Sales volumes of the group of medicines used in the treatment of dementia 107 Figure 4.44. Sales volumes of medicines used in the treatment of dementia according to INN (packages) 108 Figure 4.45. Sales volumes of medicines used in the treatment of dementia according to INN (UAH) 108 Figure 4.46. Sales volumes of medicines used in the treatment of dementia according to INN (USD) 108 Figure 4.47. Volumes of public procurement of medicines used in the treatment of dementia 109 Figure 4.48. Volumes of public procurement of medicines used in the treatment of dementia according to INN (packages) 109 Figure 4.49. Volumes of public procurement of medicines used in the treatment of dementia according to INN (UAH) 110 Figure 4.50. Volumes of public procurement of medicines used in the treatment of dementia according to INN (USD) 110 Figure 4.51. Total volume of pharmacy sales and public procurement of medicines used in the treatment of alcohol addiction 111 Figure 4.52. Sales volumes of the group of medicines used in the treatment of alcohol addiction 111 8 | LIST OF FIGURES Figure 4.53. Sales volumes of medicines used in the treatment of alcohol addiction according to INN (packages) 112 Figure 4.54. Sales volumes of medicines used in the treatment of alcohol addiction according to INN (UAH) 112 Figure 4.55. Sales volumes of medicines used in the treatment of alcohol addiction according to INN (USD) 113 Figure 4.56. Volumes of public procurement of group of medicines used in the treatment of alcohol addiction 113 Figure 4.57. Volumes of public procurement of medicines used in the treatment of alcohol addiction according to INN (packages) 114 Figure 4.58. Volumes of public procurement of medicines used in the treatment of alcohol addiction according to INN (UAH) 114 Figure 4.59. Volumes of public procurement of medicines used in the treatment of alcohol addiction according to INN (USD) 114 Figure 4.60. Total volume of pharmacy sales and public procurement of medicines used in the treatment of opioid addiction 115 Figure 4.61. Sales volumes of the group of medicines used in the treatment of opioid addiction 115 Figure 4.62. Sales volumes of medicines used in the treatment of opioid addiction according to INN (packages) 116 Figure 4.63. Sales volumes of medicines used in the treatment of opioid addiction according to INN (UAH) 116 Figure 4.64. Sales volumes of medicines used in the treatment of opioid addiction according to INN (USD) 116 Figure 4.65. Volumes of public procurement of medicines used in the treatment of opioid addiction treatment of opioid addiction 117 Figure 4.66. Volumes of public procurement of medicines used in the treatment of opioid addiction according to INN (packages) 117 Figure 4.67. Volumes of public procurement of medicines used in the treatment of opioid addiction according to INN (UAH) 118 Figure 4.68. Volumes of public procurement of medicines used in the treatment of opioid addiction according to INN (USD) 118 Figure 4.69. Total volume of pharmacy sales and public procurement of medicines used in the treatment of nicotine addiction 119 Figure 4.70. Sales volumes of the group of medicines used in the treatment of nicotine addiction 119 Figure 4.71. Sales volumes of medicines used in the treatment of nicotine addiction according to INN (packages) 120 Figure 4.72. Sales volumes of medicines used in the treatment of nicotine addiction according to INN (UAH) 120 LIST OF FIGURES | 9 Figure 4.73. Sales volumes of medicines used in the treatment of nicotine addiction according to INN (USD) 120 Figure 5.1. Pharmacy sales of medicines available in the State Formulary of Medicines (% of all medicines that can be used to treat persons with mental disorders) 121 Figure 5.2. Public procurement of medicines available in the State Formulary of Medicines (% of all medicines that can be used to treat persons with mental disorders) 121 Figure 5.3. Total volume of pharmacy sales and public procurement of medicines that can be used to treat persons with mental disorders 122 Figure 5.4. Volumes of pharmacy sales and public procurement of separate groups of medicines that can be used to treat persons with mental disorders (packages) 122 Figure 5.5. Volumes of pharmacy sales and public procurement of separate groups of medicines that can be used to treat persons with mental disorders (UAH) 123 Figure 5.6. Volumes of pharmacy sales and public procurement of separate groups of medicines that can be used to treat persons with mental disorders (USD) 123 Figure 5.7. Volumes of pharmacy sales of medicines that can be used to treat persons with mental disorders 124 Figure 5.8. Volumes of pharmacy sales of separate groups of medicines that can be used to treat persons with mental disorders (packages) 124 Figure 5.9. Volumes of pharmacy sales of separate groups of medicines that can be used to treat persons with mental disorders (UAH) 125 Figure 5.10. Volumes of pharmacy sales of separate groups of medicines that can be used to treat persons with mental disorders (USD) 125 Figure 5.11. Volumes of public procurement of medicines that can be used to treat persons with mental disorders 126 Figure 5.12. Volumes of public procurement of separate groups of medicines that can be used to treat persons with mental disorders (packages) 126 Figure 5.13. Volumes of public procurement of separate groups of medicines that can be used to treat persons with mental disorders (UAH) 127 Figure 5.14. Volumes of public procurement of separate groups of medicines that can be used to treat persons with mental disorders (USD) 127 Figure 5.15. Total volume of pharmacy sales and public procurement of nootropic and psychostimulant medicines 128 Figure 5.16. Sales volumes of the group of nootropic and psychostimulant medicines 128 Figure 5.17. Sales volumes of nootropic and psychostimulant medicines according to INN (packages) 129 Figure 5.18. Sales volumes of nootropic and psychostimulant medicines according to INN (UAH) 130 Figure 5.19. Sales volumes of nootropic and psychostimulant medicines according to INN (USD) 131 10 | LIST OF FIGURES Figure 5.20. Volumes of public procurement of group of nootropic and psychostimulant medicines 132 Figure 5.21. Volumes of public procurement of nootropic and psychostimulant medicines according to INN (packages) 133 Figure 5.22. Volumes of public procurement of nootropic and psychostimulant medicines according to INN (UAH) 134 Figure 5.23. Volumes of public procurement of nootropic and psychostimulant medicines according to INN (USD) 135 Figure 5.24. Total volume of pharmacy sales and public procurement of hypnotics and sedatives 136 Figure 5.25. Sales volumes of the group of hypnotics and sedatives 136 Figure 5.26. Sales volumes of hypnotics and sedatives according to INN (packages) 137 Figure 5.27. Sales volumes of hypnotics and sedatives according to INN (UAH) 138 Figure 5.28. Sales volumes of hypnotics and sedatives according to INN (USD) 139 Figure 5.29. Volumes of public procurement of hypnotics and sedatives 140 Figure 5.30. Volumes of public procurement of hypnotics and sedatives according to INN (packages) 141 Figure 5.31. Volumes of public procurement of hypnotics and sedatives according to INN (UAH) 142 Figure 5.32. Volumes of public procurement of hypnotics and sedatives according to INN (USD) 143 Figure 5.33. Total volume of pharmacy sales and public procurement of antiepileptic medicines 144 Figure 5.34. Sales volumes of the group of antiepileptic medicines 144 Figure 5.35. Sales volumes of antiepileptic medicines according to INN (packages) 145 Figure 5.36. Sales volumes of antiepileptic medicines according to INN (UAH) 146 Figure 5.37. Sales volumes of antiepileptic medicines according to INN (USD) 147 Figure 5.38. Volumes of public procurement of antiepileptic medicines 148 Figure 5.39. Volumes of public procurement of antiepileptic medicines according to INN (packages) 148 Figure 5.40. Volumes of public procurement of antiepileptic medicines according to INN (UAH) 149 Figure 5.41. Volumes of public procurement of antiepileptic medicines according to INN (USD) 150 Figure 5.42. Total volume of pharmacy sales and public procurement of antiparkinsonian medicines 151 Figure 4.23. Sales volumes of the group of antiparkinsonian medicines 151 LIST OF FIGURES | 11 Figure 5.44. Sales volumes of antiparkinsonian medicines according to INN (packages) 152 Figure 5.45. Sales volumes of antiparkinsonian medicines according to INN (UAH) 153 Figure 5.46. Sales volumes of antiparkinsonian medicines according to INN (USD) 154 Figure 5.47. Volumes of public procurement of antiparkinsonian medicines 155 Figure 5.48. Volumes of public procurement of antiparkinsonian medicines according to INN (packages) 155 Figure 5.49. Volumes of public procurement of antiparkinsonian medicines according to INN (UAH) 156 Figure 5.50. Volumes of public procurement of antiparkinsonian medicines according to INN (USD) 156 Figure 5.51. Total volume of pharmacy sales and public procurement of the ‘Other medicines’ group 157 Figure 5.52. Sales volumes of the ‘Other medicines’ group 157 Figure 5.53. Sales volumes of the ‘Other medicines’ group according to INN (packages) 158 Figure 5.54. Sales volumes of the ‘Other medicines’ group according to INN (UAH) 159 Figure 5.55. Sales volumes of the ‘Other medicines’ group according to INN (USD) 160 Figure 5.56. Volumes of public procurement of the ‘Other medicines’ group 161 Figure 5.57. Volumes of public procurement of the ‘Other medicines’ group according to INN (packages) 162 Figure 5.58. Volumes of public procurement of the ‘Other medicines’ group according to INN (UAH) 163 Figure 5.59. Volumes of public procurement of the ‘Other medicines’ group according to INN (USD) 164 Figure 6.1. Volumes of pharmacy sales of dietary supplements that may be associated with mental health treatment 165 Figure 6.2. Volumes of pharmacy sales of some groups of dietary supplements that may be associated with mental health treatment (packages) 165 Figure 6.3. Volumes of pharmacy sales of some groups of dietary supplements that may be associated with mental health treatment (UAH) 166 Figure 6.4. Volumes of pharmacy sales of some groups of dietary supplements that may be associated with mental health treatment (USD) 166 Figure 6.5. Volumes of pharmacy sales of dietary supplements that may be associated with CNS activity 167 Figure 6.6. Sales of dietary supplements that may be associated with CNS activity by content (packages) 168 Figure 6.7. Sales of dietary supplements that may be associated with CNS activity by content (UAH) 169 12 | LIST OF FIGURES Figure 6.8. Sales of dietary supplements that may be associated with CNS activity by content (USD) 170 Figure 6.9. Volumes of pharmacy sales of dietary supplements that may be used in connection with alcohol consumption 171 Figure 6.10. Sales of dietary supplements that may be used in connection with alcohol consumption by content (packages) 172 Figure 6.11. Sales of dietary supplements that may be used in connection with alcohol consumption by content (UAH) 172 Figure 6.12. Sales of dietary supplements that may be used in connection with alcohol consumption by content (USD) 173 Figure 6.13. Volumes of pharmacy sales of dietary supplements that can be used in connection with smoking 174 Figure 6.14. Sales of dietary supplements that can be used in connection with smoking by content (packages) 174 Figure 6.15. Sales of dietary supplements that can be used in connection with smoking by content (UAH) 175 Figure 6.16. Sales of dietary supplements that can be used in connection with smoking by content (USD) 175 Figure 7.1. The volumes of pharmacy sales of the group of medicines available in the following ‘old’ pharmacist protocols: ‘Symptomatic treatment of stress,’ ‘Promotion of smoking cessation,’ and ‘Symptomatic treatment of insomnia’ (valid until up to January 5, 2022) 176 LIST OF TABLES Table 2.1. Estimated funding for psychiatric care facilities, under the PMG in Q2–Q4 2020 71 Table 2.2. Estimated funding for psychiatric care facilities under the PMG in Q1 2021 71 Table 3.1. General statistics on the provision of outpatient psychiatric care to persons diagnosed with mental disorders (2015–2019) 72 Table 3.2. General statistical information on the provision of inpatient psychiatric care to persons diagnosed with mental disorders (2015–2019) 74 Table 7.1. Mental health medicines previously recommended by the pharmacist protocols (valid until up to January 5, 2022) 176 LIST OF FIGURES | 13 ACRONYMS ADHD Attention De cit Hyperactivity Disorder ATC Anatomical Therapeutic Chemical CNS Central Nervous System ESPAD European School Survey Project on Alcohol and Drugs EuroPoPP-MH European Pro le of Prevention and Promotion of Mental Health GABA Gamma-Aminobutyric Acid HBSC Health Behaviour in School-Aged Children ICD-10 International Statistical Classi cation of Diseases and Related Health Problems, 10th Revision INN International Nonproprietary Name mhGAP Mental Health Gap Action MTD Medical and Technological Document NHSU National Health Service of Ukraine OTC Over-the-Counter PHC Primary Health Care PMG Program of Medical Guarantees SAFEMed Safe, A ordable, and E ective Medicines for Ukrainians SKU Stock Keeping Unit SMD Support in Market Development OAMT Opioid Agonist Maintenance Treatment SSRI Selective Serotonin Reuptake Inhibitor STEPS STEPwise Approach to Surveillance UNDP United Nations Development Programme USAID United States Agency for International Development VAT Value Added Tax WHO World Health Organization 14 | ACRONYMS EXECUTIVE SUMMARY Ukraine has inherited a high burden of mental health issues from its past. Mental health disorders, including a high prevalence of depression, alcohol use disorder, and suicide, are the second leading cause of disability burden, a ecting up to 30 percent 12021 Yale Institute of the population1. Unsurprisingly, Ukraine was identi ed as a priority country for the for Global Health Case Competition Mental World Health Organization (WHO) Special Initiative for Mental Health (2019–2023)2. This Health in Ukraine. resulted in recognition of the integrality of mental health in people’s overall well-being, followed by a renewed level of political commitment and investment in mental health 2Ukraine WHO Special Initiative for Mental Health promotion and awareness activities. situational assessment. WHO, University of Washington. July 2020 As part of the ongoing structural transformation of the health system, the Government of Ukraine revealed its commitment to providing all components of health care to its citizens. The health system reform process allowed Ukraine to transition from a traditionally centralized health care service provision toward a more decentralized model while integrating primary care and adopting a holistic approach to the delivery of mental health in the country. Despite these reforms, the Ukrainian mental health system remains largely centralized. Pharmacists often act as the entry point for patients with mental health conditions. The pharmacists often take care of screening, detection, medication, and referring to primary health care (PHC) and higher levels of medical care. The empowerment of community-based, patient-oriented care in mental health is currently signi cantly lacking. The provision of inpatient and outpatient care to people with mental disorders primarily involves the use of medicines and nonmedicinal treatments such as psychological assistance, social services, and so on. In addition to prescription medicines, which can be prescribed only by doctors, some medications can also be recommended by pharmacists or purchased for self-medication. Starting from the end of 2021, a certain number of medicines for inpatient and outpatient treatment of mental health conditions are provided free of charge under the A ordable Medicines Program. Because of the relative novelty of this program, a vast majority of pharmacy-sold medications used to treat mental disorders are still bought out of pocket. This is especially true for patients who prefer more modern (and often more expensive) medicines or replace generic medicines with original ones. Public spending on mental health, which accounts for more than 4 percent of total Program of Medical Guarantees (PMG) funding in 2021, and EXECUTIVE SUMMARY | 15 out-of-pocket spending are the two major components of mental health care nancing in Ukraine. This report attempts to provide a comprehensive summary of the relevant indicators of mental health and present a detailed analysis of the cost of psychiatric care, particularly highlighting the cost of mental health medications and dietary supplements in Ukraine. Our study strives to shed light on the pharmaceutical aspect of providing care to people with mental health conditions in Ukraine. This report consciously presents data and analysis from the pre-COVID times in Ukraine as the impact of the COVID-19 pandemic signi cantly disrupted access to health care and medicines. Our analytical framework’s key results reveal that out-of-pocket costs of medicines used to treat mental disorders may exceed government spending on the entire psychiatric care network. At the same time, the ‘out-of-pocket’ costs of the population for nonmedicinal mental health services (including psychological services), as well as for the services of private institutions and private practitioners, remain unknown and present interest for further research. Depending on the probability of their use in the treatment of mental disorders, medicines and dietary supplements were conditionally divided in this report into two groups: (a) medicines mainly used in the treatment of people with mental disorders (neuroleptics, tranquilizers, antidepressants, and so on) and (b) medicines that can provisionally be used in the treatment of people with mental disorders (nootropics, hypnotics, antiepileptic medicines, and so on). The rst category of medicines has a strong evidence base, and medicines from this category are available in the State Formulary of Medicines. The medicines of the second category are mostly purchased over the counter (OTC), including for self-medication; many of them have quite a weak evidence base and are mostly absent from the State Formulary of Medicines. Our results indicate that in 2019, the annual volume of pharmacy sales of medicines for the rst group, ‘medicines mainly used in the treatment of persons with mental disorders,’ amounted to UAH 1.065 billion for 6.5 million packages. The annual volume of public procurement of medicines in this category in 2019 amounted to UAH 185 million for 1.3 million packages. Antianxiety and antipsychotic medicines and antidepressants have been leaders in this section for ve years. As of 2019, antianxiety medicines ranked rst in the number of packages, and antipsychotics ranked rst in monetary terms. The annual volume of pharmacy sales for the second group, ‘medicines that can be used in the treatment of people with mental disorders,’ amounted to UAH 3.126 billion for 30.5 million packages in 2019. The annual volume of public procurement of medicines in this category amounted to UAH 95 million for 0.8 million packages in the same year. The large volume of pharmacy sales of this type of medication, comparable to the state 16 | EXECUTIVE SUMMARY funding of psychiatric care in health care facilities, indicates a signi cant unmet need for quality mental health services. Regarding the number of packages throughout the ve years, sleeping pills and sedatives accounted for 57 percent of the total section in 2019 decreasing from 70 percent in 2015. The costs of dietary supplements that may be associated with mental health were analyzed separately. Some dietary supplements may contain the same chemicals as in medicines – that is, it depends on how the manufacturer has registered it. In 2019, the pharmacy network sold 2.6 million packages of such dietary supplements worth UAH 139 million. Given the signi cant volume of sales in supermarkets, online stores, and so on, it is di cult to estimate the market size of dietary supplements. Despite Ukraine’s well-intentioned e orts, the emphasis on inpatient delivery and the associated signi cant out-of-pocket spending reveals the mental health system’s inadequacy and unresponsiveness in meeting the population’s needs. The lack of community and primary level of care, lack of trust in the psychiatric system, stigma and shame, and low awareness and understanding of mental health issues are major barriers to mental health-seeking behavior. In addition, there is a serious lack of continuum of care due to a poor referral system and limited communication between providers from di erent layers of the health care system. Human resources for mental health are also severely constrained due to an outdated professional education system, lack of professional regulation, and absence of personal licensing among psychologists, psychotherapists, and medical doctors. There is also a concern about the lack of evidence-based practice in the prescription of medication for the treatment of mental health conditions in Ukraine. Ukraine will need to continue endorsing the criticality of mental health in the overall well-being of its population. Investments in mental health promotion and awareness activities must be prioritized to destigmatize mental health-related problems. Ukraine will need to embark on a journey of structural transformations of the health system by making primary care responsible for gatekeeping along with the integration of the availability of mental health services at all levels of care focused on improving the accessibility of mental health care and reducing the nancial burden associated with mental health treatments. The integration of community-based services should be done in parallel. It is equally important to change the trend and tendency of self-medication and treatment by medications without proven e ectiveness that have the potential of doing more harm than good. In the future, evidence-based decision-making with the help of mental health technology assessments must be fully functional. EXECUTIVE SUMMARY | 17 1. INTRODUCTION Mental health that encompasses psychological, emotional, and social well-being is a vital part of our life as it a ects our thoughts, behaviors, and emotions3. Given the 3WHO’s Comprehensive Mental Health Action Plan critical impact of mental health on the quality of life, investing in mental health must 2013-2030 https://www. who.int/publications/i/ be prioritized globally. Over a long period of time, impact of mental health on other item/9789240031029 health conditions has been largely neglected, which has led to the underestimation of the mental health burden in the population. However, over the last decades, there has 4Ukraine WHO Special Initiative for Mental Health been a growing consensus on the fundamentality of mental health in the overall health Situational Assessment. WHO, University of system and outcomes. Washington. July 2020. Accessed February 28, 2022. https:// cdn.who.int/media/ Historically, Ukraine has been ghting a long and arduous battle with mental health docs/default-source/ mental-health/who- due to a high burden of mental illness and a particularly high prevalence of depression, special-initiative-country- report---ukraine---2020. alcohol use disorder, and suicide4. Mental health disorders a ect close to 30 percent pdf?sfvrsn=ad137e9_4 of the population, making it the second leading cause of disability in the country. The ongoing process of health system reforms initiated in 2017 established the Program of Medical Guarantees (PMG), which promised universal health care to all Ukrainians and o ered an opportunity to revitalize the service delivery of the health system, including mental health in the country. Despite the health system reforms, Ukraine continues to have a centralized mental health care system with services provided mainly through psychiatric clinics. The mental health system in Ukraine is characterized by fragmented service delivery, channeling of public health resources to nance the cost of medical services, and limited contribution of public resources in the procurement of medicines for mental health, which leads to a high level of out-of-pocket spending on drugs that are not evidence based. Going forward, Ukraine will need to prioritize decentralization of the service delivery of mental health services and the provision of integrated and holistic care by including primary and community-level health care supported by nonspecialized sta such as general doctors and family physicians. 18 | 1. INTRODUCTION This report aims to understand the cost of mental health, with pharmaceutical treatments constituting a signi cant proportion of it from both the public funding and out-of- pocket expenditures perspectives. The understanding of the cost of mental health in the country is important from the perspective of the government as it in uences the nancial allocation to health care providers under the PMG. The report aims to serve as a background research paper for decision-makers and specialists with the power to in uence the use of public funds more e ciently and improve the quality of mental health care provision. Finally, the report can also be used as a guide and reference on the circulation of all registered drugs in Ukraine in 2015–2019 used in treating mental disorders. The report captures data regarding pharmaceutical retail for 2015–2019. Recent year data were deliberately not included in the analysis due to the outbreak of the COVID-19 pandemic that signi cantly altered the health priorities and patients’ health behavior as well as the ongoing structural transformation of mental health nancing. 1. INTRODUCTION | 19 2. MENTAL HEALTH SITUATION IN UKRAINE 2.1 Legislation The Law on Psychiatric Care of 2000 supports the psychiatric-oriented approach rather than a holistic mental health framework that de nes the terms of mental health support and patient rights protection in Ukraine. However, in line with the ongoing health system reforms in the country, the centralized and tertiary-centric mental health system has also undergone signi cant structural transformations. The development of the National Concept Note on Mental Health Care Development in Ukraine for 2018–2030 in 2017, and the integration of mental health at the primary level in 2019, followed by the enforcement of the Mental Health Action Plan for 2021– 2023, were signi cant steps in this direction. The health nancing reforms ensuring the free provision of all levels of health care within the PMG included psychiatric care as an integral health component. This led to the transition of the historical nancing of mental health by the state budget through subvention mechanism and from local budgets to central funding through the National Health Service of Ukraine (NHSU) in 2020. The NHSU included more than 60 drugs related to mental health treatment under the A ordable Medicine Program that provides medication prescribed by doctors for free in 2021. 2.2 Mental Health Indicators The signi cant deterioration in mental health indicators has been an increasing concern at the global and national levels. Ukraine’s story is similar to other countries in the Eastern European region for all the indicators except major depressive disorder (MDD), which has a 3.4 percent prevalence in Ukraine compared to a lower 2.9 percent in the region. The prevalence of alcohol use disorders is much higher in Ukraine (6.0 percent) than the global average of 1.5 percent. Ukraine has a higher estimated suicide rate than the Eastern Europe regional average (29.6 deaths per 100,000 population) and the global average (10.4 deaths per 100,000 population). Gender disparities in these indicators are also signi cant, with more men being prone to death by suicides (56.7 per 100,000 5https://cdn.who.int/ media/docs/default- versus 8.4 per 100,000 among women) and disorders due to alcohol use (11.5 percent source/mental-health/ who-special-initiative- versus 1.4 percent). However, women were found to have a higher estimated prevalence country-report-- -ukraine---2020. of MDD (3.9 percent versus 2.7 percent)5. pdf?sfvrsn=ad137e9_4 20 | 2. MENTAL HEALTH SITUATION IN UKRAINE 6 http://medstat.gov.ua/ This report presents data on mental health prevalence distinguished based on im/upload/2015.zip outpatient and inpatient care over ve years (2015–2019)6,7. Over this period, the total number of people diagnosed with mental health disorders decreased. During the same 7 https://cmhmda. org.ua/wp-content/ period, following a decrease in the population of Ukraine, a 9 percent decrease in the uploads/2020/07/ Form10_2019_Ukraine_ number of people with mental disorders was registered. However, the use of inpatient ukr.xlsx care in terms of hospitalizations and bed-days increased. There was an increase in the number of people with mental health disorders receiving inpatient care from 18 percent 8Such calculations are possible provided that to 20 percent from 2015 to 20198 Patients with mental health disorders, who received 100 percent of persons who received inpatient inpatient psychiatric care, spent in hospitals on average 41 days in 2015 and 43 days in psychiatric care also received outpatient 2019. The service utilization by types of mental disorders is described below. psychiatric care the same year. However, not all patients apply for outpatient services 2.2.1 Mental disorders due to alcohol use after discharge from the hospital. People with mental disorders due to alcohol use (F10 according to ICD-109) are the most frequent outpatient and inpatient psychiatric care users. Statistics reveal that in 9ICD-10 = International Statistical Classi cation of 2015 around 50 and 36 percent of rst-time diagnosed patients with mental issues and Diseases Related Health Problems, 10th Revision. utilization of outpatient psychiatric care were those with disorders related to alcohol use, respectively. Although over the next four years, the overall share of people with 10Prevalence is de ned as mental disorders due to alcohol use slightly decreased, the relevant indicators remained the number of people in service as of the year-end. the highest, with a prevalence rate of 32 percent and an incidence rate of 45 percent10. Incidence is de ned as the number of people with Mental disorders due to alcohol use were also the leading cause of hospitalization. The newly diagnosed ( rst time in their life) mental proportion of such diagnoses increased during the provision of inpatient psychiatric disorder during the year. care from 33 to 36 percent between 2015 and 2019. 2.2.2 Schizophrenia disorders People with schizophrenia disorders (F20-F29 according to ICD-10) accounted for 10 percent of all outpatient psychiatric care recipients in 2015 and 11 percent in 2019. Patients diagnosed with schizophrenia (F20 by ICD-10) accounted for a vast majority (72 percent) of this group. There was a 4 and 2 percent decline in outpatient and inpatient care episodes for patients with schizophrenia disorders, respectively, re ecting the overall decrease of patients by 4 percent over ve years. However, in terms of bed- days, the patients diagnosed with schizophrenia ranked highest at 42 percent of the total number of days spent in hospitals by patients with mental disorders to receive psychiatric care. The number of bed-days of inpatient treatment for persons diagnosed with schizophrenia increased by 8 percent, from 5 million bed-days in 2015 to 5.4 million bed-days in 2019, indicating that inpatient care interventions are more often applied to patients with schizophrenia. Patients with schizophrenia disorders spent on average 82 days in hospital in 2015 and about 93 days in 2019. 2.2.3 Mood (a ective) disorders At the end of 2019, about 3 percent of persons who received outpatient psychiatric care were diagnosed with mood (a ective) disorders (F30–F39 according to ICD-10). 2. MENTAL HEALTH SITUATION IN UKRAINE | 21 Mood disorders include depressive disorders (59 percent of the cases in this group) or bipolar disorders (15 percent of all cases in this group). Among those receiving inpatient psychiatric care, more than 4 percent were patients with mood disorders, of which 66 percent were persons with depressive disorders and 25 percent with bipolar disorder. Since disaggregated data within the group were rst presented in 2018, the ve-year dynamic is unavailable. However, the mood disorders group is characterized by minor changes in the ve years: a 5 percent decrease and a 2 percent increase in diagnosed and hospitalized cases, respectively. 2.2.4 Neurotic disorders Persons with neurotic disorders (F40–F48 according to ICD-10) accounted for about 8 and 5 percent of outpatient and inpatient psychiatric care, respectively, in both 2015 and 2019. Unfortunately, government statistical reporting does not provide disaggregated information on anxiety disorders, but antianxiety medicines are prescribed for many patients with neurotic (and other) disorders. There was an 8 percent decrease in patients receiving outpatient care and a 5 percent increase in hospitalized patients with neurotic disorders. 2.2.5 Dementia Persons diagnosed with dementia made up about 3 percent of all persons who received outpatient and inpatient psychiatric care in 2019. However, persons with dementia make up 6 percent of the bed-days spent in inpatient psychiatric care. The ve-year trend for persons with dementia shows a 2 and 15 percent decrease in the number of outpatients and hospitalized diagnosed patients, respectively, with a 3 percent increase in the number of bed-days spent in inpatient care. 22 | 2. MENTAL HEALTH SITUATION IN UKRAINE Figure 1. Persons who started outpatient psychiatric care with a newly diagnosed mental disorder (2019) Depressive disorders Bipolar affective disorder (F32-F33) (1.5%) & manic episode Mental disorders (F30-F31) (0.3%) due to use of opioids (F11) (2.7%) Schizophrenia, schizotypal and delusional disorders (F20-F29) (3.2%) Mental disorders due to use of tobacco (F17) (3.2%) Dementia (F00-F03) (3.2%) Neurotic, stress-related Mental disorders and somatoform disorders 2019 due to use of alcohol (F10) (45.3%) (F40-F48) (10.3%) 189 thousand persons Other mental disorders (30.3%) Source: Medical Statistical Form 10, Report on provision of psychiatry care for 2019. Figure 2. Persons receiving outpatient psychiatric care as of the end of the year (2019) Bipolar affective disorder Mental disorders & manic episode due to use of tobacco (F30-F31) (0.5%) (F17) (0.4%) Depressive disorders (F32-F33) (1.6%) Mental disorders due to use of opioids (F11) (2.8%) Dementia (F00-F03) (2.8%) Neurotic, stress-related and somatoform disorders Other mental (F40-F48) (7.8%) disorders (41.0%) Schizophrenia, schizotypal and delusional disorders 2019 (F20-F29) (10.9%) 1.5 million persons Mental disorders due to use of alcohol (F10) (32.2%) Source: Medical Statistical Form 10, Report on provision of psychiatry care for 2019. 2. MENTAL HEALTH SITUATION IN UKRAINE | 23 Figure 3. Persons who received inpatient psychiatric care (2019) Mental disorders Bipolar affective disorder due to use of opioids & manic episode (F11) (2.2%) (F30-F31) (1.2%) Dementia (F00-F03) (2.6%) Depressive disorders (F32-F33) (2.8%) Neurotic, stress-related and somatoform disorders Mental disorders (F40-F48) (5.5%) due to use of alcohol (F10) (35.8%) 2019 302 thousand Schizophrenia, schizotypal persons and delusional disorders (F20-F29) (23.7%) Other mental disorders (26.2%) Source: Medical Statistical Form 10, Report on provision of psychiatry care for 2019. Figure 4. Bed-days spent by patients per year in inpatient psychiatric care (2019) Bipolar affective disorder Mental disorders & manic episode due to use of opioids (F30-F31) (1.4%) (F11) (0.6%) Depressive disorders (F32-F33) (2.3%) Neurotic, stress-related and somatoform disorders (F40-F48) (3.0%) Dementia (F00-F03) (5.4%) Mental disorders due to use of alcohol (F10) (11.1%) 2019 Schizophrenia, schizotypal and delusional disorders 13 million (F20-F29) (47.3%) bed-days Other mental disorders (28.9%) Source: Medical Statistical Form 10, Report on provision of psychiatry care for 2019. 24 | 2. MENTAL HEALTH SITUATION IN UKRAINE 2.3 Financing and Cost of Mental Health Mental health in Ukraine is primarily funded by the government or out-of-pocket spending of people. Such nancing is mainly absorbed to (a) nance mental health services in psychiatric care facilities; (b) pay for medicines, medical supplies, dietary supplements, and so on; and (c) pay for psychological and psychotherapeutic care, social, and other services. Psychiatric care facilities provide some medicines and psychosocial services. However, a signi cant proportion of users receive them outside these facilities by purchasing medicines and dietary supplements in pharmacies and paying for consultations with psychologists and other private practitioners out of pocket. Until 2020, comprehensive data on funding for health facilities, including psychiatric facilities, were unavailable for analysis. The data on funding of psychiatric care facilities in Ukraine were rst made publicly available on April 1, 2020, after the start of the payment reform of specialized medical care by the NHSU. In 2021, the bene ts package ‘psychiatric care provided by mobile multidisciplinary teams’ (e ective since July 1, 2021) was added to the list of mental health bene ts packages. Also, the package ‘inpatient care for adults and children without surgery’ starting from 2021 included the possibility of providing mental health services, according to certain diagnosis-related groups. Therefore, the NHSU nanced psychiatric care through di erent packages of services (see Annex 2, Table 2.2). Mental health care is additionally provided by institutions that are not specialized in providing psychiatric care as part of the ‘outpatient secondary (specialized) and tertiary (highly specialized) medical care for adults and children, including medical rehabilitation and dental care’ package. Still, these expenditures were not included in the study, as a detailed analysis of the funding for each institution was not conducted. After the launch of the payment reform in April 2020, designated mental health facilities (364) received close to UAH 2.8 billion of public funding, which amounted to 3 percent of total PMG funding in 2020 (see Figure 5). However, if a period of 12 months is considered (Q2 2020–Q1 2021), the mental health sector received an allocation of at least UAH 3.97 billion of public funding, accounting for more than 4 percent of total PMG funding, even after an increase in PMG funding in 2021. 2. MENTAL HEALTH SITUATION IN UKRAINE | 25 Figure 5. Funding of psychiatric care facilities under the PMG in Q2– Q4 2020 Other packages OAMT (234 facilities), (25 specialized facilities**), UAH 25 million (1%) UAH 112 million (4%) Outpatient specialized and highly specialized medical care (63 specialized facilities**), UAH 122 million (4%) Transitional funding starting from September 1, 2020 (85 specialized facilities**), UAH 239 million (8%) UAH 2.8 billion in 2020 Transitional funding starting from July 1, 2020 (61 specialized facilities**), UAH 585 million (21%) Psychiatric care for adults and children (198 facilities), UAH 1,720 million (61%) Mental health sector (3.0%) UAH 92.2 billion in 2020 Other sectors within the PMG (97.0%) Source: NHSU. Note: **Specialized institutions refer to institutions whose main specialization is the provision of psychiatric care to the population. The analysis was conducted by the authors. Funding for outpatient psychiatric care and transitional nancial support are not considered in nonspecialized institutions that have not bene tted from the ‘psychiatric care for adults and children’ package. According to the research by the European Pro le of Prevention and Promotion of 11https://ec.europa.eu/ health/sites/default/ les/ Mental Health (EuroPoPP-MH)11 conducted in 2013 for 22 countries, the cost of mental mental_health/docs/ europopp_full_en.pdf health as a percentage of funding of all health care costs di ered signi cantly—from 2 percent in Bulgaria up to 18 percent in Norway (see Figure 6). However, the di erence in mental health nancing across the European region may also re ect di erences in methodological approaches used to calculate this indicator. Some countries may only include direct costs (spending on hospitals, salaries for the personnel in public facilities, medicines, and so on), leaving indirect costs (opportunity costs associated with the 26 | 2. MENTAL HEALTH SITUATION IN UKRAINE absence of the patient at work during treatment, the time spent by the caregiver for the patients care, and so on) unaccounted. For instance, provided numbers of mental health nancing in Ukraine include only direct costs nanced by the government. Figure 6. Mental health expenditure in % of total health care funding Norway (2011) 18,0% Luxembourg (2005) 13,4% Great Britain (2012) 13,0% France (2011) 12,9% Germany (2011) 11,0% Netherlands (2009) 11,0% Sweden (2011) 10,0% Denmark (2009) 8,0% Malta (2011) 6,7% Belgium (2009) 6,0% Latvia (2011) 5,9% Estonia (2011) 5,8% Ireland (2012) 5,3% Portugal (2011) 5,2% Hungary (2009) 5,1% Poland (2011) 5,1% Ukraine Italy (2007) 5,0% Cyprus (2011) 4,8% Mental health sector Greece (2011) 4,4% (3.0%) Finland (2011) 3,9% Czechia (2011) 2,9% Bulgaria (2012) 2,0% UAH 92.2 billion in 2020 Other sectors within the PMG (97.0%) Source: EuroPoPP-MH 2013. Note: The green chart represents the total PMG expenditures in 2020. 2.4 Service Delivery for Mental Health in Ukraine The mental health service provision in Ukraine comprises specialist inpatient and outpatient care represented by a network of district psychiatrists. In the case of Ukraine, district psychiatrists, and not the primary health care (PHC) practices that are the cornerstone of any health system, are the usual rst point of contact for patients seeking mental health care. The psychiatrists are responsible for assessing the level of mental 2. MENTAL HEALTH SITUATION IN UKRAINE | 27 disability of the patient, making a diagnosis, providing treatment and medication, and then making a referral to the hospital or clinic. The provision of mental health by PHC sta is minor. By 2022, only about 300 physicians and nurses were trained to provide mental health services, which made up less than 1 percent of practicing PHC physicians. The provision of inpatient and outpatient care to people with mental disorders primarily involves using medicines and non-medicinal treatments such as psychological assistance and social services. In addition to prescription medicines, which can be prescribed only by doctors, some medicines can be recommended by pharmacists or purchased for self-medication. Prescribing medicines for mental health care is fairly common at the primary care level. For instance, in 2019, 285 health care facilities that provided PHC purchased 166,000 packages of medicines (with a total value of UAH 15 million). While a signi cant proportion of medicines are provided at public expense during inpatient psychiatric care, free medical treatment during outpatient psychiatric care is extremely limited. Starting from October 2021, some psychotropic medicines were included in the A ordable Medicines Program12. Despite this, a vast majority of pharmacy-sold medications used to treat mental disorders were bought out of pocket. Certain medications are also available free of charge during inpatient hospitalization 12Reimbursement of some drugs that can be stays. Hence, high rates of inpatient psychiatric care can be, to a certain extent, explained used in the treatment of mental and neurological by greater availability of free medicines during hospital stays. However, even during disorders as part of the A ordable Medicines inpatient treatment, patients buy some medicines out of their pockets. This is especially Program started from October 1, 2021, but true for patients who prefer more modern (and often more expensive) medicines or this is possible only with a prescription replace generic medicines with original ones. from a specialist (that is, a psychiatrist or neurologist). 2.5 Categorization of Psychotropic Medicines It is also important to note that a fairly wide range of medicines fall under the category of medicines that can potentially be used in the treatment of people with mental disorders. It is di cult in some cases to clearly distinguish these medicines from other categories, given the possibility of using psychotropic medicines in providing care for other disorders and conditions. For instance, the antipsychotic drug haloperidol can be used in general somatic practice in psychomotor arousal and severe aggression and for tic disorders or the tranquilizer diazepam can also be used for psychomotor arousal as well as during premedication and epilepsy. At the same time, medicines used in the treatment of other diseases may be useful in the treatment of people with mental disorders. For example, antiepileptic drug carbamazepine can be used as a normothymic drug for patients with bipolar disorder, antiparkinsonian drug trihexyphenidyl can be used to help people with common side e ects after use of typical antipsychotics (extrapyramidal syndrome), and the antihypertensive drug clonidine can be used in the treatment of opioid dependence. Medicinal treatment for people with mental disorders is often not limited to psychotropic medicines and can be used in conjunction with general infusion therapy (especially for people with mental health disorders). Nootropics, neurotonics, vitamins, and so on can 28 | 2. MENTAL HEALTH SITUATION IN UKRAINE be used both upon a doctor’s recommendation and during self-medication as well as to achieve nonmedical goals (for example, to increase concentration and improve memory during training). Thus, not all ‘psychotropic’ medicines are used to treat mental disorders. 2.6 Standardization of the use of medicines in the field of mental health The cost of mental health service provision largely depends on available regulations and guidelines that de ne the quality of services. The cost of used medicines in mental health care exceeds the state funding of psychiatric facilities. The quality of medicines includes not only the registration of medicines, control of production, storage, and transportation to the points of sale but also prescriptions and use of medicines. This section looks at the standardization processes of the latter two stages. Not all medicines are used appropriately. While prescription medicines are more strictly regulated, over-the-counter (OTC) medicines can be o ered by a pharmacist directly in a pharmacy, recommended by any specialist or even a nonspecialist, or purchased under the in uence of advertising or outdated traditions of drug use. The lion’s share of medicines remains outside the regulation of the system of standardization of health technologies. Advertising and other marketing campaigns have a signi cant impact on the sales of medicines. Practices of symptomatic consumption of traditional medicines are widespread. Some of the products are sold as dietary supplements, although there are registered medicines with similar content. There are other shortfalls; for example, there are many cases of purchasing prescription medicines in pharmacies without a prescription, alcohol tinctures can be consumed as an alternative to alcoholic beverages, and some medications may be used not for their intended purpose, posing serious challenges to the health system and health of the population. 2.6.1 Use of the State Formulary of Medicines The State Formulary of Medicines has been one of the industry standards in the eld of health care since 2009. It is updated annually by the relevant order of the Ministry of Health of Ukraine. According to the de nition in the 2009 Order of the Ministry of Health of Ukraine No. 52913, the State Formulary of Medicines is a guide to the rational use of medicines. It contains a list of medicines registered in Ukraine that are of good quality, e cient, safe, cost-e ective, and supported by evidence-based practice. Given that the formulary includes medicines with proven e cacy and pharmacoeconomic 13https://zakon.rada. e ectiveness, one of the objectives of this study was to compare the circulation of gov.ua/laws/show/z1003- 09#Text medicines available in the formulary with the medicines outside the formulary. The di erence between groups of medicines in terms of availability in the formulary is signi cant. However, there is an increase over ve years in the share of use of medicines recorded in the State Formulary of Medicines (see Figure 7). 2. MENTAL HEALTH SITUATION IN UKRAINE | 29 Figure 7. Significant di erences between groups of medicines in terms of their availability in the State Formulary of Medicines 100 100 1 2 Medicines used mainly for treatment of Medicines that can be used to treat persons with mental disorders 80 80 persons with mental disorders Public procurement, packages 60 Public procurement, UAH 60 Pharmacy sales, packages Pharmacy sales, UAH 40 40 Public procurement, packages Public procurement, UAH 20 20 Pharmacy sales, UAH Pharmacy sales, packages 2015 2016 2017 2018 2019 2015 2016 2017 2018 2019 2.6.2 Use of other industry standards for medicines In view of the provisions of Article 14-1 of the Fundamentals of Health Care Legislation, industry standards may also include the protocols of a pharmacist dispensing OTC medicines, approved by the 2013 Order of the Ministry of Health of Ukraine No. 87514 14https://zakon.rada.gov. ua/rada/show/v0875282- and updated by the 2022 Order of the Ministry of Health of Ukraine No. 715. Areas of 13#Text mental health in the ‘old’ pharmacist protocols (valid until January 5, 2022) were directly connected to three other protocols: (a) symptomatic treatment of stress, (b) promotion 15https://zakon.rada.gov. ua/rada/show/v0007282- of smoking cessation, and (c) symptomatic treatment of insomnia. Despite the absence 22#Text of planned annual updates for eight years and signi cant discrepancies with the State Formulary of Medicines, the protocols in Order No. 875 were still valid, as of December 2021, and they were used by pharmacists all that time. It is noteworthy that the volume of pharmacy sales of mental health medicines available in the three ‘old’ pharmacist protocols amounted to 63.5 percent of the total number of all mental health medicine packages (considered in this report) sold by the pharmacy network in 2015. This share decreased to 46 percent in 2019. In monetary value, the share of these medicines, from the entire range of medicines covered by this report, was smaller: 19.5 percent in 2015 and 13 percent in 2019. In absolute terms, there was a decrease from 33 to 17 million packages from 2015 to 2019, with a relatively stable share of expenditures of UAH 484 million/US$22.2 million to UAH 547 million/US$21.3 million from 2015 to 2019. At the same time, only 1.5–3.0 percent (within ve years) of the sold packages are medicines available in the State Formulary of Medicines. In monetary terms, the share of 30 | 2. MENTAL HEALTH SITUATION IN UKRAINE medicines from the State Formulary of Medicines is much higher due to the higher cost of the average package and amounted to 14–20 percent of the total (within ve years). 2.6.3 National List of Essential Medicines According to the 2021 Resolution of the Cabinet of Ministers of Ukraine No. 13316, 16https://zakon.rada.gov. reimbursement of select mental health medicines available in the National List of ua/laws/show/133-2021- %D0%BF#Text Essential Medicines17 was made available within the A ordable Medicine Program, which took e ect on October 1, 2021. It includes medication for outpatient treatment 17https://zakon.rada.gov. of some mental disorders and epilepsy, especially the following International ua/laws/show/333-2009- %D0%BF#n15 Nonproprietary Names (INNs): phenobarbital, phenytoin, carbamazepine, valproic acid, lamotrigine, haloperidol, clozapine, risperidone, clomipramine, amitriptyline, and uoxetine. Reimbursement of the listed medicines is possible if they are prescribed by a specialist—psychiatrist or neurologist. According to the 2020 Resolution of the Cabinet of Ministers of Ukraine No. 130018, an approved assessment of medical technologies for the lists of drugs purchased from 18https://zakon.rada.gov. ua/laws/show/1300-2020- the state budget but not included in the National List of Essential Medicines is planned %D0%BF#Text until January 2023 to decide on the appropriateness of their further purchase. This is a major decision given the high out-of-pocket spending to purchase medicines for mental health that can potentially place a signi cant nancial burden on a ected families. It may help formalize reimbursement of generic medicines with proven e cacy (and not only those available in the National List of Essential Medicines), which is a necessary measure to reduce this burden. 2.6.4 Involvement of PHC providers The 13th issue of the State Formulary of Medicines, approved by the 2021 Order of the Ministry of Health of Ukraine No. 79219, mentioned the possibility of family 19https://moz.gov.ua/ doctors prescribing all psychotropic medicines from Section 5 of the State Formulary article/ministry-mandates/ nakaz-moz-ukraini- of Medicines that can be used in the treatment of mental disorders. Such additional vid-22042021--792- pro-zatverdzhennja- regulation enforces the earlier de ned option in clinical protocols. However, from 2021, trinadcjatogo-vipusku- derzhavnogo-formuljara- a separate special primary care formulary was created under the State Formulary of likarskih-zasobiv-ta- zabezpechennja-jogo- Medicines to approve local formularies in primary care facilities. dostupnosti Currently, at the PHC level, prescribing medicines for mental health care is not yet widespread (see Figure 8). Therefore, special attention should be paid to equip PHC sta with knowledge and skills to identify mental health disorders and provide the necessary services at the level of primary care and, if necessary, refer to a specialized level of care. An active participation of primary care professionals in service delivery would also help in the destigmatization of mental health care. 2. MENTAL HEALTH SITUATION IN UKRAINE | 31 Figure 8. Procurement of medicines among those analyzed in this study - in PHC facilities PHC (8,0%) PHC (5,3%) Рackages UAH 2019 2019 Other (92,0%) Other (94,7%) 2.7 Cost on Medicines for Mental Health In 2019, the cost of medicines used mainly in the treatment of persons with mental disorders amounted to UAH 1.250 billion (including the volume of pharmacy sales of UAH 1.065 billion); the cost of medicines that can be used in the treatment of persons with mental disorders amounted to UAH 3.221 billion (including UAH 3.126 billion of pharmacy sales). Dietary supplements that may be related to mental health were almost entirely sold through pharmacies for the total cost of UAH 0.139 billion. The volume of sales of dietary supplements outside the pharmacy network (in supermarkets, e-commerce, and so on) is currently unknown. In total, pharmacy sales of medicines of both these groups together with the dietary supplements analyzed in this study amounted to UAH 4.330 billion in 2019, which is higher than available mental health nancing under the PMG20. 20Nonspeci c mental health medicines (for In 2019, of the total of UAH 4.19 billion spent in pharmacies on medicines associated example, infusion solutions), medical with treatment of mental health disorders, only 37.5 percent (UAH 1.57 billion) was spent supplies, psychological and social services, and on medicines with strong evidence, if classi ed by their presence in the State Formulary so on, which are widely used in the provision of of Medicines (see Figure 9). The largest share of medicines that patients bought out of services to persons with mental disorders, are pocket in pharmacies belongs to the group of nootropic and psychostimulant medicines not considered, and cost estimates require further (UAH 1.06 billion), antiepileptic (UAH 0.53 billion), and hypnotics with sedatives (UAH research. 0.47 billion). The results of the study con rm that much more than half of the costs in the eld of mental health are covered by the population at their own expense (see Figure 10). A signi cant amount of ‘out-of-pocket’ spending goes to use of medicines and not in favor of psychology, psychotherapy, psychosocial support, and recovery approaches. The State Formulary of Medicines and the level of evidence for their e ectiveness are often not a convincing argument for many doctors and pharmacists and, consequently, for patients. In addition, medicines that are not included in the State Formulary of Medicines can be found in the current uni ed clinical protocols of health care and in pharmacist protocols. 32 | 2. MENTAL HEALTH SITUATION IN UKRAINE Figure 9. Expenditures on medicines associated with mental health disorders in 2019 in Ukraine (UAH, billions) Included in Formulary Not in Formulary 3.000 2.500 2.000 2.491 1.500 1.000 0.126 0.500 0.939 0.635 0.001 0.184 0.068 0.027 treatment Medicines used mainly for tr Medicines that can be used to treat treatment Medicines used mainly for tr Medicines that can be used to treat disorders. of persons with mental disorders. disorders. persons with mental disor of persons with mental disor disorders. ders. disorders. persons with mental disor ders. Pharmacy sales Pharmacy sales pr Public procurements pr Public procurements As a result, the cost of symptomatic medical treatment in the eld of mental health by medicines without a reliable evidence base signi cantly exceeds the sales of medicines available in the State Formulary of Medicines. Figure 10. The cost of mental health in Ukraine (direct costs) UAH 3,223 million in 2019 Public Medicines funding that can be used to UAH 1,250 million treat persons with in 2019 mental disorders UAH 139 million Medicines used in 2019 Dietary mainly for treatment suppl. ? of persons with mental disorders Out-of-pocket Other expenditures UAH 3,969 million medicines during 12 months NHSU funding for institutions providing (Q2-Q4 2020 + ? memtal health Q1 2021) services ? Psychological and Medical supplies social services 2. MENTAL HEALTH SITUATION IN UKRAINE | 33 3. METHODOLOGY The report is prepared using the database that contains information for 2015–2019 on retail (pharmacy) sales of medicines as well as on public procurement that includes the following types of procurement of medicines: (a) centralized by the Ministry of Health and procurement agencies, (b) regional tenders, (c) regional subthreshold procurement, (d) tenders in health facilities, and (e) subthreshold procurement in the health facilities. The scope of the primary database is detailed in the Annex. In this analysis, medicines used for the treatment of people with mental disorders are conditionally divided into two groups, depending on the frequency of use of medicines for the treatment of mental and behavioral disorders. The rst group includes medicines used mainly in the treatment of people with mental disorders (neuroleptics, tranquilizers, and antidepressants and so on), and the second group includes medicines that can provisionally be used in the treatment of people with mental disorders (nootropics, hypnotics, antiepileptic medicines, and so on). A more detailed presentation of the expenditures included in the study is presented in Annex 1. 34 | 3. METHODOLOGY 4. OVERVIEW OF THE RESULTS In 2019, the annual volume of pharmacy sales of medicines for the rst group ‘medicines used mainly in the treatment of persons with mental disorders’, amounted to UAH 1.065 billion for 6.5 million packages. The annual volume of public procurement of medicines in this category in 2019 amounted to UAH 185 million for 1.3 million packages. Antianxiety and antipsychotic medicines and antidepressants have been leaders in this section for ve years. In 2019, antianxiety medicines and antipsychotics ranked rst in the number of packages and in monetary terms, respectively. The annual volume of pharmacy sales of medicines for the second group ‘medicines that can be used in the treatment of people with mental disorders,’ amounted in 2019 to UAH 3.126 billion for 30.5 million packages. The annual volume of public procurement of medicines in this category in 2019 amounted to UAH 95 million for 0.8 million packages. The large volume of pharmacy sales of this type of medication, which is comparable to the state funding of psychiatric care providers, indicates a signi cant unmet need for health services. In terms of the number of packages throughout the ve years, sleeping pills and sedatives accounted for 57 percent of the total section in 2019 and 70 percent in 2015. The costs of dietary supplements that may be associated with mental health were analyzed separately. It should be noted that some dietary supplements may contain the same chemicals as in medicines—that is, it depends on how the manufacturer has registered it. During 2019, the pharmacy network alone sold 2.6 million packages of such dietary supplements worth UAH 139 million. Given the signi cant volume of sales in supermarkets, online stores, and so on, it is di cult to estimate the market size of dietary supplements. 4. OVERVIEW OF THE RESULTS | 35 5. RESULTS AND DISCUSSION 5.1 Medicines Used Mainly for Treatment of Persons with Mental Disorders General characteristics of medicines included in the category This section includes a review of medicines that are prescribed primarily for the treatment of the following groups of mental disorders, according to the ICD-10: schizophrenia, depression, anxiety disorders, dementia, and mental disorders due to alcohol, opioids, and nicotine use. A substantial number of medicines presented in this section have a strong evidence base and are available in the State Formulary of Medicines. The groups of medicines are categorized (according to the Anatomical Therapeutic Chemical [ATC] classi cation) as follows: y N05A Antipsychotic medicines y N05B Antianxiety medicines y N06A Antidepressants y N06D Medicines for the treatment of dementia y N07BB Medicines for the treatment of alcohol addiction y N07BC Medicines for the treatment of opioid addiction y N07BA Medicines for the treatment of nicotine addiction Pharmacy sales of medicines used mainly in the treatment of people with mental disorders (medicines that are prescribed primarily for the treatment of schizophrenia, depression, anxiety disorders, dementia, mental disorders due to alcohol, opioids, and nicotine use) increased over ve years (2015–2019) by 17 percent in number of packages and by 91 percent in Ukrainian hryvnia. Antianxiety and antipsychotic medicines and antidepressants have been leaders in this section for ve years. Some psychotropic medicines in this category can also be used for treatment of disorders and conditions other than mental and behavioral disorders. For example, as mentioned earlier, haloperidol, the antipsychotic drug, is used in general treatment of psychomotor 36 | 5. RESULTS AND DISCUSSION arousal and severe aggression and in the treatment of tic, and diazepam, the tranquilizer, is also used for psychomotor arousal as well as in premedication for epilepsy and more. Figure 11 clearly indicates that in 2019, the total volume of pharmacy sales and public procurement of medicines used mainly in the treatment of people with mental disorders amounted to UAH 1.25 billion for 7.8 million packages (see Annex 4 Figure 4.3–Figure 4.7). Pharmacy sales of medicines in this group increased over ve years by 17 percent in the number of packages, 91 percent in Ukrainian hryvnia, and 62 percent in US dollar (see Annex 4 Figure 4.8–Figure 4.12), re ecting a signi cant increase in the average cost of packaged drug in this category. Public procurement increased over ve years by 127 percent in the number of packaged drugs, 218 percent in Ukrainian hryvnia, and 165 percent in US dollar (see Annex 4 Figure 4.13–Figure 4.17). The share of publicly procured drugs in this category increased over ve years—from 9 to 17 percent for all packaged drugs and from 9 to 15 percent in total volume of sales. Given that evidence-based e ectiveness of most medicines described in this section, such upward trends may indicate an increase in e ectiveness of use of medicines in the treatment of mental disorders, contributing to increasing the availability of pharmacotherapy for mental disorders. Antianxiety and antipsychotic medicines and antidepressants were leaders in this section for ve years. As of 2019, antianxiety medicines and antipsychotics ranked rst in the number of packages and in monetary terms, respectively. If pharmacy sales and public procurement are analyzed separately, the rating slightly changes. In the pharmacy sales of medicines (in monetary terms), antidepressants rise from the third place to the second. In public procurement (both in the number of packages and in monetary terms), the rating is as follows: antipsychotics come rst, antianxiety medicines second, and medicines used in the treatment of opioid dependence take the third place. Antidepressants were pushed down to the fourth place. At the same time, the statistics suggest a decreasing number of persons who received outpatient and inpatient care and therefore do not match and do not explain the changes in the volume of pharmacy sales and public procurement of medicines, which are grouped in this category. This may be due to a number of reasons: inaccuracy in statistical reporting in terms of outpatient psychiatric care (discrepancies in the number of persons diagnosed with mental disorders and those who received services), the possibility of prescribing a wider range of medicines during treatment of mental disorders, increased use of some of these medicines for treatment of other disorders, or changing approaches to psychopharmacotherapy, among others. Medicines in this category mostly correspond to the approved list of medication in the State Formulary of Medicines. Among the medicines mentioned in this category, which were sold by the pharmacies in 2019, the sales of medicines available in the State Formulary of Medicines amounted to 5.9 million packages worth UAH 939 million or 90 percent of packages and 88 percent of total value of medicines in this category. It 5. RESULTS AND DISCUSSION | 37 can also be noted that for ve years the share of medicines from the State Formulary of Medicines increased both in packaged drugs (from 86 percent in 2015 to 90 percent in 2019) and in cash equivalent (from 82 percent in 2015 to 88 percent in 2019) (see Annex 4 Figure 4.1). Among the medicines in this category that were part of public procurement during 2019, procurement of medicines listed in the State Formulary of Medicines amounted to 1.3 million packages worth UAH 184 million. During 2015–2019, the share of publicly procured medicines from the State Formulary of Medicines was close to 100 percent and continued to increase both in packaged drugs (from 98.7 percent in 2015 to 99.7 percent in 2019) and in cash equivalent (from 98.2 percent in 2015 to 99.3 percent in 2019) (see Annex 4 Figure 4.2). 5.1.1 Antipsychotic medicines (N05A according to ATC classification)21 21Lithium medicines were transferred from N05A (antipsychotic medicines) to N06A (antidepressants). Pharmacy sales of antipsychotics increased over ve years by 35 percent in packaged drugs, 130 percent in Ukrainian hryvnia, and 95 percent in US dollar. The share of public procurement also increased in ve years—from 21 to 31 percent in packaged drugs. Chlorpromazine, clozapine, and sulpiride were the leaders in the number of packages of antipsychotic medicines sold by the pharmacies during ve years. In monetary terms, quetiapine, risperidone, and sulpiride were the leaders. Total sales in 2019 UAH 408 million 2.5 million packages Publicly procured 19 percent 31 percent Antipsychotic medicines (neuroleptics) are used primarily in the treatment of disorders of the schizophrenia group as well as in the treatment of psychotic forms of depression and bipolar disorders and organic mental disorders among children and adults with pervasive developmental disorders (disorders of autism). They are also used to provide emergency care in case of acute mental disorders, accompanied by psychosis with aggressive behavior, agitated depression, delirium, and so on. According to o cial statistics22, in Ukraine in 2019 due to mental disorders of the schizophrenia group (F20–F29 according to ICD-10), outpatient psychiatric care was 22https://cmhmda.org.ua/ provided to 176,000 persons and 72,000 persons received inpatient psychiatric care. A statistics/ considerable proportion of patients required long-term treatment and received both inpatient and outpatient psychiatric care. A total of 16,000 patients were hospitalized two or more times a year, and 3,000 persons were hospitalized for more than six months during 2019. Most persons with psychotic disorders receive antipsychotic medication while receiving psychiatric care. 38 | 5. RESULTS AND DISCUSSION Figure 11. Medicines used mainly for treatment of persons with mental disorders: pharmacy sales and public procurement of separate groups of medicines Public procurement (17%) Public procurement (15%) Рackages 2019 2019 UAH Pharmacy sales (83%) Pharmacy sales (85%) Medicines for the Medicines for the Medicines for the Medicines for the treatment of opioid treatment of nicotine treatment of alcohol treatment of opioid addiction (N07BC) (2.8%) addiction (N07BA) (2.3%) addiction (N07BB) (3.3%) addiction (N07BC) (2.0%) 5. RESULTS AND DISCUSSION | 39 Medicines for the Medicines for the treatment of dementia Anti-anxiety treatment of nicotine Antipsychotic (N06D) (4.4%) medicines addiction (N07BA) (3.9%) medicines Medicines for the (N05B) (33.4%) Medicines for the (N05A) (33.3%) treatment of alcohol 7.8 million treatment of dementia UAH addiction (N07BB) (6.0%) (N06D) (10.9%) packages 1.2 billion Antidepressants (N06A) (18.7%) in 2019 in 2019 Antidepressants (N06A) (21.2%) Antipsychotic Anti-anxiety medicines medicines (N05A) (32.4%) (N05B) (25.4%) In 2019, the total volume of pharmacy sales and public procurement of antipsychotic medicines amounted to UAH 408 million for 2.5 million packages (see Annex 4 Figure 4.15). Pharmacy sales of medicines in this group increased over ve years by 35 percent in packaged drugs, 130 percent in Ukrainian hryvnia, and 95 percent in US dollar (see Annex 4 Figure 4.16). Public procurement increased in ve years by 131 percent in packaged drugs, 170 percent in Ukrainian hryvnia, and 126 percent in US dollar (see Annex 4 Figure 4.22). The share of public procurement increased in ve years—from 21 to 31 percent in packaged drugs and from 17 to 19 percent in monetary terms. Chlorpromazine, clozapine, and sulpiride were the three leaders in the number of packages of antipsychotic medicines sold by the pharmacies during ve years, and in monetary terms, quetiapine, risperidone, and sulpiride were the leaders in the same period (see Annex 4 Figure 4.17 and Figure 4.19). In 2018, amisulpride took the third place in monetary terms. In 2015–2016, the neuroleptics haloperidol and tri uoperazine ranked fourth and fth, respectively, in the number of packages, but by 2019 they were signi cantly outpaced by the antipsychotics quetiapine and risperidone. At the same time, sales volumes in packages of haloperidol and tri uoperazine did not decrease signi cantly. The signi cant increase in sales of the following antipsychotics is also noteworthy. Olanzapine increased from UAH 1.5 million in 2015 to UAH 21 million in 2019 ( fth place), aripiprazole from UAH 1.3 million in 2015 to UAH 13 million in 2019 (seventh place), and paliperidone from UAH 0.2 million in 2015 up to UAH 10 million in 2019 (thirteenth place). Among the antipsychotic medicines sold by the pharmacy network in 2019, sales of medicines from the State Formulary of Medicines (all except melperone, prochlorperazine, and tiapride) amounted to 1.7 million packages worth UAH 322 million, which was 98 percent in packaged drugs and 98 percent in monetary value. The public procurement leaders in the number of packages for all ve years were chlorpromazine and haloperidol, with a signi cant predominance of chlorpromazine, which as of 2019 had 40 percent among all public procurement of antipsychotic medicines (see Annex 4 Figure 4.21 and Figure 4.23). In 2017, haloperidol was supplanted by another typical neuroleptic—tri uoperazine. Clozapine and risperidone supplanted tri uoperazine in ve years in the number of packages. In monetary terms, risperidone was the public procurement leader for all ve years. In 2017, the cost of risperidone increased sharply (3.5 times) with the growth in sales of packaged drugs by only 54 percent, which was due to the centralized procurement of antipsychotics that started in 2017 as well as the purchase of 3,500 packages of prolonged-release risperidone by psychiatric institutions in Kyiv in the amount of UAH 9.4 million in 2017. Among antipsychotic medicines that were part of public procurement during 2019, sales of medicines from the State Formulary of Medicines (all except melperone, prochlorperazine, and tiapride) were almost 100 percent in packaged drugs and in cash from the total turnover of this group of medicines. 40 | 5. RESULTS AND DISCUSSION 5.1.2 Antianxiety medicines (N05B according to ATC classification) Pharmacy sales of tranquilizers increased over ve years by 2 percent in packaged drugs, 53 percent in Ukrainian hryvnia, and 29 percent in US dollar. Public procurement increased over ve years by 41 percent in packaged drugs, 273 percent in Ukrainian hryvnia, and 207 percent in US dollar. The share of public procurement increased over ve years from 6 to 8 percent in packaged drugs and from 10 to 22 percent in monetary terms. Hydazepam was the leader among the antianxiety medicines sold by the pharmacy network both in packaged drugs and in monetary terms for the ve years, when sales accounted for 73 percent of packages of all tranquilizers sold in 2019. Total sales in 2019 UAH 310 million 2.6 million packages Publicly procured 22 percent 8 percent Antianxiety medicines (tranquilizers) are used primarily in the treatment of anxiety disorders as well as sleep disorders associated with anxiety and withdrawal syndrome. They are also used to provide emergency care in case of acute mental disorders accompanied by aggressive behavior. There are no data on the number of persons with anxiety disorders in the o cial statistical reporting, but it is known that in 2019 in Ukraine due to neurotic, stress-related, and somatoform disorders (F40-F48 according to ICD-10), outpatient psychiatric care was provided to 141,000 persons, and 17,000 persons received inpatient psychiatric care23. 23https://cmhmda.org.ua/ statistics/ Given that anxiety, as a symptom, is inherent not only in neurotic disorders but also in many organic mental disorders, those caused by the use of psychoactive substances and others, including psychosomatic and somatic disorders, the need of care is signi cant. Such care often includes prescription of antianxiety medicines, and at a practical level they are prescribed by specialists of various specialties—not only psychiatrists, narcologists, and neurologists but also cardiologists, therapists, and others. In 2019, the total volume of pharmacy sales and public procurement of antianxiety medicines amounted to UAH 310 million for 2.6 million packages (see Annex 4 Figure 4.25). Pharmacy sales of medicines in this group increased over ve years by 2 percent in packaged drugs, 53 percent in Ukrainian hryvnia, and 29 percent in US dollar (see Annex 4 Figure 4.25). Public procurement increased over ve years by 41 percent in packaged drugs, 273 percent in Ukrainian hryvnia, and 207 percent in US dollar (see Annex 4 Figure 4.29). The share of public procurement increased over ve years from 6 to 8 percent in packaged drugs and from 10 to 22 percent in monetary terms. Hydazepam was the leader among the antianxiety medicines sold by the pharmacies both in packaged drugs and in monetary terms for the ve years and accounted for 73 percent of packages and 57 percent in monetary value of all tranquilizers sold in 2019 (see Annex 4 Figure 4.26 and Figure 4.27-28). In addition to its leading position, hydazepam also showed an increase in sales of packaged drugs and in monetary value: 5. RESULTS AND DISCUSSION | 41 1.6 million packages were sold in 2015, 2 million in 2018, and 1.8 million in 2019. The second place, also in packaged drugs and monetary value, was occupied by mebicar. Sales of hydazepam and mebicar together accounted for 88 percent of packages and 84 percent in cash of all tranquilizers sold in 2019. Diazepam ranked third in 2019, but this was not always the case. In 2015–2016, it was outpaced by fabomotizole, but sales of this drug have fallen to almost zero in recent years. The variety of antianxiety medicines on the Ukrainian market is quite small compared to many foreign countries. Several more anxiolytics have been registered in Ukraine in recent years, but their use is currently limited. Among the antianxiety medicines sold by the pharmacy network in 2019, sales of medicines from the State Formulary of Medicines (all except chlordiazepoxide, etifoxin, fabomotizole, and oxazepam) amounted to 2.4 million packages worth UAH 239 million, which was 99.5 percent in packaged drugs and 99 percent in cash. The leaders in public procurement in the number of packages for all ve years were diazepam and hydazepam, with a signi cant predominance of diazepam, which as of 2019 was responsible for 77 percent of all public procurement of antianxiety medicines, while hydazepam was responsible for another 18 percent (see Annex 4 Figure 4.30 and Figure 4.31-32). These two medicines together accounted for 95 percent of public procurement of tranquilizers by the number of packages. An analysis of government procurement of diazepam also shows that over the ve years there was an increase of 56 percent in the number of packages procured, but in monetary terms in Ukrainian hryvnias, the increase was more than 4 times (and almost 3.5 times in US dollar). The reason for this increase was a signi cant rise in the average cost per package of injectable diazepam over the ve years. Phenazepam ranked third in the number of packages. Among the antianxiety medicines that were part of public procurement in 2019, sales of medicines from the State Formulary of Medicines (all except chlordiazepoxide, etifoxin, fabomotizole, and oxazepam) were almost 100 percent in packaged drugs and monetary value. 5.1.3 Antidepressants (N06A according to ATC classification)24 24Lithium medicines were transferred from N05A (antipsychotic medicines) Amitriptyline, escitalopram, and uoxetine were the top three antidepressants in the to N06A (antidepressants). number of packages sold by the pharmacy network in all ve years. Amitriptyline left the competitors far behind while accounting for more than one-third of all antidepressant packages in 2019. In monetary terms, the leaders in 2019 were escitalopram, paroxetine, and sertraline, with sales of escitalopram accounting for 23 percent of the group. Total sales in 2019 UAH 286 million 1.5 million packages Publicly procured 5.1 percent 6.3 percent 42 | 5. RESULTS AND DISCUSSION According to the STEPwise approach to surveillance (STEPS) study conducted in 25А national survey Ukraine in 201925, every eighth adult (12 percent) in Ukraine reported symptoms that of the prevalence of major risk factors for correspond to the clinical diagnosis of depression. However, only one in four persons noncommunicable diseases, aligned with the with symptoms of depression (3 percent of the total population) had a con rmed WHO-endorsed STEPS. diagnosis. Only 0.4 percent of the population received treatment with antidepressants or psychological therapy, which is equivalent to the level of treatment coverage of only 26https://www.euro. who.int/__data/assets/ 3 percent of possible cases of depression26. Most persons diagnosed with moderate to pdf_ le/0004/469174/ Risk-factors-NCD-Ukraine- severe depression receive antidepressant medication while receiving psychiatric care. summary-ukr.pdf https://apps.who. In 2019, the total volume of pharmacy sales and public procurement of antidepressants int/iris/bitstream/ handle/10665/336643/ amounted to UAH 286 million for 1.5 million packages (see Annex 4 Figure 4.33). Phar- WHO-EURO-2020-1468- 41218-56061-ukr.pdf macy sales of medicines in this group increased over ve years by 45 percent in pack- aged drugs, 120 percent in Ukrainian hryvnia, and 87 percent in US dollar (see Annex 4 Figure 4.34). Public procurement increased over ve years by 105 percent in packaged drugs, 134 percent in Ukrainian hryvnia, and 98 percent in US dollar (see Annex 4 Figure 4.38). The share of public procurement increased over ve years—from 4.5 to 6.3 percent in packaged drugs and from 4.9 to 5.1 percent in monetary terms. Amitriptyline, escitalopram, and uoxetine were the top three antidepressants in the number of packages sold by the pharmacy network in all ve years. Amitriptyline left the competitors far behind accounting for 35 percent of all antidepressant packages in 2019 (see Annex 4 Figure 4.235 and Figure 4.36). In monetary terms, the leaders in 2019 were escitalopram, paroxetine, and sertraline, and sales of escitalopram accounted for 23 percent of the group. All antidepressants among these leaders, except amitriptyline, that is, escitalopram, uoxetine, paroxetine, and sertraline, are selective serotonin reup- take inhibitors (SSRIs). Noradrenergic multimodal drug mianserin held the third place in monetary terms before 2019. The lithium medicines considered in this study in the section along with antidepressants are not represented in Ukraine by lithium carbonate available in the National List of Essential Medicines. This category has only one INN— lithium gamma-hydroglutaminate. We noted the increase in sales of lithium gamma-hy- droglutaminate from 2,000 packages in 2015 to 8,000 in 2019. Among the antidepressants sold by the pharmacies in 2019, sales of medicines from the State Formulary of Medicines (all except desvenlafaxine, tianeptine, medicines with hypericin, lavender, and homeopathic medicines) amounted to 1.3 million packages worth UAH 261 million, which was 97.4 percent in packaged drugs and 96.4 percent in monetary value. Amitriptyline remained the number one medicine in public procurement by the number of packages for all ve years, with a signi cant gap separating it from all other medicines in the group. In 2019, it represented 46 percent of packages in all public procurement of antidepressants (see Annex 4 Figure 4.39 and Figure 4.40-41). Fluoxetine and mianserin were also in the top three in the number of packages. In monetary terms, venlafaxine was the leader in public procurement for all ve years, except in 2015, when escitalo- 5. RESULTS AND DISCUSSION | 43 pram had the rst place. In 2019, escitalopram, amitriptyline, and mianserin were next to venlafaxine, with almost the same numbers. Public procurement of lithium gamma-hy- droglutaminate amounted to 1,900 packages in 2018 and only 1,000 packages in 2019. Among antidepressants that were part of public procurement during 2019, sales of medicines from the State Formulary of Medicines (all except desvenlafaxine, tianeptine, and medicines with hypericin) were 99.7 percent in packaged drugs and 99.5 percent in monetary terms. 5.1.4 Medicines used in the treatment of dementia (N06D according to ATC classification) According to o cial statistics, in 2019, outpatient psychiatric care for dementia (F00-F03 according to ICD-10) was provided to 47,000 persons in Ukraine. A total of 8,000 persons received inpatient psychiatric care for dementia. Pharmacy sales of medicines used in the treatment of dementia increased over ve years by 54 percent in packaged drugs, 108 percent in Ukrainian hryvnia, and 76 percent in US dollar. Public procurement grew over ve years by 380 percent in packaged drugs, 376 percent in Ukrainian hryvnia, and 307 percent in US dollar. Among the medicines used in the treatment of dementia, which were part of public procurement during 2019, the share of medicines from the State Formulary of Medicines was only 67 percent in packaged drugs. Total sales in 2019 UAH 133 million 342,000 packages Publicly procured 2.1 percent 2.8 percent Alzheimer’s disease is the most common cause of dementia, but in Ukraine the diagnosis of dementia due to Alzheimer’s disease (F00 according to ICD-10) is rarely established (in 2019 only 3,000 persons received outpatient psychiatric care and 1,000 persons received inpatient care in connection with this diagnosis). In contrast, vascular dementia (F01 according to ICD-10) is a common diagnosis, relating to which 28,000 persons received outpatient psychiatric care in 2019 and 4,000 received inpatient care27. 27https://cmhmda.org.ua/ statistics/ Persons with dementia may be prescribed medicines for treating dementia during psy- chiatric care. This section does not cover nootropic medicines, which are discussed sep- arately in Section 5.2.1. In 2019, the total volume of pharmacy sales and public procurement of medicines used in the treatment of dementia amounted to UAH 133 million for 342,000 packages (see Annex 4 Figure 4.42). Pharmacy sales of medicines in this group increased over ve years by 54 percent in packaged drugs, 108 percent in Ukrainian hryvnia, and 76 percent in US dollar (see Annex 4 Figure 4.43). Public procurement grew over ve years by 380 percent in packaged drugs, 376 percent in Ukrainian hryvnia, and 307 percent in US dollar (see 44 | 5. RESULTS AND DISCUSSION Annex 4 Figure 4.47). The share of public procurement increased over ve years from 0.9 to 2.8 percent in packaged drugs and from 0.9 to 2.1 percent in cash. The three leaders among medicines used in the treatment of dementia over ve years were ipidacrine, memantine, and donepezil—both in the number of packages sold by the pharmacy network and in monetary terms (see Annex 4 Figure 4.44 and Figure 4.45- 46). At the same time, in 2019 the rst two accounted for 89 percent of packages among all medicines in the group and 93 percent of monetary value. Among the medicines used in the treatment of dementia (medicines sold by the phar- macy network in 2019), sales of medicines available in the State Formulary of Medicines (donepezil, memantine, and galantamine) amounted to 147,000 packages worth UAH 58 million, which was 44 percent in packaged drugs and 44 percent in cash. The leaders in public procurement in the number of packages for all ve years were the same medicines, but memantine was rst in 2019 (both in packages and in monetary equivalent) with 48 percent in terms of packages and 51 percent in monetary value (see Annex 4 Figure 4.48 and Figure 4.49-50). Among the medicines used in the treatment of dementia, which were part of public procurement during 2019, sales of medicines listed in the State Formulary of Medicines (donepezil, memantine, and galantamine) amounted to 6,400 packages worth UAH 1.8 million, which was 67 percent in packaged drugs and 64 percent in cash. 5.1.5 Medicines used in the treatment of alcohol addiction (N07BB according to ATC classification) Pharmacy sales of medicines used in the treatment of alcohol addiction decreased over ve years by 22 percent in packaged drugs, which corresponds to a 11 percent increase in Ukrainian hryvnia and a 6 percent decrease in US dollar. Over ve years, public procurement increased by 144 percent in packaged drugs, decreased by 24 percent in Ukrainian hryvnia, and decreased by 32 percent in US dollar. The absolute leader in public procurement both in the number of packages and in monetary terms for all ve years was disul ram, which as of 2019 accounted for more than 95 percent. Total sales in 2019 UAH 40 million 472,000 packages Publicly procured 0.1 percent 0.5 percent 28A national survey According to the results of the STEPS survey conducted in Ukraine in 201928, alcohol of the prevalence of major risk factors for consumption in Ukraine was frequent and high. Two-thirds of men and almost half of noncommunicable diseases, aligned with the women reported having consumed alcohol in the past 30 days, with one in ve (20 WHO-endorsed STEPwise approach to surveillance percent) consuming six or more doses of alcohol per episode of consumption (excessive (STEPS). episodic use). One in eight persons (13 percent) said they could not stop drinking after 5. RESULTS AND DISCUSSION | 45 they started drinking, and one in ten (11 percent) said they could not do what was expected from them the next day. One in eight persons (13 percent) consumed alcohol in the morning to alleviate the hangover29. In support of these data, the high prevalence of 29https://www.euro. alcohol use among adolescents has already been identi ed by recent Health Behaviour who.int/__data/assets/ pdf_ le/0004/469174/ in School-Aged Children (HBSC)30 and European School Survey Project on Alcohol and Risk-factors-NCD-Ukraine- summary-ukr.pdf Drugs (ESPAD)31 surveys and is also a cause for concern. https://apps.who. int/iris/bitstream/ Persons with mental disorders due to alcohol use can be prescribed speci c medicines handle/10665/336643/ WHO-EURO-2020-1468- during psychiatric (narcological) care which are used in the treatment of alcohol 41218-56061-ukr.pdf addiction, but much more often they receive nonspeci c detoxi cation therapy, the cost 30http://www.uisr.org. of which is currently di cult to measure. ua/hbsc In 2019, the total volume of pharmacy sales and public procurement of medicines used 31http://www.uisr.org. ua/espad in the treatment of alcohol addiction amounted to UAH 40 million for 472,000 packages (see Annex 4 Figure 4.51). Pharmacy sales of medicines in this group decreased over ve years by 22 percent in packaged drugs, increased by 11 percent in Ukrainian hryvnia, and decreased by 6 percent in US dollar (see Annex 4 Figure 4.52). Over ve years, public procurement increased by 144 percent in packaged drugs, decreased by 24 percent in Ukrainian hryvnia, and decreased by 32 percent in US dollar (see Annex 4 Figure 4.56). The share of public procurement increased over ve years from 0.1 to 0.5 percent in packaged drugs and decreased from 0.2 to 0.1 percent in monetary terms. The leader both in the number of packages sold by the pharmacy network and in cash for ve years was a combined drug containing glycine, sodium format, and dextrose, with 67 percent of sales of the whole group in packages and 64 percent in cash (see Annex 4 Figure 4.53 and Figure 4.54-55). Disul ram and metadoxine were also among the top three in the number of packages sold in all ve years. The same medicines remained in the top three during 2017–2019 in cash, although in 2015–2016, cyanamide took the second place in monetary terms. Among the medicines used in the treatment of alcohol dependence, which were sold by the pharmacies in 2019, sales of disul ram, the only drug listed in the State Formulary of Medicines, amounted to 87,000 packages worth UAH 8.8 million, which corresponded to 18.5 percent in packages and 22 percent in monetary terms of all medicines in this group. Disul ram was also the absolute leader in public procurement both in the number of packages and in monetary terms for all ve years. In 2019, it accounted for more than 95 percent in both packaging and monetary value among the whole group (see Annex 4 Figure 4.57 and Figure 4.58-59). However, in 2015, when purchases of the group’s medicines were much lower, the combined drug containing glycine, sodium format, and dextrose came rst in monetary terms. Among the medicines used in the treatment of alcohol addiction, which were part of public procurement during 2019, sales of the medicines from the State Formulary of 46 | 5. RESULTS AND DISCUSSION Medicines (disul ram) amounted to 2,100 packages worth UAH 57,000, which accounted for 97.4 percent in packaged drugs and 95.8 percent in cash. 5.1.6 Medicines used in the treatment of opioid addiction (N07BC according to ATC classification)32 32It includes buprenorphine from N02A (opioid analgesics). Currently, opioid agonist maintenance treatment (OAMT) is mainly prescribed in Ukraine to provide medical care to persons with mental disorders caused by opioid use. Over ve years, pharmacy sales of medicines in this group decreased by 20 percent in packages while public procurement increased by 653 percent in packaged drugs. Total sales in 2019 UAH 24 million 219,000 packages Publicly procured 82 percent 85 percent According to a biobehavioral study in 2019, 317,000 persons in Ukraine used injection drugs, including 278,000 opioid users33. According to o cial statistics, in 2019 in Ukraine outpatient psychiatric care for mental 33https://www.dec. disorders due to opioid use (F11.0-7 according to ICD-10) was provided to 46,000 gov.ua/wp-content/ uploads/2020/10/proekt_ persons, of whom 38,000 received care in connection with addiction or withdrawal nakazy_opioidy.pdf (F11.2-3 according to ICD-10). A total of 6,600 persons received inpatient psychiatric 34https://cmhmda.org.ua/ care, of whom 6,300 received care in connection with addiction or withdrawal34. statistics/ Currently, OAMT is mainly prescribed in Ukraine to provide medical care to persons with 35https://phc.org.ua/ kontrol-zakhvoryuvan/ mental disorders caused by opioid use. As of March 1, 2021, 15,300 persons received zalezhnist-vid- psikhoaktivnikh-rechovin/ OAMT, including methadone (13,400 persons) and buprenorphine (1,900)35. zamisna-pidtrimuvalna- terapiya-zpt/statistika-zpt In 2019, the total volume of pharmacy sales and public procurement of medicines used in the treatment of opioid dependence amounted to UAH 24 million for 219,000 packages (see Annex 4 Figure 4.60). Pharmacy sales of medicines in this group decreased over ve years by 20 percent in packaged drugs but increased by 44 percent in Ukrainian hryvnia and 20 percent in US dollar (see Annex 4 Figure 4.61). Public procurement increased over ve years by 653 percent in packaged drugs, 456 percent in Ukrainian hryvnia, and 365 percent in US dollar (see Annex 4 Figure 4.65). In ve years, the share of public procurement increased from 37 to 85 percent in packaged drugs and from 54 to 82 percent in cash. On average, during 2015–2019, buprenorphine and methadone were the leaders both in the number of packages sold by the pharmacy network and in cash (see Annex 4 Figure 4.62 and Figure 4.63-64). Buprenorphine was in the lead in monetary terms for all ve years. But in the number of packages, methadone held the rst place in 2016–2018. In 2019, the pharmacy sales of methadone fell sharply, and naloxone took the second place. 5. RESULTS AND DISCUSSION | 47 Among the medicines used in the treatment of opioid dependence, which were sold both by the pharmacy network and as part of public procurement over ve years, all medicines were available in the State Formulary of Medicines. Methadone and buprenorphine were also leaders in public procurement both in the number of packages and in cash in all ve years, with a signi cant predominance of methadone in 2018–2019 and a predominance of buprenorphine in 2015–2017 (see Annex 4 Figure 4.66 and Figure 4.67-68). Methadone was not procured at all in 2015, and in 2016 procurement was less than 1,000 packages. Naloxone ranked third in all respects, but in 2015–2016 naltrexone was the second in cash, due to the high cost per package. 5.1.7 Medicines used in the treatment of nicotine addiction (N07BA according to ATC classification) Pharmacy sales of medicines in this group increased over ve years by 33 percent in packaged drugs, while public procurement was insigni cant. The leaders in the number of packages sold by the pharmacy network and in monetary terms were cytisine and nicotine. Total sales in 2019 UAH 48 million 183,000 packages Publicly procured Insigni cant Insigni cant According to a STEPS survey conducted in Ukraine in 201936, 34 percent of the population 36A national survey of the prevalence of ages 18–69 were active tobacco smokers. Half (50 percent) of all men and one in six (17 major risk factors for noncommunicable percent) women reported smoking in the last 30 days. One in ve smokers (21 percent) diseases, aligned with the WHO-endorsed STEPwise tried to quit unsuccessfully; the ratio was particularly high among women ages 18–29, approach to surveillance (STEPS). where almost half (49 percent) made unsuccessful attempts to quit smoking37. 37https://www.euro. At the same time, according to the o cial statistical reports, in 2019 in Ukraine who.int/__data/assets/ pdf_ le/0004/469174/ outpatient psychiatric care for mental disorders due to tobacco use (F17.0-3 according Risk-factors-NCD-Ukraine- summary-ukr.pdf to ICD-10) was provided to 10,000 persons, of whom only 31 received care in connection https://apps.who. with addiction or withdrawal (F17.2–3 according to ICD-10). Only 3 persons received int/iris/bitstream/ handle/10665/336643/ inpatient psychiatric care for mental disorders due to tobacco use38. WHO-EURO-2020-1468- 41218-56061-ukr.pdf In 2019, the total volume of pharmacy sales and public procurement of medicines used 38https://cmhmda.org.ua/ in the treatment of nicotine addiction amounted to UAH 48 million for 183,000 packages statistics/ (see Annex 4 Figure 4.69). Pharmacy sales of medicines in this group increased over ve years by 33 percent in packaged drugs, 59 percent in Ukrainian hryvnia, and 33 percent in US dollar (see Annex 4 Figure 4.70). Public procurement was insigni cant. In ve years, only 15 packages of medicines of this group, worth UAH 3,400, were purchased. The leaders in the number of packages sold by the pharmacy network and in monetary terms for ve years were cytisine and nicotine (except in 2015, when nicotine packages 48 | 5. RESULTS AND DISCUSSION were sold slightly more) (see Annex 4 Figure 4.71-4.73 ). The sales of varenicline grew signi cantly during 2017–2019. Among the medicines used in the treatment of nicotine addiction, which were sold by the pharmacies in 2019, sales of medicines from the State Formulary of Medicines (cytisine and nicotine) amounted to 179,000 packages worth UAH 45 million, which was 98 percent in packages and 93 percent in monetary terms. 5.2 Medicines That Can Be Used to Treat Persons with Mental Disorders General characteristics of medicines included in the section This section includes two types of medicines. The rst type is prescribed primarily or largely for the treatment of disorders of the nervous system, such as epilepsy and parkinsonism. But these medicines are also used in the treatment of persons with other mental disorders. For example, antiepileptic medicines carbamazepine and lamotrigine are prescribed for persons with bipolar disorder, and for the patients with a common side e ect of typical antipsychotics (extrapyramidal syndrome), an antiparkinsonian medication trihexyphenidyl is prescribed. A signi cant number of medicines of the rst type have a strong evidence base and are available in the State Formulary of Medicines. The second type of medication in this section is represented by medicines that are mostly purchased over the counter and are often used for self-medication; they have a weaker evidence base and are mostly absent from the State Formulary of Medicines. The groups of medicines, which are aggregated by the general characteristics of the section (according to ATC classi cation), are as follows: y N06B Nootropic and psychostimulant medicines y N05C Hypnotics and sedatives y N03 Antiepileptic medicines y N04 Antiparkinsonian medicines y Other medicines that can be used in the treatment of persons with mental disorders. In addition to medicines for the treatment of epilepsy and parkinsonism, the section includes medicines that are often prescribed as symptomatic therapy for sleep disorders, anxiety disorders, memory disorders, and organic brain damage, including those used for self-medication. These are groups of sleeping pills and sedatives, nootropics, and other medicines. The large volume of pharmacy sales of this type of medication, which is comparable to the state funding of psychiatric care in health care facilities, indicates a signi cant unmet need for quality mental health services. 5. RESULTS AND DISCUSSION | 49 Pharmacy sales of medicines that can be used to treat persons with mental disorders (medicines that are prescribed primarily for the treatment of other non-psychiatric disorders as well as a wide range of OTC medicines that often are used for self-medication) decreased over the ve years by 34 percent in packaged drugs but increased by 63 percent in Ukrainian hryvnia and by 39 percent in US dollar. For medicines in this group, an increasing sale of more expensive medicines is observed in pharmacies. Public procurement grew over ve years by 38 percent in packaged drugs, 128 percent in Ukrainian hryvnia, and 93 percent in US dollar. Figure 12 clearly shows that in 2019, the total volume of pharmacy sales and public procurement of medicines that can be used in the treatment of persons with mental disorders amounted to UAH 3.2 billion for 31.3 million packages (see Annex 5 Figure 5.3–Figure 5.6). Pharmacy sales of medicines in this section decreased over the ve years by 34 percent in packaged drugs but increased by 63 percent in Ukrainian hryvnia and by 39 percent in US dollar. These signi cant changes in the structure of circulation of medicines in this group indicate increasing pharmacy sales of more expensive medicines (see Annex 5 Figure 5.7–Figure 5.10). Public procurement grew over ve years by 38 percent in packaged drugs, 128 percent in Ukrainian hryvnia, and 93 percent in US dollar (see Annex 5 Figure 5.11–Figure 5.14). The share of public procurement increased over ve years from 1.2 to 2.5 percent in packaged drugs and from 2.1 to 2.9 percent in cash. Despite the dominance of pharmacy sales of medicines included in this section, public procurement showed an increase in packaged drugs more than two times over ve years and a signi cant increase in monetary terms. The medicines in this section are quite heterogeneous, so it is necessary to analyze trends and draw conclusions separately for each group of medicines, considering the signi cant di erences among them. The leading positions of individual groups of medicines in this section varied signi cantly, depending on whether the focus is on the number of packages or the total cost of medicines. In terms of the number of packages throughout the ve years, the top three remained unchanged: (1) sleeping pills and sedatives (by a signi cant margin—in 2019 this group accounted for 57 percent of the total section and in 2015 for 70 percent), (2) the group of nootropic and psychostimulant medicines, and (3) the group of ‘other medicines’ (see their description in Subsections 5.2.5). In monetary terms, the rst place for all ve years was occupied by the group of nootropic and psychostimulant medicines, and the group of ‘other medicines’ consistently was second. The leaders of the section in the number of packages (sleeping pills and sedatives) took only the fourth place in 2019 in monetary terms, and antiepileptic medicines took the third place in 2019. Among the medicines of this category, which were sold by the pharmacy network in 2019, the sales of medicines available in the State Formulary of Medicines amounted to 3.9 million packages worth UAH 636 million. For ve years, the share of medicines sales 50 | 5. RESULTS AND DISCUSSION from in the State Formulary of Medicines increased both in packaged medicines (from 7 percent in 2015 to 13 percent in 2019) and in cash equivalent (from 16 percent in 2015 to 20 percent in 2019) (see Annex 5 Figure 5.1). The use of medicines with a weak evidence base in the treatment of mental disorders and medicines outside the State Formulary of Medicines is a common practice. This requires improving the quality of the health technology assessment system, especially during the development of clinical protocols, standards, and guidelines as well as overseeing their compliance and monitoring and evaluation of the quality of services provided. In public procurement, the situation is signi cantly di erent. According to the number of packages, the top three positions were taken by the following medicines (by a small margin): (1) antiepileptic medicines, (2) nootropic and psychostimulant medicines, and (3) hypnotic and sedative medicines. In monetary terms, for ve years, the rating was topped by nootropic and psychostimulant medicines, followed by antiepileptic medicines, which took the second place since 2018, and the ‘other medicines’ group. Among the medicines of this section, which were part of public procurement during 2019, the sales of medicines from the State Formulary of Medicines amounted to 289,000 packages worth UAH 26.6 million. During 2015–2019, the share of procured medicines from the State Formulary of Medicines increased both in packaged drugs (from 27 percent in 2015 to 37 percent in 2019) and in cash equivalent (from 20 percent in 2015 to 28 percent in 2019) (see Annex 5 Figure 5.2). 5. RESULTS AND DISCUSSION | 51 Figure 12. Medicines that can be used to treat persons with mental disorders: pharmacy sales and public procurement of separate 52 | 5. RESULTS AND DISCUSSION groups of medicines Public procurement (2%) Public procurement (3%) Рackages 2019 2019 UAH Pharmacy sales (98%) Pharmacy sales (97%) Antiparkinsonian Antiparkinsonian Antiepileptic medicines medicines medicines (N04) (2.3%) Hypnotics and (N04) (4.8%) (N03) (9.0%) sedatives (N05С) (14.8%) Nootropic and Other medicines psychostimulant that can be used medicines in the treatment of persons with mental UAH UAH (N06B) (34.4%) disorders (14.4%) 3.2 billion 3.2 billion in 2019 Antiepileptic in 2019 Hypnotics and sedatives medicines (N05С) (57.3%) (N03) (17.1%) Nootropic and Other medicines psychostimulant that can be used medicines in the treatment of (N06B) (17.0%) persons with mental disorders (28.9%) 5.2.1 Nootropic and psychostimulant medicines (N06B according to ATC classification) Pharmacy sales of nootropics decreased over ve years by 10 percent in packaged drugs but increased by 71 percent in Ukrainian hryvnia and 45 percent in US dollar. Such signi cant changes in the structure of these medicines indicate an increase in sales of more expensive medicines. Phenibut, citicoline, and piracetam were in the top three in the number of packages sold by the pharmacies among nootropic medicines in 2019. Total sales in 2019 UAH 1.1 billion 5.3 million packages Publicly procured 3.7 percent 3.6 percent In 2019, the total volume of pharmacy sales and public procurement of nootropic and psychostimulant medicines amounted to UAH 1.1 billion for 5.3 million packages (see Annex 5 Figure 5.15). Pharmacy sales of medicines in this group decreased over ve years by 10 percent in packaged drugs but increased by 71 percent in Ukrainian hryvnia and 45 percent in US dollar (see Annex 5 Figure 5.16). Public procurement decreased over ve years by 1 percent in packaged drugs but increased by 133 percent in Ukrainian hryvnia and 99 percent in US dollar (see Annex 5 Figure 5.20). The share of public procurement increased over the ve years from 3.3 to 3.6 percent in packaged drugs and from 2.7 to 3.7 percent in cash. Such signi cant changes in the structure of used drugs indicate an increase in pharmacy sales of more expensive medicines. Public procurement also showed an increase in packaged drugs and a signi cant increase in monetary terms. Phenibut, citicoline, and piracetam were the top three in the number of packages sold by the pharmacy network among nootropic medicines in 2019 (1,559,000 packages of phenibut), amounting to about 31 percent of the total group (see Annex 5 Figure 5.17 and Figure 5.18-19). Piracetam was the leader in the group until 2017, with sales amounting to 1,239,000 packages in 2015. Glycine held the third place in 2016–2017. In 2015, the third place was taken by combined medicine of piracetam and cinnarizine. It should be noted that glycine is also included in the ‘other medicines’ section, which is associated with di erent methods of medicines registration. Choline alfoscerate showed rapid growth and in 2019 it came in the fourth place. In monetary terms, the three leaders in 2015–2019 were citicoline, phenibut, and cattle brain hydrolysate. In 2016–2019, choline alfoscerate took the fourth place. Another hydrolysate (of the brain of cattle embryos) showed signi cant annual growth and reached the ninth place in 2019, with sales of UAH 29 million. Ginkgo biloba medicines ranked fourth in monetary terms in 2015, although their sales declined slightly, resulting in the sixth place in 2019. Each of the combinations of piracetam featuring thiotriazoline and cinnarizine yielded more cash than piracetam alone, and in 2019 they held the fth and the seventh places, respectively, while piracetam held the eighth place. 5. RESULTS AND DISCUSSION | 53 Among nootropic and psychostimulant medicines sold by the pharmacies in 2019, sales of gamma-aminobutyric acid (GABA), the only medicine in this group from the State Formulary of Medicines, amounted to 114,000 packages worth UAH 2.6 million, which was 2 percent in packaged medicines and 0.2 percent in cash. The leader in public procurement in the number of packages for all ve years was piracetam, which as of 2019 had 45 percent among all public procurement of nootropic and psychostimulant medicines (see Annex 5 Figure 5.21and Figure 5.22-23). Citicoline and the combination of piracetam with thiotriazoline were also among the top three over ve years. Phenibut had the fourth place during 2017–2019. In terms of cash, citicoline was the leader in public procurement during 2015–2017, although in 2018– 2019 psychostimulant ca eine citrate took the rst place (a high-value medicine for treatment of primary apnea in premature infants). The top three in 2019 also included atomoxetine—a medicine used in the treatment of attention de cit hyperactivity disorder (ADHD). Cattle brain hydrolysate, which held the second place in 2015–2017, moved down to the fth place in 2019, while the combination of piracetam with thiotriazoline and piracetam took the fourth and the sixth places, respectively. Choline alfoscerate and phenibut held seventh and eighth places, respectively. Among nootropic and psychostimulant medicines that were part of public procurement in 2019, the sales of the medicine from the State Formulary of Medicines (GABA) amounted to 4,000 packages worth UAH 90,000, which was 2 percent in packages and 0.2 percent in monetary value. 5.2.2 Hypnotics and sedatives (N05C according to ATC classification) In terms of the number of packages throughout the ve years, the sleeping pills and sedatives were the leaders in this section by a signi cant margin—in 2019 this group accounted for 57 percent of the total section and in 2015 for 70 percent. But in monetary terms, they took only the fourth place in 2019, because most of such medicines are quite cheap but so widespread. Total sales in 2019 UAH 477 million 17.9 million packages Publicly procured 1.0 percent 1.3 percent In 2019, the total volume of pharmacy sales and public procurement of sleeping pills and sedatives amounted to UAH 477 million for 17.9 million packages (see Annex 5 Figure 5.24). Pharmacy sales of medicines in this group decreased over ve years by 46 percent in packaged drugs, increased by 15 percent in Ukrainian hryvnia, and decreased by 3 percent in US dollar (see Annex 5 Figure 5.25). Public procurement over ve years increased by 21 percent in packaged drugs, 114 percent in Ukrainian hryvnia, and 81 percent in US dollar (see Annex 5 Figure 5.29). The share of public procurement increased over ve years from 0.5 to 1.0 percent in packaged drugs and from 0.7 to 1.3 percent in 54 | 5. RESULTS AND DISCUSSION monetary terms. Nearly double decrease in the volume of pharmacy sales of the group’s medicines was accompanied by a signi cant increase in public procurement, the share of which in the overall turnover structure doubled. However, pharmacy sales still made up 99 percent of the group’s total volumes. The combined medicine of phenobarbital with ethyl ester of bromoisovaleric acid was the absolute leader in the number of packages sold by the pharmacy network and in monetary terms among hypnotics and sedatives for all ve years. More than 6 million packages worth about UAH 114 million were sold, accounting for 33 percent of packages and 24 percent in monetary terms in the whole group as of 2019 (see Annex 5 Figure 5.26 and Figure 5.27-28). Valerian preparations ranked second under all indicators for the whole period. More than 5 million packages were sold in pharmacies with a total value of UAH 106 million, which was about 28 percent of packages and 23 percent in cash in the whole group as of 2019. In previous years, sales of these drugs were higher, with a maximum amount in 2015, when sales of the combined drug of phenobarbital with ethyl ester of bromoisovaleric acid exceeded 12 million packages and sales of valerian preparations reached 11 million packages. It is also important to emphasize that in the number of packages sold, the three leaders of this group were also in the top three among the total number of drugs discussed in this report—during all ve years covered by the study. In 2015, more than 27 million packages of these three drugs were sold, which accounted for more than half (52.0 percent) of all packaged drugs included in the rst and second sections of this report. In 2019, their share of sales decreased but still accounted for more than one-third (35.6 percent) of all packages of medicines included in this report. The third and the fourth places in the number of packages for all ve years were taken by motherwort preparations and doxylamine, respectively. The third place (in cash) was held by doxylamine for ve years, and the fourth place for all these years belonged to the combined preparations of valerian, mint, and lemon balm. Only two of all INNs in this group are available in the State Formulary of Medicines—zopiclone and zaleplon—with a signi cant predominance of the rst medicine in the ranking. In 2019, zopiclone was in the 8th place with 309,000 packages, although it held the 5th place in monetary terms (UAH 19 million), while zaleplon held much lower positions—27th and 22nd—in the number of packages and in cash, respectively. Homeopathic medicines also had high demand, which together occupied the sixth position in monetary terms, with sales amounting to UAH 18 million as of 2019. Among the sleeping pills and sedatives sold by the pharmacy network in 2019, sales of medicines from the State Formulary of Medicines (zopiclone and zaleplon) amounted to 331,000 packages worth UAH 22.7 million, which was only 2 percent in packaging and 5 percent in monetary terms. The leader in public procurement in the number of packages for all ve years was the combination of phenobarbital with ethyl ester of bromoisovaleric acid, which in 2019 5. RESULTS AND DISCUSSION | 55 accounted for almost 50 percent of packages of medicines in this group, and valerian medicines consistently were second with 26 percent of packages, as of 2019 (see Annex 5 Figure 5.30- Figure 5.32). The top three in 2019 also included a combination of valerian, mint, and lemon balm. In 2019, zopiclone and zaleplon held the fourth and tenth places, respectively, by the number of packages. In monetary terms, the rst place was taken by phenobarbital preparations with ethyl ester of bromoisovaleric acid until 2018 and in 2019 they were overtaken by dexmedetomidine used for sedation of adult patients in intensive care units and procedural sedation. The third place in monetary terms was taken by the combined preparations of valerian, mint, and lemon balm, and the fourth place was taken by the preparations of valerian. Zopiclone and zaleplon had the fth and seventh places, respectively, in monetary value. Among the sleeping pills and sedatives that were part of public procurement in 2019, sales of medicines available in the State Formulary of Medicines (zopiclone and zaleplon) amounted to 9,000 packages worth UAH 626,000, which was 5 percent in packages and 10 percent in cash. 5.2.3 Antiepileptic medicines (N03 according to ATC classification) Pharmacy sales of antiepileptics increased over ve years by 39 percent in packaged medicines, 126 percent in Ukrainian hryvnia, and 92 percent in US dollar. Public procurement increased over ve years by 228 percent in packaged drugs, 249 percent in Ukrainian hryvnia, and 199 percent in US dollar. Total sales in 2019 UAH 551 million 2.8 million packages Publicly procured 4.4 percent 7.9 percent In 2019, the total volume of pharmacy sales and public procurement of antiepileptic medicines amounted to UAH 551 million for 2.8 million packages (see Annex 5 Figure 5.26). Pharmacy sales of medicines in this group increased over ve years by 39 percent in packaged medicines, 126 percent in Ukrainian hryvnia, and 92 percent in US dollar (see Annex 5 Figure 5.34). Public procurement increased over ve years by 228 percent in packaged drugs, 249 percent in Ukrainian hryvnia, and 199 percent in US dollar (see Annex 5 Figure 5.38). The share of public procurement increased over ve years from 3.5 to 7.9 percent in packaged drugs and from 2.9 to 4.4 percent in monetary value. A signi cant increase in pharmacy sales of medicines in this group, especially a threefold increase in public procurement, indicates an increase in coverage of the need for anticonvulsants, some of which can be used as normothymics in treatment of persons with bipolar disorder and more. In 2019, pregabalin, carbamazepine, and valproate were among the top three in the number of packages sold by the pharmacy network among antiepileptic medicines (see Annex 5 Figure 5.35 - Figure 5.37). Until 2018 carbamazepine held the rst place in the group, before the rapid annual growth in sales of pregabalin brought it to the rst place in 56 | 5. RESULTS AND DISCUSSION 2019. The fourth and fth places in 2019 were occupied by lamotrigine and gabapentin. In monetary terms, pregabalin was rst in 2016–2019. Its leading position among the competitors increased annually and in 2019 the sales of pregabalin accounted for 40 percent of all antiepileptic medicines in cash. The second and third places during 2016– 2019 were taken by valproate and carbamazepine, respectively. In 2015, the rst place was held by valproate, followed by carbamazepine and pregabalin. In 2019, places 4 to 7 were held, respectively, by levetiracetam, lamotrigine, gabapentin, and topiramate. Among the antiepileptic medicines sold by the pharmacy network in 2019, the sales of medicines available in the State Formulary of Medicines (pregabalin, carbamazepine, valproate, lamotrigine, gabapentin, topiramate, phenytoin, clonazepam, and phenobarbital) amounted to 2.4 million packages worth UAH 458 million, which was 92 percent in packaged drugs and 87 percent in monetary value. The leader in public procurement in the number of packages for all ve years was carbamazepine, which amounted to 52 percent of packages in all public procurement of antiepileptic medicines as of 2019 (see Annex 5 Figure 5.39 - Figure 5.41). The second place, also for all ve years, was taken by valproate, which covered 24 percent of packages. Places 3 to 5 in the number of packages were occupied by lamotrigine, pregabalin, and phenobarbital, respectively, with a signi cant gap separating them from the rest of the medicines in the list. In monetary terms, for ve years, valproate took the lead while yielding 48 percent of sales in cash as of 2019. Carbamazepine and pregabalin were also in the top three with lamotrigine and levetiracetam taking the fourth and the fth place as of 2019. Topiramate, which had the second place in monetary terms in 2015–2016 and third place in 2017 had only the eighth place in 2019 after a sharp drop in sales in 2018. Among the antiepileptic medicines that were part of public procurement in 2019, sales of medicines available in the State Formulary of Medicines (pregabalin, carbamazepine, valproate, lamotrigine, gabapentin, topiramate, phenytoin, clonazepam, and phenobarbital) amounted to 215,000 packages worth UAH 22.5 million, which was 96 percent in packaged drugs and 93 percent in monetary value. It should be noted that lamotrigine and carbamazepine can be used not only as antiepileptic medicines but also as normothymics in the treatment of bipolar a ective disorder and other disorders. However, the research methodology does not allow to determine the proportion of these medicines used in the treatment of bipolar a ective disorder and the proportion in the treatment of patients with epilepsy. 5. RESULTS AND DISCUSSION | 57 5.2.4 Antiparkinsonian medicines (N04 according to ATC classification) Pharmacy sales of antiparkinsonian medicines increased over ve years by 25 percent in packaged drugs, 87 percent in Ukrainian hryvnia, and 58 percent in US dollar. Public procurement decreased in ve years by 15 percent in packaged medicines but increased by 71 percent in Ukrainian hryvnia and 44 percent in US dollar. Among antiparkinsonian medicines that were part of public procurement during 2019, the share of medicines from the State Formulary of Medicines (all except the combined drug levodopa with benserazide) was 99.96 percent in packaged drugs and 99.5 percent in cash. Total sales in 2019 UAH 156 million 736,000 packages Publicly procured 1.7 percent 7.1 percent In 2019, the total volume of pharmacy sales and public procurement of antiparkinsonian medicines amounted to UAH 156 million for 736,000 packages (see Annex 5 Figure 5.42). Pharmacy sales of medicines in this group increased over ve years by 25 percent in packaged drugs, 87 percent in Ukrainian hryvnia, and 58 percent in US dollar (see Annex 5 Figure 5.43). Public procurement decreased in ve years by 15 percent in packaged medicines but increased by 71 percent in Ukrainian hryvnia and 44 percent in US dollar (see Annex 5 Figure 5.47). The share of public procurement decreased over ve years from 10.0 to 7.1 percent in packaged medicines and from 1.9 to 1.7 percent in cash. In contrast to the group of antiepileptic medicines, the antiparkinsonian medicines showed strengthening in the pharmacy out-of-pocket segment and weakening in public procurement. Trihexyphenidyl was the absolute leader in the number of packages sold by the pharmacies among antiparkinsonian medicines during 2015–2019, the sales volume of which was 46 percent of the whole group (see Annex 5 Figure 5.44 - Figure 5.46). Pramipexole and levodopa+carbidopa were also in the top three in 2019 in the number of packages, while amantadine was fourth. In monetary terms, the same medicines were consistently in the top four during the ve years but in a di erent order: (1) levodopa+carbidopa, (2) pramipexole, (3) amantadine, and (4) trihexyphenidyl (although in 2018 rasagiline temporarily pushed trihexyphenidyl down to the fth place). Among the antiparkinsonian medicines sold by the pharmacy network in 2019, sales of medicines available in the State Formulary of Medicines (all except the combined medicine levodopa with benserazide, rasagiline, and rotigotine) amounted to 669,000 packages worth UAH 144 million, which was 98 percent in packaged drugs and 95 percent in cash. The absolute leader in public procurement both in the number of packages and in cash for all ve years was trihexyphenidyl, which as of 2019 had 91 percent of all public procurement of antiparkinsonian medicines in packages and only 41 percent in cash 58 | 5. RESULTS AND DISCUSSION due to low cost, compared with other medicines in the group (see Annex 5 Figure 5.48 - Figure 5.50). The top three in 2019 both in packaging and cash also included levodopa+carbidopa and amantadine. Among antiparkinsonian medicines that were part of public procurement during 2019, the share of medicines from the State Formulary of Medicines (all except the combined drug levodopa with benserazide) was 99.96 percent in packaged drugs and 99.5 percent in cash. 5.2.5 Other medicines that can be used in the treatment of persons with mental disorders In 2019, the total volume of pharmacy sales and public procurement of this mixed group of di erent medicines that are not included in the previous groups amounted to UAH 932 million for 4.5 million packages. Pharmacy sales of medicines in this group decreased over ve years by 20 percent in packaged medicines but increased by 60 percent in Ukrainian hryvnia and 36 percent in US dollar. Public procurement grew over ve years by 44 percent in packaged medicines, 63 percent in Ukrainian hryvnia, and 36 percent in US dollar. Total sales in 2019 UAH 932 million 4.5 million packages Publicly procured 2.2 percent 2.8 percent The list of medicines included in this group is formed from the number of medicines that are not included in the previous sections but target the nervous system, have a calming e ect, and so on. They can be further re ected in brand names by using letter combinations such as ‘… nevr…’, ‘… nerv…’, ‘… neuro…’, and ‘… sed…’. In addition, this group includes a part of medicines from the N07X group according to the ATC classi cation. In 2019, the total volume of pharmacy sales and public procurement of this group of medicines amounted to UAH 932 million for 4.5 million packages (see Annex 5 Figure 5.51). Pharmacy sales of medicines in this group decreased over ve years by 20 percent in packaged medicines but increased by 60 percent in Ukrainian hryvnia and 36 percent in US dollar (see Annex 5 Figure 5.52). Public procurement grew over ve years by 44 percent in packaged medicines, 63 percent in Ukrainian hryvnia, and 36 percent in US dollar (see Annex 5 Figure 5.56). The share of public procurement increased over ve years from 1.6 to 2.8 percent in packaged medicines and from 2.1 to 2.2 percent in cash. For all ve years, the leader in the number of packages sold by the pharmacy network was a medicine combining three B vitamins: thiamine, pyridoxine, and cyanocobalamin (the brand names of most of the medicines with this composition available in the market contain elements such as ‘…nevr…’, ‘…nerv…’, ‘…neuro…’, and ‘…axon…’) (see Annex 5 Figure 5.53 - Figure 5.55). The second place in packaging in 2018–2019 was taken by ethylmethylhydroxypyridine succinate, although before 2018 the second place 5. RESULTS AND DISCUSSION | 59 was occupied by glycine, which has moved down to the third place since 2018. It should be noted that glycine is also included in the ‘nootropic and psychostimulant medicines’ section, which is associated with di erent methods of medicines registration. The fourth place in 2019 was taken by clonidine, which is mainly prescribed as an antihypertensive medication but can also be used in the treatment of persons with mental disorders due to opioid use, and the fth place was occupied by deproteinized hemoderivative from the blood of calves, which in 2017–2018 had the fourth place and the third place in 2015–2016. The combined drug of cytidine and uridine ranked sixth in 2019. The leader in monetary terms during 2018–2019 was ethylmethylhydroxypyridine succinate, which amounted to 43 percent of the group’s cash yield. A combined medicine containing three B vitamins (thiamine, pyridoxine, and cyanocobalamin) had the second place in 2019, and the third place was occupied by deproteinized hemoderivative from the blood of calves, which in 2018 took the second place in the group and the rst place in 2015–2017, amounting to 35 percent of monetary value in 2015. Among the ‘other medicines’ sold by the pharmacy network in 2019, sales of clonidine, the only medicine in the group from the State Formulary of Medicines, amounted to 412,000 packages worth UAH 9.4 million, which was 9 percent in packaged drugs and only 1 percent in monetary terms. The leader in public procurement in the number of packages during four out of the ve years was a drug combining three B vitamins: thiamine, pyridoxine, and cyanocobalamin, slightly giving way in 2016 to the deproteinized hemoderivative from calf blood (see Annex 5 Figure 5.57 - Figure 5.59). The top three as of 2019 included the combined medicine pyridoxine and benfotiamine as well as glycine. In 2019, ethylmethylhydroxypyridine succinate, a deproteinized hemoderivative from calf blood, and clonidine were fourth, fth, and sixth, respectively, with a signi cant gap separating them from other medicines. In monetary terms, in 2019, the top three medicines were ethylmethylhydroxypyridine succinate; deproteinized hemoderivative from calf blood; and a combined drug of thiamine, pyridoxine, and cyanocobalamin; it should also be noted that deproteinized hemoderivative from calf blood took the lead in the group until 2018. Among the ‘other medicines’ that were part of public procurement during 2019, sales of the medicines listed in the State Formulary of Medicines (clonidine) amounted to 9,000 packages worth UAH 0.7 million, which was 7.5 percent in packaged drugs and 3.4 percent in cash. 60 | 5. RESULTS AND DISCUSSION 5.3 Dietary Supplements That May Be Associated with Mental Health Treatment Dietary supplements are not coded in the ATC classi cation; instead, they are classi ed into groups according to the internal classi cation used by Support in Market Development (SMD), whose initial data were used in this study. The list of groups of dietary supplements, which are presented in aggregated form in the general characteristics of the section is as follows: y Dietary supplements that may be associated with central nervous system (CNS) function39 39Bath salts not included. y Dietary supplements that may be used in connection with alcohol consumption y Dietary supplements that can be used in connection with smoking. In 2019, pharmacy sales of dietary supplements that may be related to mental health amounted to UAH 139 million for 2.6 million packages. Pharmacy sales of items in this section increased over ve years by 17 percent in packaged medicines, 107 percent in Ukrainian hryvnia, and 78 percent in US dollar. Total sales in 2019 UAH 139 million 2.6 million packages Publicly procured insigni cant insigni cant Despite the higher value added tax (VAT) in the category of dietary supplements (20 percent), compared to medicines (7 percent), the simpli ed registration requirement for dietary supplements often encourages manufacturers to produce their products containing plant components, vitamins, minerals, and so on as dietary supplements. Estimation of sales of dietary supplements is complicated by the fact that their sales are signi cant not only in pharmacies but also in supermarkets, online stores, and more. Sales of these products are likely also a driver of out-of-pocket costs, which showed growth over the ve years. The analysis presented in this section applies only to the pharmacy sales of dietary supplements. In 2019, pharmacy sales of dietary supplements that may be related to mental health amounted to UAH 139 million for 2.6 million packages (Figure 13 and Annex 6 Figure 6.1–Figure 6.4). Pharmacy sales of items in this section increased over ve years by 17 percent in packaged medicines, 107 percent in Ukrainian hryvnia, and 78 percent in US dollar. Public procurement of dietary supplements in the above groups is insigni cant. 5. RESULTS AND DISCUSSION | 61 Figure 13. Dietary supplements that may be associated with mental health treatment: pharmacy sales and public procurement of 62 | 5. RESULTS AND DISCUSSION separate groups of dietary supplements Public procurement (0%) Public procurement (0%) Рackages UAH 2019 2019 Pharmacy sales (100%) Pharmacy sales (100%) Dietary supplements Dietary supplements Dietary supplements Dietary supplements that may be used that can be used that may be used that can be used in connection with in connection with in connection with in connection with alcohol consumption smoking (0.1%) alcohol consumption smoking (0.1%) (5.4%) (10.1%) 2.6 million UAH packages 139 million in 2019 in 2019 Dietary supplements Dietary supplements that may be associated that may be associated with central nervous with central nervous system activity (94.5%) system activity (89.8%) 40Bath salts not included. 5.3.1 Dietary supplements that may be associated with CNS activity40 In 2019, the pharmacy sales of dietary supplements that may be associated with the functioning of the CNS amounted to UAH 131 million for 2.3 million packages (see Annex 6 Figure 6.6). The combination of di erent phyto-ingredients took the lead in the number of packages sold in this group of dietary supplements during all ve years (see Annex 6 Figure 6.7 - Figure 6.9). For four out of ve years, the second place was occupied by supplements containing valerian, and the third place for most of the years was held by supplements with ginkgo biloba, which had the second place in 2016 and lost its third place to glycine in 2019. The fth place in 2019 was taken by combined supplements with di erent composition. In monetary terms, the top ve leaders were the abovementioned supplements but in a slightly di erent order. The combinations of di erent phyto- components took the lead again during all ve years. The supplements with ginkgo biloba, combined supplements with di erent composition, valerian, and glycine held second to fth places, respectively, in 2019. 5.3.2 Dietary supplements that may be used in connection with alcohol consumption In 2019, the pharmacy sales of dietary supplements that may be used in connection with alcohol consumption amounted to UAH 7 million for 260,000 packages (see Annex 6 Figure 6.9). The leader in the number of packages sold and in cash in this group of dietary supplements for all ve years was supplements containing parsley (see Annex 6 Figure 6.10 - Figure 6.12). In 2019, the combination of phenylalanine, pyroglutamate, and chitosan had the second place, and third place was taken by the combination of succinic acid, silicon dioxide, and other components. In monetary terms, the rst three leaders were these supplements, although the combination of succinic acid, silicon dioxide, and other components took the second place. 5.3.3 Dietary supplements that can be used in connection with smoking In 2019, pharmacy sales of dietary supplements that can be used in connection with smoking amounted to UAH 97,000 for 2,000 packages (see Annex 6 Figure 6.13). The leader in the number of packages sold in 2019 was combinations of di erent phyto- ingredients (see Annex 6 Figure 6.14 - Figure 6.16). During four out of ve years, the second place was taken by supplements containing thermopsis and plantain, and these supplements were the leader of the group in 2016. In monetary terms, the rst two places were occupied by the same supplements, but supplements containing thermopsis and plantain were in the rst place as of 2019. 5. RESULTS AND DISCUSSION | 63 6. KEY CHALLENGES High out-of-pocket spending. Mental disorders pose a serious problem globally as well as in Ukraine. The majority of public resources allocated for mental health are channeled to nance the cost of medical service, and participation of public resources in procurement of mental health medication is limited. The share of publicly procured medication increased in 2015–2019, but a signi cant number of drugs associated with treatment of mental health disorders are still procured by patients out of pocket. Only a limited share of such medications procured directly by patients are evidence based. Out-of-pocket costs of purchasing medicines and dietary supplements in pharmacies listed in this study exceed the funding for mental health under the PMG, which places a signi cant nancial burden on the families with family members su ering from mental disorders. Low awareness. As a result of stigmatization, in Ukraine it is customary not to seek help in case of sleep disorders, anxiety, low mood, memory problems, and chronically severe disorders or prolonged symptoms. As a result, individuals’ mental health problems are deeply ingrained and symptomatic treatment and self-medication become a common practice. Lack of primary care. The ‘entry points’ for people seeking or in need of mental health care are often general practitioners, neurologists, cardiologists, other specialists, and nurses or at the tertiary level of care. At the primary care level, prescribing medicines for mental health care is a common but irregular practice. Although the gatekeeping role of primary care is globally recognized, in Ukraine primary care has played a limited role in the service delivery of mental health. Role of pharmacies. The pharmacy network is the main ‘entry point’ for most persons with mental disorders in Ukraine. Pharmacies are responsible for treating a majority of mental health patients and the volume of drugs sold in this context is signi cant. However, the current pharmacist protocols for dispensing OTC medicines have not been updated since 2013 and are signi cantly inconsistent with the State Formulary of Medicines. In addition, worryingly it is found that there is a serious lack of training and expertise among the pharmacists in the eld of mental health. High rate of hospitalizations. Availability of medicines during inpatient care is higher compared to outpatient care, leading to unnecessary hospitalizations and longer hospital stays. It is also a common practice to purchase some medicines at own expense 64 | 6. KEY CHALLENGES during inpatient treatment, especially when it comes to replacing generic medicines with original medicines. Development and usage of standards. The use of medicines with a weak evidence base in the treatment of mental disorders as well as medicines that are not in the State Formulary of Medicines is a common practice. Some valid uni ed clinical health care protocols which could be used simultaneously with the new clinical protocols still contain medicines that are not included in the State Formulary of Medicines, leading to poor quality of medical care and excessive ine cient spending. Data concerns. Statistical indicators of psychiatric care provided do not correspond to the indicators of medicine ow and fail to explain year-to-year changes in the volume of pharmacy sales and public procurement of medicines. That may be due to (a) inaccuracy of statistical reporting, (b) practices of prescribing an extensive range of medicines in the treatment of mental disorders, (c) use of medicines in the treatment of both mental and other disorders, and (d) poorly regulated practice of symptomatic treatment and self-medication. Access to electronic data on mental health services provided is currently limited. The reimbursement of some psychotropic drugs, initiated in 2021, has signi cantly accelerated the integration of electronic medical record systems in this eld, but the process of digitalization still has a long way to go. 6. KEY CHALLENGES | 65 7. RECOMMENDATIONS Improving mental health awareness. Following the feedback from the National Mental Health Concept Note which suggested the lack of awareness of mental health in the society and insu cient knowledge of prevention approaches, Ukraine has invested in mental health promotion activities. Given the signi cant volume of pharmacy sales of mental health drugs, going forward Ukraine must look to integrate awareness activities within the mental health service delivery with the aim of destigmatizing the mental health sector as well as encourage demand for mental health seeking behavior. Promoting the gatekeeping role of PHCs. There is a dire need for the Government of Ukraine to make concerted e orts toward integrating mental health into the service delivery at the primary level. In addition, the gatekeeping function of screening and case detection, service delivery, and appropriate referral to specialist care must be the responsibility of PHC givers, which is currently lacking. To expand mental health capacity in primary care, the Mental Health Gap Action (mhGAP) was constituted in 2019 to train family doctors and nurses, which is a step in the right direction and must be scaled up to the national level. Human health resources. It is critical for mental health care providers to undergo continuous training and capacity-building exercise to cater to the needs of patients seeking help and treatment. This includes professional training for all levels of service providers including specialists, nurses, and pharmacists. Rightly, Ukraine is expanding training programs and centers for mental health professionals and practitioners with the aim of providing person-centered and rights-based care to the needy. Health technology assessment. Ukraine must look to build a strong and high-quality medical technology assessment system that will assist in evidence-based decision- making in the eld of mental health. This is particularly relevant for the development of clinical protocols, standards, and guidelines; maintaining of transparency and accountability in the system; and monitoring and evaluation of the quality of services provided. Expanding electronic prescriptions to all prescription and OTC medicines can be considered. Ensuring open access to data on prescription and receipt of medicines with the assistance of the NHSU and the State Enterprise ‘Electronic Health’ system can also be explored while protecting sensitive personal data of patients. 66 | 7. RECOMMENDATIONS Improving nancial protection. Ukraine’s mental health system continues to bear the burden of high out-of-pocket spending particularly on drugs for mental disorders. Reimbursement of generic medicines with proven e cacy is a necessary measure to reduce the nancial burden on people with mental disorders and their families. There is an urgent need to increase the availability of medicines used to help people with mental disorders. This will potentially include the expansion of the A ordable Medicines Program, broadening the National List of Essential Medicines and as well as reimbursement of some psychotropic medicines outside the list but from the State Formulary of Medicines. Ukraine might also consider the reimbursement of mental health medicines prescribed by primary care specialists at the PHC level. 7. RECOMMENDATIONS | 67 8. CONCLUSION Ukraine spends a considerable amount on mental health. The government nances mental health close to UAH 4 billion on the contracts with providers of psychiatric care. In addition, out-of-pocket expenditures associated with treatment of mental health conditions made up close to 3 percent of total health care expenditure amounting to UAH 4.5 billion in 2019. This number does not include payment for psychotherapy, social services, and psychosocial support interventions which are incurred but for which data are unavailable. However, the spending also includes signi cant cost of medicines which did not have a su cient evidence base. Our analysis shows that the system of standardization of medical services in the eld of mental health needs to be updated and the gaps need to be lled. Internal contradictions between di erent elements of the system need to be eliminated and greater transparency must be ensured. The process of the use of medical documents by service providers and ensuring their availability for service users could be further simpli ed. The importance of leadership at the government and professional levels is underscored for proper regulation and standardization of legislation, protocols, and the listing of Formulary of Medicines. Finally, it is important to recognize that health care response will be much more e ective if it focusses on promotion of mental health and prevention of acute mental health conditions. While the government allocates the budget at the tertiary level and patients spend most of their budget on medicines, those expenses are for reactive treatment rather than the promotion of mental health. Ukraine is currently undergoing the process of integrating mental health at the PHC level. Mental health services should be provided for patients starting from their family doctors. Interventions should be not only pharmaceutical focused but evidence based and human oriented with a focus on psychosocial services and with medicines only in accordance with the guidelines for medical care. Appropriate leadership and policy could improve access to mental health services, e ective use of the state budget, and investment in people’s health. 68 | 8. CONCLUSION ANNEXES Annex 1. Methodology Retail (pharmacy) sales. A sample of data of retail sales through pharmacies became the basis for creating a retail database. As of the end of 2020, the sample of data extracted presented data for about 12 percent of the general number of pharmacies. The sample included pharmacies of di erent types of ownership and a liated with di erent pharmacy networks. The sample was evenly distributed throughout Ukraine, in proportion to the distribution of pharmacy outlets among all the pharmacies. A mathematical model of extrapolation of strati ed random sampling was used to form the database with self-learning multilayer neural networks. The national and regional data were generated for the whole range of medicines with the extrapolation method. Public procurement. Starting from April 2016, public procurements were organized through the web portal Prozorro. Data were extracted from all completed transactions published on the Prozorro website. To create a database, the package of tender documents was standardized, processed, and brought in compliance with a standard form for further analysis and decision-making. Information on each transaction was taken from the contracts (speci cations and appendixes) and entered into the database with the level of granularity down to the description of the purchased item (down to stock keeping unit [SKU]), indicating manufacturers, distributors, the number of packages, and prices. The data were standardized, speci cally by assigning the ATC classi cation code and the INN and also by using the information on the availability of essential medicines in the national list, the category of prescription/OTC medicines, and so on. The database of Ukrainian public procurement consists of the following levels: (a) Procurement from the national budget • The centralized procurement process is re ected in the orders of the Ministry of Health of Ukraine for the distribution of medicines on the website of the ministry as well as the international United Nations Development Programme (UNDP) organizations and Crown Agents. • Procurement agencies use the ‘Medical Procurement of Ukraine,’ a state- owned enterprise. This organization provides for the centralized procurement of medicines and medical devices from the state budget under selected ANNEXES 1 | 69 centralized programs (information on concluded contracts after bidding is from the Prozorro website). (b) Procurement from the regional budget • Regional tenders include tenders by the health departments of state administrations of regions and oblast-level special distribution hubs (for biddings completed before 2016, information is from the public procurement web portal41; from 2016 to 2019, information on contracts concluded after 41https://tender.me.gov. bidding is from the Prozorro website). ua; http://tendergid.ua • Regional subthreshold procurements include those made by local authorities worth less than UAH 200,000. The information was taken from the contracts concluded after the bidding process held by the health departments of state administrations of regions and regional special distribution hubs and from the Prozorro website. (c) Health care facilities’ budgets • Tenders of health care facilities: communal health care facilities; research institutions; military, penitentiary, and other facilities (for biddings completed before 2016, information is from the public procurement web portal; from 2016 to 2019, information on contracts concluded after bidding is from the Prozorro website). • Subthreshold procurement of health care facilities: acquisitions worth less than UAH 200,000 made directly by health care facilities (from the Prozorro website). 70 | ANNEXES 1 Annex 2. Financing of Mental Health System Table 2.1. Estimated funding for psychiatric care facilities, under the PMG in Q2–Q4 2020 Funding (for 9 months No. of NHSU packages starting from April 1, 2020), facilities UAH, millions Psychiatric care for adults and children 198 1,720 OAMT of persons with mental and behavioral 234 25 disorders due to use of opioids Outpatient secondary (specialized) and tertiary 63 122 a (highly specialized) medical care for adults and (specialized ) children, including medical rehabilitation and dental care Other packages, in addition to the above 25 112 a (specialized ) Transitional funding of comprehensive health 61 585 a,b care delivery by health care facilities (starting (specialized ) from July 1, 2020) Transitional funding of comprehensive health 85 239 care delivery by health care facilities (starting (specializeda,b) from September 1, 2020) Total 364 2,803 Source: NHSU42. The analysis was conducted by the authors. Funding for outpatient psychiatric care and 42https://nszu.gov.ua/e- transitional nancial support are not considered in nonspecialized institutions that have not bene tted from the data/dashboard/pmg- ‘psychiatric care for adults and children’ package. contracts Note: At least UAH 2.8 billion was spent on mental health services as part of the PMG (since April 1, 2020). a. Refers to institutions whose main specialization is provision of psychiatric care to the population. b. Refers to facilities that were considered as loss-making after the implementation of the new provider payment methods and therefore eligible for ‘transitional funding of comprehensive health care delivery by health care facilities. Table 2.2. Estimated funding for psychiatric care facilities under the PMG in Q1 2021 Funding (for 3 months, starting No. of NHSU packages from January 1, 2021), UAH facilities million Psychiatric care for adults and children 197 574 OAMT of persons with mental and 225 8 behavioral disorders due to use of opioids Other packages, in addition to the above 83 584 a (specialized ) Total 354 1,166 ANNEXES 2 | 71 Annex 3. Statistics with Regard to Mental Health Care Indicators 72 | ANNEXES 3 Table 3.1. General statistics on the provision of outpatient psychiatric care to persons diagnosed with mental disorders (2015– 2019) 2015 2019 Changes for 2015–2019 No. of No. Persons No. ICD-10 persons Total no. of persons Total no. with newly Diagnostic group of persons codes with newly % of persons as % with newly % of persons % diagnosed as of Dec diagnosed of Dec 31 diagnosed as of Dec 31 disorders 31 (%) disorders disorders (%) Total F00–F99 194,479 100 1,681,577 100 189,005 100 1,524,699 100 −3 −9 Dementia F00–F03 6,207 3.2 43,086 2.6 6,075 3.2 42,325 2.8 −2 −2 Mental disorders due to use of F10 96,694 49.7 605,500 36.0 85,623 45.3 490,703 32.2 −11 −19 alcohol Of them, dependence F10.2.3 26,835 13.8 468,746 27.9 29,013 15.4 376,362 24.7 +8 −20 syndrome and withdrawal Mental disorders due to use of F11 n.a. n.a. n.a. n.a. 5,055 2.7 42,221 2.8 n.a. n.a. opioids Of them, dependence F11.2.3 n.a. n.a. n.a. n.a. 2,918 1.5 35,653 2.3 n.a. n.a. syndrome and withdrawal Mental disorders due to use of F17 7,861 4.0 8,087 0.5 6,074 3.2 6,188 0.4 −23 −23 tobacco Table 3.1. General statistics on the provision of outpatient psychiatric care to persons diagnosed with mental disorders (2015– 2019) 2015 2019 Changes for 2015–2019 No. of No. Persons No. ICD-10 persons Total no. of persons Total no. with newly Diagnostic group of persons codes with newly % of persons as % with newly % of persons % diagnosed as of Dec diagnosed of Dec 31 diagnosed as of Dec 31 disorders 31 (%) disorders disorders (%) Of them, dependence F17.2.3 7 <0.1 8 <0.1 22 <0.1 31 <0.1 ×3.1 ×3.9 syndrome and withdrawal Schizophrenia, schizotypal, and F20–F29 6,763 3.5 173,157 10.3 6,085 3.2 166,931 10.9 −10 −4 delusional disorders Of them, schizophrenia F20 2,476 1.3 125,111 7.4 2,042 1.1 116,741 7.7 −18 −7 Mood disorders F30–F39 3,422 1.8 44,526 2.6 4,112 2.2 42,361 2.8 +20 −5 Of them, bipolar a ective F30–F31 n.a. n.a. n.a. n.a. 521 0.3 8,086 0.5 n.a. n.a. disorder, and manic episode Including bipolar a ective F31 n.a. n.a. n.a. n.a. 380 0.2 6,202 0.4 n.a. n.a. disorder Of them, depressive disorders F32–F33 n.a. n.a. n.a. n.a. 2,867 1.5 24,785 1.6 n.a. n.a. Including recurrent depressive F33 n.a. n.a. n.a. n.a. 830 0.4 13,237 0.9 n.a. n.a. ANNEXES 3 | 73 disorder Neurotic, stress-related, and F40–F48 18,203 9.4 129,746 7.7 19,394 10.3 119,269 7.8 +7 −8 somatoform disorders Table 3.2. General statistical information on the provision of inpatient psychiatric care to persons diagnosed with mental disorders 74 | ANNEXES 3 (2015–2019) 2015 2019 Changes for 2015–2019 ICD-10 No. of persons No. of persons Persons Bed- Diagnostic group who received who received who received codes % Bed-days % % Bed-days % days inpatient inpatient inpatient psychiatric (%) psychiatric care psychiatric care care (%) Total F00– 297,063 100 12,102,183 100 302,218 100 12,987,547 100 +2 +7 F99 Dementia F00– 9,097 3.1 681,665 5.6 7,737 2.6 703,659 5.4 −15 +3 F03 Mental disorders due to 99,218 33.4 1,478,632 12.2 108,307 35.8 1,444,595 11.1 +9 −2 F10 use of alcohol Of them, dependence 76,512 25.8 1,241,062 10.3 76,129 25.2 1,130,877 8.7 −1 −9 F10.2.3 syndrome and withdrawal Mental disorders due to n.a. n.a. n.a. n.a. 6,560 2.2 77,841 0.6 n.a. n.a. F11 use of opioids Of them, dependence n.a. n.a. n.a. n.a. 6,260 2.1 71,843 0.6 n.a. n.a. F11.2.3 syndrome and withdrawal Mental disorders due to n.a. n.a. n.a. n.a. 3 <0.1 55 <0.1 n.a. n.a. F17 use of tobacco Of them, dependence n.a. n.a. n.a. n.a. 3 <0.1 55 <0.1 n.a. n.a. F17.2.3 syndrome and withdrawal Table 3.2. General statistical information on the provision of inpatient psychiatric care to persons diagnosed with mental disorders (2015–2019) 2015 2019 Changes for 2015–2019 ICD-10 No. of persons No. of persons Persons Bed- Diagnostic group who received who received who received codes % Bed-days % % Bed-days % days inpatient inpatient inpatient psychiatric (%) psychiatric care psychiatric care care (%) Schizophrenia, schizotypal F20– 73,309 24.7 5,544,898 45.8 71,549 23.7 6,142,952 47.3 −2 +11 and delusional disorders F29 Of them, schizophrenia F20 60,941 20.5 5,000,941 41.3 58,380 19.3 5,403,482 41.6 −4 +8 Mood disorders F30– 12,647 4.3 495,226 4.1 12,840 4.2 491,784 3.8 +2 −1 F39 Of them, bipolar a ective n.a. n.a. n.a. n.a. 3,652 1.2 185,002 1.4 n.a. n.a. F30– disorder, and manic F31 episode Including bipolar a ective n.a. n.a. n.a. n.a. 3,235 1.1 132,361 1.0 n.a. n.a. F31 disorder Of them, depressive F32– n.a. n.a. n.a. n.a. 8,447 2.8 297,880 2.3 n.a. n.a. disorders F33 Including recurrent n.a. n.a. n.a. n.a. 6,273 2.1 228,687 1.8 n.a. n.a. F33 ANNEXES 3 | 75 depressive disorder Neurotic, stress-related, F40– 15,797 5.3 392,671 3.2 16,665 5.5 386,181 3.0 +5 −2 and somatoform disorders F48 Note: n.a. = Not applicable. Use of standards According to Article 14-1 of the Fundamentals of Health Legislation43, the system of 43https://zakon.rada. gov.ua/laws/show/2801- standards in the eld of health care consists of state social norms and industry standards. 12#Text Industry standards in the eld of health care include (a) health care standard (medical standard), (b) clinical protocol, (c) protocol for the provision of rehabilitation in the eld of health care, (d) table for material and technical equipment, and (e) formulary of medicines. Industry standards in the eld of health care are developed and approved by the Ministry of Health of Ukraine. Industry standards in the eld of health care also include other norms, rules, and regulations provided by the laws governing the work in this eld. Only the following uni ed clinical protocols44 for provision of health care to persons 44https://www.dec.gov. ua/cat_mtd/galuzevi- with the following mental health disorders have been developed after the approval of standarti-ta-klinichni- nastanovi/ the medical and technological document (MTD) development mechanism in 2012 in the eld of mental health: (a) Depression (b) Dementia (c) Reaction to severe stress and maladaptation. Post-traumatic stress disorder (d) Autism spectrum disorders (pervasive developmental disorders) (e) Gender dysphoria. There are two other uni ed clinical protocols related to mental health: (a) Epilepsy in children (b) Epilepsy in adults. However, all uni ed clinical care protocols are outdated and need to be revised. Two standards of health care have also been approved: (a) Cessation of tobacco use (b) Mental and behavioral disorders due to opioid use. As of December 2021, there are no new clinical protocols in the eld of mental health approved by the orders of the Ministry of Health of Ukraine (except for the New Clinical Protocol ‘Emergency Care: Prehospital Stage’ approved by the Order of the Ministry of Health of Ukraine No. 1269, dated 05.06.201945, which contains guidelines 3.5. ‘Mental 45https://zakon.rada.gov. ua/rada/show/v1269282- Disorders’ and 3.3. ‘Excited or Aggressive Patient/Behavioral Emergency Care’). 19#Text As of December 2021, the ‘old’ clinical protocols for health care under the ‘Psychiatry’ specialty46 approved in 2007 remain in e ect (until September 1, 2022) in addition to 46https://zakon.rada.gov. ua/rada/show/v0059282- the uni ed and new clinical protocols of health care speci ed in Order No. 751. However, 07#Text 76 | ANNEXES 3 the ‘old’ clinical protocols under the ‘Narcology’ specialty were abolished by the Order of 47https://zakon.rada.gov. the Ministry of Health of Ukraine No. 2555, dated 09.11.202047. ua/rada/show/v2555282- 20#Text The use of industry standards is, however, not straightforward. The Order of the Ministry of Health of Ukraine No. 751, dated 28.09.201248, was amended in accordance with the 48https://zakon.rada. gov.ua/laws/show/z2001- Order of the Ministry of Health of Ukraine No. 1422, dated 29.12.201649, to introduce 12#Text a possibility to use new clinical health care protocols. As a result, the new clinical 49https://zakon.rada. protocols became equally eligible along with the uni ed clinical protocols. gov.ua/laws/show/z0530- 17#Text The amendments to Order No. 751 came into force in April 2017. They introduced new clinical protocols, that is, allowed to apply the guidelines from the approved international sources (listed in Annex 4 of this order) without adaptation. While this approach was meant to solve the problem of insu cient coverage of the main mental health disorders with uni ed clinical protocols and prevent the inclusion of medicines and technologies without a strong evidence base in the protocols, the issues with their translation into Ukrainian and the need to approve their introduction by an internal order of the health care facility have hampered the widespread introduction of new clinical protocols in practice. Therefore, the following guidelines in the mental health eld, already translated into Ukrainian, may be approved as new clinical protocols by an internal order of the health care facility head: 50https://guidelines.moz. (a) Guidelines of Duodecim, the Finnish Medical and Research Society50, among gov.ua/ which there are more than 100 guidelines in the eld of mental health (b) mhGAP Guide: for mental, neurological, and substance use disorders for nonspecialized health settings, version 2.0, developed by the World Health 51https://www.who. Organization (WHO)51. int/publications/i/item/ mhgap-intervention- guide---version-2.0 Since 2019, various organizations, including the WHO o ce in Ukraine, the World Bank Group o ce in Ukraine, the Mental Health for Ukraine Project (MH4U Project) and others, have been participating in the implementation of mhGAP in several regions of Ukraine. The Order of the Cabinet of Ministers of Ukraine No. 1215-r, dated 06.10.202152, approved 52https://zakon.rada.gov. the Action Plan for 2021-2023 on the implementation of the Concept of mental health in ua/laws/show/1215-2021- %D1%80#Text Ukraine until 2030, which, in particular, plans to develop a standard for providing mental health care services (up to Q2 2022), as well as medical and technological documents for the standardization of psychiatric care on the basis of evidence-based medicine (up to Q4 2023) and development of state standards of social services to be provided to people with mental disorders (up to Q4 2022). ANNEXES 3 | 77 Annex 4. Medicines Used Mainly for Treatment of Persons with Mental Disorders Figure 4.1. Pharmacy sales of medicines available in the State Formulary of Medicines (% of all medicines in the section used mainly for treatment of persons with mental disorders) In packages, % In cash, % 2015 86.3 82.3 2016 86.5 82.3 2017 88.6 86.2 2018 90.5 88.9 2019 90.1 88.2 Figure 4.2. Public procurement of medicines available in the State Formulary of Medicines (% of all medicines in the section used mainly for treatment of persons with mental disorders) In packages, % In cash, % 2015 98.7 98.2 2016 99.3 98.9 2017 99.8 99.5 2018 99.8 99.6 2019 99.7 99.3 78 | ANNEXES 4 Figure 4.3. Total volume of pharmacy sales and public procurement of medicines used mainly for treatment of persons with mental disorders Packages UAH USD 2015 6,163,028 614,240,094 28,141,293 2016 6,007,553 642,730,033 25,112,328 2017 7,107,589 858,910,791 32,293,800 2018 7,833,757 1,092,566,676 40,181,694 2019 7,828,775 1,249,687,487 48,318,775 Figure 4.4. Volumes of pharmacy sales and public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (packages) 2015 2016 2017 2018 2019 N05B Anti-anxiety medicines 2,509,890 2,262,096 2,676,309 2,886,383 2,614,724 N05A Antipsychotic medicines 1,637,757 1,768,490 2,086,514 2,358,496 2,535,031 N06A Antidepressants 992,651 1,014,045 1,210,971 1,386,087 1,463,022 N07BB Medicines for the treatment of 601,527 523,300 534,544 471,999 472,311 alcohol addiction N06D Medicines for the treatment of 217,360 213,103 256,628 305,605 341,686 dementia N07BC Medicines for the treatment of 66,373 88,846 220,848 258,400 219,379 opioid addiction N07BA Medicines for the treatment of 137,470 137,673 121,775 166,787 182,622 nicotine addiction ANNEXES 4 | 79 Figure 4.5. Volumes of pharmacy sales and public procurement of separate groups of medicines used mainly for treatment of persons 80 | ANNEXES 4 with mental disorders (UAH) 2015 2016 2017 2018 2019 N05A Antipsychotic medicines 171,978,760 188,670,594 273,865,239 346,048,231 407,512,587 N05B Anti-anxiety medicines 176,427,007 192,468,720 236,089,213 280,178,932 310,162,061 N06A Antidepressants 129,165,782 133,060,689 189,985,523 262,692,459 285,739,901 N06D Medicines for the treatment of 63,352,062 64,634,395 86,979,327 114,127,260 133,480,908 dementia N07BA Medicines for the treatment of 30,394,334 21,699,234 23,823,370 36,879,349 48,243,433 nicotine addiction N07BB Medicines for the treatment of 36,309,970 30,439,418 30,089,597 31,343,919 40,272,347 alcohol addiction N07BC Medicines for the treatment of 6,612,178 11,756,982 18,078,521 21,296,525 24,276,250 opioid addiction Figure 4.6. Volumes of pharmacy sales and public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (USD) 2015 2016 2017 2018 2019 N05A Antipsychotic medicines 7,852,042 7,377,852 10,308,054 12,694,576 15,742,181 N05B Anti-anxiety medicines 8,105,767 7,508,982 8,863,721 10,347,761 11,962,264 N06A Antidepressants 5,896,483 5,200,751 7,144,562 9,656,899 11,081,226 N06D Medicines for the treatment of 2,905,751 2,526,132 3,271,573 4,194,278 5,176,926 dementia N07BA Medicines for the treatment of 1,410,841 849,026 896,894 1,349,902 1,875,461 nicotine addiction N07BB Medicines for the treatment of 1,671,190 1,193,167 1,130,058 1,151,013 1,571,850 alcohol addiction N07BC Medicines for the treatment of 299,219 456,417 678,938 787,265 908,869 opioid addiction (a) Pharmacy sales Figure 4.7. Volumes of pharmacy sales of medicines used mainly for treatment of persons with mental disorders Packages UAH USD 2015 5,593,885 556,127,490 25,503,622 2016 5,215,052 554,377,359 21,675,167 2017 6,071,369 726,998,634 27,332,640 2018 6,451,669 927,753,779 34,050,232 2019 6,534,372 1,064,705,607 41,343,123 Figure 4.8. Volumes of pharmacy sales of separate groups of medicines used mainly for treatment of persons with mental disorders (packages) 2015 2016 2017 2018 2019 N05B Anti-anxiety medicines 2,352,372 2,079,604 2,465,130 2,645,942 2,393,033 N05A Antipsychotic medicines 1,298,387 1,265,986 1,409,311 1,459,350 1,751,743 N06A Antidepressants 947,909 951,160 1,137,978 1,302,681 1,371,280 N07BB Medicines for the treatment of 600,631 522,587 532,850 470,614 470,119 alcohol addiction N06D Medicines for the treatment of 215,397 205,710 251,162 301,448 332,104 dementia N07BA Medicines for the treatment of 137,470 137,668 121,770 166,787 182,617 nicotine addiction N07BC Medicines for the treatment of 41,719 52,337 153,168 104,847 33,476 opioid addiction ANNEXES 4 | 81 Figure 4.9. Volumes of pharmacy sales of separate groups of medicines used mainly for treatment of persons with mental disorders 82 | ANNEXES 4 (UAH) 2015 2016 2017 2018 2019 N05A Antipsychotic medicines 142,666,113 146,419,782 199,902,876 263,469,929 328,273,482 N06A Antidepressants 122,896,435 125,034,941 179,232,212 251,672,660 271,057,792 N05B Anti-anxiety medicines 158,151,814 162,244,320 197,914,513 224,778,778 241,901,735 N06D Medicines for the treatment of 62,755,895 63,023,928 85,538,365 112,906,343 130,645,394 dementia N07BA Medicines for the treatment of 30,394,334 21,698,209 23,822,380 36,879,349 48,242,069 nicotine addiction N07BB Medicines for the treatment of 36,231,467 30,392,512 30,012,474 31,286,009 40,212,419 alcohol addiction N07BC Medicines for the treatment of 3,031,432 5,563,667 10,575,814 6,760,711 4,372,717 opioid addiction Figure 4.10. Volumes of pharmacy sales of separate groups of medicines used mainly for treatment of persons with mental disorders (USD) 2015 2016 2017 2018 2019 N05A Antipsychotic medicines 6,521,233 5,723,904 7,516,680 9,629,002 12,730,380 N06A Antidepressants 5,611,430 4,886,109 6,738,942 9,249,397 10,518,456 N05B Anti-anxiety medicines 7,274,130 6,342,958 7,437,852 8,275,697 9,413,983 N06D Medicines for the treatment of 2,878,340 2,463,536 3,216,984 4,149,063 5,066,917 dementia N07BA Medicines for the treatment of 1,410,841 848,987 896,857 1,349,902 1,875,410 nicotine addiction N07BB Medicines for the treatment of 1,667,741 1,191,317 1,127,159 1,148,880 1,569,597 alcohol addiction N07BC Medicines for the treatment of 139,907 218,356 398,165 248,291 168,382 opioid addiction (b) Public procurement Figure 4.11. Volumes of public procurement of medicines used mainly for treatment of persons with mental disorders Packages UAH USD 2015 569,143 58,112,604 2,637,671 2016 792,501 88,352,674 3,437,161 2017 1,036,220 131,912,157 4,961,160 2018 1,382,088 164,812,897 6,131,462 2019 1,294,403 184,981,880 6,975,652 Figure 4.12. Volumes of public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (packages) 2015 2016 2017 2018 2019 N05A Antipsychotic medicines 339,370 502,504 677,203 899,146 783,288 N05B Anti-anxiety medicines 157,518 182,492 211,179 240,441 221,691 N07BC Medicines for the treatment of 24,654 36,509 67,680 153,553 185,903 opioid addiction N06A Antidepressants 44,742 62,885 72,993 83,406 91,742 N06D Medicines for the treatment of 1,963 7,393 5,466 4,157 9,582 dementia N07BB Medicines for the treatment of 896 713 1,694 1,385 2,192 alcohol addiction N07BA Medicines for the treatment of 0 5 5 0 5 nicotine addiction ANNEXES 4 | 83 Figure 4.13. Volumes of public procurement of separate groups of medicines used mainly for treatment of persons with mental 84 | ANNEXES 4 disorders (UAH) 2015 2016 2017 2018 2019 N05A Antipsychotic medicines 29,312,647 42,250,812 73,962,363 82,578,302 79,239,105 N05B Anti-anxiety medicines 18,275,193 30,224,400 38,174,700 55,400,154 68,260,326 N07BC Medicines for the treatment of 3,580,746 6,193,315 7,502,707 14,535,814 19,903,533 opioid addiction N06A Antidepressants 6,269,347 8,025,748 10,753,311 11,019,799 14,682,109 N06D Medicines for the treatment of 596,167 1,610,467 1,440,962 1,220,917 2,835,514 dementia N07BB Medicines for the treatment of 78,503 46,906 77,123 57,910 59,928 alcohol addiction N07BA Medicines for the treatment of 0 1,025 990 0 1,365 nicotine addiction Figure 4.14. Volumes of public procurement of separate groups of medicines used mainly for treatment of persons with mental disorders (USD) 2015 2016 2017 2018 2019 N05A Antipsychotic medicines 1,330,809 1,653,948 2,791,374 3,065,574 3,011,801 N05B Anti-anxiety medicines 831,637 1,166,024 1,425,869 2,072,064 2,548,281 N07BC Medicines for the treatment of 159,312 238,061 280,773 538,974 740,487 opioid addiction N06A Antidepressants 285,053 314,643 405,620 407,502 562,770 N06D Medicines for the treatment of 27,411 62,596 54,588 45,214 110,009 dementia N07BB Medicines for the treatment of 3,449 1,850 2,899 2,132 2,253 alcohol addiction N07BA Medicines for the treatment of 0 39 37 0 51 nicotine addiction 1. Antipsychotic medicines (N05A according to ATC classi cation) 53 Figure 4.15. Aggregate indicators of pharmacy sales and public procurement of antipsychotic medicines Packages UAH USD 2015 1,637,757 171,978,760 7,852,042 2016 1,768,490 188,670,594 7,377,852 2017 2,086,514 273,865,239 10,308,054 2018 2,358,496 346,048,231 12,694,576 2019 2,535,031 407,512,587 15,742,181 (a) Pharmacy sales Figure 4.16. Sales volumes of antipsychotic medicines Packages UAH USD 2015 1,298,387 142,666,113 6,521,233 2016 1,265,986 146,419,782 5,723,904 2017 1,409,311 199,902,876 7,516,680 2018 1,459,350 263,469,929 9,629,002 2019 1,751,743 328,273,482 12,730,380 53Lithium medicines were transferred from N05A (antipsychotic medicines) to N06A (antidepressants) ANNEXES 4 | 85 Figure 4.17. Sales volumes of antipsychotic medicines, according to INN (packages) 2015 2016 2017 2018 2019 86 | ANNEXES 4 Chlorpromazine 315,852 282,215 294,125 235,181 275,284 Clozapine 200,964 212,670 244,419 242,527 260,271 Sulpiride 209,855 212,524 189,138 171,920 244,000 Quetiapine 68,514 86,111 122,962 170,220 211,523 Risperidone 73,528 71,719 116,880 150,642 187,755 Haloperidol 134,851 126,785 128,694 108,098 131,498 Tri uoperazine 110,019 104,076 94,457 84,796 90,541 Aripiprazole 4,924 8,365 17,781 32,664 46,359 Olanzapine 2,468 1,226 13,893 35,975 44,751 Amisulpride 23,776 25,740 32,609 37,086 44,116 Chlorprothixene 30,176 29,131 32,520 35,268 39,826 Flupenthixol 12,788 13,609 18,589 37,756 39,025 Thioridazine 39,663 23,124 22,405 27,661 28,709 Prochlorperazin 22,000 25,752 23,496 27,337 26,376 Levomepromazine 17,558 20,133 21,180 21,790 25,652 Zuclopenthixol 14,292 14,258 15,979 17,121 23,273 Fluphenazine 12,033 4,645 13,182 14,843 20,613 Tiapride 2,245 1,807 3,246 2,679 4,633 Sertindole 1,496 1,223 2,163 2,820 3,329 Ziprasidone 1,338 812 1,374 1,811 2,474 Paliperidone 34 61 219 1,155 1,735 Melperon 13 0 0 0 0 Figure 4.18. Sales volumes of antipsychotic medicines, according to INN (UAH) 2015 2016 2017 2018 2019 Quetiapine 18,319,917 20,798,740 32,327,789 47,017,624 62,861,313 Risperidone 18,669,729 18,913,847 32,008,344 49,159,684 51,682,843 Sulpiride 23,645,104 25,799,465 23,286,399 20,379,051 31,774,361 Amisulpride 12,184,099 13,319,636 18,328,621 21,833,115 28,934,104 Olanzapine 1,546,851 854,475 8,037,817 18,916,034 21,132,786 Zuclopenthixol 8,299,524 9,178,018 10,520,762 10,974,510 14,550,669 Aripiprazole 1,297,978 1,882,250 4,630,519 8,999,812 13,086,270 Fluphenazine 5,516,739 2,402,800 7,204,711 8,777,059 12,220,045 Flupenthixol 4,310,722 5,207,414 6,764,425 12,020,772 12,001,404 Chlorpromazine 6,978,919 7,348,441 8,619,863 8,330,915 11,868,093 Chlorprothixene 7,864,804 8,249,712 9,728,665 11,293,526 11,536,956 Haloperidol 9,252,845 10,003,765 10,642,843 8,862,099 10,825,170 Paliperidone 207,658 152,079 1,147,900 6,839,779 10,027,672 Thioridazine 9,140,358 6,444,205 6,883,483 8,759,072 9,308,171 Clozapine 5,645,231 5,506,599 6,856,602 6,851,441 7,601,857 Tri uoperazine 3,852,581 4,109,599 4,047,335 4,103,807 5,043,374 Prochlorperazin 1,581,805 2,216,446 2,554,779 3,323,041 4,495,676 Sertindole 978,635 925,433 1,968,518 2,475,839 2,815,613 ANNEXES 4 | 87 Ziprasidone 1,279,310 972,017 1,590,662 1,890,893 2,586,803 Levomepromazine 1,583,754 1,657,290 1,849,812 1,940,381 2,556,403 Tiapride 508,844 477,551 903,027 721,475 1,363,901 Melperon 706 0 0 0 0 Figure 4.19. Sales volumes of antipsychotic medicines, according to INN (USD) 88 | ANNEXES 4 2015 2016 2017 2018 2019 Quetiapine 844,032 813,211 1,216,667 1,724,701 2,440,018 Risperidone 852,315 739,512 1,205,041 1,798,226 2,004,056 Sulpiride 1,081,378 1,007,969 873,181 747,220 1,232,880 Amisulpride 556,442 521,060 688,921 801,633 1,116,567 Olanzapine 72,258 33,350 302,468 696,154 820,988 Zuclopenthixol 378,212 359,154 395,597 402,481 564,871 Aripiprazole 57,698 73,529 174,192 328,819 509,031 Fluphenazine 251,697 92,820 270,726 322,093 475,918 Flupenthixol 196,041 203,678 254,030 441,830 464,171 Chlorpromazine 318,707 287,621 324,304 305,676 461,035 Chlorprothixene 361,460 322,418 365,653 415,262 447,456 Haloperidol 421,097 391,529 400,284 326,820 420,379 Paliperidone 8,632 5,955 43,972 216,048 387,056 Thioridazine 418,065 251,953 258,573 322,134 360,306 Clozapine 258,349 215,293 257,836 251,790 295,306 Tri uoperazine 175,209 160,949 152,120 150,901 196,152 Prochlorperazin 71,287 86,550 96,128 122,324 174,880 Sertindole 45,253 36,093 73,815 89,436 108,538 Ziprasidone 57,882 37,922 59,650 67,852 99,280 Levomepromazine 71,927 64,858 69,458 71,245 98,648 Tiapride 23,255 18,479 34,065 26,355 52,844 Melperon 37 0 0 0 0 (b) Public procurement Figure 4.20. Volumes of public procurement of antipsychotic medicines Packages UAH USD 2015 339,370 29,312,647 1,330,809 2016 502,504 42,250,812 1,653,948 2017 677,203 73,962,363 2,791,374 2018 899,146 82,578,302 3,065,574 2019 783,288 79,239,105 3,011,801 ANNEXES 4 | 89 Figure 4.21. Volumes of public procurement of antipsychotic medicines according to INN (packages) 90 | ANNEXES 4 2015 2016 2017 2018 2019 Chlorpromazine 145,363 196,712 256,960 379,373 314,026 Haloperidol 57,742 84,133 81,918 169,585 118,342 Clozapine 22,065 43,518 78,689 111,368 98,566 Risperidone 21,891 27,004 41,742 68,653 86,856 Tri uoperazine 44,604 69,392 100,979 79,490 54,640 Quetiapine 11,226 16,457 28,182 19,514 31,524 Levomepromazine 3,057 14,205 21,053 16,784 16,712 Sulpiride 5,614 13,838 16,189 8,057 11,666 Aripiprazole 689 2,786 11,322 8,240 10,599 Chlorprothixene 6,542 8,888 7,381 8,423 10,346 Olanzapine 837 1,470 6,642 4,548 7,831 Amisulpride 4,805 5,882 8,577 6,549 6,898 Zuclopenthixol 7,260 6,511 7,349 5,568 5,129 Thioridazine 4,581 8,227 6,109 5,663 4,518 Fluphenazine 246 629 1,807 4,968 3,723 Flupenthixol 1,594 2,391 2,113 1,707 1,713 Ziprasidone 685 370 22 0 90 Paliperidone 154 24 13 417 78 Prochlorperazin 25 7 42 239 15 Tiapride 0 0 0 0 9 Sertindole 380 60 115 0 7 Melperon 10 0 0 0 0 Figure 4.22. Volumes of public procurement of antipsychotic medicines according to INN (UAH) 2015 2016 2017 2018 2019 Risperidone 6,353,558 6,372,642 21,253,349 21,819,679 17,337,677 Chlorpromazine 3,219,866 5,034,288 8,004,313 13,431,565 13,889,501 Quetiapine 3,479,400 5,043,287 7,095,475 5,825,585 9,106,671 Haloperidol 2,600,797 4,633,537 5,535,707 9,772,508 7,974,185 Zuclopenthixol 3,315,220 4,087,659 5,589,794 4,622,221 3,663,918 Olanzapine 676,046 1,049,258 3,008,958 2,380,548 3,654,127 Amisulpride 2,346,334 3,194,741 4,500,360 3,314,248 3,509,706 Clozapine 716,489 1,228,893 2,292,417 3,734,069 3,281,306 Tri uoperazine 1,537,496 2,360,630 3,979,518 3,600,138 2,945,009 Chlorprothixene 1,108,128 2,166,098 1,841,340 2,051,251 2,573,507 Aripiprazole 141,948 568,785 2,831,624 2,239,337 2,513,033 Fluphenazine 121,921 254,564 1,002,526 3,091,298 2,404,864 Sulpiride 626,424 1,503,321 2,206,018 1,210,877 1,814,915 Levomepromazine 305,013 1,181,847 1,988,705 1,569,468 1,753,067 Thioridazine 957,276 2,299,501 1,881,837 1,883,680 1,597,610 Paliperidone 358,207 57,921 38,642 1,343,321 611,958 Flupenthixol 381,831 777,959 802,533 648,154 532,326 Ziprasidone 794,058 391,678 18,063 0 65,864 Sertindole 271,816 43,881 85,182 0 5,264 ANNEXES 4 | 91 Tiapride 0 0 0 0 2,700 Prochlorperazin 366 321 6,003 40,354 1,897 Melperon 453 0 0 0 0 Figure 4.23. Volumes of public procurement of antipsychotic medicines according to INN (USD) 92 | ANNEXES 4 2015 2016 2017 2018 2019 Risperidone 284,056 251,184 808,174 808,491 655,020 Chlorpromazine 146,858 196,518 301,009 501,861 524,033 Quetiapine 159,499 198,906 266,973 213,236 353,702 Haloperidol 118,267 180,611 208,338 362,983 302,138 Olanzapine 29,842 41,064 114,160 87,330 140,611 Zuclopenthixol 151,434 159,978 209,759 172,309 138,821 Amisulpride 107,773 125,562 169,310 123,348 133,393 Clozapine 32,415 48,005 86,037 139,448 123,935 Tri uoperazine 69,808 92,053 150,490 133,053 111,726 Chlorprothixene 50,837 83,894 69,140 76,850 97,720 Aripiprazole 6,512 22,415 106,582 82,190 95,746 Fluphenazine 5,597 9,965 37,607 115,189 89,963 Sulpiride 28,882 58,720 82,913 44,998 68,840 Levomepromazine 13,985 46,498 74,798 58,246 67,606 Thioridazine 43,904 88,999 70,447 69,951 60,677 Paliperidone 16,226 2,327 1,474 50,328 24,743 Flupenthixol 17,616 30,107 30,033 24,248 20,044 Ziprasidone 35,077 15,384 683 0 2,703 Sertindole 12,184 1,746 3,223 0 213 Tiapride 0 0 0 0 100 Prochlorperazin 17 12 225 1,517 68 Melperon 19 0 0 0 0 2. Antianxiety medicines (N05B according to ATC classi cation) Figure 4.24. Total indicators of pharmacy sales and public procurement of antianxiety medicines Packages UAH USD 2015 2,509,890 176,427,007 8,105,767 2016 2,262,096 192,468,720 7,508,982 2017 2,676,309 236,089,213 8,863,721 2018 2,886,383 280,178,932 10,347,761 2019 2,614,724 310,162,061 11,962,264 (a) Pharmacy sales Figure 4.25. Sales volumes of the group of antianxiety medicines Packages UAH USD 2015 2,352,372 158,151,814 7,274,130 2016 2,079,604 162,244,320 6,342,958 2017 2,465,130 197,914,513 7,437,852 2018 2,645,942 224,778,778 8,275,697 2019 2,393,033 241,901,735 9,413,983 ANNEXES 4 | 93 Figure 4.26. Sales volumes of antianxiety medicines according to INN (packages) 94 | ANNEXES 4 2015 2016 2017 2018 2019 Hydazepam 1,594,557 1,334,189 1,779,226 1,981,635 1,754,679 Mebicar 366,711 311,465 343,175 392,209 366,688 Diazepam 100,542 128,177 109,483 111,350 91,527 Hydroxyzine 52,730 46,344 49,984 53,326 72,169 Phenazepam 66,872 86,175 69,277 63,781 58,622 Buspirone 25,459 23,915 25,353 33,984 38,182 Etifoxine 3,878 4,388 6,583 9,508 11,166 Chlordiazepoxide 923 937 0 0 0 Fabomotizole 140,590 144,014 82,049 149 0 Oxazepam 110 0 0 0 0 Figure 4.27. Sales volumes of antianxiety medicines according to INN (UAH) 2015 2016 2017 2018 2019 Hydazepam 76,613,587 71,422,100 107,464,181 129,522,931 137,973,410 Mebicar 39,884,721 38,368,405 47,524,401 63,167,200 65,385,863 Diazepam 9,687,771 16,155,066 15,935,085 17,683,701 19,528,741 Buspirone 2,891,086 3,186,137 3,966,559 6,075,052 8,598,809 Hydroxyzine 3,953,172 3,500,675 4,071,865 4,559,149 5,576,322 Etifoxine 738,182 837,474 1,311,592 1,898,104 2,730,057 Phenazepam 1,613,006 2,283,271 1,940,144 1,837,431 2,108,533 Chlordiazepoxide 34,532 18,463 0 0 0 Fabomotizole 22,731,813 26,472,729 15,700,686 35,210 0 Oxazepam 3,944 0 0 0 0 Figure 4.28. Sales volumes of antianxiety medicines according to INN (USD) 2015 2016 2017 2018 2019 Hydazepam 3,541,756 2,793,009 4,041,023 4,771,316 5,365,087 Mebicar 1,828,287 1,499,266 1,784,246 2,324,048 2,540,951 Diazepam 441,167 632,689 598,828 650,568 769,384 Buspirone 131,424 124,276 148,957 222,668 333,421 Hydroxyzine 180,630 136,894 152,881 168,238 216,633 ANNEXES 4 | 95 Etifoxine 33,423 32,667 49,390 69,759 106,141 Phenazepam 73,709 89,334 72,877 67,794 82,366 Chlordiazepoxide 1,594 713 0 0 0 Fabomotizole 1,041,957 1,034,110 589,648 1,306 0 Oxazepam 183 0 0 0 0 (b) Public procurement 96 | ANNEXES 4 Figure 4.29. Volumes of public procurement of antianxiety medicines Packages UAH USD 2015 157,518 18,275,193 831,637 2016 182,492 30,224,400 1,166,024 2017 211,179 38,174,700 1,425,869 2018 240,441 55,400,154 2,072,064 2019 221,691 68,260,326 2,548,281 Figure 4.30. Volumes of public procurement of antianxiety medicines according to INN (packages) 2015 2016 2017 2018 2019 Diazepam 108,928 123,652 156,253 189,636 169,893 Hydazepam 27,086 36,826 32,646 37,678 39,611 Phenazepam 12,280 17,030 19,055 10,106 7,862 Mebicar 2,175 2,363 2,760 2,444 3,202 Lorazepam 0 0 0 0 450 Buspirone 205 1,068 236 420 410 Alprazolam 0 0 0 0 200 Hydroxyzine 327 280 60 149 54 Etifoxine 0 0 5 8 9 Chlordiazepoxide 600 300 0 0 0 Fabomotizole 5,017 256 164 0 0 Oxazepam 900 717 0 0 0 Figure 4.31. Volumes of public procurement of antianxiety medicines according to INN (UAH) 2015 2016 2017 2018 2019 Diazepam 15,540,546 27,262,159 35,243,121 51,905,936 63,837,610 Hydazepam 1,393,937 1,950,823 2,046,119 2,759,976 3,276,627 Mebicar 117,040 155,543 237,224 264,917 435,290 Phenazepam 308,917 490,503 564,546 367,527 393,828 Lorazepam 0 0 0 0 144,030 Buspirone 25,532 200,666 46,081 86,943 106,855 Alprazolam 0 0 0 0 58,890 Hydroxyzine 23,152 25,053 4,463 13,051 4,551 Etifoxine 0 0 991 1,805 2,644 Chlordiazepoxide 23,418 32,832 0 0 0 Fabomotizole 799,648 45,255 32,157 0 0 Oxazepam 43,004 61,567 0 0 0 ANNEXES 4 | 97 Figure 4.32. Volumes of public procurement of antianxiety medicines according to INN (USD) 98 | ANNEXES 4 2015 2016 2017 2018 2019 Diazepam 707,779 1,051,241 1,315,971 1,942,143 2,378,100 Hydazepam 63,826 75,757 76,822 102,533 125,662 Mebicar 5,392 6,046 8,961 9,871 17,127 Phenazepam 13,807 18,759 20,995 13,777 14,726 Lorazepam 0 0 0 0 6,028 Buspirone 1,118 7,881 1,708 3,186 3,981 Alprazolam 0 0 0 0 2,378 Hydroxyzine 1,059 961 165 485 173 Etifoxine 0 0 38 69 106 Chlordiazepoxide 1,045 1,245 0 0 0 Fabomotizole 35,690 1,785 1,209 0 0 Oxazepam 1,920 2,350 0 0 0 3. Antidepressants (N06A according to ATC classi cation)54 Figure 4.33. Total volume of pharmacy sales and public procurement of antidepressants Packages UAH USD 2015 992,651 129,165,782 5,896,483 2016 1,014,045 133,060,689 5,200,751 2017 1,210,971 189,985,523 7,144,562 2018 1,386,087 262,692,459 9,656,899 2019 1,463,022 285,739,901 11,081,226 (a) Pharmacy sales Figure 4.34. Sales volumes of the group of antidepressants Packages UAH USD 2015 947,909 122,896,435 5,611,430 2016 951,160 125,034,941 4,886,109 2017 1,137,978 179,232,212 6,738,942 2018 1,302,681 251,672,660 9,249,397 2019 1,371,280 271,057,792 10,518,456 54Lithium medicines were transferred from N05A (antipsychotic medicines) to N06A (antidepressants) ANNEXES 4 | 99 Figure 4.35. Sales volumes of antidepressants according to INN (packages) 100 | ANNEXES 4 2015 2016 2017 2018 2019 Amitriptyline 366,572 411,990 459,115 447,649 486,898 Escitalopram 73,733 83,005 115,764 175,146 205,248 Fluoxetine 125,401 118,775 146,725 153,017 136,440 Paroxetine 67,122 54,987 65,007 79,010 87,309 Sertraline 37,430 33,958 44,127 59,798 79,198 Venlafaxine 13,600 18,293 31,870 44,557 55,036 Duloxetine 0 0 6,150 22,750 43,277 Trazodone hydrochloride 31,416 27,681 27,951 29,223 33,943 Mianserin 61,197 40,926 63,002 90,776 31,538 Clomipramine 29,466 24,930 32,973 30,699 29,989 Mirtazapine 17,761 22,421 21,443 30,509 27,669 Doxepin 18,687 14,292 19,921 28,283 27,252 Agomelatine 37,025 32,233 29,656 26,463 25,699 Imipramine 16,728 26,758 24,009 22,866 21,903 Vortioxetine 1,611 3,654 8,924 15,954 16,193 Hypericum 7,828 8,029 7,847 8,868 13,110 Lavandula 0 1,179 5,400 7,597 10,894 Trazodone 0 1,008 3,875 6,201 9,976 Lithium gamma-hydroglutamate 2,321 3,282 7,032 5,596 8,383 Desvenlafaxine succinate 0 167 2,544 5,644 7,483 Fluvoxamine 4,359 3,734 5,410 5,976 6,425 Homeopatia 6,609 4,710 1,971 2,951 4,175 Citalopram 4,008 2,383 3,169 3,112 3,240 Hypericin 24,735 12,725 4,093 36 2 Bupropion 300 0 0 0 0 Tianeptine 0 40 0 0 0 Figure 4.36. Sales volumes of antidepressants according to INN (UAH) 2015 2016 2017 2018 2019 Escitalopram 25,481,540 25,934,879 39,707,146 59,128,332 63,181,749 Paroxetine 19,328,760 17,762,278 24,502,824 33,404,088 36,022,652 Sertraline 9,881,541 9,627,700 13,072,081 18,396,156 24,215,610 Venlafaxine 5,490,247 7,009,942 13,199,368 18,885,772 24,007,028 Amitriptyline 7,658,451 8,713,304 11,507,192 14,669,432 17,277,736 Trazodone hydrochloride 7,894,197 8,442,908 9,880,796 10,948,491 13,700,197 Mirtazapine 6,282,339 8,124,054 8,333,761 13,140,070 13,534,988 Duloxetine 0 0 1,949,797 7,563,381 13,151,012 Vortioxetine 985,418 2,356,138 7,093,326 13,028,071 12,277,001 Mianserin 12,290,165 10,193,235 14,667,106 22,538,784 8,377,152 Clomipramine 7,246,008 7,109,455 8,971,755 8,196,637 7,977,118 Agomelatine 8,340,384 7,405,373 8,084,991 7,803,126 7,853,627 Fluoxetine 2,365,963 2,859,615 4,007,522 5,127,329 5,677,275 Desvenlafaxine succinate 0 97,175 1,504,972 3,208,987 4,030,536 Doxepin 1,368,456 1,342,247 2,465,962 4,046,502 3,675,944 Hypericum 874,251 932,252 1,114,138 1,497,416 3,503,116 Trazodone 0 275,572 1,097,651 1,806,108 2,937,704 Imipramine 1,645,123 2,423,175 2,345,436 2,265,117 2,488,455 Fluvoxamine 1,437,412 1,384,892 2,083,199 2,212,502 2,331,709 Citalopram 2,314,107 1,662,571 2,081,260 2,011,821 2,099,115 Lavandula 0 162,520 820,447 1,221,547 1,851,180 Lithium gamma-hydroglutamate 74,627 145,239 315,759 257,771 443,518 Homeopatia 615,880 451,420 222,501 313,460 443,280 Hypericin 1,151,269 617,383 203,222 1,760 88 | 101 Bupropion 170,297 0 0 0 0 Tianeptine 0 1,614 0 0 0 Figure 4.37. Sales volumes of antidepressants according to INN (USD) 102 | ANNEXES 4 2015 2016 2017 2018 2019 Escitalopram 1,159,012 1,013,783 1,492,504 2,174,678 2,454,077 Paroxetine 883,119 694,420 920,960 1,229,015 1,393,918 Sertraline 453,302 376,483 491,467 673,202 938,159 Venlafaxine 251,631 273,582 497,690 694,549 929,945 Amitriptyline 347,937 340,375 432,501 540,132 671,790 Trazodone hydrochloride 358,868 329,573 370,675 400,914 530,795 Mirtazapine 287,327 317,684 313,861 481,937 521,492 Duloxetine 0 0 73,516 277,079 510,568 Vortioxetine 44,102 92,009 266,887 479,639 475,102 Mianserin 565,158 399,260 550,504 828,474 338,505 Clomipramine 330,272 278,424 337,532 302,932 309,908 Agomelatine 384,681 288,790 304,044 286,899 304,121 Fluoxetine 106,653 111,356 150,813 188,783 220,955 Desvenlafaxine succinate 0 3,742 56,524 117,668 155,588 Doxepin 62,438 52,286 92,705 148,938 141,967 Hypericum 39,752 36,368 41,851 54,869 135,231 Trazodone 0 10,636 41,161 66,134 113,788 Imipramine 74,967 94,928 88,349 83,362 96,461 Fluvoxamine 65,720 54,032 78,287 80,639 89,146 Citalopram 106,218 64,962 78,449 73,691 80,625 Lavandula 0 6,270 30,863 44,817 72,093 Lithium gamma-hydroglutamate 3,332 5,638 11,870 9,464 17,118 Homeopatia 28,001 17,456 8,376 11,515 17,102 Hypericin 51,278 23,989 7,555 64 4 Bupropion 7,662 0 0 0 0 Tianeptine 0 63 0 0 0 Get the data • Created with Datawrapper (b) Public procurement Figure 4.38. Volumes of public procurement of antidepressants Packages UAH USD 2015 44,742 6,269,347 285,053 2016 62,885 8,025,748 314,643 2017 72,993 10,753,311 405,620 2018 83,406 11,019,799 407,502 2019 91,742 14,682,109 562,770 ANNEXES 4 | 103 Figure 4.39. Volumes of public procurement of antidepressants according to INN (packages) 104 | ANNEXES 4 2015 2016 2017 2018 2019 Amitriptyline 24,554 33,918 36,844 42,846 42,561 Fluoxetine 2,416 4,892 3,906 11,452 9,655 Mianserin 495 2,628 7,063 4,090 7,138 Escitalopram 5,688 4,567 5,998 3,391 6,203 Venlafaxine 3,609 5,501 6,140 4,382 5,563 Clomipramine 579 1,739 526 4,856 4,963 Sertraline 1,167 2,571 3,726 2,140 4,425 Paroxetine 3,168 2,701 3,941 3,207 3,413 Duloxetine 0 0 20 2,854 2,838 Trazodone hydrochloride 458 379 621 412 1,689 Lithium gamma-hydroglutamate 475 627 605 1,876 978 Mirtazapine 506 624 1,147 205 770 Vortioxetine 0 168 355 580 584 Imipramine 214 1,260 1,011 657 486 Desvenlafaxine succinate 0 0 110 57 290 Trazodone 0 10 2 0 101 Citalopram 676 219 119 160 75 Doxepin 25 18 80 10 10 Agomelatine 689 1,049 748 231 0 Bupropion 0 10 0 0 0 Fluvoxamine 4 0 0 0 0 Hypericin 6 5 30 0 0 Hypericum 0 0 1 0 0 Lithium carbonate 1 0 0 0 0 Pirlindole 6 0 0 0 0 Tianeptine 6 0 0 0 0 Figure 4.40. Volumes of public procurement of antidepressants according to INN (UAH) 2015 2016 2017 2018 2019 Venlafaxine 1,441,614 1,767,315 2,259,533 1,933,199 2,335,038 Escitalopram 1,906,328 1,208,066 1,666,089 941,403 1,804,876 Amitriptyline 702,154 1,078,935 1,204,108 1,519,537 1,787,737 Mianserin 94,515 603,844 1,586,858 984,149 1,785,000 Clomipramine 123,373 420,341 146,813 1,343,886 1,359,057 Paroxetine 870,359 918,896 1,475,674 1,227,162 1,294,565 Sertraline 257,043 937,213 979,431 614,006 1,049,855 Duloxetine 0 0 7,021 961,036 897,755 Trazodone hydrochloride 119,154 93,768 145,350 94,467 832,187 Fluoxetine 48,727 147,690 125,241 521,680 462,606 Vortioxetine 0 118,508 262,767 478,162 422,701 Mirtazapine 158,821 205,970 421,056 44,557 394,684 Desvenlafaxine succinate 0 0 49,473 30,803 75,065 Imipramine 24,968 113,933 107,071 69,071 55,752 Lithium gamma-hydroglutamate 14,175 27,011 29,749 90,149 53,942 Citalopram 280,805 123,557 66,087 92,867 41,619 Trazodone 0 2,884 424 0 28,040 Doxepin 2,116 1,473 8,609 2,278 1,630 Agomelatine 223,854 249,902 210,420 71,387 0 Bupropion 0 6,196 0 0 0 Fluvoxamine 445 0 0 0 0 Hypericin 277 248 1,441 0 0 Hypericum 0 0 97 0 0 Lithium carbonate 19 0 0 0 0 Pirlindole 7 0 0 0 0 Tianeptine 594 0 0 0 0 ANNEXES 4 | 105 Figure 4.41. Volumes of public procurement of antidepressants according to INN (USD) 106 | ANNEXES 4 2015 2016 2017 2018 2019 Venlafaxine 65,976 69,440 85,251 70,983 88,634 Escitalopram 85,535 47,624 62,978 34,629 70,517 Mianserin 4,114 23,700 59,603 36,445 67,933 Amitriptyline 31,866 41,399 45,114 56,834 67,550 Clomipramine 5,593 16,591 5,392 50,387 50,839 Paroxetine 40,404 35,980 55,539 45,476 50,698 Sertraline 11,641 37,015 37,370 22,561 41,438 Duloxetine 0 0 255 35,123 34,368 Trazodone hydrochloride 5,387 3,686 5,429 3,488 32,293 Fluoxetine 2,221 5,704 4,690 19,657 17,323 Vortioxetine 0 4,678 10,057 17,059 16,447 Mirtazapine 7,288 8,150 16,070 1,669 14,933 Desvenlafaxine succinate 0 0 1,887 1,111 2,916 Imipramine 1,094 4,478 4,023 2,589 2,186 Lithium gamma-hydroglutamate 640 1,037 1,120 3,328 2,007 Citalopram 13,055 4,876 2,513 3,458 1,552 Trazodone 0 112 16 0 1,074 Doxepin 94 57 319 81 62 Agomelatine 10,086 9,863 7,934 2,626 0 Bupropion 0 242 0 0 0 Fluvoxamine 19 0 0 0 0 Hypericin 12 10 53 0 0 Hypericum 0 0 4 0 0 Lithium carbonate 1 0 0 0 0 Pirlindole 0 0 0 0 0 Tianeptine 27 0 0 0 0 4. Medicines used in the treatment of dementia (N06D according to ATC classi cation) Figure 4.42. Total volume of pharmacy sales and public procurement of medicines used in the treatment of dementia Packages UAH USD 2015 217,360 63,352,062 2,905,751 2016 213,103 64,634,395 2,526,132 2017 256,628 86,979,327 3,271,573 2018 305,605 114,127,260 4,194,278 2019 341,686 133,480,908 5,176,926 (a) Pharmacy sales Figure 4.43. Sales volumes of the group of medicines used in the treatment of dementia Packages UAH USD 2015 215,397 62,755,895 2,878,340 2016 205,710 63,023,928 2,463,536 2017 251,162 85,538,365 3,216,984 2018 301,448 112,906,343 4,149,063 2019 332,104 130,645,394 5,066,917 ANNEXES 4 | 107 Figure 4.44. Sales volumes of medicines used in the treatment of dementia according to INN (packages) 108 | ANNEXES 4 2015 2016 2017 2018 2019 Ipidacrine 125,403 113,247 142,465 165,203 177,417 Memantine 62,412 63,623 82,188 105,492 116,692 Donepezil 21,297 24,636 23,116 27,061 30,147 Rivastigmine 2,793 1,190 1,807 3,387 7,848 Galantamine 3,492 3,014 1,586 305 0 Figure 4.45. Sales volumes of medicines used in the treatment of dementia according to INN (UAH) 2015 2016 2017 2018 2019 Ipidacrine 40,331,587 40,597,272 51,843,871 65,177,187 71,686,756 Memantine 18,212,971 17,967,769 28,701,160 40,211,456 50,441,388 Donepezil 3,407,171 3,799,338 4,397,547 7,148,820 7,695,669 Rivastigmine 414,908 200,686 323,313 320,666 821,581 Galantamine 389,258 458,863 272,474 48,214 0 Figure 4.46. Sales volumes of medicines used in the treatment of dementia according to INN (USD) 2015 2016 2017 2018 2019 Ipidacrine 1,849,500 1,587,358 1,949,407 2,397,572 2,786,087 Memantine 835,589 702,334 1,079,840 1,475,931 1,953,768 Donepezil 156,416 148,196 165,324 262,053 295,237 Rivastigmine 19,313 7,758 12,177 11,733 31,824 Galantamine 17,522 17,890 10,236 1,775 0 (b) Public procurement Figure 4.47. Volumes of public procurement of medicines used in the treatment of dementia Packages UAH USD 2015 1,963 596,167 27,411 2016 7,393 1,610,467 62,596 2017 5,466 1,440,962 54,588 2018 4,157 1,220,917 45,214 2019 9,582 2,835,514 110,009 Figure 4.48. Volumes of public procurement of medicines used in the treatment of dementia according to INN (packages) 2015 2016 2017 2018 2019 Memantine 1,254 2,729 2,659 1,756 4,790 Ipidacrine 371 3,972 1,659 1,797 3,226 Donepezil 338 692 1,098 603 1,566 Galantamine 0 0 50 1 0 ANNEXES 4 | 109 Figure 4.49. Volumes of public procurement of medicines used in the treatment of dementia according to INN (UAH) 110 | ANNEXES 4 2015 2016 2017 2018 2019 Memantine 434,128 707,755 728,882 508,279 1,439,836 Ipidacrine 103,884 772,020 496,605 611,346 1,080,186 Donepezil 58,155 130,692 209,347 101,174 315,492 Galantamine 0 0 6,129 118 0 Figure 4.50. Volumes of public procurement of medicines used in the treatment of dementia according to INN (USD) 2015 2016 2017 2018 2019 Memantine 20,086 27,753 27,662 18,703 56,513 Ipidacrine 4,769 29,701 18,738 22,724 41,307 Donepezil 2,556 5,142 7,949 3,783 12,189 Galantamine 0 0 239 4 0 5. Medicines used in the treatment of alcohol addiction (N07BB according to ATC classi cation) Figure 4.51. Total volume of pharmacy sales and public procurement of medicines used in the treatment of alcohol addiction Packages UAH USD 2015 601,527 36,309,970 1,671,190 2016 523,300 30,439,418 1,193,167 2017 534,544 30,089,597 1,130,058 2018 471,999 31,343,919 1,151,013 2019 472,311 40,272,347 1,571,850 (a) Pharmacy sales Figure 4.52. Sales volumes of the group of medicines used in the treatment of alcohol addiction Packages UAH USD 2015 600,631 36,231,467 1,667,741 2016 522,587 30,392,512 1,191,317 2017 532,850 30,012,474 1,127,159 2018 470,614 31,286,009 1,148,880 2019 470,119 40,212,419 1,569,597 ANNEXES 4 | 111 Figure 4.53. Sales volumes of medicines used in the treatment of alcohol addiction according to INN (packages) 112 | ANNEXES 4 2015 2016 2017 2018 2019 Aminoacetic acid+Format sodium+Dextrose 361,402 334,336 343,875 312,973 313,435 Disul ram 173,852 137,805 124,104 91,607 87,340 Metadoxine 35,763 32,706 54,827 57,797 57,844 Homeopatia 31 986 10,014 8,237 11,500 Cianamid 29,574 16,754 30 0 0 L-threonine+Pyridoxine 4 0 0 0 0 Veratrum 5 0 0 0 0 Figure 4.54. Sales volumes of medicines used in the treatment of alcohol addiction according to INN (UAH) 2015 2016 2017 2018 2019 Aminoacetic acid+Format sodium+Dextrose 16,142,123 16,227,183 19,453,229 19,624,101 25,656,969 Disul ram 6,954,021 5,712,937 6,286,548 7,014,633 8,824,404 Metadoxine 2,065,031 2,104,770 3,531,186 3,981,184 4,663,104 Homeopatia 2,043 75,107 728,173 666,091 1,067,942 Cianamid 11,067,780 6,272,515 13,338 0 0 L-threonine+Pyridoxine 238 0 0 0 0 Veratrum 231 0 0 0 0 Figure 4.55. Sales volumes of medicines used in the treatment of alcohol addiction according to INN (USD) 2015 2016 2017 2018 2019 Aminoacetic acid+Format sodium+Dextrose 746,446 635,745 729,268 720,108 1,003,715 Disul ram 318,773 223,897 237,492 257,842 343,430 Metadoxine 94,890 82,152 132,581 146,574 181,243 Homeopatia 91 2,892 27,318 24,357 41,208 Cianamid 507,522 246,631 500 0 0 L-threonine+Pyridoxine 10 0 0 0 0 Veratrum 9 0 0 0 0 (b) Public procurement Figure 4.56. Volumes of public procurement of group of medicines used in the treatment of alcohol addiction Packages UAH USD 2015 896 78,503 3,449 2016 713 46,906 1,850 2017 1,694 77,123 2,899 2018 1,385 57,910 2,132 2019 2,192 59,928 2,253 ANNEXES 4 | 113 Figure 4.57. Volumes of public procurement of medicines used in the treatment of alcohol addiction according to INN (packages) 114 | ANNEXES 4 2015 2016 2017 2018 2019 Disul ram 498 519 1,516 1,377 2,136 Aminoacetic acid+Format sodium+Dextrose 248 163 178 5 56 Cianamid 0 31 0 0 0 Metadoxine 150 0 0 3 0 Figure 4.58. Volumes of public procurement of medicines used in the treatment of alcohol addiction according to INN (UAH) 2015 2016 2017 2018 2019 Disul ram 19,706 18,217 44,430 57,539 57,398 Aminoacetic acid+Format sodium+Dextrose 47,263 14,105 32,693 188 2,530 Cianamid 0 14,584 0 0 0 Metadoxine 11,534 0 0 183 0 VFigure 4.59. Volumes of public procurement of medicines used in the treatment of alcohol addiction according to INN (USD) 2015 2016 2017 2018 2019 Disul ram 913 718 1,672 2,119 2,148 Aminoacetic acid+Format sodium+Dextrose 1,985 562 1,227 7 106 Cianamid 0 570 0 0 0 Metadoxine 550 0 0 7 0 6. Medicines used in the treatment of opioid addiction (N07BC according to ATC classi cation)55 Figure 4.60. Total volume of pharmacy sales and public procurement of medicines used in the treatment of opioid addiction Packages UAH USD 2015 66,373 6,612,178 299,219 2016 88,846 11,756,982 456,417 2017 220,848 18,078,521 678,938 2018 258,400 21,296,525 787,265 2019 219,379 24,276,250 908,869 (a) Pharmacy sales Figure 4.61. Sales volumes of the group of medicines used in the treatment of opioid addiction Packages UAH USD 2015 41,719 3,031,432 139,907 2016 52,337 5,563,667 218,356 2017 153,168 10,575,814 398,165 2018 104,847 6,760,711 248,291 2019 33,476 4,372,717 168,382 55There was added buprenorphine from N02A (opioid analgesics). ANNEXES 4 | 115 Figure 4.62. Sales volumes of medicines used in the treatment of opioid addiction according to INN (packages) 116 | ANNEXES 4 2015 2016 2017 2018 2019 Buprenorphine 21,649 17,638 49,586 33,065 24,377 Naloxone 1,831 4,293 4,113 3,839 4,830 Methadone 18,044 30,406 99,469 67,932 4,231 Naltrexonum 195 0 0 11 38 Figure 4.63. Sales volumes of medicines used in the treatment of opioid addiction according to INN (UAH) 2015 2016 2017 2018 2019 Buprenorphine 1,779,994 3,851,099 6,332,445 3,987,820 3,091,109 Naloxone 107,549 327,060 389,424 397,282 582,422 Methadone 1,030,550 1,385,508 3,853,945 2,280,580 386,066 Naltrexonum 113,339 0 0 95,029 313,120 Figure 4.64. Sales volumes of medicines used in the treatment of opioid addiction according to INN (USD) 2015 2016 2017 2018 2019 Buprenorphine 82,909 151,302 238,746 145,593 118,975 Naloxone 4,798 12,721 14,634 14,686 22,716 Methadone 47,084 54,333 144,786 84,380 15,146 Naltrexonum 5,116 0 0 3,633 11,545 (b) Public procurement Figure 4.65. Volumes of public procurement of medicines used in the treatment of opioid addiction Packages UAH USD 2015 24,654 3,580,746 159,312 2016 36,509 6,193,315 238,061 2017 67,680 7,502,707 280,773 2018 153,553 14,535,814 538,974 2019 185,903 19,903,533 740,487 Figure 4.66. Volumes of public procurement of medicines used in the treatment of opioid addiction according to INN (packages) 2015 2016 2017 2018 2019 Methadone 0 600 22,229 118,388 145,107 Buprenorphine 18,186 26,736 37,983 22,661 28,819 Naloxone 6,323 9,010 7,458 12,504 11,977 Naltrexonum 145 163 10 0 0 ANNEXES 4 | 117 Figure 4.67. Volumes of public procurement of medicines used in the treatment of opioid addiction according to INN (UAH) 118 | ANNEXES 4 2015 2016 2017 2018 2019 Methadone 0 147,390 1,935,356 9,108,155 12,680,769 Buprenorphine 2,045,208 4,504,190 4,707,639 3,930,023 5,673,935 Naloxone 470,881 722,365 759,111 1,497,637 1,548,829 Naltrexonum 1,064,657 819,371 100,601 0 0 Figure 4.68. Volumes of public procurement of medicines used in the treatment of opioid addiction according to INN (USD) 2015 2016 2017 2018 2019 Methadone 0 5,724 71,912 337,534 474,777 Buprenorphine 90,620 172,871 176,477 145,552 206,637 Naloxone 21,163 28,007 28,638 55,888 59,073 Naltrexonum 47,529 31,459 3,745 0 0 7. Medicines used in the treatment of nicotine addiction (N07BA according to ATC classi cation) Figure 4.69. Figure 4.54. Total volume of pharmacy sales and public procurement of medicines used in the treatment of nicotine addiction Packages UAH USD 2015 137,470 30,394,334 1,410,841 2016 137,673 21,699,234 849,026 2017 121,775 23,823,370 896,894 2018 166,787 36,879,349 1,349,902 2019 182,622 48,243,433 1,875,461 (a) Pharmacy sales Figure 4.70. Sales volumes of the group of medicines used in the treatment of nicotine addiction Packages UAH USD 2015 137,470 30,394,334 1,410,841 2016 137,668 21,698,209 848,987 2017 121,770 23,822,380 896,857 2018 166,787 36,879,349 1,349,902 2019 182,617 48,242,069 1,875,410 ANNEXES 4 | 119 Figure 4.71. Sales volumes of medicines used in the treatment of nicotine addiction according to INN (packages) 120 | ANNEXES 4 2015 2016 2017 2018 2019 Cytisine 66,161 85,634 82,063 113,938 103,633 Nicotine 70,075 50,933 39,033 51,197 75,411 Varenicline 292 173 184 1,650 3,570 Homeopatia 942 928 490 2 3 Figure 4.72. Sales volumes of medicines used in the treatment of nicotine addiction according to INN (UAH) 2015 2016 2017 2018 2019 Cytisine 17,214,882 13,364,887 16,143,742 25,828,991 29,939,701 Nicotine 12,938,015 8,122,504 7,462,483 9,688,293 14,963,634 Varenicline 206,270 173,976 197,307 1,361,995 3,338,633 Homeopatia 35,167 36,842 18,848 70 101 Figure 4.73. Sales volumes of medicines used in the treatment of nicotine addiction according to INN (USD) 2015 2016 2017 2018 2019 Cytisine 802,552 523,728 607,309 948,248 1,163,451 Nicotine 597,496 317,088 281,440 355,532 582,849 Varenicline 9,276 6,755 7,402 46,118 129,106 Homeopatia 1,517 1,416 706 3 4 (b) Public procurement In ve years, only 15 packages of medicines used in the treatment of nicotine addiction were purchased at the cost of UAH 3,400. Annex 5. Medicines That Can Be Used to Treat Persons with Mental Disorders Figure 5.1. Pharmacy sales of medicines available in the State Formulary of Medicines (% of all medicines that can be used to treat persons with mental disorders) Figure 5.2. Public procurement of medicines available in the State Formulary of Medicines (% of all medicines that can be used to treat persons with mental disorders) ANNEXES 5 | 121 Figure 5.3. Total volume of pharmacy sales and public procurement of medicines that can be used to treat persons with mental 122 | ANNEXES 5 disorders Packages UAH USD 2015 46,947,911 1,966,506,173 89,987,745 2016 40,058,413 2,052,561,696 80,164,653 2017 38,961,774 2,527,592,194 94,987,071 2018 34,722,572 2,941,959,427 108,251,699 2019 31,246,390 3,221,166,235 125,212,541 Figure 5.4. Volumes of pharmacy sales and public procurement of separate groups of medicines that can be used to treat persons with mental disorders (packages) 2015 2016 2017 2018 2019 N05C Hypnotics and sedatives 33,017,454 26,926,089 24,753,308 20,921,475 17,912,388 N06B Nootropics and psychostimulants 5,770,345 5,439,258 6,044,571 5,777,014 5,274,168 Other* 5,623,204 4,966,281 5,026,824 4,735,846 4,508,974 N03 Antiepileptic medicines 1,928,831 2,059,961 2,396,454 2,573,171 2,814,527 N04 Antiparkinsonian medicines 608,078 666,825 740,617 715,067 736,333 Note: *Other medicines that can be used in the treatment of persons with mental disorders. Figure 5.5. Volumes of pharmacy sales and public procurement of separate groups of medicines that can be used to treat persons with mental disorders (UAH) 2015 2016 2017 2018 2019 N06B Nootropics and psychostimulants 642,119,896 660,633,595 839,572,456 1,029,523,572 1,105,703,831 Other* 587,798,723 577,048,291 728,663,767 835,872,822 931,827,961 N03 Antiepileptic medicines 240,631,141 303,455,473 367,934,117 460,032,433 551,308,824 N05C Hypnotics and sedatives 412,131,472 418,219,181 473,585,314 474,101,892 476,725,575 N04 Antiparkinsonian medicines 83,824,941 93,205,156 117,836,540 142,428,708 155,600,043 Figure 5.6. Volumes of pharmacy sales and public procurement of separate groups of medicines that can be used to treat persons with mental disorders (USD) 2015 2016 2017 2018 2019 N06B Nootropics and psychostimulants 29,367,960 25,795,217 31,555,074 37,872,112 42,970,686 Other* 26,883,034 22,517,848 27,370,583 30,757,956 36,270,729 N03 Antiepileptic medicines 11,007,332 11,863,377 13,832,371 16,928,231 21,418,526 N05C Hypnotics and sedatives 18,901,504 16,344,504 17,796,883 17,457,664 18,515,782 N04 Antiparkinsonian medicines 3,827,915 3,643,707 4,432,160 5,235,737 6,036,818 Note: *Other medicines that can be used in the treatment of persons with mental disorders. ANNEXES 5 | 123 (a) Pharmacy sales 124 | ANNEXES 5 Figure 5.7. Volumes of pharmacy sales of medicines that can be used to treat persons with mental disorders Packages UAH USD 2015 46,382,889 1,924,915,509 88,097,099 2016 39,279,456 1,987,578,754 77,648,121 2017 38,009,111 2,445,892,913 91,909,639 2018 33,832,209 2,842,834,025 104,592,288 2019 30,466,307 3,126,287,368 121,565,489 Figure 5.8. Volumes of pharmacy sales of separate groups of medicines that can be used to treat persons with mental disorders (packages) 2015 2016 2017 2018 2019 N05C Hypnotics and sedatives 32,862,491 26,719,399 24,458,012 20,694,862 17,724,937 N06B Nootropics and psychostimulants 5,576,047 5,192,917 5,764,668 5,557,549 5,082,158 Other* 5,535,855 4,817,245 4,887,260 4,615,665 4,383,863 N03 Antiepileptic medicines 1,861,350 1,950,254 2,216,604 2,312,302 2,591,365 N04 Antiparkinsonian medicines 547,146 599,641 682,567 651,831 683,984 Note: *Other medicines that can be used in the treatment of persons with mental disorders. (b) Public procurement Figure 5.9. Volumes of pharmacy sales of separate groups of medicines that can be used to treat persons with mental disorders (UAH) 2015 2016 2017 2018 2019 N06B Nootropics and psychostimulants 624,460,011 636,284,171 807,273,555 977,914,743 1,064,393,419 Other* 575,262,631 553,268,001 707,915,947 820,076,260 911,387,987 N03 Antiepileptic medicines 233,745,779 292,124,792 348,388,302 436,541,443 527,162,328 N05C Hypnotics and sedatives 409,196,332 414,569,506 467,343,829 468,547,181 470,432,157 N04 Antiparkinsonian medicines 82,250,756 91,332,285 114,971,280 139,754,397 152,911,478 Figure 5.10. Volumes of pharmacy sales of separate groups of medicines that can be used to treat persons with mental disorders (USD) 2015 2016 2017 2018 2019 N06B Nootropics and psychostimulants 28,565,924 24,850,657 30,337,207 35,976,929 41,373,734 Other* 26,309,157 21,601,977 26,590,662 30,173,565 35,488,104 N03 Antiepileptic medicines 10,697,949 11,422,749 13,095,249 16,054,667 20,495,960 N05C Hypnotics and sedatives 18,767,126 16,201,854 17,562,677 17,250,859 18,273,103 N04 Antiparkinsonian medicines 3,756,943 3,570,885 4,323,844 5,136,268 5,934,588 Note: *Other medicines that can be used in the treatment of persons with mental disorders. ANNEXES 5 | 125 Figure 5.11. Volumes of public procurement of medicines that can be used to treat persons with mental disorders 126 | ANNEXES 5 Packages UAH USD 2015 565,022 41,590,664 1,890,646 2016 778,958 64,982,941 2,516,532 2017 952,663 81,699,281 3,077,432 2018 890,363 99,125,403 3,659,411 2019 780,083 94,878,866 3,647,052 Figure 5.12. Volumes of public procurement of separate groups of medicines that can be used to treat persons with mental disorders (packages) 2015 2016 2017 2018 2019 N03 Antiepileptic medicines 67,481 109,706 179,850 260,869 223,162 N06B Nootropics and psychostimulants 194,298 246,341 279,903 219,465 192,010 N05C Hypnotics and sedatives 154,963 206,690 295,296 226,613 187,451 Other* 87,349 149,036 139,564 120,181 125,111 N04 Antiparkinsonian medicines 60,932 67,184 58,050 63,236 52,349 Note: *Other medicines that can be used in the treatment of persons with mental disorders. Figure 5.13. Volumes of public procurement of separate groups of medicines that can be used to treat persons with mental disorders (UAH) 2015 2016 2017 2018 2019 N06B Nootropics and psychostimulants 17,659,885 24,349,424 32,298,901 51,608,828 41,310,413 N03 Antiepileptic medicines 6,885,362 11,330,681 19,545,815 23,490,990 24,146,496 Other* 12,536,092 23,780,290 20,747,820 15,796,562 20,439,974 N05C Hypnotics and sedatives 2,935,140 3,649,675 6,241,485 5,554,711 6,293,418 N04 Antiparkinsonian medicines 1,574,185 1,872,871 2,865,260 2,674,311 2,688,565 Figure 5.14. Volumes of public procurement of separate groups of medicines that can be used to treat persons with mental disorders (USD) 2015 2016 2017 2018 2019 N06B Nootropics and psychostimulants 802,036 944,560 1,217,867 1,895,183 1,596,952 N03 Antiepileptic medicines 309,383 440,628 737,121 873,564 922,567 Other* 573,877 915,870 779,921 584,391 782,625 N05C Hypnotics and sedatives 134,378 142,650 234,206 206,804 242,679 N04 Antiparkinsonian medicines 70,972 72,823 108,316 99,469 102,229 Note: *Other medicines that can be used in the treatment of persons with mental disorders. ANNEXES 5 | 127 1. Nootropic and psychostimulant medicines (N06B according to ATC classi cation) 128 | ANNEXES 5 Figure 5.15. Total volume of pharmacy sales and public procurement of nootropic and psychostimulant medicines Packages UAH USD 2015 5,770,345 642,119,896 29,367,960 2016 5,439,258 660,633,595 25,795,217 2017 6,044,571 839,572,456 31,555,074 2018 5,777,014 1,029,523,572 37,872,112 2019 5,274,168 1,105,703,831 42,970,686 (a) Pharmacy sales Figure 5.16. Sales volumes of the group of nootropic and psychostimulant medicines Packages UAH USD 2015 5,576,047 624,460,011 28,565,924 2016 5,192,917 636,284,171 24,850,657 2017 5,764,668 807,273,555 30,337,207 2018 5,557,549 977,914,743 35,976,929 2019 5,082,158 1,064,393,419 41,373,734 Figure 5.17. Sales volumes of nootropic and psychostimulant medicines according to INN (packages) 2015 2016 2017 2018 2019 Phenibut 741,202 967,681 1,305,896 1,551,068 1,558,986 Citicoline 451,985 493,782 524,418 553,742 672,648 Piracetam 1,238,528 1,037,391 958,121 746,080 658,680 Choline alfoscerate 102,838 121,353 226,861 285,105 354,274 Piracetam+Cinnarizine 723,472 556,677 473,346 357,376 279,784 Piracetam+Thiotriazoline 431,260 377,758 437,320 355,264 270,139 Hydrolysate of horned animal brain 79,468 80,507 114,047 211,839 230,810 Glycine 686,247 609,954 730,941 513,881 215,264 Ginkgo biloba 315,913 215,181 229,387 219,870 178,622 Gamma-aminobutyric acid 159,748 131,356 140,113 132,614 114,461 Hopantenic acid 95,539 102,841 131,406 125,506 107,639 Homeopatia 99,237 107,258 93,035 99,711 95,379 Cerebrolysin 158,591 118,079 113,099 104,696 82,703 Ginkgo biloba+Pollen+Vitamins 50,466 67,480 79,851 89,833 69,383 Succinic acid+Inosine+Nicotinamide+Ribo avin 88,712 78,596 75,217 79,739 57,469 Threonine+Gamma-aminobutyric acid+Magnesium glutamate+Pyridoxine 36,673 31,104 40,087 50,929 50,931 Pramiracetam 36,128 34,712 31,613 27,009 25,374 Gamma-aminobutyric acid+Piracetam 50,116 32,797 30,129 26,595 22,793 Fenilpiracetam 12,993 11,976 10,346 12,690 14,818 Phenibut+Ipidacrine 0 566 3,804 7,043 8,264 Hydrolysate of horned animal embryo brain 1,600 2,170 2,182 3,312 4,653 Armoda nil 0 0 0 0 4,126 Heptapeptide 2,715 809 691 2,091 2,416 Herbal components 4 0 0 0 1,741 Caffeine citrate 0 240 1,057 674 484 Atomoxetine 6 3 68 408 312 ANNEXES 5 | 129 Pyritinol 12,550 12,635 11,632 471 5 Fenotropil 55 10 1 0 0 Picamilon 1 0 0 3 0 Figure 5.18. Sales volumes of nootropic and psychostimulant medicines according to INN (UAH) 130 | ANNEXES 5 2015 2016 2017 2018 2019 Citicoline 134,135,783 144,460,468 172,926,781 196,298,145 242,344,220 Phenibut 83,870,829 107,038,413 152,131,543 196,188,187 214,839,253 Choline alfoscerate 37,382,633 44,665,801 80,452,980 101,044,541 134,491,370 Hydrolysate of horned animal brain 37,718,105 35,335,583 51,286,607 101,523,127 111,803,221 Cerebrolysin 77,211,537 66,697,819 71,088,861 79,697,159 65,933,013 Piracetam+Thiotriazoline 32,676,295 37,641,920 51,510,554 54,425,393 51,557,103 Ginkgo biloba 48,549,144 32,064,214 34,427,798 38,948,565 36,369,253 Piracetam+Cinnarizine 36,224,571 30,065,348 32,619,271 37,860,562 35,176,644 Piracetam 31,908,822 29,048,424 28,819,284 28,084,593 28,949,826 Hydrolysate of horned animal embryo brain 6,641,953 10,471,447 13,441,226 20,219,097 28,733,955 Succinic acid+Inosine+Nicotinamide+Ribo avin 27,877,144 26,110,821 26,659,790 30,066,116 28,267,109 Hopantenic acid 11,873,702 12,844,004 18,388,192 19,286,026 19,838,834 Threonine+Gamma-aminobutyric acid+Magnesium glutamate+Pyridoxine 6,358,911 5,904,306 8,617,014 12,832,349 11,932,744 Homeopatia 7,984,575 9,074,086 8,599,390 9,969,286 10,708,513 Pramiracetam 8,704,112 8,774,142 8,955,185 8,203,918 7,087,317 Glycine 16,690,928 16,762,957 21,421,603 15,379,917 6,835,340 Fenilpiracetam 4,483,550 4,545,428 4,241,350 6,010,308 6,809,408 Ginkgo biloba+Pollen+Vitamins 3,097,086 4,718,290 6,249,106 7,380,499 6,662,088 Phenibut+Ipidacrine 0 254,481 1,730,103 3,607,113 4,244,360 Heptapeptide 2,298,778 899,404 925,917 2,402,069 3,167,229 Gamma-aminobutyric acid+Piracetam 3,231,238 2,251,135 2,174,005 2,917,076 2,689,886 Gamma-aminobutyric acid 2,752,243 2,484,742 2,806,787 2,931,553 2,563,352 Caffeine citrate 0 990,650 4,459,895 2,179,377 2,217,242 Armoda nil 0 0 0 0 705,710 Atomoxetine 1,786 914 72,547 346,168 302,647 Herbal components 87 0 0 0 161,743 Pyritinol 2,778,050 3,176,629 3,267,364 113,430 2,035 Fenotropil 8,095 2,745 402 0 0 Picamilon 54 0 0 169 0 Figure 5.19. Sales volumes of nootropic and psychostimulant medicines according to INN (USD) 2015 2016 2017 2018 2019 Citicoline 6,151,620 5,644,000 6,501,479 7,217,708 9,439,707 Phenibut 3,843,611 4,178,658 5,714,625 7,219,703 8,339,478 Choline alfoscerate 1,711,589 1,747,165 3,024,008 3,715,360 5,247,334 Hydrolysate of horned animal brain 1,713,974 1,378,271 1,926,490 3,736,641 4,371,200 Cerebrolysin 3,522,113 2,605,642 2,672,163 2,932,766 2,556,684 Piracetam+Thiotriazoline 1,492,810 1,469,359 1,934,043 2,006,622 2,000,683 Ginkgo biloba 2,241,386 1,252,780 1,294,863 1,432,979 1,403,069 Piracetam+Cinnarizine 1,662,989 1,173,930 1,221,095 1,394,390 1,365,498 Piracetam 1,447,239 1,133,357 1,082,734 1,033,454 1,121,047 Hydrolysate of horned animal embryo brain 302,953 409,211 507,352 739,045 1,111,074 Succinic acid+Inosine+Nicotinamide+Ribo avin 1,273,408 1,019,708 1,004,033 1,107,364 1,089,469 Hopantenic acid 536,401 502,222 690,510 709,741 770,521 Threonine+Gamma-aminobutyric acid+Magnesium glutamate+Pyridoxine 290,655 230,582 323,734 471,814 463,760 Homeopatia 360,393 354,001 322,812 366,359 414,626 Pramiracetam 398,087 342,476 336,364 301,712 274,812 Fenilpiracetam 204,649 177,624 159,431 220,730 263,686 Glycine 764,854 655,389 805,208 567,248 262,225 Ginkgo biloba+Pollen+Vitamins 139,837 184,076 235,015 271,344 258,836 Phenibut+Ipidacrine 0 9,828 65,136 132,506 162,747 Heptapeptide 107,084 34,978 34,778 87,664 121,896 Gamma-aminobutyric acid+Piracetam 147,842 87,864 81,686 107,313 103,733 Gamma-aminobutyric acid 125,251 97,084 105,506 107,998 99,133 Caffeine citrate 0 38,272 168,218 79,437 85,137 Armoda nil 0 0 0 0 29,011 Atomoxetine 111 36 2,742 12,919 12,000 Herbal components 3 0 0 0 6,292 ANNEXES 5 | 131 Pyritinol 126,665 124,040 123,168 4,105 76 Fenotropil 398 104 15 0 0 Picamilon 2 0 0 6 0 (b) Public procurement 132 | ANNEXES 5 Figure 5.20. Volumes of public procurement of group of nootropic and psychostimulant medicines Packages UAH USD 2015 194,298 17,659,885 802,036 2016 246,341 24,349,424 944,560 2017 279,903 32,298,901 1,217,867 2018 219,465 51,608,828 1,895,183 2019 192,010 41,310,413 1,596,952 Figure 5.21. Volumes of public procurement of nootropic and psychostimulant medicines according to INN (packages) 2015 2016 2017 2018 2019 Piracetam 99,044 139,137 143,466 100,556 86,648 Citicoline 23,149 29,422 34,358 32,943 28,082 Piracetam+Thiotriazoline 28,505 21,862 30,714 23,855 21,047 Phenibut 8,874 11,027 16,819 19,176 15,658 Choline alfoscerate 3,220 11,690 6,166 6,528 7,289 Cerebrolysin 7,021 11,078 8,617 7,124 6,083 Glycine 248 228 9,469 5,112 4,671 Piracetam+Cinnarizine 8,649 6,915 6,522 4,541 4,648 Hopantenic acid 1,148 1,931 6,072 4,030 4,001 Atomoxetine 4,057 0 2,468 3,601 3,750 Gamma-aminobutyric acid 7,340 9,996 10,731 3,399 3,709 Caffeine citrate 0 150 949 5,362 3,275 Hydrolysate of horned animal brain 561 479 453 663 1,387 Ginkgo biloba 1,055 333 1,479 1,476 856 Succinic acid+Inosine+Nicotinamide+Ribo avin 921 1,725 949 447 398 Ginkgo biloba+Pollen+Vitamins 3 0 97 290 294 Pramiracetam 492 231 292 83 146 Homeopatia 0 28 150 67 54 Fenilpiracetam 0 1 10 10 6 Pyritinol 0 40 55 10 5 Threonine+Gamma-aminobutyric acid+Magnesium glutamate+Pyridoxine 0 0 45 18 2 Gamma-aminobutyric acid+Piracetam 1 2 16 170 1 Heptapeptide 0 0 0 4 0 Hydrolysate of horned animal embryo brain 10 67 7 0 0 ANNEXES 5 | 133 Figure 5.22. Volumes of public procurement of nootropic and psychostimulant medicines according to INN (UAH) 134 | ANNEXES 5 2015 2016 2017 2018 2019 Caffeine citrate 0 649,730 3,850,608 22,729,977 12,888,928 Citicoline 5,364,221 6,773,663 8,301,345 8,070,520 7,600,951 Atomoxetine 1,979,068 0 2,334,476 4,192,006 4,242,162 Piracetam+Thiotriazoline 2,187,719 2,272,582 3,786,636 3,828,457 4,057,502 Cerebrolysin 2,899,864 5,353,746 4,503,338 4,442,777 3,288,141 Piracetam 1,995,101 2,972,175 3,425,855 2,370,088 2,687,617 Choline alfoscerate 888,756 3,326,127 1,965,661 2,125,598 2,362,720 Phenibut 896,731 944,311 1,568,534 2,058,881 1,928,750 Hydrolysate of horned animal brain 274,108 200,863 193,482 339,831 704,513 Hopantenic acid 150,509 248,922 888,251 670,529 681,686 Piracetam+Cinnarizine 236,129 251,112 315,802 229,320 312,754 Glycine 6,873 6,972 254,920 170,673 166,351 Succinic acid+Inosine+Nicotinamide+Ribo avin 410,291 884,276 400,116 137,872 158,591 Gamma-aminobutyric acid 122,077 197,594 205,221 72,790 90,025 Ginkgo biloba 104,160 17,066 155,154 81,375 61,749 Pramiracetam 107,077 54,393 72,282 18,845 37,191 Ginkgo biloba+Pollen+Vitamins 154 0 7,486 26,577 28,540 Homeopatia 0 2,214 14,935 6,164 6,232 Fenilpiracetam 0 256 3,324 5,554 3,163 Pyritinol 0 10,325 16,161 3,130 2,126 eonine+Gamma-aminobutyric acid+Magnesium Threonine+Gamma-aminobutyric 0 0 11,669 5,269 572 glutamate+P glutamate+Pyrido yridoxine glutamate+Pyridoxine Gamma-aminobutyric acid+Piracetam 69 132 1,248 17,517 150 Heptapeptide 0 0 0 5,080 0 Hydrolysate of horned animal embryo brain 36,979 182,969 22,394 0 0 Figure 5.23. Volumes of public procurement of nootropic and psychostimulant medicines according to INN (USD) 2015 2016 2017 2018 2019 Caffeine citrate 0 25,271 145,096 830,617 502,281 Citicoline 243,148 262,606 312,461 298,570 290,876 Atomoxetine 84,829 0 90,365 150,972 169,121 Piracetam+Thiotriazoline 100,005 88,943 142,418 142,479 154,455 Cerebrolysin 134,733 206,900 168,961 163,023 127,145 Piracetam 91,299 115,608 128,943 87,764 102,613 Choline alfoscerate 40,691 128,021 74,045 79,201 90,885 Phenibut 40,721 36,899 59,287 76,393 74,050 Hydrolysate of horned animal brain 12,935 7,860 7,215 12,404 26,609 Hopantenic acid 6,791 9,739 33,344 24,921 25,980 Piracetam+Cinnarizine 10,817 9,846 11,875 8,534 11,928 Glycine 296 270 9,566 6,203 6,324 Succinic acid+Inosine+Nicotinamide+Ribo avin 18,663 34,512 14,967 5,032 5,971 Gamma-aminobutyric acid 5,632 7,696 7,783 2,710 3,426 Ginkgo biloba 4,762 650 5,895 3,027 2,356 Pramiracetam 4,967 2,129 2,720 716 1,402 Ginkgo biloba+Pollen+Vitamins 7 0 280 1,009 1,068 Homeopatia 0 87 558 228 236 Fenilpiracetam 0 10 125 201 123 Pyritinol 0 409 605 120 76 ANNEXES 5 | 135 eonine+Gamma-aminobutyric acid+Magnesium Threonine+Gamma-aminobutyric 0 0 442 196 21 glutamate+P glutamate+Pyrido yridoxine glutamate+Pyridoxine Gamma-aminobutyric acid+Piracetam 3 5 48 666 5 Heptapeptide 0 0 0 194 0 Hydrolysate of horned animal embryo brain 1,738 7,099 869 0 0 2. Hypnotics and sedatives (N05C according to ATC classi cation) 136 | ANNEXES 5 Figure 5.24. Total volume of pharmacy sales and public procurement of hypnotics and sedatives Packages UAH USD 2015 33,017,454 412,131,472 18,901,504 2016 26,926,089 418,219,181 16,344,504 2017 24,753,308 473,585,314 17,796,883 2018 20,921,475 474,101,892 17,457,664 2019 17,912,388 476,725,575 18,515,782 (a) Pharmacy sales Figure 5.25. Sales volumes of the group of hypnotics and sedatives Packages UAH USD 2015 32,862,491 409,196,332 18,767,126 2016 26,719,399 414,569,506 16,201,854 2017 24,458,012 467,343,829 17,562,677 2018 20,694,862 468,547,181 17,250,859 2019 17,724,937 470,432,157 18,273,103 Figure 5.26. Sales volumes of hypnotics and sedatives according to INN (packages) 2015 2016 2017 2018 2019 Phenobarbital+Ethyl ether bromisovaleric acid+Combination 12,434,254 10,091,604 9,253,086 7,319,555 6,060,758 Valeriana 10,983,777 8,555,490 7,329,650 5,986,669 5,025,224 Leonurus 3,625,347 2,930,058 2,736,967 2,475,985 2,081,394 Doxylamine 1,205,604 1,063,970 1,119,906 999,174 877,562 Paeonia 573,078 430,550 446,835 453,295 385,875 Valeriana+Mentha+Melissa 553,575 456,088 450,268 397,204 345,793 Convallaria+Valeriana+Belladonna+Menthol 443,684 361,248 352,465 384,593 309,888 Zopiclone 248,779 306,670 317,740 271,976 308,582 Guaifenesin+Doxylamine+Ethyl ether bromisovaleric acid 0 166,996 235,224 284,821 295,191 Herbal components 674,514 443,302 361,826 319,991 290,821 Phenobarbital+Ethyl ether bromisovaleric acid 454,305 336,434 295,895 251,019 209,633 Guaifenesin+Herbal complex 263,841 258,270 176,267 192,684 176,921 Levana monohydrate 98,637 116,672 141,651 167,954 176,449 Sodium bromide 0 464 543 60,207 169,312 Homeopatia 218,893 180,945 181,359 162,595 147,585 Valeriana+Leonurus+Crataegus 143,104 168,073 184,602 123,513 122,540 Melissa 186,180 130,302 110,922 97,023 102,946 Ethyl ether bromisovaleric acid+Menthol in menthyl isovalerate+Combination 123,105 113,822 159,354 114,828 99,506 Valeriana+Leonurus+Crataegus+Melissa 639 29,407 38,538 91,746 97,289 Passi ora 153,824 144,352 132,715 116,004 80,698 Pyridoxine+Nicotinamide+Herbal complex 239,058 166,362 136,656 104,607 80,634 Passi ora+Herbal components 0 7,895 80,390 94,016 75,162 Passi ora+Ethyl ether bromisovaleric acid+Menthol 104,398 119,111 82,491 77,212 47,584 Phenobarbital+Ethyl ether bromisovaleric acid+Menthol oil 1,504 23,344 17,098 31,812 38,735 Hypericum+Valeriana 8,145 14,290 25,521 33,085 31,393 Sodium bromide+Herbal complex 25,052 21,977 27,833 28,709 29,352 Zaleplon 22,785 21,621 19,744 26,081 22,401 Humulus lupulus 21,754 15,664 14,583 13,743 14,551 Passi ora+Crataegus 21,146 10,889 3,488 27 9,793 Valeriana+Melissa 7,625 7,011 5,376 3,749 4,745 Ethyl ether bromisovaleric acid+Valeriana 0 0 1,453 8,708 4,435 Dexmedetomidine 40 76 114 277 1,217 Valeriana+Melissa+Passi ora+Combination 0 0 0 0 628 Combination 0 1 1,001 0 233 Valeriana+Mentha+Sodium bromide+Combination 38 2,207 6,512 1,789 107 Adonis+Potassium bromide 20 0 0 0 0 Bromcamphora 22,513 22,077 5,326 18 0 Diazepam+Cyclobarbital 2 0 0 0 0 Hypericum+Humulus lupulus 39 0 0 0 0 Valeriana+Humulus lupulus 3,224 2,157 4,613 193 0 Lupulus+Valeriana 8 0 0 0 0 ANNEXES 5 | 137 Figure 5.27. Sales volumes of hypnotics and sedatives according to INN (UAH) 2015 2016 2017 2018 2019 Phenobarbital+Ethyl ether bromisovaleric acid+Combination 128,336,512 121,800,128 133,966,520 121,652,320 114,027,050 Valeriana 71,856,039 86,173,739 101,582,871 102,140,299 105,990,049 Doxylamine 47,183,708 44,435,295 52,280,025 49,760,281 47,480,779 Valeriana+Mentha+Melissa 32,703,656 27,601,067 29,888,927 28,835,999 27,425,852 Zopiclone 9,111,779 12,891,046 16,594,910 16,041,639 19,336,922 Homeopatia 17,560,711 16,072,121 16,360,385 18,200,557 18,396,883 Guaifenesin+Herbal complex 18,317,778 17,473,321 13,981,543 13,585,550 14,090,383 Phenobarbital+Ethyl ether bromisovaleric acid 17,949,813 16,068,862 15,427,567 15,544,167 13,824,844 Valeriana+Leonurus+Crataegus+Melissa 33,423 1,937,635 3,420,298 9,128,996 12,053,360 Levana monohydrate 3,134,827 4,225,482 6,184,928 8,585,340 11,375,146 Herbal components 15,256,859 11,596,538 10,831,837 10,428,190 11,102,487 Valeriana+Leonurus+Crataegus 5,995,522 7,123,152 9,753,960 9,260,956 10,325,641 Guaifenesin+Doxylamine+Ethyl ether bromisovaleric acid 0 3,118,782 5,437,169 7,619,662 8,823,638 Leonurus 8,637,866 7,434,907 7,714,639 7,879,290 8,142,461 Passi ora+Herbal components 0 400,796 5,190,803 7,157,371 6,724,412 Passi ora+Ethyl ether bromisovaleric acid+Menthol 1,940,888 5,280,792 6,151,442 8,812,578 6,348,746 Passi ora 9,866,913 10,550,373 10,440,390 9,803,923 5,714,964 Pyridoxine+Nicotinamide+Herbal complex 8,064,553 6,791,089 6,760,469 6,089,727 5,571,499 Dexmedetomidine 108,889 373,002 343,157 854,701 4,642,799 Paeonia 3,340,115 2,888,427 3,228,779 3,657,628 3,995,922 Hypericum+Valeriana 625,147 1,049,495 1,986,400 3,158,897 3,748,111 Zaleplon 2,262,050 2,819,148 2,878,290 3,909,148 3,314,932 Ethyl ether bromisovaleric acid+Menthol in menthyl isovalerate+Combination 990,739 1,400,459 2,334,100 1,814,814 1,852,577 Melissa 1,537,937 1,380,054 1,428,613 1,446,004 1,840,618 Convallaria+Valeriana+Belladonna+Menthol 1,314,089 1,253,632 1,303,375 1,529,332 1,466,972 Passi ora+Crataegus 1,588,769 936,220 347,551 2,758 961,961 Valeriana+Melissa 718,442 587,643 640,609 452,303 569,124 Humulus lupulus 358,915 312,364 344,431 351,319 446,026 Phenobarbital+Ethyl ether bromisovaleric acid+Menthol oil 2,294 136,287 101,041 213,301 401,394 Sodium bromide+Herbal complex 87,423 90,826 120,659 137,562 181,449 Sodium bromide 0 2,439 2,948 404,972 169,312 Ethyl ether bromisovaleric acid+Valeriana 0 0 10,013 64,792 43,549 Valeriana+Melissa+Passi ora+Combination 0 0 0 0 39,977 Valeriana+Mentha+Sodium bromide+Combination 230 30,669 71,520 16,999 1,622 Combination 0 4 11,500 0 696 Adonis+Potassium bromide 316 0 0 0 0 Bromcamphora 239,056 277,508 110,699 611 0 Diazepam+Cyclobarbital 68 0 0 0 0 Hypericum+Humulus lupulus 939 0 0 0 0 Valeriana+Humulus lupulus 69,870 56,204 111,461 5,195 0 Lupulus+Valeriana 197 0 0 0 0 138 | ANNEXES 5 Figure 5.28. Sales volumes of hypnotics and sedatives according to INN (USD) 2015 2016 2017 2018 2019 Phenobarbital+Ethyl ether bromisovaleric acid+Combination 5,925,346 4,764,770 5,034,400 4,483,568 4,429,669 Valeriana 3,271,943 3,366,747 3,820,899 3,760,326 4,121,248 Doxylamine 2,173,491 1,738,824 1,961,263 1,829,165 1,844,669 Valeriana+Mentha+Melissa 1,495,827 1,077,661 1,123,616 1,059,793 1,063,806 Zopiclone 418,757 504,494 624,009 591,255 752,602 Homeopatia 800,444 627,702 614,945 669,799 712,867 Guaifenesin+Herbal complex 838,533 683,165 526,062 500,936 546,723 Phenobarbital+Ethyl ether bromisovaleric acid 826,934 628,651 579,976 572,055 536,179 Valeriana+Leonurus+Crataegus+Melissa 1,993 75,762 128,070 335,141 468,880 Levana monohydrate 142,389 164,883 232,477 315,693 443,045 Herbal components 700,414 451,475 406,610 383,633 429,593 Valeriana+Leonurus+Crataegus 272,858 276,815 366,755 341,264 401,055 Guaifenesin+Doxylamine+Ethyl ether bromisovaleric acid 0 121,805 204,336 281,123 342,875 Leonurus 394,380 289,832 289,820 290,263 316,085 Passi ora+Herbal components 0 15,417 194,949 262,974 260,363 Passi ora+Ethyl ether bromisovaleric acid+Menthol 87,174 206,643 231,150 323,833 244,795 Passi ora 450,807 412,132 392,263 362,490 220,929 Pyridoxine+Nicotinamide+Herbal complex 368,023 265,257 253,687 224,390 216,140 Dexmedetomidine 4,949 14,908 12,895 31,135 184,864 Paeonia 150,745 112,304 121,211 134,569 155,069 Hypericum+Valeriana 27,828 40,882 74,596 116,532 144,620 Zaleplon 104,720 110,163 108,313 144,016 126,938 Ethyl ether bromisovaleric acid+Menthol in menthyl isovalerate+Combination 44,964 54,821 87,688 66,773 72,104 Melissa 68,387 53,434 53,570 53,107 71,670 Convallaria+Valeriana+Belladonna+Menthol 59,084 48,758 49,008 56,370 56,925 Passi ora+Crataegus 70,914 36,640 12,918 103 37,946 Valeriana+Melissa 32,793 22,870 24,021 16,704 22,148 Humulus lupulus 15,962 12,141 12,944 12,923 17,268 Phenobarbital+Ethyl ether bromisovaleric acid+Menthol oil 95 5,232 3,806 8,004 15,114 Sodium bromide+Herbal complex 3,598 3,462 4,543 5,090 6,900 Sodium bromide 0 95 111 14,586 6,576 Valeriana+Melissa+Passi ora+Combination 0 0 0 0 1,693 Ethyl ether bromisovaleric acid+Valeriana 0 0 377 2,427 1,656 Valeriana+Mentha+Sodium bromide+Combination 9 1,181 2,677 612 64 Combination 0 0 433 0 26 Adonis+Potassium bromide 19 0 0 0 0 Bromcamphora 10,548 10,764 4,099 22 0 Diazepam+Cyclobarbital 2 0 0 0 0 Hypericum+Humulus lupulus 40 0 0 0 0 Valeriana+Humulus lupulus 3,148 2,166 4,179 187 0 Lupulus+Valeriana 8 0 0 0 0 ANNEXES 5 | 139 (b) Public procurement 140 | ANNEXES 5 Figure 5.29. Volumes of public procurement of hypnotics and sedatives Packages UAH USD 2015 154,963 2,935,140 134,378 2016 206,690 3,649,675 142,650 2017 295,296 6,241,485 234,206 2018 226,613 5,554,711 206,804 2019 187,451 6,293,418 242,679 Figure 5.30. Volumes of public procurement of hypnotics and sedatives according to INN (packages) 2015 2016 2017 2018 2019 Phenobarbital+Ethyl ether bromisovaleric acid+Combination 73,962 120,145 155,585 113,826 93,106 Valeriana 35,690 46,675 78,898 62,106 47,887 Valeriana+Mentha+Melissa 7,876 4,752 11,661 13,585 12,251 Zopiclone 8,323 7,734 6,373 8,928 7,413 Pyridoxine+Nicotinamide+Herbal complex 4,451 4,207 10,705 6,065 4,975 Ethyl ether bromisovaleric acid+Menthol in menthyl isovalerate+Combination 12,005 14,109 13,382 3,670 4,738 Leonurus 118 776 2,807 4,078 3,226 Herbal components 3,951 2,308 3,607 4,147 2,556 Doxylamine 397 328 1,287 1,559 2,310 Zaleplon 90 260 703 250 1,521 Valeriana+Mentha+Sodium bromide+Combination 760 340 675 1,274 1,365 Phenobarbital+Ethyl ether bromisovaleric acid 1,281 749 1,195 592 967 Dexmedetomidine 247 322 524 328 800 Valeriana+Leonurus+Crataegus 907 870 1,235 1,170 797 Passi ora 1,729 1 178 197 657 Hypericum+Valeriana 0 0 20 20 490 Sodium bromide 311 548 1,842 1,969 484 Phenobarbital+Ethyl ether bromisovaleric acid+Menthol oil 0 130 419 35 401 Convallaria+Valeriana+Belladonna+Menthol 286 184 400 498 350 Paeonia 10 46 297 202 255 Guaifenesin+Herbal complex 38 110 636 391 223 Passi ora+Ethyl ether bromisovaleric acid+Menthol 0 1 143 183 167 Sodium bromide+Herbal complex 1,244 302 1,398 653 147 Guaifenesin+Doxylamine+Ethyl ether bromisovaleric acid 0 105 111 256 140 Homeopatia 0 24 114 108 78 Levana monohydrate 380 550 130 13 42 Passi ora+Herbal components 0 0 37 126 33 Citral+Combination 200 270 270 116 30 Herbal complex+Menthol 0 0 0 10 20 Melissa 0 0 46 4 10 Valeriana+Melissa 0 0 0 0 10 Passi ora+Crataegus 0 0 0 0 1 Potassium bromide 0 0 90 0 1 Bromcamphora 6 534 528 0 0 Combination 0 0 0 250 0 Diazepam+Cyclobarbital 700 300 0 0 0 Valeriana+Leonurus+Crataegus+Melissa 0 0 0 4 0 Lupulus+Valeriana 1 10 0 0 0 ANNEXES 5 | 141 Figure 5.31. Volumes of public procurement of hypnotics and sedatives according to INN (UAH) 2015 2016 2017 2018 2019 Dexmedetomidine 584,258 882,207 1,507,930 1,009,175 1,742,072 Phenobarbital+Ethyl ether bromisovaleric acid+Combination 1,049,357 1,467,358 2,132,025 1,913,988 1,515,396 Valeriana+Mentha+Melissa 334,983 194,369 505,469 677,752 719,690 Valeriana 128,438 244,230 532,189 499,294 654,813 Zopiclone 210,342 241,863 249,195 428,201 386,334 Pyridoxine+Nicotinamide+Herbal complex 142,130 169,468 610,952 371,306 346,212 Zaleplon 2,838 27,797 86,367 36,347 239,593 Doxylamine 16,622 14,911 55,169 85,736 122,391 Herbal components 125,719 81,094 106,751 143,395 93,204 Valeriana+Leonurus+Crataegus 46,026 51,498 70,679 93,869 83,139 Valeriana+Mentha+Sodium bromide+Combination 13,851 9,668 26,383 52,529 66,690 Ethyl ether bromisovaleric acid+Menthol in menthyl isovalerate+Combination 99,480 153,569 136,385 45,039 63,403 Hypericum+Valeriana 0 0 1,712 1,608 56,572 Passi ora 116,553 78 11,290 14,197 48,479 Phenobarbital+Ethyl ether bromisovaleric acid 19,609 16,686 41,569 26,302 40,947 Passi ora+Ethyl ether bromisovaleric acid+Menthol 0 146 12,558 20,338 24,075 Guaifenesin+Herbal complex 5,006 5,150 38,934 32,663 17,739 Sodium bromide 3,028 11,524 36,280 31,516 14,187 Leonurus 268 2,219 7,946 13,278 12,906 Phenobarbital+Ethyl ether bromisovaleric acid+Menthol oil 0 859 4,843 366 12,462 Homeopatia 0 2,906 17,557 17,170 10,755 Guaifenesin+Doxylamine+Ethyl ether bromisovaleric acid 0 1,714 2,382 6,370 4,680 Levana monohydrate 10,829 32,424 5,167 519 4,484 Passi ora+Herbal components 0 0 3,733 11,651 3,455 Paeonia 75 353 2,327 1,396 2,962 Convallaria+Valeriana+Belladonna+Menthol 954 754 1,761 2,227 1,811 Herbal complex+Menthol 0 0 0 608 1,378 Sodium bromide+Herbal complex 3,263 1,639 6,871 3,342 1,129 Citral+Combination 4,500 6,075 10,805 4,743 1,081 Valeriana+Melissa 0 0 0 0 1,080 Melissa 0 0 555 51 159 Passi ora+Crataegus 0 0 0 0 121 Potassium bromide 0 0 1,158 0 22 Bromcamphora 90 8,580 14,543 0 0 Combination 0 0 0 9,199 0 Diazepam+Cyclobarbital 16,898 20,304 0 0 0 Valeriana+Leonurus+Crataegus+Melissa 0 0 0 537 0 Lupulus+Valeriana 23 230 0 0 0 142 | ANNEXES 5 Figure 5.32. Volumes of public procurement of hypnotics and sedatives according to INN (USD) 2015 2016 2017 2018 2019 Dexmedetomidine 26,858 34,965 56,190 37,739 68,221 Phenobarbital+Ethyl ether bromisovaleric acid+Combination 47,984 57,014 80,408 71,234 57,995 Valeriana+Mentha+Melissa 15,360 7,592 18,881 25,338 27,255 Valeriana 5,820 9,491 20,132 18,560 25,627 Zopiclone 9,661 9,401 9,393 15,966 14,692 Pyridoxine+Nicotinamide+Herbal complex 6,535 6,659 22,703 13,680 13,483 Zaleplon 135 1,095 3,294 1,373 9,165 Doxylamine 929 580 2,065 3,156 4,624 Herbal components 5,809 3,160 4,002 5,331 3,547 Valeriana+Leonurus+Crataegus 2,039 2,044 2,656 3,460 3,156 Valeriana+Mentha+Sodium bromide+Combination 596 393 976 1,980 2,534 Ethyl ether bromisovaleric acid+Menthol in menthyl isovalerate+Combination 4,553 5,956 5,180 1,666 2,395 Hypericum+Valeriana 0 0 64 59 2,220 Passi ora 5,203 3 425 528 1,833 Phenobarbital+Ethyl ether bromisovaleric acid 907 652 1,568 964 1,606 Passi ora+Ethyl ether bromisovaleric acid+Menthol 0 6 466 751 892 Guaifenesin+Herbal complex 230 199 1,466 1,185 682 Sodium bromide 127 445 1,356 1,181 525 Leonurus 12 87 299 492 491 Phenobarbital+Ethyl ether bromisovaleric acid+Menthol oil 0 33 183 13 488 Homeopatia 0 114 661 637 406 Levana monohydrate 496 1,231 192 20 177 Guaifenesin+Doxylamine+Ethyl ether bromisovaleric acid 0 66 89 238 175 Passi ora+Herbal components 0 0 137 443 128 Paeonia 3 14 87 52 110 Convallaria+Valeriana+Belladonna+Menthol 43 29 66 83 69 Herbal complex+Menthol 0 0 0 23 51 Sodium bromide+Herbal complex 137 64 260 124 42 Citral+Combination 182 250 399 174 41 Valeriana+Melissa 0 0 0 0 40 Melissa 0 0 21 2 6 Passi ora+Crataegus 0 0 0 0 4 Potassium bromide 0 0 43 0 1 Bromcamphora 4 330 541 0 0 Combination 0 0 0 336 0 Diazepam+Cyclobarbital 754 770 0 0 0 Valeriana+Leonurus+Crataegus+Melissa 0 0 0 19 0 Lupulus+Valeriana 1 9 0 0 0 ANNEXES 5 | 143 3. Antiepileptic medicines (N03 according to ATC classi cation) 144 | ANNEXES 5 Figure 5.33. Total volume of pharmacy sales and public procurement of antiepileptic medicines Packages UAH USD 2015 1,928,831 240,631,141 11,007,332 2016 2,059,961 303,455,473 11,863,377 2017 2,396,454 367,934,117 13,832,371 2018 2,573,171 460,032,433 16,928,231 2019 2,814,527 551,308,824 21,418,526 (a) Pharmacy sales Figure 5.34. Sales volumes of the group of antiepileptic medicines Packages UAH USD 2015 1,861,350 233,745,779 10,697,949 2016 1,950,254 292,124,792 11,422,749 2017 2,216,604 348,388,302 13,095,249 2018 2,312,302 436,541,443 16,054,667 2019 2,591,365 527,162,328 20,495,960 Figure 5.35. Sales volumes of antiepileptic medicines according to INN (packages) 2015 2016 2017 2018 2019 Pregabalin 74,016 178,858 301,497 649,469 832,779 Carbamazepine 897,131 887,942 941,348 751,820 750,071 Valproic acid 254,107 228,462 281,442 285,288 291,457 Lamotrigine 161,027 143,259 162,033 177,291 216,092 Gabapentin 187,918 206,455 211,135 161,684 162,219 Levetiracetam 34,568 56,901 75,843 81,605 103,913 Topiramate 51,624 51,948 59,350 67,812 86,052 Benzobarbital 68,684 70,308 67,688 59,103 60,301 Phenytoin 94,524 85,651 68,892 35,151 40,435 Oxcarbazepine 17,373 16,059 25,175 25,935 26,363 Clonazepam 11,589 14,266 13,918 9,664 10,295 Phenobarbital 6,644 10,084 7,409 5,529 7,327 Lacosamide 1,976 62 874 1,951 4,061 Homeopatia 169 0 0 0 0 ANNEXES 5 | 145 Figure 5.36. Sales volumes of antiepileptic medicines according to INN (UAH) 146 | ANNEXES 5 2015 2016 2017 2018 2019 Pregabalin 46,123,637 94,341,355 95,866,158 169,341,703 210,284,383 Valproic acid 57,723,149 54,514,189 72,876,115 77,279,779 86,339,026 Carbamazepine 46,164,848 46,838,108 55,183,710 58,215,154 67,644,832 Levetiracetam 18,020,071 27,960,934 42,344,604 48,296,686 59,515,391 Lamotrigine 22,043,223 22,695,435 30,287,986 32,646,701 40,587,652 Gabapentin 25,727,377 26,779,473 28,424,093 25,166,800 28,250,768 Topiramate 9,274,464 10,255,909 13,899,571 15,862,281 21,730,220 Benzobarbital 2,552,169 3,154,226 3,487,213 3,643,809 4,360,370 Oxcarbazepine 1,422,923 1,384,834 2,582,626 2,986,071 3,536,655 Phenytoin 3,333,626 3,179,910 2,099,550 1,628,651 2,352,842 Lacosamide 714,514 15,464 370,329 708,771 1,509,623 Clonazepam 452,285 691,608 723,530 566,369 712,172 Phenobarbital 190,184 313,346 242,817 198,668 338,394 Homeopatia 3,309 0 0 0 0 Figure 5.37. Sales volumes of antiepileptic medicines according to INN (USD) 2015 2016 2017 2018 2019 Pregabalin 2,110,849 3,690,185 3,599,882 6,229,675 8,177,316 Valproic acid 2,643,353 2,131,316 2,740,779 2,841,947 3,358,005 Carbamazepine 2,117,845 1,832,112 2,075,602 2,144,212 2,632,406 Levetiracetam 823,198 1,093,129 1,591,559 1,773,961 2,309,942 Lamotrigine 1,008,945 887,067 1,138,626 1,199,792 1,577,049 Gabapentin 1,174,831 1,046,865 1,069,203 925,267 1,097,054 Topiramate 424,756 400,333 522,236 581,957 846,318 Benzobarbital 116,030 123,291 131,073 134,105 169,667 Oxcarbazepine 64,926 54,237 97,148 109,940 137,015 Phenytoin 150,953 124,297 78,909 59,874 91,362 Lacosamide 33,017 629 13,855 25,763 58,728 Clonazepam 20,467 27,027 27,251 20,856 27,822 Phenobarbital 8,624 12,261 9,127 7,317 13,276 Homeopatia 155 0 0 0 0 ANNEXES 5 | 147 (b) Public procurement 148 | ANNEXES 5 Figure 5.38. Volumes of public procurement of antiepileptic medicines Packages UAH USD 2015 67,481 6,885,362 309,383 2016 109,706 11,330,681 440,628 2017 179,850 19,545,815 737,121 2018 260,869 23,490,990 873,564 2019 223,162 24,146,496 922,567 Figure 5.39. Volumes of public procurement of antiepileptic medicines according to INN (packages) 2015 2016 2017 2018 2019 Carbamazepine 33,776 59,134 92,048 152,235 114,762 Valproic acid 10,668 18,783 34,517 58,685 53,770 Lamotrigine 6,351 8,156 11,039 14,672 13,722 Pregabalin 1,193 1,900 6,751 6,991 12,504 Phenobarbital 4,170 3,483 10,497 6,638 11,421 Benzobarbital 950 4,269 4,340 7,554 4,699 Phenytoin 288 2,015 2,844 4,104 3,700 Levetiracetam 1,484 1,448 3,489 3,097 3,089 Gabapentin 2,435 4,021 3,121 3,977 2,597 Topiramate 5,100 5,282 9,171 2,129 1,908 Clonazepam 974 946 1,166 528 496 Oxcarbazepine 92 269 867 258 494 Figure 5.40. Volumes of public procurement of antiepileptic medicines according to INN (UAH) 2015 2016 2017 2018 2019 Valproic acid 1,743,856 3,971,024 7,272,043 11,216,464 11,448,154 Carbamazepine 994,494 1,555,405 2,908,810 4,771,151 4,094,358 Pregabalin 637,258 1,182,485 2,399,799 1,938,595 3,293,437 Lamotrigine 774,207 1,071,627 1,549,805 2,148,809 2,113,028 Levetiracetam 938,384 863,980 1,668,749 1,518,854 1,244,780 Phenobarbital 101,554 147,428 412,268 216,636 503,096 Gabapentin 240,435 405,895 379,363 455,885 426,745 Topiramate 1,372,611 1,724,772 2,406,162 460,485 368,825 Benzobarbital 39,362 210,584 251,467 508,048 365,685 Phenytoin 4,552 105,155 124,186 185,277 178,104 Oxcarbazepine 7,894 23,818 85,819 31,329 64,900 Clonazepam 30,755 68,507 87,344 39,457 45,386 ANNEXES 5 | 149 Figure 5.41. Volumes of public procurement of antiepileptic medicines according to INN (USD) 150 | ANNEXES 5 2015 2016 2017 2018 2019 Valproic acid 79,139 154,813 274,718 417,482 436,063 Carbamazepine 45,395 60,876 109,186 177,658 154,291 Pregabalin 29,032 46,377 90,670 70,902 129,782 Lamotrigine 34,447 41,582 57,949 80,478 80,016 Levetiracetam 41,587 33,336 62,855 56,465 47,665 Phenobarbital 4,512 5,750 15,149 8,099 19,942 Gabapentin 11,025 15,929 14,302 17,055 16,198 Topiramate 60,552 66,157 91,800 17,024 13,997 Benzobarbital 1,755 8,157 9,407 18,856 13,744 Phenytoin 206 4,109 4,638 6,933 6,665 Oxcarbazepine 357 942 3,201 1,166 2,456 Clonazepam 1,374 2,601 3,246 1,445 1,749 4. Antiparkinsonian medicines (N04 according to ATC classi cation) Figure 5.42. Total volume of pharmacy sales and public procurement of antiparkinsonian medicines Packages UAH USD 2015 608,078 83,824,941 3,827,915 2016 666,825 93,205,156 3,643,707 2017 740,617 117,836,540 4,432,160 2018 715,067 142,428,708 5,235,737 2019 736,333 155,600,043 6,036,818 (a) Pharmacy sales Figure 5.43. Sales volumes of the group of antiparkinsonian medicines Packages UAH USD 2015 547,146 82,250,756 3,756,943 2016 599,641 91,332,285 3,570,885 2017 682,567 114,971,280 4,323,844 2018 651,831 139,754,397 5,136,268 2019 683,984 152,911,478 5,934,588 ANNEXES 5 | 151 Figure 5.44. Sales volumes of antiparkinsonian medicines according to INN (packages) 152 | ANNEXES 5 2015 2016 2017 2018 2019 Trihexyphenidyl 283,981 335,588 380,115 297,586 316,953 Pramipexole 60,608 68,935 85,291 110,100 126,701 Levodopa+Carbidopa 97,055 91,741 109,320 128,007 125,409 Amantadine 50,618 51,630 51,330 60,797 68,375 Piribedil 34,285 33,012 32,267 24,483 20,761 Rasagiline 1,087 3,283 8,771 12,019 8,608 Levodopa+Carbidopa+Entacapone 1,927 1,891 2,303 4,869 6,988 Levodopa+Benserazide 6,131 3,642 5,452 6,218 5,988 Selegiline 10,114 9,288 7,093 7,216 4,201 Ropinirole 656 170 147 3 0 Rotigotine 684 461 478 533 0 Figure 5.45. Sales volumes of antiparkinsonian medicines according to INN (UAH) 2015 2016 2017 2018 2019 Levodopa+Carbidopa 30,606,817 35,327,585 44,656,230 51,406,093 56,404,362 Pramipexole 22,477,241 22,535,017 28,598,745 38,777,181 46,223,245 Amantadine 10,232,708 12,022,526 14,026,492 21,104,299 23,215,190 Trihexyphenidyl 4,991,461 6,308,353 7,216,164 5,959,984 7,026,117 Levodopa+Carbidopa+Entacapone 1,891,490 1,696,538 1,993,341 3,541,201 5,094,010 Rasagiline 732,037 2,267,769 6,079,456 6,324,223 4,818,636 Levodopa+Benserazide 2,294,494 2,266,223 3,922,291 4,776,632 4,498,775 Piribedil 4,311,969 4,497,668 5,098,296 4,241,898 3,778,657 Selegiline 3,399,321 3,379,540 2,767,297 2,900,459 1,852,486 Ropinirole 161,040 53,242 33,072 688 0 Rotigotine 1,152,178 977,824 579,896 721,739 0 ANNEXES 5 | 153 Figure 5.46. Volumes of public procurement of the ‘Other medicines’ group according to INN (USD) 154 | ANNEXES 5 2015 2016 2017 2018 2019 Levodopa+Carbidopa 1,402,048 1,382,369 1,680,187 1,893,310 2,193,315 Pramipexole 1,026,228 881,564 1,075,013 1,423,865 1,791,305 Amantadine 466,850 469,637 527,165 771,973 901,690 Trihexyphenidyl 230,478 246,823 271,298 219,363 273,961 Levodopa+Carbidopa+Entacapone 82,946 65,820 74,795 130,357 196,138 Rasagiline 32,692 88,215 229,084 232,694 186,478 Levodopa+Benserazide 104,101 88,482 147,509 175,964 174,057 Piribedil 197,745 175,981 191,680 156,216 146,387 Selegiline 155,935 132,192 104,136 105,345 71,258 Ropinirole 7,607 2,140 1,251 26 0 Rotigotine 50,313 37,660 21,726 27,156 0 (b) Public procurement Figure 5.47. Volumes of public procurement of antiparkinsonian medicines Packages UAH USD 2015 60,932 1,574,185 70,972 2016 67,184 1,872,871 72,823 2017 58,050 2,865,260 108,316 2018 63,236 2,674,311 99,469 2019 52,349 2,688,565 102,229 Figure 5.48. Volumes of public procurement of antiparkinsonian medicines according to INN (packages) 2015 2016 2017 2018 2019 Trihexyphenidyl 59,276 64,727 53,369 58,481 47,432 Levodopa+Carbidopa 577 833 2,020 2,219 2,409 Amantadine 807 799 1,411 1,558 1,676 Pramipexole 208 610 771 769 675 Levodopa+Carbidopa+Entacapone 0 0 432 190 132 Levodopa+Benserazide 0 0 25 19 20 Selegiline 11 150 17 0 5 Piribedil 53 65 5 0 0 ANNEXES 5 | 155 Figure 5.49. Volumes of public procurement of antiparkinsonian medicines according to INN (UAH) 156 | ANNEXES 5 2015 2016 2017 2018 2019 Trihexyphenidyl 1,031,461 1,233,103 1,064,650 1,223,858 1,091,983 Levodopa+Carbidopa 159,161 314,518 765,983 751,827 958,193 Amantadine 281,614 116,942 326,652 291,444 338,968 Pramipexole 90,749 172,471 227,978 249,542 189,043 Levodopa+Carbidopa+Entacapone 0 0 453,412 143,460 94,644 Levodopa+Benserazide 0 0 18,645 14,180 13,160 Selegiline 4,005 25,634 7,017 0 2,574 Piribedil 7,194 10,203 925 0 0 Figure 5.50. Volumes of public procurement of antiparkinsonian medicines according to INN (USD) 2015 2016 2017 2018 2019 Trihexyphenidyl 46,302 47,773 40,124 45,558 41,516 Levodopa+Carbidopa 7,297 12,319 29,029 28,061 36,313 Amantadine 12,824 4,572 12,398 10,908 13,116 Pramipexole 4,040 6,763 8,596 9,340 7,140 Levodopa+Carbidopa+Entacapone 0 0 17,168 5,101 3,529 Levodopa+Benserazide 0 0 699 501 513 Selegiline 189 995 267 0 102 Piribedil 319 401 35 0 0 5. Other medicines that can be used in the treatment of persons with mental disorders Figure 5.51. Total volume of pharmacy sales and public procurement of the ‘Other medicines’ group Packages UAH USD 2015 5,623,204 587,798,723 26,883,034 2016 4,966,281 577,048,291 22,517,848 2017 5,026,824 728,663,767 27,370,583 2018 4,735,846 835,872,822 30,757,956 2019 4,508,974 931,827,961 36,270,729 (a) Pharmacy sales Figure 5.52. Sales volumes of the ‘Other medicines’ group Packages UAH USD 2015 5,535,855 575,262,631 26,309,157 2016 4,817,245 553,268,001 21,601,977 2017 4,887,260 707,915,947 26,590,662 2018 4,615,665 820,076,260 30,173,565 2019 4,383,863 911,387,987 35,488,104 ANNEXES 5 | 157 Figure 5.53. Sales volumes of the ‘Other medicines’ group according to INN (packages) 158 | ANNEXES 5 2015 2016 2017 2018 2019 Thiamine+Pyridoxine+Cyanocobalamin 1,507,148 1,355,445 1,484,284 1,394,419 1,417,960 Ethylmethylhydroxypyridine succinate 486,182 494,905 758,523 893,092 1,008,554 Glycine 1,346,895 1,083,254 1,017,650 829,748 655,765 Clonidine 523,497 485,804 463,550 394,174 412,391 Derivative deproteinized calves' blood 668,784 607,806 612,907 531,987 390,110 Cytidine+Uridine 204,448 165,757 203,756 213,031 203,113 Pyridoxine+Benfotiamine 65,439 65,875 61,938 66,343 84,407 Crataegus+Ginkgo biloba+Pueraria 55,572 40,587 32,821 23,958 81,568 Vitamins B+Ascorbinic acid 72,822 69,564 27,030 35,225 49,154 Glutamic acid 107,563 72,911 53,158 54,140 41,757 Homeopatia 24,536 22,421 20,243 22,459 23,645 Vitamins B 249,541 194,618 124,966 140,862 10,611 Thiamine+Pyridoxine+Cyanocobalamin+Lidocaine 0 0 0 0 4,423 Herbal components 29,496 3,087 1,936 1,025 322 Acetylsalicylic acid+Aminoacetic acid+Combination 54,281 37,457 22,637 15,202 83 Acetylsalicylic acid+Citric acid+Sodium hydrocarbonate 139,634 117,754 1,861 0 0 Vitamins 12 0 0 0 0 Derivative deproteinized calves' blood+Dextrose 5 0 0 0 0 Figure 5.54. Sales volumes of the ‘Other medicines’ group according to INN (UAH) 2015 2016 2017 2018 2019 Ethylmethylhydroxypyridine succinate 100,733,143 109,944,125 196,231,619 282,984,743 389,267,189 Thiamine+Pyridoxine+Cyanocobalamin 119,178,778 115,901,591 141,808,261 159,968,547 191,028,652 Derivative deproteinized calves' blood 200,629,876 190,094,283 227,446,372 212,558,096 167,861,053 Cytidine+Uridine 37,866,944 34,996,980 48,896,362 56,963,535 55,356,154 Glycine 34,450,524 33,460,915 38,835,533 38,646,833 36,488,426 Pyridoxine+Benfotiamine 10,005,037 9,860,511 12,484,277 17,789,288 23,104,154 Crataegus+Ginkgo biloba+Pueraria 7,279,091 5,605,853 5,020,880 4,188,337 14,755,411 Homeopatia 9,777,725 9,081,300 8,598,695 10,693,558 11,604,205 Clonidine 5,745,067 5,818,825 6,224,585 6,974,122 9,418,008 Vitamins B+Ascorbinic acid 4,916,927 5,085,513 2,383,678 5,360,014 9,357,676 Vitamins B 26,031,876 23,473,075 16,927,161 21,942,823 2,150,161 Thiamine+Pyridoxine+Cyanocobalamin+Lidocaine 0 0 0 0 703,147 Glutamic acid 447,175 337,593 268,766 285,516 230,034 Herbal components 4,337,252 457,687 303,041 165,713 54,561 Acetylsalicylic acid+Aminoacetic acid+Combination 4,198,917 3,348,633 2,388,425 1,555,135 9,156 Acetylsalicylic acid+Citric acid+Sodium hydrocarbonate 9,662,769 5,801,117 98,292 0 0 Vitamins 535 0 0 0 0 Derivative deproteinized calves' blood+Dextrose 995 0 0 0 0 ANNEXES 5 | 159 Figure 5.55. Sales volumes of the ‘Other medicines’ group according to INN (USD) 160 | ANNEXES 5 2015 2016 2017 2018 2019 Ethylmethylhydroxypyridine succinate 4,599,803 4,289,359 7,365,456 10,404,884 15,208,735 Thiamine+Pyridoxine+Cyanocobalamin 5,458,539 4,527,342 5,329,465 5,878,145 7,426,503 Derivative deproteinized calves' blood 9,169,017 7,420,250 8,543,683 7,834,209 6,510,589 Cytidine+Uridine 1,729,847 1,366,012 1,838,785 2,097,686 2,150,428 Glycine 1,576,012 1,307,925 1,457,283 1,423,091 1,419,742 Pyridoxine+Benfotiamine 456,174 385,214 469,840 654,802 897,247 Crataegus+Ginkgo biloba+Pueraria 333,191 219,079 188,433 151,430 572,587 Homeopatia 446,723 354,199 322,721 392,159 451,502 Clonidine 262,265 227,557 233,722 256,875 368,110 Vitamins B+Ascorbinic acid 224,485 198,577 88,248 196,400 364,657 Vitamins B 1,190,631 916,453 637,784 810,111 79,506 Thiamine+Pyridoxine+Cyanocobalamin+Lidocaine 0 0 0 0 27,399 Glutamic acid 19,935 13,110 10,166 10,594 8,724 Herbal components 200,607 18,023 11,336 6,089 2,030 Acetylsalicylic acid+Aminoacetic acid+Combination 194,792 131,026 90,103 57,090 344 Acetylsalicylic acid+Citric acid+Sodium hydrocarbonate 447,072 227,852 3,637 0 0 Vitamins 23 0 0 0 0 Derivative deproteinized calves' blood+Dextrose 41 0 0 0 0 (b) Public procurement Figure 5.56. Volumes of public procurement of the ‘Other medicines’ group Packages UAH USD 2015 87,349 12,536,092 573,877 2016 149,036 23,780,290 915,870 2017 139,564 20,747,820 779,921 2018 120,181 15,796,562 584,391 2019 125,111 20,439,974 782,625 ANNEXES 5 | 161 Figure 5.57. Volumes of public procurement of the ‘Other medicines’ group according to INN (packages) 162 | ANNEXES 5 2015 2016 2017 2018 2019 Thiamine+Pyridoxine+Cyanocobalamin 30,247 50,322 61,701 55,256 46,834 Pyridoxine+Benfotiamine 1,719 2,629 3,513 2,504 18,867 Glycine 11,577 18,485 22,750 28,214 18,031 Ethylmethylhydroxypyridine succinate 6,457 8,401 12,245 8,265 14,769 Derivative deproteinized calves' blood 27,261 52,344 25,862 13,574 12,153 Clonidine 8,893 14,105 9,158 10,035 9,384 Thiamine+Pyridoxine+Cyanocobalamin+Lidocaine 0 0 0 0 2,605 Cytidine+Uridine 1,145 2,045 2,692 926 1,406 Glutamic acid 12 481 1,269 968 752 Vitamins B 27 195 337 316 232 Vitamins B+Ascorbinic acid 2 25 13 102 40 Crataegus+Ginkgo biloba+Pueraria 0 0 12 0 28 Crataegus+Valeriana+Viscum 0 0 0 0 5 Homeopatia 1 4 12 16 3 Herbal components 0 0 0 0 2 Acetylsalicylic acid+Citric acid+Sodium hydrocarbonate 0 0 1 5 0 Derivative deproteinized calves' blood+Dextrose 8 0 0 0 0 Figure 5.58. Volumes of public procurement of the ‘Other medicines’ group according to INN (UAH) 2015 2016 2017 2018 2019 Ethylmethylhydroxypyridine succinate 1,382,793 1,983,844 3,447,933 2,737,827 5,785,890 Derivative deproteinized calves' blood 8,323,921 16,512,831 9,242,908 5,108,222 5,268,880 Thiamine+Pyridoxine+Cyanocobalamin 1,849,691 3,348,479 5,344,124 5,096,643 5,210,106 Pyridoxine+Benfotiamine 123,925 168,961 571,976 425,507 1,330,393 Glycine 284,137 568,879 897,563 1,385,364 1,008,467 Thiamine+Pyridoxine+Cyanocobalamin+Lidocaine 0 0 0 0 736,075 Clonidine 367,876 744,322 562,169 734,682 702,622 Cytidine+Uridine 199,756 420,555 614,485 221,302 331,480 Vitamins B 3,044 25,701 48,600 52,665 46,017 Vitamins B+Ascorbinic acid 129 2,199 1,168 18,978 7,920 Crataegus+Ginkgo biloba+Pueraria 0 0 1,983 0 4,882 Glutamic acid 54 2,479 7,761 5,665 4,749 Homeopatia 459 2,040 7,055 9,048 2,071 Herbal components 0 0 0 0 316 Crataegus+Valeriana+Viscum 0 0 0 0 106 Acetylsalicylic acid+Citric acid+Sodium hydrocarbonate 0 0 94 660 0 Derivative deproteinized calves' blood+Dextrose 306 0 0 0 0 ANNEXES 5 | 163 Figure 5.9. Volumes of public procurement of the ‘Other medicines’ group according to INN (USD) 164 | ANNEXES 5 2015 2016 2017 2018 2019 Ethylmethylhydroxypyridine succinate 62,539 76,271 129,481 101,244 222,429 Derivative deproteinized calves' blood 382,392 634,300 346,602 189,224 202,055 Thiamine+Pyridoxine+Cyanocobalamin 84,468 129,898 201,325 187,458 199,547 Pyridoxine+Benfotiamine 5,356 6,412 21,538 15,854 49,915 Glycine 13,094 22,089 33,766 51,756 38,662 Thiamine+Pyridoxine+Cyanocobalamin+Lidocaine 0 0 0 0 28,002 Clonidine 16,961 29,197 21,315 27,502 26,616 Cytidine+Uridine 8,884 16,449 23,381 8,185 12,921 Vitamins B 143 990 1,830 1,911 1,730 Vitamins B+Ascorbinic acid 6 87 43 682 296 Crataegus+Ginkgo biloba+Pueraria 0 0 75 0 184 Glutamic acid 3 100 293 211 176 Homeopatia 22 78 269 337 77 Herbal components 0 0 0 0 12 Crataegus+Valeriana+Viscum 0 0 0 0 4 Acetylsalicylic acid+Citric acid+Sodium hydrocarbonate 0 0 3 25 0 Derivative deproteinized calves' blood+Dextrose 13 0 0 0 0 Annex 6. Dietary Supplements That May Be Associated with Mental Health Treatment Pharmacy sales Figure 6.1. Volumes of pharmacy sales of dietary supplements that may be associated with mental health treatment Packages UAH USD 2015 2,204,454 66,876,530 3,034,510 2016 1,554,090 56,181,930 2,186,927 2017 1,674,107 65,426,815 2,457,255 2018 1,843,712 84,305,703 3,093,083 2019 2,582,977 138,756,558 5,411,812 Figure 6.2. Volumes of pharmacy sales of some groups of dietary supplements that may be associated with mental health treatment (packages) 2015 2016 2017 2018 2019 y supplements that may Dietary may be 1,797,771 1,262,456 1,389,430 1,587,328 2,320,510 associated with CNS activity y supplements that may Dietary may be used 393,370 284,577 280,290 253,622 260,397 in connection with alcohol consumption y supplements that can be used Dietary 13,313 7,057 4,387 2,762 2,070 in connection with smoking ANNEXES 6 | 165 Figure 6.3. Volumes of pharmacy sales of some groups of dietary supplements that may be associated with mental health treatment 166 | ANNEXES 6 (UAH) 2015 2016 2017 2018 2019 y supplements that may Dietary may be 57,736,811 49,198,934 57,740,467 77,002,387 131,201,763 associated with CNS activity y supplements that may Dietary may be used 8,758,744 6,673,655 7,525,318 7,190,670 7,458,140 in connection with alcohol consumption y supplements that can be used Dietary 380,975 309,341 161,030 112,646 96,654 in connection with smoking Figure 6.4. Volumes of pharmacy sales of some groups of dietary supplements that may be associated with mental health treatment (USD) 2015 2016 2017 2018 2019 y supplements that may Dietary may be 2,617,306 1,914,159 2,168,307 2,823,670 5,118,421 associated with CNS activity y supplements that may Dietary may be used 400,341 260,773 282,946 265,265 289,660 in connection with alcohol consumption y supplements that can be used Dietary 16,863 11,996 6,002 4,147 3,731 in connection with smoking 1. Dietary supplements that may be associated with CNS activity56 Pharmacy sales Figure 6.5. Volumes of pharmacy sales of dietary supplements that may be associated with CNS activity Packages UAH USD 2015 1,797,771 57,736,811 2,617,306 2016 1,262,456 49,198,934 1,914,159 2017 1,389,430 57,740,467 2,168,307 2018 1,587,328 77,002,387 2,823,670 2019 2,320,510 131,201,763 5,118,421 56Bath salts not included. ANNEXES 6 | 167 Figure 6.6. Sales of dietary supplements that may be associated with CNS activity by content (packages) 2015 2016 2017 2018 2019 Herbal components 599,519 387,654 396,125 464,619 491,162 Valeriana 347,474 154,080 301,445 235,834 475,130 Glycine 27,358 35,233 83,417 132,516 242,804 Ginkgo biloba 167,321 162,841 161,760 149,173 232,891 Combination 92,016 85,255 86,727 104,127 111,886 Melissa+Leonurus+Valeriana 10,118 13,908 0 32,934 107,256 Valeriana+Humulus lupulus+Lavandula 0 0 0 16,954 68,345 Glycine+Vit B complex 14,899 19,260 24,296 73,152 36,719 Valeriana+Combination 8,469 16,598 21,438 32,912 30,267 Melissa 50,375 37,411 31,658 29,341 28,539 Gamma-aminobutyric acid+Herbal complex 23,311 27,361 29,723 33,370 27,736 Essential oils 91,534 72,877 34,352 32,374 25,986 Leonurus 27,115 12,510 16,428 16,664 24,842 Piracetam+Ginkgo biloba+Combination 69,724 32,737 15,597 12,498 23,944 Ginkgo biloba+Combination 8,424 4,636 11,346 20,236 21,658 Ginkgo biloba+Centella asiatica+Lecithin 3,707 2,915 6,745 13,836 21,264 Conifer 28,427 20,959 21,316 20,522 19,724 Ginkgo biloba+Ascorbic acid 36,110 29,102 21,840 20,590 17,841 Valeriana+Humulus lupulus 0 0 578 4,435 16,275 Cytidine+Uridine+Folic acid+Cyanocobalamine 0 0 0 27 14,885 Amino acids+Vitamins B 3,864 2,559 8,758 10,524 14,571 Herbal complex+Tryptophan+Combination 450 1,292 3,182 7,777 13,096 Leonurus+Magnesium+Pyridoxine 776 2,264 7,074 7,843 11,920 Herbal complex+Combination 1,254 1,498 690 1,028 10,978 Hypericum+Leonurus+Pion 2,417 4,456 5,286 8,644 10,067 Passi ora 267 423 580 726 9,982 Tilia+Chamomilla+Melissa 0 0 0 6,495 9,824 Melatoninum 11,245 10,191 4,560 2,812 9,785 Valeriana+Mentha+Melissa 36 94 4,510 8,409 9,517 Foeniculum 18,046 15,447 7,595 7,818 8,782 Vitamins B+Combination 1,810 2,475 3,470 4,712 8,769 Withania somnifera+Bacopa monnieri 0 0 0 0 8,444 Conifer+Bisho t 0 11 1,496 3,975 8,208 Cutellaria+Passi ora 4,462 3,100 5,242 6,993 7,435 a incarnat Withania somnifera+L-theanine+Passi ora 0 0 0 239 7,248 go biloba+В1+В2+В6 Ginkgo 5,611 5,420 5,107 5,360 6,892 Mentha 2,305 2,308 2,259 1,052 6,289 Ginkgo biloba+Panax+Ribes 724 3,589 3,752 4,122 5,968 Amino acids+Vitamins 0 0 0 681 5,702 Vitis Vinifera 0 0 0 0 5,437 Epilobium+Melissa 4,415 1,175 1,145 1,961 5,362 Crataegus+Mentha+Valeriana 0 0 0 0 5,206 Cosmoceutica 11,199 8,187 5,749 4,753 4,821 Primrose oil 1,375 1,450 1,456 2,386 4,337 Magnesium+Pyridoxine+Herbal complex 0 0 0 37 4,275 N-Pep-12 0 0 0 0 4,154 Valeriana+Melatonine+L-theanine 0 0 0 157 4,152 Mentha+Melissa 15,110 7,089 8,192 3,261 4,020 Valeriana+Humulus lupulus+Passi ora+Melissa+Combination 1,089 1,364 1,875 2,608 3,372 Mentha+Leonurus 2,223 1,608 4,275 3,143 3,260 Leonurus+Passi ora 2,203 1,378 987 1,605 2,719 Note: The list shows the top 50 items for 2019 (by content) with 2,261,000 packages sold. The sales of the remaining 98 items (by content) covered 59,000 packages (3 percent of the total). 168 | ANNEXES 6 Figure 6.7. Sales of dietary supplements that may be associated with CNS activity by content (UAH) 2015 2016 2017 2018 2019 Herbal components 13,535,493 12,071,880 16,181,455 19,822,657 25,441,088 Ginkgo biloba 7,564,069 7,508,779 9,135,529 10,419,775 14,498,135 Combination 4,792,050 4,155,129 4,729,407 7,798,870 10,611,270 Valeriana 8,365,979 2,712,678 3,608,976 4,210,375 8,685,527 Glycine 459,652 656,856 1,571,912 2,158,992 5,707,338 Melissa+Leonurus+Valeriana 209,969 279,779 0 785,980 4,226,283 N-Pep-12 0 0 0 0 3,480,966 Valeriana+Combination 573,260 1,440,274 2,073,529 3,348,248 3,242,694 Gamma-aminobutyric acid+Herbal complex 1,817,887 2,311,138 2,851,352 3,205,010 3,159,267 Valeriana+Humulus lupulus+Lavandula 0 0 0 589,079 2,888,753 Ginkgo biloba+Centella asiatica+Lecithin 461,180 312,515 765,895 1,651,075 2,810,071 Ginkgo biloba+Combination 656,560 539,843 1,381,237 2,271,519 2,745,021 Vitamins+Minerals+Combination 211,293 320,935 1,148,411 1,546,995 2,591,290 Herbal complex+Tryptophan+Combination 74,276 284,077 781,720 1,765,482 2,558,134 Valeriana+Humulus lupulus 0 0 91,630 643,467 2,484,335 Cytidine+Uridine+Folic acid+Cyanocobalamine 0 0 0 3,919 2,240,430 Herbal complex+Combination 41,550 90,578 32,406 179,633 1,835,459 Passi ora 7,834 13,264 18,476 106,149 1,631,406 Hypericum+Leonurus+Pion 246,205 519,155 667,584 1,141,263 1,415,463 Glycine+Vit B complex 395,495 575,276 944,952 1,384,239 1,307,545 Primrose oil 375,274 469,783 523,381 693,610 1,293,914 Ginkgo biloba+Panax+Ribes 136,143 762,676 863,052 881,068 1,292,471 Piracetam+Ginkgo biloba+Combination 4,968,995 2,667,514 1,165,977 939,882 1,249,068 Tilia+Chamomilla+Melissa 0 0 0 749,845 1,202,265 Withania somnifera+Bacopa monnieri 0 0 0 0 1,155,051 Essential oils 1,776,360 1,522,450 904,173 1,099,108 1,094,847 Vitamins B Complex 0 0 0 0 1,089,781 Amino acids+Vitamins 0 0 0 111,529 1,078,896 a incarnat Withania somnifera+L-theanine+Passi ora 0 0 0 38,594 1,056,222 Valeriana+Mentha+Melissa 886 7,874 395,875 867,096 1,043,999 Vitis Vinifera 0 0 0 0 1,042,635 Melatoninum 464,014 533,801 453,382 306,720 1,041,049 Cutellaria+Passi ora 470,000 335,022 619,486 812,167 1,031,625 Ginkgo biloba+Ascorbic acid 1,146,356 1,090,619 848,711 835,786 948,657 Vitamins B+Combination 175,148 255,222 374,708 446,741 923,207 go biloba+В1+В2+В6 Ginkgo 216,529 244,840 253,414 274,724 828,265 Conifer 657,553 572,194 741,873 661,237 757,859 Citicoline 0 0 0 626,165 622,221 Leonurus+Magnesium+Pyridoxine 13,774 86,688 321,520 375,511 583,514 Valeriana+Melatonine+L-theanine 0 0 0 19,808 497,212 Leonurus 1,110,702 485,115 344,198 313,723 493,389 Magnesium+Pyridoxine+Herbal complex 0 0 0 3,474 416,894 Ginkgo biloba+Magnesium 386,681 329,584 374,788 319,301 413,841 Lecitin+Ginkgo biloba 0 0 96,429 197,307 408,870 Melissa 394,005 342,768 343,699 373,412 402,702 Amino acids+Vitamins B 100,323 67,442 229,187 272,254 378,936 Crataegus+Mentha+Valeriana 0 0 0 0 339,077 Vitamins+Minerals 0 0 80,372 345,767 299,170 Melatoninum+Pyridoxine+Herbal complex 13,584 12,398 13,553 92,389 278,692 Conifer+Bisho t 0 272 27,975 107,324 261,318 Cosmoceutica 340,855 262,365 217,401 190,090 240,646 Note: The list shows the top 50 items for 2019 (by content) with UAH 127.1 million of sales. The sales of the remaining 98 items (by content) covered UAH 4.1 million (3 percent of the total). ANNEXES 6 | 169 Figure 6.8. Sales of dietary supplements that may be associated with CNS activity by content (USD) 2015 2016 2017 2018 2019 Herbal components 613,749 469,522 607,260 725,765 989,758 Ginkgo biloba 342,145 292,505 343,348 382,777 563,870 Combination 212,135 161,626 178,021 286,090 414,352 Valeriana 390,446 105,966 135,082 155,054 343,241 Glycine 20,659 25,613 59,081 78,956 220,771 Melissa+Leonurus+Valeriana 8,951 10,888 0 28,473 164,222 N-Pep-12 0 0 0 0 136,680 Valeriana+Combination 25,741 56,001 77,962 123,110 126,185 Gamma-aminobutyric acid+Herbal complex 82,108 90,150 107,043 118,033 122,115 Valeriana+Humulus lupulus+Lavandula 0 0 0 21,238 113,652 Ginkgo biloba+Centella asiatica+Lecithin 21,127 12,151 28,689 60,441 109,456 Ginkgo biloba+Combination 30,047 21,058 51,870 83,299 105,957 Vitamins+Minerals+Combination 9,736 12,549 43,069 56,794 101,516 Herbal complex+Tryptophan+Combination 3,370 11,000 29,487 65,303 100,221 Valeriana+Humulus lupulus 0 0 3,456 23,433 98,286 Cytidine+Uridine+Folic acid+Cyanocobalamine 0 0 0 141 87,058 Herbal complex+Combination 1,793 3,555 1,219 6,446 72,283 Passi ora 342 512 695 3,957 66,104 Hypericum+Leonurus+Pion 10,898 20,230 25,040 41,827 55,149 Primrose oil 17,001 18,310 19,689 25,347 50,071 Ginkgo biloba+Panax+Ribes 5,911 29,806 32,327 32,264 50,052 Glycine+Vit B complex 17,299 22,382 35,373 50,439 50,037 Piracetam+Ginkgo biloba+Combination 225,800 103,791 43,694 34,455 49,143 Tilia+Chamomilla+Melissa 0 0 0 27,480 46,435 Withania somnifera+Bacopa monnieri 0 0 0 0 45,055 Vitamins B Complex 0 0 0 0 44,384 Amino acids+Vitamins 0 0 0 3,997 42,280 Essential oils 79,102 58,358 33,960 40,254 42,150 Melatoninum 20,717 20,783 17,102 11,177 41,668 a incarnat Withania somnifera+L-theanine+Passi ora 0 0 0 1,389 41,430 Cutellaria+Passi ora 21,324 13,039 23,269 29,866 40,183 Valeriana+Mentha+Melissa 46 301 14,875 31,967 39,807 Vitis Vinifera 0 0 0 0 39,683 Ginkgo biloba+Ascorbic acid 51,079 42,375 31,940 30,766 37,121 Vitamins B+Combination 7,875 9,924 14,035 16,344 35,727 go biloba+В1+В2+В6 Ginkgo 9,794 9,537 9,513 10,144 32,698 Conifer 29,525 22,065 27,896 24,309 29,321 Citicoline 0 0 0 22,352 23,988 Leonurus+Magnesium+Pyridoxine 595 3,386 12,100 13,830 22,829 Valeriana+Melatonine+L-theanine 0 0 0 713 19,538 Leonurus 50,722 18,772 12,914 11,556 19,111 Magnesium+Pyridoxine+Herbal complex 0 0 0 125 16,233 Lecitin+Ginkgo biloba 0 0 3,614 7,263 16,157 Ginkgo biloba+Magnesium 17,749 12,864 14,102 11,800 16,155 Melissa 17,507 13,155 12,888 13,725 15,553 Amino acids+Vitamins B 4,420 2,577 8,609 10,054 14,624 Crataegus+Mentha+Valeriana 0 0 0 0 14,361 Vitamins+Minerals 0 0 3,012 12,813 11,511 Melatoninum+Pyridoxine+Herbal complex 575 453 505 3,348 10,814 Conifer+Bisho t 0 11 1,053 3,958 9,774 Note: The list shows the top 50 items for 2019 (by content) with UAH 127.1 million of sales. The sales of the remaining 98 Cosmoceutica 14,963 10,099 8,171 7,010 9,285 items (by content) covered UAH 4.1 million (3 percent of the total). 170 | ANNEXES 6 2. Dietary supplements that may be used in connection with alcohol consumption Pharmacy sales Figure 6.9. Volumes of pharmacy sales of dietary supplements that may be used in connection with alcohol consumption Packages UAH USD 2015 393,370 8,758,744 400,341 2016 284,577 6,673,655 260,773 2017 280,290 7,525,318 282,946 2018 253,622 7,190,670 265,265 2019 260,397 7,458,140 289,660 ANNEXES 6 | 171 Figure 6.10. Sales of dietary supplements that may be used in connection with alcohol consumption by content (packages) 172 | ANNEXES 6 2015 2016 2017 2018 2019 Petroselinum 240,974 205,650 208,525 198,606 177,108 Phenilalanin+Pyroglutamic acid+Chitosan 51,943 16,948 15,113 8,132 40,338 Succinic acid+Silicon dioxide+Combination 30,885 18,303 23,400 19,084 18,259 Herbal components 55,459 32,004 15,944 19,718 12,917 Combination 12,328 10,322 14,754 5,158 6,007 Succinic acid+Combination 0 12 109 2,210 2,396 Salvia 1,158 1,082 1,785 244 2,391 Vitamins+Minerals 0 0 262 465 973 Succinic acid 0 0 0 5 8 Veratrum 623 256 398 0 0 Figure 6.11. Sales of dietary supplements that may be used in connection with alcohol consumption by content (UAH) 2015 2016 2017 2018 2019 Petroselinum 4,454,074 4,318,933 5,019,337 4,953,380 5,211,424 Succinic acid+Silicon dioxide+Combination 1,625,806 1,162,036 1,706,892 1,406,897 1,214,100 Phenilalanin+Pyroglutamic acid+Chitosan 1,185,889 404,182 238,390 85,095 486,528 Herbal components 1,219,556 564,630 204,894 251,999 179,180 Vitamins+Minerals 0 0 36,831 54,555 144,379 Combination 170,549 165,491 224,864 79,007 128,001 Succinic acid+Combination 0 636 4,540 358,270 71,454 Salvia 6,192 10,893 18,848 1,321 22,781 Succinic acid 0 0 0 146 293 Veratrum 96,678 46,854 70,722 0 0 Figure 6.12. Sales of dietary supplements that may be used in connection with alcohol consumption by content (USD) 2015 2016 2017 2018 2019 Petroselinum 203,152 168,995 188,751 182,758 202,759 Succinic acid+Silicon dioxide+Combination 75,091 45,438 64,236 51,729 46,758 Phenilalanin+Pyroglutamic acid+Chitosan 54,725 15,720 8,913 3,095 18,944 Herbal components 55,094 21,950 7,711 9,351 6,981 Vitamins+Minerals 0 0 1,372 2,028 5,628 Combination 7,534 6,407 8,438 2,921 4,873 Succinic acid+Combination 0 25 171 13,330 2,845 Salvia 224 406 708 48 861 Succinic acid 0 0 0 5 11 Veratrum 4,521 1,832 2,646 0 0 ANNEXES 6 | 173 3. Dietary supplements that can be used in connection with smoking 174 | ANNEXES 6 Pharmacy sales Figure 6.13. Volumes of pharmacy sales of dietary supplements that can be used in connection with smoking Packages UAH USD 2015 13,313 380,975 16,863 2016 7,057 309,341 11,996 2017 4,387 161,030 6,002 2018 2,762 112,646 4,147 2019 2,070 96,654 3,731 Figure 6.14. Sales of dietary supplements that can be used in connection with smoking by content (packages) 2015 2016 2017 2018 2019 Herbal components 8,828 2,670 1,327 2,225 1,414 Thermopsis+Plantago 2,176 3,173 1,068 468 623 Eucalyptus 0 894 1,826 64 33 Combination 27 0 0 5 0 Essential oils 341 20 15 0 0 Thermopsis lanceolata 1,535 142 151 0 0 Herbal complex+Combination 406 158 0 0 0 Figure 6.15. Sales of dietary supplements that can be used in connection with smoking by content (UAH) 2015 2016 2017 2018 2019 Thermopsis+Plantago 129,435 206,035 78,718 41,711 55,244 Herbal components 163,949 65,175 40,000 68,645 40,576 Eucalyptus 0 17,884 36,040 1,414 834 Combination 3,666 0 0 876 0 Essential oils 2,663 152 167 0 0 Thermopsis lanceolata 56,759 5,714 6,105 0 0 Herbal complex+Combination 24,503 14,381 0 0 0 Figure 6.16. Sales of dietary supplements that can be used in connection with smoking by content (USD) 2015 2016 2017 2018 2019 Thermopsis+Plantago 5,486 8,001 2,947 1,542 2,149 Herbal components 7,405 2,514 1,493 2,522 1,548 Eucalyptus 0 693 1,326 52 33 Combination 188 0 0 32 0 Essential oils 136 6 6 0 0 Thermopsis lanceolata 2,564 220 229 0 0 Herbal complex+Combination 1,084 561 0 0 0 ANNEXES 6 | 175 Annex 7. Standardization of the Use of Medicines in the Field of Mental Health Table 7.1. Mental health medicines previously recommended by the pharmacist protocols (valid until up to January 5, 2022) Symptomatic treatment Symptomatic treatment of stress Promoting smoking cessation of insomnia List of OTC medicines for symptomatic The list of OTC medicines that help The list of OTC medicines for treatment of stress: quit smoking or reduce the need for the symptomatic treatment of • Medications for nervous system (1 smoking: insomnia: INN) • Smoking cessation medicines • Hypnotics and sedatives • Anxiolytics (1 INN) (2 INNs) (16 INNs) • Antidepressants of plant origin (1 • Symptomatic treatment: • Homeopathic medicines INN) (a) Sedatives and hypnotics of (without INNs) • Homeopathic medicines (without plant origin (8 INNs) INNs) (b) Antidepressants of plant origin • Hypnotics and sedatives of plant (1 INN) origin (9 INNs) (c) Medicines acting on the nervous system (1 INN) Figure 7.1. The volumes of pharmacy sales of the group of medicines available in the following ‘old’ pharmacist protocols: ‘Symptomatic treatment of stress,’ ‘Promotion of smoking cessation,’ and ‘Symptomatic treatment of insomnia’ (valid until up to January 5, 2022) Packages UAH USD 2015 32,764,123 484,307,535 22,221,451 2016 26,592,291 473,074,388 18,489,612 2017 24,361,298 532,539,432 20,010,475 2018 20,357,422 548,438,739 20,186,594 2019 16,963,687 547,246,547 21,257,607 176 | ANNEXES 7