Treating China

An average 685 Chinese take their own lives each day. China has about 60 million clinically depressed people. Untreated depression costs China about US$3.5 billion each year. Glum statistics, but they suggest a potential billion-dollar market for Western pharmaceutical giants, which are experiencing decelerating growth in anti-depressant sales at home.

Predicting double-digit annual growth in China over the next few years, the world's largest drugmakers, including GlaxoSmithKline, Wyeth, Pfizer, have opened Offices in Hong Kong, Shanghai or Beijing. Anti-depressant sales in China pulled in US$123 million in 2004, up 41% from the year before. The anti-depressant market is the fastest-growing pharmaceutical segment in China, said Sam Ma, marketing manager for GlaxoSmithKline, China.

Still, the approximately US$10 million GSK made last year on China sales of its anti-depressant Seroxat is nothing compared to the money pulled in from developed markets. And while the infancy of China's anti-depressant market can mean big growth rates, it can also mean big obstacles.

An increasingly depressed population

One reason depression rates are on the rise in China is the increasing success of diagnoses. Only in the last few years have the government, doctors and patients paid more attention to the condition, thereby helping to identify more cases, said Dr Zhang Kan, of the Institute of Psychology in Beijing.

Depression cases are not only being more accurately identified, but the real number may also be rising due to China's unique historical trajectory.

"In China we have a special situation, we are in a transition now – in a transition period everything is being changed," Dr Zhang said. "So the certainty of people's lives, including family life and working life – for example, job security, become sometimes quite unpredictable. There is a gap between the current situation and the ability of people to adapt to the situation, so this brings more pressure to people and pressure can cause depression."

Whatever the triggers, the fact remains that suicide is the number one cause of death for Chinese ages 20-35, according to a recent Health Ministry study. China's average of 22 suicides for every 100,000 people is about 50% more than the global average, state media has reported. For the population as a whole, suicide is the fifth biggest cause of death, after lung cancer, traffic accidents, heart disease and other illness.

Beyond the human toll, suicides cost China about US$600,000 million annually, according to research conducted by the Social and Economic Burden of Depression (SEBoD) initiative, a group of medical experts researching depression-related issues in Asia. Depression in all its forms costs the nation US$3.5 billion each year, owing in part to absenteeism -depressed individuals on average lose 60 days of work each year. According to the SEBoD interviews with 500 patients in five major Chinese cities, caregivers spend 17-25% of their annual income and an average of 17 hours a week tending to depressives.

Pharma's challenges

Though the statistics suggest a lucrative market for the makers of anti-depressants, supply and demand have struggled to find each other in China's mental healthcare market. Even in Shanghai, which boasts the highest rate of treatment in China, less than 15% of depressed people receive proper care, leaving 85% of Shanghai depressives either untreated or undiagnosed, according to GSK's Ma.

The route to treatment is often blocked by lack of awareness, prohibitive costs, and most significant, by the cultural stigma attached to mental illness. "Patients try to avoid being diagnosed for depression and anxiety," said Ma "They usually go to a general practitioner to get treatment rather than going to a psychiatrist or psychologist." Often these depressed patients treat the symptoms of depression rather than the depression itself, according to Ma. For example, if they're having problems sleeping -a potential symptom of depression – they resort to sleeping pills.

In what he describes as a typical case, Zhang recently received a phone call from a woman concerned about her granddaughter who was exhibiting bizarre symptoms. "It is clear she is depressed," Zhang said. "but the family and the girl do not accept this decision. They refuse to go to any clinic to have any treatment or diagnosis. This is very common in China."

"Chinese people like face," Zhang continued. "Depression should be seen as a disease – but the people usually feel public shame to say themselves depressed." The fact that countries the world over show similar proportions of depressed people in their population (about 3-5%) is evidence that depression is biologically-driven, and not a byproduct of culture, said Zhang.

In a country where there is a significant stigma attached to mental illness, the drug companies may need to use aggressive marketing campaigns. But even with successful marketing, some people worry about how successful the patient care will be. Mark Pummell, a UK-trained psychiatrist who treats Chinese and expatriate patients at his Shanghai psychotherapy practice, just recently worked with a woman who had been prescribed three different redundant drugs by her general practitioner. Pummell shares concerns with other experts about pharmaceutical companies leading the charge. "Drug companies don't have a historical record for their highly ethical behavior," he said.

Industry outlook

Still, drugmakers have the money and incentive to enact change, and they are making inroads in the market through increased marketing and education. Some patients are receiving treatment. GSK forecasts 30% annual growth over the next few years in China sales of the antidepressant Seroxat.

The SEBoD initiative, whose stated goal is to reduce social, economic, cultural and regulatory barriers to diagnosing and treating depression is funded by Wyeth Company, the US-based producer of such anti-depressants as Venlafaxine HCl. GlaxoSmithKline is working with the Chinese Ministry of Health on several education programs, specifically one that trains doctors in depression diagnosis.

Also, the government and psychological institutes have sponsored advertisements on TV and radio that seek to raise awareness and acceptance of depression as a disease.

The last few years have seen some changes. Two years ago, the first national suicide prevention center opened in Beijing, and has since received 220,000 calls. Several Chinese celebrities, including CCTV star Cui Yongyuan, have admitted to suffering from depression. And phrases like jiaolu (anxiety) and yi yu zheng (the depression syndrome) which didn't even exist a few years ago, have entered the Chinese vernacular.

Pummell has seen the number of his Chinese patients rise from about 20% a few years ago to between 40-50% today. One stand-out trend is a growing number of uber-rich male business executives subscribing to his 'executive coaching' service. Basically, they're getting therapy by a more socially acceptable name, according to Pummell.

The next ten years

While the Chinese populace may have an increasing awareness of depression and its potential treatments, there is still a long way to go toward general acceptance.

The Chinese government has set a goal in the next ten years to treat just 10% of all depression patients, or six million of China's approximately 60 million depressed. This will add a large consumer base for anti-depressant sales, but will leave the majority of the ill untreated.

"It's becoming better particularly in the big cities: in Beijing, Shanghai, Guangzhou," Ma said. "But in some small cities or rural areas, it's still a big problem. It will take a long time to change the stigma."