Depression sufferers still reluctant to see physician

It's estimated that 34 million people suffer from MDD in the western world, but new research estimates that the number of individuals with MDD will grow only minimally in the next two decades, to 37 million by 2025.

Unlike a number of other global health issues such as cancer and Parkinson's disease, the aging nature of the world's population won't significantly increase the number of those suffering from MDD. However, that is not to say MDD isn't an extremely relevant health risk, for both society and the individual sufferer.

In fact, MDD has been estimated to be the leading cause of disability in the and established market economies worldwide. While medication exists to treat MDD, getting patients to present to physicians and then be accurately diagnosed is an ongoing problem. Furthermore, the leading classes of drugs used to treat MDD have also been associated with increased risk of suicide.

Sufferers backward in coming forward

MDD is characterized by one or more major depressive episodes involving symptoms such as depressed mood and diminished interest or pleasure in work and social activities. Although the severity of symptoms varies with individuals and varies over time, MDD can cause clinically important distress and impair work, social or personal functioning. 

Presentation rates vary significantly with the severity of MDD. However, what is known is that less than half of those with mild or moderate MDD present to a physician. This issue is likely related to the inherent nature of the illness, as depressed patients may become reclusive, choosing to remain at home rather than go out to seek help. In less severe cases, patients, or their friends and family, may consider it to just be part of the 'ups and downs' of normal life.

To counteract this problem, manufacturers should seek to increase patient awareness and encourage them to seek help. Given the stigma that is still associated with MDD, methods such as online screeners may prove useful.

It is also important to ensure that patients are accurately diagnosed once they do present to a physician. As many as half of milder patients are not accurately diagnosed at first presentation. Obviously, greater accuracy in the diagnosis of patients would improve patient treatment and ultimate outcomes.

Not surprisingly, severe MDD patients make up the largest diagnosed patient pool and thus represent the key target market for manufacturers. However, the greatest scope for increasing market potential lies in getting milder patients to present to physicians and increasing diagnosis rates.

Suicide risk?

Antidepressants, in particular those of the selective serotonin reuptake inhibitor (SSRI) class, have been associated with an increased risk of suicidal ideation. However, interviewed physicians have indicated to Datamonitor that they do not generally share this concern. While the benefits of antidepressants in young people have not been clearly demonstrated, in adult patients, the benefits are felt to outweigh the small risk of increased suicidal ideation that may be linked with their use. There is obviously an inherent risk of suicide involved with not treating patients effectively anyway.

However, the reports associating antidepressant use with an increase in suicide risk have had some effect. Across the seven major markets, Datamonitor found that 11% of physicians had changed their prescription habits following reports of the potential increase in suicidality. These changes included use of certain drugs less frequently or a greater use of non-pharmacological methods. But, according to opinion leaders, patients tend to be more concerned about getting better or the day-to-day side effects such as nausea or insomnia.

In spite of the reported link between SSRI use and suicide, SSRIs, which are available as both branded and generic versions, dominate prescription choices in the largest antidepressant market - the . Originally introduced in the 1980s, later market entrants such as 's Lexapro (escitalopram) have been successful in achieving first-line use, along with the likes of Wyeth's serotonin norepinephrine reuptake inhibitor (SNRI) Effexor (venlafaxine). Gaining a position in this competitive arena will now, however, be an increasingly difficult challenge for new products.

Cymbalta struggling to make up ground

Lilly's Cymbalta (duloxetine) is the most recent addition to physicians' considerable arsenal of antidepressants. Uptake in the has been unimpressive since its launch in 2004 and the European rollout continues over 2006. As another SNRI, it is up against the might of Wyeth's Effexor.

Lilly has concentrated on marketing Cymbalta's ability to treat the painful physical symptoms of depression. Interviewed physicians have, however, indicated that the painful symptoms are not a key focus. While opinion leaders recognize the benefits of treating the painful physical symptoms, they indicated that efficacy is a far more influential factor when choosing a treatment choice.

Furthermore, while experience with duloxetine in MDD may be only limited to date, interviewed physicians did not consider it to have a significantly greater ability to treat the painful physical symptoms of depression than other antidepressants. 

While there is little apparent variation in the efficacy of different treatments, Cymbalta's dual action takes hold at lower doses than does Effexor. As such, the dose-related cardiovascular risks that are associated with both drugs might be more avoidable with Cymbalta. Opinion leaders have suggested that Cymbalta may otherwise just be seen as a copycat drug.

There is still scope for another SNRI alongside Effexor and subtle differences are likely to be key to prescription choices.

With the growing number of cheaper generic antidepressants in this increasingly competitive market, manufacturers need to make the most of the available patient potential. The proportion of individuals with MDD making it through accurate diagnosis to treatment is still low, so the use of innovative methods to encourage those with depression to present to physicians will unlock further sales.

Manufacturers also need to focus on the key unmet treatment needs to ensure that their treatment is used instead of others.

Related research:

§          Stakeholder Insight: Major Depressive Disorder - Duloxetine - Fulfilling An Unmet Need? priced $15,200

§          Pipeline Insight: Anxiety Disorders - A decade of declining revenues priced $11,400

§          Top CNS Portfolios in 2004 - The Industry Gold Standards priced $1,900