Israel doctors prescribing 'trendy' antidepressant to the masses

While the field of mental health continues to be discredited in Israel, the developers of psychiatric drugs are nevertheless enjoying an upswing in sales. One representative example of this trend is Cipralex, a drug produced by Denmark's Lundbeck pharmaceutical company to treat depression.

The medication has been on the market for many years but only recently experienced a dramatic rise in sales.

"'Trend' is indeed the right word," said a pharmacist in the center of the country. He said Cipralex (the brand name for the selective serotonin re-uptake inhibitor Escitalopram) "is no different from other drugs on the market, but it continues to dominate in sales over similar products like Prozac and Seroxat."

The use of antidepressant medications in Israel has transformed in recent years from a taboo to a legitimate subject which many in the public eye feel no hesitation about discussing openly. Actor and director Menashe Noy and journalist Hanoch Daum are but a few to have sung the praises of Cipralex.

"There is definitely a feeling that more and more people are living off of Cipralex," said Shira Tofer, who takes the drug.

"I've had problems with depression in the past, and a psychiatrist wrote me different prescriptions for various periods of time," Tofer said.

"A family doctor prescribed Cipralex, and because I had already heard about it from several people I started taking it. I also renewed the prescription several times without being asked too many questions ¬ it was really convenient," she added.

Cipralex is intended for use against depression and anxiety. Since its launch in June 2003 it has become the most prescribed treatment for depression in 26 countries, earning profits of $1.2 billion in 2007.

In Israel, the drug costs NIS 142 for a monthly dosage, and is not included in basic health care packages ("health baskets"). However, it can be obtained at a discount only by customers subscribing to upgraded packages with their health maintenance organizations.

Moreover, because it is a new drug, its patent prevents it from being reproduced in cheaper, generic versions until 2012. Some 80 percent of the Israeli market for antidepressants consists of generic drugs, which are included in health baskets and cost only NIS 15-25 per month.

According to the consulting and data services company IMS Health, some 40,000 prescriptions for Cipralex are filled in Israel every month, making up one fifth of the total market share. Figures from Lundbeck's branch in Israel indicate the drug is the leading antidepressant prescribed in the country.

A company report released last summer indicated 38 percent of general practitioners identified Cipralex as their first preference for the treatment of depression and anxiety. Thirty-three percent of psychiatrists listed the drug as their first preference for combating depression, and 39 percent for anxiety.

Since January 2007, all physicians in Israel have been authorized to prescribe psychiatric drugs. Since that year, pharmaceutical companies have also been allowed to market their products to GPs.

"Many patients go to GPs who have questionable expertise in diagnosis and treatment" of mental health disorders, said one senior psychiatrist. In addition, he said, many physicians do not adequately monitor the patient over time, but renew prescriptions on an automatic basis.

"If we add to this the very active marketing, and I'm talking about the most aggressive marketing there is, a trend develops ¬ and not necessarily around the best drug, since Cipralex is no better than other antidepressants," he said.

"This is a trend of being 'trigger happy' in the prescription of psychiatric drugs including Cipralex," said Dr. Eli Lublinsky, an psychotherapist at the Israel Psychoanalytic Society in Jerusalem.

"People come in and ask for Cipralex because that's what they heard about from others, and they want 'instant' treatment," he said. "They don't understand that it will cause the symptoms to fade away, but will not treat the core of the problem."

Lublinsky said effective treatment must combine "psychotherapeutic treatment, medication and, if necessary, athletic activity to deal with the root of the problem," and that he prescribes Cipralex along with other drugs based on the symptoms accompanying the specific patient's depression.

Lublinsky described Cipralex as little more than an older drug repackaged with a new patent. "Before Cipralex, Lundbeck had Cipramil, which had the same active ingredient as Cipralex. When Cipramil became generic, the company took a mirror image of the molecule of the active ingredient and made it into a new patent ¬ Cipralex."

Lublinsky said another reason for Cipralex's success stems from its very absence from the health basket, which leads HMOs to encourage the prescription of the more expensive drug over its cheaper alternatives as a way of cutting their own costs.

Lundbeck Israel Ltd. offered this response: "The company operates transparently in light of its obligations to the stricted ethical codes." The company added that research has shown Cipralex to be the most effective, quickest treatment for depression and anxiety.