Welcome to depression 2.0

The concept of depression 2.0

The P V Narasimha Rao Govt. ushered economic glasnost in India. The present Prime Minister of India, Mr. Manmohan Singh, was the Finance Minister then (check our Prime Minister’s biodata – CLICK HERE. No wonder, Mr. Singh is regarded a genius). It was, in fact, the challenging economic situation of India that goaded the Central Govt. of India to begin dismantling the license-permit-quota raj and start speeding economic liberalization.

Celebrated economist Ajit Ranade has written:

By the end of June 1991, foreign currency reserves had dwindled down to USD 975 million, hardly enough to pay for two weeks of imports. India had to ship part of her gold reserves and pledge it as collateral to be able to access the international overnight market and avoid a loan default. Export growth had turned negative and foreign commercial lenders had shut the door to India. Industrial growth was negative 1.3 per cent and inflation was soaring above 16 per cent. GDP growth for FY92 was less than 1 per cent. The predicament that India found herself during the summer of 1991 was the culmination of fiscal profligacy during the 1980s, and the legacy of inward looking and high cost import substitution policies combined with excessive controls followed in the past. The immediate trigger for the balance of payment crisis in 1991 was the oil price shock and sudden drying up of remittances from the Middle East caused by the gulf war. The situation was compounded by a quick succession of changing governments.

Ten years later in May 2001 the picture provides a sharp contrast. Foreign currency reserves are now USD 43 billion, equivalent of nine months of imports. The debt service ratio at 16 per cent is the lowest in ten years, the current account deficit is close to 1 per cent of GDP, and GDP growth is itself among the highest in the world, having
accelerated to 7.25 per cent by the mid 1990s. Foreign direct investment during the decade has been about USD 18 billion, and a much larger quantum stands approved. During this decade the economy has successfully withstood several harsh tests, which
included negative agricultural growth due to adverse weather (FY96), the Asian financial crisis during 1997-98, the international sanctions following India’s nuclear tests in 1998, and considerable volatility in world commodity and oil prices during 1998-2000.

(The complete article is availablehttp://www.abnamro.co.in/Research/pdf/decade-of-reforms.pdf.)

This economic resurgence of India (by the end of 2001) also coincided with the start of web 2.0 era (the web 2.0 era too is said to have started at the end of 2001).

(CLICK HERE for more on the web 2.0 concept)

So, to sum up, there are three cardinal forces that have shaped India in the recent past –

(a) Economic liberalization - authored by the World Bank, IMF and Govt. of India
(b) Social liberalization through the internet and media revolution, and
(c) The IT-software-BPO-KPO-telecom revolution, which created a grand socio-economic growth and boosted the purchasing power in India. The success of this segment has had a tremendous multiplier effect, on the socio-economic scene. For eg., during a journey recently, this month, by bus, from Hassan to Mysore, I happened to talk to an interesting gentleman, Mr. Venkatesh, my co-passenger, who was among various things such as a coffee planter, a micro artist too. This gentleman paints on raw rice grains. These are then sold as micro art abroad and to corporates like iGate for their corporate gifting activities. In fact, Mr. Venkatesh has named his firm TANDULA (this means rice grain in Sanskrit). Mr. Venkatesh is also a regular traveler to European countries to promote his micro art products. During conversations, Mr Venkatesh reiterated that the way foreign buyers and people interacted with him in 2000 and in say 2005 saw a sea of difference. In 2005 he observed that he commanded better attention with his European prospects thanks to the remarkable image of global India ushered in by the new economy companies. It is this multiplier effect both in India and abroad that the digital age companies have created.

These three cardinal forces have helped swell the numbers of the celebrated Indian middle class. The ‘middle class’ is indeed very important for the Indian society since it is the middle class people who supply the quality educated workforce, and they are the most important contributors of taxes to the Govt.

The above three cardinal forces have awakened Indians to competition and consumerism; dared Indians to dream and court despair too; compete, win, lose and hope... In this pot pourri of emotions a single strand of negative emotion is gaining currency – DEPRESSION. This clinical condition was certainly present in the pre-economic liberalization phase of India. However, it was hidden, neglected, shunned, under diagnosed, stigmatized, and never acknowledged unless it gained ‘schizophrenic proportions’ – pun intended. Today in digital era India, new trends are seen at the clinical and societal level. Chronic illnesses such as diabetes, cardiovascular diseases, geriatric diseases (dementia to arthritis), CNS ailments, anxiety, sadness and overwhelming sadness (or depression) - that are closely related to affluence, nuclear families, and a sedentary lifestyle - are overshadowing infectious diseases. And this new era of clinical depression in India has its genesis in the start of the economic liberalization process, which incidentally coincided with the start of web 2.0 revolution. So I reiterate WELCOME TO DEPRESSION 2.0 in India.

Rise and shine, dear Sertraline

Sertraline is an anti depressant. This molecule created a media sensation in India recently, with its rapid growth. Look at this report from the Times of India –

Not so long ago, men and women suffered depression silently. This appears to be changing — instead of getting bogged down by low moods, people are combating it to go ahead with their demanding, stress-laden lives. The result: there's a spurt in the sale of anti-depressant drugs.

Check this out — Dr Reddy's Lab, which makes bulk anti-dep drug Sertraline, recorded a stunning 258% increase in sales in 2005 –06. Sales of Sertraline for Dr Reddy's to major markets in India and worldwide, are pegged at Rs 50 crore alone in 2005-06. According to IMS data till January 2007, Sertraline is the fastest growing drug in the segment, showing over 40% sales growth for Pfizer and 16% for Unichem over the corresponding period last year. There are 8-10 brands marketing Sertraline in India, with Pfizer (Daxid) and Sun Pharma (Zosert) being major players. Overall, the Rs 300-crore anti-depressant market registered a growth of 12%, with Abbott's drug Prothiaden (Dothiapin) leading the pack with a market share of 6.1%. Industry sources say, with over 200 brands fighting for a share, the anti-depressant market has seen some aggressive and innovative promotion.

The panacea anti depressant (?)

For many decades in India we have had a topper pharma brand that also induces euphoria on misuse. This well-known brand is the Rs. 100 crore plus brand - COREX. The anti-tussive codeine phosphate is an important active ingredient in Corex. The other ingredient is the CNS depressant and antihistaminic chlorphenaramine maleate. This wiki: http://en.wikipedia.org/wiki/Corex reiterates the well-known truth about Corex – 90% of its sales in India come over-the-counter and not via prescriptions, although Corex is technically a prescribed medicine. This also reiterates one of the home truths of the great Indian pharma market. The reality is that the Indian pharma market is OTX (over-the-counter plus prescriptions). Market savvy companies like Mankind and Laborate have understood this undiluted reality and are registering scorching growth. Micro Labs, Bangalore, Ranbaxy, and Cipla are past masters in the operations of this complex OTX pharma Indian market. Nevertheless, success of Corex as the top most brand of India is an anachronism in the practice of 21st century modern allopathic medical science. It is a wonder Govt. authorities and NGOs in India have not asked – aren’t there any better alternatives to codeine phosphate syrup as an anti-tussive. I can volunteer a safer alternative of the semi synthetic narcotic class – dextromethorphan HBr. Innovator company Pfizer, markets Corex in India, Pakistan, Bangladesh, and a few South Asian countries - http://en.wikipedia.org/wiki/Corex - (we are the lucky few). Why is Corex not a # 1 brand in European countries or USA? Why are the patients of USA denied the benefits of Corex for the management of dry cough? Oh, may be there is more of productive cough there. Corex has had a safe run unlike nimesulide, which apparently, in hindsight, ran in to unjustified rough weather on an allegedly extraordinarily worrisome adverse effect profile. Right now, both Corex and nimesulide are doing very well in the great Indian pharma market.

Codeine phosphate is an opiate, well absorbed by the GIT, undergoes very less first-pass metabolism in the liver (morphine undergoes extensive first-pass metabolism) and interacts with the mu receptors of the brain giving the same CNS effects of morphine – creates a sense of contentment. Codeine gets converted to morphine in the brain. You will enjoy reading more on codeine phosphate here: http://opioids.com/codeine/codeinefaq.html

Now the question is - did Corex syrup create a sense of contentment in the era of depression 1.0 (?). That is a question to mull over.

High potential for HCPs

Big money wants more money. If depression 2.0 is a goldmine opportunity for pharma companies, lifestyle change promotion is the last thing on the mind of big money. It is going to be sertraline promotion all the way – and for the less privileged it is glug-glug.

So who will fill the void in helping patients make active informed decisions about depression management? I still would say health counsel providers (HCPs). For eg., yoga has profound positive influence in depression management. And so do some ayurvedic drugs like tagara, ashvagandha, brahmi…

In the Times Wellness section of The Times of India, Bangalore dated 19.5.2007; there is a report that Bangalore alone has 6000 cases of brain tumor. The report shows that brain tumor diagnosis can be tricky as the signs are often subtle. So this is where HCPs can step in aiding patients and guiding them to appropriate specialists.

The 3 G (third generation) mobile technology mainly based on the CDMA 2000 and wideband CDMA are rewriting convergence. A 3 G handset in the near future will allow users to talk, and obtain services like news, music, games, ticker services, streaming music, weather, videos, movies or audio books. Now you can also add the possibility of health counsel. For eg. Dr. Nikil Jain, CTO, Qualcomm India (reference – Business Standard, Weekend section, 19/5/2007 & 20/5/2007) says: “Men and women could probably seek visually interactive medical aid at the press of the button”. Now that is the eHCP (electronic HCP) like the eMR concept that was seen in an earlier blogpost.

Closing remarks:

The depression 2.0 period has begun in India. While sertraline and other anti depressant drugs look to have a rosy future, Indians with their long tradition of Yoga, spirituality, innate love and respect to traditions and elders, and Ayurveda will certainly look for lifestyle modifications. In essence the Gen X and Gen Y will rediscover their roots. Ancient India resurfaces.

Want to take a online test for depression? CLICK HERE. No wonder I call it depression 2.0!

(Thnks for the very warm appreciative comments on the blogpost COFFEE WITH DR. RANGESH, please also read all other blogposts. sunilchiplunkar@gmail.com)