Mind over matter

Anti-depressants growing in Lebanon but stigma around mental health treatment remains

One in four people in Lebanon suffer from at least one mental health issue in their lifetime. This figure was among the findings of the latest comprehensive scientific study, by doctors Elie Karam et al, published in 2006 by the scientific journal Lancet. It places mental disorders among the most common health problems in Lebanon.

“We now have a waiting list,” says Dr. Ziad Nahas, head of the psychiatry department at the American University of Beirut Medical Center (AUBMC). “We have made headway into breaking down the stigma, but there is still a long way to go.”

Stigma, and a lack of awareness around mental health issues, keeps sufferers away from specialists, which often results in improper treatment and medication misuse.

“The problem in Lebanon is that a lot of patients seeking treatment for mental health issues do it in primary healthcare structures,” says Nahas. “They may see a general practitioner, a neurologist or even a brain surgeon, as long as it is not a psychiatrist.” Not getting therapy for mental disturbances of psychological and psychiatric origin often leads to an unneeded consumption of mental health drugs. “Patients who visit a psychiatrist would get treatments which are not addictive, like psychotherapy for example, before even thinking of medication,” Nahas says.

Risks of addiction

Based on medical research published in 2000 by scientific journal Acta Psychiatrica Scandinavica, the consumption of benzodiazepine, an addictive anxiolytic drug, had already reached the levels of major western Europe cities, where access to specialized medical structures and prescriptions is easier and insurance coverage wider. This may be because physicians, rather than psychiatrists, account for most prescriptions of mental health drugs, while a large percentage of consumers of such drugs simply rely on their pharmacists’ or friends’ advice.

The most consumed category of mental health drugs is still antidepressants, with a number of international producers bringing foreign brands to Lebanon via local manufacturers or distributors, and only a small number of Lebanese players in the market. Fluoxetine, branded in the US as Prozac and commercialized by Eli Lilly, is the most expensive of its kind in Lebanon; the price of a 20 mg Prozac capsule is $1.75. The cheapest fluoxetine sold in Lebanon is produced by Jordanian Pharmaceutical Manufacturing and sold at 65 cents per 20 mg tablet.

In the case of sertraline, another antidepressant drug, Lebanon’s Mediphar’s Sertine is the cheapest product, at 40 cents per 50 mg pill. Despite the convenience in price when purchasing local or generic products, Lebanese drug consumers have a preference for western manufacturers. “Lebanese people tend to prefer brand names,” Nahas says, “even when it comes to medication.” Unsurprisingly, Lebanon is a net importer of pharmaceutical products, with the total value of imports reaching $970 million in 2012, a 12.9 percent increase compared with 2010 according to data from the Investment Development Authority of Lebanon. Only ten percent of pharmaceutical drugs sold in the country are manufactured locally whilst the remaining 90 percent is imported, mainly from France, the UK, Germany and Switzerland. In this context, mental health drugs represent a difficult market for local manufacturers to break in to. The lack of insurance coverage for most pharmaceutical treatments and prescriptions has not helped the sector develop properly. Some Lebanese producers, though, are prepared to take a bet.

Domestic production

Local drug manufacturer Arwan, which opened its plant in Jadra, Mount Lebanon last year, has decided to enter the market of psycholeptics. Its antipsychotic drug Zyrwan, which was launched four months ago, targets the one percent share of Lebanese population affected by schizophrenia, and the one percent who will suffer from a bipolar disorder at one stage of their life, based on figures from the World Health Organization.
According to the International Monetary Fund, around 2 million units of psycholeptics are sold in Lebanon every year, for a total $15 million. This compares with 1.5 million boxes of antidepressants for a total $24 million.

Roua Hamandi, Arwan’s product manager for the psychiatric, cardiovascular and anesthesia line, says that facing competition from established foreign brands has not been easy, as many buyers and doctors tend not to trust local products. “This is the case for all pharmaceutical sectors in Lebanon. But we are meeting the international standards and changing doctors’ perceptions. We are focused on gaining the doctors’ trust.”
Hamandi says that it is still too early to have detailed figures on sales, as the product has only been on the market for just over three months, but that they have had good feedback so far.

The loxapine psychotic drug produced by Arwan will be exported to the Gulf and the whole MENA region, where the company is registered. “There is a deficiency of certain products in the Arab market, and a difficulty in the supply. It is a big market with a small number of products,” Hamandi adds. “We can sell directly to hospitals but our direct clients are the doctors who prescribe medications and send patients to pharmacies.”

The issue of insurance

Yet due to Lebanon’s health insurance system, getting a prescription for psychiatric treatments from a specialist in the sector may not come cheap for patients. The lack of insurance coverage is still preventing many people from seeking proper help.

“Only a small portion of affected people seek treatment,” says AUBMC’s Nahas. “They can stay with their illness for years before they come on board and spend a long time struggling with issues that could have been solved earlier before they became more serious.”

Few insurance companies in Lebanon cover psychiatric care while public health funds mostly cover inpatient care and minimal outpatient rates, roughly $17 per psychiatric session, which on average costs $100. When it comes to prescriptions, most insurance companies refuse to cover those signed by psychiatrists. “If I prescribe a blood test, some insurances would refuse to cover it,” Nahas says. “This contributes to patients going to non-specialists.”

The insurance administrator GlobeMed offers hospitalization cover for a maximum of 30 days per year, and for psychotic disorders only, excluding other mental health issues. It doesn’t cover any prescriptions for mental health treatment.

Even the AUB only fully covers staff and students affected by mental health issues for a maximum of three days of hospitalization, or two clinic visits, exclusively for diagnostic purposes. The cost of an added maximum of 13 days of hospitalization or 10 visits per year for those needing psychiatric care is shared between the insurance plan and the patient, who pays 10 percent of the hospital bill and 20 percent of the cost of visits. Farah Yehia, who works at AUBMC’s Psychiatry Department, says they’ve tried to start a dialogue with insurance companies and public health funds to convince them to extend their mental health coverage. This, Yehia says, could be a profitable strategy.

“By covering mental illnesses they are saving costs elsewhere. Cancer patients who are treated for depression, for instance, are hospitalized less often.” Yehia also works with Embrace, a fund co-launched by Nahas which helps cover treatment for patients who cannot afford it. “Mental illness and poverty are usually associated,” Yehia explains. “But treatment is mainly self-founded, which means that poor people are at the same time the most affected and the least able to afford treatment.”

Her team achieved a small victory in their struggle for the extension of insurance coverage last November, when public health funds agreed to cover damage resulting from suicide attempts. “This was scored,” she says with a smile, “but we are trying to keep the discussion going.”

“This speaks a lot about the stigma but also about awareness,” says Nahas. “If you have a chest pain that propagates to your left arm you would immediately think of a heart attack and get help. But most people wouldn’t know the symptoms of a panic attack. Similarly, somatization of psychological symptoms may make you see other doctors before you even consider stress.”  In March this year, the public health ministry launched a mental health program aimed at improving and extending mental health treatment in public hospitals and clinics. “This is a very important initiative as a lot of primary health clinics have been trying to integrate mental health treatment.”

But, he argues, training physicians and other medical staff in mental healthcare is necessary before any progress can be made.

Tiziana Cauli is a Lebanon-based Italian journalist specializing in real estate and business