Mental Illness Drug Payments Call
BBC News. January 1, 2007

This is an interesting discussion of the practical aspects of compliance management in day-to-day clinical practice.

The issues are basic:

• Noncompliance is a common problem in psychiatric practices; 20-50% of these patients are believed to be non-adherent to prescribed medication
• Paying people with severe mental illnesses to take medication may encourage some to stick to their drug regime
• There are practical and ethical concerns about using cash payments to enhance compliance

Commentary

While the clinical study is interesting, the BBC story is more provocative, and its issues may well be more significant than the research findings in determining if the strategy of financially rewarding patients for adherence is put into practice.

The quote from Marjorie Wallace, of the charity Sane, exemplifies the resistance to this tactic:

Even the chief author of the study, Dr Dirk Claassen, indicated that such measures, if used at all, would be applied to a limited group: “Financial incentives might be a treatment option for a high-risk group of non-adherent patients with whom all other interventions to achieve adherence have failed.”

While the use of loaded terminology such as “bribes” triggers a multitude of negative connotations, especially when the patients bear psychiatric diagnoses, the same basic considerations are the essence of the ethical struggle over any compliance enhancement schemes.

It seems intuitively apparent, for example, that the approval of an authority figure can be as powerful or more powerful than a cash payment. Are the urgings of the doctors as unacceptable as monetary reinforcements? What if the urgings come from friends and family? How about reminders to take medication or a physician’s listing of research indicating the effectiveness of a medications? Is there any difference in promoting compliance with psychiatric medications and adherence to treatment for HIV disorders? If paying patients to take an anti-psychotic unethical, should states rescind laws legally forcing resistant patients to take drugs to treat tuberculosis? For that matter, should the government be allowed to enforce regulations requiring childhood vaccinations or restricting the use of tobacco or serving of certain foods?

Indeed, one school of bioethics maintains that any reinforcement, encouragement, or even commendation of treatment adherence is the equivalent of coercion on the part of the clinician, some holding that even subtleties as seemingly innocuous as a physician’s tone of voice, however benign his or her intent, represent intimidation of the client.

For clinicians such as myself, however, the notion of simply laying out various treatment options, including no treatment at all, in a value-neutral manner without indicating my recommendation is unpalatable and smacks of shirking ones duties.

The precedent that comes to mind is the battle between physicians and the antivivisectionists in the early 20th century.¹

My guess is that most clinicians charged with the care of patients make many decisions every day that involve parsing such ethical dilemmas with the well-being of a human being in the balance. For that reason, if no other, I believe that an automatic dismissal of material inducements, one of the few compliance enhancements strategies shown to routinely be effective, is counter to the best interests of patients and deserves further consideration.

Footnotes

1. E.g., William Osler performed vivisection to study typhoid and tapeworm in pigs and testified against antivivisection legislation in government hearings in the U.S. and England [back]

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