(I’m not sure if this has already been featured on MN, so apologies if you now have a strong sense of déjà vu).
Whilst doing some studying (don’t look at me like that, it has been known) I came across this article (which I hope everyone can see). The authors argue that offering money in exchange for compliance with medication regimes is a
“non-coercive and effective option to achieve medication adherence in otherwise non-adherent assertive outreach patients”.
In the two part study, they examined attitudes towards financial incentives displayed by assertive outreach (AO) team managers, and also offered five previously non-compliant AO patients a payment of £5-15 per single depot injection. 76% of team managers specified objections to the practice, with reasons ranging from it being ‘unethical’ and ‘coercive’ to manipulative, disempowering and exploitative. Some also expressed concerns about where the money would come from for such a scheme. Of the 5 patients offered money, 4 accepted it and subsequently had improved adherence.
The study isn’t exactly great from a methodological point; a 47% response rate to the questionnaire and 5 participants hardly inspires confidence. But for me it’s more about the issue it raises.
Is it ethical to offer patients money to take medication? I once knew a CPN who offered one obese lady bars of chocolate to take her pills; she had a BMI of over 50 when she was admitted to the ward. Personally, I found this shocking enough. But maybe in her case money would have been a healthier option? Is it right to dangle cash in front of people struggling to survive on benefits as long as they do what we want? Can this ever be considered non-coercive, as the authors argue? Or is it just a sensible option that gives patients a bit of extra cash for something that will (hopefully) benefit them in the long run?
On one level it sounds a little manipulative, but then I guess if it encourages someone to comply with their meds and therefore not wind up getting sectioned later on, then it could be considered a net gain in terms of that person’s freedom.
One note of concern: part of me wonders whether any patients might start refusing to comply in the hope of getting some money.
I think I’d be more comfortable with the offering of small gifts of food etc rather than actual money, as that has less connotations of bribery to it (even though it IS bribery, which is why the drug companies are so keen to offer us a sandwich).
I was horrified when I first found out about this study last year, I am still horrified, and I will remain horrified by the idea even if the cleverest moral philosophers in the history of the entire universe suddenly appear on this site to tell me how great the idea is.
“One note of concern: part of me wonders whether any patients might start refusing to comply in the hope of getting some money.”
Quite apart from the moral issues, this practical aspect would worry me a lot.
I work managing hardship funds for students. We have to be very careful about what we make awards for, how much we explain ourselves to our students, and checking evidence. If we once gave out a hint of being nice and providing an easy way to get money, our doors would be kicked in by the screaming hordes. Once a precedent has been set, it is very hard to back out of it.
(Despite my phrasing, we are really very nice and quite generous. No, really).
I will remain horrified by the idea even if the cleverest moral philosophers in the history of the entire universe suddenly appear on this site to tell me how great the idea is
Ok, I’ll give it a go.
(I’m a Leo and meant to be arrogant – don’t blame me – it’s Russel Grant’s fault)
I love the opening line of the article:
Although financial incentives to improve treatment adherence have been found effective in various medical specialties…
Like what?
A 10p lolly for not crying at the dentist? 100,000 quid for donating the healthy leg to studies on surgical errors?
It gives absolutely no example of this claim. Anyone any ideas/examples?
Of course there’s a potential beneficence to the individual in this scheme – but it’s the unfairness (injustice) on the rest of the population that’s at stake – especially when they’re all paying or when they don’t get the same incentive for taking medical advice.
Overall – crap idea. (How’s that for convincing ya Jan?)
In my not-at-all-ethically-challenging part of the world, community patients can be re-admitted for not taking medication – regardless of presence of symptoms (more for those with forensic history who’s MHRT approved community leave orders include compliance a part of the leave conditions). That’s a fair motivation I think (!)
However, to widen the debate -
The burden of disease on the taxpayer is getting bigger and this is primarily diet related; smoking related; mental health related or carcenogenic related. <– “educated” guess – please verify.
(Figures please, experimentalchimp?)
Current trends are increasingly for everyone to take steps to a healthier lifestyle – not just MH patients – or they may face exclusion from surgery or medical treatment if they don’t give up smoking/lose weight/stop drinking alcohol/stop living under electric pylons.
Of those who become so incapacitated – ie on Incapacity Benefit / DLA (I forget the technical differences of the benefit scheme) – is it not a good thing that the person ‘earn’ some of that ‘benefit’ by taking a responsibility for their beneficial improvement?
If financial incentives are fair to be used on the mentally incapacitated – then I’d say it’s to be used on all and widen it to all DLA recipients.
And how this compares against the unhealthy rich I am not sure – but they can pay their own way in private care so it becomes less of a taxpayer issue – just a socially moral one then.
Before I get flamed – I am aware and empathic that getting ‘better’ is more than just wanting to and is not completely in the hands of the individual. But for those things that are – why not link part of the payment to health care compliance… oops – concordance?
Of course, how you’d ‘police’ whether Mr Bucket is eating salad or Macca’s is an entirely different story and such a process stands to be as ‘fair’ as the DLA assessment itself.
Oh – and MH patients getting money for taking medication – would be great if the medication was really that much use and didn’t come with a shit load of side effects that cause further burden of disease like type-II diabetes; obesity; heart conditions; at further cost to the taxpayer.
I really have no idea what I’m arguing here.
What’s the going rate for a respiridone consta jab?
I guess the recipients of this particularly daft scheme can always spend the money on some class A drugs to counteract the side effects from the depot.
It’s almost as daft as this scheme (http://news.bbc.co.uk/1/hi/health/7650055.stm ). Paying fat, stupid smokers in Essex to go to their GP once in a while. My parents had to pay to see their family doctor hence hardly ever went except when at deaths door. How in one generation have we gone from this to having to pay people to take medication/ go to see their doctor?
The world – at least the capitalist part – is at odds with itself.
No longer can it afford to pay for the social and health care it used to because everyone got to relying on it – hence – we don[‘t need to care about our well being – the state will do it.
Now the state is getting broke and can’t afford it
It’s kinda like having a lazy teenager stuck at home refusing to go get a job – until you pay him to go find work – or start charging him full costs of board and lodging.
The whole nanny state thing is like kindergarten for whole populations….
ok children… take your nasty anti-mental medication and we’ll give you some sweety money. And Smithers if you don’t stop picking your nose I will put tax on snot.
What’s the going rate for a respiridone consta jab?
From the BNF: -
Risperdal Consta®(Janssen-Cilag)
Injection, powder for reconstitution, risperidone 25-mg vial, net price = £82.92; 37.5-mg vial = £115.84; 50-mg vial = £148.55 (all with diluent)
Pragmatism leads me to think that it’s not that bad an idea to give AO patients money to take meds, given the consequences when they don’t.
lsnduck – no chance of me getting a new kitchen out of the hardship fund then?
Damn…back to the drawing board…
My own opinion on this was something close to Jan’s; I was horrified, but am not entirely sure why. The cold, logical part of me thinks it is not so different to behavioural modification programs. The emotional bit is screaming no, it’s just wrong. Perhaps I need to reflect on it some more…
I think partly it’s because paying people to take meds is uncomfortably close to admitting that people often take them for us (i.e MH professionals), rather than for their own benefit. Society allows us to pay people for services they provide us; this is what we are doing when we pay patients to take the drugs. They are doing something for us by taking them. I don’t know why I feel so strongly about it; patients already take meds for reasons other than their own, e.g.so that the MDT will let them get discharged.
Also, it strikes me as being odd that people who are so unwilling to comply with a medication regime will suddenly agree for the sake of a fiver. I assume they have serious issues with the drugs in order to go to such great lengths to avoid them; why does five quid change this? You would have to pay me a lot more than that to take the risperidone consta jab. Unless they are absolutely desperate for the cash, in which case the ethics become more dubious.
Ok, not sure whether that makes sense….
Mr Ian, you are perilously close to inciting my ire there making comments about people needing to lose weight. Be careful or I will bounce you across the Irish sea with my humongous belly, assuming I am not distracted by a nearby pie or ten.
If someone doesn’t want to take their pills, maybe the question to ask is, why? Why aren’t they doing it? If I believed that I wasn’t ill and my psychiatrist was an evil witch trying to poison me, 5, or 10, or 50, or even 2,000 quid wouldn’t make me take olanzapine daily. Actually, you’d have to work pretty hard as it is to convince me to do that even without anosognosia or paranoia.
Careful Beakie linking to the BNF you know how Z is with linking to right wing political parties.
Ms DeeDee – You may bounce me all you like but this 120kg lard arse will probably not budge – unless you offer me a cigarette.
I’m no angel.
The truth is that people are cajoled into taking their meds through the promise/threat of things that are far less tangible – and in ways less honest and open – than an offer of money. I think we’re all agreed that psychiatry can be/is generally coercive in nature and that nurses, docs and the rest of the “interprofessional team” are all basically in the business of social control and we rely on service users to “play the game” to a large extent. I can’t think of a good enough reason why service users shouldn’t make a bit of spare cash out of this situation.
Hmmmmmm. There seems to be a tide of opinion here saying “we can’t get people to take meds for the right reasons, so perhaps we should get people to take meds for the wrong reasons instead.” I hope I’m not the only one who’s extremely uncomfortable about this.
Perhaps I should repeat my call to “the cleverest moral philosophers in the history of the entire universe “. No rush guys. In your own time.
@beakie –
“I can’t think of a good enough reason why service users shouldn’t make a bit of spare cash out of this situation.”
I can,
We already spend £80bn on health as it is, the banking system is going into meltdown and the country is heading towards the worse recession since the 1980′s. Now is the time we should be saving money not giving it away as a reward for refusing medication.
(Can I have £5 for eating some fresh fruit & vegetables and not buying any fags today?)
If a fiver stopped someone from getting sectioned, wouldn’t that save money by not having to keep him/her in hospital?
There seems to be a tide of opinion here saying “we can’t get people to take meds for the right reasons, so perhaps we should get people to take meds for the wrong reasons instead.”
I can’t offer any moral philosophy, just plain old pragmatism. Because isn’t this pretty much what happens anyway? I can think of several people I’ve worked with who grudgingly take the meds because it gets the psychiatrist off their backs or stops them being dragged into hospital or because they think it will get them better (when we know that most people experience residual symptoms and/or horrible side effects) or just because they like the nurse offering it.
Concordance therapy (oh let’s call a spade a spade – COMPLIANCE therapy) is basically about getting people to play the game, just with more frills attached (Rachel Perkins has compared it to brainwashing and I tend to agree). Why not supplement it with a bit of spending money.
E – I hear what you’re saying but a few fivers hither and yon are not going to bring the economy crashing down around our ears. The govt could afford how many bejillions to bail out Northern Rock and B&B? It’s probably a net saving to dish out a bit of cash to people to continue with the depots. Cost of one day’s hospital stay runs into the hundreds.
I just think it sends out the wrong message is all and it is difficult to put a precise figure on the cost of sending out wrong messages. (Anyone care to put a figure on moral fiber, self reliance and independence ?)
Again, I hear what you’re saying but the right messages so often make so little real impact.
Sorry Mr Ian you’ll have to bum a ciggie from someone else, I don’t smoke. I do have a tin of organic catnip sitting around somewhere though.
How on earth is a fiver going to persuade someone to take tablets if they don’t like the side effects and don’t think they are ill? I don’t see that happening.
And as for so-called self-reliance, that’s all very well but if you’re disabled and on the social you don’t get to trudge out into remote parts of Utah accompanied only by your trusty steed and loyal dog, hunting coyotes and watching tumbleweed in the wind, followed by a knees-up in the local saloon bar. (And no, the piano player doesn’t stop when you walk in, and the rest of the clientele don’t all turn towards the door – that’s your paranoia talking).
@zarathustra -
You are assuming that antipsychotic medication is a reliable and effective treatment for psychosis. I don’t think too many researchers run around claiming that a lack of dopamine causes schizophrenia for certain; at the end of the day we have no clue what truly drives schizophrenia.
If these disorders were truly biologically based, then anti-depressants, antipsychotic medication and mood stabilizers would work at all times for all people.
The serotonin theory of depression for instance (on which the effectiveness of SSRI’s is based) is a highly contentious theory. According to Stanford Psychiatrist David Burns
“I have never seen any convincing evidence that any psychiatric disorder results from a deficiency of serotonin.”
And yet the effectiveness of SSRI’s is based on the so-called serotonin hypothesis and I think the same probably goes for antipsychotic medication. Before we start bribing patients to stay on their medication perhaps we should have a little more evidence that it actually works. After all if it were an effective treatment then presumably it would be unnecessary to bribe patients to take the stuff in the first place.
http://medicine.plosjournals.o.....4f74b9d0f9
What they have ascertained though unanimously, it’s that taking risperdal consta is a right pain in the arse
. (See, someone had to make that joke…).
Yes yes and yes again E. The dopamine hypothesis is indeed looking a little ragged round the edges, and considering we don’t really know where normal thought comes from let alone thought, the likelihood is that future years will prove our current meds to be a rather large chemical sledgehammer rather than the finely-tuned pharmaceuticals we make them out to be. And of course, the notion that they are “antipsychotic”, eliminating psychosis in the same way as antibiotics tackle pathogens is ridiculous. They’re major tranquillisers, and all they do for some people is make them less preoccupied with and distressed by their symptoms while not stopping the symptoms to any large extent.
Having said all that, the meds ARE an effective treatment for about 2/3 people at least, and they’re still the best we have to offer. Oh yes, we have the all-conquering CBT for psychosis now, but the evidence I’ve seen suggests that a) it’s not that great in that it appears to help fewer people than meds and b) it works best in combination with meds anyway. So medication is part and parcel of treatment, and likely to be for many many years to come, whether we like it or not.
I guess what I’m saying is that we shouldn’t throw the baby out with the bathwater. As far as I’m aware, some physical meds don’t have the 66% success rate of neuroleptics.
Sorry, there should be a “disordered” inserted before the second “thought” in the second sentence there. Dunno where it went!
Ah, perhaps my previous conclusion that the tide of opinion seemed to be in favour of getting people to “take meds for the wrong reasons” was a little too hasty. I have revised my opinion based on latter discussions.
The following premises appear to have been established:
1. Psychiatric medication isn’t brilliantly effective, but we’re still going to give it to people anyway;
2. Psychopharmacology is at best based on speculation;
3. Many undesirable techniques are already employed to get people to take their meds.
In light of the above I can conclude that there are quite enough morally dodgy things happening in the name of psychiatric medication already, and we would therefore be foolish to introduce another one by paying people to take their meds. It might tip the balance and lead to people struggling to trust institutional psychiatry. Heaven forbid!
Well actually the premises I was talking from were: -
1) Psychiatric medication, in the form of neuroleptics, is effective for around two thirds of the people who take them
2) For those two thirds, it’s the best we have at the moment
3) Yes, psychopharmacology is based on speculation, but anyone who thinks that large areas of medicine aren’t similarly speculative is naive at best.
4) People take psychiatric medication for all sorts of reasons, not necessarily the “right” ones, whatever they might be.
Points taken Beakie, and perhaps it was a tad unjust of me to err on the side of the fascile in my summing up.
The sad thing that I see is that MH staff tend to forget that treatments have limitations as well as capabilities, that they can cause harm as well as do good. The negative sides are rarely given the attention they warrant when professionals debate the whole “compliance” bit. I regard it as healthy that such consideration happens, and I once again find it refreshing that this website fosters such debates, and that its contributors do not blind themselves to the unpleasant aspects of treatments like so many MH staff do.
Perhaps the most troubling manifestation of this blindness that I’ve seen is when MH staff have stated that they “would take antipsychotic medication” if they were diagnosed with a condition that warranted it. I find it incredible that people believe they can predict that they would respond ratinally if they developed a condition that affected their capacity for rationality.
Anyway, I still think offering payment for taking meds is wrong. Realistically, how many MH staff can you think of who would willingly trade an arse full of neuroleptic for a fiver?
The sad thing that I see is that MH staff tend to forget that treatments have limitations as well as capabilities, that they can cause harm as well as do good.
Damn right, Jan. And this leads them to what are basically dishonest discussions with service users.
I can remember working on the acute ward when risperidone was new on the market. So totally had the professionals swallowed the propaganda about its efficacy versus its side effect profile that when service users complained about muscle stiffness, it was assumed they were only after procyclidine and the attendant rush it can bring.