Have ethicists overlooked obvious benefits of financial incentives for antipsychotics?

By Nathan Hodson.

It is late evening on an acute psychiatry ward and I’m the on-call doctor responsible for clerking a new patient with acute psychosis. I look in the notes and see that despite a history of detention for paranoid schizophrenia, he has been well on an antipsychotic depot for 5 years. Why relapse now? Then I find the most recent letter and discover that he stopped accepting his depot two months ago and rapidly declined. This terrible pattern is a common occurrence in acute psychiatry. Patients are deprived of their liberty and detained under the Mental Health Act because of depot non-adherence. Financial incentives may be one way to address this problem but progress has been slow.

Two medium-sized RCTs have shown that adherence to antipsychotic depot injections is improved when patients are offered a small financial incentive (worth roughly 2 and a half hours at the minimum wage). These studies are conducted among patients who have discussed depot treatment and agreed to it but are at risk of missing doses perhaps due to distractions or inconvenience. Nevertheless, a range of ethical and practical issues have been raised in empirical and philosophical studies. These questions are fascinating and important and while there are some answers emerging from the literature, many questions have not been fully addressed. We catalogued the full range of published objections in our recent systematic review.

Some claims about financial incentives for antipsychotics are difficult to evaluate because there is no useful data. For example, we do not know whether incentives improve mental health outcomes, reduce hospitalization, or benefit patients with good compliance. There have been no studies comparing different incentive designs despite extensive evidence that different incentive designs have different results. Similarly, there is no evidence whether incentives mean patients explore their options less assiduously or hide adverse effects. Overall there is no useful evidence regarding cost effectiveness.

However, many questions which have been raised about financial incentives have been answered by empirical study. Can incentives increase depot adherence? Yes (in both RCTs). Can they increase overall engagement with treatment? Yes (44% of the time). Can they upset patients not offered incentives? Occasionally (one report of a patient missing a dose in protest from all studies so far). Does withdrawing incentives undermine intrinsic motivation and adherence? No (no difference between incentive and control group in intrinsic motivation). Will patients become financially dependent? No (not reported in any study so far).

But we also identified certain objections that were simply not amenable to direct empirical study. These included impact on patient dignity and autonomy, coercion, exploitation, and disrespect for settled decisions. These questions require philosophical research with empirical scaffolding.

Interestingly, a key part of that empirical scaffolding already exists. Our new paper Take patients seriously when they say financial incentives help with adherence reviews evidence to support the simple but important observation that patients view incentives favourably. Compared to mental health staff, patients are much more positive about incentives. They report that they enjoy having extra money. They dislike the idea of non-cash incentives. Altogether, patients are – and it is not surprising in retrospect – hugely positive about receiving some spending money for doing something they were probably going to do anyway. It is striking that mental health staff (just like me and my colleagues) overlooked this benefit

Patients also took a surprising moral view. Unlike mental health staff, they endorsed the idea that financial incentives are an appropriate reward for good behaviour and that, in this case, accepting their antipsychotic depot constitutes good behaviour. This view is more in keeping with Kohlberg’s preconventional stage of moral development where people are driven by reward and punishment. I think many ethicists would balk at this particular justice-based argument for incentivising people to accept treatment which is their best chance at staying well and out of hospital.

But in another sense, many of us view healthy actions as morally good. Working out, staying hydrated, avoiding sugary foods – we attribute moral value to them all. Does that mean we should all get incentives? Maybe not. But it does explain why incentives make sense to patients with schizophrenia. We could construe such incentives as celebrations or well dones. The fact that this view seems to be meaningful to patients perhaps suggests ethicists have overlooked a very simple dynamic in the relationship between psychiatrists and psychotic patients and the exact meaning given to any financial incentive.

It is nice to receive a celebration, or acknowledgement, that you have done something good. Evidence given by patients reveals a positive regard for incentives and this perhaps surprising ethical interpretation. In light of these findings, it becomes more difficult (although not impossible) to make the case that incentives are problematically paternalist or coercive. I suggest that these surprising findings do, however, make a prima facie case for further research into financial incentives for depot antipsychotics as one means of reducing psychotic relapses like the ones I see in hospital. The onus is on opponents of financial incentives for antipsychotic treatment to present arguments which outweigh patient preference.

Author: Nathan Hodson

Affiliations: Academic Clinical Fellow, Unit of Mental Health and Wellbeing, Warwick Medical School

Competing interests: None

Social media account of post author: @nathanhodson

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