Psychiatric Bulletin (2007) 31: 193. doi: 10.1192/pb.31.5.193
© 2007 The Royal College of Psychiatrists
Incentives for medication adherence
Guy Molyneux, Specialist Registrar in Psychiatry
Psychiatric Unit, Adelaide Meath National Children’s Hospital,
Dublin 24, email:
guymoly{at}gmail.com
Patrick Devitt, Consultant Psychiatrist
Adelaide Meath National Children’s Hospital, Dublin
As members of an assertive outreach team covering a socially deprived area
of south-west Dublin, we read with interest the paper on money for medication
by Claassen et al (Psychiatric Bulletin, January 2007,
31, 4-7) and congratulate the authors for applying contingency
management measures, which are useful in other areas of medicine, in such an
innovative, pragmatic way. Our team has not used financial incentives but has
used other incentives to improve adherence to depot antipsychotics in a number
of patients with severe illness and a high rate of hospitalisation. The
incentives were negotiated with the patient and involved judicious and
appropriate prescription of low doses of medications requested by the patient
(such as low-dose hypnotics).
We discerned that the key ethical issues were undue influence and imbalance
of power. We accept Claassen et al’s differentiation of offer
and threat, although we should point out that when a patient is taking
medication for payment, an implicit threat exists in that failure to continue
results in a loss for the patient. However, against a background of several
hospitalisations associated with serious reduction in quality of life because
of nonadherence to effective medications, it does appear reasonable and
ethical to regard the benefits to the patient of adherence as overcoming such
negative factors as imperfect consent. We would counsel that such arrangements
be subject to external review and monitoring.
