In a recently published open forum article in Psychiatric Services, the authors discuss the use of “behavioral economics” as a way of improving “adherence” to psychiatric medications. The article looks at the use of payments to people for taking their medications for diagnosed psychiatric disorders. I was horrified to read it. Let me explain why.
First, to put it in context for the reader, and to acknowledge my own experience and biases, I have experience with what was diagnosed as psychosis, I have been involuntarily committed to a psychiatric hospital, and I have been medicated with Haldol against my will. I self-deprescribed all my medications, against the advice of my psychiatrist, and might I say, with great benefit to my health and well-being. I currently take no psychiatric medications, although I leave the door open if I have need for them in the future. When I was first prescribed medication I was told that I would need it, like insulin, for “the rest of your life.” I tested that hypothesis, and found it sorely wanting.
I also have Young Onset Parkinson’s Disease. I was diagnosed at age 39, and now take medications six times a day that allow me to move my arms and legs. I am typing this article now only through the miracle of medications — my right and left hands would not coordinate to type without doses of Sinemet (carbidopa/levidopa) or Requip (ropinirole). I am not anti-medication in any way. I would go to extreme lengths to make sure I have medications available to me, as I like being able to take care of my six-year-old daughter, and I enjoy being able to walk the two blocks from my car to my office. Medication has allowed me to continue to function on a very basic level for the past six years, and I am extremely grateful for that.
The use of incentives for medication in psychiatric care, though, strikes a deep fear in me. From the article: “Financial reinforcement based on behavioral economic principles has been proposed as a potential strategy to enhance medication adherence in severe mental illness, and some studies show that small incentives significantly increase adherence to long-acting injectable treatment.” That is, in plain language: we are paying people to take their meds, and it works. But not for long, it seems, as “[a]fter the intervention is stopped, however, adherence appears to decline.” So, when paid, people take the meds, but after the money is gone, the behavior (mostly) appears to return to baseline.
What does this say about the use of incentives in the case of psychiatric medications? For me it brings up several issues. The first is consent. For many people with what are termed serious mental illnesses, like ‘bipolar disorder’ and ‘psychotic disorders’, a small amount of money makes a huge difference. With the rates of unemployment at an estimated 45% (combining unemployed and those considered out of the workforce, Luciano & Meara, 2014)1 and the pittance of disability payments in the US upon which many people are surviving, a $15-30 incentive is huge. Close to 40% of people diagnosed with serious mental illness live on less than $10,000 a year. While the authors identify the “ethical concerns” inherent in this approach, they do not mention the rates of poverty and the relative strength of this incentive for many. Addressing the ethical concerns raised by this approach seems almost impossible to do, along with ensuring that true consent is obtained when enrolling people in these studies.
Along with the ethical quandaries, the article in no way addresses the differences between diagnosed mental disorders and other medical conditions for which behavioral economics have been utilized to encourage following treatment recommendations. The underlying assumption seems to be that “mental illnesses are illnesses like any other,” a phrase previously used to combat “stigma” around mental illness. I find this phrase and idea intensely misguided. First, to say these are “illnesses” is debatable. Authors of the DSM, Michael First for example, are quick to say that the DSM does not diagnose illnesses or diseases, but identifies disorders. These clusters of symptoms thrust into categories have not yet been mapped onto any “natural” category that we have been able to verify biologically. Instead, we use our best estimation to categorize that which we have named and to which we have applied arbitrary time frames (e.g. two weeks for a major depressive episode). Timeframes that do not have empirical evidence to support them (13 days? No. 14 days? Yes!). So to presume that this “illness like any other” is both correctly diagnosed and treatment correctly identified, one must overlook major disparities, including ignoring the racial bias in diagnosing, where black people are 2-3 times more likely to be diagnosed with schizophrenia than white people, a longstanding finding (Olbert et al., 2018).2 The use of long-acting injectable medications varies by race as well, with racial discrepancies in prescribing; being black disproportionately predicted being prescribed injectable medications in 12 states according to state Medicaid data (Brown et al., 2014).3 This racial disparity has been shown in retrospective analyses of prescribing practices elsewhere as well (Aggarwal et al., 2012)4 and is not a new phenomenon (Covell et al., 2002).5 Recommending using payments to incentivize taking medication requires the use of one’s powers of denial and rationalization. Incentivizing what may not be a necessary or effective treatment (and may actually cause iatrogenic harm), and what may be the result or reflection of systemic and racial bias (Gurek et al., 2018),6 seems unethical from the start.
Also unaddressed are the sociocultural factors that play into taking medications for psychiatric disorders versus other medical conditions. The meaning and social pressures to “stay on your meds” and the social context of discrimination and prejudice are unaddressed in this account. I fear that this type of intervention will be looked at as a cheap way to keep people on meds, with cost-saving valorized over the actual health and well-being of the person. Why are we not asking about the reasons that the participants in these studies are non-adherent or partially adherent to the regimen? It is as if this phenomenon of non-adherence is some kind of actual independent thing divorced from culture and context, that if just given the right incentives, people will overcome. I venture that there is choice, decision-making, ambivalence, and a whole host of other reasons that people choose not to take their medications as prescribed. Do these medications work as we would like them to? Are there other options for care that might be more effective or acceptable to the person? The economic incentive approach vastly simplifies the issue, especially in light of the limitations of psychiatric medications in actually alleviating psychological distress, and the disabling and distressing side effects which often outweigh the benefits.
Would I take money to adhere to my Parkinson’s medications? Heck yeah! I open the door to anyone willing to incentivize my pill taking. I am completely clear as to my need for the medications, and that they are the only treatment (besides exercise, which I do my best at) that can address the symptoms of my illness. And yet, sometimes I mistime doses. I miss doses. I do my best. But an extra $30 in my pocket for taking them exactly right? I think that would have a good effect. I have Parkinson’s Disease. It is a degenerative neurological condition, and I need my medication. Did anyone in the studies cited in this article have a similar reaction to their medication? If not, why not? Does that not deserve some attention? Where is the voice of those not taking medications “as prescribed”? We need to reevaluate our prescribing practices, and the true risk-benefit ratio for these drugs, before we throw money at people along with pills. As the article concludes, “Nonetheless, offering financial incentives should be considered as a strategy to enhance adherence to treatment and increase system-level savings…” Unfortunately, this seems to be a possible explanation for it after all — “systems-level savings.” Are we sacrificing autonomy for these savings, to try and medicate away what is truly a need for social change and economic justice?
My timer just rang to let me know I need another dose of meds. Think about it, while I go take my pills.
- Luciano, A., & Meara, E. (2014). Employment status of people with mental illness: National survey data from 2009 and 2010. Psychiatric Services, 65(10), 1201-1209. ↩
- Olbert, C. M., Nagendra, A., & Buck, B. (2018). Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities? Journal of Abnormal Psychology, 127(1), 104-115. ↩
- Brown, J. D., Barrett, A., Caffrey, E., Hourihan, K., & Ireys, H. T. (2014). State and demographic variation in use of depot antipsychotics by Medicaid beneficiaries with schizophrenia. Psychiatric Services, 65(1), 121-124. ↩
- Aggarwal, N. K., Rosenheck, R. A., Woods, S. W., & Sernyak, M. J. (2012). Race and long-acting antipsychotic prescription at a community mental health center: a retrospective chart review. The Journal of Clinical Psychiatry, 73(4), 513-517. ↩
- Covell, N. H., Jackson, C. T., Evans, A. C., & Essock, S. M. (2002). Antipsychotic prescribing practices in Connecticut’s public mental health system: Rates of changing medications and prescribing styles. Schizophrenia Bulletin, 28(1), 17-29. ↩
- Gurak, K., Maura, J., de Mamani, A. W., De Andino, A. M., & Rosenfarb, I. (2018). Racial and ethnic diagnostic patterns in schizophrenia spectrum disorders. In C. L. Frisby & W. T. O’Donohue (Eds.), Cultural competence in applied psychology (pp. 603-617): Springer Nature. ↩