Blowing the whistle on pharmaceutical companies for fraud in the USA may be financially lucrative but the personal costs are high, according to a new study.

The analysis, in the New England Journal of Medicine notes 90% of health care fraud cases are qui tam actions in which whistle-blowers with direct knowledge of the alleged fraud initiate the litigation on behalf of the US government. However, the authors note that popular portrayals of whistle-blowers vary widely: “some anecdotes paint them as heroes struggling against corporate greed, emphasizing the hardships and retaliation they must endure,” while “other accounts question their motives and the "excessive" rewards they receive”.

The goal of the study is to “shed light on the motivations and experiences of whistle-blowers” and involved interviews with 26 of them. It claims that all of the interviewees stated “that the financial bounty offered under the federal statute had not motivated their participation in the qui tam lawsuit” but their actions were due to four “non–mutually exclusive themes: integrity, altruism or public safety, justice, and self-preservation”.

For 82% of the 22 ‘insiders’ polled, they claimed that they were subjected to various pressures by the company in response to their complaints and at least eight insiders said the financial consequences were “devastating”. One said: “I just wasn't able to get a job…I had to sell the house…financially I went under..then it really gets difficult…I lost everything. Absolutely everything”.

The NEJM study goes on to note that six insiders reported divorces, severe marital strain, or other family conflicts during this time. Half the interviewees reported having stress-related health problems, including shingles, psoriasis, autoimmune disorders, panic attacks, asthma, insomnia, migraines and generalised anxiety.

All 26 received a share of the financial recovery, ranging from $100,000 to $42 million, with an average of $3 million. Despite the negative experiences, 22 of the 26 till felt that what they did was important for “ethical and other psychological or spiritual reasons”.

The authors conclude that qui tam litigation’s capacity to curb fraud could be enhanced if US Justice Department investigators and others involved in the process “were more cognisant of the tribulations faced by relators, or if relators received needed resources (for example, temporary financial or medical benefits during unemployment) during the course of litigation”. They add that “shortening the timelines and attendant stresses…requires more resources for enforcement, an investment that should more than pay for itself”.

The study goes on to state that “financial recovery appeared to be quite disproportionate”, so “more sophisticated approaches to determining relators' recoveries could be used to promote both equity and more responsible whistle-blowing”. Finally the authors state that “protections are not fully effective, particularly for insiders” and “often, the retaliation was more subtle than overt harassment”.

Commenting on the report, Erika Kelton, a lawyer with Phillips & Cohen who has represented several whistleblowers, including the sales rep whose case against Pfizer for marketing of the withdrawn anti-inflammatory Bextra (valdecoxib) finally settled last year for $1.8 billion, including a $1.3 criminal fine, said it “confirms our experience”. She added that most complain internally “assuming - or hoping - that their employer will change. Whistleblowers generally are loyal employees” but “unfortunately employers often tend to repay that loyalty by retaliating against those who speak out”

Ms Kelton concluded by saying that “whistleblowers decide to file a qui tam lawsuit as a last resort. Most are motivated more by exposing wrongdoing and stopping what often are harmful or dangerous practices than by any hope for a reward”.