Can incentives improve antipsychotic adherence in major mental illness? A mixed-methods systematic review

Abstract

ObjectivesIncentives have been effectively used in several healthcare contexts. This systematic review aimed to ascertain whether incentives can improve antipsychotic adherence, what ethical and practical issues arise and whether existing evidence resolves these issues.DesignSystematic review of MEDLINE, EMBASE and PsycINFO. Searches on 13 January 2021 (no start date) found papers on incentives for antipsychotics. Randomised controlled trials (RCTs), cohort studies, qualitative research and ethical analyses were included. Papers measuring impact on adherence were synthesised, then a typology of ethical and policy issues was compiled, finally the empirical literature was compared with this typology to describe current evidence and identify remaining research questions.Results26 papers were included. 2 RCTs used contingent financial incentives for long-acting injectable antipsychotic preparations. Over 12 months, there were significantly larger increases in adherence among the intervention groups versus control groups in both RCTs. There were no consistently positive secondary outcomes. 39 ethical and practical issues were identified. 12 of these are amenable to empirical study but have not been researched and for 7 the current evidence is mixed.ConclusionsIn keeping with other areas of healthcare, antipsychotic adherence can be increased with financial incentives. Payments of 2.5 times minimum wage changed behaviour. The typology of issues reported in this systematic review provides a template for future policy and ethical analysis. The persistence of the effect and the impact of incentives on intrinsic motivation require further research.PROSPERO registration numberCRD42020222702.

Take patients seriously when they say financial incentives help with adherence

“…2 In psychiatry, financial incentives have been shown to improve adherence to antidepressants and long-acting injectable antipsychotics, as well as reducing substance use. [3][4][5] In the UK, the new Office for Health Improvement and Disparities has a remit including public mental health and financial incentives, but has yet to combine the two, and similar programmes are emerging elsewhere in the world. 6 It seems likely that mental health policy around the world will increasingly grapple with the appropriateness of financial incentives.…”

“…There are also legitimate safeguarding concerns and practical challenges to overcome when giving vulnerable people monthly cash bonuses and, at some point, withdrawing them. 3 A comprehensive review of objections to financial incentives, and whether these have empirical support, is available elsewhere. 3 It would be easy to conclude that these objectionsranging from philosophical to pragmaticfatally undermine the project.…”

“…3 A comprehensive review of objections to financial incentives, and whether these have empirical support, is available elsewhere. 3 It would be easy to conclude that these objectionsranging from philosophical to pragmaticfatally undermine the project. But we propose a different place to begin: the patient.…”

“… 3 A comprehensive review of objections to financial incentives, and whether these have empirical support, is available elsewhere. 3 …”

“…8 Our recent systematic review found no evidence of patients feeling that the incentives were so large as to create problems. 3 …”