Financial incentives to improve adherence to antipsychotic maintenance medication in non-adherent patients: a cluster randomised controlled trial

Abstract

BackgroundPoor adherence to long-term antipsychotic injectable (LAI) medication in patients with psychotic disorders is associated with a range of negative outcomes. No psychosocial intervention has been found to be consistently effective in improving adherence.ObjectivesTo test whether or not offering financial incentives is effective and cost-effective in improving adherence and to explore patient and clinician experiences with such incentives.DesignA cluster randomised controlled trial with economic and nested qualitative evaluation. The intervention period lasted for 12 months with 24 months’ follow-up. The unit of randomisation was mental health teams in the community.SettingCommunity teams in secondary mental health care.ParticipantsPatients with a diagnosis of schizophrenia, schizoaffective psychosis or bipolar illness, receiving ≤ 75% of their prescribed LAI medication. In total, 73 teams with 141 patients (interventionn = 78 and controln = 63) were included.InterventionsParticipants in the intervention group received £15 for each LAI medication. Patients in the control group received treatment as usual.Main outcome measuresPrimary outcome: adherence to LAI medication (the percentage of received out of those prescribed). Secondary outcomes: percentage of patients with at least 95% adherence; clinical global improvement; subjective quality of life; satisfaction with medication; hospitalisation; adverse events; and costs. Qualitative evaluation: semistructured interviews with patients in the intervention group and their clinicians.ResultsPrimary outcome: outcome data were available for 131 patients. Baseline adherence was 69% in the intervention group and 67% in the control group. During the intervention period, adherence was significantly higher in the intervention group than in the control group (85% vs. 71%) [adjusted mean difference 11.5%, 95% confidence interval (CI) 3.9% to 19.0%;p = 0.003]. Secondary outcome: patients in the intervention group showed statistically significant improvement in adherence of at least 95% (adjusted odds ratio 8.21, 95% CI 2.00 to 33.67;p = 0.003) and subjective quality of life (difference in means 0.71, 95% CI 0.26 to 1.15;p = 0.002). Follow-ups: after incentives stopped, adherence did not differ significantly between groups, neither during the first 6 months (adjusted difference in means –7.4%, 95% CI –17.0% to 2.1%;p = 0.175) nor during the period from month 7 to month 24 (difference in means –5.7%, 95% CI –13.1% to 1.7%;p = 0.130). Cost-effectiveness: the average costs of the financial incentives was £303. Overall costs per patient were somewhat higher in the intervention group, but the difference was not significant. Semistructured interviews: the majority of patients and clinicians reported positive experiences with the incentives beyond their monetary value. These included improvement in the therapeutic relationship. The majority of both patients and clinicians perceived no negative impact after the intervention was stopped after 1 year.ConclusionsFinancial incentives are effective in improving adherence to LAI medication. Health-care costs (including costs of the financial incentive) are unlikely to be increased substantially by this intervention. Once the incentives stop, the advantage is not maintained. The experiences of both patients and clinicians are largely, but not exclusively, positive. Whether or not financial incentives are effective for patients with more favourable background, those on oral mediation or for shorter or longer time periods remains unknown.Trial registrationCurrent Controlled Trials ISRCTN77769281.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 70. See the NIHR Journals Library website for further project information.

Changing health behaviors using financial incentives: a review from behavioral economics

“…Similarly, an immediate financial incentive has been shown to improve adherence to anti-psychotic medications [50]. This trial offered a £15 incentive to one group of patients for each medication taken, whilst a second group received usual care.…”

A systematic narrative review of the literature: adherence to pharmacological and nonpharmacological treatments among adolescents with mental disorders

“…Another problem is the absence of consistent evidence for the effectiveness of established interventions; the availability of such evidence would significantly improve medication adherence in nonadherent community patients (Priebe et al . ).…”

“…It may well prove beneficial to adopt alternative methods for monitoring adherence such as computerised patient medication records, because self-reports may overestimate adherence (Maguire et al 2008). Another problem is the absence of consistent evidence for the effectiveness of established interventions; the availability of such evidence would significantly improve medication adherence in nonadherent community patients (Priebe et al 2009).…”

Feasibility of implementing a behavioral economics mobile health platform for individuals with behavioral health conditions

“…In a cluster randomized controlled trial, individuals with schizophrenia were offered financial incentives over the course of one year to improve observance of taking an antipsychotic. Results from the intervention group demonstrated an 11.5% increase in following one's medication regimen and improved overall ratings on subjective quality of life metrics [9]. Moreover, a robust body of research demonstrates that incentives are most effective when coupled as closely as possible with the behavior being reinforced, as delays between the delivery of the incentive and the performance of the desired behavior are less effective in driving sustained behavioral change [10].…”