Mulder, CL

Priebe, S

Staring, ABP

English

Queen Mary Research Online

Brief report	Financial incentives to improve adherence to medication in five patients with schizophrenia in The NetherlandsRunning head		Financial incentives for adherence – a pilotABP Staring, M.A. 1, 2				tonnie@backwash.org (​mailto:tonnie@backwash.org​)Professor CL Mulder, M.D., PhD. 1, 2		niels.clmulder@wxs.nl (​mailto:niels.clmulder@wxs.nl​) Professor S Priebe, M.D., PhD. 3		s.priebe@qmul.ac.uk (​mailto:s.priebe@qmul.ac.uk​)1)	Erasmus University Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands2)	Bavo Europoort Psychiatric Institute, Prins Constantijnweg 48-54, 2066 TA Rotterdam, The Netherlands3)	Queen Mary University of London, Newham Centre for Mental Health, London E13 8SP, United KingdomCorrespondence: Anton B.P. StaringTrouwlaan 104, 5021 WN Tilburg, the NetherlandsTelephone: +31 (0)6 525 68 313E-mail: tonnie@backwash.org (​mailto:tonnie@backwash.org​) DetailsVersion: 							: 22-12-2009Words in abstract						: 150Words in text (excludes abstract, references and tables)		: 1 213Total number of pages						: 10Tables								: 1 (p10)Key wordsSchizophrenia; adherence; medication; antipsychotic medicationAbstractObjectiveNon-adherence to antipsychotic medication is common and increases the risk of psychotic relapse. A promising intervention may be a strategy wherein financial incentives are offered. MethodsIn a pilot study in The Netherlands, five patients with schizophrenia were offered financial incentives for a duration of one year to improve adherence to medication. Adherence and hospital days were measured. ResultsThe percentage of accepted depot injections increased from an average of 44% in the previous year to 100% in the year when financial incentives were offered. While patients had been hospitalised for an average of 100.2 days in the previous year, only one was re-admitted for 17 days during the year of the intervention. ConclusionsThe differences in adherence before and after the intervention were large and of clinical significance. However, randomised controlled trials are required to provide conclusive evidence on the effectiveness of offering financial incentives and potential consequences. IntroductionNon-adherence to antipsychotic medication in schizophrenia is high (1, 2) and is associated with a three to five times increased risk of relapse (3, 4, 5). Developing effective interventions for improving adherence is a major challenge to mental health care. In the UK, Claassen et al. (6) used financial incentives to improve the adherence to antipsychotic maintenance medication in five formerly non-adherent patients. Results were promising, yet no other studies have since been published. We conducted a pilot study to test the feasability of using financial incentives to improve adherence and explore potential benefits for patients in an Assertive Community Treatment (act) team. MethodsProcedurePatients were gathered in Rotterdam, The Netherlands. Written informed consent was obtained from all patients after providing them with a complete description of the study. The intervention was over a one year period and the study was conducted from July 2008 to October 2009. A Medical Ethics Committee (METIGG, The Netherlands) approved the study (ref-number: 8208; CCMO number: NL22014.097.08). Intervention: financial incentives for adherencePatients received ten to twenty Euro cash (fifteen to thirty US $) for each depot injection of antipsychotic medication. The amount of money depended on the frequency of the depot. Ten Euro were offered for a depot administered every two weeks, 15 Euro for a depot every weeks, and 20 Euro for a depot every four weeks. RespondentsInclusion criteria were (1) a diagnosis of schizophrenia or schizoaffective disorder, (2) being treated in the act-team for a period of one year or more, (3) the prescription of depot antipsychotic medication, (4), non-adherence, as defined by either not accepting all depot injections or repeated resistance and discussion when accepting the medication, (5) having been admitted to a psychiatric hospital in the past year as a consequence of non-adherence (as assessed by the responsible clinician). Six patients were asked to participate out of which one refused and five decided to participate. Two patients were native to The Netherlands. The others were first-generation immigrants; one from Suriname, one from Turkey, and one from the Dutch Antilles. For more details, see Table 1. MeasurementsFor both the year before and the year during which the intervention was applied, the following data were collected from the patients’ files: (1) the number of administered depot injections as compared to the prescribed one; and (2) the number of days the patient spent in psychiatric in-patient treatment. Furthermore, we designed a short questionnaire to capture the views of patients, their relatives and clinicians (workers in the act-team) on the experiences with offering financial incentives. ResultsDepot acceptance and hospital daysAs Table 1 shows, all five patients accepted every depot injection of antipsychotic medication during the year of the intervention. During the year before the intervention, adherence was much lower. Patient B had previously always declined a depot injection of antipsychotics, despite the fact that mental health professionals had often tried to motivate him because of his poor compliance with oral medication and his recurring and severe psychotic relapses. 	The number of days patients spent in psychiatric in-patient care decreased during the intervention. Only one of the five patients was admitted whilst being offered financial incentives. However, the same patient (B), during the period of the intervention, had been in detention for 195 days for domestic violence while being in a psychotic state. Thus, the incentives improved adherence, but the medication did not sufficiently control his psychotic symptoms. -- insert Table 1 somewhere here --Views of patients, relatives and clinicians In the short questionnaire on the experiences with the intervention all five patients considered the intervention to be a good project. The reasons they gave were “I don’t like the injection, but money makes it better,” “Money keeps me motivated,” and “The depot injections keep me balanced.” When prompted, two patients said that they perceived financial incentives as a voluntary and non-coercive measure, two patients did not know what to think about this, and one indicated that he perceived financial incentives as a coercive measure, saying that “I have to take the medication anyway.” All patients said that they spent the money on food and on cigarettes, and one patient also bought household products. It was observed, however, that at least one patient had spent some of the money on cannabis. All five patients stated that the amount of money was too low. None of them, however, had asked for more money during the intervention. All five patients said that they preferred receiving cash to other systems of reward such as vouchers for food, sports activities, etc. Three patients either had no relatives or did not allow us to interview them in this study. The two interviewed relatives – two mothers – indicated that they considered financial incentives to be a good measure, saying that “There can never be enough research” and “This project is in the best interest of both the patient and his parents.” They considered the amount of money to be sufficient, and they preferred the reward of money over vouchers. During the intervention, two patients had repeatedly asked for their depot injections sooner than scheduled, which was always declined. Despite this, no clinician reported a negative impact on the therapeutic relationship. Two patients complained about side-effects, and one expressed concerns that the depot injection could kill him, after watching a TV program in which someone died as a result of medication. No other patient in the care of the team complained about unequal treatment or demanded to be paid for taking their medication as well. DiscussionThe pilot results are promising and seem to indicate that offering financial incentives can increase adherence with depot antipsychotics and, as a consequence, reduce the risk of relapse in patients with schizophrenia that are treated in an ACT-team. The difference in adherence and clinical outcomes with the total prevention of further hospitalisations in four out of five patients is substantial. The benefits of such changes for the patients concerned and their relatives as well as the reduction of service costs appear to justify the intervention. The positive results are consistent with findings of a previous study in the UK (6). Unlike that previous study, we also assessed experiences of patients, relatives, and clinicians. Overall, experiences were positive, cash incentives were preferred to vouchers, other patients did not ask to be offered incentives as well, and no negative impacts on therapeutic relationships were noted. However, the reported experiences also indicated potential problems with offering incentives. Some patients felt they should receive more money and the issue of a coercive nature of the intervention was raised. Some of these issues are linked to ethical considerations about offering financial incentives to change health behaviour in general (7) and particularly for improving medication adherence in patients with schizophrenia which have been discussed elsewhere (6, 8). Conclusions The differences in adherence before and after the beginning of the intervention were large and of clear clinical significance. However, randomised controlled trials are required to provide conclusive evidence on the effectiveness of offering financial incentives and potential consequences (9). Such research should distinguish between an effect on adherence itself and a positive impact of the medication. AcknowledgementsNo formal funding was used for this study. The money that the participating patients received was provided by their psychiatric health center. References1. Weiden PJ: Discontinuing and switching antipsychotic medications: understanding the CATIE schizophrenia trial. J Clin Psychiat. 2007;68(suppl 1):12-19. 2. Cramer JS, Rosenheck R: Compliance with medication regimes for mental and physical disorders. Psychiatr Serv. 1998;49:196-201. 3. Fenton WS, Blyer C, Heinssen RK: Determinants of medication compliance in schizophrenia: empirical and clinical findings. Schizophrenia Bull. 1997;23:637-651. 4. Ucok, A., Polat, A., Cakir, S., et al: One year outcome in first episode schizophrenia; predictors of relapse. Eur Arch Psy Clin N. 2006;256:37-43. 5. Weiden PJ, Kozma C, Grogg A, et al: Partial compliance and risk of rehospitalization among California medicaid patients with schizophrenia. Psychiatr Serv. 2004;55:886-891. 6. Claassen D, Walid K, Fakhoury RF, et al: Money for medication: financial incentives to improve medication adherence in assertive outreach. Psychiat Bull. 2007;31:4-7. 7. Prendergast M, Podus D, Finney J, et al: Contingency management for treatment of substance use disorders: a meta-analysis. Addiction. 2006;101:1546-1560.8. Claassen D: Financial incentives for antipsychotic depot medication: ethical issues. J Med Ethics. 2007;33:189-193. 9. Priebe S, Burton A, Ashby D, et al: Financial incentives to improve adherence to antipsychotic maintenance medication in non-adherent patients - a cluster randomised controlled trial (FIAT). BioMed Centr Psychiat. 2009;9:61. Table 1		Hospital days and depot acceptance both before and during the intervention		One year before the intervention	One year during the interventionPatient (sex; age)	DSM-IV diagnosis	Hospital days	Depots accepted*	Hospital days	Depots accepted*A (male; 23 yrs)	Schizophrenia, paranoid subtype	76	45%	0	100%B (male; 24 yrs)	Schizophrenia, paranoid subtype	260	0%	17	100%C (male; 21 yrs)	Schizophrenia, paranoid subtype	89	20%	0	100%D (male; 43 yrs)	Schizophrenia, paranoid subtype	14	100%	0	100%E (male; 34 yrs)	Schizophrenia, disorganised subtype	62	55%	0	100%* This is the percentage of depot injections that were effectively given to the patient in comparison to what was officially prescribed, counting only the out-patient days. PAGE  1Financial incentives for adherence – a pilot

Financial Incentives to Improve Adherence to Medication in Five Patients with Schizophrenia in The Netherlands

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Financial Incentives to Improve Adherence to Medication in Five Patients with Schizophrenia in The Netherlands

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