Background

Around 1% of the population are living with a psychotic illness such as schizophrenia or bipolar disorder, characterised by symptoms such as hearing voices, having delusional ideas, mood swings, lack of concentration and behavioural abnormalities. Anti-psychotic medication in the form of tablets or long-acting injections, helps to control these symptoms and prevent relapses. If patients receive this medication as an injection, they need to attend appointments at their mental health team to receive them.  However, not all patients attend these appointments for various reasons. Some of them are particularly ‘difficult to engage’, lead seriously disrupted lives or pose a significant risk to harm themselves or others. When patients fail to attend their appointments and take this medication, there is an increased risk of being re-hospitalised.

While there have been previous attempts to improve adherence to medication, the effectiveness of these appear to be limited.  However, offering financial incentives (i.e. money) may be an option.  A small-scale study has shown financial incentives to improve medication adherence in this challenging group of patients.  However, there has been no research on a larger scale to date showing the effectiveness and cost-effectiveness of offering financial incentives improve adherence to anti-psychotic medication.

Focus groups with clinicians (e.g. doctors/nurses), mental health service managers and patients were conducted to determine their attitudes towards offering patients financial incentives as a means of improving anti-psychotic medication adherence. The groups raised a range of concerns relating to how the incentives can be implemented, whether they will be effective, will this change the relationship between mental health staff and patients and whether patients may use this money to fund drug, alcohol or gambling addictions.

Research questions

• What is the effectiveness and cost-effectiveness of offering financial incentives to improve anti-psychotic medication adherence?
• What are the views of offering/receiving financial incentives for both clinicians and patients in the trial, to determine whether concerns raised in focus groups became a reality?

Research activities

• We recruited community mental health teams (CMHT) and assertive outreach teams (AOTs) across England and Wales. These teams nominated patients who are known to show poor attendance rates to receive their anti-psychotic medication (≤ 75% attendance rates).  These teams (and patients) were randomly assigned to two groups: (i) receiving the financial incentives (intervention group) or (ii) continue treatment as usual (control group). Patients in the intervention group were offered £15 each time they attended an appointment to receive their anti-psychotic medication. Patients in the control group did not receive any financial incentives and continued their treatment as usual. This occurred over a period of 12 months.
• We assessed attendance rates in for patients receiving the incentives for anti-psychotic medication or continuing treatment as usual, mental health improvement as rated by the patient’s clinician, the number of untoward incidents (hospitalisation, arrests by police, physical violence and suicide attempts).  We also asked patients to complete a questionnaire rating their quality of life.
• We found that patients receiving the financial incentives for their anti-psychotic medication showed much higher attendance rates compare to those not receiving them. We also found that those receiving the incentives reported a better quality of life. There were no differences in untoward incidents or the level of mental health improvement between both groups. Furthermore, offering financial incentives was no more expensive that current practice in the NHS.
• We conducted interviews with clinicians to find out whether they had noticed any changes with their patients as a result of offering the incentives and what their opinions were on offering financial incentives.  We also conducted interviews with patients receiving the incentives at the end of the study period to find out how they felt about receiving the incentives, and whether they felt this had made a difference to them.
• Clinicians and patients reported a variety of views about offering/receiving financial incentives respectively.  However, the views of the clinicians highlighted more negative aspects that the patient interviews.

Conclusion

Offering financial incentives is an effective and cost-effective method of improving medication adherence amongst patients who showed poor anti-psychotic medication adherence.

Since the main study we have been conducting a follow-up study at six and 24 months after the study of all patients and mental health teams involved in the trial, looking at the long term effects of offering financial incentives for anti-psychotic medication adherence.  We are also interviewing clinicians and patients for their views on financial incentives for medication since the incentives have stopped.  We hope to have the results within the foreseeable future.

Useful links

• www.isrctn.com/ISRCTN77769281

Staff

• Stefan Priebe
• Hana Pavlickova
• Katie Moran
• Adam Ziecik

Associated papers

Highton-Williamson, E et al. (in press) Offering financial incentives to increase adherence to antipsychotic medication: The clinician experience.

Priebe, S. et al. (2009). Financial incentives to improve adherence to anti-psychotic maintenance medication in non-adherent patients - a cluster randomised controlled trial (FIAT). BMC Psychiatry, 9(1), 61. doi:10.1186/1471-244X-9-61

Priebe, S. et al. (2010). Acceptability of offering financial incentives to achieve medication adherence in patients with severe mental illness: a focus group study. Journal of Medical Ethics, 36(8), 463-468. doi:10.1136/jme.2009.035071

Priebe, S. et al. (2013). Effectiveness of financial incentives to improve adherence to antipsychotic maintenance medication - a cluster randomised controlled trial. British Medical Journal, 347,f5847. doi: dx.doi.org/10.1136/bmj.f5847

Funder

National Institute for Health Research, Health Technology Assessment