Getting patients to take their medication as prescribed is notoriously difficult. Regardless of condition only about 50% of patients adhere to prescribed regimes. This is particularly the case in chronic or complex conditions worldwide and improving this problem has the potential to save considerable health burden and costs.
Adherence in mental health is no different. Previous attempts to improve adherence to anti-psychotic medications have been fairly limited. However, it is widely know that paying people to take their medication has been both clinically and cost effective, if not controversial in a number of other health conditions.
The authors aimed to establish if paying patients to receive their depot medication (a long lasting injection) would lead to better outcomes.
Methods
A cluster randomised controlled trial of patients with schizophrenia who adhered to less than 75% of their injections in the last 4 months. The study only included patients who wanted to take their medication, rather than those who didn’t want to. One intervention group received an additional £15 per injection. A large number of clinical teams were recruited, these were stratified before block randomisation.
The primary outcome was the percentage of depot injections given over 12 months. A range of secondary outcomes were included percentage of adherence >95%, clinical symptoms and quality of life.
Results
- 141 patients were randomised across 73 teams
- 12 month adherence from the adherence group was 85% (from 69%) this was statistically significant (CI 3.9% to 19.0%, P=0.0003), the control group increased to 71% (from 67%)
- 95% adherence was significantly higher in the intervention group (adjusted OR 8.21, CI 2.00-33.67, P=0.003)
- There was no statistical difference in clinical outcomes
- Quality of life was significantly better in the intervention group (CI 0.26 to 1.15, P=0.002)
Conclusions
The researchers concluded that offering small payments improved adherence
The authors concluded:
Offering modest financial incentives to patients with psychotic disorders is an effective method for improving adherence to maintenance treatment with anti-psychotics.
Discussion
Paying people to take their treatment is one potential intervention which could improve adherence to prescribed medications. This potentially could save the NHS considerable money but only if increased adherence reduced relapse and hospital admissions. In this study these were low frequency events. Simply paying individuals to do as they are told may not be the answer; it potentially leads to blindly obeying doctor’s orders, and limits an individual’s ability to make an informed choice about their own health.
That participants reported an increase of quality of life, could have been due to many factors, gaining extra income is probably most significant of these.
Links
Priebe, S. et al Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial BMJ 2013;347:f5847 (Open Access paper featuring a video interview with the lead author Stefan Priebe).
Kendall, T. Paying patients with psychosis to improve adherence (editorial). BMJ 2013;347:f5782
My immediate reaction on reading this was horror. Firstly because I was diagnosed/labelled with schizoaffective disorder and managed to taper and withdraw from psychiatric drugs, completely recovering in 2004. Also I’ve had other family members labelled with schizo disorders who came off their drugs and led responsible, full lives.
I believe that the schizophrenia diagnosis/label is flawed and that psych drug treatment causes bipolar disorder. Paying someone to take psych drugs because of subjective psychiatric opinions and a lifelong mental illness prognosis is wrong on many levels. In my opinion.
Two wrongs don’t make a right.
If I pay you, will you have your injection?: Getting patients to take their medication as prescribed is notori… http://t.co/Uhl4QSzMqN
If I pay you, will you have your injection? http://t.co/uHct2OvjVu via @sharethis
Can cash incentives make people take their medicine? RT @Mental_Elf: If I pay you, will you have your injection? http://t.co/lJi5zLsu3F
My latest @Mental_Elf blog – If I pay you, will you have your injection? http://t.co/mkWVqxzAsk
@JohnBaker_UoM @benhannigan @Mental_Elf Interesting one, but not exactly an upstream attempt at public responsibility for health in opinion
@AlresfordBear @JohnBaker_UoM @Mental_Elf Controversial, too, as John notes in his post.
@benhannigan @JohnBaker_UoM @Mental_Elf Indeed :) One of these ones which never has a solution lol :)
@JohnBaker_UoM @Mental_Elf quelle surprise!
@JohnBaker_UoM on @BMJ_latest RCT of financial incentives to improve adherence to antipsychotic maintenance treatment http://t.co/mYnXFJWu9R
If I pay you, will you have your injection?
http://t.co/40QT1UypaA
An interesting thought
Is it acceptable to pay people with schizophrenia to take their antipsychotics? http://t.co/mYnXFJWu9R @JohnBaker_UoM
@Mental_Elf @JohnBaker_UoM Surely it would be better to pay them with money.
@Mental_Elf @JohnBaker_UoM – Pharmas make billions off #NHS – paying mentally ill to consume dangerous chemicals suits Management.
@Mental_Elf @JohnBaker_UoM I’d say there are too many people taking them that don’t need to, and visa versa.
@Mental_Elf @JohnBaker_UoM Surely having them take some responsibility for their health is better? Would they just take the money though?
The Mental Elf @Mental_Elf 9m
If I pay you, will you have your injection? http://t.co/K5GQOLVX1v http://t.co/PpICcH2nrn
New cluster RCT finds that paying £15 per injection improves adherence to antipsychotic maintenance treatment http://t.co/mYnXFJWu9R
RCT finds that paying £15 per injection improves adherence to antipsychotic. Adherence up, autonomy down. http://t.co/uXT7Jta97O”
MT @Mental_Elf If I pay you, will you have your injection? http://t.co/nOJt7EkEf9 Surely better to reformulate… e.g. transdermal patch
In case you missed it earlier: my latest @Mental_Elf blog – If I pay you, will you have your injection? http://t.co/mkWVqxzAsk
@JohnBaker_UoM @Mental_Elf, helpful blog summary re. FIAT RCT: ‘If I pay you, will you have your injection?’ http://t.co/3GpiYgb4cw
Cool study MT @mental_elf: Cluster RCT finds paying £15 per injection improves adherence to antipsychotic treatment http://t.co/q9BgmIDod9
In case you missed it earlier: If I pay you, will you have your injection? http://t.co/mYnXFJWu9R #schizophrenia #antipsychotics
@Mental_Elf Interesting – no difference in clinical outcomes and valid points in discussion
Mental Elf: If I pay you, will you have your injection? http://t.co/9w4YU8AHrk
The problem is that with financial incentives you are offering to pay for something that most people do for free.
Once the offer of financial incentives is on the table how many of those who would have been compliant would become non compliant? How many of those with other diagnosis would attempt to be diagnosed with illnesses which attract financial incentives. If incentives are only offered to those on depot injections how many of those on effective oral medications such as clozapine would insist on depots. If the incentive is offered per depot injection how many patients would push for being on a depot with more regular scheduling.
Unfortunately although this study shows that the individuals were more compliant there was no significant effect on how well they were. This might be due to the study being too short or small to pick up these differences, or possible due to financial incentives having a negative effect on the therapeutic relationship or the illness. This needs to be looked at in more depth before thinking about actually introducing financial incentives in practice.
Out of 540 teams approached only 73 teams were agreeable to this study demonstrating that the use of financial incentives is unlikely to prove acceptable to the mental health teams expected to deliver them
[…] original study can be found here, or if you prefer you can read my Mental Elf blog which discusses the […]