Cash incentives for compliance with psychiatric treatment works, but is it right?

Study finds that offering £15 incentives boosts adherence to antipsychotic medication but critics argue controversial practice is coercive

An interesting, and controversial, study just popped into my inbox. Researchers at Queen Mary University of London have found that offering £15 to people with severe mental illness in return for them taking antipsychotic medication is an effective way of improving their adherence to treatment.

The study, published in the British Medical Journal, is dealing with an important issue. Non-compliance with antipsychotic medication is linked to, among various things, hospital readmissions as people become unwell and relapse. But the intervention being tested – cash incentives – is controversial. Mental health campaigners have previously warned the practice is coercive and counter to informed decision making.

I’ll lay out the key elements of the latest research below. After you’ve digested it, do leave a comment below on whether you feel financial incentives should be considered or not. The study authors admit this is a controversial practice.

Who took part in the study: 141 patients with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar who had been prescribed long acting antipsychotic injections but had received 75% or less of the injections. The group was split into an ‘intervention group’ of patients who received £15 incentives in return for taking each depot injection and a ‘control group’ who didn’t receive payments.

The results: Average adherence in the ‘intervention group’ rose from an average of 69% to 85% over 12 months in the group that received cash incentives. Average adherence in the ‘control group’ rose from 67% to 71% in the same time period. Some 28% of people in the intervention group had ‘complete adherence’ to treatment during the study. 5% of people in the control group had complete adherence.

“The number of admissions to hospital and adverse events were low in both groups and did not show substantial differences,” the study found.

Implications: Here’s what, Stefan Priebe, Professor of Social Community & Psychiatry at Queen Mary University, had to say:

“Our study concludes offering a modest financial incentive is the most effective method shown so far to improve adherence to antipsychotic treatment. It should be considered if poor treatment adherence poses a risk to patients’ health and if other methods to achieve adherence have failed.

“Whether offering higher financial incentives would be ethically acceptable and more effective remains unclear. Further research is needed to test the longer-term impact of offering financial incentives.  In addition, we must continue looking into the psychological mechanisms that can give insight into the positive effects of offering financial incentives – not only on treatment adherence but on subjective quality of life.”

So what do you think? Is this something you’d feel comfortable being offered to people on your caseload who are at risk of relapsing due to non-compliance or is offering cash incentives coercive and unethical? If you receive treatment do you agree with the idea of cash incentives for adherence? Leave comments below.

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4 Responses to Cash incentives for compliance with psychiatric treatment works, but is it right?

  1. Steve Chamberlain October 22, 2013 at 11:01 pm #

    How about offering people with long term mental ill health money to undertake meaningful supported occupation as a means of improving their psychological well-being and self-esteem. I don’t have any references off-hand, but I’m pretty confident there is evidence to support the fact that meaningful occupation improves mental health.
    The money that people would be given could be imaginatively called wages…

    • Mairead O October 28, 2013 at 9:07 pm #

      The financial incentives could support compliance with medication as well for meaningful supported occupation. Both these interventions are extremely important for people with chronic psychotic illnesses to manage their own mental health. Relapse can have an adverse life changing effect on the function of a person who is diagnosed with schizophrenia so any preventative measure such as this could be worthwhile to that person and their carer’s.

    • Moira Ferguson October 29, 2013 at 12:26 am #

      I would agree Steve and I would add that a financial incentive to pay for alternatives to medication where it is possible for the person to manage without would be helpful.Both work and leisure,with support as needed help people have a normal life and a social network as well as the psychological well being and self esteem you refer to. The idea of a small financial incentive to take medication as the study suggests rings bells with the person who asked the priest not to pray for him for healing as he would loose his benefits if he were healed i.e. dependence on both medication and a financial incentive in my view would be better not to be linked. I guess the idea also dates back to the 70’s when people would be ‘blackmailed’ for want of a better word, into having their depot injection if they wanted their giro ! I have forgotten the exact details of how this worked but I know on occasions it was used and had the desired effect from the doctors’ and perhaps the point of view of others,family and professionals alike. Self-esteem is generated when the person feels more in control of their own life though support may be needed to achieve this consistently. I suppose part-time work with or without support which is fairly well paid plus an incentive to help pay for alternative therapeutic leisure pursuits may be a compromise that could be aimed for. I note the study that was undertaken was principally with people with more serious diagnoses so hopefully meant serious presenting symptoms. I have read about the effects of medication,and the effects of coming off some medication and the effects on changes in the brain caused by medication which can in itself cause psychotic symptoms. I know medication can help but I also have reservations about it if the person can be helped to manage without and live safely and without putting the general public at risk.

  2. A depressed man October 23, 2013 at 10:08 am #

    After 10 years on tablets, I began to feel that I didn’t need them.
    I did discuss it with my GP several times. He was very cautious and kept on advising me to stay on them.
    Eventually I weaned myself off them. I stayed well, and I’ve never looked back. After a couple of months I told my GP.
    As money is hard to find, this approach might well have kept me on them as I would have needed the money.
    I agree taking prescribed medication regularly is important, but many people with depression like myself find some medication works for one person and not for another, so this approach might discourage people from raising concerns about their medication.
    And like my GP many health professionals are rightly cautious about upsetting the apple-cart. But medication has it’s downsides too. How about paying me an incentive to stay off medication?