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  3. Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial
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Research

Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5847 (Published 07 October 2013) Cite this as: BMJ 2013;347:f5847
  1. Stefan Priebe, professor of social and community psychiatry1,
  2. Ksenija Yeeles, research fellow2,
  3. Stephen Bremner, lecturer in medical statistics3,
  4. Christoph Lauber, medical director4,
  5. Sandra Eldridge, professor of biostatistics3,
  6. Deborah Ashby, professor of medical statistics and clinical trials5,
  7. Anthony S David, professor of cognitive neuropsychiatry6,
  8. Nicola O’Connell, research assistant1,
  9. Alexandra Forrest, research assistant2,
  10. Tom Burns, professor of social psychiatry2
  1. 1Unit for Social and Community Psychiatry, Queen Mary University of London, Newham Centre for Mental Health, London E13 8SP, UK
  2. 2Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
  3. 3Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
  4. 4Services psychiatriques, Jura bernois, Bienne-Seeland, Bellelay, Switzerland
  5. 5School of Public Health, Imperial College London, St Mary’s Campus, London, UK
  6. 6Department of Psychosis Studies, Institute of Psychiatry, King’s College London, UK
  1. Correspondence to: S Priebe s.priebe{at}qmul.ac.uk
  • Accepted 28 August 2013

Abstract

Objective To test whether offering financial incentives to patients with psychotic disorders is effective in improving adherence to maintenance treatment with antipsychotics.

Design Cluster randomised controlled trial.

Setting Community mental health teams in secondary psychiatric care in the United Kingdom.

Participants Patients with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder, who were prescribed long acting antipsychotic (depot) injections but had received 75% or less of the prescribed injections. We randomly allocated 73 teams with a total of 141 patients. Primary outcome data were available for 35 intervention teams with 75 patients (96% of randomised) and for 31 control teams with 56 patients (89% of randomised).

Interventions Participants in the intervention group were offered £15 (€17; $22) for each depot injection over a 12 month period. Participants in the control condition received treatment as usual.

Main outcome measure The primary outcome was the percentage of prescribed depot injections given during the 12 month intervention period.

Results 73 teams with 141 consenting patients were randomised, and outcomes were assessed for 131 patients (93%).⇓ Average baseline adherence was 69% in the intervention group and 67% in the control group. During the 12 month trial period adherence was 85% in the intervention group and 71% in the control group. The adjusted effect estimate was 11.5% (95% confidence interval 3.9% to 19.0%, P=0.003). A secondary outcome was an adherence of ≥95%, which was achieved in 28% of the intervention group and 5% of the control group (adjusted odds ratio 8.21, 95% confidence interval 2.00 to 33.67, P=0.003). Although differences in clinician rated clinical improvement between the groups failed to reach statistical significance, patients in the intervention group had more favourable subjective quality of life ratings (β=0.71, 95% confidence interval 0.26 to 1.15, P=0.002). The number of admissions to hospital and adverse events were low in both groups and did not show substantial differences.

Conclusion Offering modest financial incentives to patients with psychotic disorders is an effective method for improving adherence to maintenance treatment with antipsychotics.

Trial registration Current Controlled Trials ISRCTN77769281.

Footnotes

  • Members of the full Financial Incentives for Adherence Trial (FIAT) research group:Richard Ashcroft, Claudia Ashton, Deborah Ashby, Kerri Bailey, Kirsten Barnicot, Stephen Bremner, Tom Burns, Anthony David, Philip Eldridge, Sandra Eldridge, Mike Firn, Alexandra Forrest, Connie Geyer, Elizabeth Highton-Williamson, Catherine Henderson, Lauren Kelley, Martin Knapp, Christoph Lauber, Helen Morley, Nicola O’Connell, Stefan Priebe, Sarah Watkins, and Ksenija Yeeles.

  • The study protocol can be accessed at www.biomedcentral.com/1471-244X/9/61.

  • Contributors: SP (chief investigator) conceived and designed the study, developed the intervention, managed the study, and monitored recruitment and data collection for the London site and the whole trial. He is the guarantor. KY managed the study, developed the intervention, designed the data collection tools, monitored recruitment for the Oxford site and data collection for the whole trial, and managed and cleaned the data. SB designed and conducted the statistical analysis and supervised the study. CL conceived, designed, and managed the study, developed the intervention, and monitored recruitment for the Liverpool site. SE and DA conceived, designed, and supervised the study, and designed the statistical analysis. ASD conceived, designed, and supervised the study. NO’C and AF implemented the study and managed the recruitment, data collection, and data. TB conceived, designed, and managed the study, developed the intervention, and monitored recruitment and data collection for the Oxford site. All authors helped write and review the report.

  • Funding: This trial was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project No 07/60/43) and will be published in full in Health Technology Assessment. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS, or the Department of Health. The trial is registered with ISRCTN (SRCTN77769281) and is adopted into the UKCRN and MHRN portfolios. The funder had no role in study design, data collection, data analysis, interpretation, writing of the report, or decision to submit for publication. All study researchers were independent from a funder. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; ASD received personal fees from Janssen-Cilag and Eli Lilly and TB received lecture fees from Janssen and Otsuka during the conduct of the study; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the NRES Ealing and West London Research Ethics Committee (reference No 09/H0710/35).

  • Data sharing: Patient level data and the statistical code are available from the corresponding author at s.priebe@qmul.ac.uk. Consent for data sharing was not obtained but the presented data are anonymised and the risk of identification is low.

  • Declaration of transparency: The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. The lead author in this statement is the study guarantor.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.

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