Incentives Raise Attendance of Substance Abuse Therapy
> 3/12/2008 2:39:50 PM

The majority of mental health media attention falls on new treatment or diagnosing techniques. State-of-the-art pharmaceuticals and brain-imagers are indisputably important, but they would be of little use if patients decline to participate in the process. If subjects do not volunteer for experiments, then our understanding of mental illness will not advance. If patients refuse treatment, or do not follow it reliably, then they will not receive the benefits of scientific advancement. This is why it is so important to perform experiments like the one recently run by Dr. Luba Leontieva to explore the viability of an incentive program.

The experiment, which appears in the March issue of Psychiatric Services, involved 61 outpatient schizophrenics coming in for tri-weekly treatment for alcoholism with the help of the drug naltrexone. Patients with schizophrenia are not only more likely to have addiction problems, but they have particularly poor rates of attendance and compliance with medication regimens, making their treatment a constant battle. To win this struggle, Dr. Leontieva employed an incentive structure based on vouchers.

The vouchers had a clear monetary value that could be redeemed at the clinic to purchase a variety of desirable rewards such as portable electronics and gift certificates. Assumably, the system did not directly hand subjects cash so that researchers could both observe spending trends and ensure that the money was not misused. The vouchers started at $5 dollars per session, and increased by one dollar for every consecutive session, dropping back to $5 if any session was missed. This progressive pay-scale encouraged consistency, which is crucial for naltrexone and many other drugs.

Patients attended an average of 31 out of the 38 possible sessions (82%). This is significantly better attendance than normal for schizophrenics, a group from which close to 50% drop out of research trials entirely. However, this study suffers because there was no control group to serve as a benchmark for those in the exact same situation but without vouchers to motivate them.

One promising finding from this study is that patients were just as motivated by vouchers regardless of their economic status, or the severity of their psychosis or alcohol dependence. This suggests that a wide variety of mentally ill patients can be motivated to become more reliable partners in their recovery by incorporating an incentive system into their treatment. The finding that the incentive was universally effective also has interesting research implications, because it implies that even severely psychotic patients can plan ahead and make rudimentary economically rational decisions.

The authors of this study admit that their method is labor intensive and expensive. We can hold out reasonable hope that the labor intensive part of the equation can be lowered. For instance, a new pill-sensing necklace can record whether medication is taken on time and this technology might be modified to automatically reward compliant patients with rewards or praise. The expenditure for vouchers may be more difficult to escape. In this experiment, $20,144 was spent on vouchers alone. If that money can help the mentally ill escape addiction, which severely complicates their treatment and lowers their quality of life, then it will be well worth the cost.


I think it is very difficult to treat addiction because certain therapies/drugs can often exacerbate the dysphoria as a result withdrawal from the drugs. So anything that can potentially increase compliance is certainly good news.
Posted by: Mike 3/12/2008 7:52:55 AM

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