BMJ 2013;347:f5782 doi: 10.1136/bmj.f5782 (Published 22 October 2013)
Page 1 of 2
Editorials
EDITORIALS Paying patients with psychosis to improve adherence This approach can work Tim Kendall director National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E18AA, UK
Poor adherence to treatment is a problem across the whole of medicine, with people not attending appointments, not taking their drugs as prescribed, or not taking them at all. More than 50% of people with schizophrenia have been estimated not to adhere to prescribed drugs,1 leading to higher rates of relapse and hospital admission, as well as increased costs.2 3 Attempts to improve adherence in this population using interventions such as “compliance/adherence therapy,”4 along with the development of long acting depot antipsychotics, have not produced the expected benefits. In a linked paper (doi:10.1136/ bmj.f5847), Priebe and colleagues found that modest financial incentives significantly improved adherence in people treated with depot drugs for schizophrenia and other psychoses in the United Kingdom.5
It is difficult to achieve adherence to antipsychotic drugs in people with psychoses for several reasons. Many do not accept that they are ill so do not believe that they need treatment. Antipsychotics are associated with serious side effects including diabetes, obesity, and neurological problems, especially if used at higher doses. Although other effective treatments for psychosis—including family interventions, cognitive behavioural therapy, early intervention services, arts therapies, and supported employment—are available,6 evidence suggests that they work best when people also take antipsychotic drugs. Therefore, as well as directly improving outcomes, adherence to drugs may also improve outcomes from other treatments. Although Priebe and colleagues showed that improved adherence is also associated with improvements in quality of life, there is no evidence that it leads to reduced rates of relapse or hospital admission (although the rates of hospital admission in this trial were probably too low to make firm conclusions).5 The efficacy of financial incentives may well be linked to the size and duration of the incentive. A trial of financial incentives to promote smoking cessation in a large company in the United States found significantly better results when rewards were more substantial, with a phased increase of incentives linked to successful smoking cessation.7 Perhaps higher incentives that increase over a longer period could improve clinical outcomes further for people taking depot drugs.
We know that financial incentives can help change the behaviour of people with obesity or drug misuse,8 and that they can
improve adherence to treatment in a range of settings.9 Financial incentives in healthcare are, nevertheless, controversial, and nowhere more so than in mental health. In 2007, the National Institute for Health and Care (formerly Clinical) Excellence in England and Wales published a guideline on psychosocial interventions for drug misuse. In this guideline, most of the key recommendations were for financial (or equivalent) incentives that aimed to promote adherence to methadone maintenance treatment, to encourage abstinence from stimulants, and to improve engagement with physical health interventions.10 Broadly welcomed by professionals working in substance misuse services, this guideline ignited fierce opposition in many newspapers, some of which reacted with moral outrage. This sparked a debate in the BMJ in which Joanne Shaw, then vice chair of the national help line NHS Direct, rejected financial incentives on the grounds that they might undermine informed decision making and the doctor-patient relationship and could lead to fraud. For the “no” camp, incentives are never justified, even among patients who are the most vulnerable.11 Some of the most vulnerable people in mental health services are those with schizophrenia and other psychoses. A growing number in the UK are placed on community treatment orders so that they can be recalled to hospital by law if they do not adhere to treatment. They may also be subject to other sections of the Mental Health Act to compulsorily admit them to hospital and forcibly treat them with antipsychotics when they relapse. Relapse is a common consequence of stopping antipsychotic drugs. Some commentators argue that depriving people of their liberty and physically enforcing adherence when they are ill, but then rejecting the use of financial incentives to encourage adherence to the same treatment to help them stay well, is ethically and morally contradictory.12
Financial incentives are not risk free—they may adversely affect the doctor-patient relationship and internal reward mechanisms.8 More research is needed to explore how to improve adherence through other means. However, when the illness impairs insight, as is common in people with psychoses such as schizophrenia, or leads to an erosion of willpower, as can occur in people who misuse substances, supplementing internal rewards with external incentives deserves serious consideration. The doctor-patient relationship is already subject to financial influences. Doctors
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BMJ 2013;347:f5782 doi: 10.1136/bmj.f5782 (Published 22 October 2013)
Page 2 of 2
EDITORIALS
receive incentives from the state (salary, payments for clinical excellence and for meeting quality targets), directly from patients in the private sector, and from healthcare organisations including drug companies. In addition, patients can receive state benefits that are dependent on reports from their doctors. The offer of financial incentives should depend on the severity and chronicity of the illness; its impact on cognition, will, and decision making; and on the particular context of individual patients. Priebe and colleagues have shown that incentives can change the behaviour of people with severe mental health problems and improve adherence to treatment. We now need longer term research to determine if, for this group of disadvantaged and often vulnerable people, carefully used financial incentives can improve long term outcomes and be cost effective. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None. Provenance and peer review: Commissioned; not externally peer reviewed. 1
Nose M, Barbui C, Tansella M. How often do patients with psychosis fail to adhere to treatment programmes? A systematic review. Psychol Med 2003;33:1149-60.
For personal use only: See rights and reprints http://www.bmj.com/permissions
2 3 4 5 6 7 8 9 10 11 12
Robinson DG, Woerner MG, Alvir JMJ, Geisler S, Koreen A, Sheitman B, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999;56:241-7. Novick D, Haro JM, Suarez D, Perez V, Dittmann RW, Haddad PM. Predictors and clinical consequences of non-adherence with antipsychotic medication in the outpatient treatment of schizophrenia. Psychiatry Res 2010;176:109-13. Kemp R, Hayward P, Applewhaite G, Everitt B, David A. Compliance therapy in psychotic patients: a randomised controlled trial. BMJ 1996;312:345-9. Priebe S, Yeeles K, Bremner S, Lauber C, Eldridge S, Ashby D, et al. Effectiveness of financial incentives to improve adherence to antipsychotic maintenance treatment with antipsychotics: cluster randomised controlled trial. BMJ 2013;347:f5847. National Institute for Health and Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. CG82. 2009. http://guidance.nice.org.uk/CG82/NICEGuidance/pdf/English. Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med 2009;360:699-709. Marteau TM, Ashcroft RE, Oliver A. Using financial incentives to achieve healthy behaviour. BMJ 2009;338:b1415. Giuffrida A, Torgerson DJ. Should we pay the patient? Review of financial incentives to enhance patient compliance. BMJ 1997;315:703-7. National Collaborating Centre for Mental Health. Drug misuse: psychosocial interventions. British Psychological Society and Royal College of Psychiatrists, 2007. www.nice.org.uk/ nicemedia/live/11812/35975/35975.pdf. Shaw J. Is it acceptable for people to be paid to adhere to medication? No. BMJ 2007;335:233. Burns T. Is it acceptable for people to be paid to adhere to medication? Yes. BMJ 2007;335:232.
Cite this as: BMJ 2013;347:f5782 © BMJ Publishing Group Ltd 2013
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS Paying patients with psychosis to improve adherence This approach can work Tim Kendall director National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E18AA, UK
Poor adherence to treatment is a problem across the whole of medicine, with people not attending appointments, not taking their drugs as prescribed, or not taking them at all. More than 50% of people with schizophrenia have been estimated not to adhere to prescribed drugs,1 leading to higher rates of relapse and hospital admission, as well as increased costs.2 3 Attempts to improve adherence in this population using interventions such as “compliance/adherence therapy,”4 along with the development of long acting depot antipsychotics, have not produced the expected benefits. In a linked paper (doi:10.1136/ bmj.f5847), Priebe and colleagues found that modest financial incentives significantly improved adherence in people treated with depot drugs for schizophrenia and other psychoses in the United Kingdom.5
It is difficult to achieve adherence to antipsychotic drugs in people with psychoses for several reasons. Many do not accept that they are ill so do not believe that they need treatment. Antipsychotics are associated with serious side effects including diabetes, obesity, and neurological problems, especially if used at higher doses. Although other effective treatments for psychosis—including family interventions, cognitive behavioural therapy, early intervention services, arts therapies, and supported employment—are available,6 evidence suggests that they work best when people also take antipsychotic drugs. Therefore, as well as directly improving outcomes, adherence to drugs may also improve outcomes from other treatments. Although Priebe and colleagues showed that improved adherence is also associated with improvements in quality of life, there is no evidence that it leads to reduced rates of relapse or hospital admission (although the rates of hospital admission in this trial were probably too low to make firm conclusions).5 The efficacy of financial incentives may well be linked to the size and duration of the incentive. A trial of financial incentives to promote smoking cessation in a large company in the United States found significantly better results when rewards were more substantial, with a phased increase of incentives linked to successful smoking cessation.7 Perhaps higher incentives that increase over a longer period could improve clinical outcomes further for people taking depot drugs.
We know that financial incentives can help change the behaviour of people with obesity or drug misuse,8 and that they can
improve adherence to treatment in a range of settings.9 Financial incentives in healthcare are, nevertheless, controversial, and nowhere more so than in mental health. In 2007, the National Institute for Health and Care (formerly Clinical) Excellence in England and Wales published a guideline on psychosocial interventions for drug misuse. In this guideline, most of the key recommendations were for financial (or equivalent) incentives that aimed to promote adherence to methadone maintenance treatment, to encourage abstinence from stimulants, and to improve engagement with physical health interventions.10 Broadly welcomed by professionals working in substance misuse services, this guideline ignited fierce opposition in many newspapers, some of which reacted with moral outrage. This sparked a debate in the BMJ in which Joanne Shaw, then vice chair of the national help line NHS Direct, rejected financial incentives on the grounds that they might undermine informed decision making and the doctor-patient relationship and could lead to fraud. For the “no” camp, incentives are never justified, even among patients who are the most vulnerable.11 Some of the most vulnerable people in mental health services are those with schizophrenia and other psychoses. A growing number in the UK are placed on community treatment orders so that they can be recalled to hospital by law if they do not adhere to treatment. They may also be subject to other sections of the Mental Health Act to compulsorily admit them to hospital and forcibly treat them with antipsychotics when they relapse. Relapse is a common consequence of stopping antipsychotic drugs. Some commentators argue that depriving people of their liberty and physically enforcing adherence when they are ill, but then rejecting the use of financial incentives to encourage adherence to the same treatment to help them stay well, is ethically and morally contradictory.12
Financial incentives are not risk free—they may adversely affect the doctor-patient relationship and internal reward mechanisms.8 More research is needed to explore how to improve adherence through other means. However, when the illness impairs insight, as is common in people with psychoses such as schizophrenia, or leads to an erosion of willpower, as can occur in people who misuse substances, supplementing internal rewards with external incentives deserves serious consideration. The doctor-patient relationship is already subject to financial influences. Doctors
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f5782 doi: 10.1136/bmj.f5782 (Published 22 October 2013)
Page 2 of 2
EDITORIALS
receive incentives from the state (salary, payments for clinical excellence and for meeting quality targets), directly from patients in the private sector, and from healthcare organisations including drug companies. In addition, patients can receive state benefits that are dependent on reports from their doctors. The offer of financial incentives should depend on the severity and chronicity of the illness; its impact on cognition, will, and decision making; and on the particular context of individual patients. Priebe and colleagues have shown that incentives can change the behaviour of people with severe mental health problems and improve adherence to treatment. We now need longer term research to determine if, for this group of disadvantaged and often vulnerable people, carefully used financial incentives can improve long term outcomes and be cost effective. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None. Provenance and peer review: Commissioned; not externally peer reviewed. 1
Nose M, Barbui C, Tansella M. How often do patients with psychosis fail to adhere to treatment programmes? A systematic review. Psychol Med 2003;33:1149-60.
For personal use only: See rights and reprints http://www.bmj.com/permissions
2 3 4 5 6 7 8 9 10 11 12
Robinson DG, Woerner MG, Alvir JMJ, Geisler S, Koreen A, Sheitman B, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999;56:241-7. Novick D, Haro JM, Suarez D, Perez V, Dittmann RW, Haddad PM. Predictors and clinical consequences of non-adherence with antipsychotic medication in the outpatient treatment of schizophrenia. Psychiatry Res 2010;176:109-13. Kemp R, Hayward P, Applewhaite G, Everitt B, David A. Compliance therapy in psychotic patients: a randomised controlled trial. BMJ 1996;312:345-9. Priebe S, Yeeles K, Bremner S, Lauber C, Eldridge S, Ashby D, et al. Effectiveness of financial incentives to improve adherence to antipsychotic maintenance treatment with antipsychotics: cluster randomised controlled trial. BMJ 2013;347:f5847. National Institute for Health and Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. CG82. 2009. http://guidance.nice.org.uk/CG82/NICEGuidance/pdf/English. Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med 2009;360:699-709. Marteau TM, Ashcroft RE, Oliver A. Using financial incentives to achieve healthy behaviour. BMJ 2009;338:b1415. Giuffrida A, Torgerson DJ. Should we pay the patient? Review of financial incentives to enhance patient compliance. BMJ 1997;315:703-7. National Collaborating Centre for Mental Health. Drug misuse: psychosocial interventions. British Psychological Society and Royal College of Psychiatrists, 2007. www.nice.org.uk/ nicemedia/live/11812/35975/35975.pdf. Shaw J. Is it acceptable for people to be paid to adhere to medication? No. BMJ 2007;335:233. Burns T. Is it acceptable for people to be paid to adhere to medication? Yes. BMJ 2007;335:232.
Cite this as: BMJ 2013;347:f5782 © BMJ Publishing Group Ltd 2013
Subscribe: http://www.bmj.com/subscribe
