title: Financial incentives for improving adherence to maintenance treatment in patients with psychotic disorders (Money for Medication): a multicentre, open-label, randomised controlled trial.
abstract: Provision of financial incentives is a promising intervention for improving adherence in patients taking antipsychotic medication. We aimed to assess the effectiveness of this intervention for improving adherence to antipsychotic depot medication in patients with psychotic disorders, irrespective of their previous compliance.
  
  
  
  We did this multicentre, open-label, randomised controlled trial at three mental health-care institutions in secondary psychiatric care services in the Netherlands. Eligible patients were aged 18-65 years, had been diagnosed with schizophrenia or another psychotic disorder, had been prescribed antipsychotic depot medication or had an indication to start using depot medication, and were participating in outpatient treatment. Patients were randomly assigned (1:1), via computer-generated randomisation with a block size of four, to receive 12 months of either treatment as usual plus a financial reward for each depot of medication received (€30 per month if fully compliant; intervention group) or treatment as usual alone (control group). Randomisation was stratified by treatment site and suspected prognostic factors: sex, comorbid substance-use disorder (absent vs present), and compliance with antipsychotic medication in the 4 months before baseline (<50% vs ≥50%). Patients, clinicians, interviewers, and research assistants were masked to group allocation before, but not after, group assignment. The primary outcome was the Medication Possession Ratio (MPR), defined as the number of depots of antipsychotic medication received divided by the total number of depots of antipsychotic medication prescribed during the 12 month intervention period. Patients were followed up for 6 months, during which time no monetary rewards were offered for taking antipsychotic medication. We did analysis by intention to treat. This trial is registered with the Nederlands Trial Register, number NTR2350.
  
  
  
  Between May 21, 2010, and Oct 15, 2014, we randomly assigned 169 patients to the intervention group (n=84) or the control group (n=85). Primary outcome data were available for 155 (92%) patients. At baseline, the mean MPR was 76·0% (SD 28·2%) in the intervention group versus 77·9% (28·5%) in the control group. At 12 months, the mean MPR was higher in the intervention group (94·3% [SD 11·3%]) than in the control group (80·3% [19·1%]), with an adjusted difference of 14·9% (95% CI 8·9-20·9%; p<0·0001). This difference was maintained throughout the 6 month follow-up period: mean MPR of 86·6% (SD 22·2%) in the intervention group versus 76·0% (22·7%) in the control group (adjusted difference 6·5%, 95% CI 2·0-10·9; p=0·047).
  
  
  
  Financial incentives are an effective way of improving adherence to antipsychotic depot medication among patients with psychotic disorders. Further research is needed to study the long-term effects of this intervention.
  
  
  
  Dual Diagnosis Center.
authors.affiliation: Dual Diagnosis Center (CDP) Palier, Parnassia Psychiatric Institute, The Hague, Netherlands; Department of Psychiatry, Epidemiological and Social Psychiatric Research institute, Erasmus University Medical Center, Rotterdam, the Netherlands. Electronic address: e.noordraven@erasmusmc.nl.
authors.forename: Ernst L
authors.initials: EL
authors.lastname: Noordraven
authors.affiliation: Department of Psychiatry, Epidemiological and Social Psychiatric Research institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: André I
authors.initials: AI
authors.lastname: Wierdsma
authors.affiliation: Parnassia Addiction Research Centre (PARC), Brijder Addiction Treatment, Parnassia Psychiatric Institute, The Hague, Netherlands.
authors.forename: Peter
authors.initials: P
authors.lastname: Blanken
authors.affiliation: Dual Diagnosis Center (CDP) Palier, Parnassia Psychiatric Institute, The Hague, Netherlands.
authors.forename: Anthony F T
authors.initials: AF
authors.lastname: Bloemendaal
authors.affiliation: Altrecht, Department for young adults with Psychosis and Early Detection, Utrecht, Netherlands.
authors.forename: Anton B P
authors.initials: AB
authors.lastname: Staring
authors.affiliation: Department of Psychiatry, Epidemiological and Social Psychiatric Research institute, Erasmus University Medical Center, Rotterdam, the Netherlands; Bavo-Europoort Mental Health Care, Rotterdam, Netherlands.
authors.forename: Cornelis L
authors.initials: CL
authors.lastname: Mulder
mesh_terms: D000328:Adult; D014150:Antipsychotic Agents / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D009042:Motivation; D009426:Netherlands / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D011618:Psychotic Disorders / Q000188:drug therapy / Q000191:economics* / Q000523:psychology; D012559:Schizophrenia / Q000188:drug therapy / Q000191:economics*; D016903:Drug Monitoring
chemical_list: D014150:Antipsychotic Agents