Increasing the Impact of Interventions Incentivizing Psychiatric Treatment Engagement: Challenges and Opportunities

Poor treatment engagement is a substantial barrier to improving mental health outcomes. Individuals pursuing psychiatric treatment often do not attend their initial appointments or discontinue treatment early, resulting in little improvement in symptoms. Only one-third of individuals with psychiatric disorders receive minimally adequate treatment, and engagement is lower for psychiatric services than for other medical services (1, 2).

Financial Incentives to Increase Engagement in Psychiatric Treatment

Financial incentives have been shown to increase several components of psychiatric treatment engagement, including the target behavior itself (e.g., abstinence from substance use, adherence to psychiatric medications) and engagement with mechanisms that lead to behavior change (e.g., treatment attendance and completion of treatment goals) (3). Most research on incentive-based programs has focused on the effectiveness of providing financial incentives for abstinence among individuals with substance use disorders, an intervention called contingency management. Many studies have also incentivized health behaviors, such as exercising, losing weight, and controlling chronic conditions (e.g., HIV). Overall, these interventions result in medium effect sizes and are cost effective in the long term (3–5). Additionally, certain intervention characteristics increase the effectiveness of these programs (e.g., providing greater incentives and delivering them immediately after the behavior is completed) (3). Recently, studies have found that incentives can increase psychiatric treatment engagement more broadly, including outcomes such as treatment attendance, medication adherence, and completion of homework or other treatment goals. Although these studies have been conducted largely among individuals experiencing substance use disorders, emerging evidence shows that incentives can also improve treatment engagement among individuals with other psychiatric conditions (6–8).

The U.S. Department of Veterans Affairs (VA) Initiative as a Model for Implementation

Evidence that providing financial incentives for abstinence is highly effective prompted the VA to initiate a nationwide effort in 2011 to increase access to contingency management (9). This effort is the largest-scale initiative by a health care system to implement an incentive program supporting abstinence or other forms of psychiatric treatment engagement. By 2018, 126 VA medical centers had implemented contingency management for veterans with substance use disorders, with clinical outcomes comparable to those from studies conducted in community clinics (9, 10). The success of this initiative can be attributed to various factors, some of which we review below (9, 10).

First, program costs are reduced through the use of a probability-based prize system that distributes coupons provided by the Veterans Canteen Service, a business within the VA. Second, the VA provided support for initial training and continues to support ongoing implementation, including input from subject matter experts who encourage providers to implement programs that use evidence-based strategies. Third, providers and administrators are motivated to participate in contingency management through social and organizational incentives. Monthly e-mails with program success stories and buy-in from team leaders offer social incentives for provider participation. Additionally, disbursal of coupons to medical centers is contingent on their exclusive use for contingency management and provider participation in coaching designed to ensure treatment fidelity. Finally, medical centers receive hospital system performance credit for offering this treatment.

Increasing the Impact of Incentive-based Interventions

The VA’s implementation of contingency management has been nationally successful in reaching patients and producing outcomes comparable to those of clinical trials of this treatment. Although other health care systems have not yet systematically implemented financial incentives for psychiatric treatment engagement, comparable incentive programs have been implemented to encourage general medical health (e.g., employee wellness programs) and to reimburse providers on the basis of performance (e.g., pay-for-performance programs) (11). Renewed efforts to implement evidence-based, patient-centered treatments for psychiatric disorders, along with a growing body of research highlighting the efficacy and acceptability of incentive-based interventions, suggest that other health care systems should consider implementing these programs. Both the VA and other health care systems hoping to benefit from incentive-based interventions can increase their impact in four key ways.

Extending interventions to target a range of psychiatric disorders.

Several recent studies (6–8, 12) have demonstrated that incentives can improve outcomes among individuals with psychiatric disorders aside from substance use, including improved medication adherence and psychotherapy attendance among those with depression, anxiety, or psychosis, as well as reductions in hoarding behavior. Other studies (13) have incentivized completion of homework or treatment-consistent goals among patients with substance use disorders by using methods that could easily be applied to other psychiatric disorders.

Although studies have consistently found that incentives increase occurrence of the targeted behavior (e.g., attendance), additional research is needed to determine the extent to which incentivizing treatment participation (e.g., attendance or completion of treatment goals) versus treatment outcomes (e.g., abstinence or medication adherence) leads to improved outcomes. Research is also needed to establish operational definitions of new target behaviors (e.g., level of homework completion in cognitive-behavioral therapy for depression) and acceptable and feasible methods of monitoring these behaviors. There is great potential for incentive-based interventions to improve treatment engagement across psychiatric disorders; however, research and implementation efforts must be extended to target treatments for disorders besides substance use.

Adapting interventions for new clinical contexts.

Incentive-based interventions can be adapted for new clinical contexts through the use of hybrid effectiveness-implementation clinical trials, which test intervention effectiveness and implementation processes (e.g., type of training required for providers) simultaneously. These designs are particularly appropriate for adapting evidence-based interventions to specific clinical contexts, because they shorten the research-to-practice pipeline, increase stakeholder buy-in, and illuminate the relationship between effectiveness and implementation outcomes (14). Other methods, such as rapid-cycle approaches that allow for intervention refinement through rapid, iterative testing, can also accelerate the adaptation of incentive-based interventions to new clinical contexts (15).

Using insights from behavioral economics.

Just as methods from implementation science can inform study design, insights from behavioral economics can improve the efficacy and reach of incentive-based interventions. Although findings from behavioral economics are beginning to inform the design of studies testing incentive-based interventions for outcomes such as weight loss (16), they have rarely been incorporated into studies targeting engagement in psychiatric treatment. These insights can enhance the impact of incentive-based interventions by shaping how interventions are presented to participants (e.g., framing incentives as money to be lost versus gained), how funds are distributed (e.g., the size, frequency, and timing of incentives), how providers are motivated to implement interventions (e.g., incentives or buy-in resulting from training), and the nature of the incentives (e.g., financial versus social support). In the future, principles of behavioral economics may also provide a framework for adapting incentive-based interventions to the unique needs of specific individuals and contexts.

Partnering with corporations.

The VA’s incentive program has expanded across the country in large part because of the support of the Veterans Canteen Service, although VA clinical funds are also used for training and incentives. Because incentive programs are limited by health care systems’ financial constraints and by poor reimbursement for behavioral health interventions, wider implementation of these programs would benefit from partnerships with corporations that can fund incentives directly (with items or gift cards) or indirectly (by providing financial support). These partnerships would benefit health care systems by decreasing implementation costs and would benefit corporations by connecting them with members of their communities and allowing their philanthropic contributions to have a direct impact on patient care. Additionally, just as corporations act in their best interests by sponsoring incentive-based wellness programs for employees to improve their medical health, they could extend these programs to promote employee mental health by incentivizing outcomes such as psychiatric treatment attendance or goal completion. Importantly, such programs would need to prioritize employee privacy and autonomy to ensure that they do not have stigmatizing or punitive effects. Finally, although studies have demonstrated the cost-effectiveness of incentive-based interventions, additional evidence from health care and employment settings would further encourage implementation of these interventions.

Implementation Challenges

Certain features of incentive-based interventions present challenges to implementation that can be addressed with additional research, training, or advocacy. First, because the effects of incentives on behaviors tend to diminish once incentives are withdrawn, research is needed to determine ways to maintain treatment gains over time. Second, providers and administrators may hesitate to buy in to incentive-based interventions because of concern that they are coercive or will change the patient-provider relationship. These concerns can be addressed by adapting intervention features (e.g., not having the patient’s main provider deliver incentives), training providers and allowing them to observe the intervention’s effectiveness, and motivating providers to implement these interventions through social or organizational incentives, as described above. Third, although concerns about the widespread abuse of financial incentives are not supported by research (17), they can lead to policies that limit the effectiveness of incentive-based interventions. For example, recent policy changes by the U.S. Department of Health and Human Services may constrain the amount of financial incentives that federally funded treatment providers can offer patients (18). This policy, together with research showing that low reward amounts are typically ineffective (19), present a significant barrier to implementation. Those advocating for the removal of this policy have noted that any potential for abuse can be reduced by providing gift cards for specific items or stores or smart debit cards that prohibit cash withdrawals and high-risk purchases (e.g., liquor).

Conclusions

In sum, the VA is an example of a health care system that has successfully implemented a financial incentive program aimed at improving psychiatric treatment engagement. This success can be attributed in part to the attention paid to motivating providers to implement these programs, support for training and implementation, and partnership with a business that helps provide sustained funding for incentives. Health care systems, including the VA, interested in implementing these interventions can increase their impact in the four key ways described. Although implementation challenges remain, they can be addressed through research, training, and advocacy.