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Kichler Z, Andermann L, Chow W, Gnanapragasam G, Law S. A Leg to Stand On: Working With Marginal Decision-making Capacity in a Patient With a Severe Leg Infection and Schizophrenia. J Psychiatr Pract 2023; 29:154-159. [PMID: 36928203 DOI: 10.1097/pra.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Assessment of a patient's capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.
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Hodson N, Majid M, Vlaev I, Singh SP. Take patients seriously when they say financial incentives help with adherence. BJPsych Bull 2023; 47:149-152. [PMID: 36796418 DOI: 10.1192/bjb.2022.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Small financial incentives have been proven effective at promoting healthy behaviours across medicine, including in psychiatry. There are a range of philosophical and practical objections to financial incentives. Drawing on the existing literature, specifically attempts to use financial incentives to promote antipsychotic adherence, we propose a 'patient-centred' view of evaluating financial incentive regimes. We argue that there is evidence that mental health patients like financial incentives, considering them fair and respectful. The enthusiasm of mental health patients for financial incentives lends support to their use, although it does not invalidate all objections against them.
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Chang C, Palermo E, Deswert S, Brown A, Nuske HJ. Money can't buy happiness: A randomized controlled trial of a digital mental health app with versus without financial incentives. Digit Health 2023; 9:20552076231170693. [PMID: 37361441 PMCID: PMC10286537 DOI: 10.1177/20552076231170693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 04/03/2023] [Indexed: 06/28/2023] Open
Abstract
Mental health disorders are prevalent among college students and increasing in frequency and severity. However, there is a significant gap between those who need treatment and those who engage in treatment. Given the documented efficacy of financial incentives for promoting health behavior change and engagement in treatment, financial incentives may help, along with nonfinancial behavioral incentives such as motivational messaging, gamification, and loss aversion techniques. We compared brief (28-day) use of two versions of a behavioral economics-inspired digital mental health app, NeuroFlow: (1) the full app including financial incentives and nonfinancial behavioral incentives (treatment group) and (2) a version of the app with nonfinancial behavioral incentives only (control group). In our intent-to-treat analyses, in order to examine the primary outcome of app engagement, a one-way analysis of variance (ANOVA) (treatment vs. control) was conducted, and to examine the secondary outcomes (depression, anxiety, emotion dysregulation, and wellbeing), a two-way repeated measures ANOVAs (treatment vs. control × baseline vs. post-trial) were conducted. We found that there were no differences between treatment groups on app engagement or the change in the mental health/wellness outcome measures. There was a main effect of timepoint on symptoms of anxiety and emotion dysregulation, such that there were significantly lower self-reported symptoms at post-trial relative to baseline. Our results suggest that financial incentives in digital mental health apps over and above nonfinancial behavioral incentives do not have an impact on app engagement or mental health/wellness outcomes.
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Affiliation(s)
- Cheryl Chang
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Emma Palermo
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, Penn Center for Mental Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sky Deswert
- Department of Psychiatry, Penn Center for Mental Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alyssa Brown
- Department of Psychiatry, Penn Center for Mental Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Heather J Nuske
- Department of Psychiatry, Penn Center for Mental Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Guinart D, Sobolev M, Patil B, Walsh M, Kane JM. A Digital Intervention Using Daily Financial Incentives to Increase Medication Adherence in Severe Mental Illness: Single-Arm Longitudinal Pilot Study. JMIR Ment Health 2022; 9:e37184. [PMID: 36222818 PMCID: PMC9607890 DOI: 10.2196/37184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Medication nonadherence is prevalent in severe mental illness and is associated with multiple negative outcomes. Mobile technology and financial incentives show promise to improve medication adherence; however, studies in mental health, especially with oral medications, are lacking. OBJECTIVE The aim of this paper is to assess the feasibility and effectiveness of offering financial incentives through a mobile app based on behavioral economics principles to improve medication adherence in severe mental illness. METHODS A 10-week, single-arm longitudinal pilot study was conducted. Patients earned rewards in the context of app-based adherence incentives. The reward was split into biweekly payments made in increments of US $15, minus any US $2 per day penalties for missed check-ins. Time-varying effect modeling was used to summarize the patients' response during the study. RESULTS A total of 25 patients were enrolled in this pilot study, of which 72% (n=18) were female, and 48% (n=12) were of a White racial background. Median age was 24 (Q1-Q3: 20.5-30) years. Participants were more frequently diagnosed with schizophrenia and related disorders (n=9, 36%), followed by major depressive disorder (n=8, 32%). App engagement and medication adherence in the first 2 weeks were higher than in the last 8 weeks of the study. At study endpoint, app engagement remained high (n=24, Z=-3.17; P<.001), but medication adherence was not different from baseline (n=24, Z=-0.59; P=.28). CONCLUSIONS Financial incentives were effectively delivered using an app and led to high engagement throughout the study and a significantly increased medication adherence for 2 weeks. Leveraging behavioral economics and mobile health technology can increase medication adherence in the short term. TRIAL REGISTRATION ClinicalTrials.gov NCT04191876; https://clinicaltrials.gov/ct2/show/NCT04191876.
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Affiliation(s)
- Daniel Guinart
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, United States.,Institute of Behavioral Science, The Feinstein Institutes for Medical Reseach, Manhasset, NY, United States.,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.,Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, Barcelona, Spain
| | - Michael Sobolev
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, United States.,Cornell Tech, Cornell University, New York, NY, United States
| | - Bhagyashree Patil
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, United States
| | - Megan Walsh
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, United States
| | - John M Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, United States.,Institute of Behavioral Science, The Feinstein Institutes for Medical Reseach, Manhasset, NY, United States
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Khazanov GK, Forster SE, DePhilippis D, McKay JR. Increasing the Impact of Interventions Incentivizing Psychiatric Treatment Engagement: Challenges and Opportunities. Psychiatr Serv 2022; 73:580-583. [PMID: 34496628 PMCID: PMC9716479 DOI: 10.1176/appi.ps.202100100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Individuals with psychiatric disorders often struggle to initiate and engage in treatment. Financial incentives improve treatment engagement, including treatment attendance, medication adherence, and abstinence from substance use. The U.S. Department of Veterans Affairs (VA) recently made the first large-scale, successful effort to implement incentive-based interventions in substance use disorder treatment. Health care systems, including the VA, can increase the impact of these interventions by extending them to target a range of psychiatric disorders, adapting them for specific clinical contexts, using insights from behavioral economics, and partnering with corporations to fund incentives and implement interventions.
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Affiliation(s)
- Gabriela K Khazanov
- Veterans Integrated Service Network 4 (VISN 4) Mental Illness Research, Education, and Clinical Center (MIRECC) (Khazanov) and Center of Excellence in Substance Addiction Treatment and Education (DePhilippis, McKay), Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia; VISN 4 MIRECC, VA Pittsburgh Healthcare System, Pittsburgh (Forster); Department of Psychiatry, University of Pennsylvania, Philadelphia (McKay)
| | - Sarah E Forster
- Veterans Integrated Service Network 4 (VISN 4) Mental Illness Research, Education, and Clinical Center (MIRECC) (Khazanov) and Center of Excellence in Substance Addiction Treatment and Education (DePhilippis, McKay), Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia; VISN 4 MIRECC, VA Pittsburgh Healthcare System, Pittsburgh (Forster); Department of Psychiatry, University of Pennsylvania, Philadelphia (McKay)
| | - Dominick DePhilippis
- Veterans Integrated Service Network 4 (VISN 4) Mental Illness Research, Education, and Clinical Center (MIRECC) (Khazanov) and Center of Excellence in Substance Addiction Treatment and Education (DePhilippis, McKay), Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia; VISN 4 MIRECC, VA Pittsburgh Healthcare System, Pittsburgh (Forster); Department of Psychiatry, University of Pennsylvania, Philadelphia (McKay)
| | - James R McKay
- Veterans Integrated Service Network 4 (VISN 4) Mental Illness Research, Education, and Clinical Center (MIRECC) (Khazanov) and Center of Excellence in Substance Addiction Treatment and Education (DePhilippis, McKay), Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia; VISN 4 MIRECC, VA Pittsburgh Healthcare System, Pittsburgh (Forster); Department of Psychiatry, University of Pennsylvania, Philadelphia (McKay)
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Khazanov GK, Forbes CN, Dunn BD, Thase ME. Addressing anhedonia to increase depression treatment engagement. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2021; 61:255-280. [PMID: 34625993 DOI: 10.1111/bjc.12335] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/30/2021] [Indexed: 12/14/2022]
Abstract
Anhedonia, or reward system dysfunction, is associated with poorer treatment outcomes among depressed individuals. The role of anhedonia in treatment engagement, however, has not yet been explored. We review research on components of reward functioning impaired in depression, including effort valuation, reward anticipation, initial responsiveness, reward learning, reward probability, and reward delay, highlighting potential barriers to treatment engagement associated with these components. We then propose interventions to improve treatment initiation and continuation by addressing deficits in each component of reward functioning, focusing on modifications of existing evidence-based interventions to meet the needs of individuals with heightened anhedonia. We describe potential settings for these interventions and times at which they can be delivered during the process of referring individuals to mental health treatment, conducting intakes or assessments, and providing treatment. Additionally, we note the advantages of using screening processes already in place in primary care, workplace, school, and online settings to identify individuals with heightened anhedonia who may benefit from these interventions. We conclude with suggestions for future research on the impact of anhedonia on treatment engagement and the efficacy of interventions to address it. PRACTITIONER POINTS: Many depressed individuals who might benefit from treatment do not initiate it or discontinue early. One barrier to treatment engagement may be anhedonia, a core symptom of depression characterized by loss of interest or pleasure in usual activities. We describe brief interventions to improve treatment engagement in individuals with anhedonia that can be implemented during the referral process or early in treatment. We argue that interventions aiming to improve treatment engagement in depressed individuals that target anhedonia may be particularly effective.
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Affiliation(s)
- Gabriela K Khazanov
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | | | | | - Michael E Thase
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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Beidas RS, Buttenheim AM, Mandell DS. Transforming Mental Health Care Delivery Through Implementation Science and Behavioral Economics. JAMA Psychiatry 2021; 78:941-942. [PMID: 34076686 PMCID: PMC8744069 DOI: 10.1001/jamapsychiatry.2021.1120] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Psychiatric disorders account for more years lived with disability globally than any other disease category. Currently, effective mental health treatments are variably deployed in community practice and patient outcomes are less robust than clinical trials. A major frontier in psychiatry is to develop strategies that increase the use of evidence-based assessment, prevention, and intervention approaches, galvanizing the new field of implementation science. In this Viewpoint, we argue that we must bring concepts from behavioral economics to implementation science to accelerate the reach and impact of psychiatric treatments.
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Affiliation(s)
- Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3015, Philadelphia, PA 19104,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA,Corresponding author,
| | - Alison M. Buttenheim
- University of Pennsylvania School of Nursing, 416 Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104
| | - David S. Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3015, Philadelphia, PA 19104
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