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PSYCHIATRIC SERVICES ♦ps.psychiatryonline.org ♦March 2008 Vol. 59 No. 3
331100
Objective: This study assessed the
feasibility of voucher-based in-
centives for attendance for di-
rectly observed naltrexone treat-
ment in a controlled trial for al-
cohol use disorders in schizo-
phrenia. Methods: Cash-value
voucher-based incentives were
contingent on attendance at three
research visits per week over 12
weeks for 61 participants. Vouch-
ers increased in value based on
consecutive attendance. Missed
visits resulted in reduction of
voucher value. Results: Partici-
pants attended 82% of all re-
search visits. Average value of
vouchers earned was $330 (78%
of the maximum possible). Psy-
chotic symptom severity at base-
line did not affect the utilization
of vouchers, and 94% of partici-
pants perceived the incentive sys-
tem as helpful. Conclusions: The
incentive system was well accept-
ed and used despite psychosis
severity, and the attendance rate
was high, although causality be-
tween incentives and attendance
could not be examined. A vouch-
er-based incentive system for at-
tendance can be successfully ap-
plied in a clinical trial for alcohol
dependence treatment in schizo-
phrenia. (Psychiatric Services 59:
310–314, 2008)
Comorbid alcohol use disorders
are known to have significant
adverse effects on the course of
schizophrenia and are associated
with worsening of psychiatric symp-
toms and increased risk of rehospi-
talization (1). Naltrexone is an effec-
tive pharmacotherapy for alcohol
dependence, and several studies
have found that it can reduce alco-
hol use by patients with schizophre-
nia (2,3). Adherence is essential to
naltrexone’s effectiveness; recent
studies have shown significant dif-
ferences in outcomes between nal-
trexone and placebo among only pa-
tients who demonstrated adherence
to more than 80% of possible nal-
trexone doses (4).
Poor adherence to medication is
well documented for patients with
schizophrenia, and among the pa-
tients with this disorder, substance
abuse and dependence are strongly
associated with nonadherence (5).
Patients with serious mental illness
also have poor treatment attendance
and high dropout rates in clinical re-
search trials. Recent meta-analyses
have shown pooled dropout rates
that ranged from 28% to 55% (6). Pa-
tients with schizophrenia also have
poor attendance at outpatient visits,
particularly if they have co-occurring
substance use disorders (7).
Adherence to naltrexone or other
medications could be improved by
ensuring attendance at scheduled
visits. Attendance is particularly cru-
cial for directly observed treatment
interventions, because patients must
be present in order to receive med-
ication. In clinical trials, attendance
is essential for pharmacotherapy, psy-
chotherapy, and administration of re-
search measures. The use of incen-
tives is one possible method to in-
crease attendance and thereby facili-
tate treatment adherence. This ap-
proach has its roots in the token-
economy social learning studies of
the past several decades (8). More
recently, voucher-based incentives
have been shown to be effective in
the treatment of substance use disor-
ders (9). Silverman and colleagues
(10) have shown that abstinence is in-
creased by an incentive system with
escalating rates of reimbursement
based on consecutive drug-free urine
tests.
Only a few studies have extended
the use of incentives in substance
abuse treatment to patients with co-
morbid severe mental illness (3,11–
13). For example, Petrakis and col-
leagues (3) studied a sample of 31 pa-
Voucher-Based Incentives for Naltrexone
Treatment Attendance in Schizophrenia
and Alcohol Use Disorders
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JJaaccqquueelliinnee AA.. DDiimmmmoocckk,, PPhh..DD..
PPaauull WW.. GGaatteellyy,, BB..AA..
LLiissaa GGaalllliinnggeerr
RRoobbeerrtt PPlloouuttzz--SSnnyyddeerr,, PPhh..DD..
SStteevveenn LL.. BBaattkkii,, MM..DD..
Dr. Leontieva, Dr. Dimmock, Mr. Gately,
and Ms. Gallinger are affiliated with the
Department of Psychiatry, State Universi-
ty of New York Upstate Medical Universi-
ty, 750 East Adams St., Syracuse, NY
13210 (e-mail: leontiel@upstate.edu). Dr.
Ploutz-Snyder is also with the university,
at the Center for Outcomes Research and
Evaluation. Dr. Batki is with the Depart-
ment of Psychiatry, University of Califor-
nia, San Francisco, and the San Francisco
Veterans Affairs Medical Center.
BBrriieeff RReeppoorrttss
tients with schizophrenia or schizoaf-
fective disorder and provided incen-
tives in the form of cash reimburse-
ment at a fixed rate of $10 per each
weekly research visit. They achieved
81% retention in a 12-week trial of
naltrexone. Strong Kinnaman and
colleagues (13) used contingent, es-
calating, low-cost, voucher-based in-
centives to reinforce drug-negative
urine tests as a part of the behavioral
treatment of substance use among 59
patients with comorbid serious men-
tal illness, of whom 34% had schizo-
phrenia or schizoaffective disorder.
Although they found that severity of
psychiatric symptoms did not appear
to impair the ability of participants to
utilize incentives, a diagnosis of
schizophrenia was associated with
lower incentive earnings.
To our knowledge, there are no re-
ports of studies using contingent
voucher-based incentives to increase
treatment attendance of patients
with schizophrenia and substance
use disorders. Given that incentive
programs may be useful in research
or clinical treatment settings that re-
quire frequent visits, we report the
application of a voucher-based incen-
tive system for ensuring attendance
by patients with alcohol use disorders
and schizophrenia. We assessed the
effect of psychosis severity and other
variables on utilization of incentives.
Methods
This study analyzed data from the
first 61 participants who entered a
controlled clinical trial funded by the
National Institute on Alcohol Abuse
and Alcoholism, which involved di-
rectly observed treatment with oral
naltrexone or placebo for alcohol use
disorders co-occurring with schizo-
phrenia (14). The target number for
the parent trial is an eventual 90 par-
ticipants; the study is projected to be
completed by June 2008. The goal of
the parent study is to assess the ef-
fectiveness of directly observed nal-
trexone treatment. The incentive sys-
tem was used to recruit and retain
participants. All participants received
incentives for attendance, and there
was no control group because the
parent study was not designed to
evaluate the efficacy of incentives.
This report provides a description
of the voucher-based incentive sys-
tem and its feasibility for use with pa-
tients with schizophrenia or schizoaf-
fective disorder and an alcohol use
disorder. Participants were recruited
from community mental health clin-
ics in Syracuse, New York, and pro-
vided written informed consent ap-
proved by the State University of
New York Upstate Medical Universi-
ty Institutional Review Board. Data
were collected from November 2003
to August 2006. All participants were
confirmed to be in routine outpatient
clinical treatment; all were con-
firmed to be prescribed antipsychot-
ic medications by their clinical treat-
ment providers. The baseline demo-
graphic characteristics of participants
are outlined in Table 1. [A table list-
ing participants’ baseline clinical
characteristics is provided in an on-
line supplement to this brief report at
ps.psychiatryonline.org.] Overall, the
sample was primarily male, single,
Caucasian, and unemployed, and
they earned a low income (most pa-
tients received disability payments).
Participants were asked to attend
three visits per week for directly ob-
served treatment with oral naltrex-
one or placebo over 12 weeks. All re-
ceived weekly motivational counsel-
ing sessions and were seen in re-
search offices located at their respec-
tive outpatient clinical sites. If need-
ed, participants were provided assis-
tance with transportation (with bus
tokens, bus passes, or taxi service).
A monetary-value, voucher-based
incentive system was implemented to
maximize attendance and to reim-
burse participants for their time.
Vouchers were dispensed on comple-
tion of each study visit and could be
exchanged for goods or services at
any time. At each visit, participants
could choose to either use (“spend”)
the vouchers, by asking to exchange
them for items, or save them for fu-
ture use. The voucher-based incen-
tive system was modeled on the work
of Silverman and colleagues (10),
wherein cash-value vouchers in-
PSYCHIATRIC SERVICES ♦ps.psychiatryonline.org ♦March 2008 Vol. 59 No. 3 331111
TTaabbllee 11
Sociodemographic characteristics of 61 study participants with schizophrenia or
schizoaffective disorder and a co-occurring alcohol use disorder
Characteristic N %
Gender
Male 47 77
Female 14 23
Race
Caucasian 27 44
African American 22 36
Other 12 20
Ethnicity
Non-Hispanic 57 93
Hispanic 4 7
Married 5 8
Living independently 41 67
Income source
Disability benefits 44 72
Public assistance or welfare 10 16
Other 4 7
Employment 3 5
Employed 6 10
Payee manages participant’s money 24 39
Age (M±SD) 42±9
Education (M±SD years) 12±2
Monthly income
M±SD $736±$341
Median $666
Interquartile range $587–$912
Money under participant’s control
M±SD $489±$357
Median $482
Interquartile range $180–$690
creased in value with each visit at-
tended and were reset to a lower val-
ue after a missed visit.
In this study, vouchers began at $5
per visit and increased in increments
of $1 for each consecutively attend-
ed visit until a maximum of $10 per
visit was reached. This maximum
level was maintained unless the par-
ticipant missed an appointment. In
the event of an unexcused missed
visit, the voucher value for the next
visit was reset to $5. Participants
could earn a maximum of $425 in
vouchers during the 12-week treat-
ment phase. As in the Silverman
team’s design, this schedule was
meant not only to increase the ab-
solute number of attended visits but
also to reinforce the consistency of
attendance. On the basis of our prior
work (2), a wide range of items—
such as gift certificates to grocery
stores and restaurants, bus tokens,
and portable CD players—were of-
fered in an effort to provide specific
rewards that had high salience to
participants. [An appendix describ-
ing the voucher-based incentive sys-
tem in more detail is provided in an
online supplement to this brief re-
port at ps.psychiatryonline.org.]
The following measures were ad-
ministered at baseline: Positive and
Negative Syndrome Scale (PANSS),
Calgary Depression Scale for Schizo-
phrenia (CDSS), Addiction Severity
Index (ASI), and Time Line Follow
Back (TLFB). At the end of treat-
ment, participants completed an
end-of-study form that included a
question about the helpfulness of the
voucher incentive system (the 5-
point Likert scale of responses
ranged from not helpful at all to very
helpful).
On the basis of their attendance at
the three-times-per-week study vis-
its, participants were classified as ei-
ther consistent attendees, who at-
tended 80% or more of visits, or in-
consistent attendees, who attended
less than 80%. This dichotomy was
based on previous studies of naltrex-
one treatment in which adherence to
naltrexone was defined by whether
80% of doses were taken (4). To cal-
culate attendance percentage, the to-
tal number of completed study visits
was divided by the total number of
possible visits minus the number of
visits missed as a result of circum-
stances beyond the participant’s con-
trol (because of hospitalization, for
example). Voucher spending was as-
sessed by the percentage of visits at
which participants spent some or all
portions of their earned incentives.
Sociodemographic data, psychiatric
status (measured by the PANSS and
CDSS), and alcohol severity (meas-
ured by the ASI and TLFB) were
also measured at baseline.
We used Spearman’s rho correla-
tions to assess the relationships be-
tween spending rates and other con-
tinuous variables (PANNS, CDSS,
and TLFB results). We compared
spending rates by using categorical
variables and Student’s t test or one-
way analysis of variance. We com-
pared continuous outcomes by atten-
dance categories (consistent atten-
dance or inconsistent attendance) us-
ing Student’s t test. Data were ana-
lyzed with SPSS (version 14.1) for
Windows.
Results
Of a possible 38 total research visits
(with visits missed for hospitalization
or incarceration factored out), mean±
SD attendance was 31±10 visits
(82%). Of the 61 participants, 47
(77%) were consistent attendees,
present at 80% or more visits, and 14
(23%) were inconsistent attendees.
Consistent attendees made 96%±5%
of the visits; inconsistent attendees
made 49%±28% of the visits.
The total amount of incentives
earned by 61 participants over the
course of 12 weeks was $20,144. The
amount of incentives earned by each
participant was $330±$123 (78% of
the maximum possible), with a medi-
an of $386 (interquartile range
$274–$425, which was 91% of the
maximum possible). The participants
spent incentives at 42%±22% of their
visits. The descriptions and frequen-
PSYCHIATRIC SERVICES ♦ps.psychiatryonline.org ♦March 2008 Vol. 59 No. 3
331122
TTaabbllee 22
Description, quantity, cost, and frequency of incentives purchased by 61 patients with schizophrenia or schizoaffective
disorder and a co-occurring alcohol use disorder
Purchases Participants who
(N=1,599) Cost made purchases
Category and items N % Total ($)a%N%
Fast-food restaurant gift certificates 718 45 3,845 18 49 80
Groceries (certificates or items) 469 29 3,611 17 34 56
Electronicsb73 5 4,158 20 32 52
Shopping mall or retailer gift certificates 66 4 4,659 22 24 39
Transportation vouchers 162 10 1,492 7 24 39
Clothing 61 4 1,419 7 18 30
Entertainment (CDs, books, and movie
tickets) 19 1 340 2 9 15
Bill payments (for utilities or credit cards) 19 1 1,282 6 8 13
Household items 9 .6 297 1 7 11
Health items 3 .2 149 .7 2 3
aThe grand total of $21,252 is slightly higher than the total amount of incentives earned ($20,144) because some participants saved points earned in
screening visits to purchase items during the study.
bTelevisions, portable players, radios, DVD players or VCRs, and gift certificates to electronics stores
cies of incentives purchased as well
as their quantities and cost are dis-
played in Table 2. The incentives
purchased most frequently were
restaurant gift certificates, followed
by groceries and electronics items.
Spending was inversely correlated
with participants’ income (ρ=–.33,
p<.02) and the amount of funds un-
der participants’ direct control (ρ=
–.36, p<.005). The participants with
a payee who managed their money
were expected to have less direct
control over their funds and were
found to spend significantly more
frequently than participants without
a payee (at 58% of visits versus 28%,
p<.001).
Our t-test comparisons of consis-
tent attendees with inconsistent at-
tendees in regard to demographic
characteristics (age, gender, race,
ethnicity, years of education, marital
and employment status, living situa-
tion, income source, monthly in-
come and amount under control, and
payee status) and clinical character-
istics (measured by the PANSS,
CDSS, ASI, and TLFB) revealed no
significant differences between
groups. Consistent attendees also
were not significantly different from
inconsistent attendees in spending
frequencies.
Utilization of vouchers as meas-
ured by spending rates did not signif-
icantly vary by severity of psychotic
symptoms or depressive symptoms.
Of 53 respondents 94% perceived
the incentive system as very helpful
or helpful (very helpful, 37 partici-
pants, or 70%; helpful, 13 partici-
pants, or 25%). Only three partici-
pants (6%) indicated that their per-
ception of incentives was neutral.
Discussion
Voucher-based incentives that esca-
late in value to ensure attendance at
research visits for directly observed
alcohol pharmacotherapy are feasible
to use and are acceptable for patients
with schizophrenia spectrum disor-
ders. Although Medicaid and other
insurance programs do not cover the
cost of incentives, other potential
funding sources may include com-
munity-based agencies, local busi-
nesses, or government grants.
The incentive system used in this
study was established to maximize at-
tendance and was tailored to individ-
ual study participants. More than
three-quarters of participants were
consistent attendees, attending more
than 80% of visits. This result is par-
ticularly impressive in that the de-
mands placed on participants were
high, with a requirement to attend
three times per week for 12 weeks.
Although these high attendance rates
were attained in the presence of in-
centives, we cannot draw conclusions
regarding causality because there was
no control group and all participants
received incentives. Nearly three-
fourths of participants chose to save
their vouchers rather than immedi-
ately spending them at each visit.
These participants chose to purchase
higher-cost items rather than imme-
diately buying a lower-priced item.
Voucher utilization was not related
to severity of psychotic or other
symptoms, indicating that patients
with schizophrenia spectrum disor-
ders may be cognitively organized
enough to plan ahead and save
vouchers for larger purchases. Par-
ticipants preferred food items over
other incentives, which may be un-
derstandable given that most partici-
pants had low income and nearly
90% were receiving disability in-
come or public assistance. It may be
useful for researchers and clinicians
designing future incentive-based
programs to tailor potential incen-
tives to participants’ sociodemo-
graphic characteristics.
Patterns of spending appeared to
have no significant relationship to de-
mographic characteristics or severity
of psychiatric symptoms, a finding
that supports similar conclusions re-
garding the use of incentives by
Strong Kinnaman and colleagues
(13). Our data provide evidence that
such an incentive system is feasible
and applicable to a diverse popula-
tion with a wide range of demograph-
ic characteristics, psychopathology,
and severity of alcohol use disorder
symptoms.
Economic variables, such as in-
come and the amount of funds under
the participant’s control, affected the
rate of spending versus saving of
vouchers. Participants with more
money available to them under their
direct control may have been able to
better “afford” to save more in com-
parison with those with less money
available for their immediate needs.
Conclusions
It is feasible to apply an escalating
system of voucher-based incentives
to reinforce attendance for directly
observed medication of participants
with schizophrenia and alcohol use
disorders. Participants had high at-
tendance rates, were able to save in-
centives for future larger purchases,
and found the incentives helpful.
The incentive system described here
may be applicable to research and
clinical programs, particularly those
that require frequent attendance for
directly observed treatment or other
intensive interventions. A limitation
of the incentive system reported here
is that it is time-consuming and la-
bor-intensive to implement.
Although broad application of the
incentive system to clinical practice
with patients with co-occurring dis-
orders may be problematic because
of cost, the methodology can be mod-
ified to fit the needs of different clin-
ical settings. Less expensive ap-
proaches have been developed, using
intermittent reinforcement, for ex-
ample, by giving patients a chance to
draw from a jar to win prizes that are
of modest cost (15). Future con-
trolled studies are needed to meas-
ure the efficacy of voucher-based in-
centive systems in improving the
treatment of patients with schizo-
phrenia or schizoaffective disorder
and substance use disorders.
Acknowledgments and disclosures
This work was made possible by grant R01-
AA-013655 from the National Institute on Al-
cohol Abuse and Alcoholism. The authors
greatly appreciate the assistance of Michelle
Cavallerano, B.A., Sara DeRycke, B.S., and
Katherine Strutynski, B.A., in implementing
this research project. The authors also thank
the patients and staff of Hutchings Psychiatric
Center, Syracuse VA Medical Center, and St.
Joseph’s Mental Health for their assistance
with the project.
The authors report no competing interests.
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SSuubbmmiissssiioonnss ffoorr DDaattaappooiinnttss CCoolluummnn IInnvviitteedd
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