Incentive Payments for Attendance at Appointments for Depression Among Low-Income African Americans Edward P. Post, M.D., Ph.D. Mario Cruz, M.D. Jeffrey Harman, Ph.D.
Objective: The purpose of this study was to evaluate the effect of nominal incentive payments on attendance at therapy appointments among 50 low-income African Americans with depression. Methods: Attendance at therapy appointments for depression without incentive was tracked for 12 weeks, followed by tracking of 12 weeks during which $10 payments were given at regular appointments and a third 12-week period of appointments without payments. Results: After adjustment for rescheduling, 54 percent of patients had better adherence when payments were attached to appointments, and an additional 14 percent continued with perfect attendance throughout this second period. In the third period, when payments were no longer made, 66 percent had a decline in adherence. Less rescheduling was also observed during the incentive period. Conclusion: Incentive payments have the potential to improve appointment adherence
Dr. Post is affiliated with the department of medicine and the department of psychiatry of the University of Pittsburgh, Center for Research on Health Care, 230 McKee Place, Suite 600, Pittsburgh, Pennsylvania 15213 (e-mail,
[email protected]). Dr. Cruz is with the department of psychiatry of the University of Pittsburgh. Dr. Harman is with the department of health services research, management, and policy of the University of Florida in Gainesville. 414
among low-income African Americans with depression. (Psychiatric Services 57:414–416, 2006)
T
he provision of optimal depression treatment raises many challenges and barriers, such as access and adherence to therapy for vulnerable populations. For example, African Americans tend to be underrepresented in outpatient treatment populations but overrepresented in emergency and inpatient settings (1). As a result, low-income African Americans and patients with Medicaid insurance are less likely than their white, privately insured counterparts to receive continuous therapy for mental health conditions (2). This dynamic of episodic care in emergency and inpatient settings is believed to be rooted more in poverty, attitudes about seeking help, and a lack of community support than in clinician bias in diagnosis and treatment (3). Mutable barriers to outpatient mental health treatment among African Americans could be most proximally related to financial and logistic problems in keeping appointments, beyond that of the direct cost of clinical services. Previous studies of persons with non–mental health conditions have shown dramatic differences in adherence rates when patients were offered nominal payments for adherence (4–6). When drug users were administered tuberculosis tests, 33 percent (33 of 100) returned for skin test readings when no payments or other interventions were offered, 34 percent (34 of 99) returned PSYCHIATRIC SERVICES
when they were provided with motivational education, and 93 percent (186 of 200) returned when they were offered $10 to do so (6). In a similar study, 84 percent of patients (69 of 82) with tuberculosis attended follow-up appointments when offered $5, compared with 53 percent (42 of 79) of those who were not offered payments (4). When pregnant teenage mothers were asked to attend weekly peer-support groups, 58 percent of 107 mothers who were offered $7 to attend each session participated at least once, compared with only 9 percent of 24 mothers who were not offered payments (5). We found no previous studies of similar incentives in adult mental health treatment. Using an interrupted time-series trial, we evaluated the effect of nominal payments to offset incidental expenses of attending scheduled therapy appointments for low-income African Americans with depressive disorders and assessed self-perceived barriers to attendance.
Methods We enrolled patients who had billing diagnoses of major depression or depression not otherwise specified at a clinic affiliated with a university mental health center. The three master’s-level therapists at the clinic provide eclectic psychotherapy to a predominately lowincome African-American population in concert with psychiatrist-supervised pharmacotherapy. Sixty patients who were in active treatment (with a median treatment duration of two years) were referred to the study by thera-
♦ ps.psychiatryonline.org ♦ March 2006 Vol. 57 No. 3
Results The mean±SD age of the 54 participants was 46±9.6 years; 46 participants (85 percent) were female, 52 (96 perPSYCHIATRIC SERVICES
cent) were African American, and 45 (83 percent) had children (although not all children still lived at home). The mean baseline PHQ-9 score was 13.6±6.1, indicating on average a significant level of depression. Forty participants (74 percent) traveled to appointments by bus and described transportation expenses that study payments would cover (the median one-way fare was $1.75, with a range of $0 to $4.50). At baseline, 37 participants (69 percent) reported having missed appointments in the past. Forty-two (78 percent) endorsed the consistent effectiveness of therapy, and 28 (52 percent) reported that they would attend a session for $10 even if the therapy was not helpful. At baseline, only four respondents (7 percent) identified transportation as a reason for missing appointments; 15 (28 percent) cited physical or unspecified health problems; seven (13 percent) cited mental health symptoms; and 13 (24 percent) cited competing obligations, of which approximately one-third were related to child care. However, no participant reported at baseline paying for child care to attend an appointment, and none identified work-related barriers. Only one person (2 percent) reported an out-of-pocket payment ($3) for the clinic visit. Figure 1 shows the distribution of changes in individual appointment adherence between periods, adjusted for rescheduling. As illustrated, 27 of 50 participants (54 percent) had improved adherence during the incentive period; 12 participants (24 percent) had unchanged adherence, seven of whom continued with perfect attendance; and 11 (22 percent) had reduced adherence. These results represent a significant increase in adjusted adherence for individuals during period 2 (Sign statistic [M]=8, p< .014), with a mean absolute improvement of 6±21 percent. In keeping with an aggregate decline in the postincentive period, 29 of 44 participants (66 percent) had a decline in individual adherence between periods 2 and 3 (M=–10, p
