Improving Medication Adherence to Reduce Involuntary Hospitalizations

illustration of an injection in a vial with a cloudy background — Illustration: Eric Nyquist

Involuntary hospitalization of people experiencing a mental health crisis is common across the U.S. In fact, involuntary hospitalization occurs at an annual rate (357 detentions per 100,000 residents) that is comparable to the rate of imprisonment in state and federal prisons (355 sentenced prisoners per 100,000 residents).

Individuals who are involuntarily hospitalized have elevated risks of adverse outcomes. In Allegheny County, Pennsylvania, for instance, 20% of these individuals die within 5 years of their first evaluation for involuntary hospitalization. This rate is higher than that for individuals exiting jail or entering homeless shelters. Over 23% are charged with a crime within 5 years of release from the hospital and 60% use an emergency room within one year of release. Further, these individuals account for nearly $1 of every $4 of behavioral health Medicaid spending in the county, despite representing only 1.5% of Medicaid enrollees.

One major obstacle standing in the way of better outcomes for those who experience involuntary hospitalization is medication non-adherence. In Allegheny County, about 60% of Medicaid enrollees discharged from involuntary hospitalization do not attend outpatient services in the following 90 days, despite being discharged with a referral to outpatient care. For Medicaid enrollees with schizophrenia, for example, adherence to oral formulations of medication 6 months prior to involuntary hospitalization is 18% and only 20% in the 6 months after hospitalization.

Financial rewards, through contingency management, have been found to be an effective way to initiate and sustain behavioral change for people struggling with drug addiction. With this project, our team seeks to understand if financial rewards can also help patients with schizophrenia or bipolar disorder adhere to prescribed medication, specifically in the form of long-acting injections. In partnership with the Allegheny County Department of Human Services, we will conduct a randomized controlled trial to test the effectiveness of financial rewards at increasing medication adherence, decreasing difficult and costly involuntary hospitalizations, and decreasing adverse outcomes like criminal charges and death.