Can Financial Incentives Improve Medication Adherence and Patient Outcomes After Involuntary Hospitalization?

The investigators seek to understand the effectiveness of financial incentives at reducing medication non-adherence and costly involuntary hospitalizations for individuals with acute mental health needs. The focus will be on patients diagnosed with schizophrenia, schizoaffective disorder, and/or bipolar disorder who have recent experiences with involuntary hospitalization and possibly a co-occurring substance use disorder. This population has been documented to have particularly high healthcare expenditures and mortality, as well as incidence of criminal charges. Partnering with UPMC Western Psychiatric Hospital (WPH), Pittsburgh Mercy, and the Allegheny County Department of Human Services (ACDHS), the investigators will run a randomized controlled trial (RCT) where the treatment group is offered financial incentives for long-acting injectable (LAI) versions of the antipsychotic and substance use disorder medications they need. If effective, financial incentives for LAIs can be a scalable tool for addressing a range of costly problems facing the whole country.

Investigators will enroll eligible individuals at discharge from involuntary hospitalization at WPH, in WPH outpatient clinics, and in the field with Pittsburgh Mercy's community treatment teams. Eligible individuals will be those who have a diagnosis of schizophrenia, schizoaffective disorder, and/or bipolar disorder, who were involuntary hospitalized within the last year or who are deemed by ACDHS models to be at high risk of involuntary hospitalization, and whose prescribed medication has an LAI formulation. Investigators will hire and train a research team to enroll patients in the study, randomize patients into treatment and control groups, and work with their physicians to keep track of who is taking up LAIs and who needs to receive the incentives. Each participant will experience a study duration of 12 months.

The primary hypotheses are that financial incentives for LAIs can increase medication adherence in this particularly hard-to-treat population and (2) increased medication adherence will decrease the incidence of involuntary hospitalization. Additional hypotheses, based on ongoing research in Allegheny County (Emanuel, Welle, and Bolotnyy, 2025), are that criminal charges and mortality will also decline if medication adherence improves and there will be improvements in housing stability, employment, subjective well being, relationships with others, and attitudes towards long-acting injections and the healthcare system.

Outcomes will be measured using ACDHS administrative data, including Medicaid claims and prescription refill records, death and Medical Examiner records, county court records, utilization data for homeless shelters in Allegheny County, and employment and income data from Pennsylvania's Department of Labor and Industry. Additionally, study participants will be surveyed every month during the study period and 6 months and 12 months after the end of the study. Surveys will collect information on participants' subjective wellbeing, the quality of their relationships, as well as their attitudes towards long-acting injections and the healthcare system. Outcomes will be measured and effects assessed at the end of the study period for all participants and after the follow-up survey data are collected. Priebe et al. (2013) and Noordraven et al. (2017) work with patients with a baseline adherence rate of 70-80%; the comparable adherence rate in our setting is 52%.

Randomization Plan