Naltrexone is an effective treatment for alcohol dependence when taken consistently; however, poor adherence to medication is common in patients with severe mental illness. To recruit and retain participants in a study of the effectiveness of naltrexone, a subset of 61 participants who had both schizophrenia and an alcohol use disorder were offered vouchers that could be cashed in for tangible items when they attended clinic visits to receive oral naltrexone.

Clinic visits were scheduled 3 days a week for 12 weeks at the participants’ community mental health centers. Vouchers started at $5 per visit and increased $1 a day for consecutive visits to a maximum of $10. An unexcused absence reset the amount to $5.

• Overall average visit attendance was 82%.
• Consistent attendance, defined as attending 80% of all sessions, was achieved in 77% of participants.
• The average cost per participant for the vouchers was $330.
• The severity of psychosis at the start of the study was not a factor in attendance.

Comments by Michael Boyle, MA
Although the study design precludes determination of causality, the high adherence rate supports the need for further investigation of the effectiveness of motivational incentives in treating patients with schizophrenia and alcohol dependence. System changes at both the provider and state level are needed if effective adherence measures are to be implemented. The Strengthening Treatment Access and Retention—State Implementation (STAR-SI) project implemented by the Center for Substance Abuse Treatment (CSAT), which promotes the use of incentives and motivational interviewing to engage clients in the early phases of treatment, is a good example of how state/provider partnerships can promote these system changes.