Escalating Financial Incentives Over 6 Weeks Improves Adherence to Antidepressant Therapy

Some Antidepressants Contribute to Weight Gain
Some Antidepressants Contribute to Weight Gain
This randomized clinical trial compared 2 behavioral economics–based financial incentives for daily antidepressant adherence.

Providing escalating financial incentives to patients with depression during the first 6 weeks of starting antidepressant therapy may improve adherence to therapy, a study in JAMA Psychiatry suggests.

The researchers identified patients with depression from electronic health records from 5 primary care practices in Philadelphia. Patients were between the ages of 21 and 64 years, had scores of ≥10 on the Patient Health Questionnaire–9, and were starting antidepressant treatment at the time of randomization.

Patients were randomly assigned to a 6-week regimen of either usual care (n=40), usual care with escalating daily financial incentives (n=40), or usual care with deescalating financial incentives (n=40).

In the escalating group, patients received $2/day which was increased by $1/week to up to $7/day. Patients in the deescalating group received $7/day followed by a gradual reduction to $2/day. The primary endpoint of the study included the mean change in antidepressant adherence.

Patients in the escalating incentives group were more likely to be adherent to their antidepressant therapy over the 6-week follow-up period compared with patients who received usual care only (mean adherence, 90.7% vs 74.9%, respectively; difference, 15.8%; 95% CI, 7.0%-24.6%; <.001). In terms of adherence, there was no statistically significant difference between the escalating group and deescalating group (83.4%; P =.09).

Compared with patients who received usual care only, patients who received escalating financial incentives over 6 weeks were more likely to achieve symptom response (65.0% vs 40.0%; P =.04), remission (35.0% vs 8.6%; P =.01), and adherence to treatment of ≥80% (87.5% vs 47.4%; P <.001).

Participants who received deescalating incentives also achieved symptom response (63.2% vs 40.0%; P =.048) and remission (26.3% vs 8.6%; P =.048) more frequently than controls, but there was no difference between these groups in terms of adherence of ≥80% (P =.06).

Post hoc analyses revealed that patients who received escalating incentives were more likely than patients in the deescalating group to have adherence of ≥80% (87.5% vs 68.4%, respectively; P =.04). There was no difference between these groups in regard to the likelihood of achieving symptom response or remission.

Limitations of this study included the small overall sample size, the limited follow-up period, and the lack of elderly patients and/or patients with common psychiatric comorbidities.

In their research letter, the investigators wrote that additional “research should include evaluations of financial incentives powered to ascertain sustainability of antidepressant adherence and symptom improvement.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Marcus SC, Reilly ME, Zentgraf K, Volpp KG, Olfson M. Effect of escalating and deescalating financial incentives vs usual care to improve antidepressant adherence: A pilot randomized clinical trial [published online September 23, 2020]. JAMA Psychiatry. doi: 10.1001/jamapsychiatry.2020.3000