Murphy SM, McDonell MG, McPherson S, Srebnik D, Angelo F, Roll JM, Ries RK. An economic evaluation of a contingency-management intervention for stimulant use among community mental health patients with serious mental illness. Drug and Alcohol Dependence, 2015; 153:293-9.
Murphy and his colleagues conducted a 12-week randomized control trial to determine the efficacy of contingency management (CM) when added to treatment as usual (TAU) for patients diagnosed with serious mental illness (SMI) and stimulant dependency. In this study, patients drew tokens whenever their urine tested negative for stimulants, as well as for alcohol, marijuana, and opioids. These tokens ranged in value, and patients had the opportunity to draw tokens three times per week if their results were negative. The number of token draws for TAU participants were the same as those for CM+TAU participants, but were not dependent on being stimulant free. TAU services included mental health, addiction, housing, and vocational.
All 176 patients were treated at a community mental health center for their SMI and addiction. Participants were also assessed during a 12-week follow-up period for a primary economic outcome—quality-adjusted life-years (QALYs)—and a primary clinical outcome—stimulant-free year (SFY). Both the perspectives of the patient and the provider were taken into account. Researchers found that the QALLYs did not differ significantly for the two groups. However, the CM+TAU participants experienced significantly more SFYs at 12 weeks and at 24 weeks. This finding illustrates the value of using CM in increasing the likelihood of patients having more SFYs.
From Dr. Durant
The article addresses an ongoing concern in a public health/managed care system about the affordability of various evidence-based practices with indigent patients. Specifically, this article addresses the cost effectiveness of contingency management (CM) with patients who have co-morbid substance abuse and serious mental illness (SMI). The authors detail a number of deleterious outcomes with untreated cohorts such as increased homelessness, psychiatric hospitalization, emergency room use, and incarceration. Despite CM being an efficacious treatment for substance use disorders with co-morbid SMI, the perceived cost has become a barrier to its implementation. However, it appears that the old adage, “you only get out what you put in” may reflect the merits of this approach considering the outcomes of this study.
Given that the monetary and psychosocial ramifications are far reaching for these recipients, as well as the payers of evidence-based approaches, the use of urine screens, tangible reinforcers (money, vouchers, gifts), and staffing expense should be considered another “cost of doing business.” The findings from the article support that the effects of CM, coupled with treatment as usual, are clinically appropriate and fiscally responsible. It will be important for clinicians, provider agencies, and managed care organizations to continue to consider the long-term benefits (clinically and fiscally) of the additional upfront treatment expense of implementing CM with high cost, difficult-to-treatment populations.
About Dr. Durant
Dr. Lauren Durant, Executive Director and Clinical Director with B & D Behavioral Health Services, holds master’s and doctoral degrees in Clinical Psychology. Since May 2003, she has been licensed as a mental health service provider by the North Carolina Psychology Board and became duly licensed in 2010 by the North Carolina Substance Abuse Board. Dr. Durant began her career at Duke University Medical Center in 2001 as a post-doctoral fellow and clinician in the Department of Psychiatry where she served as an Academic Lead for the Duke Clinical Trials Network (CTN). Concurrently, Dr. Durant founded B & D Behavioral Health Services in 2005 and fully transitioned to B & D as an Executive Director and part-time Clinical Director in 2008. Dr. Durant has been a delegate of the North Carolina Practice Improvement Collaborative (NC PIC) since 2010. Dr. Durant is a former member of the Durham Provider Council (2010-12) and has been an elected member of the Alliance Provider Advisory Council since February 2013.