Study Derives Optimal Payment Incentives for Contingency Management

Effective contingency management (CM) programs for stimulant and/or opioid use disorder have median inflation-adjusted payment incentives of $128 per week for voucher protocols and $55 per week for prize protocols, according to a report in JAMA Psychiatry.

“These data are intended as starting points or a guide; complex protocols or programs that focus on challenging clinical presentations may need to consider more robust reinforcement schedules,” wrote lead author Carla J. Rash, Ph.D., of the University of Connecticut Health School of Medicine, and colleagues.

CM interventions—such as the California Recovery Incentives Program—make use of monetary incentives (typically gift cards/vouchers or entries for a cash prize drawing) to encourage patient participation in substance abuse treatment. While CM programs have more than 40 years of research support, they are not widely used in the United States.

Rash and colleagues reviewed 112 published CM protocols that involved reinforcement of stimulant- and/or opioid-negative urine drug tests and categorized each protocol as having small, medium, or large effect sizes compared with a non-CM program. They then computed weekly inflation-adjusted incentive payments for voucher- and prize-based protocols.

Of the 112 protocols coded, 49 protocols (44%) reinforced stimulant-negative urine drug tests only, seven protocols (6%) reinforced opioid-negative urine drug tests only, 24 (21%) reinforced both stimulant- and opioid-negative urine drug tests, and 32 protocols (29%) reinforced treatment for additional drugs beyond stimulants and/or opioids (alcohol, benzodiazepines, cannabis, barbiturates, phencyclidine).

Results showed that for the most common protocol length of 12 weeks, the optimal weekly payments in programs that showed moderate to large effect sizes would total about $1,536 ($128/week) for voucher and $660 ($55/week) for prize protocols.

To put these numbers in context, the authors noted that weekly estimated costs for first-line treatments approved by the Food and Drug Administration for opioid use disorder are $126 for methadone treatment, $115 for buprenorphine, and $271 for injectable naltrexone.

“At this time, CM is the treatment with the strongest evidence of efficacy for stimulant use disorders, yet CM remains underused in clinical applications,” they wrote. “In the midst of the continuing opioid and stimulant crisis, our field has the opportunity to invest in evidence-based CM as an effective treatment for substance use disorders.”

For more information, see the Psychiatric News article “Experts Discuss Options for Treating Stimulant Use Disorder.”

(Image: Getty Images/iStock/CarlosDavid.org)

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Esketamine Monotherapy Outperforms Placebo for Treatment-Resistant Depression

Esketamine nasal spray monotherapy showed significant and clinically meaningful improvement over placebo in adults with treatment-resistant depression (TRD) starting within 24 hours after initial dosing, according to the results of a study mounted by drugmaker Janssen and published today in JAMA Psychiatry.

Pharmacotherapy for patients with TRD “commonly involves augmentation or combination approaches. However, some of these patients encounter tolerability issues (e.g., weight gain, sexual dysfunction, lethargy, gastrointestinal issues) … which significantly contribute to nonadherence or discontinuation,” wrote Adam Janik, M.D., an investigator with Janssen’s parent company, Johnson & Johnson, and colleagues. “Esketamine monotherapy may expand treatment options for adult patients with TRD by addressing an unmet need of patients experiencing treatment-limiting tolerability concerns and non-response.”

Esketamine was initially approved by the Food and Drug Administration (FDA) in 2019 as an adjunct medication for TRD. Earlier this year, the FDA expanded the indication to allow esketamine as a stand-alone TRD therapy based on the findings of this study.

Janik and colleagues randomized 378 adults with moderate to severe TRD without psychotic features to receive 56 mg esketamine (n= 86), 84 mg esketamine (n = 95), or placebo spray (n = 197) twice weekly. Researchers assessed participants’ changes on the Montgomery-Åsberg Depression Rating Scale (MADRS) over 28 days, after which most participants opted into an open-label study of esketamine (variable dosing) or traditional oral antidepressants for 12 additional weeks.

After 28 days of treatment, the individuals taking either esketamine dose had larger average reductions in their MADRS scores (13 points for the 56 mg group and 14 for the 84 mg group) than those taking placebo (average seven-point reduction). Response and remission rates were also about two to three times as high in the esketamine groups compared with placebo.

In participants who continued esketamine in the 12-week, open-label phase, depressive symptoms remained stable or improved. Adverse events were common among participants given esketamine, most commonly nausea (25%), dissociation (24%), dizziness (22%), and headache (19%).

Limitations of this study include the exclusion of patients with significant psychiatric or medical comorbidities or substance dependence, as well as limited racial and ethnic diversity among participants. Also, the well-known adverse events that are associated with esketamine, such as dissociation and dizziness, led to many participants correctly guessing their treatment, which could have influenced the study results.

For related information, see the Psychiatric News articles “Helping Patients With Treatment-Resistant Depression Reach Remission” and “Disappointing Results for Esketamine as an Add-On After Acute Phase.”

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Intensive Residential Dynamic Psychotherapy Effective for Personality Disorders

A six-month residential program that incorporates intensive short-term dynamic psychotherapy (ISTDP) can produce lasting improvements for individuals with difficult-to-treat personality disorders, according to a study in the American Journal of Psychotherapy.

ISTDP is a therapeutic modality that helps patients understand and confront their inner conflicts, using a strong therapeutic alliance to break down patients’ maladaptive defenses and self-defeating behaviors. This treatment has shown good success in outpatient settings for people with personality disorders, and starting in 1994, the Viersprong hospital in Amsterdam built it into their residential program for treatment-resistant personality disorders, shifting the traditionally individual psychotherapy to a group model—as described in an accompanying article.

Kees L.M. Cornelissen, M.A., a private practice psychotherapist at ISTDP-House in Bergen op Zoom, the Netherlands, and colleagues examined the long-term outcomes of 155 patients who were admitted to the residential ISTDP program between 1995 and 2005. Of these, 107 patients completed questionnaires and interviews in 2006, providing up to 10 years of post-discharge data; for the remaining patients, data previously acquired at discharge and scheduled one- and two-year follow-ups were included.

Personality disorder severity was assessed with the Symptom Checklist-90-Revised, which examines eight domains: agoraphobia, anxiety, hostility, cognitive deficits, depression, interpersonal sensitivity and mistrust, sleeping difficulties, and somatization.

Over the 10-year follow-up, the researchers found that patient symptom scores remained stable after discharge, while overall functioning increased slightly. At residential program admission, 39% of patients had a job, and by year 10 this had increased to 88%. Conversely, the number of patients receiving social welfare benefits dropped from more than 50% at admission to less than 10% at 10 years. The number of patients living with a partner fluctuated during the follow-up but was generally between 30% and 40%.

Residential ISTDP “comes with higher upfront treatment costs than outpatient services,” Cornelissen and colleagues wrote. However, given “the significant costs to both the individual and society associated with personality disorders in terms of functional impairments, disability, and time away from work, administrators should consider the cost-effectiveness of investing in an intensive residential program.”

For related information, see the American Journal of Psychotherapy article “Benefits of Using Intensive Short-Term Dynamic Psychotherapy in Psychiatric Practice.”

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