Behavioral Economics and Financial Incentive-Based Strategies to Optimize Post-CSC Outcomes

This K23 application requests funds to develop and test a set of behavioral economics and financial incentive- based strategies to improve patients' treatment engagement, medication adherence, and substance avoidance as they transition from Coordinated Specialty Care (CSC) for first-episode psychosis (FEP) to post-CSC care. While CSC was conceived as a means to improve short-term and long-term outcomes, evidence suggests that its short-term gains are lost after discharge. Improving treatment engagement, medication adherence, and substance avoidance during post-CSC care promises to mitigate this loss of gains. Behavioral economic and financial incentive-based behavior change strategies improve treatment plan adherence for people with other health conditions, including general psychosis. But these interventions have not been tested in the post-CSC period, where they face two obstacles: (1) frequent loss of contact in care transition and (2) concerns about the ethical acceptability of these interventions. Yet, preliminary research suggests that text messaging and emerging mHealth apps like mindLAMP will increase continued contact and that behavioral economic and financial incentive-based interventions will be acceptable when designed in participatory, ethically-informed ways. I will pursue 3 research aims to develop ethically-informed behavioral economics and financial incentive- based strategies to improve treatment plan adherence for people transitioning from CSC to post-CSC care. Guided by principles of community-based participatory research, a Steering Committee involving stakeholders, including CSC researchers, patients, family members, and clinicians, will oversee all aims. In Aim 1, I will assess facilitators of and barriers to using behavioral economic and financial incentive-based strategies in the post-CSC period. Using data from Aim 1, in Aim 2, I will adapt and sequentially improve these strategies while leveraging text messaging and mindLAMP to monitor and reinforce patients' adherence. In Aim 3, I will conduct a pilot RCT to examine preliminary effectiveness, utility of the measurement battery, success of recruitment and retention strategies, and feasibility and acceptability of the intervention developed in Aim 2. I will also pursue training goals in (1) decision science, (2) mHealth, (3) mixed methods analysis, and (4) field trials in order to become an independent clinician-scientist and psychosis a leader in the use of behavioral economics and financial incentives in treatment and an expert in the ethical application of these strategies. Successful completion of these aims will lead to an R01 application to conduct an RCT testing effectiveness, cost implications, and implementation issues. Related future research will apply similar methods to enhance engagement and monitoring in other domains of psychosis care. Ultimately, the research and training plans in this K23 will launch my career as an independent clinician-scientist and and leader in the use of behavioral economics financial incentives in psychosis treatment and an expert in the ethical application of these strategies.