A randomized clinical trial of supported employment for inner-city patients with severe mental disorders

Health and well-being of homeless veterans participating in transitional and supported employment: Six-month outcomes

Supported employment, specifically individual placement and support (IPS), improves competitive employment (CE) rates for individuals with serious mental illness, but has not shown greater improvement in non-vocational outcomes than other rehabilitation approaches. The Department of Veterans Affairs offers two types of vocational services, IPS and transitional work experience (TWE), but no study has compared the effectiveness of these approaches. This secondary analysis of data from a study of homeless veterans compared 6 mo improvement in diverse outcomes for five employment patterns: never worked, worked only in TWE, worked in TWE followed by CE, worked in CE without IPS, and worked in CE with IPS referral. Veterans referred to IPS were more likely to be competitively employed. Those who worked in CE (whether following TWE or with or without IPS referral) showed the greatest increase in days worked, employment income, and total income and the greatest decrease in public support income when compared with those who worked only in TWE or not at all. Veterans in TWE showed the greatest increase in residential treatment days, but there were no other differences in non-vocational outcomes between groups. There are multiple paths to CE, but few differences in non-vocational outcomes across employment experiences.

Improving access to competitive employment for service users in forensic psychiatric units

Employment has been proven to be an effective recovery tool and therapeutic intervention for those with severe and enduring mental health conditions. Aside from monetary reward, employment is a means of structuring time and provides a sense of worth and achievement, which enhances self-esteem and confidence. A social identity is developed through employment, encouraging social support and increasing social networks. Securing employment can bring about improved quality of life and positive change in one's social circumstances; therefore it can reduce symptoms associated with mental illness and potentially prevent re-offending, as the individual develops a sense of independence, self-efficacy, and value.

Barriers to employment exist for forensic mental health service users and therefore it is imperative that employment needs are addressed at the earliest possible stage in recovery. An evaluation of employment activities across two forensic mental health units revealed a lack of appropriate employment opportunities for service users, and those roles available were not implemented in line with recommended best practice. In response to this issue several enterprises were established to offer opportunities for service users to engage in meaningful employment and develop skills that a future employer would value. Each enterprise responds to a business need within the units to ensure sustainability of services. The enterprises are essentially micro-businesses with social objectives whose surpluses are reinvested for the purpose of increasing opportunities for service users.

The enterprises are underpinned by the philosophy of the Individual Placement and Support (IPS) model; empirical evidence suggests that the IPS model is the most effective intervention, based on the ‘place then train’ philosophy. The model recommends a focus upon rapid job search to achieve competitive employment for those who want to work; opportunities sourced should be consistent with individual preference and benefits counselling offered. Support should be time unlimited and integrated with mental health treatment. A person-centred and strengths-based approach is also adopted to support people to build on their strengths, establish goals, and encourage motivation.

Employment program for patients with severe mental illness in Malaysia: a 3-month outcome

OBJECTIVE

This study aimed to examine the rate and predictive factors of successful employment at 3 months upon enrolment into an employment program among patients with severe mental illness (SMI).

METHODS

A cross-sectional study using universal sampling technique was conducted on patients with SMI who completed a 3-month period of being employed at Hospital Permai, Malaysia. A total of 147 patients were approached and 126 were finally included in the statistical analyses. Successful employment was defined as the ability to work 40 or more hours per month. Factors significantly associated with successful employment from bivariate analyses were entered into a multiple logistic regression analysis to identify predictors of successful employment.

RESULTS

The rate of successful employment at 3 months was 68.3% (n=81). Significant factors associated with successful employment from bivariate analyses were having past history of working, good family support, less number of psychiatric admissions, good compliance to medicine, good interest in work, living in hostel, being motivated to work, satisfied with the job or salary, getting a preferred job, being in competitive or supported employment and having higher than median scores of PANNS on the positive, negative and general psychopathology. Significant predictors of employment, from a logistic regression model were having good past history of working (p<0.021; OR 6.12; [95% CI 2.1-11.9]) and getting a preferred job (p<0.032; [OR 4.021; 95% CI 1.83-12.1]).

CONCLUSION

Results showed a high employment rate among patients with SMI. Good past history of working and getting a preferred job were significant predictors of successful employment.

Measuring participation in an evidence-based practice: illness management and recovery group attendance

Given the important role of treatment attendance as an indicator of program implementation and as a potential moderator of program effectiveness, this study sought to develop useful indicators of attendance for evidence-based practices. The current study examined consumer attendance patterns in a randomized controlled trial comparing illness management and recovery (n=60) to a problem solving control condition (n=58). Associations were examined between consumer clinical indicators, demographics, and level of recovery and indices of attendance. Attendance was poor, but comparable to rates found in many other studies. Four indicators of attendance (percent sessions attended, time enrolled, periods of attendance, and longest period of attendance) were highly inter-related and were more sensitive to baseline differences than a traditional approach of dichotomizing participants into "attenders" and "non-attenders." Older age, lower hostility, fewer psychotic symptoms, and more education were associated with higher group attendance in both treatment conditions; the client-reported illness management and recovery scale was associated with attendance in the control group. Indicators of attendance were an advancement over dichotomous classification. Strategies to increase attendance are still needed, particularly for younger consumers with greater positive symptoms.

The effect of IPS-modified, an early intervention for people with mood and anxiety disorders: study protocol for a randomised clinical superiority trial

BACKGROUND

Anxiety and affective disorders can be disabling and have a major impact on the ability to work. In Denmark, people with a mental disorder, and mainly non-psychotic disorders, represent a substantial and increasing part of those receiving disability pensions. Previous studies have indicated that Individual Placement and Support (IPS) has a positive effect on employment when provided to people with severe mental illness. This modified IPS intervention is aimed at supporting people with recently diagnosed anxiety or affective disorders in regaining their ability to work and facilitate their return to work or education.

AIM

To investigate whether an early modified IPS intervention has an effect on employment and education when provided to people with recently diagnosed anxiety or affective disorders in a Danish context.

METHODS/DESIGN

The trial is a randomised, assessor-blinded, clinical superiority trial of an early modified IPS intervention in addition to treatment-as-usual compared to treatment-as-usual alone for 324 participants diagnosed with an affective disorder or anxiety disorder living in the Capital Region of Denmark. The primary outcome is competitive employment or education at 24 months. Secondary outcomes are days of competitive employment or education, illness symptoms and level of functioning including quality of life at follow-up 12 and 24 months after baseline.

DISCUSSION

If the modified IPS intervention is shown to be superior to treatment-as-usual, a larger number of disability pensions can probably be avoided and long-term sickness absences reduced, with major benefits to society and patients. This trial will add to the evidence of how best to support people's return to employment or education after a psychiatric disorder.

TRIAL REGISTRATION

NCT01721824.

Supported employment for adults with severe mental illness

BACKGROUND

People who suffer from severe mental disorder experience high rates of unemployment. Supported employment is an approach to vocational rehabilitation that involves trying to place clients in competitive jobs without any extended preparation. The Individual placement and support (IPS) model is a carefully specified form of supported employment.

OBJECTIVES

1. To review the effectiveness of supported employment compared with other approaches to vocational rehabilitation or treatment as usual.2. Secondary objectives were to establish how far:(a) fidelity to the IPS model affects the effectiveness of supported employment,(b) the effectiveness of supported employment can be augmented by the addition of other interventions.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (February 2010), which is compiled by systematic searches of major databases, handsearches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, of working age (normally 16 to 70 years), where supported employment was compared with other vocational approaches or treatment as usual. Outcomes such as days in employment, job stability, global state, social functioning, mental state, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

Two review authors (YK and KK) independently extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% (CI). We employed a fixed-effect model for analyses. A random-effects model was also employed where heterogeneity was present.

MAIN RESULTS

A total of 14 randomised controlled trials were included in this review (total 2265 people). In terms of our primary outcome (employment: days in competitive employment, over one year follow-up), supported employment seems to significantly increase levels of any employment obtained during the course of studies (7 RCTs, n = 951, RR 3.24 CI 2.17 to 4.82, very low quality of evidence). Supported employment also seems to increase length of competitive employment when compared with other vocational approaches (1 RCT, n = 204, MD 70.63 CI 43.22 to 94.04, very low quality evidence). Supported employment also showed some advantages in other secondary outcomes. It appears to increase length (in days) of any form of paid employment (2 RCTs, n = 510, MD 84.94 CI 51.99 to 117.89, very low quality evidence) and job tenure (weeks) for competitive employment (1 RCT, n = 204, MD 9.86 CI 5.36 to 14.36, very low quality evidence) and any paid employment (3 RCTs, n = 735, MD 3.86 CI -2.94 to 22.17, very low quality evidence). Furthermore, one study indicated a decreased time to first competitive employment in the long term for people in supported employment (1 RCT, n = 204, MD -161.60 CI -225.73 to -97.47, very low quality evidence). A large amount of data were considerably skewed, and therefore not included in meta-analysis, which makes any meaningful interpretation of the vast amount of data very difficult.

AUTHORS' CONCLUSIONS

The limited available evidence suggests that supported employment is effective in improving a number of vocational outcomes relevant to people with severe mental illness, though there appears to exist some overall risk of bias in terms of the quality of individual studies. All studies should report a standard set of vocational and non-vocational outcomes that are relevant to the consumers and policy-makers. Studies with longer follow-up should be conducted to answer or address the critical question about durability of effects.

The effectiveness of individual placement and support for people with mental illness new on social benefits: a study protocol

BACKGROUND

In Switzerland, people with a severe mental illness and unable to work receive disability benefits ('IV-pension'). Once they are granted these benefits, the chances to regain competitive employment are usually small. However, previous studies have shown that individual placement and support (IPS) supports a successful reintegration into competitive employment. This study focuses on the integration of newly appointed IV-pensioners, who have received an IV-pension for less than a year.

METHOD/DESIGN

The present pilot project ZHEPP (Zürcher Eingliederungs-Pilot Projekt; engl.: Zurich integration pilot project) is a randomized controlled trial (RCT). The 250 participants will be randomized to either the intervention or the control group. The intervention group receives support of a job coach according to the approach of IPS. Participants in the control group do not receive IPS support. Participation takes a total of two years for each participant. Each group is interviewed every six months (T0-T4). A two-factor analysis of variance will be conducted with the two factors group (intervention versus control group) and outcome (employment yes/no). The main criterion of the two-factor analysis will be the number of competitive employment contracts in each group.

DISCUSSION

This study will focus on the impact of IPS on new IV-pensioners and aims to identify predictors for a successful integration. Furthermore, we will examine the effect of IPS on stigma variables and recovery orientation.

TRIAL REGISTRATION

ISRCTN54951166.

The balanced care model for global mental health

BACKGROUND

For too long there have been heated debates between those who believe that mental health care should be largely or solely provided from hospitals and those who adhere to the view that community care should fully replace hospitals. The aim of this study was to propose a conceptual model relevant for mental health service development in low-, medium- and high-resource settings worldwide. Method We conducted a review of the relevant peer-reviewed evidence and a series of surveys including more than 170 individual experts with direct experience of mental health system change worldwide. We integrated data from these multiple sources to develop the balanced care model (BCM), framed in three sequential steps relevant to different resource settings.

RESULTS

Low-resource settings need to focus on improving the recognition and treatment of people with mental illnesses in primary care. Medium-resource settings in addition can develop 'general adult mental health services', namely (i) out-patient clinics, (ii) community mental health teams (CMHTs), (iii) acute in-patient services, (iv) community residential care and (v) work/occupation. High-resource settings, in addition to primary care and general adult mental health services, can also provide specialized services in these same five categories.

CONCLUSIONS

The BCM refers both to a balance between hospital and community care and to a balance between all of the service components (e.g. clinical teams) that are present in any system, whether this is in low-, medium- or high-resource settings. The BCM therefore indicates that a comprehensive mental health system includes both community- and hospital-based components of care.

The relationships between employment, clinical status, and psychiatric hospitalisation in patients with schizophrenia receiving either IPS or a conventional vocational rehabilitation programme

PURPOSE

Positive relationships between employment and clinical status have been found in several studies. However, an unequivocal interpretation of these relationships is difficult on the basis of common statistical methods.

METHODS

In this analysis, a structural equation model approach for longitudinal data was applied to identify the direction of statistical relationships between hours worked, clinical status and days in psychiatric hospital in 312 persons with schizophrenia who participated in a multi-centre randomised controlled trial comparing the effectiveness of Individual Placement and Support (IPS) with conventional vocational services in six study settings across Europe. Data were analysed by an autoregressive cross-lagged effects model, an autoregressive cross-lagged model with random intercepts and an autoregressive latent trajectory model.

RESULTS

Comparison of model fit parameters suggested the autoregressive cross-lagged effects model to be the best approach for the given data structure. All models indicated that patients who received an IPS intervention spent more hours in competitive employment and, due to indirect positive effects of employment on clinical status, spent fewer days in psychiatric hospitals than patients who received conventional vocational training.

CONCLUSIONS

Results support the hypothesis that the IPS intervention has positive effects not only on vocational but also on clinical outcomes in patients with schizophrenia.

Merging the fields of mental health and social enterprise: lessons from abroad and cumulative findings from research with homeless youths

Despite the growing integration of supported employment within the mental health system in the United States as well as the widespread use of social enterprises abroad, the fields of mental health and social enterprises remain largely separate in the USA. The mental health field currently lacks a response that strengthens homeless youths' existing human and social capital, provides them with marketable job skills and employment, and impacts their mental health. To address this gap, this paper establishes a case for using social enterprises with homeless youths, drawing on both global precedents and findings from a mixed-methods study of a social enterprise intervention with homeless youths. Recommendations are offered for how to integrate social enterprises with mental health treatment as well as how to evaluate their impact on mental health outcomes.

Enhancing work-focused supports for people with severe mental illnesses in australia

Persons with severe mental illness (SMI) have reduced workforce participation, which leads to significant economic and social disadvantage. This theoretical review introduces the strategies that have been implemented to address this issue. These include Individual Placement and Support (IPS) services, the most widely researched form of supported employment, to which cognitive remediation has more recently been recognised in the USA, as an intervention to improve employment outcomes by addressing the cognitive impairments often experienced by people with SMI. The authors review the international literature and discuss specifically the Australian context. They suggest that Australia is in a prime position to engage clients in such a dual intervention, having had recent success with increasing access to supported employment programs and workforce reentry, through implementation of the Health Optimisation Program for Employment (HOPE). Such programs assist with gaining and maintaining employment. However, they do not address the cognitive issues that often prevent persons with SMI from effectively participating in work. Thus, optimising current interventions, with work-focused cognitive skills development is critical to enhancing employment rates that remain low for persons with SMI.

Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US

While reviews of controlled studies of the Individual Placement and Support (IPS) model of supported employment for clients with severe mental illness have documented its effectiveness in the US, its generalizability to other countries has not been systematically evaluated. This is the first review to compare US to non-US studies. We identified 15 randomized controlled trials of IPS programs, 9 in the US and 6 outside the US. We examined competitive employment outcomes, including employment rate, days to first job, weeks worked during follow-up, and hours worked. We also considered noncompetitive employment, program retention, and nonvocational outcomes. IPS programs had significantly better outcomes across a range of competitive employment indicators and higher retention in services than control groups. The overall competitive employment rate for IPS clients in US studies was significantly higher than in non-US studies (62% vs. 47%). The consistently positive competitive employment outcomes strongly favoring IPS over a range of comparison programs in a group of international studies suggest that IPS is an evidence-based practice that may transport well into new settings as long as programs achieve high fidelity to the IPS model, but further research is needed on international adaptations.

Helping homeless individuals with co-occurring disorders: the four components

Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorder are one of the most vulnerable populations. This article provides practitioners with a framework and strategies for helping this client population. Four components emerged from a literature review: (1) ensuring an effective transition for individuals with CODs from an institution (such as a hospital, foster care, prison, or residential program) into the community, a particularly important component for clients who were previously homeless, impoverished, or at risk of homelessness; (2) increasing the resources of homeless individuals with CODs by helping them apply for government entitlements or supported employment (3) linking homeless individuals to supportive housing, including housing first options as opposed to only treatment first options, and being flexible in meeting their housing needs; and (4) engaging homeless individuals in COD treatment, incorporating modified assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help groups.

Effectively working on rehabilitation goals: 24-month outcome of a randomized controlled trial of the Boston psychiatric rehabilitation approach

OBJECTIVE

To investigate the effect of the Boston Psychiatric Rehabilitation (PR) Approach on attainment of personal rehabilitation goals, social functioning, empowerment, needs for care, and quality of life in people with severe mental illness (SMI) in the Netherlands.

METHOD

A 24-month, multicentre, randomized controlled trial was used to compare the results of PR to care as usual (CAU). Patients with SMI were randomly assigned by a central randomization centre to PR (n = 80) or CAU (n = 76). The primary outcome of goal attainment was assessed by independent raters blind to treatment allocation. Measures for secondary outcomes were change in work situation and independent living, the Personal Empowerment Scale, the Camberwell Assessment of Needs, and the World Health Organization Quality of Life assessment. Effects were tested at 12 and 24 months. Data were analyzed according to intention to treat. Covariates were psychiatric centre, psychopathology, number of care contacts, and educational level of the professionals involved.

RESULTS

The rate of goal attainment was substantially higher in PR at 24 months (adjusted risk difference: 21%, 95% CI 4% to 38%; number needed to treat [NNT] = 5). The approach was also more effective in the area of societal participation (PR: 21% adjusted increase, CAU: 0% adjusted increase; NNT = 5) but not in the other secondary outcome measures.

CONCLUSIONS

The results suggest that PR is effective in supporting patients with SMI to reach self-formulated rehabilitation goals and in enhancing societal participation, although no effects were found on the measures of functioning, need for care, and quality of life.

Randomized controlled trial of supported employment in England: 2 year follow-up of the Supported Work and Needs (SWAN) study

Studies from North America have concluded that supported employment using the Individual Placement and Support (IPS) model is effective in helping individuals with severe and persistent mental illness gain competitive employment. The aim of this study was to investigate the effectiveness and cost-effectiveness of IPS in England in patients followed up for 2 years. Patients with severe mental illness were randomised to IPS or local vocational services (treatment as usual). Service use and costs were measured. Two hundred-nineteen participants were randomised, and 86% re-assessed 2 years later. In the multivariate analysis, relatively low rates of competitive employment were found in both the intervention group and the treatment as usual group, although significantly more patients obtained competitive employment in the treatment arm (22% vs. 11%, p=0.041). There were no significant differences in costs. The employment rate among participants receiving IPS was lower than in previously published reports, and the number needed to treat to obtain the benefit of IPS was relatively high. This may reflect difficulties in the implementation of IPS where it is not structurally integrated within mental health teams, as well as economic disincentives which lead to lower levels of motivation for patients and mental health professionals.

Who benefits from supported employment: a meta-analytic study

AIMS

This meta-analysis sought to identify which subgroups of clients with severe mental illness (SMI) benefited from evidence-based supported employment.

METHODS

We used meta-analysis to pool the samples from 4 randomized controlled trials comparing the Individual Placement and Support (IPS) model of supported employment to well-regarded vocational approaches using stepwise models and brokered services. Meta-analysis was used to determine the magnitude of effects for IPS/control group differences within specific client subgroups (defined by 2 work history, 7 sociodemographic, and 8 clinical variables) on 3 competitive employment outcomes (obtaining a job, total weeks worked, and job tenure).

RESULTS

The findings strongly favored IPS, with large effect sizes across all outcomes: 0.96 for job acquisition, 0.79 for total weeks worked, and 0.74 for job tenure. Overall, 90 (77%) of the 117 effect sizes calculated for the 39 subgroups exceeded 0.70, and all 117 favored IPS.

CONCLUSIONS

IPS produces better competitive employment outcomes for persons with SMI than alternative vocational programs regardless of background demographic, clinical, and employment characteristics.

Employers' attitudes to people with mental health problems in the workplace in Britain: changes between 2006 and 2009

AIM

This study examines whether there have been improvements in mental health-related knowledge, attitudes and workplace practices among British employers between 2006 and 2009.

METHOD

In 2006, the Shaw Trust surveyed 550 British employers. Telephone interviews ascertained their knowledge, attitudes and practices related to mental health in the workplace. This study compares their findings with a repeat survey of 500 employers in 2009.

RESULTS

In 2006, 33% of employers reported that none of their employees would develop a mental health problem during their working lifetime, dropping to 7% in 2009. In both years, less than a third of companies had formal policies on stress and mental health. In 2006, 68% agreed they would be flexible in offering adjustments to someone with mental ill-health, rising to 87% in 2009. In 2006, 76% agreed that British industry needs more support to improving the way it deals with mental health in the workplace, increasing to 88% in 2009.

CONCLUSIONS

While employers' mental health knowledge significantly improved and many offer 'reasonable adjustments', there is a need to formalise these arrangements and for further training and support. Resistance to the Equality Bill amendment banning pre-employment health questions, with exceptions, is predicted based on employers' preference for pre-employment disclosure.

Social value of supported employment for psychosocial program participants

Members of a psychiatric psychosocial program designed to provide both supported employment and peer support were surveyed about their current social activities, sources of social support, and social life improvement since joining the program. Survey respondents who worked a mainstream job (n=17) reported greater peer contact in community locations, and correspondingly greater social life improvement, than those who remained unemployed or worked volunteer jobs (n=45). Results of a hierarchical regression analysis (N=62) that explored this positive correlation between mainstream work, community-based peer contact, and social life satisfaction suggest that working a job in an integrated setting that paid at least minimum wage encouraged program participants to meet and interact in community locations, thereby strengthening peer mutual support while furthering social integration. This unique pattern of findings requires replication, and we recommend that other psychosocial programs conduct similar quality improvement studies to provide further insights into the relationship between peer support and community integration.

Reducing disparities in mental health care: suggestions from the Dartmouth-Howard collaboration

This article presents recent collaborative efforts between the Dartmouth Psychiatric Research Center and Howard University to understand (and ultimately reduce) disparities in mental health care among African Americans. Researchers from Dartmouth and Howard recently formalized a longstanding collaboration through the support of a grant aimed at understanding recovery and rehabilitation for African Americans with severe mental illness. Grant-sponsored efforts have included two seminars between multi-disciplinary mental health researchers and clinicians to inform the implementation of a collaborative research and training program. This article outlines the prominent themes arising from these seminars on the issue of health disparities agreed upon by our multi-disciplinary research team. These are (1) situating disparity research in the context of social justice; (2) understanding trends in disparities; (3) promoting a sophisticated understanding of 'culture' and its role in disparities; (4) critically assessing strategies that attempt to mitigate disparities; (5) developing a reflexive research agenda.

The Effectiveness of Supported Employment in People With Dual Disorders

OBJECTIVE: This study compared the effectiveness of the Individual Placement and Support (IPS) model of supported employment to control vocational rehabilitation programs for improving the competitive work outcomes of people with a severe mental illness and co-occurring substance use disorder. METHODS: A secondary data analysis was conducted drawing from four randomized controlled trials comparing IPS supported employment to conventional vocational rehabilitation programs for severe mental illness, and focusing on the 106 clients with a recent (past 6 months) substance use disorder. Competitive work outcomes were tracked across an 18-month follow-up period. Analyses compared the IPS and comparison vocational programs on cumulative work over the 18 months, including attainment of work, hours and weeks worked, job tenure, wages earned, and days to first job. RESULTS: In the total study group, clients who participated in IPS had better competitive work outcomes than those who participated in a comparison program, with cumulative employment rates of 60% vs. 24%, respectively. Among clients who obtained work during the study period, those receiving IPS obtained their first job significantly more quickly and were more likely to work 20 or more hours per week at some point during the 18-month follow-up. CONCLUSIONS: The IPS model of supported employment is more effective than alternative vocational rehabilitation models at improving the competitive work outcomes of clients with a dual disorder.

Implementing the individual placement and support (IPS) approach for people with mental health conditions in England

Despite the overwhelming evidence of the effectiveness of the individual placement and support (IPS) approach to vocational rehabilitation for people with mental health conditions, there is very limited evidence of implementation in the UK. Both government policy and national clinical guidelines have set out a need for the availability of this effective approach in favour of other approaches, yet implementation appears to be an exception rather than a rule. This paper sets out four key challenges to implementing the IPS approach within mental health services in England: fear on the part of professionals, individuals and their families; a culture of low expectations; a failure to provide the support that we know works, and the global 'credit crunch' recession. Using a framework from implementation science, this review identifies the key features of implementing IPS within routine clinical practice from the experience of two large mental health NHS trusts in England.

First episode psychosis and employment: a review

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.

Client predictors of employment outcomes in high-fidelity supported employment: a regression analysis

Research on vocational rehabilitation for clients with severe mental illness over the past 2 decades has yielded inconsistent findings regarding client factors statistically related to employment. The present study aimed to elucidate the relationship between baseline client characteristics and competitive employment outcomes-job acquisition and total weeks worked during an 18-month follow-up-in Individual Placement and Support (IPS). Data from 4 recent randomized controlled trials of IPS were aggregated for within-group regression analyses. In the IPS sample (N = 307), work history was the only significant predictor for job acquisition, but receiving Supplemental Security Income-with or without Social Security Disability Insurance-was associated with fewer total weeks worked (2.0%-2.8% of the variance). In the comparison sample (N = 374), clients with a diagnosis of mood disorder or with less severe thought disorder symptoms were more likely to obtain competitive employment. The findings confirm that clients with severe mental illness interested in competitive work best benefit from high-fidelity supported employment regardless of their work history and sociodemographic and clinical background, and highlight the needs for changes in federal policies for disability income support and insurance regulations.

Implementation of the thinking skills for work program in a psychosocial clubhouse

OBJECTIVE

Cognitive remediation programs aimed at improving role functioning have been implemented in a variety of different mental health treatment settings, but not in psychosocial clubhouses. This study sought to determine the feasibility and preliminary outcomes of providing a cognitive remediation program (the Thinking Skills for Work program), developed and previously implemented in supported employment programs at mental health agencies, in a psychosocial club-house.

METHODS

Twenty-three members with a history of difficulties getting or keeping jobs, who were participating in a supported employment program at a psychosocial clubhouse, were enrolled in the Thinking Skills for Work program. A neurocognitive battery was administered at baseline and 3 months later after completion of the computer cognitive training component of the program. Hours of competitive work were tracked for the 2 years before enrollment and 2 years following enrollment. Other work-related activities (school, volunteer) were also tracked for 2 years following enrollment.

RESULTS

Twenty-one members (91%) completed 6 or more computer cognitive training sessions. Participants demonstrated significant improvements on neurocognitive measures of processing speed, verbal learning and memory, and executive functions. Sixty percent of the members obtained a competitive job during the 2-year follow-up, and 74% were involved in some type of work-related activity. Participants worked significantly more competitive hours over the 2 years after joining the Thinking Skills for Work program than before.

CONCLUSIONS

The findings support the feasibility and promise of implementing the Thinking Skills for Work program in the context of supported employment provided at psychosocial clubhouses.

The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

Reduction of functional disability with atypical antipsychotic treatment: a randomized long term comparison of ziprasidone and haloperidol

BACKGROUND

Recent interest has focused on the definition and measurement of clinical remission in people with schizophrenia. This study examined the process of development of "functional remission" in a long-term comparative double-blind study of haloperidol and the atypical antipsychotic medication ziprasidone.

METHODS

Community dwelling patients with schizophrenia were randomized to treatment with haloperidol (n=47) or ziprasidone dosed either once or twice daily (n=139). They were re-examined at follow-up intervals that ranged up to 196 weeks. Their community functioning was examined with the Heinrichs-Carpenter Quality of Life Scale (QLS). Total scores for occupational and interpersonal functioning and achievement of improvement milestones across the individual items were both analyzed.

RESULTS

Mixed model repeated measures analyses detected a significant (p<.05) treatment effect over time favoring ziprasidone for interpersonal functioning. While the mixed model was not significant for role functioning, the mean change at endpoint was significantly greater than 0 for the ziprasidone group but not the haloperidol group. Analyses of the distributions of change scores across the items showed that the number of items where endpoint scores were 5 or 6 (reflecting minimal to no impairment) was significantly higher in ziprasidone treated patients, (p=.03).

IMPLICATIONS

Long term treatment with ziprasidone was associated with greater functional gains than treatment with haloperidol, even when the time course of dropout was controlled. Both treatment retention and functional gains favored the atypical treatment in this long-term study. Future long-term studies will be needed to clarify the determinants of these functional changes.

Review of critical factors related to employment after spinal cord injury: implications for research and vocational services

BACKGROUND/OBJECTIVE

Employment rates after spinal cord injury (SCI) vary widely because of discrepancies in studies' definition of employment and time of measurement. The objective of this study was to provide a comprehensive summary of the literature on employment rates, predictors of employment, and the benefits and barriers involved.

METHODS

A search using the terms spinal cord injury and employment in the databases PubMed, PsycINFO, and MEDLINE. The search included a review of published manuscripts from 1978 through 2008.

RESULTS

A total of 579 articles were found and reviewed to determine the presence of reported employment rates. Of these, 60 articles were found to include a report of employment rates for individuals with SCI. Results indicated that, in studies that examined paid employment, the average rate of any employment after SCI was approximately 35%.

CONCLUSIONS

Characteristics associated with employment after SCI include demographic variables, injury-related factors, employment history, psychosocial issues, and disability benefit status. It is recommended that researchers studying employment after SCI use common outcome measures such as competitive employment rates, duration of employment, and job tenure. Empirical evidence is lacking in regard to the most effective methods of vocational rehabilitation among this population. Evidence-based supported employment practices seem to be the most applicable model for assisting persons with SCI in restoring meaningful employment. Controlled studies are needed to test this assumption.

Preference in random assignment: implications for the interpretation of randomized trials

Random assignment to a preferred experimental condition can increase service engagement and enhance outcomes, while assignment to a less-preferred condition can discourage service receipt and limit outcome attainment. We examined randomized trials for one prominent psychiatric rehabilitation intervention, supported employment, to gauge how often assignment preference might have complicated the interpretation of findings. Condition descriptions, and greater early attrition from services-as-usual comparison conditions, suggest that many study enrollees favored assignment to new rapid-job-placement supported employment, but no study took this possibility into account. Reviews of trials in other service fields are needed to determine whether this design problem is widespread.

The impact of supported employment and working on clinical and social functioning: results of an international study of individual placement and support

BACKGROUND

Concerns are frequently expressed that working might worsen the mental health of people with severe mental illness (SMI). Several studies of Individual Placement and Support (IPS), however, have found associations between working and better nonvocational outcomes. IPS has been found to double the return to work of people with SMI in 6 European countries.

AIMS

To explore separately associations between IPS, returning to work, and clinical and social outcomes.

METHODS

Patients (n = 312) in a randomized controlled trial of IPS in 6 European centers were followed up for 18 months.

RESULTS

There were no differences in clinical and social functioning between IPS and control patients at 18 months. Those who worked had better global functioning, fewer symptoms, and less social disability at final follow-up; greater job tenure was associated with better functioning. Working was associated with concurrently better clinical and social functioning, but this contrast was stronger in the control group, suggesting that IPS was better than the control service at helping more unwell patients into work. Working was associated with having been in remission and out of hospital for the previous 6 months. It was also associated with a slight decrease in depression and with being in remission over the subsequent 6 months.

CONCLUSIONS

Concerns among clinicians about possible detrimental effects of working and supported employment have been misplaced. Although some of the associations found may have been selection effects, there is sufficient evidence of work having beneficial effects on clinical and social functioning to merit further exploration.

Unmet need for mental health care in schizophrenia: an overview of literature and new data from a first-admission study

We present an overview of the literature on the patterns of mental health service use and the unmet need for care in individuals with schizophrenia with a focus on studies in the United States. We also present new data on the longitudinal course of treatments from a study of first-admission patients with schizophrenia. In epidemiological surveys, approximately 40% of the respondents with schizophrenia report that they have not received any mental health treatments in the preceding 6-12 months. Clinical epidemiological studies also find that many patients virtually drop out of treatment after their index contact with services and receive little mental health care in subsequent years. Clinical studies of patients in routine treatment settings indicate that the treatment patterns of these patients often fall short of the benchmarks set by evidence-based practice guidelines, while at least half of these patients continue to experience significant symptoms. The divergence from the guidelines is more pronounced with regard to psychosocial than medication treatments and in outpatient than in inpatient settings. The expansion of managed care has led to further reduction in the use of psychosocial treatments and, in some settings, continuity of care. In conclusion, we found a substantial level of unmet need for care among individuals with schizophrenia both at community level and in treatment settings. More than half of the individuals with this often chronic and disabling condition receive either no treatment or suboptimal treatment. Recovery in this patient population cannot be fully achieved without enhancing access to services and improving the quality of available services. The recent expansion of managed care has made this goal more difficult to achieve.

Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness

We examined the effectiveness of an integrated supported employment (ISE) program, which augments Individual Placement & Support (IPS) with social skills training (SST) in helping individuals with SMI achieve and maintain employment. A total of 163 participants were randomly assigned to three vocational rehabilitation programs: ISE, IPS, and traditional vocational rehabilitation (TVR). After fifteen months of services, ISE participants had significantly higher employment rates (78.8%) and longer job tenures (23.84 weeks) when compared with IPS and TVR participants. IPS participants demonstrated better vocational outcomes than TVR participants. The findings suggested that ISE enhances the outcomes of supported employment, endorsing the value of SST in vocational rehabilitation.

Outcomes of public concern in schizophrenia

BACKGROUND

Schizophrenia is known to be associated with a range of adverse outcomes, which have an impact atthe societal level and are therefore of public concern.

AIMS

To examine the epidemiology and methods for measuring six adverse outcomes in schizophrenia: violence, victimisation, suicide/self-harm, substance use, homelessness and unemployment.

METHOD

A review ofthe literature was carried out for each adverse outcome, with attention to critical appraisal of existing measurement tools.

RESULTS

Schizophrenia is associated strongly with all six outcomes, although research has mainly focused on violence. Each outcome acts as a risk factor for at least some of the other outcomes. There are few standardised or validated measures for these 'hard' outcomes. Each measure has inherent biases but a growing trend is for these to be minimised by using multiple measures.

CONCLUSIONS

A single instrument which systematically measures multiple societal outcomes of schizophrenia would be extremely useful for both clinical and research purposes.

Predictors of employment for people with severe mental illness: results of an international six-centre randomised controlled trial

BACKGROUND

An international six-centre randomised controlled trial comparing individual placement and support (IPS) with usual vocational rehabilitation for people with serious mental illness found IPS to be more effective for all vocational outcomes.

AIMS

To determine which patients with severe mental illness do well in vocational services and which process and service factors are associated with better outcomes.

METHOD

Patient characteristics and early process variables were tested as predictors of employment outcomes. Service characteristics were explored as predictors of the effectiveness of IPS.

RESULTS

Patients with previous work history, fewer met social needs and better relationships with their vocational workers were more likely to obtain employment and work for longer. Remission and swifter service uptake were associated with working more. Having an IPS service closer to the original IPS model was the only service characteristic associated with greater effectiveness.

CONCLUSIONS

The IPS service was found to be more effective for all vocational outcomes. In addition, maintaining high IPS fidelity and targeting relational skills would be a valuable focus for all vocational interventions, leading to improved employment outcomes. Motivation to find work may be decreased by satisfaction with current life circumstances.

Counseling Psychology and Chronic Health Conditions: A Call for Action

The authors support the assertion that counseling psychology expertise should be present at all levels of therapeutic activity that may benefit persons who live with chronic health conditions. They consider the impact of the increasing rates of chronic health conditions on health care systems, society, and health service professions. In order for the field to have an influential role in service delivery and policy formation that benefit individuals with chronic health conditions, the authors offer four recommendations: (a) Participate in, promote, and reward interdisciplinary research and service; (b) conduct, promote, and reward policy-relevant research programs; (c) promote and utilize participatory research methods; and (d) consider the implications of these activities for our training programs.

Changes in social network diversity and perceived social support after psychiatric hospitalization: results from a longitudinal study

BACKGROUND

There is a large empirical basis for the importance of social networks and support for people with a mental illness. However, only a few studies have examined the predictors, changes and correlations of these constructs within a longitudinal framework.

AIM

To analyze changes in social network diversity as measured by the number of social roles and perceived social support over the course of three years after a psychiatric hospitalization while controlling for sociodemographic and clinical variables. A further aim was to inquire whether some social roles are perceived as being more supportive than others.

METHOD

Random coefficient models were applied to the data of a longitudinal study on the life circumstances of people with affective disorders or schizophrenia (N = 183).

RESULTS

The majority of participants had relatives, friends and co-workers, while a markedly smaller proportion had a spouse/partner or children. Social network diversity increased during the time period observed while the perception of social support did not change. Being male, without a job (competitive or sheltered), or having a low income predicted less diverse networks. Partners and friends were perceived as most supportive. Persons without a close friendship perceived less overall support, but only at baseline (hospitalization), while persons with a job on the competitive labor market felt better supported.

CONCLUSIONS

Social disintegration in the course of mental illness that is found in some studies has no equivalent in our study in what concerns network diversity and perceived support. According to our results, characteristics of vocational and economic integration are of much greater relevance, as they enhance or hinder access to social participation.

Substance use and abuse in first-episode psychosis: prevalence before and after early intervention

Despite the high prevalence of substance abuse among first-episode psychosis (FEP) populations, few studies examine whether early intervention (EI) improves substance abuse.

OBJECTIVE

To examine the prevalence and pattern of substance use and abuse among an FEP sample over 12 months.

METHODS

All the participants were diagnosed with a first episode of a schizophrenia spectrum disorder. The participants were followed prospectively. The prevalence rates of substance use and abuse from this sample were compared before and after 12 months of EI services and were compared with rates observed in a sample from the general population.

RESULTS

A total of 200 participants (80.0% males; mean age 24 years) entered the study: 183 participants completed all the assessments at baseline, 131 participants completed all the assessments at 12 months. At baseline, the findings showed similar prevalence rates between the FEP sample and the general sample for lifetime cannabis use (60% vs 55%, respectively) and hazardous alcohol use (26% vs 21%) but significantly different prevalence rates for lifetime hallucinogen (29% vs 15%; P < .001) and cocaine use (20% vs 14%; P < .001). At 12 months, the prevalence rates for drug abuse (P < .01), hazardous alcohol use (P < .01), and concurrent drug abuse and hazardous alcohol use (P < .05) were significantly lower than at baseline.

CONCLUSION

Substance use and abuse decreased significantly after 12 months of EI services; EI services may be able to detect and to reduce substance use among FEP patients before it becomes a more serious disorder.

The stigma of schizophrenia from patients' and relatives' view: A pilot study in an Italian rehabilitation residential care unit

OBJECTIVE

To identify the constituent elements of the stigma from the perspective of those having first-hand experiences of it.

METHODS

Subjective experiences of stigma were explored in six focus groups: three with people suffering from schizophrenia and three with patients' relatives. Focus group sessions were tape-recorded, transcribed and analyzed by means of an inductive method, forming categories from the texts, as a basis for coding. Analysis aimed at establishing a typology of stigmatization experiences from the spoken words of the focus group participants.

RESULTS

Four dimensions of stigma were identified: access to social roles; internalization of stigma; quality of mental health services, public image of mental illness.

CONCLUSION

The most frequently found topics concerned experiences of marginalization and discrimination that people with schizophrenia experience in their daily life. These results mirror the findings of similar studies obtained in other cultural contexts.

The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial

BACKGROUND

The value of the individual placement and support (IPS) programme in helping people with severe mental illness gain open employment is unknown in Europe. Our aim was to assess the effectiveness of IPS, and to examine whether its effect is modified by local labour markets and welfare systems.

METHODS

312 patients with severe mental illness were randomly assigned in six European centres to receive IPS (n=156) or vocational services (n=156). Patients were followed up for 18 months. The primary outcome was the difference between the proportions of people entering competitive employment in the two groups. The heterogeneity of IPS effectiveness was explored with prospective meta-analyses to establish the effect of local welfare systems and labour markets. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, with the number NCT00461318.

FINDINGS

IPS was more effective than vocational services for every vocational outcome, with 85 (55%) patients assigned to IPS working for at least 1 day compared with 43 (28%) patients assigned to vocational services (difference 26.9%, 95% CI 16.4-37.4). Patients assigned to vocational services were significantly more likely to drop out of the service and to be readmitted to hospital than were those assigned to IPS (drop-out 70 [45%] vs 20 [13%]; difference -32.1% [95% CI -41.5 to -22.7]; readmission 42 [31%] vs 28 [20%]; difference -11.2% [-21.5 to -0.90]). Local unemployment rates accounted for a substantial amount of the heterogeneity in IPS effectiveness.

INTERPRETATION

Our demonstration of the effectiveness of IPS in widely differing labour market and welfare contexts confirms this service to be an effective approach for vocational rehabilitation in mental health that deserves investment and further investigation.

Rehabilitation and recovery in schizophrenia

The combination of new medications and effective psychosocial rehabilitation interventions has the potential to improve outcomes for individuals with schizophrenia significantly. Patients who have persistent positive symptoms can benefit from cognitive behavior therapy. Impairments in social competence can be addressed with social skills training. Supported employment programs may increase the ability of patients who have schizophrenia to obtain competitive employment. Family psychoeducational approaches, treatments for comorbid substance abuse, and cognitive rehabilitation approaches that enhance or bypass impairments in cognitive functioning are discussed. This article describes current efforts to incorporate these evidence-based principles of rehabilitative medicine into the management of schizophrenia.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To estimate the effects of supportive therapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (January 2004), supplemented by manual reference searching and contact with authors of relevant reviews or studies.

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the relative risk (RR) fixed effect with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, we calculated the number needed to treat/harm (NNT/H). We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

We included 21 relevant studies. We found no significant differences in the primary outcomes between supportive therapy and standard care. There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (3 RCTs, n=241, RR 2.12 CI 1.2 to 3.6, NNT 8) but not relapse rates (5 RCTs, n=270, RR 1.18 CI 0.9 to 1.5). We found that the results for general functioning significantly favoured cognitive behavioural therapy compared with supportive therapy in the short (1 RCT, n=70, WMD -9.50 CI -16.1 to -2.9), medium (1 RCT, n=67, WMD -12.6 CI -19.4 to -5.8) and long term (2 RCTs, n=78, SMD -0.50 CI -1.0 to -0.04), but the clinical significance of these findings based on few data is unclear. Participants were less likely to be satisfied with care if receiving supportive therapy compared with cognitive behavioural treatment (1 RCT, n=45, RR 3.19 CI 1.0 to 10.1, NNT 4 CI 2 to 736). The results for mental state and symptoms were unclear in the comparisons with other therapies. No data were available to assess the impact of supportive therapy on engagement with structured activities.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models

OBJECTIVE

In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services.

METHODS

Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt.

RESULTS

Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay.

CONCLUSIONS

Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.