Vocational rehabilitation for people with severe mental illness

[How sustainable is supported employment? A follow-up investigation]

SUBJECT

The largest European multicenter randomized controlled trial to date on the effectiveness of supported employment (EQOLISE) was conducted in six European centres until 2005. It revealed that the intervention "individual placement and support" was more effective than conventional prevocational training services. The aim of this investigation was to assess the Zurich sample (individuals with schizophrenic, schizoaffective or bipolar disorders) 24 months after termination of the EQOLISE trial in terms of working situation, income, and hospital admissions. More favorable outcomes concerning these parameters were assumed for the intervention group.

METHODS

Assessment of the working situation and psychiatric hospitalizations since the end as well as the development of salaries since the start of EQOLISE. Comparisons between groups and illustration of incomes using a random coefficient model were conducted.

RESULTS

50% of the original sample could be assessed. All subjects who worked in competitive workplaces at the end of EQOLISE were met in a different situation. No differences were found concerning hospital admissions. The mean monthly income considerably increased during EQOLISE and decreased during the third year. At the time of follow-up it was approximately at the same level as the slightly increased control group.

CONCLUSIONS

This investigation points at limited sustainability of supported employment among individuals with severe mental disorders in terms of maintenance of employment and income if the job coaching is not continued.

The cost-effectiveness of supported employment for adults with autism in the United Kingdom

Adults with autism face high rates of unemployment. Supported employment enables individuals with autism to secure and maintain a paid job in a regular work environment. The objective of this study was to assess the cost-effectiveness of supported employment compared with standard care (day services) for adults with autism in the United Kingdom. Thus, a decision-analytic economic model was developed, which used outcome data from the only trial that has evaluated supported employment for adults with autism in the United Kingdom. The main analysis considered intervention costs, while cost-savings associated with changes in accommodation status and National Health Service and personal social service resource use were examined in secondary analyses. Two outcome measures were used: the number of weeks in employment and the quality-adjusted life year. Supported employment resulted in better outcomes compared with standard care, at an extra cost of £18 per additional week in employment or £5600 per quality-adjusted life year. In secondary analyses that incorporated potential cost-savings, supported employment dominated standard care (i.e. it produced better outcomes at a lower total cost). The analysis suggests that supported employment schemes for adults with autism in the United Kingdom are cost-effective compared with standard care. Further research needs to confirm these findings.

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.

Work reintegration for veterans with mental disorders: a systematic literature review to inform research

BACKGROUND

Some veterans, and especially those with mental disorders, have difficulty reintegrating into the civilian workforce.

PURPOSE

The objectives of this study were to describe the scope of the existing literature on mental disorders and unemployment and to identify factors potentially associated with reintegration of workers with mental disorders into the workforce.

DATA SOURCES

The following databases were searched from their respective inception dates: MEDLINE, EMBASE, Cumulative Index Nursing Allied Health (CINAHL), and PsycINFO.

STUDY SELECTION

In-scope studies had quantitative measures of employment and study populations with well-described mental disorders (eg, anxiety, depression, posttraumatic stress disorder, substance-use disorders).

DATA EXTRACTION

A systematic and comprehensive search of the relevant published literature up to July 2009 was conducted that identified a total of 5,195 articles. From that list, 81 in-scope studies were identified. An update to July 2012 identified 1,267 new articles, resulting in an additional 16 in-scope articles.

DATA SYNTHESIS

Three major categories emerged from the in-scope articles: return to work, supported employment, and reintegration. The literature on return to work and supported employment is well summarized by existing reviews. The reintegration literature included 32 in-scope articles; only 10 of these were conducted in populations of veterans.

LIMITATIONS

Studies of reintegration to work were not similar enough to synthesize, and it was inappropriate to pool results for this category of literature.

CONCLUSIONS

Comprehensive literature review found limited knowledge about how to integrate people with mental disorders into a new workplace after a prolonged absence (>1 year). Even more limited knowledge was found for veterans. The results informed the next steps for our research team to enhance successful reintegration of veterans with mental disorders into the civilian workplace.

From social experience to illness experience: reviewing the psychological mechanisms linking psychosis with social context

This review was undertaken to describe the psychological processes that are associated with the social experiences and behaviours of people with psychosis. A systematic search was conducted using MEDLINE and PsycINFO search engines. In each of the major topic domains, the search was comprised of review articles published from 2004 to present, and individual article searches for papers published from 2010 to present. The key psychological mechanisms in this context are social cognition, self-concept, emotion, and communication. While diverse in content, there were several cross-cutting themes in these literatures. These include evidence of the presence of social processing difficulties in high-risk and psychosis populations that have both state and trait characteristics, are related to, but not fully accounted for by, neurocognition and symptomatology, and have significant implications for social functioning. There are numerous established and promising treatments linked to our understanding of social cognition. Limitations cutting across these literatures include a substantial reliance on cross-sectional studies that use control groups comprised of people who have not experienced significant psychological or social adversity. There is also limited inquiry into how psychological mechanisms may differ owing to sex, ethnicity, and race. Despite these issues, this line of inquiry is very promising as part of the larger movement toward an integrative model of psychosis that is able to account for the complex interactions of social, biological, and psychological risks.

[How can the mentally ill achieve sustained employment? Supported employment versus pre-vocational training]

People with severe mental disorders are often without work, although work may have a positive effect on their health. The paper presents some results in this field from the German S3 guidelines on psychosocial therapies. In terms of evidence-based medicine supported employment (SE - first place then train) has proven to be most effective. Nevertheless, SE is still rare in Germany. Pre-vocational training, however, follows the concept first train then place and is offered in rehabilitation of the mentally ill (RPK) centres in Germany. There is some evidence that the programs are beneficial for users. The UN Convention for the Rights of Persons with Disabilities outlines an obligation for work on an equal basis with others and for vocational training. So far, the German mental health system only partly meets these requirements.

The impact of Vocational, Education, Training and Employment Coordinator positions on attitudes and practices in a NSW mental health service

OBJECTIVE

To determine attitudes and practices of community mental health clinicians in relation to employment and education for consumers and to assess the impact of the establishment of Vocational, Education, Training and Employment (VETE) Coordinator positions.

METHOD

A snapshot was conducted by surveying community mental health clinicians regarding every consumer on their caseload in 2007. This was repeated in 2010 and the results were compared.

RESULTS

From 2007 to 2010, the overall rates of VETE interventions increased, including a doubling of the rate of linkage to employment agencies for job seekers. Services with the consistent presence of a VETE Coordinator showed a greater impact on a number of factors, highlighted by a positive shift in clinician attitudes regarding their consumers' capacity to work.

CONCLUSION

The establishment of VETE Coordination positions in the mental health service appears to be an effective way of raising awareness of VETE issues and improving VETE service provision. An important role has been assisting clinicians to begin implementing the principles of the Individual Placement and Support model of Supported Employment and to incorporate support for employment and education as a routine part of practice.

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.

The World Health Organization Short Disability Assessment Schedule: a validation study in patients with schizophrenia

PURPOSE

The World Health Organization Short Disability Assessment Schedule (DAS-s) is used for patients with schizophrenia, although no validation is available. This manuscript addresses this issue by dealing with its psychometric properties in a clinical sample of patients with schizophrenia.

METHODS

Two hundred forty-one patients from 10 Adult Mental Health Care Centers meeting the following inclusion criteria were included: (1) International Classification of Diseases, 10th Revision, diagnosis of schizophrenia; (2) Global Assessment of Functioning scores 50 or less; (3) illness duration of more than 2 years; and (4) clinical stability at assessment time. Patients were evaluated at baseline and at 1-year follow-up regarding disability, sociodemographic and clinical variables, psychosocial measures, and use of mental health services.

RESULTS

The factor analysis revealed a single factor that explained 60.57% of the variance. Internal consistency values were appropriate for the DAS-s total (0.78 at baseline and 0.78 at 1-year follow-up). Correlations between DAS-s scores and those of global functioning, psychiatric symptoms, social support, and quality of life ranged between small and moderate (range, 0.13-0.39). There were significant differences between groups of patients with schizophrenia in the DAS-s. Patients who were unemployed, with lower global functioning, with cognitive impairment, and lacking social support scored significantly lower in DAS-s scores. After 1-year follow-up, there was a nonsignificant decrease in DAS-s scores; and patients improved significantly in overall functioning and psychiatric symptoms.

DISCUSSION

This study shows that the DAS-s has good reliability and validity and suggests that it is suitable for the assessment of disability in patients with schizophrenia.

The role of motivation for treatment success

Learning during skills-based psychosocial treatments for schizophrenia is influenced by the motivating properties of the treatment context and the motivational orientation of the client. Given that motivational impairment is a core feature of schizophrenia with significant functional implications, intervention strategies emphasizing extrinsic and/or intrinsic goals may be prescribed to enhance skill learning and treatment outcomes. The purpose of this article is to consider the role that motivation plays in treatment success by evaluating the relationship between motivation and learning during cognitive remediation for schizophrenia. As intrinsic motivation (IM) is most often associated with learning, we will integrate research findings which address 3 main questions: (1) is IM in schizophrenia static or dynamic, (2) is it possible to manipulate the state of being intrinsically motivated and if so do manipulations of IM affect learning? and (3) can motivation theory be translated into clinical practice? This knowledge can facilitate treatment strategies to address the low base rate of IM that is characteristic of schizophrenia and can be applied to cognitive remediation as well as other psychosocial interventions which require learning for treatment success.

Prognostic factors of long term disability due to mental disorders: a systematic review

INTRODUCTION In the past few decades, mental health problems have increasingly contributed to sickness absence and long-term disability. However, little is known about prognostic factors of return to work (RTW) and disability of persons already on sick leave due to mental health problems. Understanding these factors may help to develop effective prevention and intervention strategies to shorten the duration of disability and facilitate RTW. METHOD We reviewed systematically current scientific evidence about prognostic factors for mental health related long term disability, RTW and symptom recovery. Searching PubMed, PsycINFO, Embase, Cinahl and Business Source Premier, we selected articles with a publication date from January 1990 to March 2009, describing longitudinal cohort studies with a follow-up period of at least 1 year. Participants were persons on sick leave or receiving disability benefit at baseline. We assessed the methodological quality of included studies using an established criteria list. Consistent findings in at least two high quality studies were defined as strong evidence and positive findings in one high quality study were defined as limited evidence. RESULTS Out of 796 studies, we included seven articles, all of high methodological quality describing a range of prognostic factors, according to the ICF-model categorized as health-related, personal and external factors. We found strong evidence that older age (>50 years) is associated with continuing disability and longer time to RTW. There is limited evidence for the association of other personal factors (gender, education, history of previous sickness absence, negative recovery expectation, socio-economic status), health related (stress-related and shoulder/back pain, depression/anxiety disorder) and external i.e., job-related factors (unemployment, quality and continuity of occupational care, supervisor behavior) with disability and RTW. We found limited evidence for the association of personal/external factors (education, sole breadwinner, partial/full RTW, changing work tasks) with symptom recovery. CONCLUSION This systematic review identifies a number of prognostic factors, some more or less consistent with findings in related literature (mental health factors, age, history of previous sickness absence, negative recovery expectation, socio-economic status, unemployment, quality and continuity of occupational care), while other prognostic factors (gender, level of education, sole breadwinner, supervisor support) conflict with existing evidence. There is still great need for research on modifiable prognostic factors of continuing disability and RTW among benefit claimants with mental health problems. Recommendations are made as to directions and methodological quality of further research, i.e., prognostic cohort studies.

A systematic review of functioning in vocational rehabilitation using the International Classification of Functioning, Disability and Health

BACKGROUND

Vocational rehabilitation (VR) is aimed at engaging or re-engaging individuals with work participation and employment. The International Classification of Functioning, Disability and Health (ICF) by the World Health Organization can be operationalized in the context of VR. The objective of this study is to review the literature to identify outcomes or measures being used in VR using a systematic review methodology and link those measures to the ICF.

METHODS

We applied a structured search strategy using multiple databases. Items or constructs of the measures or outcomes identified were linked to the ICF by two trained individuals.

RESULTS

We have identified 648 measures which contained 10,582 concepts that were linked to the ICF which resulted in 87 second-level ICF categories. Out of the 87 categories, 31 (35.6%) were related to body functions, 43 (49.4%) were related to activities and participation, and 13 (14.9%) were related to environmental factors. No category was related to body structures.

CONCLUSIONS

Our review found great diversity in the ICF contents of the measures used in different VR settings and study populations, which indicates the complexity of VR. This systematic review has provided a list of ICF categories which could be considered towards a successful VR.

An international expert survey on functioning in vocational rehabilitation using the International Classification of Functioning, Disability and Health

BACKGROUND

Vocational rehabilitation (VR) is a key process in work disability (WD) management which aims to engage or re-engage individuals to work and employment. The International Classification of Functioning, Disability and Health (ICF) by the World Health Organization (WHO) can be interfaced with VR but there is a lack of evidence of what ICF contents experts in the field consider. The objective of this study is to survey the experts in the VR field with regard to what factors are considered important to patients participating in VR using the ICF as the language to summarize the results.

METHODS

An internet-based survey was conducted with experts from six WHO Regions (Africa, the Americas, Eastern Mediterranean, Europe, South-East Asia, and Western Pacific). Experts were asked six open-ended questions on factors that are important in VR. Each question was related to a component of the ICF (body functions, body structures, activities and, environmental factors, and personal factors). Responses were linked to the ICF.

RESULTS

Using a modified stratified randomized sampling, 201 experts were sent the survey and 151 experts responded (75% response rate). We identified 101 ICF categories: 22 (21.8%) for body functions, 13 (12.9%) for body structures, 36 (35.6%) for activities and participation, and 30 (29.7%) for environmental factors.

CONCLUSIONS

There was a multitude of ICF functioning domains according to the respondents which indicates the complexity of VR. This expert survey has provided a list of ICF categories which could be considered in VR.

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.

Developing a Core Set to describe functioning in vocational rehabilitation using the international classification of functioning, disability, and health (ICF)

INTRODUCTION

The consequences of accidents, injuries, and health conditions that prevent workers from engaging in employment are prevailing issues in the area of work disability. Vocational rehabilitation (VR) programs aim to facilitate return-to-work process but there is no universal description of functioning for patients who participate in VR. Our objective is to develop a Core Set for VR based on the international classification of functioning, disability, and health (ICF). An ICF Core Set is a short list of ICF categories with alphanumeric codes relevant to a health condition or a health-related event.

METHODS

Development process consists of three phases. First is the preparatory phase which consists of four parallel studies: (1) systematic review of the literature, (2) worldwide survey of experts, (3) cross-sectional study, and (4) focus group interview. Patients with various health conditions are to be recruited from five VR centers located in Switzerland and Germany. The second phase is a consensus conference where findings from the preparatory phase will be presented followed by a multi-stage consensus process to determine the ICF categories that will comprise the Core Set for VR. The final phase consists of validation studies in several health conditions and settings.

CONCLUSIONS

We expect the first version of the ICF Core Set for VR to be completed in 2010. The Core Set can serve as a guide in the evaluation of patients and in planning appropriate intervention within VR programs. This Core Set could also provide a standard and common language among clinicians, researchers, insurers, and policymakers in the implementation of successful VR.

Effectiveness of adjuvant occupational therapy in employees with depression: design of a randomized controlled trial

Background

Major depressive disorder is among the medical conditions with the highest negative impact on work outcome. However, little is known regarding evidence-based interventions targeting the improvement of work outcomes in depressed employees. In this paper, the design of a randomized controlled trial is presented in order to evaluate the effectiveness of adjuvant occupational therapy in employees with depression. This occupational intervention is based on an earlier intervention, which was designed and proven effective by our research group, and is the only intervention to date that specifically targets work outcome in depressed employees.

Methods/Design

In a two-arm randomized controlled trial, a total of 117 participants are randomized to either 'care as usual' or ' care as usual' with the addition of occupational therapy. Patients included in the study are employees who are absent from work due to depression for at least 25% of their contract hours, and who have a possibility of returning to their own or a new job. The occupational intervention consists of six individual sessions, eight group sessions and a work-place visit over a 16-week period. By increasing exposure to the working environment, and by stimulating communication between employer and employee, the occupational intervention aims to enhance self-efficacy and the acquisition of more adaptive coping strategies. Assessments take place at baseline, and at 6, 12, and 18-month follow-ups. Primary outcome measure is work participation (hours of absenteeism and time until work resumption). Secondary outcome measures are work functioning, symptomatology, health-related quality of life, and neurocognitive functioning. In addition, cost-effectiveness is evaluated from a societal perspective. Finally, mechanisms of change (intermediate outcomes) and potential patient-treatment matching variables are investigated.

Discussion

This study hopes to provide valuable knowledge regarding an intervention to treat depression, one of the most common and debilitating diseases of our time. If our intervention is proven (cost-) effective, the personal, economic, and health benefits for both patients and employers are far-reaching.

Trial registration number

NTR2057

Evidence of the effectiveness of a specialist vocational intervention following first episode psychosis: a naturalistic prospective cohort study

BACKGROUND

Employment rates among people with severe mental illness are low and work has beneficial effects on mental health. There is now good evidence of the effectiveness of a specialist vocational intervention (supported employment) in people with schizophrenia. However, the potential benefits of modifying this model for use in first episode psychosis cohorts remain relatively untested.

METHODS

The aim of our study was to evaluate the effectiveness of a specialist vocational intervention in aiding vocational recovery following the onset of first episode psychosis. In a naturalistic prospective cohort study, 114 first episode psychosis service users were followed up during 12 months of engagement with an early intervention service; 44 resident in an area where a vocational intervention was available and 70 in an area where it was not.

RESULTS

The main finding in our study was that having access to the specialist vocational intervention was a statistically significant independent predictor of vocational recovery during 12 months of follow-up (after adjusting for confounders). Service users who had access to the intervention had odds of achieving vocational recovery 3.53 times greater than those who did not (OR = 3.53, 95% CI = 1.25-10.00).

CONCLUSION

This study provides further preliminary evidence of the effectiveness of a specialist vocational intervention following first episode psychosis. This is an important outcome from the perspective of service users and clinicians alike (as well as having wider societal value). Other important predictors of vocational recovery cannot be modified by the time a first episode psychosis emerges.

Supported employment for adults with severe mental illness

This is the protocol for a review and there is no abstract. The objectives are as follows: To review the effectiveness of supported employment compared to other approached to vocational rehabilitation and treatment as usual.Secondary objectives are to establish how far: fidelity to the IPS model affects the effectiveness of supported employment,the effectiveness of supported employment can be augmented by the addition of other interventions.

Measuring Social Inclusion: A Staff Survey of Mental Health Service Users' Participation in Community Occupations

Mental health service users frequently experience social exclusion and limited occupational engagement. A survey was conducted to gather staff reports of 199 service users' levels of engagement and social inclusion across eight domains of community occupation.

The staff reported that the majority of service users (54%) engaged in two or fewer of the community occupation domains over a 7-day period, the most common being the use of local facilities (92%) and contact with family and friends (61%). The staff reports suggested that far fewer service users were engaged in the other domains: day centres (25%), education (14%), sport (13%), arts (12%), employment (11%) and faith (8%). With regard to social inclusion, activities occurred most frequently in mainstream settings for the domains of faith (100%), use of local facilities (98%), sport (80%), and family and friends (79%). Lower levels of social inclusion were reported for the other domains. Statistical analysis revealed that service users' occupational engagement related to their accommodation type, age and gender, but not to ethnicity.

These findings indicate that further research is needed to explore service users' views on social inclusion and what they feel would support them to engage in community occupations at a level that suits their individual needs.

A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems

BACKGROUND

A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components.

METHODS

We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery.

RESULTS

We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation).

CONCLUSION

Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.

Current approaches to the management of schizophrenia

Welcome to the second module in our Continuing Professional Development Section (CPD). CPD is now a key element in the clinical activity of all health professionals and a cornerstone of good clinical governance throughout mental health services. This section of the Irish Journal of Psychological Medicine will provide CPD modules dedicated to key topics in mental health care. In order to assist learning and self-assessment, multiple choice questions will be provided at the end of each module. This module and its multiple choice questions are available online on the website of the Irish Journal of Psychological Medicine (www.ijpm.org). The CPD policy of the College of Psychiatry of Ireland indicates that psychiatrists who participate in suitable online learning which fits the criteria for CPD may claim CPD points under the Personal CPD category (up to a maximum of 5 points per year). We are confident that this CPD Section of the Irish Journal of Psychological Medicine will prove to be a valuable resource for consultant psychiatrists, psychiatric trainees and all journal readers. We welcome feedback from readers and, especially, any suggestions for topics to be covered in future CPD modules. Suggestions should be emailed to: psychological@medmedia.ie.

Social security and mental illness: reducing disability with supported employment

Social Security Administration disability programs are expensive, growing, and headed toward bankruptcy. People with psychiatric disabilities now constitute the largest and most rapidly expanding subgroup of program beneficiaries. Evidence-based supported employment is a well-defined, rigorously tested service model that helps people with psychiatric disabilities obtain and succeed in competitive employment. Providing evidence-based supported employment and mental health services to this population could reduce the growing rates of disability and enable those already disabled to contribute positively to the workforce and to their own welfare, at little or no cost (and, depending on assumptions, a possible savings) to the government.

Effectiveness of vocational rehabilitation intervention on the return to work and employment of persons with multiple sclerosis

BACKGROUND

Multiple sclerosis is a neurological disease that frequently affects adults of working age, resulting in a range of physical, cognitive and psychosocial deficits that impact on workforce participation. Although, the literature supports vocational rehabilitation (VR) approaches in persons with multiple sclerosis (pwMS), the evidence for its effectiveness is yet to be established.

OBJECTIVES

To evaluate the effectiveness of VR programs compared to alternative programs or care as usual on return to work, workability and employment in pwMS; to evaluate the cost effectiveness of these programs.

SEARCH STRATEGY

Electronic searches included: Cochrane Central Register of Controlled Trials "CENTRAL" 2008 issue 3, MEDLINE (PubMed) (1966- 2008), EMBASE (1988- 2008), CINAHL (1982- 2008), PEDro (1990- 2008), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register.

SELECTION CRITERIA

Randomized and controlled clinical trials, including before - after controlled trials, that compare VR rehabilitation with alternative intervention such as standard or a lesser form of intervention or waitlist controls.

DATA COLLECTION AND ANALYSIS

Two reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis was performed, based on methodological quality. Trials were grouped in terms of type and setting of VR programs.

MAIN RESULTS

Two trials (one RCT and one CCT) (total 80 participants) met the review criteria. Both trials scored poorly on the methodological quality assessment. There was 'insufficient evidence' for VR programs for (a)'competitive employment', in altering rates of job retention, changes in employment, improvement in rates of re-entry into the labour force; (b) for altering 'work ability' by improving participants' confidence in the accommodation request process, or employability maturity or job seeking activity. No evidence could be assimilated for changes in proportions of persons in supported employment or on disability pensions, nor for cost-effectiveness.

AUTHORS' CONCLUSIONS

There was inconclusive evidence to support VR for pwMS. However, the review highlights some of the challenges in providing VR for pwMS. Clinicians need to be aware of vocational issues, and to understand and manage barriers for maintaining employment. Proactive and timely VR programs should incorporate practical solutions to deal with work disability, workplace accommodation and educate employers, and the wider community. Liaison with policy makers is imperative for government initiatives that encourage work focused VR programs. Future research in VR should focus on improving methodological and scientific rigour of clinical trials; on the development of appropriate and valid outcome measures; and on cost effectiveness of VR programs.

Frequency and effects of psychosocial interventions additional to olanzapine treatment in routine care of schizophrenic patients

BACKGROUND

Guidelines for the treatment of schizophrenia recommend the combination of pharmacologic and psychosocial interventions. There is a lack of data on the utilization and effects of psychosocial interventions additional to neuroleptic treatment in routine care of schizophrenic patients.

METHOD

In a drug utilization study 495 psychiatrists documented patient and disease characteristics of 1,711 schizophrenic outpatients treated with olanzapine. Data were recorded at five visits during an observation period of 6 months.

RESULTS

Psychosocial interventions were reported in 30% of all patients. Compared to patients who were treated with olanzapine alone (nPSI), patients receiving psychosocial interventions (PSI) were more likely to be unmarried and unemployed, and showed significantly higher impairment on relevant psychopathological and psychosocial parameters (e.g. PANSS, GAF, LQLP). After 6 months of treatment with olanzapine patients improved significantly in respect to their schizophrenic symptoms, psychosocial functioning, and quality of life. Patients receiving psychoeducation showed a higher degree of improvement than the other patients. They were more ill at the beginning of the study, but less ill at the end of the study. Patients receiving psychoeducation showed a trend to better medication compliance.

CONCLUSIONS

The data suggest that psychosocial interventions are a frequently used mode of treatment especially for severe cases of schizophrenia Psychoeducation appears to be especially effective for this patient group with a positive impact not only on psychosocial but also on psychopathological criteria of outcome.

Organizational change to transfer knowledge and improve quality and outcomes of care for patients with severe mental illness: a systematic overview of reviews

OBJECTIVE

To provide a comprehensive overview of the research on organizational changes aimed at improving health care for patients with severe mental illness and to learn lessons for mental health practice from the results.

METHOD

We searched for systematic literature reviews published in English during 2000 to 2007 in PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Central Register of Systematic Reviews. Three reviewers independently selected and assessed the studies' quality. Studies involving changes of who delivers health care, how care is organized, or where care is delivered were included. We categorized the studies using an existing taxonomy of 6 broad categories of strategies for organizational change.

RESULTS

A total of 21 reviews were included. Among these, 17 had reasonably good methodological quality, Almost all reviews included or intended to include randomized controlled trials (RCTs), 6 reviews did not identify studies that met eligibility criteria. Multidisciplinary teams and integrated care models had been reviewed most frequently (a total of 15 reviews). In most studies, these types of changes showed better outcomes in terms of symptom severity, functioning, employment, and housing, compared with conventional services. Different results were found on cost savings. Other types of organizational changes, such as changing professional roles or introducing quality management or knowledge management, were much less frequently reviewed. Very few reviews looked at effects of organizational changes on professional performance.

CONCLUSIONS

There is a fairly large body of evidence of the positive impact of multidisciplinary teams and integrated care changes on symptom severity, functioning, employment, and housing of people with severe mental illness, compared with conventional services. Other strategies, such as changes in professional roles, quality or knowledge management, have either not been the subject of systematic reviews or have not been evaluated in RCTs. There is still a lack of insight in the so-called black box of change processes and the impact of change on professional performance.

Treatment and prevention of mental disorders in low-income and middle-income countries

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Transitional discharge based on therapeutic relationships: state of the art

The Transitional Discharge Model (TDM) has been used to facilitate effective discharge from psychiatric hospital to community. A summary of the research to date on TDM is given. The model is based on the provision of therapeutic relationships to provide a safety net throughout the discharge and community reintegration processes. These relationships include both staff and peer involvement; hospital inpatient staff continue to remain involved with the client until a therapeutic relationship is established with a community care provider, and peer support is offered from a former consumer of mental health services who is currently living in the community. Studies found that the TDM facilitates increased discharge rates, lower readmission rates, and cost savings--making it a collaborative, cost-effective method of providing quality patient care and positive health care outcomes. The TDM Plan of Research is presented and reflects the collaboration between stakeholders and the integration of consumer advocacy, clinical practice, education, policy, and research in various countries.

Hospital-based industrial therapy units and the people who work within them - an Irish case analysis using a soft-systems approach

Occupational training and employment is seen as a central concern in the delivery of community-orientated mental health services aimed at enhancing the quality of life of people with enduring mental illness. A range of schemes from sheltered to open employment now operates in a number of countries, with a concomitant growth of interest in their evaluation. At the same time, hospital-based workshops, often referred to as industrial therapy units (ITUs), have steadily declined because they are seen as outdated and less efficacious compared with community-located training and employment. However, whether the total disappearance of the traditional ITU is a positive development may be open to question. This paper reports on a study of five mental health hospital-based sheltered workshops located in one Health Board area in Ireland, which catered for the needs of people with enduring mental health problems. Utilizing a soft-systems methodological approach, it examined their role and significance to 'users' who spent occupational time in them, the staff who worked in them and the clinicians who referred users to them.

How can doctors help their patients to return to work?

Getting back to work is important for most patients but doctors are often unsure how best to help. The article reviews evidence for the effectiveness of the interventions now available.

[Care requirements for severe mental disorders. Scientific evidence for integration of clinical psychiatry and community psychiatry]

In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.

Assessing cost-effectiveness in mental health: vocational rehabilitation for schizophrenia and related conditions

OBJECTIVE

Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia.

METHOD

The net benefit of IPS is assessed from a health sector perspective using cost-benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis.

RESULTS

The costs of IPS are 10.3M Australian dollars (95% uncertainty interval 7.4M-13.6M Australian dollars), the benefits are 4.7M (3.1M-6.5M Australian dollars), resulting in a negative net benefit of 5.6M Australian dollars (8.4M-3.4M Australian dollars).

CONCLUSIONS

The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

Improving the vocational status of patients with long-term mental illness: a randomised controlled trial of staff training

OBJECTIVE

To investigate the impact of training CMHT members in the practice of Individual Placement and Support on the vocational status of long-term patients.

METHOD

Six CMHTs received vocational training by a work co-ordinator; four continued with standard care. The best vocational status of the 1037 subjects was ascertained after one year. Factors associated with improvement in vocational status were identified.

RESULTS

There was no difference in change of vocational status. Age, previous employment and diagnosis influenced outcome.

CONCLUSION

Training in IPS at team level did not improve employment status. A dedicated, vocational worker appears to be essential for successful IPS.