An update on supported employment for people with severe mental illness

Recovery from schizophrenia: a four-year study of an inner city cohort

Converging evidence support the establishment of integrative approaches combining pharmacotherapy and psychosocial interventions for the treatment of patients with schizophrenia. Nonetheless, most studies have been limited with regard to treatment duration and their external validty has been questioned. The present study aimed at evaluating the effectiveness of the routine use of a continued integrative treatment approach in promoting clinical and social recovery from schizophrenia over 4 years. At a community mental health centre in Athens, 60 consecutive cases with a DSM-IV diagnosis of schizophrenic spectrum disorders were included into the study. Indepedent raters assessed the patients' level of functioning, cognitive impairment, disability, distress and caregivers' stress at baseline and annually for 4 years. The results of the study showed a stable linear pattern of improvement in all outcome measures with moderate to small effect sizes; while competitive employment and independent living emerged as the areas which benefited the least from the treatment program. Overall, the study supports the application of evidence-based integrative strategies to routine services, as long as they are provided in a timely and continued manner.

A location-based prompting system to transition autonomously through vocational tasks for individuals with cognitive impairments

This study assessed the possibility of training two individuals with cognitive impairments using location-based task prompting system in a supported employment program. This study was carried out according to an ABAB sequence in which A represented the baseline and B represented intervention phases. Data showed that the two participants significantly increased their target response, thus improving vocational job performance during the intervention phases. Practical and developmental implications of the findings are discussed.

A gesture recognition system to transition autonomously through vocational tasks for individuals with cognitive impairments

This study assessed the possibility of training two individuals with cognitive impairments using a Kinect-based task prompting system. This study was carried out according to an ABAB sequence in which A represented the baseline and B represented intervention phases. Data showed that the two participants significantly increased their target response, thus improving vocational job skills during the intervention phases. Practical and developmental implications of the findings are discussed.

An accelerometer-based handheld system to reduce breaks in performance of young adults with cognitive impairments

This study assessed the possibility of training two individuals with cognitive impairments using a system that reduced breaks in performance. This study was carried out according to an ABAB sequence in which A represented the baseline and B represented intervention phases. Data showed that the two participants significantly increased their target response, thus reducing breaks and improving vocational job performance during the intervention phases. Practical and developmental implications of the findings are discussed.

Insight and negative symptoms as predictors of functioning in a work setting in patients with schizophrenia

The present study was conducted to explore correlates of vocational outcome for individuals with schizophrenia. Seventy-eight individuals with schizophrenia were recruited to take part in a supported employment program in which they were provided with approximately 6 months of part-time work through a VA hospital. Positive symptoms, negative symptoms, and level of insight into mental illness were assessed once every 4 weeks, in addition to a work performance evaluation with participants' supervisors. Hierarchical longitudinal regression analysis revealed that negative symptom severity and impaired insight were significantly associated with poor work performance, and this relationship persisted over time. By contrast, positive symptom severity was not significantly associated with work performance. These results indicate that insight and negative symptoms, which can fluctuate over time, may be driving fluctuations in work performance and may therefore be a valuable target for future interventions.

Clinical and cognitive correlates of employment among patients with schizophrenia: a cross-sectional study in Malaysia

BACKGROUND

Gainful employment is one major area of functioning which is becoming an important goal in psychiatric rehabilitation of patients with schizophrenia. Studies in western countries are pointing to evidence that certain sociodemographic and clinical factors may contribute to employment outcomes in this group of people. However, the area is still largely unexplored in Malaysia. The aim of this study was to examine the sociodemographic, clinical and cognitive correlates of employment status among patients with Schizophrenia.

METHODS

This was a cross-sectional study. All participants who fulfilled the requirements of the study according to the inclusion and exclusion criteria were enrolled. Study instruments included a demographic data questionnaire, Positive and Negative Symptom Scale (PANSS), Trail Making Tests, Rey's Auditory Verbal Learning Test (RAVLT) and Digit Span. Bivariate analyses were done using chi-square for categorical data and t-test for continuous data and multiple logistic regression analysis was done to identify predictors of employment status.

RESULTS

A total of 95 participants who fulfilled the inclusion criteria were enrolled into the study. Among the sociodemographic, clinical and cognitive variables studied marital status, educational level, mean scores of negative symptoms, Digit Span and RAVLT and Trail Making Tests were found to show significant association with employment status on bivariate analyses. However, when entered into a logistic regression model, only cognitive variables ie. Trail A and B, Digit Span and RAVLT were significant predictors of employment status.

CONCLUSIONS

The results from this study support the role of cognitive function, particularly, attention, working memory and executive functioning on attaining and maintaining employment in persons with schizophrenia as measured by the RAVLT, Digit Span and Trail Making Tests. These findings may act as preliminary evidence suggesting the importance of integrating cognitive rehabilitation in the psychosocial rehabilitation program for patients with schizophrenia in Malaysia.

Low mood and employment: when affective disorders are intertwined with the workplace--a UK perspective

Working is undoubtedly an important aspect of western life. As well as structuring time, it provides financial security, meaning, identity and social participation, and has a beneficial effect on long-term physical and mental well-being. Despite this, people with mental health conditions have the lowest employment rate of any disabled group, although many of them want to work and work is highly beneficial for their physical and mental health. Existing research on mental health problems and employment outcomes have tended to focus on interventions for people with severe mental illness. Little research exists on the relationship between affective disorders, mainly depression and anxiety, and employment. This review focuses on studies conducted in the UK. Its conclusion is that there is no single rigorous investigation to test the relationship between common mental disorders and vocational outcomes.

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.

A pan-Canadian evaluation of supported employment programs dedicated to people with severe mental disorders

Supported employment (SE) is an evidence-based practice that helps people with severe mental disorders obtain competitive employment. The implementation of SE programs in different social contexts has led to adaptations of the SE components, therefore impacting the fidelity/quality of these services. The objective of this study was to assess the implementation of SE services in three Canadian provinces by assessing the fidelity and describing components of SE services using the Quality of Supported Employment Implementation Scale. About 23 SE programs participated in this study. Cluster analyses revealed six profiles of SE programs that varied from high to low level of fidelity with a stronger focus on a particular component, and reflected the reality of service delivery settings. Future investigations are warranted to evaluate relationships between the levels of implementation of SE components and work outcomes while considering individual characteristics of people registered in SE programs.

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.

Employment status amongst those with psychosis at first presentation

INTRODUCTION

Employment is generally beneficial to health and quality of life. Despite many advances in the treatment of psychosis there are continuing reports of high levels of unemployment. In most studies of first episode psychosis (FEP) only rudimentary rates of employment are provided. We sought to establish the prevalence of employment amongst those with FEP from a geographically defined area, to compare employment categories for differences in demographical and clinical characteristics and finally, to examine factors associated with employment.

METHODS

All cases of FEP were assessed from a defined suburban area with a structured clinical interview for DSM-III-R diagnosis and a standardised assessment protocol. Employment status was divided into employed, non-labour force work and unemployed.

RESULTS

Of 162 cases of psychosis, those employed (46%) were indistinguishable from those in non-labour force work (21%). Those unemployed (33%) had significantly longer DUP, more negative symptoms and lower quality of life than those engaged in non-labour force work or those employed. Having a non-affective psychosis (chi(2) = 0.05, OR = 1.2; 95% CI 1.0, 1.4) was associated with being unemployed at presentation. Better (beta = -0.2, P = 0.00) academic premorbid adjustment was associated with being employed at presentation.

CONCLUSIONS

Although 67% of those with FEP from a geographically defined area are engaged in purposeful work, the rate of unemployment is nine times the local rate. Longer DUP and negative symptoms are associated with unemployment at presentation. Standardised reporting of employment status would greatly assist research in this area.

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.

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.

Errorless learning for training individuals with schizophrenia at a community mental health setting providing work experience

The effects of errorless learning (EL) on work performance, tenure, and personal well-being were compared with conventional job training in a community mental health fellowship club offering 12-week time-limited work experience. Participants were 40 clinically stable schizophrenia and schizoaffective disorder outpatients randomly assigned to EL vs conventional instruction (CI) at a thrift-type clothing store. EL participants received training on how to perform their assigned job tasks based on principles of EL, such as error reduction and automation of task performance. CI participants received training common to other community-based entry-level jobs that included verbal instruction, a visual demonstration, independent practice, and corrective feedback. Participants were scheduled to work 2 hours per week for 12 weeks. For both groups, job training occurred during the first 2 weeks at the worksite. Work performance (assessed using the Work Behavior Inventory, WBI) and personal well-being (self-esteem, job satisfaction, and work stress) were assessed at weeks 2, 4, and 12. Job tenure was defined as the number of weeks on the job or total number of hours worked prior to quitting or study end. The EL group performed better than the CI group on the Work Quality Scale from the WBI, and the group differences were relatively consistent over time. Results from the survival analyses of job tenure revealed a non-significant trend favoring EL. There were no group differences on self-esteem, job satisfaction, or work stress. The findings provide modest support for the extensions of EL to community settings for enhancing work performance.

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.

"Every day is not always jell-o": a qualitative study of factors affecting job tenure

This qualitative study examined the reasons people with psychiatric disabilities stay on jobs and leave jobs to uncover the salient factors affecting job tenure. Fifty-one persons with psychiatric disabilities, 26 leavers and 25 stayers, participating in nine supported employment programs were interviewed. A constant comparative method was used to analyze the interview responses. Findings from the exit interviews suggest that specific factors may contribute to staying or leaving jobs, such as interest with the work, support of the supervisor, level of competence, and support of coworkers. Discussion of the findings and implications for practice and future research are presented.

Performance-based measures of functional skills: usefulness in clinical treatment studies

Recently, attention to the assessment and treatment of functional disability has increased notably. It is widely understood that impairments in everyday living skills, including independent living skills, social functions, vocational functioning, and self-care, are present in people with schizophrenia. It has also become clear recently that assessment of these skills can pose substantial challenges. These challenges include selection of meaningful short-term outcome measures and avoiding bias and reduced validity in the data. Self-report, direct observation, and informant reports of everyday disability all have certain advantages but appear to be inferior to direct assessment of skills with performance-based measures. This review outlines the issues associated with the assessment of functional skills and everyday functioning and provides a description of the strengths and weaknesses of these approaches. We conclude that direct assessment of functional capacity has substantial advantages over other measures and may actually provide a more direct and valid estimate of functional disability than performance on the more distal neuropsychological assessment measures.

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.

Schizophrenia: measurements of psychopathology

A key problem in schizophrenia research is how to assess the effects of treatment interventions given the spectrum of schizophrenia symptoms and patients' functioning. Measuring symptoms is complex, because these symptoms cover a wide variety of psychopathologic domains. The commonly recognized domains are the positive, negative, cognitive, excitement, and depression domains. This article critically reviews some of the available assessment tools of these domains together with other associated syndromes. The instruments discussed cover the broad range of psychopathology found in patients who have schizophrenia.

Analyzing vocational outcomes of individuals with psychiatric disabilities who received state vocational rehabilitation services: a data mining approach

This study examines factors affecting vocational outcomes in the vocational rehabilitation process for individuals experiencing psychiatric disabilities who had received state vocational rehabilitation (VR) services. A data mining approach was used to analyze the Rehabilitation Services Administration FY 2001 Case Service Report (RSA-911). Receiving job placement services was found to be the most important variable differentiating individuals who were working from those who were not working. Results regarding vocational outcomes suggest a positive effect for persons receiving job placement services.

Employment predictors for discharged schizophrenia patients

OBJECTIVE

To investigate predictors for competitive employment in a three-year follow-up study of discharged schizophrenia patients.

METHODS

The nationally representative sample comprised 2168 schizophrenia patients aged 15-64 years, who had been discharged from psychiatric hospitals in 1986, 1990, and 1994 in Finland. Comprehensive data were collected from psychiatric case records on the patients' sociodemographic and clinical characteristics at discharge and use of services during the follow-up period. The patients were interviewed 3 years after discharge using a structured interview schedule, which included questions on employment.

RESULTS

At follow-up, the competitive employment rate declined among the three cohorts (1989: 7.4%, 1993: 2.6% and 1997: 1.5%), whereas the rate of non-competitive employment remained at the same level (8.4%, 7.2% and 9.6%). The probability of competitive employment was higher for those who, at the time of discharge, were not on disability pension and had a current or past history of marriage, and had been discharged in the late 1980s. The probability of being competitively employed was lower for those who had no occupation at discharge and for those who had spent more time in hospital care during the three years after discharge.

CONCLUSIONS

The high unemployment rate and continuous changes in work life, which characterized Finland in the 1990s may have negatively affected the employment prospects of schizophrenia patients. Work rehabilitation should be more commonly offered, to increase their opportunities for obtaining competitive employment and for improving their quality of life.

Therapeutic alliance and improvements in work performance over time in patients with schizophrenia

While therapeutic alliance (TA) in schizophrenia has been linked with treatment adherence and outcome, less is known about its relationship to rehabilitation outcome. To examine this issue, we classified persons who had been enrolled in a rehabilitation study as having higher or lower levels of TA based on an observer assessment midway through treatment and compared their work performance at weeks 1, 11, and 23. Repeated measures analysis of variance found group effects for Work Quality and Personal Presentation with the higher TA group having better overall performance on both. Time effects were found for Work Quality and Personal Presentation with the sample overall showing improvement over the course of rehabilitation. Interactions were found for Cooperativeness and Work Quality with the higher TA group showing steady increases, whereas the lower TA group showed initial improvement followed by a decline. Results suggest that forming a strong TA may enhance rehabilitation among persons with schizophrenia.

Vocational services for traumatic brain injury: treatment definition and diversity within model systems of care

OBJECTIVE

To examine characteristics and diversity among vocational treatment services in model programs for traumatic brain injury (TBI) rehabilitation.

SETTING

Vocational or postacute treatment components of 16 TBI Model System (TBIMS) centers.

PARTICIPANTS

Vocational director/coordinator from each TBIMS surveyed in semistructured phone interview.

MEASURE

Survey of vocational services for people with TBI, with about 100 closed and open-ended questions on vocational assessments; pre- and postjob placement treatments; program philosophies; funding; and integration of cognitive, behavioral, family, and medical rehabilitation interventions.

RESULTS

Great diversity was found among the vocational services of the 16 TBIMS. Programs fell into 3 clusters emphasizing medical rehabilitation services, supported employment, or a combination of these with an emphasis on case management. Job coaching was identified as a key intervention, but there was great variability in intensity, availability, and funding of coaching services.

CONCLUSION

Diversity in vocational services appears related to funding differences and "parallel evolution" rather than strong treatment philosophy or scientific evidence base. Multicenter research on effectiveness or establishment of best practices in vocational rehabilitation after TBI must deal with substantial existing variability in treatment models and specific interventions, and must examine the relationship of treatment variations to case-mix factors.

Disability and its treatment in bipolar disorder patients

Bipolar disorders (BPD) are major, life-long psychiatric illnesses found in 2-5% of the population. Prognosis for BPD was once considered relatively favorable, but contemporary findings suggest that disability and poor outcomes are prevalent, despite major therapeutic advances. Syndromal recovery from acute episodes of mania or bipolar major depression is achieved in as many as 90% of patients given modern treatments, but full symptomatic recovery is achieved slowly, and residual symptoms of fluctuating severity and functional impact are the rule. Depressive-dysthymic-dysphoric morbidity continues in more than 30% of weeks in follow-up from initial episodes as well as later in the illness-course. As few as 1/3 of BPD patients achieve full social and occupational functional recovery to their own premorbid levels. Pharmacotherapy, though the accepted first-line treatment for BPD patients, is insufficient by itself, encouraging development of adjunctive psychological treatments and rehabilitative efforts to further limit morbidity and disability. Interpersonal, cognitive-behavioral, and psychoeducational therapies all show promise for improving symptomatic and functional outcomes. Much less is known about how these and more specific rehabilitative interventions might improve vocational functioning in BPD patients.

An innovative job placement model for unemployed methadone patients: a randomized clinical trial

This article presents the outcomes of an innovative vocational rehabilitation model designed for methadone-maintained patients -- the Customized Employment Supports (CES) model. CES counselors work intensively with a small caseload of patients to overcome the vocational as well as non-vocational barriers that hinder employment, with the goal of attaining rapid job placement. A randomized clinical trial was implemented at two methadone treatment programs in New York City and was funded by the National Institute on Drug Abuse The study tested the hypothesis that patients assigned to the experimental (CES) condition would have better employment outcomes than those assigned to a control condition who received standard vocational counseling at the programs. The data were collected from May 2001 through April 2005. The efficacy sample for the analysis consisted of 168 patients who completed follow-up interviews. The sample was 58% male, 75% minority group, average age 45 years, and in methadone treatment for an average of five years. The results supported the hypothesis for two measures of employment; i.e., the CES group was significantly more likely than the control group to obtain both any paid employment and informal paid employment. However, there were no significant differences for competitive employment or total earnings. The study's limitations are noted. Implications of the findings for the improvement of vocational rehabilitation for addiction patients are discussed.

Lessons from trial-based cost-effectiveness analyses of mental health interventions: why uncertainty about the outcome, estimate and willingness to pay matters

The principal aim of this article is to share lessons learned by the authors while conducting economic evaluations, using clinical trial data, of mental health interventions. These lessons are quite general and have clear relevance for pharmacoeconomic studies. In addition, we explore how net benefit regression can be used to enhance consideration of key issues when conducting an economic evaluation based on clinical trial data. The first study we discuss found that cost-effectiveness results varied markedly based on the choice of both the patient outcome and the willingness to pay for more of that outcome. The importance of willingness to pay was also highlighted in the results from the second study. Even with a set willingness-to-pay value, most of the time the probability that the new treatment was cost effective was not 100%. In the third study, the cost effectiveness of the new treatment varied by patient characteristics. These observations have important implications for pharmacoeconomic studies. Namely, analysts must carefully consider choice of patient outcome, willingness to pay, patient heterogeneity and the statistical uncertainty inherent in the data. Net benefit regression is a useful technique for exploring these crucial issues when undertaking an economic evaluation using patient-level data on both costs and effects.

Putative evidence of employment readiness

Readiness in the work domain has been a controversial issue for the psychiatric rehabilitation community. Judgments of a lack of readiness have relegated many persons to lives of continued unemployment and service dependency. Conversely, proponents of the rapid placement strategy of supported employment have down-played the importance of readiness. Yet, a careful review of the supported employment research suggests that readiness may indeed be an important factor in vocational outcomes. This paper presents evidence that the screening criteria employed in SE studies are often related to readiness factors and that these criteria are highly predictive of vocational outcomes. Acceptance of the importance of readiness for success in the vocational arena implies new service strategies and may serve to improve vocational outcomes in general.

Performance-based Funding of Supported Employment for Persons with Severe Mental Illness: Vocational Rehabilitation and Employment Staff Perspectives

Vocational rehabilitation (VR) supervisors and counselors (n = 35) as well as supported employment (SE) program managers and employment specialists (n = 26) were enrolled in a 12-month evaluation comparing two models of funding services for persons with severe mental illness: fee-for-service and results-based funding (RBF). Quantitative measures of job satisfaction and preference for funding method were obtained prospectively on a quarterly basis, and SE staff activity logs were collected monthly. Qualitative data were collected using a series of focus groups conducted at the conclusion of the study. Despite recording a substantial increase in semi-annualized VR billing charges when using RBF (45-49%), SE staff expressed less satisfaction with RBF over time. Staff raised concerns about increased financial risks and pressures to achieve job placements under RBF. Vocational rehabilitation staff were consistently more satisfied with RBF, expressing particular satisfaction with perceived effectiveness and the payment authorization process. Both VR and SE staff expressed some reservations about RBF, primarily concerning possible pressures for adverse client selection.

Cognitive and clinical predictors of work outcomes in clients with schizophrenia receiving supported employment services: 4-year follow-up

In a prior study we showed that cognitive functioning was a modest predictor of work and supported employment services over 2-years in 30 clients with schizophrenia, whereas symptoms were not (McGurk et al. (2003). Psychiatric Services, 58, 1129-1135). In order to evaluate whether the long-term provision of supported employment services reduced the impact of cognitive functioning on work, we examined the relationships between cognitive functioning and symptoms assessed after the initial 2 years of the program, and work and vocational services over the following 2 years (3-4 years after joining the program). Cognitive functioning was more predictive of work during the latter 2 years of the study than the first 2 years, and a similar but weaker pattern was present for the prediction of employment services. Symptoms remained weak predictors for both time periods. In addition, learning and memory and executive functions were strongly correlated with job task complexity during the 3-4 year follow-up, but not the 1-2 year follow-up, suggesting that employment specialists were able to improve their ability to match clients to jobs based on their cognitive skills. Furthermore, the specific associations between cognitive functioning, services, and work outcomes changed from years 1-2 to years 3-4, suggesting a dynamic interplay between these factors over the long-term, rather than static and unchanging relationships. The findings indicate that rather than supported employment services reducing the impact of cognitive functioning on long-term competitive work, the impact actually increases over time, suggesting that efforts to improve cognitive functioning (e.g., cognitive rehabilitation) may optimize employment outcomes in schizophrenia.

Employment and mental health service utilization in Washington State

This study examined employment among individuals utilizing publicly funded mental health services in Washington State during a 2-year period through the analysis of archival administrative data. The mean income found in this study was higher than that reported in the supported employment literature. This difference likely reflects the inclusion of individuals with less severe mental illness and ongoing employment who are typically excluded from studies of supported employment. Individuals in this study were employed in all industrial sectors in a distribution similar to the general population, although somewhat over-represented in service industries. Employment rates varied from 15% to 21% over a 3-year period and did not appear to increase after treatment. Employment rates tended to decline after the receipt of public support. Among individuals who lost employment, service utilization was found to increase prior to the loss of employment. Policy implications are discussed.

Putting community risk in perspective: a look at correlations, causes and controls

Much research, but not all, appears to show that persons with severe mental illness are more dangerous and violent than others; but it is misleading and feeds the stigma cannon. This paper critically reviews reported correlations between severe mental illness and violence, examines their statistical confounds, highlights studies which seek causal mechanisms explaining the associations, points to what those causal mechanisms tell us about controlling risk in the community, and reviews legal attempts to control community risk in light of those causal mechanisms.

Community-based vocational rehabilitation: effectiveness and cost impact of a proposed program model

OBJECTIVE

To study the vocational, service use and relative cost impact for schizophrenia or schizoaffective disorder of an innovative community-based vocational rehabilitation program.

METHOD

Participants were consecutive enrollees in a community-based vocational rehabilitation program who had remained in the program for at least 1 year. Lifetime vocational history and mental health service utilization for 2 years prior and up to 4 years subsequent to program enrollment were studied. Retrospective data were collected using a questionnaire completed by the patient and available family and case workers, patient interview and chart review.

RESULTS

Months in paid work increased after enrollment, while earned income did not (most work was low wage and/or part-time). Annual inpatient days decreased precipitously, a change which could not be explained by hospitalization trends during the same period. Average relative cost units, based on charges for mental health services used, dropped over 70% following enrollment.

CONCLUSIONS

Community-based vocational rehabilitation may be cost-effective in this population, largely as a result of its impact on hospitalizations and utilization of the most costly services. Such programs represent an important alternative to supported employment that may be particularly suited to cognitively or functionally impaired patients unwilling or unable to work in a competitive environment.

Limitations of system integration in providing employment services for persons with mental illness

This study assessed the influence of service systems integration on employment outcomes for persons with mental illness. A survey was sent to all 125 key program staff that worked for community mental health treatment agencies or vocational rehabilitation agencies. The survey found that referral and employment rates were low; but that these rates were related to characteristics of the interagency systems integration. Community mental health staff referred 448 individuals for employment services. Staff from vocational rehabilitation agencies accepted only 26% of these referrals and found work for just 11%; 7% were employed six months later. Also, 39% of respondents reported that the linkage agreement between their agencies was never established. This study suggests the need for more effective strategies for integrating mental health treatment and vocational rehabilitation systems.

Relationship of impaired processing speed and flexibility of abstract thought to improvements in work performance over time in schizophrenia

Vocational impairments in schizophrenia have been widely linked to deficits in neurocognition. This study examined the possibility that deficits in visuomotor processing speed and flexibility in abstract thought may in combination be an especially potent risk factor for poorer levels of work performance in rehabilitation. Fifty-seven participants with confirmed diagnoses of schizophrenia spectrum disorders were administered the Digit Symbol Subtest and the Wisconsin Card Sorting Test and then offered work placements in a vocational rehabilitation program. Work performance was assessed biweekly over two months using the Work Behavior Inventory. Multivariate and univariate repeated ANOVA revealed that participants classified as having no impairments in either visuomotor processing speed and flexibility in abstract thought (n=14) had superior work performance compared to participants with deficits in either one area (n=20) or both areas (n=23). Additionally, participants with no impairments were the only group to show significant improvement in work performance over 7 weeks of rehabilitation. Participants with only one deficit had significantly better work performance than participants with both deficits but showed no statistically significant improvement in work performance. Results suggest assessments of these domains of neurocognition may provide important information about individual needs for adjunct services.