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

Supportive therapy for schizophrenia

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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.

Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first-episode psychosis: employing cautious optimism

OBJECTIVE

While there are now effective interventions for the symptoms of psychosis and schizophrenia, treatment for the functional domains of these illnesses has received less attention. A key area affected by psychotic illness is vocational functioning. This area is currently of interest to clinicians, policy-makers, politicians and patients. This paper reviews several forms of vocational intervention practised over the years and highlights the issues around adopting an early intervention approach towards vocational rehabilitation. The paper has four aims: first, to consider some of the consequences of unemployment for those with psychotic illnesses; second, to review methods that have been used to address unemployment among the mentally ill; third, to highlight the importance of vocational development at a developmentally appropriate life stage; and finally, to consider the application of evidence-based vocational rehabilitation to those with first-episode psychosis.

METHOD

An initial broad literature search was conducted using PsychInfo and Medline databases. Further narrower searches were conducted electronically where indicated. Finally, some articles were sourced through manual searches of relevant journals.

RESULTS

People with psychotic illness have a high rate of unemployment at the outset of their illness which tends to worsen over time. This is complicated by systemic factors such as the structure of the welfare system. Approaches for assisting people with mental illness return to work have evolved over the history of psychiatry. There now exists an evidence-based method of intervention. To date this has not been trialled in a systematic way with people in the early stages of psychotic illness.

CONCLUSIONS

There is cause for cautious optimism in the vocational recovery of people with psychotic illnesses. Limited evidence exists that the individual placement and support approach developed with chronic populations is very effective in early episode patients. There are a number of challenges to implementing vocational intervention in first-episode psychosis. Overcoming these obstacles will require the cooperation of clinicians, those with illness, policy-makers and politicians. However, the potential economic, health and personal gains, as well as current and future research should provide sufficient motivation to overcome these barriers.

Generalisability of the individual placement and support model of supported employment: results of a Canadian randomised controlled trial

BACKGROUND

Studies conducted in the USA have found the individual placement and support model of supported employment to be more effective than traditional vocational rehabilitation at helping people with severe mental illness to find and maintain competitive employment.

AIMS

To determine the effectiveness of the individual placement and support (supported employment) model in a Canadian setting.

METHOD

A total of 150 adults with severe mental illness, who were not currently employed and who desired competitive employment, were randomly assigned to receive either supported employment (n = 75) or traditional vocational services (n = 75).

RESULTS

Over the 12 months of followup, 47% of clients in the supported employment group obtained at least some competitive employment, v. 18% of the control group (P < 0.001). They averaged 126 h of competitive work, v. 72 in the control group (P < 0.001).

CONCLUSIONS

Supported employment proved more effective than traditional vocational services in a setting significantly different from settings in the USA, and may therefore be generalised to settings in other countries.

Challenges to implementing and sustaining comprehensive mental health service programs

The President's New Freedom Commission recently concluded that the nation's mental health service delivery system is ill equipped to meet the complex needs of persons with mental illness. A major contributor to this service quality crisis has been the longstanding divergence of research efforts and clinical programs. In this article, the authors begin by describing the unique needs of persons with serious and persisting psychiatric disorders and the evolution of the mental health service system that has attempted to meet these needs. They then discuss recent efforts to upgrade services by emphasizing the use of evidence-based practices (EBPs) and the research underlying their development. Next, they describe the difficulties of using traditional research methods to develop and test interventions for persons receiving services at public mental health agencies. Finally, they outline the challenges confronted when trying to disseminate these EBPs to the wider clinical community.

[Timely diagnosis and efficient early-rehabilitation for schizophrenic disorders in the community -- perspectives of a new standard]

Schizophrenia and schizophrenia spectrum disorders are severe mental illnesses with diverse courses of illness and often severe long-term disabilities. The sooner therapeutic and rehabilitative measures are taken the better the prognostic outlook is. Wrong but persistent stereotypes of incurability and dangerousness associated with schizophrenia pose severe obstacles to timely diagnosis and interventions and must be overcome. Today various efficient methods in therapy and rehabilitation are available. Evidence-based interventions are best delivered by multi-professional teams in the community. A person-centred approach combines biological, psychological, and social treatments in an integrated model including the social network and the individual goals of patients and their families. Concepts and results of international research efforts regarding state-of-the-art management of schizophrenia are presented and discussed.

Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

Developing drugs for cognitive impairment in schizophrenia

There are strong data suggesting that improvement in the cognitive impairment associated with schizophrenia will contribute to enhanced functional outcomes for patients with this illness. Measurement and Treatment Research to Improve Cognition in Schizophrenia was established to provide a pathway for developing and registering potential cognitive-enhancing agents for this condition by addressing issues related to the content of the cognitive assessment battery and the clinical design features to be used in registration studies. This article examines key challenges related to the actual clinical development of cognitive-enhancing agents. These challenges include improving the probability of technical success and attrition rates of candidate molecules, establishing better animal models of human cognition, and developing biomarkers to decrease development costs and increase the speed of the clinical discovery process. Biomarkers are important for molecular target validation, dose selection, surrogate end points, and population segmentation. Examples of approaches for the development of agents for cognitive impairment associated with schizophrenia are discussed. It is concluded that close collaboration among academia, the National Institutes of Health, regulatory bodies, and industry will be important to advance the goal of developing drugs for this important condition.

Employment outcomes and PTSD symptom severity

A diagnosis of chronic war-related posttraumatic stress disorder (PTSD) has been linked consistently to poor employment outcomes. This study investigates the relation further, analyzing how symptom severity correlates with work status, occupation type, and earnings. Study participants were male Vietnam veterans with severe or very severe PTSD who received treatment in the Department of Veterans Affairs system (N = 325). Veterans with more severe symptoms were more likely to work part-time or not at all. Among workers, more severe symptoms were weakly associated with having a sales or clerical position. Conditional on employment and occupation category, there was no significant relation between PTSD symptom level and earnings. Alternative PTSD symptom measures produced similar results. Our findings suggest that even modest reductions in PTSD symptoms may lead to employment gains, even if the overall symptom level remains severe.

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.

Career development in schizophrenia: a heuristic framework

Adults with schizophrenia continue to have poor rates of competitive employment. We have learned how to support individuals in the workplace with supported employment (SE); but have paid limited attention to early vocational identity development, work antecedents, illness characteristics, and career preferences. Vocational identity development is an important and natural condition of human growth for all persons and is well-researched in career counseling. For young adults with schizophrenia, the predictor of positive work outcome with the most evidence has been that working competitively prior to illness leads to better chances for work post-diagnosis. A heuristic framework is proposed to conceptualize how pre-illness vocational development (paid and unpaid) plus life cycle supports can provide direction to the individual in their work recovery.

Person-related predictors of employment outcomes after participation in psychiatric vocational rehabilitation programmes--a systematic review

BACKGROUND

There is increasing recognition of the importance of psychiatric vocational rehabilitation (PVR) programmes in helping individuals with severe mental illnesses to find and secure jobs. However, little is known concerning the factors related to PVR outcomes.

OBJECTIVE

This review identifies those person-related factors which most strongly influence employment outcomes after participation in PVR programmes.

METHOD

Medline, Psychinfo, Pubmed and CINAHL were searched for studies using multivariate analysis of longitudinal data, which analysed employment outcomes after at least 6 months of programme participation, and which analysed at least three predictor domains.

RESULTS

Eight studies presented in 16 publications met all the criteria. Better employment outcomes were most strongly related to better work performance measured during PVR participation and to higher work-related self-efficacy. Better social functioning during PVR participation was also significantly related to positive employment outcomes, but this relationship was generally weaker than those of the two aforementioned factors. In most studies, employment outcomes after PVR were not related to past functioning, including work history and diagnosis. Findings on the severity of psychiatric symptoms measured during PVR were mixed. In terms of contribution to outcome, severity of symptoms usually ranked below work performance, when measured concurrently.

CONCLUSION

Contrary to previous reviews, this study suggests that the influence of past functioning, including work history, diagnosis and psychiatric history, is outweighed by work performance in PVR. Further prospective and controlled studies are needed to reach more definite conclusions about the individual contributions of person-related factors.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge.

METHOD

A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Psychotic disorders clinic and first-episode psychosis: a program evaluation

BACKGROUND

There is growing recognition that people presenting with psychotic symptoms for the first time need specialized treatment. The Hamilton Health Sciences Corporation, McMaster Hospital, offers one such program, the Psychotic Disorders Clinic (PDC); it addresses some of the problems posed by long waiting lists, lack of family interventions, and long-term hospitalizations. The PDC is affiliated with the Department of Psychiatry and Behavioural Neurosciences at McMaster University. The program's goals are to provide comprehensive outpatient care and early interventions for persons in the early stages of illness and, consequently, to improve symptom control and functioning and reduce hospitalizations. Key service components include providing low dosages of antipsychotics, offering specialized family education, and supporting return to school and work settings.

OBJECTIVES

This study compared outcomes before and after enrolment in the PDC to determine whether first-episode patients achieved improved symptom control and functioning and fewer hospitalizations.

METHOD

For a 12-month period, we followed 40 patients, aged between 16 and 45 years, who experienced their first episode of psychotic illness between 1997 and 2000. Prospective longitudinal data were collected at baseline, 3, 6, and 12 months. Outcome measures included symptoms, global functioning, employment rates, duration of untreated psychosis, and number of bed-days.

RESULTS

Of the patients, 37 completed the study at 6 months, and 31 at 12 months. Over the 12 months, significant improvements occurred in psychiatric symptoms (P < 0.001), global functioning (P < 0.001), and the mean number of hospital bed-days (P < 0.001).

CONCLUSIONS

It is feasible for small outpatient services to provide early intervention strategies and obtain good outcomes among first-episode patients.

Treatment-resistant posttraumatic stress disorder: strategies for intervention

The mainstay of treatment for chronic posttraumatic stress disorder (PTSD) is a combination of psychotherapy and medication treatments. The first-line medications for PTSD are antidepressants, with two selective serotonin reuptake inhibitors (sertraline and paroxetine) currently Food and Drug Administration-indicated for PTSD. However, many patients do not have an adequate response to antidepressants, therefore, combinations with other antidepressants or with other classes of psychotropic medication are often utilized to enhance the therapeutic response. Other agents that have been used include mood stabilizers, anti-adrenergics, anxiolytics, and atypical antipsychotics. The heterogeneity of symptom clusters in PTSD as well as the complex psychiatric comorbidities (eg, with depression or substance abuse) further support the notion that combinations of medications may be needed. To date, there is a paucity of data to support specific strategies for augmenting antidepressants in PTSD. This review will address representative existing studies and discuss several potential pharmacologic strategies for patients suffering from treatment-refractory PTSD.

Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence

BACKGROUND

There is controversy about whether mental health services should be provided in community or hospital settings. There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas.

AIMS

To provide an evidence base for this debate, and present a stepped care model.

METHOD

Cochrane systematic reviews and other reviews were summarised.

RESULTS

The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation.

CONCLUSIONS

Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.

Supported living in residential homes for the elderly: impact on patients and elder care workers

To enable older people with severe and persistent mental illness to live in the community, the Dutch mental health sector has developed a program for supported living in residential homes for the elderly. It provides for the permanent stationing of mental health workers (MHWs) in elder care facilities to support both the resident patients and the elder care staff. The authors examined associations between the number of MHW staff and the degree to which (1) patients were integrated into the community and (2) elder care workers had developed effective working alliances with their patients. Participants included 110 patients participating in 18 supported living programs in the Netherlands. Community integration was assessed in face-to-face interviews with the patients about their perceived influence over daily life, involvement in social activities, and social network size. The quality of the worker-patient relationship was assessed using the Dutch Working Alliance Questionnaire for Community Care, completed by the elder care worker primarily responsible for each patient. After differentiation of the MHW staff into medically trained and nurse-trained professionals, associations with outcome measures were found only for the nurse-trained staff. The more hours of nurse-trained staff capacity per patient, the more influence perceived by the patients, and the more directiveness shown by the elder care workers in their contacts with patients. The impact of supported living programs in residential homes for the elderly appears to be determined in part by the caseloads of the on-site MHWs.

Impact of multi-agency employment services on employment rates

Adults with severe and persistent mental illness who received employment services through mental health and/or vocational rehabilitation programs had higher employment rates than individuals who did not receive any employment services. Individuals who received services from both programs had significantly higher employment rates than individuals who received services from only one program. Results indicate that employment services had a greater relative effect on older clients and clients with a schizophrenia diagnosis than on other individuals. This state-wide study relied exclusively on analysis of administrative/operational databases that provide the employment rates for both recipients of vocational services and other clients.

The Hartford Study of Supported Employment for Persons With Severe Mental Illness

The authors compared 3 approaches to vocational rehabilitation for severe mental illness (SMI): the individual placement and support (IPS) model of supported employment, a psychosocial rehabilitation (PSR) program, and standard services. Two hundred four unemployed clients (46% African American, 30% Latino) with SMI were randomly assigned to IPS, PSR, or standard services and followed for 2 years. Clients in IPS had significantly better employment outcomes than clients in PSR and standard services, including more competitive work (73.9% vs. 18.2% vs. 27.5%, respectively) and any paid work (73.9% vs. 34.8% vs. 53.6%, respectively). There were few differences in nonvocational outcomes between programs. IPS is a more effective model than PSR or standard brokered vocational services for improving employment outcomes in clients with SMI.

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

The Generic Work Behavior Questionnaire (GWBQ): assessment of core dimensions of generic work behavior of people with severe mental illnesses in vocational rehabilitation

The purpose of this study was the development of a short self-reporting and supervisor-reporting questionnaire to assess generic work behavior of people with severe mental illnesses participating in psychiatric vocational rehabilitation. An 18-item generic work behavior questionnaire (GWBQ) was developed, which contains core dimensions derived from both supervisor scores and self-report scores. The factor structure of the GWBQ was replicated for both versions (supervisor and self reports). The GWBQ was very reliable for supervisor reports and moderately so for self-reports. Although self-report scores and supervisor scores correlated significantly, participants rated their own work behavior consistently higher than supervisors did.

Supported employment: evidence for an evidence-based practice

Supported employment for people with severe mental illnesses is an evidence-based practice, based on converging findings from 4 studies of the conversion of day treatment to supported employment and 9 randomized controlled trials comparing supported employment to a variety of alternative approaches. These two lines of research suggest that between 40% and 60% of consumers enrolled in supported employment obtain competitive employment while less than 20% of similar consumers do so when not enrolled in supported employment. Consumers who hold competitive jobs for a sustained period of time show benefits such as improved self-esteem and better symptom control, although by itself, enrollment in supported employment has no systematic impact on nonvocational outcomes, either on undesirable outcomes, such as rehospitalization, or on valued outcomes, such as improved quality of life. The psychiatric rehabilitation field has achieved consensus on a core set of principles of supported employment, although efforts continue to develop enhancements. A review of the evidence suggests strong support for 4 of 7 principles of supported employment, while the evidence for the remaining 3 is relatively weak. Continued innovation and research on principles is recommended.

Evaluation of an Individual Placement and Support model (IPS) program

While randomized clinical trials (RCTs) have helped to establish Individual Placement and Support (IPS) programs as an evidence-based practice, it is important to evaluate whether "real world" IPS programs can be implemented with fidelity and achieve outcomes comparable to programs evaluated in RCTs. The current evaluation examined retrospectively employment outcomes for go participants from an IPS-model Services for Employment and Education (SEE) program in Massachusetts over a 4.5-year period. Evaluators accessed demographic, functioning, and employment data from three sources--SEE program records/database, clinical records, and the Massachusetts Department of Mental Health Client Tracking system. Results indicate that the SEE program maintained high IPS fidelity and achieved employment outcomes comparable or superior to other SE and IPS model programs described in the literature.

Cognitive functioning and employment in severe mental illness

This study compared cognitive functioning and symptomatology of unemployed, supported employed, and independently employed clients with severe mental illness. Unemployed clients who wanted to work (N = 21) were compared with clients working in supported employment programs (N = 17) and clients who had been working independently for at least 1 year (N = 23) on a neuropsychological battery and the Positive and Negative Syndrome Scale. Clients who were unemployed had more severe symptoms and worse cognitive functioning on both positive and negative symptoms, and almost all domains of cognitive functioning. Supported employed clients had more severe psychotic symptoms and worse working memory than independently employed clients, but did not differ in negative symptoms or the other domains of cognitive functioning, including attention/concentration, psychomotor speed, verbal learning and memory, or executive functions. Finally, job complexity was correlated with impaired executive functions among clients working independently, but not in supported employment. Severe symptoms and cognitive impairment may interfere with the ability of some clients with severe mental illness to obtain competitive work. Supported employment programs appear to work by helping clients compensate for problematic symptoms and cognitive impairment and, to a lesser extent, by finding or developing environmental niches in which these impairments do not impede their ability to perform the necessary job tasks.

Vocational rehabilitation in schizophrenia and other psychotic disorders: a literature review and meta-analysis of randomized controlled trials

Although most individuals with schizophrenia are unemployed, plentiful evidence suggests that work rehabilitation is effective for this population. Yet, there have been only 11 published randomized controlled trials of work rehabilitation interventions for people with severe mental illness. We review these 11 studies, 9 of which were trials examining Individual Placement and Support (IPS) or supported employment (SE) interventions. Outcomes strongly favored the experimental groups in terms of the percentage of participants who worked at any point during the studies (weighted mean effect size = 0.66). In the 5 investigations comparing IPS/SE to conventional vocational rehabilitation services, 51% of the participants receiving IPS/SE worked competitively, versus 18% of those in the comparison groups (weighted mean effect size = 0.79). This effect size may be a useful benchmark for future trials. Further investigations should examine individual differences as predictors of response, to identify modifiable versus nonmodifiable factors that yield better outcomes.

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.

Evidence-based psychosocial treatment practices in schizophrenia: lessons from the patient outcomes research team (PORT) project

The care of persons with schizophrenia, the prototypical severe mental illness, has been a barometer of mental health care policy for decades. The prevalence, severity, and costs of schizophrenia combine to make this illness a major health problem throughout the world. In 1992, the Agency for Health Care Policy and Research and the National Institute of Mental Health funded the Schizophrenia Patient Outcomes Research Team (PORT) at the University of Maryland School of Medicine and the Johns Hopkins University School of Public Health. The PORT undertook several activities, including a comprehensive review of the empirical literature on the treatment of persons with schizophrenia; development of evidence-based treatment recommendations; description of current treatment practices; and comparison of these current practices to the evidence-based treatment recommendations, using administrative claims data and a survey of persons under treatment for schizophrenia; and dissemination of the treatment recommendations to evaluate impacts on practices. The PORT found that despite considerable evidence for effective treatments for persons with schizophrenia, most patients do not receive an appropriately comprehensive treatment "package." In particular, efficacious psychosocial treatments are highly underutilized.

Maximizing the synergy between pharmacotherapy and psychosocial therapies for schizophrenia

Although the traditional antipsychotic medications were a major advancement in schizophrenia therapeutics and made possible the era of deinstitutionalization, just maintaining a patient out of the hospital no longer can be viewed as the final goal of treatment. Most patients are able to maintain outpatient status despite persistent psychotic symptoms, pervasive negative symptoms and poor social competence. It is hoped that the availability of the atypical antipsychotic drugs will improve significantly compliance, treatment of symptoms, and possibly relapse rates and overall outcome. It should be the norm and not the exception for patients to be treated with these new medications as early as possible in their illness. The clinician should not be complacent and quick to accept persistent psychosis, and patients with various forms of treatment resistance should be tried early in the course of illness with clozapine (or other medications as they become available if they show superiority for treatment-resistant patients). Pharmacologic interventions aimed at deficit symptoms may become available in the future. Psychosocial interventions have a place in the modern therapeutic armamentarium. Relatively simple sustained family interventions and more comprehensive ACT programs are effective for relapse prevention and reduction of the "revolving door syndrome," whereas patients with psychosis nonresponsive to medication may benefit from new modalities of CBT. For patients with persistent negative symptoms and limited social competence, SST is indicated where available, and even in places where staff may be limited and social skills and other programs difficult to implement, family psychoeducational interventions can be carried out to good effect.

Practices differentiating high-performing from low-performing supported employment programs

This paper reports on a qualitative study designed to uncover the practices that differentiate programs producing high rates of competitive employment from those with low rates. The study found 13 differentiating practice factors in three areas: building consumer interest in working, getting a job, and maintaining a job. The congruence between these findings and current definitions of "best practice" is discussed.

The role of work in the recovery of persons with psychiatric disabilities

This study explored the role of work in the recovery of employed and unemployed persons with psychiatric disabilities. Fourteen persons with psychiatric disabilities participated in semi-structured interviews. Content analysis revealed that the experience of recovery was based on six major dimensions: self-definition, empowerment, connections to others, meaning of work, vocational future, and meaning of recovery. Differences in these six dimensions led to the identification of three profiles of recovery: recovery as uncertain, recovery as a self-empowering experience, and recovery as a challenging experience. Each profile described a specific context in which participation in work or avoidance of work can be understood and vocational interventions can be designed.

The trainee project: family-aided vocational rehabilitation of young people with schizophrenia

This study explored the initial results of a family-aided vocational rehabilitation program for young people with schizophrenia in The Netherlands. Their parents act as 'job-finders" and traineeship providers. The traineeships obtained for the participants reflect their interests and capabilities, and the participants reported an increase in self-esteem. Some trainees entered paid employment within one year. The results suggest that family involvement, if it is tailored to individual possibilities and combined with key elements of the Individual Placement and Support model, can make a useful contribution to the vocational rehabilitation of young people with schizophrenia.

Stages in the implementation of innovative clinical programs in complex organizations

Organizational processes can have an important impact on the introduction of innovative treatments into practice. Conceptual frameworks from organization theory and experiences implementing several hundred specialized mental health programs in the Department of Veterans Affairs (VA) over the past 15 years are used to illustrate stages and processes in the implementation of new treatment models. Four phases in the implementation of new treatments in complex organizational settings are described: a) the decision to implement, b) initial implementation, c) sustained implementation, and d) termination or transformation. Key strategies for moving research into practice include constructing decision-making coalitions, linking new initiatives to legitimate goals and values, quantitative monitoring of implementation and performance, and the development of self-sustaining communities of practice as well as learning organizations. Effective dissemination of new treatment methods requires different organizational strategies at different phases of implementation.

The challenge of psychiatric rehabilitation in schizophrenia

Many persons with schizophrenia continue to struggle with psychiatric symptoms and poor social adjustment, even when prescribed appropriate doses of antipsychotic medications. Psychiatric rehabilitation involves using psychosocial interventions to minimize symptoms and relapse while maximizing social functioning in schizophrenia. In this article, the scope of psychiatric rehabilitation is first defined and then the rationale for psychiatric rehabilitation is presented. The challenges to implementation of psychiatric rehabilitation strategies are next articulated. Finally, brief reviews of the four most empirically validated psychiatric rehabilitation techniques are presented.

Economic impacts of supported employment for persons with severe mental illness

BACKGROUND

Most persons with severe mental illness prefer competitive to sheltered vocational settings. Supported employment (SE) has become a clearly defined model for helping people with severe mental illness to find and maintain competitive jobs. It involves individualized and rapid placement, ongoing support and assessment, and integration of vocational and mental health staff within a single clinical team. Previous studies show that SE secures competitive employment much more effectively than do other approaches. This review focuses on its economic impacts.

METHODS

Studies reporting some service use or monetary outcomes of adding SE programs were identified. These outcomes were tabulated and are discussed in narrative form.

RESULTS

Five nonrandomized and 3 randomized studies compare SE programs with day treatment or transitional employment programs. The introduction of SE services can result in anything from an increase to a decrease in vocational service costs, depending on the extent to which they substitute for previous vocational or day treatment services. Overall service costs tend to be lower, but differences are not significant. Earnings increase only slightly on average.

CONCLUSIONS

Converting day treatment or other less effective vocational programs into SE programs can be cost-saving or cost-neutral from the hospital, community centre, and government points of view. Investments of new money into SE programs are unlikely to be materially offset by reductions in other health care costs, by reductions in government benefit payments, or by increased tax revenues. Such investments must be motivated by the value of increasing the community integration of persons with severe mental illness.

Does competitive employment improve nonvocational outcomes for people with severe mental illness?

The authors examined the cumulative effects of work on symptoms, quality of life, and self-esteem for 149 unemployed clients with severe mental illness receiving vocational rehabilitation. Nonvocational measures were assessed at 6-month intervals throughout the 18-month study period, and vocational activity was tracked continuously. On the basis of their predominant work activity over the study period, participants were classified into 4 groups: competitive work, sheltered work, minimal work, and no work. The groups did not differ at baseline on any of the nonvocational measures. Using mixed effects regression analysis to examine rates of change over time, the authors found that the competitive work group showed higher rates of improvement in symptoms; in satisfaction with vocational services, leisure, and finances; and in self-esteem than did participants in a combined minimal work-no work group. The sheltered work group showed no such advantage.

Work interest as a predictor of competitive employment: policy implications for psychiatric rehabilitation

Consumers with serious mental illness (N = 166) enrolling in two community-based mental health programs, a vocational Program of Assertive Community Treatment and a clubhouse certified by the International Center for Clubhouse Development (ICCD), were asked about their interest in work. About one third of the new enrollees expressed no interest in working. Equivalent supported employment services were then offered to all participants in each program. Stated interest in work and receipt of vocational services were statistically significant predictors of whether a person would work and how long it would take to get a job. Two thirds of those interested in work and half of those with no initial interest obtained a competitive job if they received at least one hour of vocational service. Once employed, these two groups held comparable jobs for the same length of time. These findings demonstrate the importance of making vocational services continuously available to all people with serious mental illness, and the viability of integrating these services into routine mental health care.

Helping people with severe mental illness to obtain work: systematic review

OBJECTIVE

To determine the most effective way of helping people with severe mental illness to obtain competitive employment-that is, a job paid at the market rate, and for which anyone can apply.

DESIGN

Systematic review.

PARTICIPANTS

Eligible studies were randomised controlled trials comparing prevocational training or supported employment (for people with severe mental illness) with each other or with standard community care.

OUTCOME MEASURES

The primary outcome was number of subjects in competitive employment. Secondary outcomes were other employment outcomes, clinical outcomes, and costs.

RESULTS

Eleven trials met the inclusion criteria. Five (1204 subjects) compared prevocational training with standard community care, one (256 subjects) compared supported employment with standard community care, and five (484 subjects) compared supported employment with prevocational training. Subjects in supported employment were more likely to be in competitive employment than those who received prevocational training at 4, 6, 9, 12, 15, and 18 months (for example, 34% v 12% at 12 months; number needed to treat 4.45, 95% confidence interval 3.37 to 6.59). This effect was still present, although at a reduced level, after a sensitivity analysis that retained only the highest quality trials (31% v 12%; 5.3, 3.6 to 10.4). People in supported employment earned more and worked more hours per month than those who had had prevocational training.

CONCLUSION

Supported employment is more effective than prevocational training at helping people with severe mental illness obtain competitive employment.

Vocational rehabilitation for people with severe mental illness

BACKGROUND

Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre-vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on-the-job support (Supported Employment). It is unclear which approach is most effective.

OBJECTIVES

To assess the effects of Pre-vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre-vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention.

SEARCH STRATEGY

Searches were undertaken of CINAHL (1982-1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1887-1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies.

SELECTION CRITERIA

Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness.

DATA COLLECTION AND ANALYSIS

Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross-checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta-analysis). A sensitivity analysis was performed, excluding poorer quality trials.

MAIN RESULTS

Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre-vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre-vocational Training. There was no evidence that Pre-vocational Training was more effective in helping clients to obtain competitive employment than standard community care.

REVIEWER'S CONCLUSIONS

Supported employment is more effective than Pre-vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre-vocational Training is effective.

Identifying clinical competencies that support rehabilitation and empowerment in individuals with severe mental illness

Individuals with severe mental illness often do not receive appropriate treatment or rehabilitation. One approach to improving their care begins by identifying competencies that clinicians should possess. This project developed a set of core clinical competencies that pertain to community-based care and support the goals of empowerment and rehabilitation. Development of the competency set began with review of existing literature and competency statements, and focus groups and interviews with clients, family members, clinicians, managers, experts, and advocates. Representatives from each of these groups participated in a national panel and used a structured process to identify 37 final competencies. Panel members agreed that these competencies are very important in determining outcomes and often are not present in current clinicians. This project demonstrates that it is possible to develop a core competency set that can be strongly supported by diverse groups of stakeholders. These competencies may be useful in clinician training, recruitment, and credentialing efforts.