Vocational rehabilitation for people with severe mental illness

Peer Facilitator Training for Diabetes Prevention in a Nigerian Drug Treatment Center

INTRODUCTION AND BACKGROUND

Individuals with substance use disorders (SUDs) are at an increased risk of developing comorbid medical conditions, including Type 2 diabetes. Although the diabetes prevention program (DPP) is efficacious and cost-effective, there is no published evidence to support its implementation in Nigeria or within SUD treatment settings. In this first known DPP within an SUD treatment program, we implemented a multiphased, nurse-led DPP at a small outpatient drug treatment center in Nigeria. The aim of this article was to describe only the processes utilized for the initial peer facilitator (PF) training (Phase 1).

METHODS

In Phase 1, a diabetes prevention master trainer delivered a virtual DPP training to the facility's lead nurse, who return-demonstrated the DPP workshop skills and competencies over four 4-hour sessions. The lead nurse then independently delivered four 8-hour training sessions to a small number of client volunteers (n = 4) who subsequently delivered the DPP lifestyle interventions to their peers in the outpatient treatment program.

RESULTS

The client volunteers attended all PF workshop sessions and were observed to be proficient in all aspects of implementation. They indicated that the training objectives were easily achieved and expressed enthusiasm for delivering DPP content to their peers. The need to better contextualize the DPP curriculum specific to Nigerian food preferences was identified.

CONCLUSION

The Phase 1 training process appears to be an appropriate and effective approach for preparing PFs to deliver health programs, like the DPP, in environments with limited resources for populations facing numerous challenges.

Predictors of return to work for people on sick leave with depression, anxiety and stress: secondary analysis from a randomized controlled trial

PURPOSE

Knowledge about predictors of return to work (RTW) in people on sick leave with common mental disorders (CMDs) may inform the development of effective vocational rehabilitation interventions for this target group. In this study, we investigated predictors of RTW at 6 and 12 months in people on sick leave with depression, anxiety disorders or stress-related disorders.

METHODS

We have performed a secondary analysis, utilizing data from two RCTs that evaluated the efficacy of an integrated health care and vocational rehabilitation intervention. Data were obtained from mental health assessments, questionnaires and registers. Using Cox regression analysis, the relationship between baseline variables and RTW was analysed at 6 and 12 months after randomization within the group of CMD as a whole and within the subgroups of depression, anxiety and stress-related disorders.

RESULTS

Symptom burden and employment status at baseline predicted RTW in the CMD group (n = 1245) and in the three diagnostic subgroups at both time points. RTW self-efficacy predicted RTW in the depression group but not in the anxiety or stress subgroups.

CONCLUSION

Many predictors of RTW were similar over time and, to some extent, across the CMD subgroups. Findings highlight the need not only to take health-related and psychological factors into account when developing vocational rehabilitation interventions but also to consider workplace strategies and options for support.

Trial-Based Economic Evaluations of Supported Employment for Adults with Severe Mental Illness: A Systematic Review

To identify, appraise, and summarize outcomes reported in trial-based economic evaluations of Individual Placement and Support programs for adults with severe mental illness. Six databases were searched, including Medline, PsycINFO, CINAHL, Cochrane, Scopus, and EconLit. Inclusion criteria were trial-based, full economic evaluations comparing Individual Placement and Support programs to traditional vocational rehabilitation programs for adults 18 years and older with severe mental illness. Study quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards statement. Of the 476 articles identified in the database search, seven were included in the review. Studies conducted across Europe (n = 4) and Japan (n = 1) suggested that Individual Placement and Support may be a cost-effective alternative to traditional vocational rehabilitation programs. Two studies conducted in the United States demonstrated that Individual Placement and Support led to better vocational outcomes, but at neutral or higher costs than traditional vocational rehabilitation, depending on the benefit measure used. Trial-based economic evaluations of supported employment for adults with severe mental illness are limited and heterogeneous. The interpretation of economic outcomes warrants consideration of factors that may impact cost-effectiveness, such as geographical location. Future studies should evaluate whether the benefits of IPS outweigh additional costs for patients and other stakeholders.

Implementing individual placement and support (IPS): the experiences of employment specialists in the early implementation phase of IPS in Northern Norway. The IPSNOR study

BACKGROUND

For decades there has been a continuous increase in the number of people receiving welfare benefits for being outside the work force due to mental illness. There is sufficient evidence for the efficacy of Individual Placement and Support (IPS) for gaining and maintaining competitive employment. Yet, IPS is still not implemented as routine practice in public community mental health services. Knowledge about implementation challenges as experienced by the practitioners is limited. This study seeks to explore the experiences of the front-line workers, known as employment specialists, in the early implementation phase.

METHODS

Qualitative data were collected through field notes and five focus group interviews. The study participants were 45 IPS employment specialists located at 14 different sites in Northern Norway. Transcripts and field notes were analysed by thematic analyses.

RESULTS

While employment specialists are key to the implementation process, implementing IPS requires more than creating and filling the role of the employment specialist. It requires adjustments in multiple organisations. The new employment specialist then is a pioneer of service development. Some employment specialists found this a difficult challenge, and one that did not correspond to their expectations going into this role. Others appreciated the pioneering role. IPS implementation also challenged the delegation of roles and responsibilities between sectors, and related legal frameworks related to confidentiality and access. The facilitating role of human relationships emphasised the importance of social support which is an important factor in a healthy work environment. Rural areas with long distances and close- knit societies may cause challenges for implementation.

CONCLUSION

The study provides increased understanding on what happens in the early implementation phase of IPS from the employment specialists' perspective. Results from this study can contribute to increased focus on job satisfaction, turnover and recruitment of employment specialists, factors which have previously been shown to influence the success of IPS. The greatest challenge for making "IPS efficacy in trials" become "IPS effectiveness in the real world" is implementation, and this study has highlighted some of the implementation issues.

Vocational Interventions to Improve Employment Participation of People with Psychosocial Disability, Autism and/or Intellectual Disability: A Systematic Review

Objective: To systematically review interventions aimed at improving employment participation of people with psychosocial disability, autism, and intellectual disability. Methods: We searched MEDLINE, Embase, PsycINFO, Web of Science, Scopus, CINAHL, ERIC, and ERC for studies published from 2010 to July 2020. Randomized controlled trials (RCTs) of interventions aimed at increasing participation in open/competitive or non-competitive employment were eligible for inclusion. We included studies with adults with psychosocial disability autism and/or intellectual disability. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias II Tool. Data were qualitatively synthesized. Our review was registered with PROSPERO (CRD42020219192). Results: We included 26 RCTs: 23 targeted people with psychosocial disabilities (n = 2465), 3 included people with autism (n = 214), and none included people with intellectual disability. Risk of bias was high in 8 studies, moderate for 18, and low for none. There was evidence for a beneficial effect of Individual Placement and Support compared to control conditions in 10/11 studies. Among young adults with autism, there was some evidence for the benefit of Project SEARCH and ASD supports on open employment. Discussion: Gaps in the availability of high-quality evidence remain, undermining comparability and investment decisions in vocational interventions. Future studies should focus on improving quality and consistent measurement, especially for interventions targeting people with autism and/or intellectual disability.

Informal Caregiver Support Policies Change Use of Vocational Assistance Services for Individuals With Disabilities

Support policies for caregivers improves care-recipient access to care and effects may generalize to nonhealth services. Using administrative data from the U.S. Department of Veterans Affairs (VA) for veterans <55 years, we assessed the association between enrollment in a VA caregiver support program and veteran use of vocational assistance services: the post-9/11 GI Bill, VA vocational rehabilitation and employment (VR&E), and supported employment. We applied instrumental variables to Cox proportional hazards models. Caregiver enrollment in the program increased veteran supported employment use (hazard ratio = 1.35, 95% confidence interval [1.14, 1.53]), decreased VR&E use (hazard ratio = 0.84, 95% confidence interval [0.76, 0.92]), and had no effect on the post-9/11 GI Bill. Caregiver support policies could increase access to some vocational assistance for individuals with disabilities, particularly supported employment, which is integrated into health care. Limited coordination between health and employment sectors and misaligned incentives may have inhibited effects for the post-9/11 GI Bill and VR&E.

Cognitive remediation and professional insertion of people with schizophrenia: RemedRehab, a randomized controlled trial

Background

People suffering from schizophrenia cannot easily access employment in European countries. Different types of vocational programs coexist in France: supported employment, sheltered employment (ShE), and hybrid vocational programs. It is now acknowledged that the frequent cognitive impairments constitute a major obstacle to employment for people with schizophrenia. However, cognitive remediation (CR) is an evidence-based nonpharmacological treatment for these neurocognitive deficits.

Methods

RemedRehab was a multicentric randomized comparative open trial in parallel groups conducted in eight centers in France between 2013 and 2018. Participants were recruited into ShE firms before their insertion in employment (preparation phase). They were randomly assigned to cognitive training Cognitive Remediation for Schizophrenia (RECOS) or Treatment As Usual (TAU). The aim of the study was to compare with the benefits of the RECOS program on access to employment and work attendance for people with schizophrenia, measured by the ratio: number of hours worked on number of hours stipulated in the contract.

Results

Seventy-nine patients were included in the study between October 2018 and September 2019. Fifty-three patients completed the study. Hours worked / planned hours equal to 1 or greater than 1 were significantly higher in the RECOS group than in the TAU group.

Conclusions

Participants benefited from a RECOS individualized CR program allows a better rate of work attendance in ShE, compared to the ones benefited from TAU. Traditional vocational rehabilitation enhanced with individualized CR in a population of patients with schizophrenia is efficient on work attendance during the first months of work integration.

Patient Perspectives on Key Outcomes for Vocational Rehabilitation Interventions Following Traumatic Injury

Returning to work after traumatic injury can have a range of benefits, but there is currently little research that incorporates patient perspectives to identify outcomes of vocational rehabilitation interventions that are important to survivors. Trauma survivors (n = 17) participated in in-depth semi-structured interviews or focus groups exploring outcomes that were important to them for recovery and return to work. Data were analysed using thematic analysis. Participants identified a range of outcomes that they considered important and necessary to facilitate a successful and sustainable return to work: physical and psychological recovery, purposeful life engagement, managing expectations of recovery, managing expectations about return to work, and employers’ expectations. Our participants advocated for a multifaceted and biopsychosocial understanding of recovery and outcomes that need to be captured for vocational rehabilitation interventions. Implications for practice and research are discussed, and recommendations are given based on the findings.

Vocational rehabilitation to enhance return to work after trauma (ROWTATE): protocol for a non-randomised single-arm mixed-methods feasibility study

Background

Traumatic injuries are common amongst working-age adults. Survivors often experience physical and psychological problems, reduced quality of life and difficulty returning to work. Vocational rehabilitation improves work outcomes for a range of conditions but evidence of effectiveness for those with traumatic injuries is lacking. This study assesses feasibility of delivering a vocational rehabilitation intervention to enhance return to work and improve quality of life and wellbeing in people with at least moderate trauma to inform design of a definitive randomised controlled trial (RCT).

Methods

Non-randomised, single-arm, multi-centre mixed-methods feasibility study with nested case studies and qualitative study. The case studies comprise interviews, observations of clinical contacts and review of clinical records. The qualitative study comprises interviews and/or focus groups. Participants will be recruited from two UK major trauma centres. Participants will comprise 40 patients aged 16–69 with an injury severity score of > 8 who will receive the intervention and complete questionnaires. Interviews will be conducted with 10 patients and their occupational therapists (OTs), clinical psychologists (CPs), employers and commissioners of rehabilitation services. Fidelity will be assessed in up to six patients by observations of OT and CP—patient contacts, review of patient records and intervention case report forms. OT and CP training will be evaluated using questionnaires and competence to deliver the intervention assessed using a team objective structured clinical examination and written task. Patients participating in and those declining participation in the study will be invited to take part in interviews/focus groups to explore barriers and facilitators to recruitment and retention. Outcomes include recruitment and retention rates, intervention fidelity, OT and CP competence to deliver the intervention, experiences of delivering or receiving the intervention and factors likely to influence definitive trial delivery.

Discussion

Effective vocational rehabilitation interventions to enhance return to work amongst trauma patients are urgently needed because return to work is often delayed, with detrimental effects on health, financial stability, healthcare resource use and wider society. This protocol describes a feasibility study delivering a complex intervention to enhance return to work in those with at least moderate trauma.

Trial registration

ISRCTN: 74668529. Prospectively registered on 23 January 20

Effectiveness of vocational interventions for gaining paid work for people living with mild to moderate mental health conditions: systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of vocational interventions to help people living with mild to moderate mental health conditions gain paid work.

METHODS

Systematic review of international, peer-reviewed literature. Development of the prepublished protocol and search strategy was done in consultation with stakeholder reference groups consisting of people with lived experience of long-term conditions, advocates and clinicians. We searched academic databases MEDLINE, EMBASE, PsychINFO, AMED, CINAHL, Proquest Dissertations and Theses database, and Business Source Complete for controlled trials comparing a specific vocational intervention against a control intervention or usual care, published between 1 January 2004 and 1 August 2019. Two authors independently screened search results, extracted data and appraised studies using the Cochrane risk of bias tool.

RESULTS

Eleven studies met inclusion criteria. Seven studies investigated Individual Placement and Support (IPS) modified for people who were not in intensive mental health treatment services. These studies occurred settings such as community vocational rehabilitation services, a housing programme and community mental health services. The studies provided very low quality evidence that people who receive IPS-style vocational rehabilitation are more likely to gain competitive employment than people who receive usual care (risk ratio 1.70, 95% CI 1.23 to 2.34, seven studies, 1611 participants). The remaining four studies considered cognitive behavioural therapy or specific vocational rehabilitation interventions designed to fit a unique context. There was insufficient evidence from these studies to draw conclusions regarding the effectiveness of non-IPS forms of vocational rehabilitation for people with mild to moderate mental health conditions.

DISCUSSION

The meta-analysis showed a clear intervention effect but low precision, and more high-quality studies are needed in this field. There is currently very low quality evidence that IPS-style intervention results in more participants in competitive employment compared with 'usual care' control groups in populations with mild to moderate mental health conditions.

INdividual Vocational and Educational Support Trial (INVEST) for young people with borderline personality disorder: study protocol for a randomised controlled trial

Background

The clinical onset of borderline personality disorder (BPD) usually occurs in young people (aged 12–25 years) and commonly leads to difficulty achieving and maintaining vocational (education and/or employment) engagement. While current psychosocial interventions lead to improvements in psychopathology, they have little effect upon functioning. Individual Placement and Support (IPS) is a client-driven model that assists individuals with severe mental illness to engage with education and/or employment appropriate to their personal goals, and that provides ongoing support to maintain this engagement. The objective of the INdividual Vocational and Educational Support Trial (INVEST) is to evaluate the effectiveness of adding IPS to an evidence-based early intervention programme for BPD, with the aim of improving vocational outcomes.

Methods/design

INVEST is a single-blind, parallel-groups, randomised controlled trial (RCT). The randomisation is stratified by gender and age and uses random permuted blocks. The interventions are 39 weeks of either IPS, or ‘usual vocational services’ (UVS). Participants will comprise 108 help-seeking young people (aged 15–25 years) with three or more DSM-5 BPD features and a desire to study or work, recruited from the Helping Young People Early (HYPE) early intervention programme for BPD at Orygen, in Melbourne, Australia. All participants will receive the HYPE intervention. After baseline assessment, staff who are blind to the intervention group allocation will conduct assessments at 13, 26, 39 and 52 weeks. At the 52-week primary endpoint, the primary outcome is the number of days in mainstream education/employment since baseline. Secondary outcomes include the cost-effectiveness of the intervention, quality of life, and BPD severity.

Discussion

Current treatments for BPD have little impact on vocational outcomes and enduring functional impairment is prevalent among this patient group. IPS is a targeted functional intervention, which has proven effective in improving vocational outcomes for adults and young people with psychotic disorders. This trial will investigate whether IPS is effective for improving vocational (employment and educational) outcomes among young people with subthreshold or full-syndrome BPD.

Trial registration

Australian New Zealand Clinical Trials Registry, ID: ACTRN12619001220156. 13 September 2019.

Symptomatic remission affects employment outcomes in schizophrenia patients

BACKGROUND

Remission criteria were proposed by Andreasen et al. for classifying patients with schizophrenia according to the severity of psychopathology. Up to the present time, there have been no cohort studies exploring the association between remission status and employment outcomes in patients with schizophrenia. The study explored whether symptomatic remission is significantly associated with employment outcomes in a two-year longitudinal study.

METHODS

All 525 stable patients with schizophrenia in the therapeutic community of a public mental hospital in Taiwan were recruited between 2013 and 2015. Employment outcomes, defined as the cumulative on-the-job duration (months/per year) and income (new Taiwan dollars, NT$/per year), were investigated at the end of 1- and 2-year follow-up periods after enrollment. For repeated measurements, linear mixed models were constructed to examine the association between symptomatic remission and employment outcomes after controlling for potential confounding variables including age, sex, education, type and daily dose of antipsychotics, cognitive function, psychosocial functioning and initial employment type.

RESULTS

The average age of patients was 51.8 years, and 65.3% were males. Among them, 124 patients (23.6%, 124/525) met the remission criteria at baseline. The linear mixed-model analysis showed that patients who had symptomatic remission were employed 0.8 of a month longer (p = 0.029) and earned NT$3250 more (p = 0.001) within 1 year than those who did not show symptomatic remission.

CONCLUSION

Our study suggests that assessing symptomatic remission is a useful part of monitoring treatment effectiveness for schizophrenia, and all strategies targeting the bio-psycho-social domains to attain symptomatic remission are paramount to maintaining favorable employment outcomes.

The Impact of Vocational Interventions on Vocational Outcomes, Quality of Life, and Community Integration in Adults with Childhood Onset Disabilities: A Systematic Review

Purpose Despite the desire and ability to work, individuals with childhood onset disabilities are under-represented in employment. Vocational interventions alleviate some barriers to obtaining and maintaining employment for this population. The research question addressed is: What is the impact of vocational interventions on vocational outcomes, quality of life (QoL), and community integration (CI) in adults with childhood onset neurological disabilities including cerebral palsy (CP), spina bifida, and acquired brain injury (ABI)? Methods A literature search was conducted in multiple electronic databases. All experimental and observational studies with comparator group(s) were included. Two reviewers independently completed titles and abstracts screening, full text screening, data abstraction, and risk of bias assessment. Results Seventeen studies were eligible for final inclusion including three randomized-controlled trials, four non-randomized studies, and ten observational studies. Sixteen of seventeen studies included only individuals with ABI, while one study included individuals with CP. Vocational interventions from experimental studies were mainly components of multi-faceted interventions. Most observational studies were from the United States Vocational Rehabilitation Service. Conclusions Vocational interventions may be effective in improving vocational outcomes, QoL, and CI for individuals with ABI. There is limited experimental evidence on interventions that specifically target employment. Observational data suggest that receiving job placement assistance, on-the-job training and supports, counselling/guidance, maintenance, and supported employment successfully predicted employment outcomes.

A meta-regression of the impact of policy on the efficacy of individual placement and support

OBJECTIVE

Individual placement and support (IPS) has shown consistently better outcomes on competitive employment for patients with severe mental illness than traditional vocational rehabilitation. The evidence for efficacy originates from few countries, and generalization to different countries has been questioned. This has delayed implementation of IPS and led to requests for country-specific RCTs. This meta-analysis examines if evidence for IPS efficacy can be generalized between rather different countries.

METHODS

A systematic search was conducted according to PRISMA guidelines to identify RCTs. Overall efficacy was established by meta-analysis. The generalizability of IPS efficacy between countries was analysed by random-effects meta-regression, employing country- and date-specific contextual data obtained from the OECD and the World Bank.

RESULTS

The systematic review identified 27 RCTs. Employment rates are more than doubled in IPS compared with standard vocational rehabilitation (RR 2.07 95% CI 1.82-2.35). The efficacy of IPS was marginally moderated by strong legal protection against dismissals. It was not moderated by regulation of temporary employment, generosity of disability benefits, type of integration policies, GDP, unemployment rate or employment rate for those with low education.

CONCLUSIONS

The evidence for efficacy of IPS is very strong. The efficacy of IPS can be generalized between countries.

Effectiveness of psychosocial interventions on quality of life of patients with schizophrenia and related disorders: A systematic review

BACKGROUND

Improving the quality of life of patients with schizophrenia is emphasized all over the world.

AIM

To identify and synthesize the best available evidence on the effectiveness of family interventions, patient education, social skills training and vocational rehabilitation on the quality of life of patients with schizophrenia and related disorders.

METHOD

A systematic literature review.

RESULTS

There is some but weak evidence that family intervention and vocational rehabilitation may enhance the quality of life of patients with schizophrenia.

CONCLUSIONS

More research is needed to determine the effectiveness of psychosocial interventions on the quality of life of patients with schizophrenia.

Employment Rates in Flexible Assertive Community Treatment Teams in The Netherlands: An Observational Study

We determined the proportions of clients treated in Flexible Assertive Community Treatment teams who were unemployed and gained employment and who were employed and lost employment. Secondly, we explored the demographical and clinical factors associated with employment. Data were collected during routine outcome monitoring. We calculated differences in employment rates over a year and explored differences in demographic characteristics at baseline between patient groups. Logistic regression analysis was used to estimate the role of clinical predictor variables on employment status. Over time, 10% remained employed, 5% lost their employment, 3% gained employment and 82% remained unemployed. Clients who found employment were younger, more often male, and had significantly fewer psychosocial problems and a higher subjective quality of life during follow-up than those who remained unemployed. Problems with motivation for treatment at baseline were related to losing employment or remaining unemployed. Better implementation of vocational services is very important for increasing the number of clients gaining employment.

Barriers to and facilitators of employment for people with psychiatric disabilities in Africa: a scoping review

BACKGROUND

Despite the importance of inclusive employment, described in Goal 8 of the Sustainable Development Goals (SDGs), employment of persons with psychiatric disabilities in Africa is lower than among the general population.

OBJECTIVE

The aim of this scoping review is to explore evidence related to the barriers to and facilitators of employment of persons with psychiatric disabilities in Africa.

METHODS

A literature search was conducted using six relevant electronic databases of articles published between 1990 and 2017.

RESULTS

Eight studies were identified and analysed regarding barriers and facilitators of employment of persons with psychiatric disabilities. The dynamic adaptation of the bio-psycho-social model was used as an analytical framework. Identified barriers include ill health, (anticipated) psychiatric illness, social stigma and discrimination, negative attitudes among employers and the lack of social support and government welfare. Facilitators of employment include stability of mental illness, heightened self-esteem, a personal decision to work despite stigma, competitive and supported employment, reduction in social barriers/stigma and workplace accommodations.

CONCLUSION

Employment of persons with psychiatric disabilities is essential, yet there is dearth of scientific evidence to identify contextual models that might be useful in African countries and other low-and middle countries (LMICs). This gap in information would benefit from further research to improve the employment rates of persons with psychiatric disabilities in Africa.

Development of a scale to assess motivation for competitive employment among persons with severe mental illness

BACKGROUND

The employment rate among people with severe mental illness has recently increased, though it is still low. The motivation to work appears to be an important role as an intermediate outcome measure in vocational rehabilitation programs. In addition, measuring the work motivation for people with severe mental illness appears to be essential to identify candidates who are likely to benefit and monitor candidates' motivation in a supported employment program. This study aimed to develop a new measure for assessing both intrinsic and extrinsic motivation to work among people with severe mental illness, as there are currently no well-established instruments of this kind.

METHODS

A focus group interview and review of previous qualitative research were used to identify possible items for inclusion in the new scale. A provisional scale was constructed and further refined for content and format based on feedback from a researcher and also three peer workers with severe mental illness. The resulting provisional 38-item version of the scale was completed by 136 respondents with severe mental illness, and we performed exploratory factor analysis to identify latent constructs within the new measure. The finalized scale was analyzed for test-retest reliability, internal consistency, and convergent validity.

RESULT

An exploratory factor analysis yielded a four-factor scale with 23 items. The finalized 23 items had high internal consistency (Cronbach's alpha = 0.91) and relatively high test-retest reliability (ICC = 0.83). The four subscales had fair internal consistency (Cronbach's alpha ≥ 0.69) and good test-retest reliability (ICC ≥ 0.61). Convergent validity was weakly supported by the significant positive correlations with the overall question on motivation to work (r ≥ 0.19, p < 0.01). Besides these correlations, only the "Pressure from others" subscale was negatively and significantly correlated with the negative symptoms evaluated using the Positive and Negative Syndrome Scale (r = -0.18, p = 0.04).

CONCLUSIONS

This study used factor analysis to develop a new multidimensional scale assessing motivation for competitive employment among persons with severe mental illness. The scale showed acceptable levels of reliability and factor-based and convergent validity. The new measure can be used for measuring the motivation for competitive employment among people with severe mental illness, and it would be useful to identify candidates who are likely to benefit from a certain supported employment program, and to monitor interim progress of the state of participants' motivation in a program.

Employment Interventions in Health Settings: A Systematic Review and Synthesis

PURPOSE

Employment is a key social determinant of health. People who are unemployed typically have worse health than those employed. Illness and disability can result in unemployment and be a barrier to regaining employment. We combined a systematic review and knowledge synthesis to identify both studies of employment interventions in health care settings and common characteristics of successful interventions.

METHODS

We searched the peer-reviewed literature (1995-2017), and titles and abstracts were screened for inclusion and exclusion criteria by 2 independent reviewers. We extracted data on the study setting, participants, intervention, methods, and findings. We also conducted a narrative synthesis and iteratively developed a conceptual model to inform future primary care interventions.

RESULTS

Of 6,729 unique citations, 88 articles met our criteria. Most articles (89%) focused on people with mental illness. The majority of articles (74%) tested interventions that succeeded in helping participants gain employment. We identified 5 key features of successful interventions: (1) a multidisciplinary team that communicates regularly and collaborates, (2) a comprehensive package of services, (3) one-on-one and tailored components, (4) a holistic view of health and social needs, and (5) prospective engagement with employers.

CONCLUSIONS

Our findings can inform new interventions that focus on employment as a social determinant of health. Although hiring a dedicated employment specialist may not be feasible for most primary care organizations, pathways using existing resources with links to external agencies can be created. As precarious work becomes more common, helping patients engage in safe and productive employment could improve health, access to health care, and well-being.

Furthering the Evidence of the Effectiveness of Employment Strategies for People with Mental Disorders in Europe: A Systematic Review

(1) Purpose: This systematic review aims to assess the effectiveness of strategies used in the professional (re)integration of persons with mental disorders (MD) in European countries; (2) Methods: We conducted a search for scientific publications available in relevant electronic databases (Medline, PsycINFO, CDR-HTA, CDR-DARE, and Cochrane Library). The present study collected evidence on the effectiveness, from 2011 to 2016, of employment strategies for persons with MDs; (3) Results: A total of 18 studies were included, representing 5216 participants (aged 18⁻65, mean age of 38.5 years old) from 7 countries. Job access programs demonstrated effectiveness in four out of six studies. Return to work (RTW) interventions showed significant positive results in two studies, while four studies did not refer to effectiveness. There were inconsistent results in another four studies; (4) Conclusions: Our findings highlight the complexities of the implementation of employment strategies (job access and return to work). Job access strategies seem to improve employment outcomes. The effectiveness of return to work strategies remains unclear. The involvement and commitment of physicians, employment specialists, and employers, and employees capacity for self-care seem decisive for employment re-integration success. Further analyses are needed to assess the cost-effectiveness of these interventions and corroborate our results, with longer follow-ups.

A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation

The Clubhouse Model has been in existence for over sixty-five years; however, a review that synthesizes the literature on the model is needed. The current study makes use of the existing research to conduct a systematic review of articles providing a comprehensive understanding of what is known about the Clubhouse Model, to identify the best evidence available, as well as areas that would benefit from further study. Findings are summarized and evidence is classified by outcome domains. Fifty-two articles met the selection criteria of Randomized Clinical Trials (RCT's), quasi-experimental studies, or observational studies for domains of employment (N = 29); quality of life/satisfaction (N = 10); reductions in psychiatric hospitalization(s) (N = 10); social relationships (N = 10); education (N = 3); and health promotion activities (N = 2). RCT results support the efficacy of the Clubhouse Model in promoting employment, reducing hospitalization(s), and improving quality of life. Quasi-experimental and observational studies offer support in education and social domains. The findings from this review indicate that Clubhouses are a promising practice but additional studies using rigorous methods that report the strength of the outcomes are needed to evaluate Clubhouse programs with fidelity to the Clubhouse Model.

How effective is the comprehensive approach to rehabilitation (CARe) methodology? A cluster randomized controlled trial

BACKGROUND

The CARe methodology aims to improve the quality of life of people with severe mental illness by supporting them in realizing their goals, handling their vulnerability and improving the quality of their social environment. This study aims to investigate the effectiveness of the CARe methodology for people with severe mental illness on their quality of life, personal recovery, participation, hope, empowerment, self-efficacy beliefs and unmet needs.

METHODS

A cluster Randomized Controlled Trial (RCT) was conducted in 14 teams of three organizations for sheltered and supported housing in the Netherlands. Teams in the intervention group received training in the CARe methodology. Teams in the control group continued working according to care as usual. Questionnaires were filled out at baseline, after 10 months and after 20 months. A total of 263 clients participated in the study.

RESULTS

Quality of life increased in both groups, however, no differences between the intervention and control group were found. Recovery and social functioning did not change over time. Regarding the secondary outcomes, the number of unmet needs decreased in both groups. All intervention teams received the complete training program. The model fidelity at T1 was 53.4% for the intervention group and 33.4% for the control group. At T2 this was 50.6% for the intervention group and 37.2% for the control group.

CONCLUSION

All clients improved in quality of life. However we did not find significant differences between the clients of the both conditions on any outcome measure. Possible explanations of these results are: the difficulty to implement rehabilitation-supporting practice, the content of the methodology and the difficulty to improve the lives of a group of people with longstanding and severe impairments in a relatively short period. More research is needed on how to improve effects of rehabilitation trainings in practice and on outcome level.

TRIAL REGISTRATION

ISRCTN77355880 , retrospectively registered (05/07/2013).

Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis

BACKGROUND

People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions.

OBJECTIVES

To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness.

SEARCH METHODS

In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials.

SELECTION CRITERIA

We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE.

MAIN RESULTS

We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions.

AUTHORS' CONCLUSIONS

Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.

The effectiveness of augmented versus standard individual placement and support programs in terms of employment: a systematic literature review

BACKGROUND

The Individual Placement and Support (IPS) program is a well-studied vocational rehabilitation program. Although it is more effective than usual care, it is not effective for everyone. This offers an opportunity for program improvement.

AIMS

This systematic literature review examines the state of knowledge regarding the effectiveness of augmented versus standard IPS for people with severe mental illness (SMI). We address the questions, "What IPS augmentations have been tested?" and "What is the evidence for the effectiveness of augmented IPS versus standard IPS in terms of employment?"

METHODS

This systematic literature review used publically available peer-reviewed studies published between January 2002 and January 2016 in either: (1) Medline Current, (2) Medline In-process, (3) PsycINFO, (4) Econlit or (5) Web of Science.

RESULTS

5718 unique citations were identified; seven articles from five studies were included. Of these studies, four were rated as having moderate risk of bias and one as having high risk.

CONCLUSIONS

The results suggest that augmentations of IPS focusing on cognitive and psychosocial skills training, may have additional effects to standard IPS. Areas in need of further research related to the process and targeting of those interventions are discussed.

Towards Employment: What Research Says About Support-to-Work in Relation to Psychiatric and Intellectual Disabilities

This article presents an overview of research about support-to-work in relation to psychiatric and intellectual disabilities. The overview shows that support-to-work services are multifaceted, and that work can be seen as a tool for individual rehabilitation or as a set of goals to achieve. Providers are presented with specific components, which are characterized by systematic, targeted, and individualized interventions. The overview illustrates a need for long-term engagement and cooperation of and between welfare services and agents within the labor market to dissolve the Gordian knot that the transition from welfare interventions to employment seems to be.

Effectiveness of work skills programmes for offenders with mental disorders: A systematic review

BACKGROUND

Academic literature and government initiatives have emphasised the importance of work as a means of improving health and reducing reoffending among offenders with mental disorders. Whilst a number of work skills programmes have shown promise for offenders more generally, evaluation of evidence for their effectiveness for those with a mental disorder is lacking, particularly in relation to improving employment outcomes.

AIMS

To assess the evidence on the effectiveness of work skills programmes for mentally disordered offenders.

METHOD

A systematic review of the literature was conducted by searching the following databases: PsycINFO, CINAHL, Cochrane Library (Trials Register), Embase and Medline, using search terms which included Work Skills Programme*, Offend* and Mental*. Any empirical comparison study of work skills programmes was included in this review. The primary outcome was employment. Secondary outcomes included employment outcomes, reoffending, education, mental state, substance misuse, global functioning, quality of life, acceptability, leaving the study early and cost effectiveness or other economic outcomes.

RESULTS

Six articles met the inclusion criteria. Collectively they provided limited evidence that work skills programmes increase the likelihood of people with mental disorder who are offenders obtaining employment in the short term, but there are insufficient studies to determine the long-term impact of work skills programmes.

CONCLUSIONS

There is modest evidence to support inclusion of specific work skills programmes in the treatment of offenders with mental disorder. Future studies should be of theoretically driven programmes, such as Individual Placement Support (IPS), and use a standard set of relevant outcome measures and long enough follow-up for testing the effectiveness of any programme on engagement in competitive, paid employment as, even if skilled, offenders with mental disorder must constitute a hard to place group. Copyright © 2015 John Wiley & Sons, Ltd.

Psychotherapeutic and work-oriented interventions: employment outcomes among young adults with work disability due to a mental disorder

BACKGROUND

We examined the extent to which psychotherapeutic and work-oriented interventions were included in a medical treatment and rehabilitation plan and whether they predicted future employment among young adults with work disability due to a mental disorder.

METHODS

Data were obtained from the treatment and rehabilitation plans of 1163 young adults aged 18‒34 years, who in 2008 were granted fixed-term work disability compensation due to a mental disorder and were followed for 5 years.

RESULTS

Forty-six percent had no proposal for psychotherapy or a work-oriented intervention in their treatment and rehabilitation plan, 22 % had a plan for only a psychotherapeutic intervention, 23 % had a plan for only a work-oriented intervention, and 10 % had both types of interventions planned. Having a planned psychotherapeutic intervention (HR = 1.35, 95 % CI 1.07-1.69) and of the work-oriented interventions, planned rehabilitative courses and training (HR = 1.34, 95 % CI 1.03-1.70) predicted quicker entry into competitive employment. Having a plan for both a psychotherapeutic and work-oriented intervention was associated with being employed at the end of the follow-up (OR = 1.77, 95 % CI 1.07-2.95).

CONCLUSIONS

Young adults with a long-term psychiatric work disability episode rarely have a recorded plan for rehabilitation in their treatment and rehabilitation plan although psychotherapeutic interventions and a combination of a psychotherapeutic and work-oriented intervention might help them gain employment.

Individual placement and support (IPS) for patients with offending histories: the IPSOH feasibility cluster randomised trial protocol

INTRODUCTION

People with involvement in forensic psychiatric services face many obstacles to employment, arising from their offending, as well as their mental health problems. This study aims to assess the feasibility of conducting a randomised controlled trial (RCT) to evaluate the effectiveness of individual placement and support (IPS), in improving employment rates and associated psychosocial outcomes in forensic psychiatric populations. IPS has been found consistently to achieve employment rates above 50% in psychiatric patients without a history of involvement in criminal justice services.

METHODS/DESIGN

This is a single-centre feasibility cluster RCT. Clusters will be defined according to clinical services in the community forensic services of Nottinghamshire Healthcare NHS Foundation Trust (NHCT). IPS will be implemented into 2 of the randomly assigned intervention clusters in the community forensic services of NHCT. A feasibility cluster RCT will estimate the parameters required to design a full RCT. The primary outcome is the proportion of people in open employment at 12-month follow-up. Secondary outcome measures will include employment, educational activities, psychosocial and economic outcomes, as well as reoffending rates. Outcome measures will be recorded at baseline, 6 months and 12 months. In accordance with the UK Medical Research Council guidelines on the evaluation of complex interventions, a process evaluation will be carried out; qualitative interviews with patients and staff will explore general views of IPS as well as barriers and facilitators to implementation. Fidelity reviews will assess the extent to which the services follow the principles of IPS prior, during and at the end of the trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the East Midlands Research Ethics Committee-Nottingham 1 (REC reference number 15/EM/0253). Final and interim reports will be prepared for project funders, the study sponsor and clinical research network. Findings will be disseminated through peer-reviewed journals, conferences and event presentations.

TRIAL REGISTRATION NUMBER

NCT02442193; Pre-results.

Recovery in Schizophrenia: What Consumers Know and Do Not Know

The recovery model has permeated mental health systems by leading to the development of new psychiatric interventions and services and the reconfiguration of traditional ones. There is growing evidence that these interventions and services confer benefits in clinical and recovery-oriented outcomes. Despite the seeming adoption of recovery by policy makers, the transformation of mental health systems into recovery-oriented systems has been fraught with challenges.

The readmission rate and medical cost of patients with schizophrenia after first hospitalization - A 10-year follow-up population-based study

BACKGROUND

Hospital readmissions caused by relapse in patients with schizophrenia are associated with prognosis. Identifying individuals at high risk of readmission and providing interventions to lower the readmission rate are important.

METHODS

Patients with schizophrenia who were hospitalized for the first time were recruited from the National Health Insurance Research Database from 2001 to 2010 (n=808, mean age 28.9years) and compared with matched controls. Data on the demographics, cost, and utilization of medical resources of patients who were readmitted were compared with non-readmitted patients. The readmission time curve was analyzed by the Kaplan-Meier method.

RESULT

570 (70.5%) patients were readmitted within 10years; the median time between admissions was 1.9years, and 25% of subjects were readmitted within 4months of the first hospitalization. There were no significant differences in age, gender, or length of hospitalization between the readmission and non-readmission groups. Taking into account all psychiatric medical services, the readmission group had a significantly higher mean frequency of care and a greater medical cost than the non-readmission group and matched controls. However, there were no significant differences with regard to non-psychiatric medical services.

CONCLUSION

Schizophrenia has a high rate of readmission and high medical cost in naturalistic settings. In addition to the traditional hospital-based treatment model for patients with schizophrenia, the development of an effective intervention program is important, especially in the early years of the disease.

Empirical evidence about recovery and mental health

BACKGROUND

Two discourses exist in mental health research and practice. The first focuses on the limitations associated with disability arising from mental disorder. The second focuses on the possibilities for living well with mental health problems.

DISCUSSION

This article was prompted by a review to inform disability policy. We identify seven findings from this review: recovery is best judged by experts or using standardised assessment; few people with mental health problems recover; if a person no longer meets criteria for a mental illness, they are in remission; diagnosis is a robust basis for characterising groups and predicting need; treatment and other supports are important factors for improving outcome; the barriers to receiving effective treatment are availability, financing and client awareness; and the impact of mental illness, in particular schizophrenia, is entirely negative. We selectively review a wider range of evidence which challenge these findings, including the changing understanding of recovery, national mental health policies, systematic review methodology and undertainty, epidemiological evidence about recovery rates, reasoning biased due to assumptions about mental illness being an illness like any other, the contested nature of schizophrenia, the social construction of diagnoses, alternative explanations for psychosis experiences including the role of trauma, diagnostic over-shadowing, stigma, the technological paradigm, the treatment gap, social determinants of mental ill-health, the prevalence of voice-hearing in the general population, and the sometimes positive impact of psychosis experience in relation to perspective and purpose.

CONCLUSION

We propose an alternative seven messages which are both empirically defensible and more helpful to mental health stakeholders: Recovery is best judged by the person living with the experience; Many people with mental health problems recover; If a person no longer meets criteria for a mental illness, they are not ill; Diagnosis is not a robust foundation; Treatment is one route among many to recovery; Some people choose not to use mental health services; and the impact of mental health problems is mixed.

International employment schemes for people with mental health problems

It has been recognised that work is a positive factor for mental health since the days of Galen (2nd century CE). It was central to the theories and practice of William Tuke at the Retreat in York (founded 1796) and has continued in different forms as a therapy and/or a form of rehabilitation ever since. These forms can be usefully divided into four main categories: sheltered work, vocational training, transitional employment (or work experience) and supported employment. These broad categories have been adapted to different cultures and economic circumstances across the world. There are advantages and disadvantages to all forms, but the burgeoning research literature of the past 20 years does show that when it comes to finding people paid work in the open labour market, supported employment is markedly more successful than other methods.

Effectiveness of the Comprehensive Approach to Rehabilitation (CARe) methodology: design of a cluster randomized controlled trial

BACKGROUND

There is an increasing amount of evidence for the effectiveness of rehabilitation interventions for people with severe mental illness (SMI). In the Netherlands, a rehabilitation methodology that is well known and often applied is the Comprehensive Approach to Rehabilitation (CARe) methodology. The overall goal of the CARe methodology is to improve the client's quality of life by supporting the client in realizing his/her goals and wishes, handling his/her vulnerability and improving the quality of his/her social environment. The methodology is strongly influenced by the concept of 'personal recovery' and the 'strengths case management model'. No controlled effect studies have been conducted hitherto regarding the CARe methodology.

METHODS/DESIGN

This study is a two-armed cluster randomized controlled trial (RCT) that will be executed in teams from three organizations for sheltered and supported housing, which provide services to people with long-term severe mental illness. Teams in the intervention group will receive the multiple-day CARe methodology training from a specialized institute and start working according the CARe Methodology guideline. Teams in the control group will continue working in their usual way. Standardized questionnaires will be completed at baseline (T0), and 10 (T1) and 20 months (T2) post baseline. Primary outcomes are recovery, social functioning and quality of life. The model fidelity of the CARe methodology will be assessed at T1 and T2.

DISCUSSION

This study is the first controlled effect study on the CARe methodology and one of the few RCTs on a broad rehabilitation method or strength-based approach. This study is relevant because mental health care organizations have become increasingly interested in recovery and rehabilitation-oriented care.

TRIAL REGISTRATION

The trial registration number is ISRCTN77355880 .

Facilitating return to work through early specialist health-based interventions (FRESH): protocol for a feasibility randomised controlled trial

Background

Over one million people sustain traumatic brain injury each year in the UK and more than 10 % of these are moderate or severe injuries, resulting in cognitive and psychological problems that affect the ability to work. Returning to work is a primary rehabilitation goal but fewer than half of traumatic brain injury survivors achieve this. Work is a recognised health service outcome, yet UK service provision varies widely and there is little robust evidence to inform rehabilitation practice. A single-centre cohort comparison suggested better work outcomes may be achieved through early occupational therapy targeted at job retention. This study aims to determine whether this intervention can be delivered in three new trauma centres and to conduct a feasibility, randomised controlled trial to determine whether its effects and cost effectiveness can be measured to inform a definitive trial.

Methods/design

Mixed methods study, including feasibility randomised controlled trial, embedded qualitative studies and feasibility economic evaluation will recruit 102 people with traumatic brain injury and their nominated carers from three English UK National Health Service (NHS) trauma centres. Participants will be randomised to receive either usual NHS rehabilitation or usual rehabilitation plus early specialist traumatic brain injury vocational rehabilitation delivered by an occupational therapist. The primary objective is to assess the feasibility of conducting a definitive trial; secondary objectives include measurement of protocol integrity (inclusion/exclusion criteria, intervention adherence, reasons for non-adherence) recruitment rate, the proportion of eligible patients recruited, reasons for non-recruitment, spectrum of TBI severity, proportion of and reasons for loss to follow-up, completeness of data collection, gains in face-to-face Vs postal data collection and the most appropriate methods of measuring primary outcomes (return to work, retention) to determine the sample size for a larger trial.

Discussion

To our knowledge, this is the first feasibility randomised controlled trial of a vocational rehabilitation health intervention specific to traumatic brain injury. The results will inform the design of a definitive trial.

Trial registration

The trial is registered ISRCTN Number 38581822.

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-015-0017-z) contains supplementary material, which is available to authorized users.

S3 guideline on psychosocial therapies in severe mental illness: evidence and recommendations

The burden of severe and persistent mental illness is high. Beside somatic treatment and psychotherapeutic interventions, treatment options for patients with severe mental illness also include psychosocial interventions. This paper summarizes the results of a number of systematic literature searches on psychosocial interventions for people with severe mental illness. Based on this evidence appraisal, recommendations for the treatment of people with severe mental illness were formulated and published in the evidence-based guideline series of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) as an evidence-based consensus guideline ("S3 guideline"). Recommendations were strongly based on study results, but used consensus processes to consider external validity and transferability of the recommended practices to the German mental healthcare system. A distinction is made between system-level interventions (multidisciplinary team-based psychiatric community care, case management, vocational rehabilitation and participation in work life and residential care interventions) and single psychosocial interventions (psychoeducation, social skills training, arts therapies, occupational therapy and exercise therapy). There is good evidence for the efficacy of the majority of psychosocial interventions in the target group. The best available evidence exists for multidisciplinary team-based psychiatric community care, family psychoeducation, social skills training and supported employment. The present guideline offers an important opportunity to further improve health services for people with severe mental illness in Germany. Moreover, the guideline highlights areas for further research.

Association between stigmatisation and experiences of evidence-based practice by psychiatric rehabilitation staff in Japan: a cross-sectional survey

BACKGROUND

Mental health professionals are one of the groups holding harmful stigmatisation towards people with mental illness.

AIMS

To investigate the association between the performance of evidence-based practice (EBP) and the staff's level of stigmatisation in Japan.

METHODS

The study enrolled 179 staff members in psychiatric day-care, psychiatric community outreach teams, and psychiatric rehabilitation teams at 14 psychiatric hospitals. The Positive Attitudes Scale (PAS), the Japanese-language version of the Social Distance Scale (SDSJ) and the Recovery Attitude Questionnaire (RAQ) were employed as outcome measures. Scores on each scale were compared between participants who performed EBPs and those who had never performed EBPs.

RESULTS

Approximately 40% of the staff engaged in at least assertive community treatment, supported employment or family psychoeducation. The staff who performed EBPs had significantly higher scores on PAS (MD, 7.09; 95% CIs, 4.09-10.09) and RAQ (MD, 1.30; 95% CIs, 0.36-2.25) but lower scores on SDSJ (MD, -2.41; 95% CIs, -3.50 to -1.32) than those who never performed EBPs. Multivariate analyses found that EBP experience was associated with a low level of staff stigmatisation after controlling for confounders.

CONCLUSION

The findings suggest that an individual EBP experience is associated with their reduced stigmatisation.

Public mental health: the time is ripe for translation of evidence into practice

Public mental health deals with mental health promotion, prevention of mental disorders and suicide, reducing mental health inequalities, and governance and organization of mental health service provision. The full impact of mental health is largely unrecognized within the public health sphere, despite the increasing burden of disease attributable to mental and behavioral disorders. Modern public mental health policies aim at improving psychosocial health by addressing determinants of mental health in all public policy areas. Stigmatization of mental disorders is a widespread phenomenon that constitutes a barrier for help-seeking and for the development of health care services, and is thus a core issue in public mental health actions. Lately, there has been heightened interest in the promotion of positive mental health and wellbeing. Effective programmes have been developed for promoting mental health in everyday settings such as families, schools and workplaces. New evidence indicates that many mental disorders and suicides are preventable by public mental health interventions. Available evidence favours the population approach over high-risk approaches. Public mental health emphasizes the role of primary care in the provision of mental health services to the population. The convincing evidence base for population-based mental health interventions asks for actions for putting evidence into practice.

How much do we know about schizophrenia and how well do we know it? Evidence from the Schizophrenia Library

BACKGROUND

True findings about schizophrenia remain elusive; many findings are not replicated and conflicting results are common. Well-conducted systematic reviews have the ability to make robust, generalizable conclusions, with good meta-analyses potentially providing the closest estimate of the true effect size. In this paper, we undertake a systematic approach to synthesising the available evidence from well-conducted systematic reviews on schizophrenia.

METHOD

Reviews were identified by searching Medline, EMBASE, CINAHL, Current Contents and PsycINFO. The decision to include or exclude reviews, data extraction and quality assessments were conducted in duplicate. Evidence was graded as high quality if reviews contained large samples and robust results; and as moderate quality if reviews contained imprecision, inconsistency, smaller samples or study designs that may be prone to bias.

RESULTS

High- and moderate-quality evidence shows that numerous psychosocial and biomedical treatments are effective. Patients have relatively poor cognitive functioning, and subtle, but diverse, structural brain alterations, altered electrophysiological functioning and sleep patterns, minor physical anomalies, neurological soft signs, and sensory alterations. There are markers of infection, inflammation or altered immunological parameters; and there is increased mortality from a range of causes. Risk for schizophrenia is increased with cannabis use, pregnancy and birth complications, prenatal exposure to Toxoplasma gondii, childhood central nervous system viral infections, childhood adversities, urbanicity and immigration (first and second generation), particularly in certain ethnic groups. Developmental motor delays and lower intelligence quotient in childhood and adolescence are apparent.

CONCLUSIONS

We conclude that while our knowledge of schizophrenia is very substantial, our understanding of it remains limited.

[Work rehabilitation in people with severe mental illnesses]

Work and employment are basic human rights. Work therapy has a long-standing tradition in mental health care. Integrating people with severe mental illness into jobs has always been considered indispensable. Germany has a good legal framework for work rehabilitation and there is solid evidence of effectiveness for a range of interventions. International models of work integration have not been implemented to a sufficient degree and this may be one of the reasons for limited success in work rehabilitation for people with mental illnesses. The need for work rehabilitation measures and the available evidence are outlined. Social legislation, conceptual and organizational aspects of rehabilitation are described. International comparisons suggest that the care system will have to integrate prevention, curative treatment, rehabilitation and long-term care in a better way.

The economic cost of schizophrenia in Ireland: a cost of illness study

Objectives: Although there are many published reports about the human cost of schizophrenia, there are far fewer estimates of its economic cost, particularly in Ireland. The aim of this study was to provide a prevalence-based estimate of the costs associated with schizophrenia in Ireland during 2006.

Method: Using standard Cost of Illness (COI) procedures we compiled data from many sources including the Health Research Board, the Department of Health and Children and other government publications. Costs relating to health and social care, informal care, lost productivity, premature mortality and other public expenditures were included. Where national data were unavailable, we used bottom-up data from a geographically defined catchment area study and, in some instances, costs from two catchment areas were averaged. We did not measure human or intangible costs.

Results: The estimated total cost of schizophrenia was €460.6 million in 2006. The direct cost of care was €117.5 million and the burden of indirect costs was €343 million. The cost of lost productivity due to unemployment, absence from work and premature mortality was €277 million. Within indirect costs, the expenditure on informal care borne by families was €43.8 million.

Conclusions: Schizophrenia is not a very common condition but is an expensive one. This is attributable to its young age at onset, relatively low mortality rate and high severity particularly in terms of its impact on future employment. Measures to improve outcomes coupled with measures to improve employment such as supported employment strategies may impact significantly on the cost of schizophrenia. The study is limited because the national unit costs of many variables are not directly available and these Irish data are likely to be an underestimate. However, the results are comparable with a 2005 cost of illness study UK study.

Return to work of workers without a permanent employment contract, sick-listed due to a common mental disorder: design of a randomised controlled trial

Background

Workers without a permanent employment contract represent a vulnerable group within the working population. Mental disorders are a major cause of sickness absence within this group. Common mental disorders are stress-related, depressive and anxiety disorders. To date, little attention has been paid to effective return to work interventions for this type of sick-listed workers. Therefore, a participatory supportive return to work program has been developed. It combines elements of a participatory return to work program, integrated care and direct placement in a competitive job.

The objective of this paper is to describe the design of a randomised controlled trial to evaluate the cost-effectiveness of this program compared to care as usual.

Methods/Design

The cost-effectiveness of the participatory supportive return to work program will be examined in a randomised controlled trial with a follow-up of twelve months.

The program strongly involves the sick-listed worker in the identification of obstacles for return to work and possible solutions, resulting in a consensus based action plan. This plan will be used as a starting point for the search of suitable competitive employment with support of a rehabilitation agency. During this process the insurance physician of the sick-listed worker contacts other caregivers to promote integrated care.

Workers eligible to participate in this study have no permanent employment contract, have applied for a sickness benefit at the Dutch Social Security Agency and are sick-listed between two and fourteen weeks due to mental health problems.

The primary outcome measure is the duration until first sustainable return to work in a competitive job. Outcomes are measured at baseline and after three, six, nine and twelve months.

Discussion

If the participatory supportive return to work program proves to be cost-effective, the social security system, the sick-listed worker and society as a whole will benefit. A cost-effective return to work program will lead to a reduction of costs related to sickness absence. For the sick-listed worker a cost-effective program results in earlier sustainable return to work, which can be associated with both social and health benefits.

Trial registration

The trial registration number and date is NTR3563, August 7, 2012.

Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis-uses ("abuses") of the concept of recovery: recovery is the latest model; recovery does not apply to "my" patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically-validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.

Resumption of work or studies after first-episode psychosis: the impact of vocational case management

BACKGROUND

Psychosis compromises the educational and professional projects of young patients. Vocational case management (VCM) offers comprehensive support for reintegration into work or studies within an early psychosis intervention programme.

AIMS

To evaluate the effectiveness of VCM in resumption of work or school and to identify the predictive factors of occupational outcome.

METHODS

This descriptive study focused on occupational status of an early psychosis cohort during the first 5 years of VCM.

RESULTS

56.6% of 97 study subjects had a diagnosis of schizophrenia, 32% had type I bipolar disorder with psychotic features. 68% held a productive occupation the year prior to admission, and 47.4% at admission. The occupational rate rose from 57.1% at 12 months to over 70% after 48 months. 65.6% maintained or improved their occupational status. Most subjects held competitive employment, and the employment rate was similar to that of the general population. Prior employment and affective psychosis were associated with better outcome. [Correction added on 2 April 2013, after first online publication: 'Non-affective psychosis' has been changed to 'affective psychosis' in the Results section.]

CONCLUSION

The majority of individuals suffering from early psychosis resume productive activity rapidly when offered VCM within an early intervention programme during a follow-up period of up to 5 years.