Rehabilitative day treatment vs. supported employment: I. Vocational outcomes

Individual placement and support: History, current status, and future directions

Over the past three decades, Individual Placement and Support (IPS) has emerged as a robust evidence-based approach to helping people with severe mental illnesses, such as schizophrenia, bipolar disorder, and major depression, to obtain and succeed in competitive employment. This review addresses the history, principles, research, and future directions of IPS. It covers current evidence on employment outcomes, cost-effectiveness, and nonvocational outcomes. It also describes current attempts to extend IPS to new populations. The authors provide an overview of numerous systematic reviews and meta-analyses of randomized controlled trials involving people with serious mental illness. For studies addressing nonvocational outcomes and new populations, the review uses best available evidence. Published reviews agree that IPS enables patients with serious mental illness in high-income countries to succeed in competitive employment at a higher rate than patients who receive other vocational interventions. Within IPS programs, quality of implementation, measured by standardized fidelity scales, correlates with better outcomes. Employment itself leads to enhanced income, psychosocial outcomes, clinical improvements, and decreased mental health service use. As IPS steadily spreads to new populations and new settings, research is active across high-income countries and spreading slowly to middle-income countries. IPS is an evidence-based practice for people with serious mental illness in high-income countries. It shows promise to help other disability groups also, and emerging research aims to clarify adaptations and outcomes.

The impact of the BEL intervention on levels of motivation, engagement and recovery in people who attend community mental health services

BACKGROUND

Community-based day centres (DC) in Sweden provide support to people with severe mental health problems. The role of DC motivation for outcomes in terms of occupational engagement and personal recovery is yet unknown.

AIMS

To compare two groups who received DC services, one of which also received the 16-week Balancing Everyday Life (BEL) intervention. The focus was motivation for DC services at baseline and after 16 weeks of services, while also investigating the importance of DC motivation for the selected outcomes and service satisfaction.

MATERIAL AND METHODS

Sixty-five DC attendees were randomised to BEL (n = 27) or standard support (n = 38) and responded to questionnaires about motivation, the selected outcomes and satisfaction with DC services.

RESULTS

The groups did not differ on any measured aspects of motivation; nor were changes seen over time. The BEL group, but not those receiving standard support, improved from baseline to 16 weeks on occupational engagement and recovery. Motivation for attending the DC was related to service satisfaction.

CONCLUSION

The BEL program could be a viable enrichment tool in the DC context and boost occupational engagement and personal recovery among the attendees.

SIGNIFICANCE

The study provided knowledge of importance when developing community-based services while enhancing motivation.

Effectiveness of supported employment in non-trial routine implementation: systematic review and meta-analysis

PURPOSE

While supported employment (SE) programs for people with mental illness have demonstrated their superiority in randomized controlled trials (RCTs) and meta-analyses, little is known about the effectiveness of non-trial routine programs. The primary objective of this study was to estimate a pooled competitive employment rate of non-trial SE programs by means of a meta-analysis. A secondary objective was to compare this result to competitive employment rates of SE programs in RCTs, prevocational training programs in RCTs and in routine implementation.

METHODS

A systematic review and a random-effects meta-analysis of proportions were conducted. Quality assessment was provided. Moderator analyses by subgroup comparisons were conducted.

RESULTS

Results from 28 samples were included in the meta-analysis. The pooled competitive employment rate for SE routine programs was 0.43 (95% CI 0.37-0.50). The pooled competitive employment rates for comparison conditions were: SE programs in RCTs: 0.50 (95% CI 0.43-0.56); prevocational programs in RCTs: 0.22 (95% CI 0.16-0.28); prevocational programs in routine programs: 0.17 (95% CI 0.11-0.23). SE routine studies conducted prior to 2008 showed a significantly higher competitive employment rate.

CONCLUSION

SE routine programs lose only little effectiveness compared to SE programs from RCTs but are much more successful in reintegrating participants into the competitive labor market than prevocational programs. Labor market conditions have to be taken into account when evaluating SE programs.

Individual placement and support: from research to practice

Vocational rehabilitation for people with severe mental health problems is poorly developed in the UK. Although there is a clear evidence base indicating the effectiveness of approaches to helping people with severe mental health problems gain and retain employment there is generally a lack of awareness of this evidence. As a result there has been a lack of implementation within routine clinical practice of the most effective approaches to improving employment outcomes for such individuals.

Staff ratings of occupational engagement among people with severe mental illness - psychometric properties of a screening tool in the day center context

Background

Staff who plan and organize day center activities may need to observe the attendees’ performance and progression. This led us to develop a tool for that purpose, termed General Occupational Engagement in people with Severe mental illness (GOES). The aim was to investigate its psychometric properties in terms of factor structure, internal consistency, corrected item-total correlations (CITC), convergent and discriminant validity, and test-retest stability.

Methods

Ninety-three day center attendees were assessed by the GOES and instruments addressing constructs hypothesized to be either similar to (activity level, motivation for day center attendance, perceptions of the worker role, hours spent in the day center) or divergent from the GOES (attendees’ ratings of engagement in specified occupations, self-rated health, psychosocial functioning, psychiatric symptoms). A second sample of 41 attendees were included for the test-retest analysis. Exploratory factor analysis, Cronbach’s alpha analysis, Pearson correlations and paired-samples t-tests were performed.

Results

Exploratory factor analysis indicated one factor, which was in line with the intentions of the scale. The alpha value was 0.85 and all CITC were above 0.30. The tests for convergent validity resulted in correlations ranging between 0.23 and 0.47, most of which were moderately strong and mainly confirmed the hypotheses. Discriminant validity was clearly indicated, since all correlations with the selected constructs were <0.20. GOES also showed preliminary test-retest stability (r = 0.32).

Conclusions

The GOES is ready for use in rehabilitation services and research where productive and other types of activities are of interest. It may serve as an important supplement to attendees’ self-reported occupational engagement.

A Randomized Clinical Trial of Vocational Rehabilitation for People With Psychiatric Disabilities

In this study, the researchers examined the effectiveness of two vocational rehabilitation interventions in improving employment, educational, clinical, and quality-of-life outcomes for people with psychiatric disabilities. The authors recruited participants in waves over a 2-year period and randomly assigned them to receive either psychiatric vocational rehabilitation (PVR) or enhanced state vocational rehabilitation (ESVR) services. Although both groups improved significantly over time in their vocational and educational outcomes, no differences were found between the two interventions on any outcomes. In this article, the authors explore why ESVR achieved better outcomes than previous research would have suggested.

Effectiveness of Psychiatric Rehabilitation Approaches for Employment of People with Severe Mental Illness

The authors review studies of (a) traditional psychiatric rehabilitation (including clubhouse programs and approaches offering an array of employment options) and (b) supported employment approaches for helping people with severe mental illness gain and maintain competitive employment. Based on the results of this review, the authors conclude that the effectiveness of traditional psychiatric rehabilitation in helping people gain competitive employment cannot be conclusively determined at this point. On the other hand, research on the effectiveness of supported employment was consistently positive. The authors recommend that further research be conducted on model definition, intermediate vocational options, interaction between client characteristics and program models, and long-term outcomes.

Work experiences among attendees of day centres for people with psychiatric disabilities

BACKGROUND

It is possible that people with psychiatric disabilities who visit day centres have previous work experiences that may be seen as resources for their current engagement in day centre activities. Research in this respect seems to lack, however.

OBJECTIVE

To investigate work experiences among attendees at day centres for people with psychiatric disabilities and relationships with current type of day centre (work-oriented, meeting place-oriented or mixed), engagement in day centre activities, motivation and socio-demographic and health-related factors.

METHODS

Seventy-seven attendees responded to questionnaires. Global Assessment of Functioning, GAF, was also used. Work was categorised into Group I (professionals, semi-professionals), Group II (clerical support, services workers) and Group III (e.g. craft workers, elementary occupations).

RESULTS

Almost everyone had previously had open-market employment; more than half for ≥ 10 years. Group I was more common in mixed centres, Group II in meeting place-oriented ones and Group III in work-oriented ones. Group I more frequently had college degree and was rated high on GAF functioning. Women were over-represented in Group II, and men in Group III and in meeting place-oriented centres. Attending mixed centres was more likely when having a college degree, scoring high on GAF functioning and being highly engaged in activities. Attendees at work-oriented day centres were characterised by being motivated for spending time alone and reporting a diagnosis of psychosis.

CONCLUSIONS

The participants had unused working capacity. No clear-cut relationships were found between work experiences and the investigated correlates.

Adding quality to day centre activities for people with psychiatric disabilities: Staff perceptions of an intervention

AIM

To evaluate an intervention aimed at enriching day centres for people with psychiatric disabilities by exploring staff experiences from developing and implementing the intervention.

METHOD

Each staff group developed a tailor-made intervention plan, following a manual, for how to enrich the day centre. They received supervision and support from the research team. The study was based on focus-group interviews with a total of 13 staff members at four day centres. Narrative analysis with a thematic approach was used. A first round resulted in one narrative per centre. These centre-specific narratives were then integrated into a common narrative that covered all the data.

RESULTS

A core theme emerged: User involvement permeated the implementation process and created empowerment. It embraced four themes forming a timeline: "Mix of excitement, worries and hope", "Confirmation and development through dialogue, feedback and guidance", "The art of integrating new activities and strategies with the old", and "Empowerment-engendered future aspirations".

CONCLUSION

The users' involvement and empowerment were central for the staff in accomplishing the desired changes in services, as were their own reflections and learning. A possible factor that may have contributed to the positive outcomes was that those who were central in developing the plan were the same as those who implemented it.

Effectiveness of an intervention to improve day centre services for people with psychiatric disabilities

Background/aim

Day centres for people with psychiatric disabilities need to be evaluated for effectiveness in order to provide the best possible support. This study aimed at investigating the effectiveness of a tailor-made intervention to improve day centre services for people with psychiatric disabilities.

Methods

The intervention was devised to bridge identified gaps in the services and lasted for 14 months. Eight centres were allotted to the intervention (55 attendees) or comparison condition (51 attendees). Fidelity to the intervention and major events in the day centres were assessed. The outcomes were degree of meaningfulness found in the day centre occupations, satisfaction with the rehabilitation received, satisfaction with everyday occupations and quality of life.

Results

The fidelity to the intervention was good, but more positive events, such as new occupational opportunities, had taken place in the comparison units. No differences were identified between the intervention and the comparison group regarding changes from baseline to the 14-month follow-up in perceived meaningfulness among day centre occupations, satisfaction with everyday occupations or quality of life.

Conclusions

The intervention seemed ineffective, but the positive events in the comparison group resembled the measures included in the tailor-made interventions. This first intervention study in the day centre context has hopefully helped to generate hypotheses and methods for future research.

Predictors of valued everyday occupations, empowerment and satisfaction in day centres: implications for services for persons with psychiatric disabilities

This study addresses predictors of occupational value, empowerment and satisfaction with the rehabilitation received in day centres for people with psychiatric disabilities. These outcomes represent varying aspects of relevance for the day centre context and together create a manifold outcome picture. This was a longitudinal study with approval from the regional research vetting board. Self-report instruments were used, and the investigated predictors motivation for going to the day centre, occupational engagement, socio-demographic factors and self-reported diagnosis. Attendees (N = 108) at 8 day centres participated and filled in self-report questionnaires regarding the predictor and outcome variables. A baseline measurement and a 14-month follow-up composed the data. Occupational engagement at baseline could predict all three outcomes at the follow-up. Motivation for the day centre activities and not preferring work before attending the day centre were positive for satisfaction with the day centre. A low participation rate, although comparable with previous studies on the target group, was a limitation of this study. To conclude, both occupational engagement and motivation are factors that can be stimulated by the staff in day centres. Actions for how to accomplish that, and thereby also more positive outcomes of the day centre services, are proposed, such as a system of freedom of choice among day centres, and between day centres and supported employment.

Supported employment: cost-effectiveness across six European sites

A high proportion of people with severe mental health problems are unemployed but would like to work. Individual Placement and Support (IPS) offers a promising approach to establishing people in paid employment. In a randomized controlled trial across six European countries, we investigated the economic case for IPS for people with severe mental health problems compared to standard vocational rehabilitation. Individuals (n=312) were randomized to receive either IPS or standard vocational services and followed for 18 months. Service use and outcome data were collected. Cost-effectiveness analysis was conducted with two primary outcomes: additional days worked in competitive settings and additional percentage of individuals who worked at least 1 day. Analyses distinguished country effects. A partial cost-benefit analysis was also conducted. IPS produced better outcomes than alternative vocational services at lower cost overall to the health and social care systems. This pattern also held in disaggregated analyses for five of the six European sites. The inclusion of imputed values for missing cost data supported these findings. IPS would be viewed as more cost-effective than standard vocational services. Further analysis demonstrated cost-benefit arguments for IPS. Compared to standard vocational rehabilitation services, IPS is, therefore, probably cost-saving and almost certainly more cost-effective as a way to help people with severe mental health problems into competitive employment.

Converting partial hospitals to community integrated recovery centers

This paper describes the conversion of partial hospitals into recovery-oriented programs as part of system transformation. Steps included: participatory planning with stakeholders; strength based assessment of resources and needs; technical assistance; and changing funding strategies. Over a period of 8 years, use of partial hospitals decreased as persons with serious mental illnesses were transitioned to community integrated recovery centers. Preliminary outcomes suggest that these programs are more effective in engaging people in the community activities of their choice, confirming previous findings that showed that partial hospitals can be converted to recovery-oriented programs that focus more directly on promoting community inclusion.

Life skills programmes for chronic mental illnesses

BACKGROUND

Most people with schizophrenia have a cyclical pattern of illness characterised by remission and relapses. The illness can reduce the ability of self-care and functioning and can lead to the illness becoming disabling. Life skills programmes, emphasising the needs associated with independent functioning, are often a part of the rehabilitation process. These programmes have been developed to enhance independent living and quality of life for people with schizophrenia.

OBJECTIVES

To review the effects of life skills programmes compared with standard care or other comparable therapies for people with chronic mental health problems.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (June 2010). We supplemented this process with handsearching and scrutiny of references. We inspected references of all included studies for further trials.

SELECTION CRITERIA

We included all relevant randomised or quasi-randomised controlled trials for life skills programmes versus other comparable therapies or standard care involving people with serious mental illnesses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random-effects model. For continuous data, we calculated mean differences (MD), again based on a random-effects model.

MAIN RESULTS

We included seven randomised controlled trials with a total of 483 participants. These evaluated life skills programmes versus standard care, or support group. We found no significant difference in life skills performance between people given life skills training and standard care (1 RCT, n = 32, MD -1.10; 95% CI -7.82 to 5.62). Life skills training did not improve or worsen study retention (5 RCTs, n = 345, RR 1.16; 95% CI 0.40 to 3.36). We found no significant difference in PANSS positive, negative or total scores between life skills intervention and standard care. We found quality of life scores to be equivocal between participants given life skills training (1 RCT, n = 32, MD -0.02; 95% CI -0.07 to 0.03) and standard care. Life skills compared with support groups also did not reveal any significant differences in PANSS scores, quality of life, or social performance skills (1 RCT, n = 158, MD -0.90; 95% CI -3.39 to 1.59).

AUTHORS' CONCLUSIONS

Currently there is no good evidence to suggest life skills programmes are effective for people with chronic mental illnesses. More robust data are needed from studies that are adequately powered to determine whether life skills training is beneficial for people with chronic mental health problems.

Day hospital versus admission for acute psychiatric disorders

BACKGROUND

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals.

OBJECTIVES

To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (June 2010) which is based on regular searches of MEDLINE, EMBASE, CINAHL and PsycINFO. We approached trialists to identify unpublished studies.

SELECTION CRITERIA

Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and cross-checked data. We calculated risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data. We calculated weighted or standardised means for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. We therefore sought individual patient data so that we could re-analyse outcomes in a common format.

MAIN RESULTS

Ten trials (involving 2685 people) met the inclusion criteria. We obtained individual patient data for four trials (involving 646 people). We found no difference in the number lost to follow-up by one year between day hospital care and inpatient care (5 RCTs, n = 1694, RR 0.94 CI 0.82 to 1.08). There is moderate evidence that the duration of index admission is longer for patients in day hospital care than inpatient care (4 RCTs, n = 1582, WMD 27.47 CI 3.96 to 50.98). There is very low evidence that the duration of day patient care (adjusted days/month) is longer for patients in day hospital care than inpatient care (3 RCTs, n = 265, WMD 2.34 days/month CI 1.97 to 2.70). There is no difference between day hospital care and inpatient care for the being readmitted to in/day patient care after discharge (5 RCTs, n = 667, RR 0.91 CI 0.72 to 1.15). It is likely that there is no difference between day hospital care and inpatient care for being unemployed at the end of the study (1 RCT, n = 179, RR 0.88 CI 0.66 to 1.19), for quality of life (1 RCT, n = 1117, MD 0.01 CI -0.13 to 0.15) or for treatment satisfaction (1 RCT, n = 1117, MD 0.06 CI -0.18 to 0.30).

AUTHORS' CONCLUSIONS

Caring for people in acute day hospitals is as effective as inpatient care in treating acutely ill psychiatric patients. However, further data are still needed on the cost effectiveness of day hospitals.

The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements

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

Predictors of referral to Supported Employment among consumers with co-occurring mental and substance use disorders

Clinical trials demonstrate that Supported Employment is effective in assisting persons with severe mental illness in obtaining competitive employment. However, little is known about the factors related to consumers' decisions to pursue employment, especially for consumers with co-occurring substance and mental disorders. This study examines the demographic, socioeconomic and illness characteristics of consumers referred for Supported Employment services. Consumers were drawn from Integrated Dual Diagnosis Treatment programs in four community mental health agencies. Study participants included 113 consumers referred for Supported Employment services and 78 randomly selected non-referred consumers as the comparison group. Results suggest that consumers who have past work experience are more likely to be referred to Supported Employment, while consumers who perceive themselves as disabled or who are diagnosed as substance dependent are less likely to be referred to Supported Employment. Implications for agency practice and future research are discussed.

Day hospital versus outpatient care for people with schizophrenia

BACKGROUND

This review considers the use of day hospitals as an alternative to outpatient care. Two types of day hospital are covered by the review: 'day treatment programmes' and 'transitional' day hospitals. Day treatment programmes offer more intense treatment for people who have failed to respond to outpatient care. Transitional day hospitals offer time-limited care to people who have just been discharged from inpatient care.

OBJECTIVES

To assess effects of day hospital care as an alternative to continuing outpatient care for people with schizophrenia and and other similar severe mental illness.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (May 2009) and references of all identified studies for further citations. If necessary, we also contacted authors of trials for further information.

SELECTION CRITERIA

Randomised controlled trials comparing day hospital care with outpatient care for those with schizophrenia and other similar severe mental illness.

DATA COLLECTION AND ANALYSIS

We extracted and cross-checked data independently. We analysed dichotomous data using fixed-effect relative risk (RR) and estimated the 95% confidence interval (CI). If continuous data were included, we analysed this data using the random-effects weighted mean difference (MD) with a 95% confidence interval.

MAIN RESULTS

We identified four relevant trials all dating from before 1986 (total n=309 participants); all but one of which (n=37) evaluated day treatment centres. Across time less people allocated to day hospital care tend to be admitted to hospital (beyond one year: n=242, 2 RCTs, RR 0.71 CI 0.56 to 0.89 day treatment centres) but data are heterogeneous (I(2) =74% P=0.05) and should not be taken into account. Data on time spent as an inpatient seem to support this finding but are poorly reported. We found no clear difference between day hospital and outpatient care for the outcome of 'lost to follow up' (at six months: n=147, 3 RCTs, RR 0.97 CI 0.48 to 1.95; at 12 months: n=117, 2 RCTs, RR 0.97 CI 0.48 to 1.95 day treatment centres / transitional day hospital). Scale derived findings on social functioning are equivocal (SAS: n=37, 1 RCT, MD 0.36 CI -0.07 to 0.79 transitional day hospital) but there was some suggestion from small studies that day hospital care may decrease the risk of unemployment (at 12 months: n=80, 1 RCT, RR 0.86 CI 0.69 to 1.06 day treatment centre). Different measures of mental state showed no convincing effect (Symptom Check List: n=30, 1 RCT, MD -90 0.31 CI -0.20 to 0.82 day treatment centre). Poorly reported economic data from decades ago suggested that day hospitals were more costly to establish and run than outpatient care but took no account of other costs such as inpatient stay.

AUTHORS' CONCLUSIONS

Evidence is limited and dated. Day hospital care may help avoid inpatient care but data are lacking on missing on a raft of outcomes that are now considered important, such as quality of life, satisfaction, healthy days, and cost.

Beyond early intervention: can we adopt alternative narratives like 'Woodshedding' as pathways to recovery in schizophrenia?

AIM

To consider how early intervention in psychosis can support a recovery paradigm.

METHODS

Significant numbers of those developing a first episode of psychosis are on a path to a persisting and potentially life long condition. Constituting the schizophrenia spectrum disorders, such conditions demand the particular qualities and attitudes inherent within recovery-based practice. This paper explores some of these qualities and attitudes by examining the tension between a traditional 'clinical' narrative used by many health providers and a 'human' narrative of users of services and their families.

RESULTS

We draw out key features and constructs of recovery practice as they relate to the EI paradigm. These include: woodshedding, turning points, discontinuous improvement models, therapeutic optimism, gradualism and narratives of story telling. We also highlight the role of family members and other close supporters and believe their potential contribution requires greater consideration.

CONCLUSIONS

The early intervention (EI) paradigm can resonate and indeed offer a stronghold for recovery-based practice where traditional mental health services have sometimes struggled. Conversely, failure of caregivers to provide such an approach in the early phase of illness can cause unnecessary and sometimes disastrous consequences.

Clinicians' attitudes to the employment of people with psychosis

BACKGROUND

Negative staff attitudes have been cited as a factor in explaining the low rates of employment in people with psychosis. We aimed to conduct the first systematic survey of staff attitudes in UK community mental health teams.

METHODS

A questionnaire survey of clinicians working in community mental health teams in North London, UK.

RESULTS

Clinicians believed that many more people with psychosis were capable of working than were actually doing so. Nevertheless they believed that about two thirds of their caseloads were either incapable of working or able only to do voluntary or sheltered work. The work roles they saw as suitable tended to be ones requiring lower levels of technical skills. Clinicians saw helping people get back to work as a core part of their role, but felt they had little relevant training and limited confidence in the vocational services currently available for their clients.

CONCLUSIONS

In this London catchment area, clinicians believed the majority of people with psychosis to be capable of some kind of work, albeit not always open market, but they had few resources available to them to facilitate this. They give priority to the development of place and support vocational services.

Impact of vocational rehabilitation on social functioning, cognitive functioning, and psychopathology in patients with chronic schizophrenia

AIM

To assess the impact of vocational rehabilitation on psychopathology, social functioning and cognitive functioning in schizophrenia

MATERIALS AND METHODS

34 patients with DSM IV diagnosis of chronic schizophrenia were compared 40 patients with same diagnosis but not attending vocational rehabilitation using PANSS, SCARF social functioning Index and MMSE.

RESULTS AND DISCUSSION

Basic psycho-socio-demographic data were comparable in both groups except more hospitalization in the no rehabilitation group. Comparison of social functioning, cognitive functioning and psychopathology showed significant improvement in rehabilitated patients. Cognitive functioning had positive correlation with occupational role in the rehabilitated group and negative correlation in the rehabilitated group. Social functioning had negative correlation with positive and negative symptoms, general psychopathology and total PANSS score and cognitive symptoms in patients without rehabilitation.

CONCLUSION

The present concludes that there is a definite limitation in the domains of social functioning, cognitive functioning and psychopathology in chronic schizophrenia patients who had no rehabilitation. However vocational rehabilitation significantly improves these limitations, which in turn help these patients to integrate into the society so as to function efficiently in their roles as parents, home makers and social beings.

Life skills programmes for chronic mental illnesses

BACKGROUND

Most people with schizophrenia have a cyclical pattern of illness characterised by remission and relapses. The illness can reduce the ability of self-care and functioning and can lead to the illness becoming chronic and disabling. Rehabilitation is one of the important parts of treatments. Life skills programmes, emphasising the needs associated with independent functioning, are often a part of the rehabilitation process. These programmes, therefore, have been developed to enhance independent living and the quality of life for people with schizophrenia living in the community.

OBJECTIVES

To review the effectiveness of life skills programmes with standard care or other comparable therapies for people with chronic mental health problems.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (May 2007) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. Hand searches and scrutiny of references supplemented this process. We inspected references of all identified studies for further trials.

SELECTION CRITERIA

We included all relevant randomised or quasi-randomised controlled trials for life skills programmes versus other comparable therapies or standard care involving people with serious mental illnesses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a random effects model.

MAIN RESULTS

We included four randomised controlled trials with a total of 318 participants. These evaluated life skills programmes versus standard care, or support group. We found no significant difference in life skills performance between people given life skills training and standard care (Patterson 2003, n=32, WMD -1.10 CI -7.8 to 5.6). Life skills training did not improve or worsen study retention (n=60, 2 RCTs, RR 1.16 CI 0.4 to 3.4). We found no significant difference in PANSS positive, negative or total scores between life skills intervention and standard care. Depression scores (HAM-D) did not reveal any significant difference between groups (Patterson 2003, n=32, WMD -0.70 CI -4.1 to 2.7). We found quality of life scores to be equivocal between participants given life skills training (Patterson 2003, n=32, WMD -0.02 CI -0.1 to 0.03) and standard care. Life skills compared with support groups also did not reveal any significant differences in PANSS scores, quality of life, or social performance skills (Patterson 2006, n=158, WMD -0.90 CI -3.4 to 1.6).

AUTHORS' CONCLUSIONS

Currently there is no good evidence to suggest life skills programmes are effective for people with chronic mental illnesses. More robust data are needed from studies that are adequately powered to determine whether life skills training is beneficial for people with chronic mental health problems.

Methodological considerations of measuring disability in bipolar disorder: validity of the Multidimensional Scale of Independent Functioning

OBJECTIVE

Recent studies have highlighted the prevalence, severity and persistence of the disability associated with bipolar disorder (BPD). Reliable instruments are needed to support research into the factors associated with disability and treatment response. Contextual factors (e.g., availability of supported employment programs) can affect functionality, posing a challenge to such investigations. We present preliminary findings regarding the validity of the Multidimensional Scale of Independent Functioning (MSIF) in BPD. The MSIF provides discrete ratings of support separate from both role responsibility and performance quality in work, residential and educational environments. These distinctions allow the 'correction' for variability explained by contextual factors that allows the comparison of studies conducted in different environments and time.

METHODS

Participants with BPD were administered the MSIF, the Social Adjustment Scale II (SAS-II) and an interview recording objective data regarding work, school and residential activities as part of an ongoing longitudinal study of BPD disability.

RESULTS

Construct validity estimated using standardized Cronbach's alpha coefficient was 0.76 (n = 58). MSIF global ratings were significantly lower (reflecting higher functionality) for subjects engaged in productive activity compared with participants who were not active (t = -3.6, p = 0.001) demonstrating external validity. Inter-rater reliability estimates ranged from 0.86 to 0.99 (n = 49). Significant, high correlations were demonstrated between comparable MSIF and SAS-II global ratings (criterion validity = 0.70-0.79) and low correlations were found between non-comparable ratings (discriminant validity = -0.07 to -0.35) (n = 14).

CONCLUSION

We conclude that the MSIF is a valid and reliable instrument optimally designed for studying determinants of disability and treatment response in BPD.

Day centres for severe mental illness

BACKGROUND

The number of people with severe mental illness who receive treatment whilst living at home has increased greatly over the last 30 years. Day centres and day hospitals frequently supplement this treatment.

OBJECTIVES

To determine the effects of non-medical day centre care for people with severe mental illness.

SEARCH STRATEGY

We updated our search in September 2005. All databases and searches are detailed in the body of the text.

SELECTION CRITERIA

We would have included all randomised controlled trials where seriously mentally ill people were allocated to non-medical day centre care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, it had been hoped to estimate the fixed effects Relative Risk (OR) with 95% confidence intervals (CI) and the number needed to treat statistic (NNT). Analysis was to have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD) and scale data presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

Electronic searches identified over 300 citations but none were relevant to this review. We found no trials of non-medical day centres.

AUTHORS' CONCLUSIONS

We feel that the inclusion of any studies less rigorous than randomised trials would result in misleading findings and that it is not unreasonable to expect well designed, conducted and reported randomised controlled trials of day centre care. More precise nomenclature would greatly help identify relevant work. At present non-randomised comparative studies give conflicting messages about the roles provided by day centres and the clinical and social needs they are able to meet. It is therefore probably best that people with serious mental illness and their carers, if given the choice, take a pragmatic decision on which type of unit best meets their needs. There is a clear need for randomised controlled trials of day centre care compared to other forms of day care, and when resources are limited, day centre care within the context of a pragmatic randomised trial may be the only way of ensuring equity of provision.

Leading a horse to water: An action perspective on mental health policy

Following publication of several landmark policy documents beginning in 1999, there are unprecedented opportunities for reforming mental health care to meet the needs of persons with mental illness. In this article, the authors suggest that transforming mental health requires dramatic changes in theory as well as in policy and practice, offering action theory as a corrective for a clinical psychology that has yet to view people as active agents shaping their own lives. A participatory approach to policy development and adoption of an action-oriented model of clinical practice provide examples of the shift, which results from treating people to enhancing their access to opportunities and offering them the in vivo supports they need to pursue meaningful lives even while disabled.

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.

The role of state mental health authorities in promoting improved client outcomes through evidence-based practice

The role of state mental health authorities (SMHA) is critical to implementing and sustaining evidence-based practices. This paper describes the seven major tasks of SMHA's that comprise that role and provides examples from states which have been actively pursuing evidence-based practices.

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.

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.

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.

Day hospital versus admission for acute psychiatric disorders

BACKGROUND

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals.

OBJECTIVES

To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (January 1966 to December 2000), EMBASE (1980 to December 2000), CINAHL (1982 to December 2000), PsycLIT (1966 to December 2000), and the reference lists of articles. We approached trialists to identify unpublished studies.

SELECTION CRITERIA

Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers and cross-checked. Relative risks and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. Individual patient data were therefore sought so that outcomes could be reanalysed in a common format.

MAIN RESULTS

Nine trials (involving 1568 people) met the inclusion criteria. Individual patient data were obtained for four trials (involving 594 people). Combined data suggested that, at the most pessimistic estimate, day hospital treatment was feasible for 23% (n=2268, CI 21 to 25) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in number of days in hospital between day hospital patients and controls (n=465, 3 RCTs, WMD -0.38 days/month CI -1.32 to 0.55). However, compared to controls, people randomised to day hospital care spent significantly more days in day hospital care (n=265, 3 RCTs, WMD 2.34 days/month CI 1.97 to 2.70) and significantly fewer days in inpatient care (n=265, 3 RCTs, WMD -2.75 days/month CI -3.63 to -1.87). There was no significant difference in readmission rates between day hospital patients and controls (n=667, 5 RCTs, RR 0.91 CI 0.72 to 1.15). For patients judged suitable for day hospital care, individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n=407, Chi-squared 9.66, p=0.002), but not social functioning (n=295, Chi-squared 0.006, p=0.941) amongst patients treated in the day hospital. Four of five trials found that day hospital care was cheaper than inpatient care (with cost reductions ranging from 20.9 to 36.9%).

REVIEWER'S CONCLUSIONS

Caring for people in acute day hospitals can achieve substantial reductions in the numbers of people needing inpatient care, whilst improving patient outcome.

Accounting for unemployment among people with mental illness

Persons diagnosed with a serious mental illness experience significantly high rates of unemployment compared with the general population. The explanations for this situation have included a focus on the symptoms associated with these disorders, a focus on the lack of effective vocational rehabilitation programs for this population, and, most recently, a focus on employer discrimination and the financial disincentives to employment in various public policies. The authors of this manuscript review the evolution in thought pertaining to the labor market experiences of persons with a serious mental illness and propose as an additional set of factors that should be considered, those labor market liabilities that this population shares with others without disabilities who experience similar employment histories. The authors conclude that the inclusion of these factors in our understanding of issues that persons with serious mental illness face in the competitive labor market will likely lead to a further evolution in program and policy development.

Interest in and obstacles to pursuing work among unemployed dually diagnosed individuals

Employment status is commonly used as a sign of stability in recovery and an outcome variable for substance abuse treatment and research. However, there has been little attention in the literature on the topic of work for the dually diagnosed (i.e., persons diagnosed with both substance use and mental health disorders). Data collected in 1999 are presented on expressed interest in and perceived barriers to pursuing work and on the utilization of vocational rehabilitation (voc-rehab) services among unemployed members of a dual recovery self-help fellowship (N= 130). While members generally expressed high interest in working, they also cited multiple obstacles to attaining and maintaining employment. A path model was specified and tested. Significant contributors to interest in working were substance use status and physical health rating. Consistent with our hypotheses, mental health symptoms and greater perceived obstacles (e.g., stigma, fear of failure, and insufficient skills) were significant contributors to perceived difficulty in pursuing work, whereas substance use, physical health, and recency of employment were not. Finally, those who perceived less difficulty in pursuing work were more likely to utilize voc-rehab services, and men were more likely than women to use these facilities; interest in work was not significantly associated with utilizing voc-rehab services. The roles of mental health disorders and substance use in relation to pursuit of employment are discussed, as well as that of perceived obstacles such as stigma. The paper addresses the setting of realistic vocational goals and possible strategies to mitigate barriers to increased employment of dually diagnosed individuals.

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.

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.

Day centres for severe mental illness

BACKGROUND

The number of people with severe mental illness who receive treatment whilst living at home has increased greatly over the last 30 years. Day centres and day hospitals frequently supplement this treatment.

OBJECTIVES

To determine the effects of non-medical day centre care for people with severe mental illness.

SEARCH STRATEGY

The Allied and Complementary Medicine Database (1985-1999), The British Nursing Index (1994-1998), The Cochrane Library (Issue 2, 1999), The Cochrane Schizophrenia Group's Register (May 1999), EMBASE (1980-1999), MEDLINE (1966-1999), PsycLIT (1887-1999), The Royal College of Nurses Database (1985-1996), and Sociological Abstracts (1963-1999) were searched. References of all identified studies were also inspected for more studies.

SELECTION CRITERIA

All randomised controlled trials where seriously mentally ill people were allocated to non-medical day centre care.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data, it had been hoped to estimate the Peto odds ratios (OR) with 95% confidence intervals (CI) and the number needed to treat statistic (NNT). Analysis was to have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD) and scale data presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

Despite extensive searching, no trials were found of non-medical day centres. The electronic search identified over 300 citations but none was relevant to this review.

REVIEWER'S CONCLUSIONS

The reviewers feel that the inclusion of any studies less rigorous than randomised trials would result in misleading findings and that it is not unreasonable to expect well designed, conducted and reported randomised controlled trials of day centre care. More precise nomenclature would greatly help identify relevant work. At present non-randomised comparative studies give conflicting messages about the roles provided by day centres and the clinical and social needs they are able to meet. It is therefore probably best that people with serious mental illness and their carers, if given the choice, take a pragmatic decision on which type of unit best meets their needs. There is a clear need for randomised controlled trials of day centre care compared to other forms of day care, such as day hospitals.

Day hospital versus out-patient care for psychiatric disorders

BACKGROUND

This review considers the use of day hospitals as an alternative to out-patient care. Three types of day hospital are covered by the review: 'day treatment programmes', 'day care centres' and 'transitional' day hospitals. Day treatment programmes offer more intense treatment for patients who have failed to respond to out-patient care (usually patients with affective or personality disorders). Day care centres offer structured support to patients with long-term severe mental disorders (mainly schizophrenia), who would otherwise be treated in the out-patient clinic. Transitional day hospitals offer time-limited care to patients who have just been discharged from in-patient care.

OBJECTIVES

The review had three objectives. First, to assess the effectiveness of day treatment programmes versus out-patient care for people with treatment-refractory disorders. Second, to assess the effectiveness of day care centres versus out-patient care for people with severe long term disorders. Third, to assess the effectiveness of transitional day hospital care for people who had just been discharged from hospital.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (January 1966 to December 2000), EMBASE (1980 to December 2000), CINAHL (1982 to December 2000), Psyc LIT (1966 to December 2000), and the reference lists of articles. Researchers were approached to identify unpublished studies.

SELECTION CRITERIA

Randomised controlled trials comparing day hospital care (including day treatment programme, day care centre, and transitional day hospital) against out-patient care. Studies were ineligible if a majority of participants were under 18 or over 65, or who had a primary diagnosis of substance abuse or organic brain disorder.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers and cross-checked. Relative risks and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data.

MAIN RESULTS

There was evidence from one trial suggesting that day treatment programmes were superior to continuing out-patient care in terms of improving psychiatric symptoms. There was no evidence that day treatment programmes were better or worse than out-patient care on any other clinical or social outcome variable, or on costs. There was no evidence that day care centres were better or worse than out-patient care on any clinical or social outcome variable. There were some inconclusive data on costs suggesting that day care centres might be more expensive than out-patient care. There was evidence from one trial suggesting that transitional day hospital care was superior to out-patient care in keeping patients engaged in treatment, however there was insufficient evidence to judge whether it was better or worse on any other clinical or social outcome variable, or on costs.

REVIEWER'S CONCLUSIONS

There is only limited evidence to justify the provision of day treatment programmes and transitional day hospital care, and no evidence to support the provision of day care centres.

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.