Benefits and costs of supported employment from three perspectives

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.

Who benefits from individual placement and support? A meta-analysis

AIMS

Individual placement and support (IPS) is an evidence-based service model to support people with mental disorders in obtaining and sustaining competitive employment. IPS is increasingly offered to a broad variety of service users. In this meta-analysis we analysed the relative effectiveness of IPS for different subgroups of service users both based on the diagnosis and defined by a range of clinical, functional and personal characteristics.

METHODS

We included randomised controlled trials that evaluated IPS for service users diagnosed with any mental disorder. We examined effect sizes for the between-group differences at follow-up for three outcome measures (employment rate, job duration and wages), controlling for methodological confounders (type of control group, follow-up duration and geographic region). Using sensitivity analyses of subgroup differences, we analysed moderating effects of the following diagnostic, clinical, functional and personal characteristics: severe mental illness (SMI), common mental disorders (CMD), schizophrenia spectrum disorders, mood disorders, duration of illness, the severity of symptoms, level of functioning, age, comorbid alcohol and substance use, education level and employment history.

RESULTS

IPS is effective in improving employment outcomes compared to the control group in all subgroups, regardless of any methodological confounder. However, IPS was relatively more effective for service users with SMIs, schizophrenia spectrum disorders and a low symptom severity. Although IPS was still effective for people with CMD and with major depressive disorder, it was relatively less effective for these subgroups. IPS was equally effective after both a short and a long follow-up period. However, we found small, but clinically not meaningful, differences in effectiveness of IPS between active and passive control groups. Finally, IPS was relatively less effective in European studies compared to non-European studies, which could be explained by a potential benefits trap in high welfare countries.

CONCLUSIONS

IPS is effective for all different subgroups, regardless of diagnostic, clinical, functional and personal characteristics. However, there might be a risk of false-positive subgroup outcomes and results should be handled with caution. Future research should focus on whether, and if so, how the IPS model should be adapted to better meet the vocational needs of people with CMD and higher symptom severity.

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.

Willingness to Report Medical Incidents in Healthcare: a Psychological Model Based on Organizational Trust and Benefit/Risk Perceptions

Many healthcare organizations have incident reporting systems to reduce and prevent medical errors. However, many systems have failed or not been implemented due to medical professionals' reluctance to report errors made by themselves or others. This study investigated the factors influencing their willingness to report incidents voluntarily. A psychological model based on the trust heuristic was proposed, hypothesizing that organizational trust could affect willingness to report based on the perceived benefits and risks of incident reporting or directly influence willingness to report. Three hundred twenty participants were recruited from 19 provinces in China to participate in an online survey conducted between June and July 2018. Participants included doctors, nurses, medical technicians, medical service staff, and administrative staff from different hospitals. All had access to incident reporting systems. Partial least squares structural equation modeling (PLS-SEM) was applied to examine the proposed psychological model. Participants had a modest willingness of reporting. Organizational trust was found to, directly and indirectly, affect participants' willingness to report their own incidents. Compared with perceived risk, perceived benefit was a more important predictor for willingness of reporting and a more important mediator in the effect of organizational trust on willingness of reporting. Our results highlight the importance of increasing the perceived benefit from incident reporting and building a "trust culture" for improving incident reporting.

Cost-utility and cost-effectiveness of individual placement support and cognitive remediation in people with severe mental illness: Results from a randomized clinical trial

BACKGROUND

Administrators and policymakers are increasingly interested in individual placement and support (IPS) as a way of helping people with severe mental illness (SMI) obtain employment or education. It is thus important to investigate the cost-effectiveness to secure that resources are being used properly.

METHODS

In a randomized clinical trial, 720 people diagnosed with SMI were allocated into three groups; (a) IPS, (b) IPS supplemented with cognitive remediation a social skills training (IPSE), and (c) Service as usual (SAU). Health care costs, municipal social care costs, and labor market service costs were extracted from nationwide registers and combined with data on use of IPS services. Cost-utility and cost-effectiveness analyses were conducted with two primary outcomes: quality-adjusted life years (QALY) and hours in employment. Incremental cost-effectiveness ratios (ICER) were computed for both QALY, using participant's responses to the EQ-5D questionnaire, and for hours in employment.

RESULTS

Both IPS and IPSE were less costly, and more effective than SAU. Overall, there was a statistically significant cost difference of €9,543 when comparing IPS with SAU and €7,288 when comparing IPSE with SAU. ICER's did generally not render statistically significant results. However, there was a tendency toward the IPS and IPSE interventions being dominant, that is, cheaper with greater effect in health-related quality of life and hours in employment or education compared to usual care.

CONCLUSION

Individual placement support with and without a supplement of cognitive remediation tends to be cost saving and more effective compared to SAU.

Disclosure of mental illness to prospective employers: Clinical, psychosocial, and work correlates in persons receiving supported employment

Deciding whether to disclose one's psychiatric disorder to a prospective employer is a complex decision for people with severe mental illness seeking to return to work, with potential advantages and disadvantages. The present study examined the rates, patterns, and correlates of disclosure in 51 participants (74.5% schizophrenia or schizoaffective disorder) receiving high fidelity Individual Placement Support (IPS) who obtained competitive work over a two-year study period. Most participants (64.7%) disclosed their psychiatric disorder in their first job, and there was a tendency for those with multiple jobs who did not disclose initially to shift to disclosure in subsequent jobs. Participants who disclosed for their first job had worse baseline cognitive scores on the Positive and Negative Syndrome Scale (PANSS), lower self-esteem, and poorer psychosocial functioning than those who did not disclose. However, participants who disclosed to their first employer were more likely to obtain jobs that matched their interests, and worked significantly longer than those who did not disclose (32.55 vs. 12.50 weeks, respectively). The findings suggest that individuals receiving supported employment who disclose their mental illness to prospective employers may have better work outcomes.

A Systematic Review of the Benefits of Hiring People with Disabilities

Purpose We reviewed literature on the benefits of hiring people with disabilities. Increasing attention is being paid to the role of people with disabilities in the workplace. Although most research focuses on employers' concerns, many companies are now beginning to share their successes. However, there is no synthesis of the peer-reviewed literature on the benefits of hiring people with disabilities. Methods Our team conducted a systematic review, completing comprehensive searches of seven databases from 1997 to May 2017. We selected articles for inclusion that were peer-reviewed publications, had a sample involving people with disabilities, conducted an empirical study with at least one outcome focusing on the benefits of hiring people with disabilities, and focused on competitive employment. Two reviewers independently applied the inclusion criteria, extracted the data, and rated the study quality. Results Of the 6176 studies identified in our search, 39 articles met our inclusion criteria. Findings show that benefits of hiring people with disabilities included improvements in profitability (e.g., profits and cost-effectiveness, turnover and retention, reliability and punctuality, employee loyalty, company image), competitive advantage (e.g., diverse customers, customer loyalty and satisfaction, innovation, productivity, work ethic, safety), inclusive work culture, and ability awareness. Secondary benefits for people with disabilities included improved quality of life and income, enhanced self-confidence, expanded social network, and a sense of community. Conclusions There are several benefits to hiring people with disabilities. Further research is needed to explore how benefits may vary by type of disability, industry, and job type.

Cost-effectiveness of cognitive remediation and supported employment for people with mental illness: a randomized controlled trial

BACKGROUND

Little is known about the economic benefits of cognitive remediation and supported employment (CR + SE). The present study aimed to investigate the cost-effectiveness of CR + SE compared with traditional vocational services (TVS).

METHOD

Individuals with mental illness and low cognitive function were recruited at six sites in Japan. A total of 111 participants were randomly allocated to the CR + SE group or the TVS group. Clinical and vocational outcomes were assessed at baseline and 12-month follow-up. Service utilization data were collected monthly. The data on outcomes and costs were combined to examine cost-effectiveness.

RESULTS

The data were obtained from a total of 92 participants. The CR + SE group resulted in better vocational and clinical outcomes (employment rate, 62.2%; work tenures, 78.6 days; cognitive improvement, 0.5) than the TVS group (19.1%, 24.9 days and 0.2). There was no significant difference in mean total costs between the groups (CR + SE group: $9823, s.d. = $6372, TVS group: $11 063, s.d. = $11 263) with and without adjustment for covariates. However, mean cost for medical services in the CR + SE group was significantly lower than that in the TVS group after adjusting covariates (Β = -$3979, 95% confidence interval -$7816 to -$143, p = 0.042). Cost-effectiveness acceptability curves for vocational outcomes illustrated the high probabilities (approximately 70%) of the CR + SE group being more cost-effective than TVS when society is not willing to pay additional costs.

CONCLUSIONS

CR + SE appears to be a cost-effective option for people with mental illness who have low cognitive functioning when compared with TVS.

Supportive therapy for schizophrenia

BACKGROUND

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

OBJECTIVES

To review the effects of supportive therapy compared with standard care, or other treatments in addition to standard care for people with schizophrenia.

SEARCH METHODS

For this update, we searched the Cochrane Schizophrenia Group's register of trials (November 2012).

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the risk ratio (RR) using a fixed-effect model with 95% confidence intervals (CIs). Where possible, we undertook intention-to-treat analyses. For continuous data, we estimated the mean difference (MD) fixed-effect with 95% CIs. We estimated heterogeneity (I(2) technique) and publication bias. We used GRADE to rate quality of evidence.

MAIN RESULTS

Four new trials were added after the 2012 search. The review now includes 24 relevant studies, with 2126 participants. Overall, the evidence was very low quality.We found no significant differences in the primary outcomes of relapse, hospitalisation and general functioning between supportive therapy and standard care.There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (4 RCTs, n = 306, RR 1.82 CI 1.11 to 2.99, very low quality of evidence), clinical improvement in mental state (3 RCTs, n = 194, RR 1.27 CI 1.04 to 1.54, very low quality of evidence) and satisfaction of treatment for the recipient of care (1 RCT, n = 45, RR 3.19 CI 1.01 to 10.7, very low quality of evidence). For this comparison, we found no evidence of significant differences for rate of relapse, leaving the study early and quality of life.When we compared supportive therapy to cognitive behavioural therapy CBT), we again found no significant differences in primary outcomes. There were very limited data to compare supportive therapy with family therapy and psychoeducation, and no studies provided data regarding clinically important change in general functioning, one of our primary outcomes of interest.

AUTHORS' CONCLUSIONS

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

Supported employment for adults with severe mental illness

BACKGROUND

People who suffer from severe mental disorder experience high rates of unemployment. Supported employment is an approach to vocational rehabilitation that involves trying to place clients in competitive jobs without any extended preparation. The Individual placement and support (IPS) model is a carefully specified form of supported employment.

OBJECTIVES

1. To review the effectiveness of supported employment compared with other approaches to vocational rehabilitation or treatment as usual.2. Secondary objectives were to establish how far:(a) fidelity to the IPS model affects the effectiveness of supported employment,(b) the effectiveness of supported employment can be augmented by the addition of other interventions.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (February 2010), which is compiled by systematic searches of major databases, handsearches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, of working age (normally 16 to 70 years), where supported employment was compared with other vocational approaches or treatment as usual. Outcomes such as days in employment, job stability, global state, social functioning, mental state, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

Two review authors (YK and KK) independently extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% (CI). We employed a fixed-effect model for analyses. A random-effects model was also employed where heterogeneity was present.

MAIN RESULTS

A total of 14 randomised controlled trials were included in this review (total 2265 people). In terms of our primary outcome (employment: days in competitive employment, over one year follow-up), supported employment seems to significantly increase levels of any employment obtained during the course of studies (7 RCTs, n = 951, RR 3.24 CI 2.17 to 4.82, very low quality of evidence). Supported employment also seems to increase length of competitive employment when compared with other vocational approaches (1 RCT, n = 204, MD 70.63 CI 43.22 to 94.04, very low quality evidence). Supported employment also showed some advantages in other secondary outcomes. It appears to increase length (in days) of any form of paid employment (2 RCTs, n = 510, MD 84.94 CI 51.99 to 117.89, very low quality evidence) and job tenure (weeks) for competitive employment (1 RCT, n = 204, MD 9.86 CI 5.36 to 14.36, very low quality evidence) and any paid employment (3 RCTs, n = 735, MD 3.86 CI -2.94 to 22.17, very low quality evidence). Furthermore, one study indicated a decreased time to first competitive employment in the long term for people in supported employment (1 RCT, n = 204, MD -161.60 CI -225.73 to -97.47, very low quality evidence). A large amount of data were considerably skewed, and therefore not included in meta-analysis, which makes any meaningful interpretation of the vast amount of data very difficult.

AUTHORS' CONCLUSIONS

The limited available evidence suggests that supported employment is effective in improving a number of vocational outcomes relevant to people with severe mental illness, though there appears to exist some overall risk of bias in terms of the quality of individual studies. All studies should report a standard set of vocational and non-vocational outcomes that are relevant to the consumers and policy-makers. Studies with longer follow-up should be conducted to answer or address the critical question about durability of effects.

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.

Cost-benefit analysis for sheltered employment service programs for people with disabilities in Taiwan - a preliminary study

PURPOSE

The aim of this study is to do a cost-benefit analysis with monetary and non-monetary benefits for sheltered employment service programs and try to provide more evidence-based information for policy makers and practitioners to understand the outcomes of sheltered employment services.

METHOD

This study analyzed 3 sheltered employment service programs for people with disabilities (2006-2007) implemented by Sunshine Social Welfare Foundation in Taiwan using cost-benefit analysis (including non-monetary benefits). Three groups were analyzed, including participants in the programs, taxpayers, and society (participants and taxpayers).

RESULTS

This study found that the net social monetary benefit was $NT29,432.07 per participant per year and the benefit cost ratio was 1.43. (In 2006-2007, $US1 = $NT32.5 averagely around.) The net monetary benefit for the participants was between $NT7,890.86 and $NT91,890.86 per participant per year. On the non-monetary benefit side, the physical health (raised 7.49%), social relationship (raised 3.36%) domains, and general quality of life (raised 2.53%) improved. However, the psychological (decreased 1.51%) and working/environment (decreased 3.85%) domains backslided. In addition, the differences between pre-test and post-test average scores of all domains were not statistically significant.

CONCLUSIONS

This study is the first to use monetary and non-monetary cost-benefit analysis methods to analyze sheltered employment service programs for people with disabilities in Taiwan. The findings indicated that sheltered employment service programs for people with disabilities could be efficient and beneficial for the whole society and sheltered employees/clients, and also helpful for raising their quality of lives.

Consumer-Operated Service Programs: monetary and donated costs and cost-effectiveness

OBJECTIVE

Examine cost differences between Consumer Operated Service Programs (COSPs) as possibly determined by a) size of program, b) use of volunteers and other donated resources, c) cost-of-living differences between program locales, d) COSP model applied, and e) delivery system used to implement the COSP model.

METHODS

As part of a larger evaluation of COSP, data on operating costs, enrollments, and mobilization of donated resources were collected for eight programs representing three COSP models (drop-in centers, mutual support, and education/advocacy training). Because the 8 programs were operated in geographically diverse areas of the US, costs were examined with and without adjustment for differences in local cost of living. Because some COSPs use volunteers and other donated resources, costs were measured with and without these resources being monetized. Scale of operation also was considered as a mediating variable for differences in program costs.

RESULTS

Cost per visit, cost per consumer per quarter, and total program cost were calculated separately for funds spent and for resources donated for each COSP. Differences between COSPs in cost per consumer and cost per visit seem better explained by economies of scale and delivery system used than by cost-of-living differences between program locations or COSP model.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Given others' findings that different COSP models produce little variation in service effectiveness, minimize service costs by maximizing scale of operation while using a delivery system that allows staff and facilities resources to be increased or decreased quickly to match number of consumers seeking services.

Predictors of on-site vocational support for people with schizophrenia in supported employment

This study examined predictors of intensity of vocational specialist support for clients with schizophrenia or schizoaffective disorder in supported employment. Sixty-nine outpatients with schizophrenia or schizoaffective disorder were recruited from a community mental health center for 12 months of vocational and cognitive rehabilitation. Neuropsychological test scores, symptom ratings, illness severity, and employment history were used to predict vocational support intensity, expressed as hours coached in ratio to total hours worked over 12 months for each client. Weekly work hours were inversely correlated with intensity of vocational support. Half of the sample averaged 10 to 40 h of work per week and received significantly lower proportions of on-site job coaching than the lowest quartile, which averaged 2 to 5 h of work per week. Regressions predicting support intensity from neuropsychological composite scores, educational/vocational, and hospitalization history were not significant. Significant regressions included PANSS, SANS, and SAPS subscales, after which individual symptoms responsible for explained variance were isolated. SANS social inattention and PANSS active avoidance together predicted 23% of the variance in support intensity. A one-way ANOVA comparing work participation quartiles on these symptoms revealed significantly higher levels of active avoidance and social inattention for participants working less than 10 h per week. A profile emerged of the high intensity client as a socially inattentive or avoidant individual requiring a limited work schedule. Results suggest that these clients require more specialist contact because of failure to adequately engage natural supports at work.

Supportive therapy for schizophrenia

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Supportive therapy for schizophrenia

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Costs of Clubhouses: An International Perspective

Costs of providing psychosocial rehabilitation services are analyzed using data from clubhouse programs in 12 countries. We explored effects of several program operating characteristics on total program cost per year, cost per member per year, and cost per visit. We also examined the relationship between program costs and the range of services offered. Clubhouse costs were found to be a function of the country in which the program was located, program age, and certification status. The number of specific services offered was not related to cost. Findings provide a more complete understanding of the operations and expenses of clubhouses.

Psychosocial treatment in the 21st century

Over the past 50 years, psychosocial treatment has played an increasingly prominent role in helping persons with mental illness live in communities rather than in institutions. This paper briefly reviews evidence for and discusses three forms of treatment-assertive community treatment, supported employment, and cognitive behavior treatment-which have been studied extensively and are widely accepted as effective interventions. Forces are discussed that have shaped these and other psychosocial treatment over the past five decades. Despite the accumulated evidence, many questions remain about the cost-effectiveness and applicability of these treatments in specific populations and service environments. The development of these and other treatments has been, and continues to be, shaped by concerns about rising health care costs, a heightened emphasis on evidence-based treatment and by consumers taking a more active role in determining the services, and outcomes that are most helpful to them.

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.

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

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

Employing persons with serious mental illness

Data from various national surveys find that approximately half the population with mental disorders is gainfully employed across the entire range of occupations; such persons have an employment rate of about two-thirds that of the general population. More than a third of persons with serious mental illness also work, and many hold high-status positions. Among those with schizophrenia, a diagnosis associated with high impairment, only slightly more than a fifth are at work, and 12 percent are working full time. Approximately two-thirds are enrolled in federal disability insurance programs. Our analyses indicate considerable diversity of jobs among persons with various mental disorders. Most persons with mental illness want to work, and some with even the most serious mental disorders hold jobs requiring high levels of functioning. Educational attainment is the strongest predictor of employment in high-ranking occupations among both the general population and persons with mental disorders.

Public policy and employment of people with disabilities: exploring new paradigms

A "sea change" in public attitudes, legislation, and political power at the end of the 20th century in the United States has helped set the stage in the early 21st century for the entry of people with disabilities into the labor force. Major pieces of federal legislation have altered national policy with the intention of maximizing the work force participation of people with disabilities. At the same time, a new theoretical paradigm of disability has emerged, which emphasizes community inclusion, accommodation, and protection of civil rights. This "New Paradigm" of disability can be applied in concert with rigorous behavioral science methodologies to shed light on the outcomes of recent federal policy changes regarding the labor force participation of people with disabilities. In so doing, social science can be used in more meaningful ways to understand both the intended and unintended consequences of federal policy.

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.

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.

Research on the individual placement and support model of supported employment

This paper reviews research on the Individual Placement and Support (IPS) model of supported employment for people with severe mental illness. Current evidence indicates that IPS supported employment is a more effective approach for helping people with psychiatric disabilities to find and maintain competitive employment than rehabilitative day programs or than traditional, stepwise approaches to vocational rehabilitation. There is no evidence that the rapid-job-search, high-expectations approach of IPS produces untoward side effects. IPS positively affects satisfaction with finances and vocational services, but probably has minimal impact on clinical adjustment. The cost of IPS is similar to the costs of other vocational services, and cost reductions may occur when IPS displaces traditional day treatment programs. Future research should be directed at efforts to enhance job tenure and long-term vocational careers.