Employment in Personality Disorders and the Effectiveness of Individual Placement and Support: Outcomes from a Secondary Data Analysis

Good psychiatric management for borderline personality disorder: A qualitative study of its implementation in a supported employment team

INTRODUCTION

People with borderline personality disorder have difficulties with work. The Individual Placement and Support model has shown its worldwide effectiveness in terms of vocational rehabilitation for individuals with psychiatric disorders. However, only a few recent studies have explored its results for people with personality disorders, and the findings were mitigated. Additionally, Individual Placement and Support job coaches reported difficulties in supporting this population. An evidence-based psychotherapeutic method, also applicable in a case management context, called Good Psychiatric Management for borderline personality disorder, could potentially overcome these obstacles. This study aimed to evaluate the initial integration of Good Psychiatric Management in Individual Placement and Support practice.

METHODS

Individual Placement and Support practitioners of Lausanne University Hospital, Switzerland, were trained in Good Psychiatric Management in January 2022. Five of them participated in a focus group to collect their impressions about the training, and six were interviewed 9 months later to assess the initial adoption of Good Psychiatric Management into their practice. Thematic analyses were conducted.

RESULTS

Job coaches were positive about this new tool. All of them found it useful and beneficial both for them and their patients. They were able to follow the main Good Psychiatric Management principles in their practice However, the findings also suggested some additional improvements in the implementation process.

CONCLUSIONS

Integrating Good Psychiatric Management in Individual Placement and Support seems feasible, and the team who appreciated it adopted it. The method offers new perspectives in community support for people living with borderline personality disorder.

Enhancing employment outcome among stable psychiatric patients: lesson learnt on innovative model of work inclusion

BACKGROUND

Poor employment rate among psychiatric patients is poorly discussed.

PURPOSE

To share our strategies in boosting employment rate among stable psychiatric patients and discuss the lessons learnt.

PARTICULAR FOCUS

Multifaceted strategies were remodelled to ensure a three-dimensional optimisation: (1) strengthening clinical service to ensure stable disease and appropriate patient selection through battery of assessments, (2) provision of psychosocial support to boost self-esteem and foster discipline among patients through encouragement, guidance and regular monitoring by the multidisciplinary community mental health team and (3) encourage willingness and confidence among stakeholders and local market to host job opportunities to stable mental health patients.

OVERVIEW

The yearly employment rate among our stable psychiatric patients under supported employment programme from 2020 to 2021 was 28.6% (2/7) and 30.0% (3/10), respectively. A qualitative survey found the main hindrance to recruitment were employers' scepticism on work performance, while poor work retention was due to patients' lack of specific skill set and discipline to adhere to routine. We restructured our supported employment programme by adding the role of community mental health facility to foster discipline and routine for 6 months prior to referral to a job coach. Until June 2022, two out of five patients managed to secure job positions (40.0%). Despite our efforts to improve employment with the instituted remedial strategy, we still fail to reach the minimum standard set by ministry. Future plan will focus on tailoring individual interests to a specific set of skills that match industrial expectation prior to seeking employment. Additionally, enhancing public education using social media may foster better inclusion of psychiatric patients and social acceptance.

Intersectional perspectives on the employment rate in Supported Employment for people with psychiatric, neuropsychiatric, or intellectual disabilities: A scoping review

BACKGROUND

Supported Employment (SE) has shown better results in the employment rate for persons with disabilities than other methods within vocational rehabilitation, but how SE affects the employment rate for subgroups in the interventions needs further attention.

OBJECTIVE

To examine previous research regarding the influence of intersecting statuses on the employment rate in SE for people with psychiatric, neuropsychiatric, or intellectual disabilities according to type of diagnosis, sex, race/ethnicity, age, level of education and previous work history.

METHODS

A systematic literature search was conducted in nine databases including peer-reviewed articles from 2000 to April 2021. Articles presenting the employment rate in SE interventions according to the intersecting statuses listed in the objective were included.

RESULTS

The searches identified 3777 unique records, of which 53 articles were included in data extraction. In most of the included articles, intersecting statuses did not affect the employment rate for people in the SE interventions with psychiatric disabilities. Few studies have examined neuropsychiatric and intellectual disabilities. A majority of the studies subjected to full-text analysis were excluded due to a lack of reporting of the effects of intersecting statuses on the employment rate. The studies that reported on the effects of intersecting statuses on the employment rate often had small samples and lacked statistical power.

CONCLUSIONS

Intersecting statuses do not appear to affect the employment rate for people receiving SE interventions, but systematic reviews with pooled samples need to be undertaken because of the low reporting rate and underpowered sample sizes in existing studies.

Guided internet-based cognitive behavioral therapy for insomnia in patients with borderline personality disorder: Study protocol for a randomized controlled trial

Borderline personality disorder (BPD) is a highly disabling psychiatric disorder with emotion dysregulation at its core, resulting in affective instability, impulsivity and sometimes self-harming or suicidal behavior. Sleep is increasingly recognized to play a crucial role in emotion regulation. BPD patients often suffer from (severe) insomnia, potentially aggravating symptoms and preventing recovery from BPD. Yet, the effects of insomnia treatments have not been investigated in context of BPD. Guided internet-based cognitive behavioral therapy for insomnia (iCBT-I; i-Sleep) has been proven effective in improving both insomnia and affective symptoms. In this randomized controlled trial among 96 patients with a DSM-5 diagnosis of BPD (or other personality disorder with ≥4 BPD traits) and insomnia symptoms, we will test the effectiveness of iCBT-I before regular BPD treatment starts, during the waitlist period, on BPD symptoms. Patients in the control group monitor their sleep through a sleep diary during the waitlist period and also receive standard BPD treatment after that. Using linear mixed models we will test the hypothesis that the iCBT-I group improves more than the control group on BPD symptoms (primary outcome), insomnia severity, additional subjective and objective sleep variables, emotion regulation, comorbid anxiety and depression complaints, and quality of life. These effects are thought to arise from a direct effect of improved sleep on emotion regulation and a synergistic effect on the consolidation and internalization of the BPD treatment effect. To our knowledge, this is the first trial assessing effectiveness of CBT-I in patients with BPD (traits). The accessibility of the studied intervention greatly facilitates clinical implication in case of positive results.

Individual placement and support and employment in personality disorders: a registry based cohort study

BACKGROUND

To explore the relative impact of Individual Placement and Support (IPS) in patients with personality disorders (PDs) as compared to patients with other mental disorders.

METHODS

Data from the Dutch Employee Insurance Agency of participants enrolled in a national IPS trajectory between 2008 and 2018 were linked to corresponding data on employment outcomes, diagnostic and sociodemographic information from Statistics Netherlands. This resulted in a sample of 335 participants with PDs who could be compared with 1073 participants with other mental disorders.

RESULTS

Participants with PD just as often found competitive employment as participants with other mental disorders (37.6% vs. 38.0%, OR_adjusted = 0.97, 95% confidence interval (CI) 0.74 to 1.27). The median time to gaining employment for those gaining employment (37.9%) was 195.5 days (mean number of days 252.5) in the PD group and 178.5 days (mean number of days 234.6) in the other mental disorders group (HR_adjusted = 0.95, 95% CI 0.77 to 1.18). Also, total number of hours paid for competitive employment did not differ significantly between groups (median hours 686.5 vs 781.5, IRR_adjusted = 0.85 95% CI 0.69 to 1.05).

CONCLUSIONS

Based on this study, which includes the largest sample of patients with PDs in any published IPS study, IPS seems to result in an equal percentage of patients with PDs and other mental disorders, gaining and maintaining employment. Although future studies should determine whether PD-specific adaptations to IPS are useful, our findings indicate that IPS could be an effective way to increase employment outcomes in PDs. This is important because the enormous societal costs of PDs are largely driven by loss of economic productivity, and because clinical recovery in PDs is suggested to be enhanced when patients are employed.

The societal cost of treatment-seeking patients with borderline personality disorder in Germany

According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered.

Long-Term Effects of the Individual Placement and Support Intervention on Employment Status: 6-Year Follow-Up of a Randomized Controlled Trial

People with mental illness often experience difficulties with reintegration into the workplace, although employment is known to assist these individuals in their recovery process. Traditional approaches of "first train, then place" have been recently replaced by supported employment (SE) methods that carry strategy of "first place, then train." Individual placement and support (IPS) is one of the best-studied methods of SE, which core principles are individualized assistance in rapid job search with consequent placement in a paid employment position. A considerable amount of high-quality evidence supported the superiority of IPS over conventional methods in providing improved employment rates, longer job tenure, as well as higher salaries in competitive job markets. Nonetheless, our knowledge about the IPS-mediated long-term effects is limited. This non-interventional follow-up study of a previously published randomized controlled trial (RCT) called ZhEPP aimed to understand the long-term impact of IPS after 6 years since the initial intervention. Participants from the ZhEPP trial, where 250 disability pensioners with mental illnesses were randomized into either IPS intervention group or treatment as usual group (TAU), were invited to face-to-face interviews, during which employment status, job tenure, workload, and salaries were assessed. One hundred and fourteen individuals agreed to participate in this follow-up study. Although during the first 2 years post-intervention, the IPS group had higher employment rates (40% (IPS) vs. 28% (TAU), p < 0.05 at 24 months), these differences disappeared by the time of follow-up assessments (72 months). The results indicated no substantial differences in primary outcome measures between IPS and TAU groups: employment rate (36 vs. 33%), workload (10.57 vs. 10.07 h per week), job tenure (29 vs. 28 months), and salary (20.21CHF vs. 25.02 CHF). These findings provide important insights regarding the long-term effects of IPS among individuals with mental health illnesses. Further research is required to advance the current knowledge about IPS intervention and its years-long impact.

Individual Health Budgets in Mental Health: Results of Its Implementation in the Friuli Venezia Giulia Region, Italy

Background: Individual Health Budget (IHB) is an intervention for recovery in mental health services, providing personalized care for subjects with severe disorders and complex needs. Little is known on its effectiveness and on the criteria for its delivery. Methods: A total of 67 IHB beneficiaries and 61 comparators were recruited among service users of the Mental Health Department of the Trieste Healthcare Agency, Italy. Data included sociodemographic and clinical variables, type of IHB, and Health of the Nation Outcome Scale (HoNOS) scores. Results: A comparison between groups showed significant differences in several socioeconomic and clinical characteristics. Multivariate logistic regression showed that IHB was positively associated to the 20–49 age group, single status, unemployment, low family support, cohabitation with relatives or friends, diagnosis of personality disorder, and a higher number of hospitalizations. The IHB group was at a higher risk of severe problems related to aggressive or agitated behaviors (OR = 1.4), hallucinations and delusions (OR = 1.5), and impairment in everyday life activities (OR = 2.1). Conclusions: IHB was used in patients with severe clinical and social problems. More resources, however, may be aimed at the working and social axes. More research is needed to better assess clinical and social outcomes of IHB and to adjust their intensity in a longitudinal perspective in order to enhance cost-effectiveness.