A 10-year study of steady employment and non-vocational outcomes among people with serious mental illness and co-occurring substance use disorders

Examination of Adaptations to the Evidence Based Supported Employment Model: Individual Placement and Support

Individual Placement and Support (IPS) is a long-standing and innovative employment service for individuals with mental illness with dozens of clinical trials demonstrating effectiveness. Little is known, however, about intentional adaptations to IPS, especially those outside of the context of research studies. Using an implementation science framework, we conducted an exploratory study to better understand the characteristics of stakeholder-reported adaptions to IPS, the impetus for their development, and perceived impacts. We conducted qualitative interviews to analyze and describe these adaptations. Numerous adaptations of IPS were found that address the needs of new and underserved populations both within and outside of the mental health field. Programs reported adapting IPS because of the dearth of other evidence-based employment services, to serve diverse populations in need, and based on financial incentives. Benefits of adaptations were weighed against impacts on fidelity. As evidence-based practices (EBPs) are adapted, developers of EBPs should determine how fidelity of a program or service can be assessed or preserved in light of adaptations. This is critical with the increase in different service delivery methods, new populations, new service recipient needs, and new settings in need of EBPs.

Adding Cognitive Remediation to Employment Support Services: A Randomized Controlled Trial

OBJECTIVE

Individual placement and support (IPS) is an evidence-based strategy that helps individuals with mental illness obtain and maintain competitive employment. Despite the approach's overall success, almost half of IPS clients do not find work. Impairment in cognitive abilities may hamper employment and limit the benefits from rehabilitation services such as IPS. This randomized controlled trial aimed to assess the effects of adding cognitive remediation therapy (CRT) for IPS clients who had difficulties finding employment.

METHODS

At 14 mental health centers in Canada, 97 clients who had not found work after 3 months of receiving IPS services were recruited. Consenting clients were randomly assigned to either continue IPS alone or receive CRT added to IPS. The CRT used the Thinking Skills for Work protocol, a 12-week program that included computerized cognitive exercises along with coping strategies for managing cognitive challenges.

RESULTS

Participants completed on average 10 of 12 individual training sessions in coping strategies and 12 of 24 computerized training sessions. The addition of CRT to IPS resulted in significantly more participants working at the 3-month (odds ratio [OR]=2.83, 95% confidence interval [CI]=1.22-6.60) and 9-month follow-ups (OR=2.91, 95% CI=1.27-6.65). Participants who received CRT worked more hours and earned more in wages than those receiving IPS alone over the 9-month follow-up period. Both groups showed significantly improved cognitive outcomes at the 3-month follow-up, with no time × group interaction.

CONCLUSIONS

Cognitive remediation, especially skills training in coping and compensatory strategies, improves employment outcomes among individuals who do not show an early benefit of using IPS services.

Serious Mental Illness Exacerbation Post-Bereavement: A Population-Based Study of Partners and Adult Children

Purpose

The death of a close family member is commonly accompanied by intense grief, stress, and loss of social support. We hypothesized that recent bereavement would be associated with an increase in symptom exacerbations among adults with serious mental illness (SMI) whose partners or parents had died.

Patients and Methods

Adults whose partners and parents had died in Denmark between January 1, 2010, and June 30, 2016, were identified using linked population-based registries. History of SMI was defined as having a diagnosis of schizophrenia and schizoaffective disorders, major depression, and bipolar disorder in the five years preceding their family member's death in the Danish Psychiatric Central Research Register using International Classification of Diseases-10 codes. The odds of SMI exacerbation (ie, attempt or completion of suicide or psychiatric hospitalization) among partners and children in the first two years after death in 3-month intervals were estimated with generalized estimating equations.

Results

12.8% of partners and 15.0% of adult children with a history of SMI experienced any SMI exacerbation two years after bereavement. Among bereaved partners, older age (80+ years) was associated with a lower risk of experiencing an SMI exacerbation compared with partners aged 18-49 years (OR_adj=0.29, [0.18-0.45]). Partners with a history of SMI had significantly increased odds of SMI exacerbations three months after their partners' death compared to prior to their partners' death (ORadj = 1.43, [1.13-1.81]). There was no evidence that adult children with SMI experience increased SMI exacerbations after the death of their parents compared to prior to death.

Conclusion

Adults with a history of SMI whose partners had died are at increased risk for an SMI exacerbation post bereavement. Additional bereavement resources and support should be provided to those with a history of SMI, especially in the period immediately after death.

Long-Term Outcomes of First-Admission Psychosis: A Naturalistic 21-Year Follow-Up Study of Symptomatic, Functional and Personal Recovery and Their Baseline Predictors

This study was aimed at characterizing long-term outcomes of first-admission psychosis and examining their baseline predictors. Participants were assessed at baseline for 38 candidate predictors and re-assessed after a median follow-up of 21 years for symptomatic, functional, and personal recovery. Associations between the predictors and the outcomes were examined using univariate and multivariate Cox regression models. At baseline, 623 subjects were assessed for eligibility, 510 met the inclusion/exclusion criteria and 243 were successfully followed-up (57.3% of the survivors). At follow-up, the percentages of subjects achieving symptomatic, functional, and personal recovery were 51.9%, 52.7%, and 51.9%, respectively; 74.2% met at least one recovery criterion and 32.5% met all three recovery criteria. Univariate analysis showed that outcomes were predicted by a broad range of variables, including sociodemographics, familial risk, early risk factors, premorbid functioning, triggering factors, illness-onset features, neurological abnormalities, deficit symptoms and early response to treatment. Many of the univariate predictors became nonsignificant when entered into a hierarchical multivariate model, indicating a substantial degree of interdependence. Each single outcome component was independently predicted by parental socioeconomic status, family history of schizophrenia spectrum disorders, early developmental delay, childhood adversity, and mild drug use. Spontaneous dyskinesia/parkinsonism, neurological soft signs and completion of high school remained specific predictors of symptomatic, functional, and personal outcomes, respectively. Predictors explained between 27.5% and 34.3% of the variance in the outcomes. In conclusion, our results indicate a strong potential for background and first-episode characteristics in predicting long-term outcomes of psychotic disorders, which may inform future intervention research.

Profiles of individuals with cannabis-related disorders

Background: Profiles of individuals with cannabis-related disorders (CRD) in specialized addiction treatment centers serving high-need patients have not been identified. This longitudinal study developed a typology for 9,836 individuals with CRD attending Quebec (Canada) addiction treatment centers in 2012-2013. Methods: Data on sociodemographic, clinical and service use variables were extracted from several databases for the years 1996-1997 to 2014-2015. Individual profiles were produced using Latent Class Analysis and compared predicting health outcomes on emergency department (ED) use, hospitalizations and suicidal behaviors for 2015-2016. Results: Six profiles were identified: 1-Older individuals, many living in couples and working, with moderate health problems, receiving intensive general practitioner (GP) care and high continuity of physician care; 2-Older individuals with chronic CRD, multiple social and health problems, and low health service use (chronic CRD referred to experiencing CRD for several years; social problems related to homelessness, unemployment, having criminal records or living alone); 3-Students with few social and health problems, and low health service use; 4-Young adults, many working, with few health problems, least health service use and continuity of physician care; 5-Youth, many working but some criminal offenders, with 1 or 2 years of CRD, few health problems and high addiction treatment center use; and 6-Older individuals with chronic CRD and multiple social and health problems, high health service use and continuity of physician care. Profiles 6 and 2 had the worst health outcomes. Conclusions: For Profiles 2 to 5, outreach and motivational services should be prioritized, integrated health and criminal justice services for profile 5 and, for Profiles 2 and 6, assertive community treatments. Screening, brief intervention and referrals to addiction treatment centers may also be encouraged for individuals with CRD, particularly those in Profile 2. This cohort had high social and health needs relative to services received, suggesting continued need for care.

Exploring Differences in Baseline Characteristics among Adults Entering Integrated Residential Treatment for Co-occurring Disorders in 2013 and 2017

Little is known about patients' addiction severity, substance use, or mental health symptoms upon entering integrated treatment. This is the first study to compare baseline characteristics among cohorts of patients with co-occurring disorders entering a private integrated residential treatment program in 2013 and 2017; a period when severe and persistent mental illness diagnoses, mental health service use, and overdose deaths increased. Our sample includes 3400 patients entering private, integrated residential treatment during 2013 (n = 1535) and 2017 (n = 1865). Trained staff completed admission interviews of all participants that included the Addiction Severity Index (ASI), a semi-structured interview to evaluate the past 30-day functioning of the following domains: medical, employment, alcohol, drug, legal, family or social support systems, and psychiatric. We used a p-value of 0.05 to assess significance. With the exception of the drug composite score, the 2017 cohort scored higher than the 2013 cohort on all other composite scores. Compared to the 2013 cohort, the 2017 cohort reported more days using alcohol, cocaine, amphetamines, and engaging in polysubstance use. Conversely, the 2017 cohort reported fewer days using other prescription opioids and sedatives than the 2013 cohort. After controlling for age, the 2017 cohort reported more days of marijuana use than the 2013 cohort. The 2017 cohort reported higher rates of the following symptoms: depression, anxiety, hallucinations, and suicidal ideation. Findings underscore differences among integrated treatment patient cohorts for baseline addiction severity, substance use, or mental health symptoms.

Moving clients forward: a grounded theory of disability employment specialists' views and practices

PURPOSE

This study sought to better understand the views and practices of disability employment specialists working with clients with mental illness. Specifically, it explored what helps and hinders employment specialists in their work.

MATERIALS AND METHODS

A constructivist grounded theory methodology was used. Semi-structured interviews with 16 disability employment specialists from four employment service providers in Victoria, Australia, were transcribed and analysed through initial coding, focused coding, and constant comparative methods.

RESULTS

Analysis led to the substantive grounded theory of "moving clients forward." The key themes included "taking a firm but fair approach," "meeting clients where they are at," "getting clients ready for work," "managing the interface between clients and employers," and as a consequence, "working under pressure."

CONCLUSIONS

These findings contribute the first grounded theory of how Australian disability employment specialists work with clients with mental illness and enhance understanding of employment specialists' notions of job readiness and their use of discretion in implementing seemingly contradictory employment-related policies. Practice tensions for these employment specialists could be reduced by modifying disability employment policies, and through training to deliver evidence-based practices that offer varied vocational services, pathways, and adjunct interventions tailored to clients' interests, needs and readiness for change.IMPLICATIONS FOR REHABILITATIONAustralian disability employment specialists experience tensions between meeting the needs of clients with mental illness and feeling pressured to adhere to performance-based funding and disability employment policies.Greater emphasis on evidence-based, individualised vocational interventions would better align with a recovery orientation and offer vocational options tailored to the needs and goals of job seekers with mental illnessFurther training and systemic support is needed for disability employment specialists to adopt evidence-based practices in their work with jobseekers with mental illness.Since Australian disability employment specialists describe considering the "job readiness" of clients in practice, the usefulness of this concept merits further investigation.

Review of Individual Placement and Support Employment Intervention for Persons with Substance Use Disorder

Objectives: Work is a critical part of recovery for many people with chronic health conditions, including Substance Use Disorders (SUD). Individual Placement and Support (IPS) is an evidence-based practice designed initially for adults with mental illness. Although the evidence for using IPS with individuals with severe mental illness is well documented, less is known about the efficacy of using IPS with consumers with substance use disorders, and the results have yet to be systematically evaluated and organized. Key components of zero exclusion, rapid competitive job search, and incorporation with treatment services as well as benefits are components that make IPS a strong practice to incorporate into substance abuse treatment. This study aims to evaluate and organize the evidence base of using IPS with adults with substance use disorders. Results: A systematic review was conducted of meta-analyses, reviews, and individual studies from 2000 through 2019, measuring the efficacy of IPS with individuals with SUD or comorbid SUD. Databases searched were Scopus, PubMed, and PsychInfo. Experimental and quasi-experimental studies are reviewed and critiqued for their application to a SUD population. Then, barriers and facilitators of IPS implementation with this population are discussed. Conclusions/Importance: There is a high evidence to support to application of IPS for persons with SUD, both singly and when combined with a mental health disorder. Barriers to IPS implementation including episodic treatment, risk of relapse, and housing or criminal justice instability make the IPS program a useful best practice to consider for this population.

Alcohol and other drug use among Belgian workers and job-related consequences

Objectives

This study aimed to obtain prevalence data on use of alcohol and other drugs (AOD) among Belgian workers, and to explore the associations between self-reported AOD use and job-related effects as experienced by workers, and the level of workers’ well-being, respectively.

Methods

In this cross-sectional study (2016), 5367 workers filled out a questionnaire including validated instruments such as the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Job-related effects were defined as: being late at work, absenteeism, loss of productivity, injuries, conflicts with co-workers and sanctions by employers. Descriptive and multiple logistic regression analyses were performed.

Results

Based on AUDIT-C, 39.1% of last year drinkers had an indication of problem drinking. The odds of experienced job-related effects was 3.6 (CI 2.86 to 4.60) times larger than the odds among workers without this indication. This ratio decreased to 3.2 (CI 2.52 to 4.11), controlling for language, gender, family context, level of education and sector. Respondents who used illicit drugs more frequently (>once a month) also had an increased risk for experienced job-related effects (OR 5.8; CI 2.87 to 11.84). Having a low level of well-being increased the risk for job-related effects due to psychoactive medication (OR 2.3, CI 1.10 to 4.91).

Discussion

In this study, self-reported AOD use was associated with short-term job-related effects. This suggests that an AOD policy in different sectors is needed with respect for the organisational culture. Its focus should lie on prevention and early detection of AOD problems, and on the mental health of workers. Attention is required for the non-medical use of prescription drugs.

Predictors of Sustained Employment Among Individuals With Serious Mental Illness: Findings From a 5-Year Naturalistic Longitudinal Study

Despite decades of research, understanding of the employment trajectories of individuals with serious mental illnesses remains elusive. We conducted a 5-year prospective, longitudinal study using a geographically broad sample of individuals who met established criteria for sustained competitive employment (N = 529). We collected data on an annual basis with a specifically designed survey instrument. Despite stable employment at study entry, more than half of the participants experienced work interruptions during the 5-year follow-up period. Predictors of sustained employment included the absence of a trauma diagnosis, Social Security disability income, psychiatric hospitalizations, and difficulties with daily functioning. The presence of a higher quality of life, workplace supports, and a flexible job were also predictive. Results dispel the myth that people with serious mental illnesses cannot be employed for prolonged periods. Interruptions in work trajectories, however, suggest that longer-term supports may increase individuals' capacity to maintain stable employment.

Employment after beginning treatment for substance use disorders: The impact of race/ethnicity and client community of residence

Employment is an important substance use treatment outcome, frequently used to assess individual progress during and after treatment. This study examined whether racial/ethnic disparities exist in employment after beginning treatment. It also examined the extent to which characteristics of clients' communities account for such disparities. Analyses are based on data that linked individual treatment information from Washington State's Behavioral Health Administration with employment data from the state's Employment Security Department. Analyses subsequently incorporated community-level data from the U.S. Census Bureau. The sample includes 10,636 adult clients (Whites, 68%; American Indians, 13%, Latinos, 10%; and Blacks, 8%) who had a new outpatient treatment admission to state-funded specialty treatment. Heckman models were used to test whether racial/ethnic disparities existed in the likelihood of post-admission employment, as well as employment duration and wages earned. Results indicated that there were no racial/ethnic disparities in the likelihood of employment in the year following treatment admission. However, compared to White clients, American Indian and Black clients had significantly shorter lengths of employment and Black clients had significantly lower wages. With few exceptions, residential community characteristics were associated with being employed after initiating treatment, but not with maintaining employment or with wages. After accounting for community-level variables, disparities in length of employment and earned wages persisted. These findings highlight the importance of considering the race/ethnicity of a client when examining post-treatment employment alongside community characteristics, and suggest that the effect of race/ethnicity and community characteristics on post-treatment employment may differ based on the stage of the employment process.

It can work: Open employment for people with experience of mental illness

BACKGROUND

Previous research has tended to focus on the barriers to employment for people with mental illness and the extra support they may need. This research contributes to the knowledge base pertaining to this population by looking at successful employment relationships in New Zealand.

OBJECTIVE

To describe factors enabling and/or sustaining the open employment of people with experience of mental illness.

METHOD

Fifteen pairs of employers and employees were interviewed individually but consecutively (using a semi-structured interview schedule) about their perceptions of the critical factors that enabled and sustained the employee's employment. Employee participants were recruited by advertisement, with employers approached through their employees. Transcripts were analysed using a thematic analysis.

RESULTS

Themes raised in the interviews included the meaning of work, disclosure of mental illness, the benefits of working, special arrangements or accommodations, the work environment and key things employers and employees do to sustain successful employment.

CONCLUSION

Four critical success factors were identified relating to disclosure, the employment relationship, freedom from discrimination and workplace flexibility.

Tobacco retail environment near housing programmes for patients with mental health conditions in New York City

OBJECTIVES

The current study sought to characterise the tobacco retail environment of supportive housing facilities for persons with mental health (MH) conditions in New York City (NYC) and to estimate the potential impact of a tobacco retail ban near public schools on the retail environment of MH housing in NYC.

METHODS

Texas A&M Geocoding Services was used to geocode the addresses of housing programmes for patients with MH conditions, non-MH residences, public schools and tobacco retailers in NYC. ESRI ArcMap was used to calculate the number of tobacco retailers within a 500-foot radius around each housing programme and school address point, and the Euclidean distance to the nearest retailer. Generalised linear models were used to compare retail counts and distance between MH and non-MH residences.

RESULTS

The mean number of tobacco retailers within 500 feet of an MH housing programme was 2.9 (SD=2.3) and the mean distance to nearest tobacco retailer was 370.6 feet (SD=350.7). MH residences had more retailers within 500 feet and a shorter distance to the nearest retailer compared with non-MH residences in Brooklyn, the Bronx and Staten Island (p<0.001). Banning tobacco licences within 350, 500 or 1000 feet of a school would significantly improve the tobacco retail environment of MH housing programmes and reduce disparities between MH and non-MH residences in some boroughs.

CONCLUSIONS

People with MH conditions residing in supportive housing in NYC encounter a heavy tobacco retail environment in close proximity to their home, and in some boroughs, one worse than non-MH residences. Implementing a ban on tobacco retail near public schools would improve the tobacco retail environment of MH housing programmes in NYC.

The Mediating Influence of Treatment Participation Rate on Post-Treatment Employment

This study explored treatment participation rate as a mediator between individuals’ baseline alcohol use, drug use, and psychiatric issue levels and post-treatment employment status. The study sample included 106 unemployed or underemployed individuals with substance use disorders who were participants in an intensive drug abuse treatment program. Structural equation modeling was applied to examine relationships between study variables. The results showed that (a) the direct effect of individuals’ baseline alcohol use, drug use, and psychiatric issue severities reduced treatment participation rate; (b) the direct effect of treatment participation rate ameliorated post-treatment employment status; and (c) the indirect effect of individuals’ baseline alcohol use, drug use, and psychiatric issue severities on post-treatment employment status was mediated by treatment participation rate, which reduced the negative influence of baseline issue severity on employment. This significant mediating effect has both practical and theoretical importance in that it indicates the need for increased focus on treatment participation in practice and future research.

Mortality among patients with schizophrenia and vocational rehabilitation program services under Taiwan's psychiatric care reform

Background

Vocational rehabilitation programs are implemented to enhance the occupational functioning of long-stay patients with schizophrenia. Unemployment is associated with a higher risk of death. Schizophrenia patients who participate in vocational rehabilitation programs may have better health outcomes with participation in employment.

Aim

To evaluate the relationship between mortality among schizophrenia patients and vocational rehabilitation program services under Taiwan’s psychiatric care reform.

Methods

A total of 2457 long-stay schizophrenia patients were followed-up retrospectively from 1998 to 2008 at Taipei Veterans General Hospital Yuli Branch in Taiwan. We collected data on annual measurements of effectiveness and the human resources utilized in the vocational rehabilitation program. Pearson’s correlations between the above-collected data and the crude death rates for all patients were examined. We also assessed the association between participation in supported or sheltered employment and death.

Results

Most of the patients were male (81.3 %). The mean ± SD age of the patients was 57.8 ± 17.0 years. The annual crude death rate averaged 5.3 %. Both the number of community workplaces and the total wages earned from sheltered and supported employment had significantly negative linear correlations with the crude death rate among all patients (both γ ≤ −0.64, p < 0.05). After controlling the confounding factors, participation in supported or sheltered employment was significantly associated with a lower risk of death (n = 2174, HR = 0.22, 95 % CI 0.16–0.29).

Conclusions

Under psychiatric care reform, the vocational rehabilitation program was more effective and there was less patient mortality. Patients who had experienced sheltered or supported employment had a lower risk of death than those who had not.

Does Competitive Work Improve Quality of Life for Adults with Severe Mental Illness? Evidence from a Randomized Trial of Supported Employment

A randomized trial comparing a facility-based Clubhouse (N = 83) to a mobile Program of Assertive Community Treatment (PACT; N = 84) tested the widely held belief that competitive employment improves global quality of life for adults with severe mental illness. Random regression analyses showed that, over 24 months of study participation, competitively employed Clubhouse participants reported greater global quality of life improvement, particularly with the social and financial aspects of their lives, as well as greater self-esteem and service satisfaction, compared to competitively employed PACT participants. However, there was no overall association between global quality of life and competitive work, or work duration. Future research will determine whether these findings generalize to other certified Clubhouses or to other types of supported employment. Multi-site studies are needed to identify key mechanisms for quality of life improvement in certified Clubhouses, including the possibly essential role of Clubhouse employer consortiums for providing high-wage, socially integrated jobs.

Quality of life in a 20-year follow-up study of people suffering from schizophrenia

AIMS

1. To assess the changes in quality of life indicators in schizophrenia sufferers at three measurement points: 7, 12 and 20 years after the first hospitalization. 2. To assess changes in the level of functioning and psychopathological state. 3. To assess the relationships between quality of life, the level of functioning and the severity of symptoms.

METHOD

A sample group of fifty-two people diagnosed with schizophrenia was investigated using the Lehman's QOLQ, the GAF scale and BPRS.

RESULTS

A deterioration was noted in the subjective and objective areas of family life and health, subjectively assessed social relationships and objectively assessed finances. The better functioning sub-group returned better scores for the following objective quality of life indicators: free time, family life, health, social relationships and financial situation. The sub-group in remission obtained better results for general, subjective quality of life and for subjectively assessed health, as well as better scores for objectively assessed free time, social relationships, financial situation and health. An improvement in general, subjective quality of life was seen in the sub-group whose symptoms had grown more severe.

CONCLUSIONS

The decline in subjective and objective quality of life in the areas of health and family life, in the subjective evaluation of social relationships and in the objective assessment of financial situation was associated with a deterioration in functioning and an absence of symptom remission. The improvement in general, subjective quality of life in the sub-group with severe symptoms may be evidence of the formation of adaptive mechanisms.

Does employment alter the course and outcome of schizophrenia and other severe mental illnesses? A systematic review of longitudinal research

INTRODUCTION

This review synthesized prospective evidence to assess whether achieving employment alters the course of schizophrenia-spectrum disorder.

METHOD

Researchers identified relevant analyses for review via PubMed, expert referral, and reference review and systematically applied two levels of screening to 1484 citations using seven a priori criteria.

RESULTS

A total of 12 analyses representing eight cohorts, or 6844 participants, compared illness course over time by employment status in majority schizophrenia-spectrum samples. Employment was consistently associated with reductions in outpatient psychiatric treatment (2 of 2 studies) as well as improved self-esteem (2 of 2 studies). Employment was inconsistently associated with positive outcomes in several other areas, including symptom severity, psychiatric hospitalization, life satisfaction, and global wellbeing. Employment was consistently unrelated to worsening outcomes.

DISCUSSION

Achieving employment does not cause harm among people with schizophrenia-spectrum disorder and other severe mental illnesses. Further detailed mechanistic analyses of adequately powered long-term follow-up studies using granular descriptions of employment are needed to clarify the nature of associations between employment and hypothesized benefit.

Health and well-being of homeless veterans participating in transitional and supported employment: Six-month outcomes

Supported employment, specifically individual placement and support (IPS), improves competitive employment (CE) rates for individuals with serious mental illness, but has not shown greater improvement in non-vocational outcomes than other rehabilitation approaches. The Department of Veterans Affairs offers two types of vocational services, IPS and transitional work experience (TWE), but no study has compared the effectiveness of these approaches. This secondary analysis of data from a study of homeless veterans compared 6 mo improvement in diverse outcomes for five employment patterns: never worked, worked only in TWE, worked in TWE followed by CE, worked in CE without IPS, and worked in CE with IPS referral. Veterans referred to IPS were more likely to be competitively employed. Those who worked in CE (whether following TWE or with or without IPS referral) showed the greatest increase in days worked, employment income, and total income and the greatest decrease in public support income when compared with those who worked only in TWE or not at all. Veterans in TWE showed the greatest increase in residential treatment days, but there were no other differences in non-vocational outcomes between groups. There are multiple paths to CE, but few differences in non-vocational outcomes across employment experiences.

Early psychosis and employment

BACKGROUND

Employment may be an important factor in helping patients with early psychosis to recover rapidly and to avoid involvement in disability and welfare programs.

METHODS

This study followed 351 patients with early psychoses, either primary psychoses or substance-induced psychoses, for two years to examine their patterns of competitive employment in relation to service use, psychosocial outcomes, and disability and welfare payments.

RESULTS

Workers differed from non-workers at baseline and over two years. At baseline, they had better educational and employment histories, were more likely to have substance-induced psychoses rather than primary psychoses, were less likely to have drug dependence, had fewer negative symptoms, and had better psychosocial adjustment. Over two years, baseline psychosocial differences persisted, and the workers used fewer medications, mental health services, and disability or welfare payments.

CONCLUSIONS

Employment predicts less service use and fewer disability claims among early psychosis patients. Thus, greater attention to supported employment early in the course of illness may reduce federal insurance costs and disability payments.