Supported employment among veterans with serious mental illness: the role of cognition and social cognition on work outcome

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.

Impact of cognitive remediation on the prediction of employment outcomes in severe mental illness

OBJECTIVE

Cognitive functioning is a potent predictor of work in people with a severe mental illness, including those receiving vocational services. Cognitive remediation has been shown to improve cognitive functioning and work outcomes in people receiving vocational services. However, it is unknown whether it reduces the strength of cognitive functioning as a predictor of work outcomes compared to people receiving vocational services alone.

METHOD

Data were pooled from five randomized controlled trials evaluating the effects of adding cognitive remediation to vocational rehabilitation vs. vocational services alone. A battery of baseline cognitive functioning measures was examined to identify predictors of competitive work outcomes over the following two years. Study condition (i.e., receipt of cognitive remediation) was included in the analyses to evaluate whether cognitive functioning was a weaker predictor of work outcomes in people receiving cognitive remediation compared to those receiving vocational services alone.

RESULTS

Cognitive functioning was a stronger predictor of wages earned and weeks worked in participants receiving vocational services alone than those who also received cognitive remediation. Cognitive functioning did not predict job acquisition in either study condition.

CONCLUSION

Cognitive remediation may improve employment outcomes in people receiving vocational services in part by reducing the adverse effects of impaired cognitive functioning on work performance.

Experiences of VA vocational and education training and assistance services: Facilitators and barriers reported by veterans with disabilities

OBJECTIVE

To understand the experiences of veterans with disabilities and caregiving needs who use Department of Veterans Affairs (VA) vocational and education services, including Supported Employment, the Post-9/11 GI Bill, and Vocational Rehabilitation and Employment.

METHOD

We conducted 26 joint semistructured interviews with post-9/11 veterans who had used at least one of three vocational and education services, and their family members who were enrolled in a VA Caregiver Support Program.

RESULTS

VA vocational and education services helped veterans with disabilities transition from the military into civilian life by providing skills and incremental exposure to engaging in everyday life tasks. Veteran motivation, caregiver support, and engaged staff at VA and academic institutions were key drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, concerns about benefits loss if they became employed, and VA and academic programs that did not accommodate the needs of nontraditional veteran learners.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a need to bolster VA vocational and educational services for veterans with disabilities in several domains, including modifying the roles of frontline staff and increasing communication between vocational counselors and health care teams to better accommodate the veteran's health-related limitations. Providing a vocational rehabilitation navigator to help veterans identify opportunities within VA and work/educational settings that are a good match for the veteran's goals and abilities could also be beneficial across vocational and educational services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Lifetime employment in schizophrenia: correlates of developing long term unemployment after being employed before

BACKGROUND

Challenges in employment are highly prevalent among people with schizophrenia regardless of their employment history. Although supportive employment can be effective, few participants sustain meaningful competitive employment. Our goal was to identify the correlates of developing sustained unemployment.

METHODS

We examined employment outcomes by comparing clinical, neurocognitive, and social cognitive features in 234 participants with Schizophrenia Spectrum Disorders across t competitive employment outcomes: currently employed, participants who had never worked for a year, and those who had been employed but developed long-term unemployment. We examined social cognition and neurocognition, as well as positive and negative schizophrenia symptoms, and premorbid functioning and demographic factors.

RESULTS

We found significant differences in age, race, premorbid functioning, cognitive performance, and social cognition between currently and formerly employed patients. When individual tasks were examined, emotion recognition and verbal working memory performance were the domains differentiating the groups. Older African Americans were over-represented in the formerly employed group.

CONCLUSIONS

There were minimal differences other than age and race between formerly employed patients and those who had never worked. These data suggest the possibility that deterioration in employment outcomes may also co-occur with declines in other abilities. Opportunities and disparities may also be a contributor to re-entering the work force.

[Cognitive disorders in schizophrenia]

Cognitive disorders in schizophrenia are highly correlated with the psychosocial level (e.g. relationships, quality of life and work). It has been shown that healthy relatives and people at ultrahigh risk also display cognitive dysfunctions albeit to a lesser degree. The cognitive impairment increases simultaneously with an acute phase and then reverts back to baseline levels. At the psychopathological level, negative symptoms and the disorganization syndrome show the strongest associations with cognitive deficits, whereby the extent of manifestation of deficits increases with increasing symptomatology. Cognitive remediation can improve the cognitive performance through training with small to moderate effects. With respect to drug therapy there is currently no drug with a positive effect on cognitive disorders.

Motivational and cognitive correlates of community integration in homeless veterans entering a permanent supported housing program

Homelessness is a major public health problem, and serious mental illness (SMI) is highly prevalent in the homeless population. Although supported housing services-which provide permanent housing in the community along with case management-improve housing outcomes, community integration typically remains poor, and little is known about the underlying determinants of poor community integration postresidential placement. The general SMI literature has indicated that motivational and cognitive ability factors are key determinants of successful community integration, which provides a foundation for examining this issue. This study evaluated whether interview- and performance-based assessments of motivation, nonsocial and social-cognitive ability, and psychiatric symptoms were associated with community integration indices in 2 samples of homeless veterans either with (N = 96) or without (N = 80) a psychotic disorder who had recently been admitted to a supported housing program but who had not yet attained housing. Motivation indices, including experiential negative symptoms and defeatist performance attitudes, stood out as the most robust correlates (rs = -.30 to -.69) of community integration across both samples, particularly for social role participation. Demographics, general psychiatric symptoms, and nonsocial cognition showed generally weak relations with community integration, though social cognition showed a few relations. The consistent findings across samples point to the importance of motivational factors for understanding the determinants of poor community integration in this complex population. Further, interventions that target motivational challenges may have widespread usefulness for enhancing community integration outcomes beyond obtaining housing. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Employment as a Social Determinant of Health: Exploring the Relationship Between Neurocognitive Function and Employment Status

Purpose:

To explore employment as a social determinant of health through examining the relationship between neurocognitive function and employment status.

Method:

The authors explored the causal relationship between employment status and neurocognitive function by conducting a systematic review of 15 longitudinal studies. The identified studies were conducted in Australia, Denmark, Norway, and the United States.

Results:

Five neurocognitive function domains were identified (i.e., complex attention, executive function, learning and memory, language, perceptual-motor function) across diagnosis (i.e., bipolar disorder, first-episode psychosis, human immunodeficiency virus, major depression, schizophrenia-spectrum disorders, traumatic brain injury). Unemployment was correlated with poorer attention, executive function, learning and memory, perceptual-motor function, and language. Employment was correlated with better attention, executive function, learning and memory, perceptual-motor function.

Conclusion:

The acknowledgment of the relationship between neurocognitive function and employment status can assist service providers in assessing and developing strategies to enhance and maintain employment outcomes. The assessment of neurocognitive function could be further explored by identifying standard measures and assessment timelines to assess the six domains across diagnosis. Vocational rehabilitation services could integrate cognitive interventions (cognitive rehabilitation, cognitive enhancement therapy, cognitive remediation) to explore the effect on neurocognitive function and employment outcomes. Further longitudinal research studies are needed, for both persons with disabilities and persons without disabilities, to elucidate the relationship between employment status and neurocognitive function.

The role of experiential and expressive negative symptoms on job obtainment and work outcome in individuals with schizophrenia

Unemployment rates for schizophrenia are high across all age groups compared to the general population. Past studies have focused on neurocognition as a key determinant of unemployment and poor work outcome in schizophrenia. However, several recent studies suggest that clinical symptoms may be equally or more important than cognitive dysfunction for understanding employment difficulties. An enhanced understanding of the domains of negative symptoms that hinder job obtainment and work outcomes in people with schizophrenia is vital for developing treatments that translate into better employment outcomes. The purpose of this study was to determine whether 112 participants with schizophrenia or schizoaffective disorder receiving supported employment services differed on experiential and expressive negative symptoms based on whether they obtained a job or remained unemployed. Further, in a subset of workers, this study examined the relationship of experiential "motivational" negative symptoms with work outcomes (weeks worked, hours worked, wages earned). Neurocognition was assessed using the MATRICS Consensus Cognitive Battery and clinical symptoms were assessed using the Scale for the Assessment of Negative Symptoms and the Brief Psychiatric Rating Scale. Experiential, but not expressive, negative symptoms were related to job obtainment, hours worked, and wages earned. However, these findings were attenuated and non-significant after controlling for age. These results suggest that experiential negative symptoms are potentially key to better understanding employment outcomes of individuals with schizophrenia receiving supported employment services, but further work is needed to untangle its significance vis-à-vis other individual, environmental, and program factors.

Neurocognition and occupational functioning in schizophrenia spectrum disorders: The MATRICS Consensus Cognitive Battery (MCCB) and workplace assessments

The MCCB is widely used in clinical trials of schizophrenia, but its relationship to occupational functioning still needs further elaboration. While previous research has indicated that various domains of neurocognition assessed by individual tests are related to work functioning, these reports preceded the development of the MCCB as the standard neurocognitive test battery in the field. In the current study, the vocational functioning of 131 Norwegian participants with schizophrenia spectrum disorders who were enrolled in a vocational rehabilitation program were assessed on the Vocational Cognitive Rating Scale (VCRS), the Work Behavior Inventory (WBI), and the Complexity Scale (CS) as well as on the MCCB. Significant correlations were found between most MCCB domains and VCRS Total Score. MCCB processing speed and attention were most powerfully related to and predictive of WBI scores. When participants were divided into "low complexity" or "higher complexity" work categories, participants in the "low-complexity" group performed significantly worse than participants in the "higher-complexity" group regarding processing speed, working memory, visual learning and the composite score. The same pattern emerged for participants working sheltered compared to competitive jobs. The VCRS, WBI and CS may be useful in vocational rehabilitation. They bridge an important gap between test- and occupational-setting, providing valuable information about impairments related to occupational functioning. We found the MCCB to be sensitive to occupational functioning as measured by VCRS, WBI and CS, with neurocognition accounting for a small but significant proportion of the variance in these different measures of occupational functioning.

Mixed methods study examining work reintegration experiences from perspectives of Veterans with mental health disorders

Recent findings have demonstrated that reintegration for Veterans is often challenging. One difficult aspect of reintegration—transitioning into the civilian workplace—has not been fully explored in the literature. To address this gap and examine work reintegration, this mixed methods study examined the perspectives of Veterans with mental health disorders receiving Department of Veterans Affairs healthcare. Forty Veterans rated factors that affect work success; participants also provided narratives on their most and least successful work experiences. We used t-tests and qualitative analysis to compare participants who did and did not serve in combat. Several themes relevant to work reintegration emerged in the narratives, particularly for Veterans who served in combat. An array of work difficulties were reported in the months following military discharge. In addition, Veterans who served in combat reported significantly more work barriers than Veterans who did not serve in combat, particularly health-related barriers. In conclusion, Veterans with mental health disorders who served in combat experienced more work reintegration difficulty than their counterparts who did not serve in combat. The role of being a Veteran affected how combat Veterans formed their self-concept, which also shaped their work success and community reintegration, especially during the early transition period.