Research on the individual placement and support model of supported employment

Cost-effectiveness of occupational therapy return-to-work interventions for people with mental health disorders: A systematic review

BACKGROUND

Return-to-work (RTW) resources for persons with mental health disorders are limited and costs are typically shared by several stakeholders in society. Occupational therapists (OT) provide RTW interventions for this target group, however, increased knowledge of health, and employment effects, as well as costs are needed to better inform decision makers in their prioritisations.

AIMS/OBJECTIVES

To identify and summarise evidence of cost-effectiveness of RTW interventions for persons with mental health disorders which OTs provide.

MATERIALS AND METHODS

A systematic search was applied and resulted in 358 articles. After screening, nine articles met inclusion criteria and were reviewed. Quality assessment was conducted using the economic evaluation tool by Joanna Briggs Institute.

RESULTS

Supported employment, Individual Placement and Support was cost-effective in several contexts while three studies showed larger effects and higher costs. An OT intervention added to treatment for major depression was indicated to be cost-beneficial and an advanced supported employment was cost-saving. The methodological quality varied considerably between studies.

CONCLUSIONS AND SIGNIFICANCE

The results of the included studies are promising, however, to further strengthen the economic perspective in OT RTW interventions, the need for conducting more and methodologically robust economic evaluations is crucial in future studies.

Unhoused and unhireable? Examining employment biases in service contexts related to perceived warmth and competence of people experiencing houselessness

Lack of safe and stable housing is a pernicious and growing social concern, and stereotypes about individuals experiencing houselessness are generally quite negative. Little scholarly work has examined housing insecurity and its associated stereotypes in employment contexts. The purpose of the current research was to examine, in the context of the hospitality industry, whether housing status influences hiring managers' perceptions of hireability (Study 1) and customers' evaluations of an organization and its employees (Study 2) using the stereotype content model. Across two experimental studies, we assessed participant attitudes toward individuals experiencing houselessness. In Study 1, we instructed 148 hotel managers to listen to a hypothetical job interview with either an unhoused or housed job applicant, and then complete measures of hireability. In Study 2, we instructed 139 hotel customers to observe a hypothetical interaction with either an unhoused or housed employee, and then evaluate the employee and the organization. Study 1's findings suggested an indirect effect of housing status on perceived hireability through warmth, and this indirect relationship was moderated by gender. Men who were houseless were rated lower in warmth, and thus lower in hireability, than non-houseless men or women regardless of their housing status. However, houseless men were perceived by customers as warmer than non-houseless men as employees, driving higher evaluations of the organization and the employee (Study 2). Hiring initiatives targeted at providing short-term housing for unhoused employees will benefit employees, employers, and the larger communities they encompass.

Participant Engagement in Supported Employment: A Systematic Scoping Review

Purpose This study aimed to synthesise the available knowledge on how participant engagement in supported employment (SE) interventions is presented, defined, and conceptualised. We also aimed to develop a working definition of participant engagement in SE based on the results of our study. Methods This systematic scoping review was conducted following the PRISMA extension for scoping reviews. The following databases were systematically searched: EBSCO, SCOPUS, Social Care Online, and JSTOR. We included peer-reviewed publications in English based on empirical studies. Results Sixteen articles met the inclusion criteria and were included in the final analysis. Thematic framework analysis resulted in three themes conveying the concept of participant engagement: self-determined choice, empowerment, and collaboration/working alliance. We suggest that participant engagement in SE is an active multifaceted process that involves the empowerment of participants, participants' exercise of self-determined informed choice, and their collaboration with SE practitioners in a working alliance. Conclusions Participant empowerment, self-determined choice, and collaboration are important aspects of participant engagement in SE. The study results will appeal to SE practitioners and make significant contributions to the broader field of other vocational services supporting people in (re-)entering the competitive labour market.

Work Patterns and Support Needs of People with Serious Mental Illness

People with serious mental illness (SMI) are frequently unemployed, despite their willingness to work. Several employment interventions approaches have proven efficacy; however, work integration rates for people with SMI continue to be low. In total, 145 participants with a SMI completed a survey, answering questions regarding their personal information, work history, whether they received supports towards work integration, and their functional level. In addition, clinical records were accessed to verify and complete clinical history. A quantitative descriptive approach was used to analyze the data. No significant differences were found between those who were working and who were not, based on age, gender, educational level, living situation, and suicide risk. Those who were working presented higher levels of functional capacity than those who were not working. Factors associated with employment outcomes continue to remain unclear, adding value to the role that the different supports towards work integration may have.

Sustainable employability in Supported Employment and IPS interventions in the context of the characteristics of work and perspectives of the employers: a scoping review protocol

INTRODUCTION

The sustainable employment outcomes and cost-effectiveness of Supported Employment (SE) and Individual Placement and Support (IPS) have been well reported. Research has also focused on various target groups, compliance with the quality criteria for the implementation of the SE/IPS method in diverse work life and social security contexts. However, the impact of employers' interests and the quality and opportunities of jobs or the work itself for sustainable working careers have not been studied extensively. The objective of the proposed scoping review is to systematically explore what is known about sustainable employability in SE and IPS interventions in the context of the characteristics of work and perspectives of the employers.

METHODS AND ANALYSES

The scoping review methodological framework by Arksey and O'Malley and its recently enhanced versions are used as guidelines in this study. The literature search, which was conducted in Medline, Scopus, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, and Social Science Premium Collection (ProQuest), identified a total of 2706 articles after the removal of duplicates. Key findings of selected studies will be charted, analysed and reported.

ETHICS AND DISSEMINATION

The study does not require ethics approval, as the data are collected from secondary sources. The final version of the scoping review will be published in a peer-reviewed academic journal. Findings of the review will be used in the upcoming ethnographic observation at work study, which is part of the Finnish Work Ability Programme Evaluation Study (2020-2023).

Contemporary approaches in mental health rehabilitation

In many European countries, deinstitutionalisation has been an ongoing process over the last few decades. Mental health organisations were transformed to provide support in a more integrated and comprehensive manner, preferably in their own homes in the community. Yet, despite the welcome aspiration of community integration for all, people with complex mental health problems (also termed severe mental illness) have continued to require high levels of support, in inpatient settings and in the community. This group's needs make them highly dependent on their caregivers. The attitudes, knowledge and skills of the staff providing treatment and support is crucial to their recovery. Rehabilitation programmes provide a much-needed framework to guide practitioners and help them organise and focus their recovery-oriented approach. In this editorial, we will provide a non-exhaustive overview of such rehabilitation programmes and interventions to illuminate the wide scope and practical usability of these interventions for this group of people with complex mental health problems.

The Recovery Movement: Implications For Mental Health Care And Enabling People To Participate Fully In Life

The recovery movement, which broadly recognizes the ability of people with mental illnesses to participate in the mainstream of society, stems from a confluence of factors, including longitudinal data showing that many people eventually recover from serious mental illness. Perhaps as important to the emergence and growth of the recovery movement has been the increasing role that people "in recovery" have played in advocating for person-centered care, greater self-determination for those with mental illnesses, and an enhanced focus on restoring functioning for individuals above and beyond symptom reduction. The Americans with Disabilities Act of 1990 redefined serious forms of mental illness as disabilities, which led to the development of a range of accommodations to enable people with psychiatric disabilities to live in their own homes, work, go to school, and perform other normative adult roles such as parent and parishioner even while suffering symptoms. The Affordable Care Act provides additional levers for expanding the use of peer health navigators and shifting care to a collaborative model in which people can play active roles in their own care. While stigma and discrimination continue to pose formidable obstacles, the foundations have been laid for mental health practice to come closer to resembling health care for other medical conditions.

Influence of an Interdisciplinary Re-employment Programme Among Unemployed Persons with Mental Health Problems on Health, Social Participation and Paid Employment

Purpose To evaluate the influence of an interdisciplinary re-employment programme on labour force participation and perceived health among unemployed persons with common mental health problems. In addition, the influence of entering paid employment on self-rated physical health and mental health was investigated. Methods In this quasi-experimental study with 2 years follow up, 869 persons were enrolled after referral to an interdisciplinary re-employment programme (n = 380) or regular re-employment programme (n = 489). The propensity score technique was used to account for observed differences between the intervention and control group. The intervention programme was provided by an interdisciplinary team, consisting of mental health care professionals as well as employment specialists. Mental health problems were addressed through cognitive counselling and individual tailored job-search support was provided by an employment professional. Primary outcome measures were paid employment and voluntary work. Secondary outcome measures were self-rated mental and physical health, measured by the Short Form 12 Health Survey, and anxiety and depressive symptoms, measured by the Kessler Psychological Distress Scale. Changes in labour force participation and health were examined with repeated-measures logistic regression analyses by the generalized estimating equations method. Results The interdisciplinary re-employment programme did not have a positive influence on entering employment or physical or mental health among unemployed persons with mental health problems. After 2 years, 10% of the participants of the intervention programme worked fulltime, compared to 4% of the participants of the usual programmes (adjusted OR 1.65). The observed differences in labour force participation were not statistically significant. However, among persons who entered paid employment, physical health improved (+16%) and anxiety and depressive symptoms decreased (-15%), whereas health remained unchanged among persons who continued to be unemployed. Conclusions Policies to improve population health should take into account that promoting paid employment may be an effective intervention to improve health. It is recommended to invest in interdisciplinary re-employment programmes with a first place and train approach.

Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis

BACKGROUND

People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions.

OBJECTIVES

To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness.

SEARCH METHODS

In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials.

SELECTION CRITERIA

We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE.

MAIN RESULTS

We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions.

AUTHORS' CONCLUSIONS

Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.

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

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

“I Get My Therapy From Work”

Although the Wellness Recovery Action Plan (WRAP) has been studied in the context of recovery from mental illness, peer-led services, effectiveness, and improving self-advocacy skills of clients, the relationship between employment success and WRAP has not yet been examined. The objective of the study was to explore the impact of WRAP on employment and how individuals with psychiatric disabilities utilized WRAP strategies for employment success. Ten working-age individuals who completed WRAP training and subsequently worked for at least 90 days engaged in semi-structured interviews about their experiences with WRAP and employment. Transcripts of the interviews were analyzed and three themes emerged from the study: (a) Then and Now, (b) Strategies for Wellness, and (c) Toward Employment Success. Findings showed that WRAP strategies facilitated success in employment and that employment was an important component of recovery from mental illness.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

Spinal cord injury combined with felony history: effect on supported employment for Veterans

In this secondary analysis of data from a randomized controlled trial comparing supported employment with treatment as usual, we sought to evaluate the study incident rate of legal involvement and subsequent effects of legal involvement on employment among 157 job-seeking Veterans with spinal cord injury. The supported employment vocational rehabilitation program, called the Spinal Cord Injury-Vocational Integration Program, adhered as closely as possible to principles of supported employment as developed and described in the individual placement and support model of supported employment for persons with mental illness. Rates of misdemeanor and felony arrests and convictions were analyzed, and their relationship to finding employment was evaluated. Findings indicate that 47% had been arrested and 25% had been convicted of a felony. Overall, those who found employment had fewer average arrests and were significantly less likely to have been convicted of a felony. Future directions and limitations are discussed.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; NCT00117806.

Cost effectiveness and budgetary impact of the Boston University approach to Psychiatric Rehabilitation for societal participation in people with severe mental illness: a randomised controlled trial protocol

BACKGROUND

People with Severe Mental Illness (SMI) frequently experience problems with regard to societal participation (i.e. work, education and daily activities outside the home), and require professional support in this area. The Boston University approach to Psychiatric Rehabilitation (BPR) is a comprehensive methodology that can offer this type of support. To date, several Randomised Controlled Trials (RCT's) investigating the effectiveness of BPR have yielded positive outcomes with regard to societal participation. However, information about the cost-effectiveness and budgetary impact of the methodology, which may be important for broader dissemination of the approach, is lacking. BPR may be more cost effective than Care As Usual (CAU) because an increase in participation and independence may reduce the costs to society. Therefore, the aim of this study is to investigate, from a societal perspective, the cost-effectiveness of BPR for people with SMI who wish to increase their societal participation. In addition, the budget impact of implementing BPR in the Dutch healthcare setting will be assessed by means of a budget impact analysis (BIA) after completion of the trial.

METHODS

In a multisite RCT, 225 adults (18-64 years of age) with SMI will be randomly allocated to the experimental (BPR) or the control condition (CAU). Additionally, a pilot study will be conducted with a group of 25 patients with severe and enduring eating disorders. All participants will be offered support aimed at personal rehabilitation goals, and will be monitored over a period of a year. Outcomes will be measured at baseline, and at 6 and 12 months after enrolment. Based on trial results, further analyses will be performed to assess cost-effectiveness and the budgetary impact of implementation scenarios.

DISCUSSION

The trial results will provide insight into the cost-effectiveness of BPR in supporting people with SMI who would like to increase their level of societal participation. These results can be used to make decisions about further implementation of the method. Also, assessing budgetary impact will facilitate policymaking. The large sample size, geographic coverage and heterogeneity of the study group will ensure reliable generalisation of the study results.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN88987322. Registered 13 May 2014.

S3 guideline on psychosocial therapies in severe mental illness: evidence and recommendations

The burden of severe and persistent mental illness is high. Beside somatic treatment and psychotherapeutic interventions, treatment options for patients with severe mental illness also include psychosocial interventions. This paper summarizes the results of a number of systematic literature searches on psychosocial interventions for people with severe mental illness. Based on this evidence appraisal, recommendations for the treatment of people with severe mental illness were formulated and published in the evidence-based guideline series of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) as an evidence-based consensus guideline ("S3 guideline"). Recommendations were strongly based on study results, but used consensus processes to consider external validity and transferability of the recommended practices to the German mental healthcare system. A distinction is made between system-level interventions (multidisciplinary team-based psychiatric community care, case management, vocational rehabilitation and participation in work life and residential care interventions) and single psychosocial interventions (psychoeducation, social skills training, arts therapies, occupational therapy and exercise therapy). There is good evidence for the efficacy of the majority of psychosocial interventions in the target group. The best available evidence exists for multidisciplinary team-based psychiatric community care, family psychoeducation, social skills training and supported employment. The present guideline offers an important opportunity to further improve health services for people with severe mental illness in Germany. Moreover, the guideline highlights areas for further research.

A 2-year follow-up study of people with severe mental illness involved in psychosocial rehabilitation

BACKGROUNDS. A focus on psychiatric rehabilitation in order to support recovery among persons with severe mental illness (SMI) has been given great attention in research and mental health policy, but less impact on clinical practice. Despite the potential impact of psychiatric rehabilitation on health and wellbeing, there is a lack of research regarding the model called the Psychiatric Rehabilitation Approach from Boston University (BPR).

AIM

The aim was to investigate the outcome of the BPR intervention regarding changes in life situation, use of healthcare services, quality of life, health, psychosocial functioning and empowerment.

METHODS

The study has a prospective longitudinal design and the setting was seven mental health services who worked with the BPR in the county of Halland in Sweden. In total, 71 clients completed the assessment at baseline and of these 49 completed the 2-year follow-up assessments.

RESULTS

The most significant finding was an improved psychosocial functioning at the follow-up assessment. Furthermore, 65% of the clients reported that they had mainly or almost completely achieved their self-formulated rehabilitation goals at the 2-year follow-up. There were significant differences with regard to health, empowerment, quality of life and psychosocial functioning for those who reported that they had mainly/completely had achieved their self-formulated rehabilitation goals compared to those who reported that they only had to a small extent or not at all reached their goals.

CONCLUSIONS

Our results indicate that the BPR approach has impact on clients' health, empowerment, quality of life and in particular concerning psychosocial functioning.

"I'm not sure that I can figure out how to do that": Pursuit of work among people with mental illnesses leaving jail

Restoring people with mental illnesses to community life after detention in jail is fraught with significant challenges. Many of these challenges mirror those faced by anyone else who has been detained in jail. Among these are the particular challenge of seeking gainful employment and financial support for day-to-day life. This challenge is intensified when individuals return from jail to impoverished communities where employment prospects are already limited for residents, and where either a criminal record or a mental illness creates still additional barriers to work. To understand these barriers more fully, this study examined the process of seeking employment among people with mental illnesses leaving jail. Seventeen individuals with a history of mental health problems and with recent jail incarcerations were recruited from either a community based employment program or a mental health service setting. The informants were interviewed using life history interview techniques. Results show that connections to the paid workforce were tenuous at best for these respondents, both before and after their jail detention. While psychiatric symptoms, addiction, and the lack of productive social connections were individual-level factors that affected employment, the most pernicious impediments were rooted in policy, community structures, stigma and other social and economic realities.. If employment interventions are to have any traction at all in these settings, interventionists need to dig for innovative ways to address these factors, which are not complications, but bedrock realities that undergird all else.

A prospective examination of the impact of a supported employment program and employment on health-related quality of life, handicap, and disability among Veterans with SCI

PURPOSES

To investigate impact of participation in a supported employment program and impact of employment itself on health-related quality of life (HRQOL), disability, and handicap among Veterans with spinal cord injury (SCI).

METHODS

We used a prospective, randomized, controlled, multi-site trial of supported employment (SE) versus treatment as usual (TAU) for vocational issues. Subjects were 157 Veterans with SCI who received either SE or TAU for vocational issues. Outcomes were examined in terms of type of vocational treatment received and whether competitive employment was obtained. Outcomes investigated were HRQOL as measured by the Veterans RAND 36-item health survey (VR-36), handicap as measured by the Craig Handicap Assessment and Reporting Technique (CHART), and disability as measured by the functional independence measure (FIM). Subjects were assessed at baseline and at 3, 6, 9, and 12 months.

RESULTS

There were no significant differences between Veterans who participated in SE compared to those who received TAU in study measures. Participants obtaining competitive employment demonstrated significantly higher scores on the Social Integration, Mobility, and Occupation dimensions of the CHART. There were no observed differences in VR-36 scores or FIM scores for those obtaining competitive employment.

CONCLUSION(S)

This study suggests that employment has a positive effect on an individual's ability to participate in social relationships, move about their home and community, and spend time in productive and usual roles. Inability to detect differences across other domains of handicap or any changes in HRQOL may have been due to several factors including level and intensity of employment, insufficient follow-up period, or measurement limitations.

Enhancing work-focused supports for people with severe mental illnesses in australia

Persons with severe mental illness (SMI) have reduced workforce participation, which leads to significant economic and social disadvantage. This theoretical review introduces the strategies that have been implemented to address this issue. These include Individual Placement and Support (IPS) services, the most widely researched form of supported employment, to which cognitive remediation has more recently been recognised in the USA, as an intervention to improve employment outcomes by addressing the cognitive impairments often experienced by people with SMI. The authors review the international literature and discuss specifically the Australian context. They suggest that Australia is in a prime position to engage clients in such a dual intervention, having had recent success with increasing access to supported employment programs and workforce reentry, through implementation of the Health Optimisation Program for Employment (HOPE). Such programs assist with gaining and maintaining employment. However, they do not address the cognitive issues that often prevent persons with SMI from effectively participating in work. Thus, optimising current interventions, with work-focused cognitive skills development is critical to enhancing employment rates that remain low for persons with SMI.

A pan-Canadian evaluation of supported employment programs dedicated to people with severe mental disorders

Supported employment (SE) is an evidence-based practice that helps people with severe mental disorders obtain competitive employment. The implementation of SE programs in different social contexts has led to adaptations of the SE components, therefore impacting the fidelity/quality of these services. The objective of this study was to assess the implementation of SE services in three Canadian provinces by assessing the fidelity and describing components of SE services using the Quality of Supported Employment Implementation Scale. About 23 SE programs participated in this study. Cluster analyses revealed six profiles of SE programs that varied from high to low level of fidelity with a stronger focus on a particular component, and reflected the reality of service delivery settings. Future investigations are warranted to evaluate relationships between the levels of implementation of SE components and work outcomes while considering individual characteristics of people registered in SE programs.

Review of critical factors related to employment after spinal cord injury: implications for research and vocational services

BACKGROUND/OBJECTIVE

Employment rates after spinal cord injury (SCI) vary widely because of discrepancies in studies' definition of employment and time of measurement. The objective of this study was to provide a comprehensive summary of the literature on employment rates, predictors of employment, and the benefits and barriers involved.

METHODS

A search using the terms spinal cord injury and employment in the databases PubMed, PsycINFO, and MEDLINE. The search included a review of published manuscripts from 1978 through 2008.

RESULTS

A total of 579 articles were found and reviewed to determine the presence of reported employment rates. Of these, 60 articles were found to include a report of employment rates for individuals with SCI. Results indicated that, in studies that examined paid employment, the average rate of any employment after SCI was approximately 35%.

CONCLUSIONS

Characteristics associated with employment after SCI include demographic variables, injury-related factors, employment history, psychosocial issues, and disability benefit status. It is recommended that researchers studying employment after SCI use common outcome measures such as competitive employment rates, duration of employment, and job tenure. Empirical evidence is lacking in regard to the most effective methods of vocational rehabilitation among this population. Evidence-based supported employment practices seem to be the most applicable model for assisting persons with SCI in restoring meaningful employment. Controlled studies are needed to test this assumption.

What's in it for me? The utility of psychiatric treatments from the perspective of the person in recovery

The aim of this contribution is to explore how different treatments are experienced from the perspective of individuals with mental illnesses. We used data drawn from qualitative, narrative interviews. When asked to discuss their lives, people rarely discuss their psychiatric treatment. When asked about treatment, they describe hospitalization and medication but not outpatient care. What is described as most helpful are relationships with others, especially in 24-hour centers, clubhouses, and user-run organizations; places where they report feeling that they are accepted, understood, and cared about. Also important are experiences of "giving back" to others and employment as ways of increasing participants' sense of self-worth and value. Participants also indicated the importance of medication, but described protracted processes of having to find the right prescriber, the right medication, at the right dosage, and taking the medication long enough to derive its benefits. For others, symptoms were described as being an integral part of who they were and not something they wanted to eliminate. Traditional treatments (e.g., medication), if given by a practitioner who understands the person and is willing to try to find the right medication and dosage, may serve as a foundation for instrumental experiences of being accepted, understood, valued, and being able to give back to others.

The Relative Efficacy of Psychotherapy: Reassessing the Methods-Based Paradigm

Because the efficacy of behavioral interventions is central to applied psychology, the relative merits of competing approaches to an intervention are important. Many comparative studies examine the differential outcomes of alternative methods of psychotherapy. This paper addresses the issue of impact differences among rival intervention methods by focusing on treatment outcome research that emphasizes the relative (or comparative) efficacy of different psychotherapies. The paper has 4 components. First, it explores the concept of relative efficacy. Second, it reviews the extensive evidence on relative efficacy, which is generally consistent with the null hypothesis. Third, it offers a 3-part explanation of the negative evidence on relative efficacy: (a) a statistical argument about how relative efficacy is bound by a modest upper limit; (b) a research design argument about how relative efficacy studies are confounded by multiple factors, which make it difficult to demonstrate differences in treatment effects; and (c) a theoretical argument about how therapists’ contributions to treatment outcomes depend more on their clinical abilities than the therapy methods they implement. The final section of the paper outlines questions for future research.

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.

Views and experiences of employment among people with psychosis: a qualitative descriptive study

BACKGROUND

Work is important for mental health but we are only just beginning to understand why so few people with psychosis in the UK work.

AIMS

To identify the opinions of a purposive sample of patients with psychosis on themes related to employment.

METHOD

A thematic analysis of 15 semi-structured interviews with people with schizophrenia or bipolar affective disorder.

RESULTS

Participants identified a range of advantages to working but also expressed substantial doubts. Symptoms, medication and potential damage to health are the problems that people believe affect their ability to work. Most people would not tell their employers about their illness because they feared discrimination during the selection process, but believed it could help their chances of retaining a job if employers knew. A number reported a lack of encouragement to work from mental health professionals and not enough helpful employment services.

CONCLUSIONS

Although most people want to work, given the pressures they face some may choose not to. Barriers that people face are both internal and external and these interact.

Employment restrictions among persons with ICD-10 anxiety disorders: characteristics from a population survey

Disability, employment, and employment restrictions among persons with ICD-10 anxiety disorders were investigated at a population level in comparison to persons without disability or long-term health conditions. Data were provided by the Australian Bureau of Statistics (ABS) collected in a 1998 national survey. Multistage sampling obtained a probability sample of 37,580 individuals in the household component of the survey. Trained lay interviewers using ICD-10 computer-assisted interviews identified household residents with anxiety disorders. Details of employment restrictions are reported and discussed. The four most commonly reported restrictions were: restricted in the type of job (24.0%); need for a support person (23.3%); difficulty changing jobs (18.6%); and restricted in the number of hours (15.4%). The nature and extent of employment restrictions characterizing persons with anxiety disorders indicates a need for strengthened disability and health condition screening at application for Government income support and at gateways to public funded vocational assistance.

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.

Productive Work and Employment for Persons With Traumatic Brain Injury

This article describes return to work outcomes for individuals with traumatic brain injury (TBI) through a selective review of the published literature and an examination of TBI labor force participation from the Rehabilitation Services Administration 91l and the Social Security Administration Benefits Planning, Assistance and Outreach databases. Implications and recommendations to further our understanding about the different parts of the work outcome profile of individuals with TBI are offered.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge.

METHOD

A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Program evaluation from an ecological perspective: supported employment services for persons with serious psychiatric disabilities

Results of large-scale program evaluations supplement other kinds of evidence regarding interventions for psychiatric disabilities. This paper describes an ongoing 11-year effort to evaluate supported employment services provided to persons with serious psychiatric disabilities by community mental health centers in one Midwestern state. Using an ecological perspective, the evaluation emphasizes multiple kinds of products and the careful development and maintenance of stakeholder relationships. Data from over 4600 individuals in supported employment programs demonstrate that services are effective and efficient, that these employees and employers are satisfied, and that stable employment may sharply reduce the overall costs of mental health care.

Delineating disability, labour force participation and employment restrictions among persons with psychosis

OBJECTIVE

To delineate at a population level: activity restrictions, labour market participation, educational attainment, employment restrictions and employment characteristics of persons with psychosis compared with healthy non-disabled persons.

METHOD

Confidentialized data files were provided by the Australian Bureau of Statistics. The data were collected in a national survey titled "Survey of Disability, Ageing and Carers, Australia 1998". Multi-stage sampling strategies obtained a probability sample of 42 664 individuals. Trained interviewers using ICD-10 computer-assisted interviews identified household residents with psychosis.

RESULTS

Among householders with psychosis aged 15-64 years, 75.2% were non-participants in the labour market, 21.1% were employed and 3.7% were looking for work. Completing school years 10 and 11, and vocational training, appeared to offer an employment advantage.

CONCLUSION

Persons with psychotic disorders have low rates of labour force participation and may benefit from greater participation in educational and vocational services. Implications for policy development are discussed.

‘How Do You Pay Your Rent?’ Social Policies And The President’s Mental Health Commission

Mental health policy involves broad social policies related to housing, education, work disability and rehabilitation, welfare, and criminal justice. The modern era of community care has moved patients, clinicians, and policymakers from closed institutions into the mainstream of society and its health and human service systems. The importance of knowing about the broad array of human services and their policies is reflected in the deliberations and policy recommendations of the President's New Freedom Commission on Mental Health. It is hoped that these recommendations will provide a roadmap for further change to enable people affected by severe mental illness "to live, learn, work, and participate fully in their communities."

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.

Research on evidence-based practices: future directions in an era of recovery

Many mental health systems are trying to promote the adoption of what has come to be known as evidence-based practices while incorporating a recovery vision into the services they provide. Unfortunately, much of the existing, published, research on evidence-based practices was conceived without an understanding of the recovery vision and/or implemented prior to the emergence of the recovery vision. As result, evidence-based practice research that has been published to date is deficient in speaking to a system being built on a recovery philosophy and mission; these deficiencies are detailed, and suggestions are advanced for new directions in evidence-based practice research.

Computer experience and training interests of psychosocial rehabilitation program participants

The authors report data from the first large-scale attempt (N = 262) to examine computer use among people with a psychiatric disability and interest in computer training. A large number of respondents have used a computer (71%) for a number of activities and approximately 56% were "very" or "quite" interested in computer training. Previous work experience, interest in a job involving computers, and a belief that training would be helpful in obtaining such a job were good predictors of interest in computer training. The results suggest that there is sufficient interest in computer training to justify the development of supported education in this area.

Beyond components: using fidelity scales to measure and assure choice in program implementation and quality assurance

Fidelity scales have become an accepted part of intervention research. Initially, fidelity scales focused on critical components of an intervention. In this paper we argue that the next generation of fidelity scales should include key process variables such as choice. Since choice is an essential element in all empowerment and recovery driven intervention models, a fidelity scale for an enhanced version of the Individual Placement and Support (IPS) supported employment model that incorporates choice as a fundamental component was developed as part of a SAMHSA community action grant. The process for developing the choice component and the dimensions measured are also described.

Psychosocial treatments for schizophrenia

As indicated in recent treatment guidelines, psychosocial treatments play a critical role in the rehabilitation of schizophrenia patients. During the past few years, novel psychosocial treatments have emerged expanding the scope of successful outcomes and designed to address the specific deficits inherent in schizophrenia. This paper provides a brief description and evaluate the efficacy of five new emerging psychosocial treatments for schizophrenia. There is strong evidence for the efficacy of supported employment programs and family therapy, especially those involving multiple family interactions. Although schizophrenia patients appear to derive benefit from cognitive behavioral therapy, no evidence supports it superiority over that of other individual psychotherapies. The trials of cognitive remediation to date have been largely unsuccessful, although new innovative approaches continue to be tested. Finally, substance use treatment specifically designed to address the deficits in schizophrenia patients have been formulated, which are supported by optimistic pilot data and awaiting the completion of on-going clinical trials.