Additional interventions to enhance the effectiveness of individual placement and support: a rapid evidence assessment

The effects of supported employment interventions in populations of people with conditions other than severe mental health: a systematic review

AIM

To assess the effectiveness of supported employment interventions for improving competitive employment in populations of people with conditions other than only severe mental illness.

BACKGROUND

Supported employment interventions have been extensively tested in severe mental illness populations. These approaches may be beneficial outside of these populations.

METHODS

We searched PubMed, Embase, CINAHL, PsycInfo, Web of Science, Scopus, JSTOR, PEDro, OTSeeker, and NIOSHTIC for trials including unemployed people with any condition and including severe mental illness if combined with other co-morbidities or other specific circumstances (e.g., homelessness). We excluded trials where inclusion was based on severe mental illness alone. Two reviewers independently assessed risk of bias (RoB v2.0) and four reviewers extracted data. We assessed rates of competitive employment as compared to traditional vocational rehabilitation or waiting list/services as usual.

FINDINGS

Ten randomised controlled trials (913 participants) were included. Supported employment was more effective than control interventions for improving competitive employment in seven trials: in people with affective disorders [risk ratio (RR) 10.61 (1.49, 75.38)]; mental disorders and justice involvement [RR 4.44 (1.36,14.46)]; veterans with posttraumatic stress disorder (PTSD) [RR 2.73 (1.64, 4.54)]; formerly incarcerated veterans [RR 2.17 (1.09, 4.33)]; people receiving methadone treatment [RR 11.5 (1.62, 81.8)]; veterans with spinal cord injury at 12 months [RR 2.46 (1.16, 5.22)] and at 24 months [RR 2.81 (1.98, 7.37)]; and young people not in employment, education, or training [RR 5.90 (1.91-18.19)]. Three trials did not show significant benefits from supported employment: populations of workers with musculoskeletal injuries [RR 1.38 (1.00, 1.89)]; substance abuse [RR 1.85 (0.65, 5.41)]; and formerly homeless people with mental illness [RR 1.55 (0.76, 3.15)]. Supported employment interventions may be beneficial to people from more diverse populations than those with severe mental illness alone. Defining competitive employment and increasing (and standardising) measurement of non-vocational outcomes may help to improve research in this area.

Employment programmes for schizophrenia and other severe mental illness in psychosocial rehabilitation: a systematic review

Introduction

Employment programmes for people with mental illness vary widely in range, but nonetheless all share the same objectives of restoring or initiating vocational roles to promote recovery in psychosocial rehabilitation. The current interventions available usually focus on the specific vocational outcomes of the intervention rather than focusing holistically on the client’s needs.

Method

This review aimed to examine the effectiveness of intervention programmes and determine the best intervention for schizophrenia and other severe mental illness, considering both vocational and non-vocational outcomes. Searching five databases – CINAHL, Medline via Ovid, Scopus, OT Seeker and Web of Science – a total of 3108 studies was identified; 24 met the selection criteria and were reviewed. Interventions were categorised into five major programmes of supported employment, integrated supported employment, vocational rehabilitation, cognitive intervention and virtual reality-based vocational training.

Results

Integrated supported employment was found to be the most effective approach for a vocational outcome. However, evidence concerning non-vocational outcomes of employment programmes and the use of cognitive training remains unclear.

Conclusion

Clinicians are advised to consider the needs and preferences of the client before selecting the best intervention programme. More research is needed to determine the applicability and the efficacy of intervention programmes.

Vocational Service Models and Approaches to Improve Job Tenure of People With Severe and Enduring Mental Illness: A Narrative Review

Employment is a valued occupation that offers a sense of meaning, identity, and belonging. For people with severe and enduring mental illness, employment has also been associated with personal recovery and decreased use of mental health services. However, this population continues to be underrepresented in the labor market. Sustainable employment is often challenging for people with severe and enduring mental illness, due to a combination of personal, organizational and systemic issues. While Individual Placement and Support is an evidence-based model of employment support known to improve job attainment for people with mental illness, job retention and sustained workforce participation continue to be challenges. This narrative literature review was undertaken to address the question: "What vocational service models and approaches improve job tenure for this population?" CinAHL, Medline, Embase, PsycINFO, and Cochrane Library were searched for the period 2005-2020, using key terms and subject headings, including "severe mental illness," "psychiatric disabilit^*," "job tenure," and "job retention." Several adjunct interventions may enhance job retention, including skills training, cognitive interventions, psychological interventions, and supported education, while social firms offer a different approach focused on creating new, sustainable job opportunities. Peer support and support from family and friends also appear to be important, and emerging evidence suggests that employment specialist practices, technology, self-management, and workplace accommodations may each also influence job tenure. Service providers could make more use of these non-clinical vocational approaches to improve employment retention for people with severe and enduring mental illness.

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.

Pushing through: Mental health consumers' experiences of an individual placement and support employment programme

Introduction

Individual placement and support is recognized as current best practice vocational rehabilitation for people living with a severe mental illness. This study aimed to provide insight into the consumer perspective of factors that impact the success of an individual placement and support programme in Australia.

Method

A qualitative study was conducted using semi-structured interviews with five participants. Participants were diagnosed with a severe mental illness and were engaged with an individual placement supported employment programme in one area health service in New South Wales, Australia. Data analysis was conducted using grounded theory methods.

Results

Analysis revealed the core category of pushing through, a three-step process that involved experiencing discomfort, learning to adapt, and getting into a groove. Pushing through described the participants' direct experience of individual placement and support, as well as their management of their health and ability to cope with everyday practicalities and relationships while engaged in the programme.

Conclusions

The participants in this study described their experiences of being involved in an individual placement and support programme as being characterized by a process of pushing through. The participants' actions and experiences at each stage of this process provide cues for more tailored support within individual placement and support to meet changing needs.

A scoping review of rapid review methods

BACKGROUND

Rapid reviews are a form of knowledge synthesis in which components of the systematic review process are simplified or omitted to produce information in a timely manner. Although numerous centers are conducting rapid reviews internationally, few studies have examined the methodological characteristics of rapid reviews. We aimed to examine articles, books, and reports that evaluated, compared, used or described rapid reviews or methods through a scoping review.

METHODS

MEDLINE, EMBASE, the Cochrane Library, internet websites of rapid review producers, and reference lists were searched to identify articles for inclusion. Two reviewers independently screened literature search results and abstracted data from included studies. Descriptive analysis was conducted.

RESULTS

We included 100 articles plus one companion report that were published between 1997 and 2013. The studies were categorized as 84 application papers, seven development papers, six impact papers, and four comparison papers (one was included in two categories). The rapid reviews were conducted between 1 and 12 months, predominantly in Europe (58 %) and North America (20 %). The included studies failed to report 6 % to 73 % of the specific systematic review steps examined. Fifty unique rapid review methods were identified; 16 methods occurred more than once. Streamlined methods that were used in the 82 rapid reviews included limiting the literature search to published literature (24 %) or one database (2 %), limiting inclusion criteria by date (68 %) or language (49 %), having one person screen and another verify or screen excluded studies (6 %), having one person abstract data and another verify (23 %), not conducting risk of bias/quality appraisal (7 %) or having only one reviewer conduct the quality appraisal (7 %), and presenting results as a narrative summary (78 %). Four case studies were identified that compared the results of rapid reviews to systematic reviews. Three studies found that the conclusions between rapid reviews and systematic reviews were congruent.

CONCLUSIONS

Numerous rapid review approaches were identified and few were used consistently in the literature. Poor quality of reporting was observed. A prospective study comparing the results from rapid reviews to those obtained through systematic reviews is warranted.