Datapoints: labor force participation by persons with mental illness

The effects of supported housing for individuals with mental disorders

Societies face the challenge of providing appropriate arrangements for individuals who need living support due to their mental disorders. We estimate the effects of eligibility to the Dutch supported housing program (Beschermd Wonen), which offers a structured living environment in the community as an intermediate alternative to independent housing and inpatient care. For this, we use exogenous variation in eligibility based on conditionally random assignment of applications to assessors, and the universe of applications to supported housing in the Netherlands, linked to rich administrative data. Supported housing eligibility increases the probability of moving into supported housing and decreases the use of home care, resulting in higher total care expenditures. This increase is primarily due to the costs of supported housing, but potentially also higher consumption of curative mental health care. Supported housing eligibility reduces the total personal income and income from work. Findings do also suggest lower participation in the labor market by the individuals granted eligibility, but the labor participation of their parents increases in the long-run. Our study highlights the trade-offs of access to supported housing for those at the margin of eligibility, informing the design of long-term mental health care systems around the world.

Shedding Light on the Main Characteristics and Perspectives of Romanian Medicinal Oxygen Market

Medicinal oxygen plays an important role in healthcare, being essential for the existence and maintenance of the health of millions of people, who depend on medicinal oxygen every day, both in hospitals and at home. Medicinal oxygen is the primary treatment administrated to the majority of patients suffering from respiratory problems and low levels of oxygen in the blood, and in the context of the actual health crisis caused by the new COVID-19, the challenge is represented by increasing the supply of medicinal oxygen while reducing cost so that it is accessible where it is needed most, free at the point of use. It will take increased investment and commitment to put oxygen at the center of strategies for universal health coverage. In this context, it becomes essential to investigate the main characteristics of the Romanian market of medicinal oxygen, highlighting top key players, market development, key driving factors, types of products, market perspectives as well as shedding light on the segmentation of this particular market based on considerations regarding regions, hospital competence class and hospital specialization. Also, the research aims to explore the regional disparities in the decision of using O93%medicinal oxygen, revealing the main factors related to the usage of this type of product among Romanian public hospitals. The research relies on the first quantitative survey regarding medicinal oxygen usage among 121 public hospital units from a total of 461 public hospitals in 2018, which meet the specific requirements: includes the entire population according to the list published on the website of the Ministry of Health, is the most recent data and does not show repetition. The sampling was of probabilistic stage-type stratification, with the following sampling layers: hospital county distribution, hospital competence class officially assigned by the Ministry of Health and also area of residence (urban/rural). In order to analyze the main characteristics of the Romanian oxygen market, the following methods have been used: analysis of variance (ANOVA) together with Kruskal-Wallis, Pearson correlation coefficient as well as Goodman and Kruskal gamma, Kendall's tau-b and Cramer's V, as well as multilevel logistic regression analysis using hierarchical data (hospitals grouped in regions). The Romanian market of medicinal oxygen is rather an oligopoly market characterized by the existence of a small number of producers and two types of products currently used for the same medical purpose and having a substitutable character: medicinal oxygen O99.5%, and medicinal oxygen O93%. An overwhelming proportion of public hospitals agree that both types of medicinal oxygen serve the same therapeutic purpose. The Romanian market of medicinal oxygen highlighted a significant segmentation on considerations based on regions, hospital competence class and hospital specialization. Regarding the main perspectives, the Romanian market of medical oxygen keeps the growth trend registered globally, with development perspectives for competitors. Exploring the regional disparities in the decision of using O93 medicinal oxygen, the empirical results acknowledged the important role of unitary price, hospital capacity and the relevance of this product seen as a medicine. Medicinal oxygen is vital in sustaining life, proving its utility mainly in the context of the actual health crisis. In this context, the Romanian local market exhibits prospects for further development, being characterized by an important segmentation depending on regions, hospital competence class and hospital specialization.

The Deployment Trauma Phenotype and Employment Status in Veterans of the Wars in Iraq and Afghanistan

OBJECTIVES

To determine the prevalence of comorbid mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), and depression, termed the deployment trauma phenotype (DTP), and its constituent diagnoses' impact on unemployment status in a national cohort of veterans.

SETTING

Retrospective analysis of the comprehensive TBI evaluation, a Veterans Affairs-wide protocol for assessing TBI, employment status, and psychiatric impressions.

PARTICIPANTS

The final data set consisted of 48 821 veterans.

MAIN OUTCOMES AND MEASURES

Frequency of mTBI, PTSD, and depression in isolation and combinations and their association with unemployment status.

RESULTS

Age- and education-adjusted risk ratios (RRs) showed that the mTBI-only group was the least likely to be unemployed, RR = 0.65 (0.59-0.71). By contrast, the greatest likelihood of unemployment was associated with membership in the DTP group, RR = 1.45 (1.36-1.56), and the comorbid PTSD and depression group, RR = 1.39 (1.27-1.52). Furthermore, the DTP was nearly 3 times more prevalent (16.4%) in this sample compared with comorbid PTSD and depression (5.7%), indicating that the DTP conveys risk for unemployment to a significantly greater number of individuals.

CONCLUSIONS AND RELEVANCE

The comorbid and interactive conditions of PTSD, depression, and mTBI, rather than mTBI in isolation, were linked to significant risk for unemployment in this veteran cohort. These findings suggest that multifaceted assessments and interventions to improve postdeployment reintegration are needed.

Conceptualizing Disability

Empirical analysis of disability identity has great potential to improve understanding of the role of disability status in identity politics. Despite ongoing discussions of the relevance of disability identity in the disability rights movement and political actions related to disability, there is limited research into its nature and its underlying psychological, social, and political constructs. This may in part be caused by the lack of a theoretical model to guide analysis. This article proposes a conceptual framework to guide empirical analysis of disability identity, outlining six potential construct domains and their sub-domains based on a review of scholarly discussions and empirical research.

Previous anxiety and depression as risk factors for early labour force exit

BACKGROUND

Individuals with a history of mental illness have lower earnings than individuals without. A possible reason is that those with prior anxiety or depression may be more likely to exit the labour force prior to retirement age, but evidence has been mixed and limited. Our objective was to compare risk of early labour force exit between employed adults with a history of depression or anxiety versus those without, separately for men and women.

METHODS

We used data from the Baltimore Epidemiological Catchment Area Follow-up Cohort, which collected baseline data in 1981 and follow-up data 1993-1996 and 2004-2005. Cox proportional hazards models estimated the relative risk of labour force exit comparing those with versus without prior history of anxiety or depressive disorders.

RESULTS

Women with prior anxiety or depression are at 37% increased risk of dropping out of the labour force as compared to women without, controlling for age, socioeconomic status, race and marital status (HR: 1.37, 95% CI 1.04 to 1.79). Men with prior anxiety or depression are 18% more likely to subsequently drop out of the labour force as compared to men without, controlling for the above confounders as well as veteran status, but this association is not statistically significant (HR: 1.18, 95% CI 0.72 to 1.27).

CONCLUSIONS

Prior anxiety or depression increases risk of early labour force exit for women. These findings may help explain previously reported lower earnings among female individuals with a history of mental illness and highlight the importance of considering anxiety and depressive disorders in policies supporting labour force participation.

Using the Knowledge Base of Health Services Research to Redefine Health Care Systems

This Perspective discusses 12 key facts derived from 50 years of health services research and argues that this knowledge base can stimulate innovative thinking about how to make health care systems safer, more efficient, more cost effective, and more patient centered, even as they respond to the needs of diverse communities.

Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK

BACKGROUND

Prevalence rates of mental disorders are frequently increased in long-settled war refugees. However, substantial variation in prevalence rates across studies and countries remain unexplained.

AIMS

To test whether the same sociodemographic characteristics, war experiences and post-migration stressors are associated with mental disorders in similar refugee groups resettled in different countries.

METHOD

Mental disorders were assessed in war-affected refugees from the former Yugoslavia in Germany, Italy and the UK. Sociodemographic, war-related and post-migration characteristics were tested for their association with different disorders.

RESULTS

A total of 854 war refugees were assessed (≥ 255 per country). Prevalence rates of mental disorders varied substantially across countries. A lower level of education, more traumatic experiences during and after the war, more migration-related stress, a temporary residence permit and not feeling accepted were independently associated with higher rates of mood and anxiety disorders. Mood disorders were also associated with older age, female gender and being unemployed, and anxiety disorders with the absence of combat experience. Higher rates of post-traumatic stress disorder (PTSD) were associated with older age, a lower level of education, more traumatic experiences during and after the war, absence of combat experience, more migration-related stress, and a temporary residence permit. Only younger age, male gender and not living with a partner were associated with substance use disorders. The associations did not differ significantly across the countries. War-related factors explained more variance in rates of PTSD, and post-migration factors in the rates of mood, anxiety and substance use disorder.

CONCLUSIONS

Sociodemographic characteristics, war experiences and post-migration stressors are independently associated with mental disorders in long-settled war refugees. The risk factors vary for different disorders, but are consistent across host countries for the same disorders.

Evidence of the effectiveness of a specialist vocational intervention following first episode psychosis: a naturalistic prospective cohort study

BACKGROUND

Employment rates among people with severe mental illness are low and work has beneficial effects on mental health. There is now good evidence of the effectiveness of a specialist vocational intervention (supported employment) in people with schizophrenia. However, the potential benefits of modifying this model for use in first episode psychosis cohorts remain relatively untested.

METHODS

The aim of our study was to evaluate the effectiveness of a specialist vocational intervention in aiding vocational recovery following the onset of first episode psychosis. In a naturalistic prospective cohort study, 114 first episode psychosis service users were followed up during 12 months of engagement with an early intervention service; 44 resident in an area where a vocational intervention was available and 70 in an area where it was not.

RESULTS

The main finding in our study was that having access to the specialist vocational intervention was a statistically significant independent predictor of vocational recovery during 12 months of follow-up (after adjusting for confounders). Service users who had access to the intervention had odds of achieving vocational recovery 3.53 times greater than those who did not (OR = 3.53, 95% CI = 1.25-10.00).

CONCLUSION

This study provides further preliminary evidence of the effectiveness of a specialist vocational intervention following first episode psychosis. This is an important outcome from the perspective of service users and clinicians alike (as well as having wider societal value). Other important predictors of vocational recovery cannot be modified by the time a first episode psychosis emerges.

Gainful employment reduces stigma toward people recovering from schizophrenia

Stigma impedes the social integration of persons recovering from psychiatric disability, especially those with criminal histories. Little is known about factors that lessen this stigma. Four hundred and four adults listened to one of four vignettes describing a 25-year-old male with schizophrenia and responded to a standard set of items measuring social distance. The individual who was gainfully employed (vs. unemployed), or who had a prior misdemeanor (vs. felony) criminal offense, elicited significantly less stigma. Employment may destigmatize a person coping with both psychiatric disability and a criminal record. Mental health services should encourage paid employment and other paths to community integration.

Physical wellness and employment status among adults with serious mental illness

This study examined whether concurrent medical status contributes to employment outcomes among those with psychiatric disabilities. Thirty-five percent (n = 70) of the 200 participants reported being currently employed. Sixty-three percent (n = 127) reported one or more co-occurring medical conditions; thirty-six percent (n = 71) reported two or more, and twenty-one percent (n = 41) reported three or more co-occurring medical conditions. Individuals with higher self-ratings of physical health functioning were more likely to be employed. Neither the number of co-occurring medical conditions nor any specific medical condition was related to employment status. Recommendations to enhance existing models of supported employment programs with physical health and wellness promotion components are offered.

Mental illness stigma in the Israeli context: deliberations and suggestions

BACKGROUND

In this paper we deliberate mental illness stigma in the Israeli context and suggest ways to reduce it, emphasizing the community's role in the rehabilitation of persons with mental illness.

MATERIAL

A literature review of Israeli and international literature of mental illness stigma.

DISCUSSION

Community mental health, in addition to its traditional focus on developing community-based services, should focus also on community-based interventions such as the delivery of anti-stigma interventions.

CONCLUSIONS

Providing individualized rehabilitation services in the community while addressing stigma-induced social barriers may create a better recovery ground for Israelis with mental illness.

Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first-episode psychosis: employing cautious optimism

OBJECTIVE

While there are now effective interventions for the symptoms of psychosis and schizophrenia, treatment for the functional domains of these illnesses has received less attention. A key area affected by psychotic illness is vocational functioning. This area is currently of interest to clinicians, policy-makers, politicians and patients. This paper reviews several forms of vocational intervention practised over the years and highlights the issues around adopting an early intervention approach towards vocational rehabilitation. The paper has four aims: first, to consider some of the consequences of unemployment for those with psychotic illnesses; second, to review methods that have been used to address unemployment among the mentally ill; third, to highlight the importance of vocational development at a developmentally appropriate life stage; and finally, to consider the application of evidence-based vocational rehabilitation to those with first-episode psychosis.

METHOD

An initial broad literature search was conducted using PsychInfo and Medline databases. Further narrower searches were conducted electronically where indicated. Finally, some articles were sourced through manual searches of relevant journals.

RESULTS

People with psychotic illness have a high rate of unemployment at the outset of their illness which tends to worsen over time. This is complicated by systemic factors such as the structure of the welfare system. Approaches for assisting people with mental illness return to work have evolved over the history of psychiatry. There now exists an evidence-based method of intervention. To date this has not been trialled in a systematic way with people in the early stages of psychotic illness.

CONCLUSIONS

There is cause for cautious optimism in the vocational recovery of people with psychotic illnesses. Limited evidence exists that the individual placement and support approach developed with chronic populations is very effective in early episode patients. There are a number of challenges to implementing vocational intervention in first-episode psychosis. Overcoming these obstacles will require the cooperation of clinicians, those with illness, policy-makers and politicians. However, the potential economic, health and personal gains, as well as current and future research should provide sufficient motivation to overcome these barriers.

Employment and mental health service utilization in Washington State

This study examined employment among individuals utilizing publicly funded mental health services in Washington State during a 2-year period through the analysis of archival administrative data. The mean income found in this study was higher than that reported in the supported employment literature. This difference likely reflects the inclusion of individuals with less severe mental illness and ongoing employment who are typically excluded from studies of supported employment. Individuals in this study were employed in all industrial sectors in a distribution similar to the general population, although somewhat over-represented in service industries. Employment rates varied from 15% to 21% over a 3-year period and did not appear to increase after treatment. Employment rates tended to decline after the receipt of public support. Among individuals who lost employment, service utilization was found to increase prior to the loss of employment. Policy implications are discussed.

Demographic characteristics and employment among people with severe mental illness in a multisite study

People with psychiatric disabilities experience disproportionately high rates of unemployment. As research evidence is mounting regarding effective vocational programs, interest is growing in identifying subgroup variations. Data from a multisite research and demonstration program were analyzed to identify demographic characteristics associated with employment outcomes, after adjusting for the effects of program, services, and study site. Longitudinal analyses found that people with more recent work history, younger age, and higher education were more likely to achieve competitive employment and to work more hours per month, while race and gender effects varied by employment outcome. Results provide strong evidence of demographic subgroup variation and need.

Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

Small business employers' views on hiring individuals with mental illness

This study investigated the beliefs of small business employers regarding hiring individuals with mental illness. Fifty-eight participants completed mail-in questionnaires concerning beliefs and willingness to hire persons with mental illness. Employers were most concerned regarding the social and emotional skills of individuals with mental illness. Those employers who reported positive beliefs, had positive interactions with individuals with mental illness, or operated in public/social services, stated greater willingness to hire a person with mental illness. Methods to decrease stigma are discussed.

Employment outcomes in Massachusetts Clubhouses

Employment outcomes of individuals participating in 17 Massachusetts Clubhouses certified by the International Center for Clubhouse Development were examined through an annual survey. Major components of employment programs in contemporary clubhouses are identified and individual employment outcomes are described. Within contemporary practice in ICCD clubhouses in this sample, clubhouses provided a three-pronged approach to employment. Between 1998-2001, 1702 individuals worked in 2714 separate job placements, employed in Transitional (TE), Supported (SE), and Independent Employment (IE). Forty percent of members with more than one job (N = 385) participated in at least one TE. Individuals with longer memberships tended to work longer and had higher job earnings.

GAMIAN-Europe/BEAM survey II: cross-national analysis of unemployment, family history, treatment satisfaction and impact of the bipolar disorder on life style

OBJECTIVES

In a previous report, we described the global analysis of the 'GAMIAN-Europe/BEAM survey' carried out in order to gain a better understanding of what is like to live with a bipolar disorder (BD). We report here on a cross-national analysis of unemployment, family history, side effects, treatment satisfaction and the impact the disorder had and has on patients' perception of life style and quality of life.

METHODS

The methodology has been described in the previous report [Morselli PL and Elgie R, J Bipolar Disord (2003) 5, 265]. The analysis was carried out on the data derived from eight countries (France, Italy, Holland, Portugal, Russia, Scotland, Spain and Sweden) on a total of 968 respondents. Data from three other countries were not evaluated because of the low number of respondents.

RESULTS

The data suggest that the problems and difficulties encountered by bipolar patients are similar throughout the various European countries, regardless of the political, social or cultural settings. The disease leads to a very high rate of unemployment and has a significant negative impact on the perception of the quality of life, both within and outside the family. Data also indicate a high level of family history. Considering the many variables analysed in the different nations, trans-national differences are often present for a given specific issue. However, with regard to the core issues, no significantly different patterns appear to emerge for any given nation. The current attitude towards the disorder displays an increased insight about the condition on the part of patients. There is also a definite trend towards an improvement in their perception of the disease with an evident minor or reduced impact of the disorder on the life-style of patients.

CONCLUSIONS

Globally, the data indicate that in all participating countries there has been, in recent years, a consistent improvement in the 'perceived quality of life' of the 'informed patient' with an increased insight into the condition and an enhanced rate of compliance. Nevertheless, a lot still needs to be done to markedly improve the 'social functioning' and the 'social integration' of those who suffer from BD. The data reported underline some of the issues that still represent a truly onerous burden for BD patients in whichever European country they may live.

Personal adjustment and substance abuse problems in a longitudinal study of TANF recipients and the potential need for treatment

OBJECTIVE

This study assessed the need over time for treatment of personal adjustment and substance abuse problems among chronic drug using and other recipients of Temporary Assistance for Needy Families (TANF).

METHODS

Participants were administered the personal adjustment problems and substance abuse problems scales contained in the Multidimensional Addictions and Personality Profile (MAPP) at intake, one-year, and two-year interviews.

RESULTS

Most participants who were not chronic users had total scale scores that would indicate no recommended referral or a referral to outpatient treatment. Approximately one-third of chronic users had scores that would indicate referral to inpatient treatment. Many chronic users had comorbid conditions but reported receiving no psychological or substance abuse treatment.

CONCLUSIONS

Many TANF recipients may be experiencing coexisting personal and substance abuse related problems that are going untreated.

Psychosocial functioning on the Independent Living Skills Survey in older outpatients with schizophrenia

Improving real-life community functioning in patients with severe mental illness has been an important recent focus of treatment outcome research. Few studies, however, have examined psychosocial functioning in older psychotic patients. The Independent Living Skills Survey (ILSS) is a measure of the basic functional living skills of individuals with severe and persistent mental illness. The self-report version of the ILSS was administered to 57 middle-aged and older community dwelling outpatients with schizophrenia and 40 age-comparable nonpsychiatric participants. Regardless of whether patients resided in assisted living or independent settings, they showed significantly impaired functioning on a majority of the functional areas assessed by the ILSS. No consistent relationship was found between symptom severity and functioning. With certain modifications, the ILSS appears to be a sensitive indicator of functional impairment in this older sample of community-dwelling outpatients with schizophrenia. Information provided by the instrument might be useful to guide rehabilitation efforts and measure functioning changes in response to treatment in this population.

Longitudinal Perspective: Adverse Childhood Events, Substance Use, and Labor Force Participation Among Homeless Adults

OBJECTIVES

We examined the long-term effects of adverse childhood events on adulthood substance use, social service utilization, and subsequent labor force participation.

METHODS

A county-wide probability sample of 397 homeless adults was interviewed three times in a 15-month period. By using a path model, literature-based relationships between adverse childhood events and labor force participation with the mediating effects of adulthood substance use and service use were tested.

RESULTS

Adverse childhood events were precursors to adulthood alcohol and drug use. Consistent substance use was negatively associated with long-term labor force participation and with social service utilization among homeless adults. Adverse events at childhood, however, were positively associated with service use.

CONCLUSIONS

Adverse childhood events may contribute to negative adulthood consequences, including consistent substance use and reduced labor force participation. Agencies that are involved in halting the abuse or neglect also should participate in more preventive interventions. Job-related assistance is particularly important to facilitate employment and labor force participation among homeless adults.

Perceived employment barriers and their relation to workforce-entry intent among people with HIV/AIDS

As treatments have improved health and quality of life for people with HIV/AIDS, many have contemplated workforce reentry. Workforce reentry rarely occurs among people with illness-related disability. The authors mailed a survey that included workforce-entry-related concerns to 1,991 HIV/AIDS clients. Factor analysis extracted 6 areas of concern (benefits loss, work-related health, job skills, discrimination, personal health care, workplace accommodation). Levels of concern generally increased with HIV acuity level and time since last worked. Work-related health concerns predicted consideration of workforce entry, and work-related health concerns and benefits-loss concerns predicted estimated time to return to work. Findings provide quantitative validation of intuitive categories of workforce-entry concerns among people with HIV/AIDS and suggest that concerns may shift with progress toward workforce entry.

Substance use and labor force participation among homeless adults

OBJECTIVES

We measured the proportion of homeless adults in the labor force and examined the impact of substance use on labor force participation.

METHODS

A county-wide probability sample of 397 homeless adults was interviewed three times in a 15-month period.

RESULTS

Almost 80% of homeless adults were employed or looking for work at one point in time; however, only 47.7% remained in the labor force over the 15-month study period. Recent drug users were only 5% as likely as other homeless adults to be in the labor force; and consistent public entitlement recipients were only 18% as likely as other homeless adults to be in the labor force.

CONCLUSIONS

Recent illicit drug use posed a deterrent to labor force participation among homeless adults, but heavy alcohol use did not. Most homeless adults were not consistently in the labor force and those who were, did not receive public entitlement benefits. This finding poses an interesting dilemma since previous studies indicated that homeless adults, who are consistent public entitlement recipients, were more likely to get housed than those who are not.