Economic impacts of supported employment for persons with severe mental illness

Trial-Based Economic Evaluations of Supported Employment for Adults with Severe Mental Illness: A Systematic Review

To identify, appraise, and summarize outcomes reported in trial-based economic evaluations of Individual Placement and Support programs for adults with severe mental illness. Six databases were searched, including Medline, PsycINFO, CINAHL, Cochrane, Scopus, and EconLit. Inclusion criteria were trial-based, full economic evaluations comparing Individual Placement and Support programs to traditional vocational rehabilitation programs for adults 18 years and older with severe mental illness. Study quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards statement. Of the 476 articles identified in the database search, seven were included in the review. Studies conducted across Europe (n = 4) and Japan (n = 1) suggested that Individual Placement and Support may be a cost-effective alternative to traditional vocational rehabilitation programs. Two studies conducted in the United States demonstrated that Individual Placement and Support led to better vocational outcomes, but at neutral or higher costs than traditional vocational rehabilitation, depending on the benefit measure used. Trial-based economic evaluations of supported employment for adults with severe mental illness are limited and heterogeneous. The interpretation of economic outcomes warrants consideration of factors that may impact cost-effectiveness, such as geographical location. Future studies should evaluate whether the benefits of IPS outweigh additional costs for patients and other stakeholders.

Group cognitive behaviour therapy for supported employment - Results of a randomized controlled cohort trial

The merging of evidence-based interventions with supported employment programs are being increasingly studied, with encouraging results. The current study is aimed at determining the impact of a brief cognitive behaviour therapy group intervention adapted for supported employment programs (called CBT-SE) on the work outcomes of: obtaining a competitive job, number of weeks worked, and number of hours worked per week. Participants were randomized to either receive the 8-session CBT-SE group on top of their supported employment program, or to only receive their support employment program. The results show that those who received CBT-SE were significantly more likely to obtain a job (75% vs 58%), and worked a significantly greater number of hours (24 vs 18 hours per week). No differences were found in terms of number of weeks worked. Those in the CBT-SE condition also experienced a significant decrease in their negative symptoms over time, compared to the control condition. Although replication is needed, these results suggest that a brief cognitive-behavioural intervention specifically tailored to work-related issues can be greatly beneficial.

A review of the economic impact of mental illness

Objective To examine the impact and cost associated with mental illness. Methods A rapid review of the literature from Australia, New Zealand, UK and Canada was undertaken. The review included literature pertaining to the cost-of-illness and impact of mental illness as well as any modelling studies. Included studies were categorised according to impact on education, labour force engagement, earlier retirement or welfare dependency. The well-accepted Drummond 10-point economic appraisal checklist was used to assess the quality of the studies. Results A total of 45 methodologically diverse studies were included. The studies highlight the significant burden mental illness places on all facets of society, including individuals, families, workplaces and the wider economy. Mental illness results in a greater chance of leaving school early, a lower probability of gaining full-time employment and a reduced quality of life. Research from Canada suggests that the total economic costs associated with mental illness will increase six-fold over the next 30 years with costs likely to exceed A$2.8 trillion (based on 2015 Australian dollars). Conclusions Mental illness is associated with a high economic burden. Further research is required to develop a better understanding of the trajectory and burden of mental illness so that resources can be directed towards cost-effective interventions. What is known about the topic? Although mental illness continues to be one of the leading contributors to the burden of disease, there is limited information on the economic impact that mental illness imposes on individuals, families, workplaces and the wider economy. What does this paper add? This review provides a summary of the economic impact and cost of mental illness. The included literature highlights the significant burden mental illness places on individuals, families, workplaces, society and the economy in general. The review identified several areas for improvement. For example, only limited information is available on the impact of attention deficit hyperactivity disorder, anxiety, cognitive function, conduct disorder, eating disorder and psychological distress. There was also a dearth of evidence on the intangible elements of pain and suffering of people and their families with depressive disorders. More research is required to better understand the full extent of the impact of mental illness and strategies that may be implemented to minimise this harm. What are the implications for practitioners? Knowing the current and future impact of mental illness highlights the imperative to develop an effective policy response.

Employment status of people with mental illness: national survey data from 2009 and 2010

OBJECTIVE

The aim of this study was to describe employment according to mental illness severity in the United States during 2009 and 2010.

METHODS

The sample included all working-age participants (ages 18-64) from the 2009 and 2010 National Survey on Drug Use and Health (N=77,326). Two well-established scales of mental health distinguished participants with none, mild, moderate, and serious mental illness. Analyses compared employment rate and income by mental illness severity. Employment status was estimated with logistic regression models that controlled for demographic characteristics and substance use disorders. In secondary analyses the relationship between mental illness and employment was assessed for variation by age and education status.

RESULTS

Employment rates decreased with increasing mental illness severity (no mental illness, 75.9% employment; mild, 68.8%; moderate, 62.7%; and serious, 54.5%, p<.001). Over a third of people with serious mental illness, 38.5%, had incomes <$10,000 (compared with 23.1% of people with no mental illness, p<.001). The gap in adjusted employment rates comparing persons with serious versus no mental illness was 1% among people 18-25 years old versus 21% among people 50-64 (p<.001).

CONCLUSIONS

More severe mental illness was associated with lower employment rates in 2009 and 2010. People with serious mental illness are less likely than people with no, mild, or moderate mental illness to be employed after age 49.

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

OBJECTIVE

Employment promotes recovery for persons with serious mental illness by providing extra income and a valued social role, but the impact of employment on other psychosocial and clinical outcomes remains unclear. This study examined non-vocational outcomes in relation to steady employment over 10 years among people with serious mental illness and co-occurring substance use disorders.

METHODS

Researchers interviewed people with co-occurring disorders at baseline and yearly for 10 years and tracked employment in relation to five non-vocational outcomes: independent living, psychiatric symptoms, substance use disorder, healthy (non-substance-abusing) relationships, and life satisfaction. Latent class trajectory analysis identified steady workers, and mixed-effects regression models compared steady workers with non-workers.

RESULTS

Both steady workers (n=51) and non-workers (n=79) improved substantially; for example, a majority of each group achieved independent housing and stable remission of substance use disorders. Steady workers achieved independent housing and higher quality of life during the first 5 years of follow-up, but the two groups achieved similar outcomes by 10 years.

CONCLUSIONS

People with co-occurring disorders can improve markedly. Those with steady employment may improve faster, but those without employment may achieve similar long-term outcomes at a slower pace.

Disappearing acts: the social networks of formerly homeless individuals with co-occurring disorders

Studies of the social lives of men and women living with co-occurring disorders (substance abuse and serious mental illness) suggest that social networks critically influence recovery. In this paper, we examine some of the reasons that the social networks of individuals with co-occurring disorders are small, and the impact of small networks for this population. Using a social capital framework with cross-case analysis, we analyze 72 in-depth qualitative interviews with 39 formerly homeless mentally ill men and women who were substance abusers. All were participants in the New York Services Study (NYSS), a federally funded study of mentally ill adults in New York City. The patterns suggest that networks shrunk because (1) social network members died prematurely, (2) study participants withdrew or pushed others away, and (3) friends and family members faced so many obstacles of their own that they could not provide resources for the study participants. We suggest that as networks diminished, some participants responded by attempting to rebuild their networks, even if the networks provided negative social capital, and others isolated themselves socially to escape the pressures and disappointments of interaction.

Employment support agencies in the UK: current operation and future development needs

Disabled people are amongst the most excluded in society, while people with learning disability have the lowest rates of employment. Supported employment promises to address the gaps, but it is a new approach, one whose development has been incremental. The present authors explore some of the features of agencies providing employment support to disabled people, together with their managers' views. This paper describes semistructured telephone interviews with the managers of 31 employment support agencies. The survey sought to understand the types of service provided, the staff and caseload numbers, the training offered, and the targets used. The authors also asked the managers what would help them in delivering employment opportunities to disabled people. The responses of the managers highlight gaps between current policy and practice. Particular attention is given to the use of targets, fragmented funding and what managers consider is required to improve employment opportunities for disabled people. Managers endorsed the vision expressed in current policy, and identified numerous obstacles to its implementation in employment support. Taken together, their views can be used to guide the development of supported employment.

Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models

OBJECTIVE

In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services.

METHODS

Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt.

RESULTS

Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay.

CONCLUSIONS

Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.

Lessons learned in implementing evidence-based practices: implications for psychiatric administrators

Factors related to the dissemination and implementation of evidence-based practices (EBPs) are discussed. Extensive effort is required to successfully implement and sustain EBPs that improve clinical outcomes. There is a rapid rate of discovery of new EBPs. Examples of large-scale implementations of EBPs in mental health are described with emphasis on the factors thought critical for success. The need for designing systems which can cost-effectively implement new EBPs is highlighted. Finally, the implications for psychiatric administrators are discussed.

[Professional integration of individuals with a mental illness: an analysis of individual characteristics]

A prospective study of individuals with a mental illness aimed to identify significant determinants of their integration in the work force. Regression and mean comparison analysis allowed exploring an individual's most typical characteristics that could explain his or her socio-professional integration, while considering several professional integration indicators. First, results suggest that linked to work (e.g. commitment to work) and socio-demographic variables (e.g. financial support received) can predict performing a work activity and obtaining competitive employment. Second, 2 additional variables can predict autonomy in employment, which are a feeling of efficiency in looking for work and a capacity to overcome obstacles to work integration. Third, cognitive and clinical variables are associated with a delay to start work. Fourth, the number of hours worked per week is explained by the feeling of efficiency in overcoming health problems and others motivational and psychosocial variables. Finally, it is important to clearly identify the professional integration indicators in order to determine the significant predictors.

Psychosocial treatment in the 21st century

Over the past 50 years, psychosocial treatment has played an increasingly prominent role in helping persons with mental illness live in communities rather than in institutions. This paper briefly reviews evidence for and discusses three forms of treatment-assertive community treatment, supported employment, and cognitive behavior treatment-which have been studied extensively and are widely accepted as effective interventions. Forces are discussed that have shaped these and other psychosocial treatment over the past five decades. Despite the accumulated evidence, many questions remain about the cost-effectiveness and applicability of these treatments in specific populations and service environments. The development of these and other treatments has been, and continues to be, shaped by concerns about rising health care costs, a heightened emphasis on evidence-based treatment and by consumers taking a more active role in determining the services, and outcomes that are most helpful to them.

Psychiatrists and psychiatric rehabilitation

Interventions that focus directly on functional impairments related to mental illnesses are termed psychiatric rehabilitation. Research demonstrates that rehabilitation services are increasingly able to help adults with psychiatric disabilities achieve the functional outcomes they desire, particularly in the areas of housing and employment. To support the community lives of adults with severe mental illnesses, psychiatrists must stay current with advances in this field and know how to integrate psychiatric rehabilitation with other interventions. This article reviews the concept of psychiatric rehabilitation, current approaches in the field, the psychiatrist's role in these services, and implications for psychiatric training and continuing education.

‘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."

[Psychiatric rehabilitation in a French-speaking setting: current practices, future challenges]

This paper aims to assess current interventions in psychiatric rehabilitation in the French-speaking world and to discuss future developments. We review examples of policies and practices in Quebec and Europe and discuss the role and involvement of professionals; namely, the psychiatrists and the nursing staff. We also present different rehabilitation strategies and techniques used in the French-speaking world, such as case management, social-skills training, cognitive therapies for psychotic symptoms, family interventions, and return-to-work interventions. In conclusion, we invite psychiatrists to play a more active role in rehabilitation. We recommend the creation of small, specialized units closely linked to the needs of clients, and we propose to integrate social and medical interventions, rather than opposing them.