Supported employment for people with severe mental illness: systematic review and meta-analysis of the international evidence

Predictors of return to work in people with major depression: Results from a supported employment program in Germany

BACKGROUND

Depression is a common mental disorder and is associated with work disability. For the implementation of evidence-based interventions, such as Individual Placement and Support (IPS) for people with depression in Germany, the aim of this study was to investigate client variables that predict return to work.

METHODS

The sample consisted of 129 participants, initially treated in a psychiatric hospital due to major depression, who participated in IPS as part of a German clinical trial. Baseline demographic (age, sex, education, sickness absence days, employment status), psychiatric (symptom severity, comorbidity, general physical and mental health, disability), and neuropsychological (self-rated deficits, test performance) variables were included. Return to work within one year was predicted using separate and overall binary logistic regression analyses.

RESULTS

A total of 70 participants (56 %) returned to work within the one-year follow-up period. >100 days of sick leave in the year prior to study entry (vs. <100 days) and higher self-rated cognitive deficits were significantly associated with reduced odds of return to work within one year of IPS.

LIMITATIONS

The sample consisted of participants with a relatively good work history who were assigned to IPS by the treatment team, thus, the generalizability of the results is limited.

CONCLUSIONS

People with depression who participate in IPS interventions might benefit from specifically targeting perceived cognitive deficits. Factors associated with prolonged sick leave due to depression and their role in return to work with IPS need further investigation.

A Participatory Evaluation of an Urban Garden Project in Ecuador: Exploring Factors That Impact the Recovery of People With Severe Mental Health Problems

For the past years, Ecuador has been transitioning away from a hospital-based model of mental healthcare to one that is community-centred. However, challenges associated with hospital-based models endure, notably financial burden faced by those with severe mental health problems (SMHPs) due to labour market discrimination. Employment access for this group is often disregarded in policy planning, despite evidence of its benefits on mental health. Huertomanías, an urban garden initiative in Ecuador founded in 2015, works with individuals with SMHPs, providing work, income, and social inclusion. A case study using a participatory approach was carried out to explore factors that impact the recovery of people with SMHPs. Twelve participants engaged in diverse stages of the research, where several participatory activities were conducted including cognitive mapping, a photovoice project, and interviews. The analysis employed a thematic approach leading to four categories of impact within the urban garden: autonomy (financial and personal), interpersonal relations and relation with the environment, mental health, and family dynamics. A final category of impact was established encompassing external factors (family support and public policy and healthcare services) that influence recovery. Findings suggest that the urban garden promotes autonomy and active participation within society, improves mental health, and transforms family dynamics. Further, this study highlights the importance of community-based mental healthcare (CBMHC), emphasising the need of public policies and healthcare in promoting autonomy through employment and community-centred services. Lastly, the study contributes insights into recovery experiences and CBMHC benefits, informing programme development and similar initiatives in Latin America.

Social representations of gender and their influence in Supported Employment: employment specialists' experiences in Sweden

PURPOSE

Gender differences have been found in the outcomes of vocational rehabilitation (VR) and in Supported Employment (SE), therefore, the purpose of this study was to explore employment specialists' (ES) social representations of gender in relation to work and VR and how these social representations influence the ES's work in the VR process according to SE.

METHODS

The qualitative method of focus group discussions was employed. Ten focus groups were held with 39 ESs from four categories of SE organizations in Sweden. Topic analysis was applied to the transcribed material from the focus groups.

RESULTS

Five themes with different social representations about gender and disability in relation to VR and working life formed in the analysis: (1) differences in personal and health factors among VR-participants, (2) gender norms in society influencing VR, (3) energy-intensive environmental issues influencing VR, (4) gender-specific interactions in VR, and (5) gendered paths in the welfare system.

CONCLUSION

Social representations of higher strains on women with disabilities compared to men with disabilities both in private and working life, which reflect the lived experiences of the ESs, is a possible explanation for gender differences in VR and working life for persons with disabilities.IMPLICATIONS FOR REHABILITATIONGender differences in the outcomes of vocational rehabilitation (VR) interventions have been noticed worldwide. In this study, pervasive social representations about gender and disability in relation to VR were found, but also unconsciousness about gender among VR professionals. Therefore, awareness of gender is necessary in VR.Individualized and person-centered approaches to VR like Supported Employment, although considered best practice, might hide structures like gender, which could lead to reproducing discriminating processes and therefore not achieving gender equality in VR. Therefore, knowledge of discrimination is important in VR.Gender-sensitivity in vocational rehabilitation models with a person-centered and individualized approach is needed and there might also be a need to systematically tailor vocational rehabilitation models to reach gender equality in the outcomes of the interventions. Therefore, gender equality indicators are needed for VR models, to evaluate model effectiveness from a gender perspective.

Interventions targeting young people not in employment, education or training (NEET) for increased likelihood of return to school or employment-A systematic review

The present systematic review aims to identify, synthesize, and evaluate evidence of effects from interventions targeting youth not in education, employment, or training (NEET). We searched relevant multidisciplinary databases to identify randomized controlled trials (RCTs) and quasi-randomized re-engagement trials. Primary outcomes were participation in education and employment, and training status. Secondary outcomes included changes in financial status, quality of life and well-being, social functioning, and physical, psychological, and behavioral outcomes. The Joanna Briggs Institute methodology and PRISMA guidelines were applied. Eligible studies were screened, included, and extracted for data. Nine trials were included (eight RCTs and one quasi-experimental study), in which samples ranged from 96 to 7346 participants. Results on primary outcomes showed that five studies found an effect of interventions on employment outcomes, while three studies indicated an effect on education or training. Results on secondary outcomes included effects on mental health, subjective health complaints, drug use, self-esteem, and self-efficacy. Studies with other main outcomes than re-engagement showed an effect of interventions on pass rates for the driving test, independent housing, and increased job-seeking activities. Limitations and future directions are discussed, including the lack of rigorous studies, theoretical underpinnings, and standardized measures for re-engagement outcomes. Systematic review registration: registered in PROSPERO, CRD42023463837.

Supported employment interventions with people who have severe mental illness: Systematic mixed-methods umbrella review

BACKGROUND/AIMS

Primary and review studies show that supported employment interventions showed promise in assisting people with severe mental illness (SMI) in achieving successful employment and health-related outcomes. This umbrella review synthesises evidence from across review studies on supported employment interventions for individuals with SMI, to identify key findings and implementation challenges in relation to five key outcomes: (1) employment, (2) quality of life, (3) social functioning, (4) clinical/service utilisation, and (5) economic outcomes.

METHODS

A systematic search of eleven databases and registers (CINAHL, Cochrane, EmCare, JBI EBP, ProQuest, PsycINFO, PubMed, Scopus, and Web of Science, and Prospero and Campbell) was conducted to identify meta-analyses and systematic reviews on supported employment interventions for individuals with SMI, peer reviewed and published in English. Quality assessment and data extraction were performed using standardised Joanna Briggs Institute (JBI) tools. A mixed-methods synthesis approach was employed to integrate both quantitative and qualitative evidence.

RESULTS

The synthesis of 26 review studies primarily focused on the Individual Placement and Support (IPS) model among various supported employment interventions. Overall, combining supported employment with targeted interventions such as neurocognitive therapy and job-related social skill training showed a positive effect on employment (including job retention) and non-employment outcomes (e.g., health, quality of life, social functioning) relative to standard forms of supported employment for people with SMI. Contextual factors (intervention fidelity, settings, systemic barriers) were important considerations for intervention implementation and effectiveness.

DISCUSSION

Significant overlap of primary studies across 26 review studies exposed considerable variations in interpretation and conclusions drawn by authors, raising questions about their reliability. High volume of overlap reporting from the USA on IPS interventions in review studies is likely to have biased perceptions of effectiveness. There is no one-size-fits-all solution for supporting individuals with SMI in obtaining and maintaining employment. Tailoring strategies based on individual needs and circumstances appears crucial to address the complexity of mental health recovery. We propose creating centralised registries or databases to monitor primary studies included in reviews, thus avoiding redundancy.

OTHER

This umbrella study was registered with PROSPERO (No. CRD42023431191).

Struggling with Fitting in: Clients Mixed Experiences of Receiving Job Support and Getting a Job When Participating in Individual Placement and Support in Norway

PURPOSE

To explore clients' experiences of receiving job support from employment specialists (ESs) working with individual placement and support (IPS) in Norway. IPS is developed to help people with severe mental illness (SMI) into competitive employment as an integral component of mental health services.

METHODS

Using a hermeneutic phenomenological methodology, this study comprises individual semi-structured interviews with ten participants engaged in IPS at two districts psychiatric centers. Data analysis was conducted according to systematic text condensation.

RESULTS

Three themes emerged: (1) ES-a door opener? (2) Striving to sidestep a "spider web" of triggers at and away from work; and (3) Calling for a safer route.

CONCLUSION

This study highlights the importance of ESs offering IPS clients' opportunities to try out diverse jobs and focusing more on assessing the work environment in the jobs they place people into. Our findings imply that ESs should spend more time on building a good working alliance with both clients and employers, and pay more attention on understanding individuals' vocational capacities and support needs at the worksite. The ES training should focus not simply on the technical processes of job development and placement, but more directly on empowering clients to stay focused on their vocational ambitions and prospects. The salutogenic model of health can help ESs to analyze whether clients experience workplaces as meaningful, manageable, and comprehensible.

Trust, discrimination and preference for shared decision-making in adolescents diagnosed with depression: Implications from Chinese mental health professionals

BACKGROUND

While evidence suggests that the attitudes of healthcare providers toward medical decision-making in adolescents diagnosed with depression merit exploration, research on their preferences for Shared Decision-Making (SDM) and the factors affecting these preferences remains limited.

OBJECTIVE

To investigate Chinese mental health professionals' (MHPs) preferences for SDM in adolescents with depression and identify the relationships between their preference for SDM and trust and discrimination.

METHODS

A cross-sectional design was used in this study. Clinical Decision-making Style-Staff (CDMS-S) was applied to evaluate their preferences for SDM. Physician Trust in the Patient Scale (PTPS) was utilised to assess their trust in consumers. Social Distance Scale to Mental Illness (SDSMI) was utilised to measure their discrimination against people with mental illness.

RESULTS

A total of 581 MHPs were identified in China. MHPs rated their preference for participation in decision making (PD) as shared (1.89 ± 0.472), information (IN) as moderate (2.62 ± 0.682), and family involvement (FI) as high (3.13 ± 0.840). The preferences for three decision topics ranked from the highest to the lowest score were working-related decision (2.35 ± 0.681), general preferences in decision (1.82 ± 0.581) and medication-related decision (1.74 ± 0.826). The mean score of PTPS and SDSMI were 34.71 (SD=9.709) and 15.17 (SD=4.299), respectively. Logistic regression indicated that the preference for PD was associated with discrimination; the preference for IN was associated with trust, discrimination and SDM-related training experience; and the preference for FI was associated with both trust and discrimination.

CONCLUSIONS

While MHPs generally exhibit a favourable attitude toward SDM, this positivity is not universally observed across all contexts. There remains room for improvement in the willingness to co-develop medication regimens and share health information. Rational recognition of depression, and building trusting and friendly therapeutic relationships are key to promoting MHPs' preferences for SDM.

PRACTICAL VALUE

MHPs' preferences for SDM have a significant impact on SDM implementation, which will be promoted by implementing SDM-related training.

Preference for Competitive Employment in People with Mental Disorders: A Systematic Review and Meta-analysis of Proportions

PURPOSE

The inclusion of people with mental disorders (MD) into competitive employment has become an important political and therapeutic goal. The present paper investigates meta-analytically to which extent people with MD who were unemployed or on sick leave due to MD prefer to work in a competitive job environment.

METHODS

For this systematic review and meta-analysis of proportions, we searched Medline, PsycInfo, Cinahl, Google Scholar, and reference lists for peer-reviewed publications from 1990 to Dec 2023, which provided data on the job preferences of people with MD. Two authors independently conducted full-text screening and quality assessments. Pooled proportions of job preferences were calculated with a random-effects meta-analysis of single proportions, and subgroup analyses were performed to examine characteristics associated with job preferences.

RESULTS

We included 30 studies with a total of 11,029 participants in the meta-analysis. The overall proportion of participants who expressed a preference for competitive employment was 0.61 (95%-CI: 0.53-0.68; I2 = 99%). The subgroup analyses showed different preference proportions between world regions where the studies were conducted (p < 0.01), publication years (p = 0.03), and support settings (p = 0.03).

CONCLUSION

Most people with MD want to work competitively. More efforts should be given to preventive approaches such as support for job retention. Interventions should be initiated at the beginning of the psychiatric treatment when the motivation to work is still high, and barriers are lower.

TRAIL REGISTRATION

The protocol is published in the Open Science registry at https://osf.io/7dj9r.

Employment support for Black people with long-term health conditions: a systematic narrative review of UK studies

BACKGROUND

Black people in the United Kingdom disproportionately acquire long-term health conditions and are marginalised from the labour market compared with other groups. These conditions interact and reinforce high rates of unemployment among Black people with long-term health conditions.

AIMS

To examine the efficacy, and experience, of employment support interventions in meeting the needs of Black service users in Britain.

METHODS

A systematic literature search was conducted focusing on peer-reviewed literature featuring samples drawn from the United Kingdom.

RESULTS

The literature search revealed a paucity of articles that include analysis of Black people's outcomes or experiences. Six articles met the selection criteria of the review, of which five focused on mental health impairments. No firm conclusions could be drawn from the systematic review; however, the evidence suggests that Black people are less likely than their White counterparts to secure competitive employment and that Individual Placement and Support (IPS) may be less effective for Black participants.

CONCLUSIONS

We argue for a greater focus on ethnic differences in employment support outcomes with an emphasis on how such services may remediate racial differences in employment outcomes. We conclude by foregrounding how structural racism may explain the dearth of empirical evidence in this review.

The effects of an interdisciplinary employment program on paid employment and mental health among persons with severe mental disorders

PURPOSE

This study evaluates the effects of the interdisciplinary employment program 'Work As Best Care (WABC)' on employment participation and mental health of persons with severe mental disorders.

METHODS

WABC is a 'work first' employment program for unemployed persons with severe mental disorders in which employment professionals work closely together with mental health professionals. In a longitudinal non-randomized controlled study, participants of WABC (n = 35) are compared with participants of the control group (n = 37), who received regular employment support. Participants were followed for 1 year and filled out questionnaires on individual characteristics and health at baseline, after 6 and 12 months. This information was enriched with monthly register data on employment status from 2015 until 2020. Difference-in-differences analyses were performed to investigate changes in employment participation among participants of WABC and the control group. A generalized linear mixed-effects model was used to compare changes in mental health (measured on 0-100 scale) between the two groups.

RESULTS

Before WABC, employment participation was 22.0%points lower among participants of WABC compared to the control group. After starting WABC, employment participation increased with 15.3%points per year among participants of WABC, compared to 5.6%points in the control group. Among all participants of WABC, no change in mental health was found (β 1.0, 95% CI - 3.4; 5.5). Only female participants of WABC showed a significant change in mental health (β 8.0, 95% CI 2.6; 13.4).

CONCLUSION

To enhance employment participation of persons with severe mental disorders, an interdisciplinary 'work-first' approach in which professionals of employment services and mental health services work in close collaboration, is of paramount importance.

Individual placement and support: A qualitative investigation of carers' experiences supporting someone experiencing mental illness into employment

BACKGROUND

Unemployment rates for people living with mental illness remain persistently high. Individual Placement Support (IPS) is an evidence-based employment model that supports people with severe mental illness to gain employment. Although carers provide emotional and instrumental support for people with mental illness, there is limited research exploring carers' perspectives of IPS.

AIMS

To explore carers' perspectives of their experience as caregivers of individuals living with mental illness who have participated in IPS.

METHODS

This qualitative descriptive study gained carers' perspectives through semi-structured interviews. A convenience sample of eight carers was recruited via a community mental health service in Adelaide. Data were analysed thematically.

FINDINGS

Three main themes were identified: (1) employment benefits, (2) factors that may impact on employment, and (3) knowledge and opinions of IPS. Within each theme, four sub-themes emerged.

CONCLUSIONS

This study addresses a gap in research and provides insights into carers' experiences of IPS. Increased communication and involvement of carers in IPS may benefit IPS participants and staff as carers provide invaluable additional insight into supporting individuals through their employment journey.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Work-related participation impairments and support needs of patients in a Swiss psychiatric university hospital

Objective

To assess work-related participation impairments and support needs of adult patients in inpatient and day-care treatment at a Swiss psychiatric university hospital.

Methodology

Cross-sectional survey on a department-dependent cut-off date in May and June 2022 using a standardized structured interview.

Results

Data were available for 93 patients (response rate 59%), of which 51% (n = 47) stated that they had a job or training place. Patients in first hospitalization and with a job or training place were approached significantly more often. Regardless of age and first hospitalization, 76% of the patients expressed a need for support, of which 92% expressed interest in job coaching. A total of 54% of the patients stated that they had received support from the treatment team.

Conclusion

From the patients' point of view, work and education were not addressed by the treatment team across the board and independently of patient characteristics. The need for support was insufficiently met. There is a considerable interest for support programs through job coaching, and this offers opportunities to promote the inclusion of patients in the regular labor market.

Perspectives on implementing Individual Placement and Support (IPS) within primary health care settings for adults living in British Columbia, Canada

BACKGROUND

Individual placement and support (IPS) is an evidence-based practice (EBP) designed to help people with severe mental illness re-enter the labour market. Implementing an IPS program within a new context (e.g., primary health care setting) to support populations that are complex and multi-barriered presents a set of unique challenges and considerations. This paper provides community-based perspectives that identify implementation strengths and challenges and highlights potential strategies aimed at addressing emergent barriers.

METHODS

A case study was conducted across three community health centres in British Columbia (BC), Canada, where a novel IPS program was embedded within primary care services. Data collection consisted of open-ended surveys and focus groups with service providers directly involved in program implementation and their associated clinical and managerial support teams (n = 15). Using the updated Consolidated Framework for Implementation Research (CFIR) as a guide, we performed deductive thematic analysis to identify key areas impacting IPS implementation.

RESULTS

Integration with existing health care systems and primary health care teams and support from leadership across all levels were identified as both key facilitators and barriers to implementation. Facilitators and barriers were identified across all domains, with those within innovation and process most easily addressed. Four cross-cutting themes emerged for promoting more integrated and sustainable program implementation: investing in pre-implementation activities, supporting a dynamic and flexible program, building from community experiences, and developing a system for shared knowledge.

CONCLUSIONS

Implementing an IPS program embedded within primary health care settings is complex and requires extensive planning and consultation with community-based service providers and decision-makers to achieve full integration. Future practice and policy decisions aimed at supporting employment and well-being should be made in collaboration with communities.

The relationship between having a job and the outcome of brief therapy in patients with common mental disorders

BACKGROUND

Previous studies have shown that being employed is associated not only with patients' health but also with the outcome of their treatment for severe mental illness. This study examined what influence employment had on improvements in mental health and functioning among patients with common mental disorders who received brief treatment and how patients' diagnosis, environmental and individual factors moderated the association between being employed and treatment outcome.

METHODS

The study used naturalistic data from a cohort of patients in a large mental health franchise in the Netherlands. The data were obtained from electronic registration systems, intake questionnaires and Routine Outcome Monitoring (ROM). The International Classification of Functioning, Disability and Health (ICF) framework was used to identify potential subgroups of patients. Logistic regression models were used to analyze the relationship between employment status and treatment outcome and to determine how the relationship differed among ICF subgroups of patients.

RESULTS

A strong relationship was found between employment status and the outcome of brief therapy for patients with common mental disorders. After potential confounding variables had been controlled, patients who were employed were 54% more likely to recover compared to unemployed patients. Two significant interactions were identified. Among patients who were 60 years of age or younger, being employed was positively related to recovery, but this relationship disappeared in patients older than 60 years. Second, among patients in all living situations there was a positive effect of being employed on recovery, but this effect did not occur among children (18+) who were living with a single parent.

CONCLUSIONS

Being employed was positively associated with treatment outcome among both people with a severe mental illness and those with a common mental disorder (CMD). The main strength of this study was its use of a large dataset from a nationwide franchised company. Attention to work is important not only for people with a severe mental illness, but also for people with a CMD. This means that in addition to re-integration methods that focus on people with a severe mental illness, more interventions are needed for people with a CMD.

Riding the tides: Directions in mental health rehabilitation in NSW

OBJECTIVE

This paper outlines the evolution of mental health rehabilitation in NSW, where allocation of health resources has repeatedly contradicted the policy intention to reorient services from inpatient to community-based services, leaving community rehabilitation the poor and disconnected cousin of inpatient services. The expanding role of community-managed organisations (CMOs) in psychosocial rehabilitation, the introduction of the National Disability Insurance Scheme (NDIS), and emerging service models have helped foster a maturing housing and social care environment, but present reality and the integration of health and social care services remains at a distance from best evidence practice.

CONCLUSION

The challenge of the next decade of mental health reform is to embrace and consolidate greater service diversity and complexity. Understanding what factors influenced present reality is important in providing guardrails for the future, enabling the current wave of renewal and reinvestment in NSW to build on the strengths of past developments and steer a course around their weaknesses.

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.

Commentary: The challenges and promises of competitively employing autistic adults in the United States

Current United States statistics suggest that autistic individuals will experience high unemployment and underemployment rates throughout their lives. Furthermore, despite the passage of federal legislation to employ young autistic adults in competitive integrated settings, where they work alongside non-disabled workers and earn at least minimum wage, most individuals receiving state services still are placed in day programs or sheltered workshops. Since meaningful employment is the most important determinant of life satisfaction, this failure is a critical societal problem, exerting increasing pressure for systems change. But the news is not all bad. Private sector companies have increased their hiring of disabled workers, producing a growing base of expertise in the recruitment, on-boarding, training, and management of autistic employees. This has led to a growing recognition that autistic individuals can be ideal workers. Autism researchers have advanced the field by investigating these private industry programs as well as conducting efficacy trials of interventions and services that help autistic individuals in the workplace. However, gaps in knowledge persist stemming from the heterogeneity of autistic workers, limited knowledge about those not receiving state services, and a system of federal services that is fragmented, poorly coordinated, difficult to navigate, and over-taxed. Autism researchers can continue to improve outcomes of autistic workers through investigations of the fit between autistic workers, their preferences, and the characteristics of available jobs, and through effectiveness trails of promising employment interventions and services that promote systems change that help break down the barriers to better integration of existing state services and resources in the United States.

Career Adaptability and Resilience of Mental Health Service Users: The Role of Career Counseling

The employment rate of people who face severe mental health issues is extremely low, while the vast majority expresses their willingness to work. There are various obstacles that impede their work re-integration process. Apart from the illnesses' symptoms and the employers' stigma, these barriers are strongly associated with the effects of long-term unemployment and the lack of positive psychosocial resources, such as career adaptability and resilience. The present study aims to investigate career adaptability and the resilience of mental health service users who receive career counseling services. The career counseling approach that was used combines elements from the IPS model and the career construction approach that has been developed to address the contemporary world of work challenges. We investigated how mental health service users view themselves in terms of career adaptability and resilience, and which factors contributed to their development or impeded them. We used a qualitative approach, which allows for an in-depth exploration of the participants' views. Fifteen mental health users who receive career counseling services were interviewed. The results showed that mental health service users believe that they can overcome any difficulties and setbacks when they have adequate support from their social network and when they receive career counseling services. They highlighted the importance of counseling services to maintain their work and cope with stressful events. Further implications of the results regarding vocational rehabilitation of mental health users as means for social inclusion are discussed.

Supported employment interventions for workplace mental health of persons with mental disabilities in low-to-middle income countries: A scoping review

OBJECTIVE

To review the evidence of supported employment interventions in low-to-middle income countries, documents their impact for persons with mental disorders in the open labour market and well as support decision making for its wider implementation in the workplace.

DESIGN

The scoping review is conducted following guidelines in the Arksey and O'Malley (2005) Framework.

DATA SOURCES AND ELIGIBILITY

Eleven databases which are PubMed, Scopus, Academic Search Premier, the Cumulative Index to Nursing and Allied Health Literature, Africa-Wide Information, Humanities International Complete, Web of Science, PsychInfo, SocINDEX, Open Grey and Sabinet were searched for articles published between January 2006 and January 2022. Both peer-reviewed articles and grey literature were eligible if they were on supported employment interventions in low-to-middle income countries. Only articles published in English were included.

STUDY APPRAISAL AND SYNTHESIS

Articles were screened at title, abstract and full article levels by two independent teams with the use of Rayyan software. Deductive thematic analysis was used to synthesize evidence on the supported employment interventions implemented in LMICs, capturing evidence of their outcomes for persons with mental disabilities securing competitive work.

RESULTS

The search yielded 7347 records and after screening by title and abstract, 188 studies were eligible for full article screening. Eight studies were included in this scoping review. Thematic descriptions of the findings were based on the availability of supported employment interventions within the context, the type of supported employment interventions as well as mental health and vocational outcomes in the workplace.

CONCLUSIONS

There is limited evidence of supported employment interventions in low-to-middle income countries despite the promising potential it has as an intervention to address mental health problems in the workplace and facilitate work participation by persons with mental disabilities.

Individual placement and support: History, current status, and future directions

Over the past three decades, Individual Placement and Support (IPS) has emerged as a robust evidence-based approach to helping people with severe mental illnesses, such as schizophrenia, bipolar disorder, and major depression, to obtain and succeed in competitive employment. This review addresses the history, principles, research, and future directions of IPS. It covers current evidence on employment outcomes, cost-effectiveness, and nonvocational outcomes. It also describes current attempts to extend IPS to new populations. The authors provide an overview of numerous systematic reviews and meta-analyses of randomized controlled trials involving people with serious mental illness. For studies addressing nonvocational outcomes and new populations, the review uses best available evidence. Published reviews agree that IPS enables patients with serious mental illness in high-income countries to succeed in competitive employment at a higher rate than patients who receive other vocational interventions. Within IPS programs, quality of implementation, measured by standardized fidelity scales, correlates with better outcomes. Employment itself leads to enhanced income, psychosocial outcomes, clinical improvements, and decreased mental health service use. As IPS steadily spreads to new populations and new settings, research is active across high-income countries and spreading slowly to middle-income countries. IPS is an evidence-based practice for people with serious mental illness in high-income countries. It shows promise to help other disability groups also, and emerging research aims to clarify adaptations and outcomes.

Associations between learning principles of cognitive remediation and cognitive and vocational outcomes in early psychosis-an exploratory analysis of RCT data

Background: Most cognitive remediation (CR) programs are based on multiple scientific learning principles. The role of those learning principles in the beneficial effects of CR is poorly understood. A better understanding of such underlying mechanisms is important to further tailor the intervention and to learn about optimal contexts.Method: An explorative secondary analysis was conducted of data from a randomized controlled trial (RCT) comparing the effects of Individual Placement and Support (IPS) with and without CR. The present study evaluated how CR learning principles of "massed practice," "errorless learning," "strategy use" and "therapist contribution" (therapist fidelity) were associated with cognitive and vocational outcomes within 26 participants in this RCT who were treatment exposed.Results: Cognitive gains after CR were positively associated with "massed practice" and "errorless learning." Negative associations were found with "strategy use" and "therapist fidelity." No direct relationship was found between CR principles and vocational outcomes.Conclusions: Results tentatively suggest that CR is most effective and efficient with a good balance between sufficient intensity, of more than 200 tasks, and a limited duration of the training up to 20 h, using tasks that remain both challenging and rewarding, being applied in a context that facilitates real-life practice.

Examination of Adaptations to the Evidence Based Supported Employment Model: Individual Placement and Support

Individual Placement and Support (IPS) is a long-standing and innovative employment service for individuals with mental illness with dozens of clinical trials demonstrating effectiveness. Little is known, however, about intentional adaptations to IPS, especially those outside of the context of research studies. Using an implementation science framework, we conducted an exploratory study to better understand the characteristics of stakeholder-reported adaptions to IPS, the impetus for their development, and perceived impacts. We conducted qualitative interviews to analyze and describe these adaptations. Numerous adaptations of IPS were found that address the needs of new and underserved populations both within and outside of the mental health field. Programs reported adapting IPS because of the dearth of other evidence-based employment services, to serve diverse populations in need, and based on financial incentives. Benefits of adaptations were weighed against impacts on fidelity. As evidence-based practices (EBPs) are adapted, developers of EBPs should determine how fidelity of a program or service can be assessed or preserved in light of adaptations. This is critical with the increase in different service delivery methods, new populations, new service recipient needs, and new settings in need of EBPs.

Working with adults with intellectual challenges to enhance their employability skills

The employability of the intellectually challenged has received little attention in the past. In order to fill this research gap, the present study was undertaken. The study is centered on the experiences of six intellectually challenged individuals who received employability training at a non-governmental organization. A focus group discussion along with a case study was conducted. The researchers employed the Rigorous and Accelerated Data Reduction (RADaR) technique to analyze the data from the focus group discussion. Results from both the focus group discussion and the case study revealed that the training program has had a significant impact on the lives of the participants and has aided them in becoming economically empowered and independent.

Approach to schizophrenia

Schizophrenia is the most common of a group of psychotic disorders that occur in approximately 3% of the population over the lifespan. It has clear genetic antecedents, which are shared across the spectrum of psychotic disorders; however, a range of other biological and social factors influence the onset and treatment of the disorder. Schizophrenia is diagnosed by a characteristic set of symptoms (positive, negative, disorganisation, cognitive and affective) accompanied by a functional decline. Investigations are used to exclude other organic causes of psychosis and to provide a baseline for the negative effects of pharmacological treatments. Treatment requires a combination of pharmacological and psychosocial interventions. Physical health is poor in this group of people and this is not helped by inconsistent care from health services. Although earlier intervention has improved the immediate outcomes, the longer-term outcome has not significantly shifted.

Factors Affecting Employability of Patients with Schizophrenia who had First Participated in Vocational Training: A Pilot Study

While vocational training may offer financial and health benefits for patients with schizophrenia (PwS), further empirical research is required to investigate the effectiveness of this intervention for PwS, as well as the factors influencing their employability. This study aimed to (i) identify the factors affecting the employability of PwS who had participated in vocational training and (ii) examine the effectiveness of vocational training. This prospective cohort study was conducted in a community rehabilitation center attached to a psychiatric hospital in southern Taiwan that provides vocational training. The participants completed two questionnaires: (i) a pre-test that served as the study's baseline; (ii) a post-test during a follow-up 12 months later. The questionnaire was divided into three parts: (i) participants' basic information, (ii) the work performance scale, and (iii) the mental state measure. The participants included 35 males and 30 females, with the average age being 45.85 years. The significant factors affecting their employability were social support, work behavior, thinking disorder, and cognitive impairment. In other words, participants with better social support, work behavior, and fewer thought disorders and cognitive impairment were more employable. Their work attitude and ability were found to have significantly improved after having participated in vocational training for 12 months. In conclusion, when conducting vocational training in the future, it is necessary to pay attention to individual participants' social support and work behavior and reduce thinking disorders and cognitive impairments. This may help improve the employability of PwS.

A relational perspective of schizophrenia at work

Purpose

Despite a plethora of research on diversity and inclusion, workplace-related issues pertaining to individuals with schizophrenia (SCZ) remain grossly underexplored. This paper seeks to develop a relational, multilevel perspective of issues and challenges faced by individuals with SCZ in the work and career.

Design/methodology/approach

The research draws on the findings from in-depth, qualitative interviews with schizophrenic individuals, individuals’ family members, healthcare professionals and nongovernmental organization (NGO) representatives.

Findings

The findings highlight the interconnected nature of multilevel issues faced by schizophrenic individuals and indicate that at the societal level, social stigma, economic conditions and inadequate government policies are the key challenges faced by them. At the organizational level workplace support and job suitability and design affect individuals’ employment. At the individual level, self-stigma affects the employability in a negative way whereas personal motivation and resilience, family and social support and realization of illness are the facilitating factors.

Originality/value

The study adds to disability and diversity literature by developing a relational perspective that holistically captures the issues faced by schizophrenic individuals and suggests that the work and employment-related issues may be simultaneously addressed at multiple levels.

Predictors of return to work for people on sick leave with depression, anxiety and stress: secondary analysis from a randomized controlled trial

PURPOSE

Knowledge about predictors of return to work (RTW) in people on sick leave with common mental disorders (CMDs) may inform the development of effective vocational rehabilitation interventions for this target group. In this study, we investigated predictors of RTW at 6 and 12 months in people on sick leave with depression, anxiety disorders or stress-related disorders.

METHODS

We have performed a secondary analysis, utilizing data from two RCTs that evaluated the efficacy of an integrated health care and vocational rehabilitation intervention. Data were obtained from mental health assessments, questionnaires and registers. Using Cox regression analysis, the relationship between baseline variables and RTW was analysed at 6 and 12 months after randomization within the group of CMD as a whole and within the subgroups of depression, anxiety and stress-related disorders.

RESULTS

Symptom burden and employment status at baseline predicted RTW in the CMD group (n = 1245) and in the three diagnostic subgroups at both time points. RTW self-efficacy predicted RTW in the depression group but not in the anxiety or stress subgroups.

CONCLUSION

Many predictors of RTW were similar over time and, to some extent, across the CMD subgroups. Findings highlight the need not only to take health-related and psychological factors into account when developing vocational rehabilitation interventions but also to consider workplace strategies and options for support.

Effectiveness of interventions to improve employment for people released from prison: systematic review and meta-analysis

BACKGROUND

People released from prison experience complex health challenges in addition to challenges resettling into the community. Consequently, employment rates are low. Participating in good quality employment can support good health and is protective against future reoffending. Multiple interventions are provided to support people into employment on release. The effectiveness of interventions for improving employment outcomes has not previously been evaluated in a meta-analysis.

AIM

Our objective was to examine the effectiveness of interventions to improve employment following release from prison.

METHOD

We searched seven databases and three trial registries for peer reviewed randomised controlled trials (RCTs), published since 2010, that included adults and measured an employment outcome(s). We conducted meta-analysis using random effects models with sub-group and sensitivity analyses. We appraised bias risk per outcome, and incorporated this into an assessment of the certainty estimates for each outcome. A group of people with experience of imprisonment met with us throughout the project to inform our search strategy and interpretation of results.

RESULTS

We included 12 RCTs (2,875 participants) which were all conducted in the USA. Few outcomes were of low risk of bias. Intervention participants were 2.5 times more likely to work at least one day (95% CI:1.82-3.43) and worked more days over 12 months (MD = 59.07, 95% CI:15.83-102.32) compared to controls. There was no effect on average employment status or employment at study end. There is moderate certainty in these estimates.

CONCLUSION

Interventions can improve some employment outcomes for people released from prison. More evidence is required to establish effective interventions for sustaining quality employment, particularly outside the USA, and which consider outcomes for different groups of people released, such as women or those with health or substance use needs.

Predictors of Return to Work for People with Anxiety or Depression Participating in a Randomized Trial Investigating the Effect of a Supported Employment Intervention

Purpose Common mental disorders have a severe impact on society and individuals; rates of unemployment and disability pensions are high. Knowing which factors facilitate or hinder people's return to work is important when designing effective vocational rehabilitation interventions. Methods We conducted secondary analyses on data from 289 participants with depression or anxiety included in the Individual Placement and Support modified for people with mood and anxiety disorders (IPS-MA) trial. Associations of baseline characteristics and employment or education after 24 months were tested in univariate logistic regression analyses, variables with a p-value below 0.1 were included in multivariate analyses. Results In the univariate analyses, self-reported level of functioning (p = 0.032), higher age (p = 0.070), and higher level of readiness to change (p = 0.001) were associated with the outcome and included in the multivariate analysis. Only age (p = 0.030) and readiness to change (p = 0.003) remained significantly associated with return to work or education after 24 months in the multivariate analysis. Conclusion Higher age and lower readiness to change were associated with a lower chance of having returned to work or education. Factors modifying the effect of higher age should be identified, just as vocational rehabilitation should focus on improving factors related to people's readiness to change.

Caregivers' experiences and perspectives of factors associated with relapse in Iranian people living with schizophrenia: A qualitative study

BACKGROUND

Relapse in People Living with Schizophrenia (PLS) has several reasons and recognizing these can increase the effectiveness of treatment interventions. Formal and informal caregivers are an informed source to reduce relapse in PLS.

AIM

This study explores the caregivers' perspective in Iran on the factors affecting relapse in PLS.

METHOD

A total of 28 caregivers (16 formal caregivers and 12 informal caregivers) of PLS were enrolled in our qualitative study. A content analysis was conducted using individual and group, semi-structured in-depth interviews with informal and formal caregivers of PLS. This study was conducted in a hospital, three universities, and a non-governmental organization in Tehran, Iran.

RESULTS

The majority (69%) of the participants were females. About half of the informal caregivers were over 60 years old and about 40% of the formal caregivers were in the age range of 30 to 40 years. The average number of years of work for informal caregivers was 17.6 years and the average of work experience among the formal caregivers was 14.1 years. Seven key dual themes were identified from data: 'awareness-stigma', 'social support-social exclusion', 'treatment adherence-treatment discontinuation', 'holistic approach - one-dimensional approach', 'supported employment-social dysfunction', 'emotional management in family - family with high emotional expression', and 'access to treatment-treatment gap'.

CONCLUSION

The results of this research can help practitioners and policymakers to enable evidence-based practices to reduce relapse in PLS by emphasizing and acting on factors identified in our analyses.

Staff Time in the Community: An Enduring Critical Component of Individual Placement and Support in the Digital Age

OBJECTIVE

This study examined the relationship between individual placement and support (IPS) employment specialists' time spent in the community and employment outcomes in the current digital age, featuring increased technology use and online hiring practices.

METHODS

The authors examined the relationship between employment outcomes and IPS employment specialists' time spent in the community at 78 sites in 2018 and 84 sites in 2019.

RESULTS

The amount of time staff spent in the community was significantly and positively associated with better employment outcomes.

CONCLUSIONS

These data support the continued importance of employment specialists' spending time in the community with employers and IPS recipients to achieve optimal outcomes for recipients.

Pre-vocational therapy in mental health. Clients' desired and achieved productivity status

BACKGROUND

Knowledge about work-related occupational therapy in psychiatric inpatient and day hospital clients is limited.

AIMS

The aim of the study was to explore the desired and achieved productivity status in mental health service users participating in a pre-vocational therapy (PVT) intervention. Outcome variables were productivity status and achievement of desired productivity status at discharge, and change or persistence of productivity status between admission and discharge.

METHODS

This is a short-term prospective study based on observational data from health records (N = 98).

RESULTS

At admission, 53.2% of participants named a clear desired productivity status; 46.8% did not. Of the former, 76.9% expressed a desire for employment or education on the regular job market; 28.0% achieved their desired outcome at discharge, whereas 72.0% did not. Overall, 58.5% retained, established or increased productive activities, while 41.5% were not engaged in or had reduced productive activities at discharge. These two groups differed in socio-economic and social-security-related characteristics, treatment-related characteristics and psychiatric diagnosis.

CONCLUSIONS AND SIGNIFICANCE

Some, but not all kinds of clients in acute psychiatric inpatient and day hospital settings manage to take a first step towards productive activities during the first phase of treatment.

30-Month Follow-Up of Individual Placement and Support (IPS) and Cognitive Remediation for People with Severe Mental Illness: Results from a Randomized Clinical Trial

Background

The individual placement and support (IPS) model for persons with severe mental illness has proven to be more effective than traditional vocational approaches in improving competitive work over 18 months. In this study, the longer-term effects of IPS over 30 months were investigated in a Danish setting.

Method

In a randomized clinical trial, we compared the effects of IPS, IPS enhanced with cognitive remediation and work-related social skills training (IPSE), and service as usual (SAU). At three locations in Denmark, 720 patients with serious mental illnesses were randomly assigned to the three groups. Competitive employment, education, and hospital admissions were tracked for 30 months using Danish national registers.

Results

The beneficial effects of IPS on competitive employment and education at the 18-month follow-up were sustained over the 30-month follow-up period. Participants receiving IPS or IPSE were more likely to obtain competitive employment or education than those who received service as usual (IPS 65%, IPSE 65%, SAU 53%, p = 0.006), and they worked on average more weeks competitively (IPS 25 weeks, IPSE 21 weeks, SAU 17 weeks; IPS vs. SAU p = 0.004 and IPSE vs. SAU p = 0.007). Moreover, participants in the two IPS groups had fewer outpatient visits during the 30-month follow-up. However, this was only statistically significant when comparing IPSE with SAU p = 0.017.

Conclusion

In conclusion, IPS and IPS enhanced with cognitive remediation and work-related skills training demonstrated that the vocational effects of the interventions are retrained over 30 months in a Danish context.

Efficacy and acceptability of psychosocial interventions in schizophrenia: systematic overview and quality appraisal of the meta-analytic evidence

Psychosocial interventions are recommended in schizophrenia and first-episode psychosis/early psychosis (EP). Nevertheless, literature is heterogeneous and often contradictory. We conducted an umbrella review of (network) meta-analyses of randomized controlled trials (RCTs) comparing psychosocial interventions vs treatment as usual (TAU)/active interventions(ACTIVE)/MIXED controls. Primary outcome was total symptoms (TS); secondary outcomes were positive/negative/depressive symptoms (PS/NS/DS), cognition, functioning, relapse, hospitalization, quality of life (QoL), treatment discontinuation. Standardized mean difference (SMD)/odds ratio (OR)/risk ratio (RR) vs TAU/ACTIVE/MIXED were summarized at end-of-treatment (EoT)/follow-up (FU). Quality was rated as high/medium/low (AMSTAR-PLUS). Eighty-three meta-analyses were included (RCTs = 1246; n = 84,925). Against TAU, regarding TS, Early Intervention Services (EIS) were superior EoT/FU in EP (SMD = -0.32/-0.21), cognitive behavioral therapy (CBT) in schizophrenia EoT/FU (SMD = -0.38/-0.19). Regarding secondary outcomes, in EP, EIS were superior for all outcomes EoT except cognition, and at FU for PS/NS/QoL, specific family interventions (FI-s) prevented relapse EoT; in schizophrenia, superiority emerged EoT for CBT for PS/NS/relapse/functioning/QoL; psychoeducation (EDU)/any FI for relapse; cognitive remediation therapy (CRT) for cognition/functioning; and hallucination-focused integrative treatment for PS. Against ACTIVE, in EP, mixed family interventions (FI-m) were superior at FU regarding TS (SMD = -0.61) and for functioning/relapse among secondary outcomes. In schizophrenia, regarding TS, mindfulness and social skills training (SST) were superior EoT, CBT at FU; regarding secondary outcomes superiority emerged at EoT for computerized cognitive drill-and-practice training for PS/DS, CRT for cognition/functioning, EDU for relapse, individual placement and support (IPS) for employment; and at FU CBT for PS/NS. Against MIXED, in schizophrenia, CRT/EDU were superior for TS EoT (d = -0.14/SMD = -0.33), CRT regarding secondary outcomes EoT for DS/social functioning, both EoT/FU for NS/cognition/global functioning; compensatory cognitive interventions for PS/functioning EoT/FU and NS EoT; CBT for PS at FU, and EDU/SST for relapse EoT. In conclusion, mental health services should consider prioritizing EIS/any FI in EP and CBT/CRT/any FI/IPS for schizophrenia, but other interventions may be helpful for specific outcomes.

Vocational rehabilitation augmented with cognitive behavioral therapy or cognitive remediation for individuals with schizophrenia: a 5-year follow-up study

INTRODUCTION

Although employment is an important part of recovery for individuals with schizophrenia spectrum disorders, the employment rate for this group remains low. Increasing evidence supports the use of augmented vocational rehabilitation (VR) programs to improve occupational outcome. The aim of this study is to explore 5-year follow-up registry data from the JUMP study, a VR program for individuals with schizophrenia spectrum disorders, specifically with regard to competitive employment outcome and predictors of competitive employment. The VR was augmented with either cognitive remediation (CR) or elements from cognitive behavior therapy (CBT).

METHODS

One hundred and forty eight participants with schizophrenia spectrum disorders from six Norwegian counties received 10 months VR augmented with either CR (n = 64) or CBT (n = 84). Both competitive and sheltered workplaces were used. Assessments were conducted at baseline, at post intervention and at 2-year follow-up. Data on employment status at 5-year follow-up was obtained by registry.

RESULTS

At 5-year follow-up 55.4% were engaged in working activity, of which 22.3% had obtained competitive employment. A further 18.2% had work placements in competitive workplaces. Number of received intervention hours and competitive employment at 2-year follow-up emerged as significant predictors of competitive employment. IQ and intervention type in marginal favor of CBT were predictors on trend level.

CONCLUSION

To the best of our knowledge, this is the first study investigating competitive employment at 5-year follow-up for individuals with schizophrenia spectrum disorders. The results add to existing evidence that competitive employment is attainable for this group.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

The effect of employment support integrated in substance use treatment: A health economic cost-effectiveness simulation of three different interventions

Background: Unemployment rates for individuals in treatment for substance use disorder (SUD) are high, with Norwegian estimates in the range of 81%–89%. Although Individual Placement and Support (IPS) represents a promising method to improved vocational outcome, cross-disciplinary investigations are needed to document implementation benefits and address reimbursements needs. The aim of this study was to model the potential socioeconomic value of employment support integrated in SUD treatment. Methods: Based on scientific publications, an ongoing randomised controlled trial (RCT) on employment support integrated in SUD treatment, and publicly available economy data, we made qualified assumptions about costs and socioeconomic gain for the different interventions targeting employment for patients with SUD: (1) treatment as usual (TAU); (2) TAU and a self-help guide and a workshop; and (3) TAU and IPS. For each intervention, we simulated three different outcome scenarios based on 100 patients. Results: Assuming a 40% employment rate and full-time employment (100%) for 10 years following IPS, we found a 10-year socioeconomic effect of €18,732,146. The corresponding effect for the more conservative TAU + IPS simulation assuming 40% part-time positions (25%) for five years, was €2,519,906. Compared to the two alternative interventions, IPS was cost-effective and more beneficial after six months to two years. Discussion: This concept evaluation study suggests that integrating employment support in the health services is socioeconomically beneficial. Our finding is relevant for decision makers within politics and health. Once employment rates from our ongoing RCT is available, real-life data will be applied to adjust model assumptions and socioeconomic value assumptions.

The impact of employment programs on common mental disorders: A systematic review

BACKGROUND

While employment programs were not created with the intent to improve common mental disorders (CMDs), they may have a positive impact on the prevalence, incidence, and severity of CMD by reducing poverty and increasing access to economic mobility.

AIM

To examine and synthesize the available quantitative evidence of the impact of employment programs on outcomes of CMD.

METHODS

Embase, Econlit, Global Health, MEDLINE, APA PsychINFO, and Social Policy and Practice were searched for experimental and quasi-experimental studies which investigated the impact of employment programs on primary and secondary outcomes of a CMD. A narrative synthesis according to Popay was conducted. The methodological quality of studies was assessed with the Cochrane Risk of Bias tool and the Newcastle-Ottawa Assessment Scale.

RESULTS

Of the 1,327 studies retrieved, two randomized controlled trials, one retrospective cohort, one pilot study with a non-randomized experimental design, and one randomized field experiment were included in the final review. Employment programs generally included multiple components such as skills-based training, and hands-on placements. Depression and anxiety were the CMDs measured as primary or secondary outcomes within included studies. Findings regarding the impact of employment programs on CMD were mixed with two studies reporting significantly positive effects, two reporting no effects, and one reporting mixed effects. The quality among included studies was good overall with some concerns regarding internal validity.

CONCLUSION

Employment programs may support a decrease in the prevalence, incidence, and severity of CMDs. However, there is high heterogeneity among study effects, designs, and contexts. More research is needed to gain further insight into the nature of this association and the mechanisms of impact. This review highlights the potential for employment programs and other poverty-reduction interventions to be utilized and integrated into the wider care, prevention, and treatment of common-mental disorders.

Reliability of the Term "Serious Mental Illness": A Systematic Review

OBJECTIVE

The term "serious mental illness" (SMI) is widely used across research, practice, and policy settings. However, there is no consistent operational definition, and its reliability has not been systematically evaluated. The purpose of this review was to provide a comprehensive qualitative content analysis of "SMI" empirical research, including study and sample characteristics and SMI operational definitions. These data can provide important considerations for how stakeholders conceptualize SMI.

METHODS

Systematic review of PsycInfo, PsycArticles, and PubMed databases from January 1, 2015, to December 31, 2019, identified 788 original empirical studies that characterized the sample as having "SMI."

RESULTS

Descriptive content analysis indicated that most studies (85%) provided no operational definition for SMI. Only 15% defined the term, and an additional 26% provided examples of SMI that included only psychiatric diagnostic categories (e.g., SMI, such as schizophrenia). Of the 327 studies that provided any description of SMI, variability was noted regarding whether criteria included any mental health diagnosis (N=31) or only specified diagnoses (N=289), functional impairment (N=73), or any specified duration of symptoms (N=39). Across all studies that characterized samples as having SMI, substantial variability was noted regarding included diagnostic classifications.

CONCLUSIONS

Referencing "SMI" is second nature for many stakeholders. Findings suggest that evidence-based practice and policy efforts should weigh the level of research support indicating that the construct and the term "SMI" lacks generalizability. Researchers and stakeholders are encouraged to develop precise and agreed-upon diagnostic language in their efforts to support and advocate for people with mental illnesses.

The impact of co-location employment partnerships within the Australian mental health service and policy context: A systematic review

Adults with a serious persistent mental illness (SPMI) express a strong desire to work. However, they continue to experience higher levels of unemployment, barriers, and occupational exclusion that impact their vocational outcomes and choice of work. The aim of this study was to investigate the impact of co-location partnerships between adult mental health and disability employment services (DES) on employment outcomes and consumer choice of work for adults with a SPMI. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, a systematic literature review was conducted by searching four databases. The relationship between mental health, employment, and DES was examined. Inclusion criteria were adults with a SPMI; employment services and outcomes; and job retention and sustainability. Twelve studies met inclusion criteria. All studies were peer-reviewed, Australian-based, and published between 01 January 2017 and 30 August 2021. Individual placement and support (IPS); DES practice, funding, policy, and reform within the Australian mental health system; and barriers to participation in DES were the three main themes that emerged. Findings highlight the importance of joint, co-location partnerships between mental health and employment services, including a collaborative approach to policy reform between both services, to assist adults with a SPMI to gain and sustain competitive employment. Vocational, non-vocational, systemic, and structural barriers still exist; hence, adults with a SPMI continue to face challenges with gaining and sustaining long-term employment. Hence, it is important for these partnerships to be systematically set up to support the complexity of the employment journey for adults with a SPMI.

Comparing Service Use and Costs of Individual Placement and Support With Usual Vocational Services for Veterans With PTSD

OBJECTIVE

Among veterans with posttraumatic stress disorder (PTSD), supported employment that utilizes the individual placement and support (IPS) model has resulted in consistently better employment and functional outcomes than usual vocational rehabilitation services. This study aimed to compare these two approaches in terms of health services use and associated costs.

METHODS

A secondary analysis of a multisite randomized controlled trial of 541 unemployed veterans with PTSD used archival data from electronic medical records to assess the use and costs of health services of IPS and usual care (i.e., a transitional work [TW] program) over 18 months. Comparisons were also made to an 18-month postintervention period.

RESULTS

The two study groups did not differ in number of inpatient days or in utilization or cost of high-intensity services. Annual per-person costs of health services were approximately 20% higher for IPS than for TW participants (mean difference=$4,910 per person per year, p<0.05) during the intervention period, largely driven by higher utilization and costs for vocational services in the IPS group (p<0.001). These costs declined postintervention to nonsignificant differences. The mean annual per-person vocational service cost was $6,388 for IPS and $2,549 for TW (mean difference=$3,839, p<0.001) during the intervention period.

CONCLUSIONS

In keeping with IPS’s intensive case management approach, veterans receiving IPS used more vocational services and had correspondingly higher costs than veterans receiving TW. The two groups did not differ in use or cost of other types of health services. Future research should examine whether higher short-term costs associated with IPS relative to usual care result in long-term cost savings or higher quality of life for persons with PTSD.

Evaluation of a supported education and employment program for adolescents and young adults with mental health problems: A study protocol of the StAB project

The majority of mental illnesses begins in childhood, adolescence and young adulthood before the age of 25. The transition from adolescence to adulthood is a particularly vulnerable time for adolescents with mental illness, affecting psychosocial functioning and participation in work life. Therefore, they need-in contrast to classic standard vocational interventions-a long-term, holistic and individually oriented vocational rehabilitation program. With the innovative model project "Start in education and employment (StAB)", adolescents and young adults with mental illnesses are to be supported with regard to their vocational perspectives and participation by a new type of individualized, holistic, long-term job coaching. It follows the Individual Placement and Support (IPS) concept, as a manualized form of the Supported Employment Approach and is based on the "first place-then train" principle. In order to evaluate the effectiveness and feasibility of the StAB program, a double-centre prospective single arm evaluation study in a mixed-methods design will be conducted. The focus is on quantitative research analysing pre-post-effects of the StAB intervention in a two-year observational study. Young people between 15 and 25 years with a psychiatric diagnosis who are currently in receipt of means-tested benefits or are entitled to them will be recruited. The study will take place in two major cities in the north-western part of Germany, Bielefeld and Dortmund. We expect to contribute to gain more empirical data about the implementation of Supported Employment and Education to severely mentally ill adolescents and young adults in German settings. Moreover, these results may also provide the scientific foundation for future measures focusing the improvement of vocational rehabilitation for young people with mental illness. The study was registered in the German Clinical Trials Register (DRKS00027576) on March 10, 2022.

Evaluation of an implementation strategy for Individual Placement and Support in the Netherlands: a 30-month observational study

BACKGROUND

Individual Placement and Support (IPS) is an evidence-based, effective approach to help people with severe mental illness (SMI) obtain and maintain competitive employment. The aim of the present study was to examine employment outcomes and associations with an organizational and a financial factor in people with SMI who participated in Individual Placement and Support using a multifaceted implementation strategy (IPS + MIS). The goal of this strategy was to improve IPS implementation by enhancing collaboration among mental health care and vocational rehabilitation stakeholders, and realizing secured IPS funding.

METHODS

An observational cohort study including 103 participants was conducted, with a 30-month follow-up. Descriptive analyses were used to examine employment outcomes. Multivariable logistic and linear regression analyses were performed to study associations with an organizational and a financial factor: the level of experience of mental health agencies with providing IPS + MIS and the type of IPS funding (i.e. municipality funding (reference group) and the Dutch Social Security Institute: the Institute for Employee Benefits Schemes (UWV) funding).

RESULTS

Forty-six percent of the participants were competitively employed at any time during the 30-month follow-up; the median number of days until competitive job obtainment and in competitive jobs was 201 and 265, respectively. The majority of all jobs obtained (81%) were categorized as 'elementary occupations', 'clerical support workers', and 'service and sales workers'. A higher level of experience of the mental health agencies with providing IPS + MIS was found to be positively associated with job obtainment (OR = 3.83, 95% CI 1.42-10.30, p = 0.01) and the number of days worked in competitive jobs (B = 1.21, 95% CI 0.36-2.07, p = 0.01). UWV funding was found to be negatively associated with job obtainment (OR = 0.30, 95% CI 0.11-0.77, p = 0.01). No association was found for the type of IPS funding and the number of days worked in competitive jobs (B = -0.73, 95% CI -1.48-0.02, p = 0.06).

CONCLUSIONS

This study shows that almost half of the people who participate in IPS + MIS obtain a competitive job within 30 months. The results further suggest that both the level of experience of mental health agencies with providing IPS + MIS, and funding may play a role in employment outcomes.

The Wither or Thrive Model of Resilience: an Integrative Framework of Dynamic Vulnerability and Resilience in the Face of Repeated Stressors During the COVID-19 Pandemic

During the first 2 years of the COVID-19 pandemic, empirical efforts in the psychological sciences have been unequivocally focused on understanding the psychosocial impact on resilience and vulnerability. While current empirical work is guided by different existing theoretical models of resilience and vulnerability, the emerging datasets have also pointed to a necessity for an update of these models. Due to the unique features and developments specific to the current pandemic such as the occurrence of repeated collective stressors of varying durations, in the current position paper, we introduce the Wither or Thrive model of Resilience (With:Resilience). It integrates key aspects of prevailing psychological resilience frameworks within the context of the COVID-19 pandemic, and extends them by (1) moving away from single scale approaches towards a higher-order latent expression of resilience and vulnerability incorporating also non-clinical mental health markers, (2) proposing different trajectories of resilience-vulnerability emerging across repeated stressors over long periods of time, and (3) by incorporating multiple influencing factors including aspects of the socio-economic concept of social cohesion as well as separate mediating processing mechanisms. We propose that With:Resilience will enable a more nuanced approach and appropriate analytical investigation of the vast incoming data on mental health and resilience during the COVID-19 pandemic, and we suggest some concrete methodological approaches. This framework will assist in the development of actionable public health guidelines for society in the present and future pandemic contexts as well as aid policy making and the interventional sciences aimed at protecting the most vulnerable amongst us.

Who benefits from individual placement and support? A meta-analysis

AIMS

Individual placement and support (IPS) is an evidence-based service model to support people with mental disorders in obtaining and sustaining competitive employment. IPS is increasingly offered to a broad variety of service users. In this meta-analysis we analysed the relative effectiveness of IPS for different subgroups of service users both based on the diagnosis and defined by a range of clinical, functional and personal characteristics.

METHODS

We included randomised controlled trials that evaluated IPS for service users diagnosed with any mental disorder. We examined effect sizes for the between-group differences at follow-up for three outcome measures (employment rate, job duration and wages), controlling for methodological confounders (type of control group, follow-up duration and geographic region). Using sensitivity analyses of subgroup differences, we analysed moderating effects of the following diagnostic, clinical, functional and personal characteristics: severe mental illness (SMI), common mental disorders (CMD), schizophrenia spectrum disorders, mood disorders, duration of illness, the severity of symptoms, level of functioning, age, comorbid alcohol and substance use, education level and employment history.

RESULTS

IPS is effective in improving employment outcomes compared to the control group in all subgroups, regardless of any methodological confounder. However, IPS was relatively more effective for service users with SMIs, schizophrenia spectrum disorders and a low symptom severity. Although IPS was still effective for people with CMD and with major depressive disorder, it was relatively less effective for these subgroups. IPS was equally effective after both a short and a long follow-up period. However, we found small, but clinically not meaningful, differences in effectiveness of IPS between active and passive control groups. Finally, IPS was relatively less effective in European studies compared to non-European studies, which could be explained by a potential benefits trap in high welfare countries.

CONCLUSIONS

IPS is effective for all different subgroups, regardless of diagnostic, clinical, functional and personal characteristics. However, there might be a risk of false-positive subgroup outcomes and results should be handled with caution. Future research should focus on whether, and if so, how the IPS model should be adapted to better meet the vocational needs of people with CMD and higher symptom severity.

"These are people just like us who can work": Overcoming clinical resistance and shifting views in the implementation of Individual Placement and Support (IPS)

Purpose

Individual Placement and Support (IPS) is a recovery-based approach to support people with mental health difficulties back into employment. Embedding of IPS within the mental health Multi-Disciplinary Team (MDT) is a key component of IPS fidelity; however, few studies have examined how those involved with IPS implementation navigate this process. This article explores how IPS Employment Specialists (ES) and Occupational Therapist (OT) Managers integrated and embedded IPS within traditionally-oriented MDTs as part of a national reform program in the Republic of Ireland.

Methods

The study design was qualitative, descriptive with data collected through three focus groups with 17 IPS ESs and 11 OT Managers. Data were analyzed using thematic synthesis.

Results

Three key themes emerged from analysis. The first characterizes the context into which IPS landed, described as one marked by clinical resistance, doubt, and fear of risk. The second explores the strategies and factors that helped with the introduction of IPS into Irish mental health services. These included strategies, such as providing education and information about IPS and reassuring the MDT about IPS governance and IPS ES’ competencies. The evidenced-based nature of IPS and its attached accountabilities through IPS fidelity measures were perceived to be an important factor in its acceptance. The final theme encapsulates perceptions of how IPS impacted on the MDTs’ views of people with mental health difficulties. Findings suggest a shift in the ways in which MDTs view their clients. Initial fears about work capacity and risk shifted towards seeing people beyond the label of ‘service user’ and their diagnosis.

Conclusions

It is contended that IPS is an approach that allows practitioners to engage with real recovery-practice and may be one key to unlocking how a recovery approach can truly trickle down and embed itself within mental health service provision and support mental health system reform.

Evaluating Educational and Employment Services for Young People With Psychiatric Conditions: A Systematic Review

OBJECTIVE

The authors conducted a systematic review of studies evaluating vocational interventions for young people with psychiatric conditions to determine the extent to which services were adapted for young people and whether services promoted gains in postsecondary education and employment.

METHODS

Five databases (PubMed, PsycINFO, Web of Science, Academic Search Premier, and ERIC) were searched. Sources eligible for inclusion were controlled studies published between 2000 and mid-2020 that evaluated a vocational intervention and examined postsecondary educational or employment outcomes for youths or young adults (ages 14-35 years) with psychiatric conditions.

RESULTS

Ten studies met the inclusion criteria. Several of the studies evaluated services that were adapted for young people, including through the incorporation of educational supports. The most consistent finding was that services based on the individual placement and support (IPS) model improved employment outcomes more effectively than did comparison approaches and treatment as usual. Fewer studies assessed educational outcomes, and they yielded mixed results; however, recent findings from a controlled trial indicate that an enhanced IPS intervention that included well-specified supported education and skills training led to significantly superior outcomes in both education and employment.

CONCLUSIONS

These results provide support for the efficacy of IPS-based services to improve employment outcomes among young people with psychiatric conditions and suggest that adapting IPS to include comprehensive educational supports and skills training may be important for efforts to improve postsecondary educational outcomes. Additional well-controlled intervention studies that examine educational and longer-term outcomes should further inform the development and delivery of vocational services for this population.

Heeding the Call of an Innovative Paradigm for Mental Health Interventions in Low- and Middle-income Countries

The provision of mental health care for people living in low- and middle-income countries presents a particularly complex problem because of fractured service availability and provision, widespread stigma associated with mental illness, and the economic burden inherent in conventional mental health service delivery. People with serious mental illness in these settings are among the most marginalized in their societies and are at risk of becoming increasingly powerless in the face of top-down, service-oriented systems. Innovative intersectoral approaches that are based on asset development and entrepreneurism and that embrace the power of peer-driven networks hold promise to effect transformative and meaningful change.