Supported Employment for the Reintegration of Disability Pensioners with Mental Illnesses: A Randomized Controlled Trial

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.

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.

Return to work factors and vocational rehabilitation interventions for long-term, partially disabled workers: a modified Delphi study among vocational rehabilitation professionals

Background

Long-term disability has a great impact on both society and workers with disabilities. Little is known about the barriers which prohibit workers with long-term disabilities from returning to work and which interventions are best suited to counteract these barriers. The main purpose of this study was to obtain consensus among professionals on important return to work (RTW) factors and effective vocational rehabilitation (VR) interventions for long-term (> 2 years), partially disabled workers. Our three research questions were: (1) which factors are associated with RTW for long-term disabled workers?; (2) which factors associated with RTW can be targeted by VR interventions?; and (3) which VR interventions are the most effective to target these factors?

Methods

A modified Delphi Study was conducted using a panel of 22 labour experts, caseworkers, and insurance physicians. The study consisted of several rounds of questionnaires and one online meeting.

Results

The multidisciplinary panel reached consensus that 58 out of 67 factors were important for RTW and that 35 of these factors could be targeted using VR interventions. In five rounds, the expert panel reached consensus that 11 out of 22 VR interventions were effective for at least one of the eight most important RTW factors.

Conclusions

Consensus was reached among the expert panel that many factors that are important for the RTW of short-term disabled workers are also important for the RTW of long-term partially disabled workers and that a substantial number of these factors could effectively be targeted using VR interventions. The results of this study will be used to develop a decision aid that supports vocational rehabilitation professionals in profiling clients and in choosing suitable VR interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13295-6.

Vocational Outcomes of the Individual Placement and Support Model in Subgroups of Diagnoses, Substance Abuse, and Forensic Conditions: A Systematic Review and Analysis of Pooled Original Data

PURPOSE

To investigate the effect of Individual Placement and Support (IPS) according to diagnoses of schizophrenia, bipolar disorder, major depression, substance use disorders, or forensic psychiatric conditions.

METHODS

A systematic search of the literature was conducted in June 2017 and repeated in December 2020. The systematic review included 13 studies. Analyses of pooled original data were based on the six studies providing data (n = 1594). No studies on forensic psychiatric conditions were eligible. Hours and weeks worked were analyzed using linear regression. Employment, and time to employment was analyzed using logistic regression, and cox-regression, respectively.

RESULTS

The effects on hours and weeks in employment after 18 months were comparable for participants with schizophrenia, and bipolar disorder but only statistically significant for participants with schizophrenia compared to services as usual (SAU) (EMD 109.1 h (95% CI 60.5-157.7), 6.1 weeks (95% CI 3.9-8.4)). The effect was also significant for participants with any drug use disorder (121.2 h (95% CI 23.6-218.7), 6.8 weeks (95% CI 1.8-11.8)). Participants with schizophrenia, bipolar disorder, and any drug use disorder had higher odds of being competitively employed (OR 2.1 (95% CI 1.6-2.7); 2.4 (95% CI 1.3-4.4); 3.0 (95% CI 1.5-5.8)) and returned to work faster than SAU (HR 2.1 (95% CI 1.6-2.6); 1.8 (95% CI 1.1-3.1); 3.0 (95% CI 1.6-5.7)). No statistically significant effects were found regarding depression.

CONCLUSIONS

IPS was effective regarding schizophrenia, bipolar disorder, and substance use disorder; however, the effect on hours, and weeks worked was not statistically significant regarding bipolar disorder. For people with depression the impact of IPS remains inconclusive. Non-significant results may be due to lack of power.

TRIAL REGISTRATION

PROSPERO protocol nr. CRD42017060524.

Predictors of employment in people with moderate to severe mental illness participating in a randomized controlled trial of Individual Placement and Support (IPS)

BACKGROUND

Many people with moderate to severe mental illness have a desire to obtain ordinary employment. To aid further development of health and social services for this group, the aim of this study was to examine candidate modifiable and prognostic markers of employment, and moderating effects of group allocation in a clinical trial.

METHOD

The sample consists of 327 patients in treatment for mental illness, randomized to Individual Placement and Support (IPS) or treatment as usual (TAU) as part of a clinical trial. Psychosocial and demographic baseline characteristics were included as predictors in log binary regression analyses with employment 18 months after inclusion as the outcome, and group allocation as the moderator (IPS or TAU).

RESULTS

Directive emotional support and non-directive instrumental support seemed to positively predict employment, but effects were small. Involuntary hospitalization seemed to be a strong negative predictor of employment. Group allocation did not moderate any main effects.

CONCLUSION

Interpretation of the findings suggest that attention should be given to certain aspects of health and social services provided to this target group, and in particular the effect of receiving appropriate types of social support. The findings are novel because social support and involuntary hospitalization do not seem to have been included in previous predictor studies. The results from this study identify new topics for research on employment outcomes for this population.

Long-Term Effects of the Individual Placement and Support Intervention on Employment Status: 6-Year Follow-Up of a Randomized Controlled Trial

People with mental illness often experience difficulties with reintegration into the workplace, although employment is known to assist these individuals in their recovery process. Traditional approaches of "first train, then place" have been recently replaced by supported employment (SE) methods that carry strategy of "first place, then train." Individual placement and support (IPS) is one of the best-studied methods of SE, which core principles are individualized assistance in rapid job search with consequent placement in a paid employment position. A considerable amount of high-quality evidence supported the superiority of IPS over conventional methods in providing improved employment rates, longer job tenure, as well as higher salaries in competitive job markets. Nonetheless, our knowledge about the IPS-mediated long-term effects is limited. This non-interventional follow-up study of a previously published randomized controlled trial (RCT) called ZhEPP aimed to understand the long-term impact of IPS after 6 years since the initial intervention. Participants from the ZhEPP trial, where 250 disability pensioners with mental illnesses were randomized into either IPS intervention group or treatment as usual group (TAU), were invited to face-to-face interviews, during which employment status, job tenure, workload, and salaries were assessed. One hundred and fourteen individuals agreed to participate in this follow-up study. Although during the first 2 years post-intervention, the IPS group had higher employment rates (40% (IPS) vs. 28% (TAU), p < 0.05 at 24 months), these differences disappeared by the time of follow-up assessments (72 months). The results indicated no substantial differences in primary outcome measures between IPS and TAU groups: employment rate (36 vs. 33%), workload (10.57 vs. 10.07 h per week), job tenure (29 vs. 28 months), and salary (20.21CHF vs. 25.02 CHF). These findings provide important insights regarding the long-term effects of IPS among individuals with mental health illnesses. Further research is required to advance the current knowledge about IPS intervention and its years-long impact.

A structured mixed method process evaluation of a randomized controlled trial of Individual Placement and Support (IPS)

Background

Individual Placement and Support (IPS) is an evidence-based work rehabilitation program helping people with moderate to severe mental illness to obtain ordinary employment. Although IPS has proven superior to other work rehabilitation programs, in many studies, the majority of the participants remain unemployed. Structured process evaluations of IPS that use mixed methods are scarce, although they could identify implementation aspects that may enhance its effect. The aim of the current study is to assess reach, fidelity, and identify barriers and facilitators to implement IPS.

Methods

The process evaluation was conducted alongside a randomized controlled trial including six IPS centers, comparing IPS with treatment as usual in a population of patients in treatment for moderate to severe mental illness. Mixed methods were used in the process evaluation, including focus group interviews with service providers, individual interviews and survey data from participants, and fidelity reviews using the validated IPS Fidelity Scale.

Results

The intervention reached the intended target group. All centers reached fair to good fidelity according to the IPS Fidelity Scale within the project period (range 97–109, SD 8.1) (see Table 5). Certain fidelity items indicated implementation issues related to employer contact, community-based services, and integration with health services. Survey data showed that less than half of the participants regarded their illness as a barrier for participating in IPS and that freedom of disclosure was important. Participant interviews gave further insight into the role of the IPS specialist, emphasizing their availability and consistent job focus.

Conclusions

Indications of implementation challenges across centers during the first year suggest special attention should be given to these aspects in an early phase to ensure higher fidelity from the start and thus enhance the effectiveness of IPS. The IPS specialist played an important role for participants and was described as positive, pushing in a positive way, and encouraging. More knowledge on the characteristics of successful IPS specialists could further enhance the effectiveness of the intervention.

Trial registration

The study was registered on clinicaltrials.gov prior to the inclusion period (reg.no: NCT01964092, registered 17/07/2013).

Supplementary information

Supplementary information accompanies this paper at 10.1186/s43058-020-00083-9.

A meta-regression of the impact of policy on the efficacy of individual placement and support

OBJECTIVE

Individual placement and support (IPS) has shown consistently better outcomes on competitive employment for patients with severe mental illness than traditional vocational rehabilitation. The evidence for efficacy originates from few countries, and generalization to different countries has been questioned. This has delayed implementation of IPS and led to requests for country-specific RCTs. This meta-analysis examines if evidence for IPS efficacy can be generalized between rather different countries.

METHODS

A systematic search was conducted according to PRISMA guidelines to identify RCTs. Overall efficacy was established by meta-analysis. The generalizability of IPS efficacy between countries was analysed by random-effects meta-regression, employing country- and date-specific contextual data obtained from the OECD and the World Bank.

RESULTS

The systematic review identified 27 RCTs. Employment rates are more than doubled in IPS compared with standard vocational rehabilitation (RR 2.07 95% CI 1.82-2.35). The efficacy of IPS was marginally moderated by strong legal protection against dismissals. It was not moderated by regulation of temporary employment, generosity of disability benefits, type of integration policies, GDP, unemployment rate or employment rate for those with low education.

CONCLUSIONS

The evidence for efficacy of IPS is very strong. The efficacy of IPS can be generalized between countries.

[Return to Work after Temporary Disability Pension]

BACKGROUND

In Germany, there are no statistics available that reveal how many temporary disability pensioners return to work. The aim of this study was to analyse how many persons to whom a temporary disability pension was granted in 2006 returned to work. Their socio-demographic, health-related and vocational characteristics were examined.

METHODS

The scientific use file "Completed Rehabilitation 2006-2013 in the Course of Individual Pension Records" provided by the research data centre of the German Pension Fund was analysed. Return to Work was assumed if a person worked at least part-time for 183 to 365 days with not less than 8.50 euro/hour in one of the following seven years after being pensioned. The development of the cohort was assessed descriptively. Cox regression analyses were conducted to determine the influence of socio-demographic, health-related and vocational characteristics of the pensioners on their return to work.

RESULTS

Between 2007 and 2013, 5.9% of the initial cohort (N=9.789) returned to work; 25% of these returned to work in all seven years. Between 2006 and 2014, 10.6% of the initial cohort died, 9.1% shifted to old-age pension and 1.4% were granted an unlimited disability pension. Regression analysis indicates that sociodemographic, health-related and vocational characteristics are associated with the probability of return to work: Disability pensioners aged between 18 and 39 years, with a somatic disease, who went through medical rehabilitation or were employed before the disability pension had the highest probability of return to work.

CONCLUSION

The results show that only few persons with temporary disability pension returned to work. Therefore, it could be concluded that criteria for temporal limitations of pensions should be sharpened in order to reduce the amount of additional medical evaluations. On the other hand, new strategies to support pensioners' potential for return to work have to be considered.

Supported employment: Meta-analysis and review of randomized controlled trials of individual placement and support

Supported employment is a treatment whereby those with severe mental illness (or other disabilities) receive aid searching for competitive employment and mental health (or other) treatments concurrently. The most popular implementation of supported employment is individual placement and support (IPS). We conducted meta-analytic analyses of the randomized controlled trials of IPS. We found that subjects in IPS, compared to usual treatment conditions, had better vocational outcomes (obtained any competitive employment: RR = 1.63, 95%CI = [1.46, 1.82]; job tenure: d = 0.55, 95%CI = [0.33, 0.79]; job length: d = 0.46, 95%CI = [0.35, 0.57]; income: d = 0.48, 95%CI = [0.36, 0.59]) Non-vocational outcomes estimates, while favoring IPS, included the null (quality of life: d = 0.30, 95%CI = [-0.07, 0.67]; global functioning: d = 0.09, 95%CI = [-0.09, 0.27]; mental health: d = 0.03, 95%CI = [-0.15, 0.21]). Analysis of the expected proportion of studies with a true effect on non-vocational outcomes with d>0.2 showed some reason to expect a possible improvement for quality of life for at least some settings (Prop = 0.57, 95%CI = [0.30, 0.84]).

Economic, Labor, and Regulatory Moderators of the Effect of Individual Placement and Support Among People With Severe Mental Illness: A Systematic Review and Meta-analysis

As Individual Placement and Support (IPS) has become the international standard for vocational rehabilitation of adults with serious mental illness, researchers must consider the relationship between IPS and local environments. This meta-analysis used mixed-effects meta-regressions to assess the impact of site-level moderators on the likelihood that IPS recipients, compared with recipients of alternative vocational services, achieved competitive employment. Potential moderators included change in gross domestic product (GDP), local unemployment and unionization rates, and indices describing employment protection regulations, level of disability benefits compensation, and efforts to integrate people with disabilities into the workforce. Regulatory moderators represent facilitators and barriers to employment that may reinforce or detract from the effectiveness of IPS. Across 30 sites drawn from 21 randomized controlled trials in 12 countries (33% in the United States), IPS recipients were 2.31 (95% CI 1.99-2.69) times more likely to find competitive employment than recipients of alternative vocational rehabilitation services. The significant competitive-employment rate advantage of IPS over control services increased in the presence of weaker employment protection legislation and integration efforts, and less generous disability benefits. Policy makers should recognize and account for the fact that labor and disability regulations can create an arrangement of incentives that reduces the relative efficacy of supported employment.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Protocol for the SEED-trial: Supported Employment and preventing Early Disability

BACKGROUND

Early withdrawal or exclusion from the labor market leads to significant personal and societal costs. In Norway, the increasing numbers of young adults receiving disability pension is a growing problem. While a large body of research demonstrates positive effects of Supported Employment (SE) in patients with severe mental illness, no studies have yet investigated the effectiveness of SE in young adults with a range of social and health conditions who are receiving benefits.

METHODS/DESIGN

The SEED-trial is a randomized controlled trial (RCT) comparing traditional vocational rehabilitation (TVR) to SE in 124 unemployed individuals between the ages of 18-29 who are receiving benefits due to various social- or health-related problems. The primary outcome is labor market participation during the first year after enrollment. Secondary outcomes include physical and mental health, health behaviors, and well-being, collected at baseline, 6, and 12 months. A cost-benefit analysis will also be conducted.

DISCUSSION

The SEED-trial is the first RCT to compare SE to TVR in this important and vulnerable group, at risk of being excluded from working life at an early age.

TRIAL REGISTRATION

Clinicaltrials.gov, registration number NCT02375074 . Registered on December 3rd 2014.