Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work

OBJECTIVE

People with psychiatric impairments (primarily schizophrenia or a mood disorder) are the largest and fastest-growing group of Social Security Disability Insurance (SSDI) beneficiaries. The authors investigated whether evidence-based supported employment and mental health treatments can improve vocational and mental health recovery for this population.

METHOD

Using a randomized controlled trial design, the authors tested a multifaceted intervention: team-based supported employment, systematic medication management, and other behavioral health services, along with elimination of barriers by providing complete health insurance coverage (with no out-of-pocket expenses) and suspending disability reviews. The control group received usual services. Paid employment was the primary outcome measure, and overall mental health and quality of life were secondary outcome measures.

RESULTS

Overall, 2,059 SSDI beneficiaries with schizophrenia, bipolar disorder, or depression in 23 cities participated in the 2-year intervention. The teams implemented the intervention package with acceptable fidelity. The intervention group experienced more paid employment (60.3% compared with 40.2%) and reported better mental health and quality of life than the control group.

CONCLUSIONS

Implementation of the complex intervention in routine mental health treatment settings was feasible, and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life.

Characterizing risk factors for pediatric lamp oil product exposures

Poisonings from lamp oil ingestion continue to occur worldwide among the pediatric population despite preventive measures such as restricted sale of colored and scented lamp oils. This suggests that optimal prevention practices for unintentional pediatric exposures to lamp oil have yet to be identified and/or properly implemented.

OBJECTIVE

To characterize demographic, health data, and potential risk factors associated with reported exposures to lamp oil by callers to poison centers (PCs) in the US and discuss their public health implications.

STUDY DESIGN

This was a two part study in which the first part included characterizing all exposures to a lamp oil product reported to the National Poison Data System (NPDS) with regard to demographics, exposure, health, and outcome data from 1/1/2000 to 12/31/2010. Regional penetrance was calculated using NPDS data by grouping states into four regions and dividing the number of exposure calls by pediatric population per region (from the 2000 US census). Temporal analyses were performed on NPDS data by comparing number of exposures by season and around the July 4th holiday. Poisson regression was used to model the count of exposures for these analyses. In the second part of this project, in order to identify risk factors we conducted a telephone-based survey to the parents of children from five PCs in five different states. The 10 most recent lamp oil product exposure calls for each poison center were systematically selected for inclusion. Calls in which a parent or guardian witnessed a pediatric lamp oil product ingestion were eligible for inclusion. Data on demographics, exposure information, behavioral traits, and health were collected. A descriptive analysis was performed and Fisher's exact test was used to evaluate associations between variables. All analyses were conducted using SAS v9.3.

RESULTS

Among NPDS data, 2 years was the most common patient age reported and states in the Midwestern region had the highest numbers of exposure calls compared to other regions. Exposure calls differed by season (p < 0.0001) and were higher around the July 4th holiday compared to the rest of the days in July (2.09 vs. 1.89 calls/day, p < 0.002). Most exposures occurred inside a house, were managed on-site and also had a "no effect" medical outcome. Of the 50 PC-administered surveys to parents or guardians, 39 (78%) met inclusion criteria for analysis. The majority of ingestions occurred in children that were 2 years of age, that were not alone, involved tiki torch fuel products located on a table or shelf, and occurred inside the home. The amount of lamp oil ingested did not appear to be associated with either the smell (p = 0.19) or the color of the oil (p = 1.00) in this small sample. Approximately half were asymptomatic (n = 18; 46%), and of those that reported symptoms, cough was the most common (n = 20, 95%) complaint.

CONCLUSIONS

Lamp oil product exposures are most common among young children (around 2 years of age) while at home, not alone and likely as a result of the product being in a child-accessible location. Increasing parental awareness about potential health risks to children from these products and teaching safe storage and handling practices may help prevent both exposures and associated illness. These activities may be of greater benefit in Midwestern states and during summer months (including the period around the July 4th holiday).

Supported employment for adults with severe mental illness

BACKGROUND

People who suffer from severe mental disorder experience high rates of unemployment. Supported employment is an approach to vocational rehabilitation that involves trying to place clients in competitive jobs without any extended preparation. The Individual placement and support (IPS) model is a carefully specified form of supported employment.

OBJECTIVES

1. To review the effectiveness of supported employment compared with other approaches to vocational rehabilitation or treatment as usual.2. Secondary objectives were to establish how far:(a) fidelity to the IPS model affects the effectiveness of supported employment,(b) the effectiveness of supported employment can be augmented by the addition of other interventions.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (February 2010), which is compiled by systematic searches of major databases, handsearches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, of working age (normally 16 to 70 years), where supported employment was compared with other vocational approaches or treatment as usual. Outcomes such as days in employment, job stability, global state, social functioning, mental state, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

Two review authors (YK and KK) independently extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% (CI). We employed a fixed-effect model for analyses. A random-effects model was also employed where heterogeneity was present.

MAIN RESULTS

A total of 14 randomised controlled trials were included in this review (total 2265 people). In terms of our primary outcome (employment: days in competitive employment, over one year follow-up), supported employment seems to significantly increase levels of any employment obtained during the course of studies (7 RCTs, n = 951, RR 3.24 CI 2.17 to 4.82, very low quality of evidence). Supported employment also seems to increase length of competitive employment when compared with other vocational approaches (1 RCT, n = 204, MD 70.63 CI 43.22 to 94.04, very low quality evidence). Supported employment also showed some advantages in other secondary outcomes. It appears to increase length (in days) of any form of paid employment (2 RCTs, n = 510, MD 84.94 CI 51.99 to 117.89, very low quality evidence) and job tenure (weeks) for competitive employment (1 RCT, n = 204, MD 9.86 CI 5.36 to 14.36, very low quality evidence) and any paid employment (3 RCTs, n = 735, MD 3.86 CI -2.94 to 22.17, very low quality evidence). Furthermore, one study indicated a decreased time to first competitive employment in the long term for people in supported employment (1 RCT, n = 204, MD -161.60 CI -225.73 to -97.47, very low quality evidence). A large amount of data were considerably skewed, and therefore not included in meta-analysis, which makes any meaningful interpretation of the vast amount of data very difficult.

AUTHORS' CONCLUSIONS

The limited available evidence suggests that supported employment is effective in improving a number of vocational outcomes relevant to people with severe mental illness, though there appears to exist some overall risk of bias in terms of the quality of individual studies. All studies should report a standard set of vocational and non-vocational outcomes that are relevant to the consumers and policy-makers. Studies with longer follow-up should be conducted to answer or address the critical question about durability of effects.

A test of the occupational matching hypothesis for rehabilitation clients with severe mental illness

PURPOSE

This study compared job matching rates for clients with severe mental illness enrolled in two types of employment programs. Also examined was the occupational matching hypothesis that job matching is associated with better employment outcomes.

METHODS

The study involved a secondary analysis of a randomized controlled trial comparing evidence-based supported employment to a diversified placement approach. The study sample consisted of 187 participants, of whom 147 obtained a paid job during the 2-year follow-up. Jobs were coded using the Dictionary of Occupational Titles classification system. Match between initial job preferences and type of job obtained was the predictor variable. Outcomes included time to job start, job satisfaction, and job tenure on first job.

RESULTS

Most occupational preferences were for clerical and service jobs, and most participants obtained employment in these two occupational domains. In most cases, the first job obtained matched a participant's occupational preference. The occupational matching hypothesis was not supported for any employment outcome. The occupational matching rate was similar in this study to previous studies.

CONCLUSIONS

Most clients who obtain employment with the help of evidence-based supported employment or diversified placement services find jobs matching their occupational preference, and most often it is a rough match. Occupational matching is but one aspect of job matching; it may be time to discard actuarial classification systems such as the Dictionary of Occupational Titles as a basis for assessing job match.

Job development guidelines in supported employment

TOPIC

This article describes methods for building relationships with employers that benefit both employers and job seekers.

PURPOSE

Many employment specialists receive little training on how to work with employers and, therefore, resort to online job searches. This article describes a simple framework for developing long-term relationships with employers.

SOURCES USED

Personal observations and published literature.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Employment specialists benefit from a structured format to develop relationships with employers, as well as good supervision in the field.

Essential evidence-based components of first-episode psychosis services

OBJECTIVE The purpose of this study was to identify essential evidence-based components of first-episode psychosis services. METHODS The study was conducted in two stages. In the first stage a systematic review of both peer-reviewed and gray literature (January 1980 to April 2010) was conducted. Databases searched included MEDLINE, PsycINFO, and EMBASE. In the second stage, a consensus-building technique, the Delphi, was used with an international panel of experts. The panelists were presented the evidence-based components identified in the review, together with the level of supporting evidence for each component. They rated the importance of each component on a 5-point scale. A score of 5 was required to determine that a component was essential. RESULTS The review identified 1,020 citations; abstracts were reviewed for relevance. A total of 280 peer-reviewed articles met criteria for relevance. Two researchers independently reviewed these articles and identified 75 unique service components. Each component was assigned a level of supporting evidence. Twenty-seven experts completed the first Delphi round, of whom 23 participated in the second. Consensus was achieved in two rounds, with 32 components rated as essential. CONCLUSIONS The two-step process yielded a manageable list of 32 evidence-based components of first-episode psychosis services. Given the proliferation of such services and the absence of an evidence-based fidelity scale, this list can form a foundation for developing a fidelity scale for such services. It may also be helpful to funders and providers as a summary of essential services.

Early psychosis and employment

BACKGROUND

Employment may be an important factor in helping patients with early psychosis to recover rapidly and to avoid involvement in disability and welfare programs.

METHODS

This study followed 351 patients with early psychoses, either primary psychoses or substance-induced psychoses, for two years to examine their patterns of competitive employment in relation to service use, psychosocial outcomes, and disability and welfare payments.

RESULTS

Workers differed from non-workers at baseline and over two years. At baseline, they had better educational and employment histories, were more likely to have substance-induced psychoses rather than primary psychoses, were less likely to have drug dependence, had fewer negative symptoms, and had better psychosocial adjustment. Over two years, baseline psychosocial differences persisted, and the workers used fewer medications, mental health services, and disability or welfare payments.

CONCLUSIONS

Employment predicts less service use and fewer disability claims among early psychosis patients. Thus, greater attention to supported employment early in the course of illness may reduce federal insurance costs and disability payments.

Employer attitudes about criminal histories

OBJECTIVE

Although the individual placement and support (IPS) approach has demonstrated superior competitive employment outcomes for people with severe mental illness, practitioners report that job obtainment for people with criminal convictions is particularly challenging. The current study examined employer hiring decisions and attitudes regarding job applicants with felonies. The main purpose of the study was to identify the percentage of employers who had knowingly hired applicants with felonies, and if the hiring patterns differed by employer type.

METHOD

Twelve employment specialists from nine states interviewed 128 employers about their past hiring practices. Two IPS trainers coordinated the project with the specialists.

RESULTS

Survey findings did not support common assumptions held by employment specialists about employer attitudes. Sixty-three percent of employers surveyed said that they had knowingly hired at least one person with a felony conviction. Further, few businesses had written policies that would prohibit the hiring of people with felony convictions.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Employers' reported reasons for having hired individuals with felony convictions provide a framework to help jobseekers improve their prospects for favorable hiring decisions. Employers suggested that relationships with employment specialists can also facilitate the hiring of applicants with felonies.

Program fidelity and beyond: multiple strategies and criteria for ensuring quality of assertive community treatment

OBJECTIVE

In most public mental health systems, assertive community treatment (ACT) is a key service for people with severe mental illness. Although considerable research supports the effectiveness of ACT as an evidence-based practice, other research indicates a failure to adequately implement or sustain ACT, resulting in a diminishing quality of services over time. There have been relatively few attempts to develop and test strategies for implementing new ACT teams and for ensuring their operational and service quality over time. The authors provide a heuristic model for administrators and providers seeking to implement and sustain high-quality ACT programs.

METHODS

The authors conducted a selected review of literature about implementation and sustainability of ACT published between January 2000 and May 2011. The review was supplemented by the authors' experiences as researchers, administrators, trainers and consultants, and practitioners.

RESULTS

A total of 57 articles were found by searches in PsycINFO and PubMed. The authors propose four major approaches for assessing and ensuring the quality of ACT programs--policy and administrative, training and consultation, team operational, and program evaluation--and identify strategies for achieving the goals in each category.

CONCLUSIONS

Although a scarcity of rigorous research makes firm conclusions difficult, the authors conclude that no single strategy is sufficient for ensuring adequate ACT implementation and services of consistently good quality. Rather, it is useful to implement a blend of policy and administrative, training and consultation, team operational, and program evaluation strategies. Additional rigorous research on implementing and sustaining the quality of ACT and other evidence-based practices is needed.

Standardizing measures in four domains of employment outcomes for individual placement and support

OBJECTIVE

Virtually all studies of the individual placement and support (IPS) model of supported employment measure outcomes for job acquisition, but studies are less consistent in measuring job tenure, hours worked, and employment earnings. Lack of a common set of employment measures limits comparisons across studies and cumulative knowledge about IPS. To lay the groundwork for standardization, this study examined measures in four employment domains and their interrelationships.

METHODS

Using a combined data set from four randomized controlled trials of IPS, this study examined mean differences between IPS participants (N=307) and participants in other vocational services (control sample) (N=374) in four domains (job acquisition, job duration, hours worked per week, and total hours and wages). Eight competitive employment measures were examined (employed at any time, total weeks worked, tenure in the longest-held job, total hours worked, average hours per week worked, total wages, days to first job, and working ≥ 20 hours per week during follow-up). Correlations between measures within both the IPS and control samples were determined.

RESULTS

IPS participants had significantly better outcomes across all employment measures and domains. Correlations between measures were strong within each domain, but they were variable between domains.

CONCLUSIONS

In addition to improving job acquisition, IPS improved job duration, hours worked per week, and total hours and wages. The correlational findings suggest proxy measures to assist meta-analysts in the synthesis of studies for which direct measures are unavailable. Initial steps toward a cross-disciplinary theoretical framework for employment outcomes are described.

Validation of the Revised Individual Placement and Support Fidelity Scale (IPS-25)

OBJECTIVE

The individual placement and support (IPS) model of supported employment for people with severe mental illness is an evidence-based practice. The 15-item IPS Fidelity Scale (IPS-15) was developed to measure program fidelity and has been shown to have good psychometric properties, including predictive validity. On the basis of field experience and research updates, the authors developed an expanded and revised version of this scale, the IPS-25, also known as the Supported Employment Fidelity Scale. This study evaluated the psychometric properties of the IPS-25.

METHODS

In addition to data on the local unemployment rate and program longevity, the authors collected IPS-25 ratings and employment data for 79 sites in eight states participating in a learning collaborative devoted to implementing the IPS model. Descriptive data for items and the total scale and predictive validity were examined.

RESULTS

Internal consistency reliability for the IPS-25 was .88. Predictive validity, measured as the correlation between the IPS-25 and site-level employment rate, was .34. Eight of the IPS-25 items were significantly positively correlated with employment rate. Items related to the vocational generalist role, disclosure, follow-along support, and vocational unit were the most strongly correlated with employment. Program longevity was positively associated with employment, whereas the unemployment rate was not.

CONCLUSIONS

The IPS-25 has promising psychometric properties, with greater precision and content coverage than the IPS-15. However, it has not demonstrated an advantage over the IPS-15 in predictive validity. Research directly comparing the two scales is needed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Community mental health agency views of research

We examined community mental health center staff perceptions of ongoing research within their agency. We interviewed upper management and conducted focus groups with medical staff, non-medical clinicians, and administrative staff. Participants were asked about (1) their attitudes towards research in general, agency research and towards the principal academic institution doing research with clients, (2) their perceptions of the value of research and (3) ideas for improving the collaboration. We identified 5 overarching themes: inter-agency communication, shared goals and equality in research, researchers adding knowledge to the agency, improving attitudes toward research, and agency involvement in research. Under these domains, specific suggestions are made for how to improve the collaboration across all stakeholder groups. Lack of shared values and inadequate communication processes can negatively impact community-based research collaborations. However, clear strategies, and adequate resources have great potential to improve community mental health collaborations.

A prospective investigation of work and nonvocational outcomes in adults with severe mental illness

This study assessed the impact of steady competitive or noncompetitive employment on nonvocational outcomes for clients with severe mental illness receiving employment services. We conducted a secondary analysis of 2-year data for 187 clients participating in a randomized controlled trial comparing two employment programs. Participants were classified according to 2-year employment outcomes into four groups: steady competitive work, steady noncompetitive work, minimal work, and no work. We compared these groups on 2-year outcomes including symptoms, hospitalizations, quality of life, and social networks. During follow-up, working clients had fewer days of hospitalization than the no-work group. The steady competitive group had greater reduction in negative symptoms than did the no-work group. The steady noncompetitive group showed greater improvement in social networks compared with the other groups. Extended periods of work are associated with improvements in nonvocational outcomes. Beneficial effects may vary according to the type of employment.

Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US

While reviews of controlled studies of the Individual Placement and Support (IPS) model of supported employment for clients with severe mental illness have documented its effectiveness in the US, its generalizability to other countries has not been systematically evaluated. This is the first review to compare US to non-US studies. We identified 15 randomized controlled trials of IPS programs, 9 in the US and 6 outside the US. We examined competitive employment outcomes, including employment rate, days to first job, weeks worked during follow-up, and hours worked. We also considered noncompetitive employment, program retention, and nonvocational outcomes. IPS programs had significantly better outcomes across a range of competitive employment indicators and higher retention in services than control groups. The overall competitive employment rate for IPS clients in US studies was significantly higher than in non-US studies (62% vs. 47%). The consistently positive competitive employment outcomes strongly favoring IPS over a range of comparison programs in a group of international studies suggest that IPS is an evidence-based practice that may transport well into new settings as long as programs achieve high fidelity to the IPS model, but further research is needed on international adaptations.

Mental Health Disability

Mental health disability imposes an enormous cost to patients, families, and society. Across free market countries, the rate of mental health disability is growing and now constitutes about one third of all disability claimants. Living on disability benefits begets demoralization and passivity. This article reviews (a) the current status of mental health disability and mental health disability systems, (b) the encouraging findings related to research on evidence-based treatments and supported employment, and (c) policy changes that might ameliorate the problem of rising rates (and costs) of mental health disability. Mental health treatments, employment services, and disability policies powerfully shape the disability experience. Evidence-based mental health and employment services can ameliorate disability and could potentially prevent disability if applied as early interventions. Yet evidence-based mental health treatments and supported employment services are rarely available. Furthermore, current disability policies tend to trap people in a “disability benefits culture.” Policy changes should recognize that people with mental health disabilities usually want to work, that they are often able to work when provided with appropriate mental health and vocational services, and that employment is highly therapeutic. Disability policies need to strengthen work incentives for beneficiaries, providers, and employers.

Service intensity as a predictor of competitive employment in an individual placement and support model

OBJECTIVES

Previous research on the individual placement and support (IPS) model of supported employment has focused on the model's effectiveness and on fidelity to the program model. Little is known about service intensity, or the number of service contacts received. This study examined several aspects of service intensity: average level, association with weeks worked, predictors, and modulators of its effect on weeks worked.

METHODS

The study used data that were collected over two years from 91 persons with severe mental illness who participated in one arm of a randomized controlled trial conducted at Thresholds, a psychosocial rehabilitation center in Chicago.

RESULTS

Services were more intense during the initial phase of services, service intensity predicted later weeks worked, and few individual demographic and clinical characteristics were related to service intensity. Finally, high levels of cognitive symptoms weakened the relationship between service intensity and weeks worked.

CONCLUSIONS

This study suggests increased IPS service intensity may lead to better employment outcomes and has implications for service provision and fidelity measurement.

Economic approaches to improving access to evidence-based and recovery-oriented services for people with severe mental illness

During the past 3 decades, research has identified several psychosocial evidence-based practices (EBPs) for people with severe mental illness (SMI). Starting from a different origin, the recovery movement has influenced perceptions of how EBPs and other services should be delivered, and also emphasized the value of peer supports. We now know much more than 30 years ago about the kinds of services that help people with SMI live satisfying lives in the community. Evidence-based and recovery-oriented services require additional resources but use them sparingly: they are highly individualized, often result in reductions in costs of other mental health services, such as hospitalizations, and favour reliance on and integration into community settings rather than mental health services. Nevertheless, access to such services remains very limited. During the same period, the place of medications in the services system has become a source of growing concern, and there are several reasons to believe that current spending on medications is excessive. Inadequate housing and community supports that increase lengths of stay unnecessarily and spending on ineffective, nonrecovery-oriented vocational services are only 2 additional forms of misallocation of resources. Devolving control over medication budgets to regional or local health authorities, introducing program budgeting and marginal analysis, and implementing individual budgets to give more control to service users (in addition to promoting shared decision making) merit further investigation as potential strategies to improve outcomes for people with SMI in Canada in the context of limited budgets.

Is job tenure brief in individual placement and support (IPS) employment programs?

OBJECTIVE

The individual placement and support (IPS) model has helped clients with severe mental illness obtain competitive jobs, but questions have been raised whether job tenure is brief. This study examined job tenure over 24 months among clients of high-fidelity IPS enrolled between November 2005 and June 2007.

METHODS

Monthly data about job tenure were collected for 82 clients upon beginning competitive employment (prospective sample) and from 60 clients who had begun competitive employment in the preceding six months (retrospective sample).

RESULTS

The 142 clients worked a mean of 12.86 months overall and 9.96 months at their first job; compared with the prospective sample, the retrospective sample worked for more months (13.69 versus 11.02; p<.05) and worked more months at the first job (12.63 versus 8.01; p<.01).

CONCLUSIONS

Job tenure among employed clients of high-fidelity IPS was twice as long as previously reported, and about 40% became steady workers over two years.