Person-related predictors of employment outcomes after participation in psychiatric vocational rehabilitation programmes--a systematic review

Purposeful Pathways: An Integrative Career Development Intervention for Vocational, Mental Health, and Substance Use Recovery

Veterans who are unemployed and living with mental health or substance use conditions are in need of integrative interventions that support their career development, mental wellness, and sobriety. However, career development interventions are often developed and implemented separate from mental health services. This paper introduces a novel intervention that supports career development of veterans with mental health and substance use concerns: Purposeful Pathways. This paper presents the results from three phases of intervention development: (1) retreats with clinical and vocational psychology experts (n=13) to develop the theoretical mechanisms of Purposeful Pathways, (2) focus groups with Veterans Health Affairs vocational counselors (n=6) who provide employment services to veterans with mental health conditions, and (3) an open trial in which veterans with mental health conditions (n=10) received Purposeful Pathways and provided feedback. Descriptions of the iterative processes of developing the Purposeful Pathways intervention are presented as a model for developing vocational interventions.

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.

Individual placement and support and employment in personality disorders: a registry based cohort study

BACKGROUND

To explore the relative impact of Individual Placement and Support (IPS) in patients with personality disorders (PDs) as compared to patients with other mental disorders.

METHODS

Data from the Dutch Employee Insurance Agency of participants enrolled in a national IPS trajectory between 2008 and 2018 were linked to corresponding data on employment outcomes, diagnostic and sociodemographic information from Statistics Netherlands. This resulted in a sample of 335 participants with PDs who could be compared with 1073 participants with other mental disorders.

RESULTS

Participants with PD just as often found competitive employment as participants with other mental disorders (37.6% vs. 38.0%, OR_adjusted = 0.97, 95% confidence interval (CI) 0.74 to 1.27). The median time to gaining employment for those gaining employment (37.9%) was 195.5 days (mean number of days 252.5) in the PD group and 178.5 days (mean number of days 234.6) in the other mental disorders group (HR_adjusted = 0.95, 95% CI 0.77 to 1.18). Also, total number of hours paid for competitive employment did not differ significantly between groups (median hours 686.5 vs 781.5, IRR_adjusted = 0.85 95% CI 0.69 to 1.05).

CONCLUSIONS

Based on this study, which includes the largest sample of patients with PDs in any published IPS study, IPS seems to result in an equal percentage of patients with PDs and other mental disorders, gaining and maintaining employment. Although future studies should determine whether PD-specific adaptations to IPS are useful, our findings indicate that IPS could be an effective way to increase employment outcomes in PDs. This is important because the enormous societal costs of PDs are largely driven by loss of economic productivity, and because clinical recovery in PDs is suggested to be enhanced when patients are employed.

Impact of cognitive remediation on the prediction of employment outcomes in severe mental illness

OBJECTIVE

Cognitive functioning is a potent predictor of work in people with a severe mental illness, including those receiving vocational services. Cognitive remediation has been shown to improve cognitive functioning and work outcomes in people receiving vocational services. However, it is unknown whether it reduces the strength of cognitive functioning as a predictor of work outcomes compared to people receiving vocational services alone.

METHOD

Data were pooled from five randomized controlled trials evaluating the effects of adding cognitive remediation to vocational rehabilitation vs. vocational services alone. A battery of baseline cognitive functioning measures was examined to identify predictors of competitive work outcomes over the following two years. Study condition (i.e., receipt of cognitive remediation) was included in the analyses to evaluate whether cognitive functioning was a weaker predictor of work outcomes in people receiving cognitive remediation compared to those receiving vocational services alone.

RESULTS

Cognitive functioning was a stronger predictor of wages earned and weeks worked in participants receiving vocational services alone than those who also received cognitive remediation. Cognitive functioning did not predict job acquisition in either study condition.

CONCLUSION

Cognitive remediation may improve employment outcomes in people receiving vocational services in part by reducing the adverse effects of impaired cognitive functioning on work performance.

Predictors of work and education among people with severe mental illness who participated in the Danish individual placement and support study: findings from a randomized clinical trial

PURPOSE

People with severe mental illness experience disproportionately high rates of unemployment. Nonetheless, a substantial amount of research has demonstrated vocational benefits of the Individual Placement and Support (IPS) model and IPS supplemented with cognitive remediation (IPSE). The present study sought to examine demographic and clinical predictors of employment or education among people with severe mental illness and to investigate if IPS or IPSE can compensate for risk factors for unemployment.

METHODS

Seven hundred twenty participants were randomly assigned to IPS, IPSE or Service as Usual. During the 18-month follow-up period participants in the two experimental groups obtained significantly more work or education. A series of univariate and multiple logistic regression analyses were conducted to assess the predictive power of demographic and clinical factors for the total population and for the three groups individually.

RESULTS

The strongest predictor for vocational recovery, besides treatment allocation, was previous work history (OR = 1.78; 95% CI = 1.28-2.47). Men had a lower probability for vocational recovery compared to women (OR = 0.71; 95% CI = 0.50-0.99) and higher age was also negatively associated with work or education (OR = 0.79; 95% CI = 0.67-0.93). Moreover, vocational recovery was predicted by higher readiness for change, measured on the readiness for change scale (OR = 1.42; 95% CI = 1.19-1.70). Participation in IPS or IPSE could not compensate for negative risk factors such as low cognitive function or negative symptoms.

CONCLUSIONS

In a multiple logistic regression analysis age, previous work history and motivation for change were statistically significant predictors of obtaining work or education among people with severe mental illness who participated in the Danish IPS trial.

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.

Do individual and work-related factors differentiate work participation trajectories before and after vocational rehabilitation?

BACKGROUND

Understanding diverse labor market trajectories around vocational rehabilitation provides important insight into potential effectiveness of rehabilitation efforts. We examined factors associated with work participation trajectories before and after vocational rehabilitation.

METHODS

Using nationwide Finnish register data of 7180 vocational rehabilitees, we constructed latent trajectory groups of work participation two years before and two years after their rehabilitation episode starting in 2008-2010. We plotted changes in labor market statuses in these groups and examined other associated factors using multinomial logistic regression.

RESULTS

We identified four trajectories based on work participation levels before and after vocational rehabilitation. The "High-Resumed" group (35.6%) typically returned to full duties. The "High-to-Negligible" group (20.7%) typically transitioned to full disability retirement or unemployment. Among the "Medium-Resumed" (25.5%) and "Longstanding Negligible" (18.3%) groups, work disability and unemployment were common before rehabilitation, but afterwards those assigned to the former group often returned to full or partial duties. Overall, older age, male gender, living in areas with lower employment rates, having lower education, being employed in the private sector, and having mental diagnoses were associated with the other three trajectories than the most favorable "High-Resumed" trajectory. Furthermore, certain industrial sectors, job exposures, and less common diagnoses further separated specific trajectories.

CONCLUSIONS

Work participation trajectories around vocational rehabilitation are diverse, only partly dependent on initial levels of work participation, and determined by various individual and work-related factors. Future nationwide studies should assess the effectiveness of vocational rehabilitation taking into consideration both individual and work-related factors.

Comparing predictors of employment in Individual Placement and Support: A longitudinal analysis

Individual Placement and Support (IPS) is an evidence-based model of supported employment for people with serious mental illness. We assessed the effects and relative contributions of predictors of employment among IPS recipients using measures of baseline client characteristics, local economic context, and IPS fidelity. A recent work history, less time on the Social Security rolls, greater cognitive functioning, and a lower local unemployment rate were associated with greater probability of employment. The ability of the model to discriminate between outcomes was limited, and substantial improvements in our understanding of IPS employment outcomes will require the study of novel client, environmental, and IPS implementation factors.

Virtual reality-based cognitive training for drug abusers: A randomised controlled trial

Non-pharmacological means are being developed to enhance cognitive abilities in drug abusers. This study evaluated virtual reality (VR) as an intervention tool for enhancing cognitive and vocational outcomes in 90 young ketamine users (KU) randomly assigned to a treatment group (virtual reality group, VRG; tutor-administered group, TAG) or wait-listed control group (CG). Two training programmes with similar content but different delivery modes (VR-based and manual-based) were applied using a virtual boutique as a training scenario. Outcome assessments comprised the Digit Vigilance Test, Rivermead Behavioural Memory Test, Wisconsin Cart Sorting Test, work-site test and self-efficacy pre- and post-test and during 3- and 6-month follow-ups. The VRG exhibited significant improvements in attention and improvements in memory that were maintained after 3 months. Both the VRG and TAG exhibited significantly improved vocational skills after training which were maintained during follow-up, and improved self-efficacy. VR-based cognitive training might target cognitive problems in KU.

Concordance of assessments of clients' mental and behavioral health with in vivo assessment of work performance

BACKGROUND

Assessing functioning and disability among individuals with mental and behavioral health disorders has historically relied on deriving accurate psychiatric diagnoses and assessing symptoms. However, growing empirical evidence suggests that this approach is inadequate to determine real world performance, particularly with respect to work.

OBJECTIVE

We examined a performance-based approach to the assessment of work functioning and its relationship to mental and behavioral health status.

METHODS

A cross-sectional study was conducted at two mental health programs. Trained employment providers conducted performance-based assessments of work function and ratings of mental and behavioral health while study participants self-reported their mental/behavioral health functioning. We hypothesized that participant and provider ratings of mental/behavioral health would be moderately correlated with performance-based assessments of work function.

RESULTS

We found no significant correlation between participants' self-report of their mental and behavioral health and performance-based assessments of work. Employment providers' ratings of participants' mental/behavioral health were moderately correlated with performance-based measures of work. Finally, we found low concordance between employment providers and study participants' with respect to ratings of their mental/behavioral health.

CONCLUSIONS

Contrary to our hypotheses, ratings of mental/behavioral health were only moderately correlated with performance-based measures of work. Results confirm earlier research suggesting that it is difficult to predict work performance from participants' self-reports of their mental/behavioral health alone. Performance-based assessments of work capacity as well as ratings of mental and behavioral health may both be needed for a more complete and complimentary picture of the ability of individuals with mental and behavioral health disorders to function in the work place.

Correlates of employment interest among adults with schizophrenia

Background/Aims:

Role functioning is an important part of recovery and psychiatric rehabilitation for people with schizophrenia. However, little is known about why some people and not others return to socially valued roles such as employment. While the demographic and clinical correlates of employment have been extensively studied, little is known about how employment interest forms and develops into actual employment activity. The aim was to compare demographic and clinical correlates of employment interest to correlates of actual employment participation.

Methods:

A community sample of 255 working-age adults with schizophrenia or schizoaffective disorder were interviewed about their current employment status and current employment interest. Univariate logistic regression was used to examine the demographic and clinical correlates of both employment interest and participation.

Findings:

Age, employment history and severity of current hallucinations were associated with both employment interest and participation, while illness severity pattern, illness course, severity of disability, and severity of avolition were associated only with employment participation.

Conclusions:

Resilience of employment interest to the clinical symptoms of schizophrenia is a promising finding. Those with more severe illness patterns and more impaired functioning can remain good candidates for vocational rehabilitation, because interest and motivation for employment may be unaffected.

An examination of concepts in vocational rehabilitation that could not be linked to the ICF based on an analysis of secondary data

BACKGROUND

In the last few years the International Classification of Functioning, Disability and Health (ICF) has become a widely known and useful reference classification in vocational rehabilitation. It would be equally important to know which aspects of work-related health information cannot be assigned to distinct ICF categories.

OBJECTIVE

The objective of this study is to examine the concepts derived from three studies conducted within the ICF Core Set for vocational rehabilitation project, which could not be linked to distinct ICF codes in order to complement the current understanding of functioning in vocational rehabilitation.

METHODS

Secondary data analysis of the concepts from the systematic literature review, expert survey and patient focus group study of the ICF Core Set for vocational rehabilitation project that were marked as nd = not definable, nc = not covered or pf = personal factor. Nd-concepts were assigned to the biopsychosocial model of the ICF; additional ICF categories were formulated where needed. Nc-concepts were grouped into common themes not covered by the ICF. Pf-categories were linked to a proposed personal factors classification.

RESULTS

1093 nd-concepts were matched to overarching terms in the ICF, and "other specified"-categories were detailed. 1924 pf-concepts were linked to 31 second level categories of a proposed personal factors classification. 441 nc-concepts were grouped into six themes including the concept of well-being and attributes related to processes and time.

CONCLUSIONS

With concepts that emerged from the secondary analysis of data gathered during the vocational rehabilitation ICF Core Set project, we have enriched the ICF model with constructs specific to vocational rehabilitation. However, additional research is needed to further explore personal factors specific to vocational rehabilitation. The influence of themes complementary to the ICF such as well-being and quality of life on return-to-work should be further investigated.

Does personality influence job acquisition and tenure in people with severe mental illness enrolled in supported employment programs?

BACKGROUND

When employment difficulties in people with severe mental illness (SMI) occur, it could be partly linked to issues not specific to SMI, such as personality traits or problems. Despite the fact that personality has a marked influence on almost every aspect of work behavior, it has scarcely been investigated in the context of employment for people with SMI.

AIMS

We aimed to evaluate if personality was more predictive than clinical variables of different competitive work outcomes, namely acquisition of competitive employment, delay to acquisition and job tenure.

METHOD

A sample of 82 people with a SMI enrolled in supported employment programs (SEP) was recruited and asked to complete various questionnaires and interviews. Statistical analyses included logistic regressions and survival analyses (Cox regressions).

RESULTS

Prior employment, personality problems and negative symptoms are significantly related to acquisition of a competitive employment and to delay to acquisition whereas the conscientiousness personality trait was predictive of job tenure.

CONCLUSION

Our results point out the relevance of personality traits and problems as predictors of work outcomes in people with SMI registered in SEP. Future studies should recruit larger samples and also investigate these links with other factors related to work outcomes.

Understanding how prevocational training on care farms can lead to functioning, motivation and well-being

PURPOSE

Prevocational training aims to improve basic vocational and social skills, supporting return to work for people who have been out of work for a long time. Care farms provide prevocational training; the aim of the study was to use the self-determination theory to gain an understanding of how these programmes can lead to healthy functioning and motivation for clients.

METHOD

A total of 194 participants in prevocational training on care farms answered questions about demographic information, their perception of being a colleague, the social community on the farm, experiencing nature and animals and need satisfaction. A cross-sectional design resulting in a structural equation model was used to understand how elements of the care farm context influence satisfaction of three psychological needs.

RESULTS

The results showed that a feeling of being a useful colleague led to competence, experiencing a sense of group belonging led to relatedness and autonomy, while receiving social support from the farmer led to satisfaction of all three needs for the participants.

CONCLUSIONS

The results explain how prevocational training can stimulate participants' functionality, motivation and well-being. This understanding enables initiators and managers of prevocational training to understand and further strengthen the need-supportive elements of such programmes. Implications for Rehabilitation Prevocational training on care farms can facilitate motivation, functioning and well-being for clients. Making clients feel like useful colleagues that belong to a client group will strengthen the positive qualities of these programmes. Support, understanding and acknowledgement from the farmer are the most important elements for a positive development for the clients.

Mental health rehabilitation in a care farm context: A descriptive review of Norwegian intervention studies

BACKGROUND

C are farming is a service developed at farms for promoting mental and physical health and is increasingly used in mental health rehabilitation in Norway.

OBJECTIVE

This article aims to present a descriptive review of Norwegian intervention research on care farms that provide rehabilitation for people with mental health disorders.

METHODS

This literature review applied a non-systematic search strategy: all articles in the field known to the authors were selected for inclusion. The selected studies were intervention studies that were conducted on farms in Norway, that used adult participants with mental health problems/disorders, and that reported outcome measures related to mental health. The studies and articles presented quantitative and/or qualitative data.

RESULTS

The findings from the published articles report improvements to mental health problems, such as depression, anxiety, perceived stress, positive affect, rumination, and self-efficacy. Qualitative data describe a variety of positive experiences, such as improved coping ability, increased social support, and appreciation of the care farm activity.

CONCLUSION

Participating in interventions on care farms positively influences mental health. Care farming may therefore be used as a supplementary approach in mental health rehabilitation, as it offers meaningful and engaging occupations and social inclusion.

Content and key components of vocational rehabilitation on care farms for unemployed people with mental health problems: A case study report

BACKGROUND

Mental health problems are a major cause for new disability grants in Norway. A variety of approaches in vocational rehabilitation is needed for this group. Green work is one such program that has been implemented at Norwegian care farms, which aims to promote health and support the transition from unemployment to working life.

OBJECTIVE

To describe care farms in Norway and identify the presence of key components of such vocational programs.

METHODS

In this case study, we used The Norwegian National Register of Care Farms to gain an overview of farms with vocational rehabilitation programs. Data consisted of written information from five farms' own web-site together with answers from a cross sectional questionnaire. Content about programs was systematically extracted by using national green work guidelines.

RESULTS

Descriptions of care farm programs showed that key components outlined by the national guidelines for green work were present. These components were; (1) variety of work activities, (2) adaptation of work tasks, (3) the farmers' support and supervision, (4) experiencing nature, (5) enhanced structure in everyday life.

CONCLUSION

The description of vocational programs on care farms in relation to these key components, gives a thorough understanding of the content and organization of such programs.

Psychological Predictors of Vocational Success for People with Psychotic Illness

People diagnosed with psychotic illness continue to be underrepresented in the workforce despite the widespread provision of vocational rehabilitation services for people experiencing mental illness. A systematic literature review was undertaken using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines to identify psychological predictors of successful return to work for this population. The databases searched were PsycARTICLES, PsycINFO, PubMed, ProQuest, Cumulative Index of Nursing and Allied Health (CINAHL), and Taylor & Francis Online. A total of 4,076 articles were located and of these, 29 articles were analysed as part of this review. The data extracted was synthesised using a narrative approach. A number of psychological factors were identified which are predictive of successful return to work. These factors include but are not limited to identity, self-management of illness, social cognition, hope and self-esteem and motivation. On the basis of the reviewed literature, practice guidelines are proposed which support the psychological processes identified as pivotal to vocational success for people diagnosed with psychotic illness.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors affecting employment outcomes for people with disabilities who received Disability Employment Services in Taiwan

PURPOSE

One of the most important rehabilitation goals is to return people with disabilities to paid employment. The purposes of this study were (1) to explore employment status and (2) to identify factors that may affect the employment outcomes of people with disabilities who received Disability Employment Services (DES).

METHODS

A retrospective study was conducted on clients who commenced and closed DES between January 2008 and December 2010 in a metropolitan city in Taiwan, using the files from the National Vocational Rehabilitation Services Documentary System.

RESULTS

Sixty-nine percent (1,684 out of 2,452) of the clients in this study were engaged in paid employment after receiving DES. Logistic regression analyses indicated that clients with no psychiatric disability or mild impairment and with useful vocational qualifications, typical work experience, more post-employment services, and less pre-employment services were associated with a higher rate of successful employment outcomes.

CONCLUSION

This study provides empirical evidence of the association between person- and DES-related factors and the employment outcomes of people with disabilities. Future improvements in health, school-to-work transition services, and vocational rehabilitation for people with disabilities should place more emphasis on providing work-based work experience, professional vocational training, access to college/professional education, career exploration, effective supported employment services, and other post-employment services.

Readiness for employment: perceptions of mental health service users

Work is good for both physical and mental health, and access to work is a basic human right. People with mental health conditions want to work and with the right support can work but are often excluded from the workplace. We explored factors influencing individual's perceptions of their readiness for employment. Participants' narratives focused particularly on personal causation and it's inter-reactions with other aspects of volition, habituation and the environment and highlight a number of key areas, which are discussed in relation to service provision. Sheltered workshops offer support and some structure and routine but may limit an individual's readiness for employment. Services should be evidence based and focused on real work opportunities which fit with individual's interests and values. Occupational therapy theory offers a unique and valuable perspective in understanding perceptions of readiness for employment and occupational therapists offer valid and useful assessments and interventions for vocational rehabilitation.

Implementing and Evaluating Goal Setting in a Statewide Psychiatric Rehabilitation Program

Although the idea of people with psychiatric disabilities determining their own treatment and rehabilitation goals is increasingly accepted, its relationship to service outcomes has rarely been evaluated programmatically. A statewide, Medicaid-funded psychiatric rehabilitation program incorporated a systematic goal setting procedure conducted by practitioners trained in helping people set their own individual rehabilitation goals. Individuals who successfully set either residential or employment goals were followed for up to 18 months to assess progress on these goals. Participants were grouped by type of goal (residential or employment) and by level of participation in the intervention (enrolled, completed 18 months, or graduated). Residential functioning for those who set residential goals increased significantly, independent of level of participation. For people who had set employment goals, only graduates of the intervention showed significant employment gains. Furthermore, employment functioning changed significantly when a goal was set in the residential area; in contrast, residential functioning did not change significantly when goals were set in the employment area. This study suggests that the programmatic effect of goal setting procedures can be evaluated, even when the person’s goals are tailored to an individual’s unique preference. Implications for rehabilitation counseling will be discussed.

Cognitive Behavioral Therapy and Work Outcomes: Correlates of Treatment Engagement and Full and Partial Success in Schizophrenia

Background: Cognitive behavior therapy (CBT) has been found to be generally effective for persons with schizophrenia. Less is known however about those who will engage in this treatment, and among those who engage, who benefits more versus less from this intervention. Aims: This study sought to identify factors associated with treatment engagement and response in persons with psychosis engaged in CBT focused on enhancing work function. Method: Participants were 50 adults with schizophrenia-spectrum disorders participating in a randomized control trial that offered both CBT and a protected employment position over 26 weeks. Survival analysis and discriminant analyses were used to analyze the data. Results: Results indicated that poor treatment engagement and engagement in work was associated with lower educational attainment, more severe baseline levels of negative symptoms, and lower baseline scores on the Arithmetic and Digit Symbol subscales of the WAIS-III. Amongst those participants who did engage, younger age and poorer working memory as assessed by the Arithmetic subscale predicted shorter initial job tenure. More severe levels of positive symptoms and lower self-esteem during the later stages of treatment were associated with worse employment outcomes across the study period. Conclusions: These findings evidence differential predictors of engagement and success and suggest that a subgroup of persons with schizophrenia engaged in CBT and a vocational placement are at risk for poor functional outcomes associated with psychological factors that evolve over time.

A virtual reality-based vocational training system (VRVTS) for people with schizophrenia in vocational rehabilitation

Employment provides schizophrenic patients with a positive identity and hope. Cognitive impairments have been suggested to slow down the progress in work rehabilitation. The purpose of this study was to investigate the efficacy and effectiveness of VR as a cognitive intervention for enhancing vocational outcomes. 95 inpatients with schizophrenia were randomly assigned to a virtual reality-based vocational training group (VRG), a therapist-administered group (TAG) and a conventional group (CG). Twenty-five of them in each group had completed the study. Their performances were evaluated, before and after interventions, by Brief Neuropsychological Cognitive Examination, Digit Vigilance Test, Rivermead Behavioural Memory Test, Wisconsin Card Sorting Test (WCST) and Vocational Cognitive Rating Scale. Patients in the VRG were found to perform better than patients in the TAG and CG in cognitive functioning, as shown by the WCST-percentage of error (F (2, 72)=7.146, p<0.001) and the WCST-percentage of conceptual level response (F (2, 72)=8.722, p<0.001). The post-hoc test revealed that the VRG showed a better performance than both the TAG (p=0.03) and the CG (p<0.001) in the WCST-percentage of error. The VRG also showed a better performance than patients in both the TAG (p=0.01) and the CG (p<0.001) in the WCST-percentage of conceptual level response. The VRG also showed a better self-efficacy score than CG. Both VRG and TAG showed a better work performance as reflected by the on-site tests. Further studies on the use of VR in schizophrenia rehabilitation and for vocational success are discussed.

The Impact of an Early Eclectic Rehabilitative Intervention on Symptoms in First Episode Depression among Employed People

Objective. To evaluate the effect of an early vocational-orientated eclectic intervention on beck depression inventory (BDI) scores compared to treatment as usual in first ever depressive episode among employed people. Design. A randomized controlled trial comparing the rehabilitative intervention and the conventional treatment. Subjects. The subjects came from occupational health care units. Methods. Employees were sent to a rehabilitation center after being screened for depression using the BDI. They were diagnosed using the structured clinical interview for DSM-IV. The participating subjects (N = 283) were randomized into intervention and control groups. The intervention group received eclectic early depression intervention treatment (N = 134) and the control group was treated in the conventional way (N = 100). They were followed for one year. Results. The mean decrease in BDI scores within the intervention group was from 20.8 to 11.6 and within the control group from 19.3 to 10.8. BDI score decreased by 10 or more points in 64% of the participants in the intervention group and in 53% of the control group (P = 0.013). Conclusions. There was some evidence that early eclectic intervention in first ever episode depression may be more effective than conventional treatments among working age people in employment.

Illness self-management assessment in psychiatric vocational rehabilitation

OBJECTIVE

People with severe mental illnesses experience difficulty finding and maintaining employment, even if they are offered psychiatric vocational rehabilitation services. When service recipients are able to apply more effective illness self-management strategies, vocational rehabilitation outcomes improve. To assess the use of these strategies, the Illness Self-Management assessment instrument for Psychiatric Vocational Rehabilitation (ISM-PVR) was developed.

METHODS

Experts were consulted to design the ISM-PVR instrument which was then tested by 8 vocational rehabilitation workers and 26 of their service recipients.

RESULTS

This study indicated sufficient internal consistency of the ISM-PVR self-report questionnaire, especially for the subscales assessing goal related self-efficacy, perceived illness-related barriers, and four of the eight coping scales. The number of self-reported illness barriers was associated with a higher number of reported work-related coping strategies. The ISM-PVR aided the identification of specific mental illness-related barriers perceived by the service recipients. The instrument also facilitated obtaining information on individual self-management strategies that clients employed to overcome such barriers or make them manageable.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The application of the ISM-PVR in vocational rehabilitation practice warrants further research. The study suggests that this instrument is a useful add-on to existing vocational assessment and provides insight in self-management strategies that people use, and that may help those people and their job coaches make more effective vocational plans.

The Impact of Illness Identity on Recovery from Severe Mental Illness

The impact of the experience and diagnosis of mental illness on one's identity has long been recognized; however, little is known about the impact of illness identity, which we define as the set of roles and attitudes that a person has developed in relation to his or her understanding of having a mental illness. The present article proposes a theoretically driven model of the impact of illness identity on the course and recovery from severe mental illness and reviews relevant research. We propose that accepting a definition of oneself as mentally ill and assuming that mental illness means incompetence and inadequacy impact hope and self-esteem, which further impact suicide risk, coping, social interaction, vocational functioning, and symptom severity. Evidence supports most of the predictions made by the model. Implications for psychiatric rehabilitation services are discussed.

Employment status amongst those with psychosis at first presentation

INTRODUCTION

Employment is generally beneficial to health and quality of life. Despite many advances in the treatment of psychosis there are continuing reports of high levels of unemployment. In most studies of first episode psychosis (FEP) only rudimentary rates of employment are provided. We sought to establish the prevalence of employment amongst those with FEP from a geographically defined area, to compare employment categories for differences in demographical and clinical characteristics and finally, to examine factors associated with employment.

METHODS

All cases of FEP were assessed from a defined suburban area with a structured clinical interview for DSM-III-R diagnosis and a standardised assessment protocol. Employment status was divided into employed, non-labour force work and unemployed.

RESULTS

Of 162 cases of psychosis, those employed (46%) were indistinguishable from those in non-labour force work (21%). Those unemployed (33%) had significantly longer DUP, more negative symptoms and lower quality of life than those engaged in non-labour force work or those employed. Having a non-affective psychosis (chi(2) = 0.05, OR = 1.2; 95% CI 1.0, 1.4) was associated with being unemployed at presentation. Better (beta = -0.2, P = 0.00) academic premorbid adjustment was associated with being employed at presentation.

CONCLUSIONS

Although 67% of those with FEP from a geographically defined area are engaged in purposeful work, the rate of unemployment is nine times the local rate. Longer DUP and negative symptoms are associated with unemployment at presentation. Standardised reporting of employment status would greatly assist research in this area.

Vocational rehabilitation for subjects with severe mental illnesses in Germany. A controlled study

OBJECTIVE

To assess the longitudinal effectiveness of a comprehensive vocational rehabilitation program in Germany.

METHODS

In a non-randomized open study, 106 participants of two comprehensive rehabilitation programs were prospectively and multidimensionally compared to a control group (n = 75) at program termination and at a 9 months follow-up. Primary outcome was employment status at 9 months follow-up, secondary outcome parameters were changes in symptoms (Positive and Negative Syndrome Scale), subjective well-being (WHOQOL-Bref), and level of functioning (Level of Functioning Scale) during the study.

RESULTS

Regarding the primary outcome measure, there was significant more day structuring employment (mainly sheltered) in the rehabilitation group than in the comparison group (39.7 vs. 18.7%) at 9 months follow-up. Regarding secondary outcomes, rehabilitation participants showed a better course in general symptoms, subjective well-being and level of functioning.

CONCLUSION

Vocational services proved to be effective to find day structuring employment for subjects with severe mental illness. Furthermore it had positive effects on functioning and psychological well-being during a 9-months follow-up period.

Factors that promote or hinder young disabled people in work participation: a systematic review

INTRODUCTION

The aim of this systematic review was to study factors which promote or hinder young disabled people entering the labor market.

METHODS

We systematically searched PubMed (by means of MESH and text words), EMBASE, PsycINFO, Web of Science and CINAHL for studies regarding (1) disabled patients diagnosed before the age of 18 years and (2) factors of work participation.

RESULTS

Out of 1,268 retrieved studies and 28 extended studies from references and four from experts, ten articles were included. Promoting factors are male gender, high educational level, age at survey, low depression scores, high dispositional optimism and high psychosocial functioning. Female and low educational level gives high odds of unemployment just like low IQ, inpatient treatment during follow up, epilepsy, motor impairment, wheelchair dependency, functional limitations, co-morbidity, physical disability and chronic health conditions combined with mental retardation. High dose cranial radiotherapy, type of cancer, and age of diagnosis also interfered with employment.

CONCLUSIONS

Of the promoting factors, education appeared to be important, and several physical obstructions were found to be hindering factors. The last mentioned factors can be influenced in contrast to for instance age and gender. However, to optimize work participation of this group of young disabled it is important to know the promoting or hindering influence for employment.

Predictors of competitive employment among patients with schizophrenia

PURPOSE OF REVIEW

Recently published studies examining predictors of competitive employment for patients with schizophrenia are reviewed.

RECENT FINDINGS

Researchers continue to examine predictors of employment among three types of variables: patient characteristics, environmental factors, and interventions. Provision of supported employment is the strongest predictor of competitive employment in this population, while patient predictors continue to show modest associations with outcomes. Environmental factors, including societal and cultural influence, local economy, labor laws, disability policies, and governmental regulations, are presumed to have major influences on employment, but these factors have been little studied.

SUMMARY

Given the strong and consistent evidence base for the effectiveness of supported employment in helping individuals with schizophrenia achieve competitive employment, mental health planners should make access to this practice a high priority. Barriers to implementation of supported employment, including finance, organization, integration, training, and supervision, need to be systematically addressed. The field currently lacks an adequate understanding of the role of societal, cultural, and regulatory factors in facilitating and hindering employment outcomes; such research is much needed.

Socio-demographic and clinical predictors of occupational status in schizophrenic psychoses--follow-up within the Northern Finland 1966 Birth Cohort

We studied occupational status of persons with schizophrenic psychoses by age 34 in a longitudinal population-based cohort and predicted which demographic and illness-related factors could support the patients to maintain their occupational capacity. Subjects of the Northern Finland 1966 Birth Cohort with the diagnosis of DSM-III-R schizophrenic psychoses (n=113) by the year 1997 were followed until the end of year 2000. Various illness and socio-demographic factors at the time of onset of illness were used as predictors. At the end of the follow-up time 50 (44%) of patients were not pensioned and 22 (20%) were also working at least half of the time during year 2000. After adjusting for gender, being unemployed at onset, educational level and proportion of time spent in psychiatric hospitals, those who were married or cohabiting at the time of onset of illness were less often on pension than those who were single (OR 6.51; 95% CI 1.83-23.12). Thus, nearly half of the patients with schizophrenic psychoses were not pensioned after an average 10 years follow-up. Based on our findings, those who were single at time of their onset of illness probably need most support to retain their contacts to work life.