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

Intersectional perspectives on the employment rate in Supported Employment for people with psychiatric, neuropsychiatric, or intellectual disabilities: A scoping review

BACKGROUND

Supported Employment (SE) has shown better results in the employment rate for persons with disabilities than other methods within vocational rehabilitation, but how SE affects the employment rate for subgroups in the interventions needs further attention.

OBJECTIVE

To examine previous research regarding the influence of intersecting statuses on the employment rate in SE for people with psychiatric, neuropsychiatric, or intellectual disabilities according to type of diagnosis, sex, race/ethnicity, age, level of education and previous work history.

METHODS

A systematic literature search was conducted in nine databases including peer-reviewed articles from 2000 to April 2021. Articles presenting the employment rate in SE interventions according to the intersecting statuses listed in the objective were included.

RESULTS

The searches identified 3777 unique records, of which 53 articles were included in data extraction. In most of the included articles, intersecting statuses did not affect the employment rate for people in the SE interventions with psychiatric disabilities. Few studies have examined neuropsychiatric and intellectual disabilities. A majority of the studies subjected to full-text analysis were excluded due to a lack of reporting of the effects of intersecting statuses on the employment rate. The studies that reported on the effects of intersecting statuses on the employment rate often had small samples and lacked statistical power.

CONCLUSIONS

Intersecting statuses do not appear to affect the employment rate for people receiving SE interventions, but systematic reviews with pooled samples need to be undertaken because of the low reporting rate and underpowered sample sizes in existing studies.

A Systematic Review and Meta-analysis of IPS Supported Employment for Young Adults with Mental Health Conditions

Young adults with mental health conditions want to work and advance their education, but many need help attaining these goals. Individual Placement and Support (IPS), originally developed for working-age adults with serious mental illness, is an evidence-based employment model that may benefit young adults. This study is the first systematic review and meta-analysis of randomized controlled trials (RCTs) of IPS for this population. We conducted a systematic review of the effectiveness of IPS for young adults with mental health conditions, supplementing our electronic search of the published literature with secondary analyses of two published RCTs. Using meta-analysis, we evaluated employment rate, job duration, and education rate. Seven studies met the inclusion criteria. Four evaluated IPS for young adults with early psychosis and three evaluated IPS for other young adult subgroups. All found a significantly higher employment rate for IPS than the control group. Overall, 208 (58.3%) of 357 IPS participants and 110 (32.4%) of 340 control participants were competitively employed during follow-up, yielding an overall risk ratio of 1.69 (95% CI 1.43, 1.99), z = 6.24, p < 0.001. Six of the seven studies also reported longer job duration for IPS than the control group, yielding an overall g = 0.34 (95% CI 0.09, 0.58), z = 2.72, p < 0.01. None of four RCTs examining education outcomes found a significant difference favoring IPS, but the overall risk ratio was significant: 1.33 (95% CI 1.06, 1.66), z = 2.51, p < 0.01. Although the empirical literature is limited, IPS appears to be effective in helping young adults with serious mental illness or early psychosis gain and keep competitive jobs. The impact of IPS on education outcomes is unclear. Future research should evaluate the generalizability of these findings to the broad range of young adults with mental health conditions needing help with their employment goals.

Maintaining functional working memory through job activities: A study among patients with schizophrenia enrolled in a supported employment program

BACKGROUND: Employment is crucial in rehabilitation of patients with schizophrenia. It may have positive effects on cognitive function, including working memory. OBJECTIVE: The objective of this study was to look for evidence to confirm continuous job activities could maintain functional working memory in patients with schizophrenia. METHODS: This was a cross-sectional study involving patients with schizophrenia enrolled in supported employment (SE) program. Informed consent was obtained. Socio-demographic, employment, and clinical data were acquired from interview and clinical notes. Mini International Neuropsychiatric Inventory (M.I.N.I) was used to confirm the diagnosis of schizophrenia. Working memory was evaluated using Weschler Memory Scale Third Edition -Letter-Number Span and Spatial Span. RESULTS: 118 patients were recruited with a mean age of 43.76 years old (SD = 8.96). Most were male, Malays, Muslims, single, and received at least secondary education. There was a significant association between working memory and employment outcome (χ 2 = 20.835, p <  .001), and past work history (χ 2 = 10.077, p = 0.002). Multiple logistic regression indicated that the employment outcome (adjusted OR: 12.50; 95% CI: 2.55–61.21; p = 0.002) and past work history (adjusted OR: 3.36; 95% CI: 1.05–10.70; p = 0.041) were significant predictors of working memory among patients with schizophrenia in SE program. CONCLUSION: This study indicated that continuous job activities could maintain functional working memory in patients with schizophrenia.

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.

Predictors of competitive employment in individuals with severe mental illness: results from an observational, cross-sectional study in Germany

Background

Employment is of great importance as it is associated with various positive effects. Individuals with severe mental illness (SMI) are often excluded from competitive employment. Current data on employment of individuals with mental illness are rare, and influencing factors are under-researched. The present study examines possible predictors of competitive employment among individuals with SMI.

Methods

This was a cross-sectional and multicentered study of 300 individuals with SMI aged 18 to 65 years. The following inclusion criteria were used: (I) diagnosis of schizophrenia, schizotypal and delusional disorders (ICD-10 F2x), or affective disorders (ICD-10 F3x), (II) duration of psychiatric illness ≥ 2 years, and (III) substantial impact of illness on social functioning. Participants were interviewed by trained staff using standardised instruments. The relationship between potential predictors (age, sex, education, marital status, living situation, migration background, psychosocial functioning, age at first mental problem, physical illness, work ability) and employment was analysed using a hierarchic binary logistic regression model.

Results

Only one-third (34%) of participants were competitively employed. Almost one-third were unemployed (30%), and 28% reported early retirement due to mental illness. Psychosocial functioning was positively associated with competitive employment (OR = 1.09, 95% CI: 1.05 – 1.13, p < 0.001); concurrent chronic physical illness was negatively associated with competitive employment (OR = 0.38, 95% CI: 0.21 – 0.71, p = 0.002).

Conclusions

Findings confirm a high risk of exclusion from competitive employment among individuals with SMI. Nonetheless, a substantial proportion of individuals are employed. Findings call for efforts to maintain or enhance workforce participation among individuals with SMI. A special focus should be placed on improving physical health and strengthening psychosocial functioning.

Trial registration

The study was registered in the German Clinical Trials Register (DRKS) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

Neuropsychological predictors of vocational rehabilitation outcomes in individuals with major depression: A scoping review

BACKGROUND

Major depression is one of the leading causes of disability and limited capacity to work. Neuropsychological impairment is a common symptom in acute and remitted major depression and is associated with poor psychosocial functioning. This scoping review aimed to identify research on the role of neuropsychological functioning in outcomes of vocational rehabilitation programs in individuals with depression.

METHODS

We report on the conduct of this pre-registered (https://osf.io/5yrnf) scoping review in accordance with PRISMA-ScR guidelines. PubMed and PsychInfo were systematically searched for English or German research articles published between 1990 and September 2021 that studied objective neuropsychological tests as predictors of vocational rehabilitation interventions and included participants with depression.

RESULTS

The systematic literature search yielded no studies that specifically targeted subjects with major depression. However, eight articles published since 2016 were included in the review, analyzing data from five trials that evaluated the effectiveness of supported employment in North America and Europe in severe mental illnesses. An estimated 31% of the total number of participants included (n = 3,533) had major depression. Using a variety of cognitive tests and covariates, seven articles found that neuropsychological functioning - especially global cognition scores, verbal and visual learning and memory - significantly predicted vocational outcomes of rehabilitation programs.

CONCLUSION

Despite a lack of studies specifically targeting major depressive disorder, the identified literature suggests that higher baseline neuropsychological functioning predicts better vocational outcomes of supported employment programs in individuals with depression. In clinical practice, additional neuropsychological modules during return-to-work interventions might be helpful for vocational outcomes of such programs.

COVID-19, Unemployment, and Behavioral Health Conditions: The Need for Supported Employment

The COVID-19 pandemic has caused massive unemployment, exacerbated pre-existing behavioral health (mental health and substance use) disorders for many people, and created new disorders for others. Although policy changes have increased health care and unemployment benefits, most people want jobs and self-sufficiency rather than handouts. A robust evidence base shows that supported employment can enable unemployed people with behavioral health conditions to find competitive, integrated employment and behavioral health supports. Millions of U.S. citizens may need these services as the pandemic recedes and jobs become available. Government attention to supported employment is necessary now more than ever.

Lifetime employment in schizophrenia: correlates of developing long term unemployment after being employed before

BACKGROUND

Challenges in employment are highly prevalent among people with schizophrenia regardless of their employment history. Although supportive employment can be effective, few participants sustain meaningful competitive employment. Our goal was to identify the correlates of developing sustained unemployment.

METHODS

We examined employment outcomes by comparing clinical, neurocognitive, and social cognitive features in 234 participants with Schizophrenia Spectrum Disorders across t competitive employment outcomes: currently employed, participants who had never worked for a year, and those who had been employed but developed long-term unemployment. We examined social cognition and neurocognition, as well as positive and negative schizophrenia symptoms, and premorbid functioning and demographic factors.

RESULTS

We found significant differences in age, race, premorbid functioning, cognitive performance, and social cognition between currently and formerly employed patients. When individual tasks were examined, emotion recognition and verbal working memory performance were the domains differentiating the groups. Older African Americans were over-represented in the formerly employed group.

CONCLUSIONS

There were minimal differences other than age and race between formerly employed patients and those who had never worked. These data suggest the possibility that deterioration in employment outcomes may also co-occur with declines in other abilities. Opportunities and disparities may also be a contributor to re-entering the work force.

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.

Individual placement and support in Italian young adults with mental disorder: Findings from the Reggio Emilia experience

AIM

Individual placement and support (IPS) has a considerable body of evidence for its effectiveness in helping people with mental disorder to achieve and maintain competitive jobs. However, little data in young adult populations are currently available, especially in Europe. Aim of this study was to assess the effect of IPS in Italian young adults with moderate-to-severe mental illness, examining the main competitive employment outcomes and drop out rates during a 3-year follow-up period.

METHODS

Participants (n = 54) were recruited from patients receiving psychiatric treatment in one of the seven adult Community Mental Health Centers of the Reggio Emilia Department of Mental Health. Together with drop out rates, we investigated job duration (total number of days worked), job acquisition (employment in the labour market for at least 1 day during the follow-up), total hours per week worked, and job tenure (weeks worked on the longest-held competitive job).

RESULTS

A crude competitive employment rate of 40.7% and a crude drop out rate of 22.2% over the 3-year follow-up period were found. However, 66% of 42 clients who remained in the program over 3 years gained competitive employment at some time during the 3-year period.

CONCLUSIONS

This research shows the feasibility of an IPS intervention model in the public mental health care system in Italy, especially for a young adult target population.

Implementation of Individual Placement and Support in Italy: The Reggio Emilia Experience

Individual placement and support (IPS) is an evidence-based intervention helping people with mental illness to obtain competitive jobs. In the last decade, European mental health leaders were interested on its implementation. Aim of the study was to assess the IPS feasibility in Italian patients with moderate-to-severe mental illness. To date, no evaluation of IPS has been conducted exclusively in Italy. Participants (n = 95) were clients of community mental health centers of the Reggio Emilia Department of Mental Health. In addition to drop-out rates, we calculated job acquisition, job duration, and total hours per week worked. A crude competitive employment rate of 41.1% and a crude drop-out rate of 30.5% were found over 42-month follow-up period. Using a Kaplan-Meyer survival analysis, the cumulative employment rate increased up to 44% at 12 months and 61% both at 24 and 42 months. This study documents the feasibility of an implementation strategy for introducing the IPS model in the public mental health care system in Italy.

An enhanced individual placement and support (IPS) intervention based on the Model of Human Occupation (MOHO); a prospective cohort study

BACKGROUND

Employment is good for physical and mental health, however people with severe mental illness (SMI) are often excluded from employment. Standard Individual Placement and Support (IPS) is effective in supporting around 55% of people with SMI into employment or education. Current research considers enhancements to IPS to improve outcomes for those requiring more complex interventions. Clinicians need to better understand who will benefit from these enhanced IPS interventions. This study offers a new enhanced IPS intervention and an approach to predicting who may achieve successful outcomes.

METHODS

This prospective cohort study included people with SMI who participated in an enhanced IPS service and had prolonged absence from employment. Secondary data analysis was conducted of data gathered in routine clinical practice. Univariate analysis coupled with previous research and clinical consultation was used to select variables to be included in the initial model, followed by a backward stepwise approach to model building for the final multiple logistic regression model with an outcome of successful or unsuccessful goal attainment (employment or education).

RESULTS

Sixty-three percent of participants in the enhanced IPS successfully attained employment or education. Significant relationships from bivariate analyses were identified between outcomes (employment or education) and seven psychosocial variables. Adapting Routines to Minimise Difficulties, Work Related Goals, and Living in an Area of Lesser Deprivation were found to be significant in predicting employment or education in the final multiple logistic regression model R² = 0.16 (Hosmer-Lemeshow), 0.19 (Cox-Snell), 0.26 (Nagelkerke). Model χ²(7) = 41.38 p < .001.

CONCLUSION

An enhanced IPS service had a 63% rate success in achieving employment or education, higher than comparable studies and provides an alternative to IPS-Lite and IPS-standard for more complex populations. Motivational and habitual psychosocial variables are helpful in predicting who may benefit from an enhanced IPS intervention supporting people after prolonged absence from employment.

TRIAL REGISTRATION

NCT04083404 Registered 05 September 2019 (retrospectively registered).

Assessing the Fidelity of Evidence-Based Practices: History and Current Status of a Standardized Measurement Methodology

Evidence-based practices are effective only when implemented faithfully. This paper explicates the history, standardization, and methods for developing and validating measures of fidelity. We overviewed the past 20 years of developing fidelity measures, summarized standardization of the development procedures, and described needed psychometric assessments. Fidelity assessment has become the sine qua non of implementation, technical assistance, and research on evidence-based practices. Researchers have established standardized procedures for scale development and psychometric testing. Widescale use of fidelity measurement remains challenging. The implementation of evidence-based practice and the development and validation of fidelity measures are interdependent. International improvements of mental health care will require attention to both.

Modifiable Predictors of Supported Employment Outcomes Among People With Severe Mental Illness

OBJECTIVE

Among people with severe mental illnesses, neuropsychological abilities may contribute to vocational outcomes, such as job attainment, job tenure, and wages earned. The current study aimed to determine the strongest neuropsychological and other modifiable predictors of work outcomes in 153 people with severe mental illness (schizophrenia, 38%; bipolar disorder, 24%; and major depression, 38%) who participated in a 2-year supported employment study.

METHODS

Assessments of neuropsychological performance, functional capacity, social skills, and psychiatric symptom severity were administered at baseline; work outcomes (job attainment, weeks worked, and wages earned) were collected weekly for 2 years.

RESULTS

Independent of education, diagnosis, and estimated intellectual functioning, more recent work history and less severe negative symptoms significantly predicted job attainment during the 2-year study. Among the 47% who obtained jobs, better global neuropsychological performance (i.e., lower global deficit score) was a significant predictor of greater weeks worked. Both global neuropsychological performance and more recent work history predicted higher wages earned.

CONCLUSIONS

Modifiable predictors of supported employment outcomes included cognitive functioning and negative symptom severity; thus, interventions to improve these factors may improve work outcomes and decrease the loss of productivity associated with severe mental illness.

Cognitive and metacognitive factors predict engagement in employment in individuals with first episode psychosis

Background

Research has demonstrated that cognitive abilities predict work outcomes in people with psychosis. Cognitive Remediation Programs go some way in improving work outcomes, but individuals still experience difficulty maintaining employment. Metacognition has been demonstrated to predict work performance in individuals with schizophrenia, but this has not yet been applied to First Episode Psychosis (FEP). This study assessed whether metacognition, intellectual aptitude and functional capacity can predict engagement in work and number of hours of work within FEP.

Methods

Fifty-two individuals with psychosis, from an Early Intervention in Psychosis service, completed measures of IQ, metacognition (Metacognitive Assessment Interview), functional capacity (UPSA), and functional outcome (hours spent in structured activity per week, including employment).

Results

Twenty-six participants (22 males, 4 females) were employed and twenty-six (22 males, 4 females) were not employed. IQ and metacognition were significantly associated with whether the individual was engaged in employment [IQ (p = .02) and metacognition (p = 006)]. When controlling for IQ, metacognition (differentiation subscale) remained significant (p = .04). Next, including only those employed, no cognitive nor metacognitive factors predicted number of hours in employment.

Discussion

This is the first study to directly assess metacognition as a predictor of work hours for individuals with FEP. This study highlights the importance of enhancing metacognitive ability in order to improve likelihood of, and engagement in, employment for those with FEP.