Reliability of instruments in a cooperative, multisite study: employment intervention demonstration program

Improving vocational recovery among people with psychosis: a two-pronged approach

Purpose

This paper aims to investigate the feasibility of conducting research on a two-pronged vocational intervention for people with first episode psychosis. The paper also aims to empirically examine the impact of a two-pronged vocational intervention for people with first episode psychosis by determining what effect, if any, introducing a two-pronged vocational intervention to an early intervention for psychosis service (EIPS) has on vocational outcomes using a prospective follow-up design. The approach consisted of supported employment (individual placement and support, IPS) for participants without a productive role and a job retention programme for those employed or studying.

Design/methodology/approach

Between 2010 and 2013, a supported employment specialist joined an EIPS where occupational therapy was available to all attenders. The appropriate intervention was determined by the occupational therapist on the team. Participants were interviewed at baseline and one follow-up. Ethical approval was attained. The Individual Placement and Support Fidelity Scale was used to ensure the quality of IPS implementation.

Findings

In total, 39 (20 men, 19 women) consented; 21 (54 per cent) of these participants were unoccupied; 18 (46 per cent) had a productive role; 87 per cent (n= 34) were followed up. The mean length of follow-up was 18 months. At follow-up, 50 per cent (n= 10) of unoccupied participants had attained a productive role, and 17 of the 18 participants had retained their productive role. Overall, participants were found to have spent an average of 62 per cent of the follow-up period in a productive role.

Research limitations/implications

Rates of vocational recovery among people affected by psychosis may be enhanced by a two-pronged approach that allows for the persons individual work circumstances to be taken into account.

Originality/value

This study highlights the impact of a two-progroned vocational intervention for people with first episode psychosis in Ireland. It is the first study of its kind to be published in the Republic of Ireland and the first world-wide to include a job retention element in its design.

Perceived Quality of the Mother-Adolescent and Father-Adolescent Attachment Relationship and Adolescents' Self-Esteem

There is consensus in the literature that self-esteem stems from relationships with others. In particular, it is assumed that parents play an important role in the development of children's self-esteem, also in adolescence. Despite the importance of parent-child attachment relationships for adolescents' self-esteem, we know very little about the extent to which fathers and mothers uniquely contribute to adolescents' self-esteem. The current study aims to contribute to acquiring knowledge in this research area in three ways. First, by separating the potential influences of father-child and mother-child attachment relationships on sons' and daughters' self-esteem, the current study is able to investigate the individual contribution of the father-child and mother-child attachment relationship to female and male adolescent's self-esteem. Second, by controlling for changes in the quality of the parental relationship and peer relationships the current study is able to isolate linkages between changes in adolescents' perceived quality of the parent-child attachment relationships and changes in adolescents' self-esteem. Third, by using longitudinal data and solely analyzing within-person variation, the current study is able to rule out stable confounding factors as alternative explanations. Self-reports of 542 adolescents (mean age at T1 = 13.6 years, percentage female = 0.51) from all three waves of the Dutch cohort study Social Development of Adolescents were used. The longitudinal fixed effects models showed that, for both sons and daughters, changes in the perceived quality of the mother-adolescent attachment relationship and changes in the perceived quality of the relationship between adolescents' parents were positively linked with changes in self-esteem. Changes in the perceived quality of the attachment relationship with father were only significantly linked to changes in daughters' self-esteem, not in that of sons. Contrary to the expectations, changes in peer relationships were not associated with changes in adolescents' self-esteem. These findings suggest that even though adolescents may be increasing their time spent with friends and romantic partners, perceived changes in the attachment relationships with fathers and mothers and in the wider family system are highly important for how adolescents think of and judge themselves.

Local and Widely Distributed EEG Activity in Schizophrenia With Prevalence of Negative Symptoms

We evaluated EEG frequency abnormalities in resting state (eyes closed and eyes open) EEG in a group of chronic schizophrenia patients as compared with healthy subjects. The study included 3 methods of analysis of deviation of EEG characteristics: genuine EEG, current source density (CSD), and group independent component (gIC). All 3 methods have shown that the EEG in schizophrenia patients is characterized by enhanced low-frequency (delta and theta) and high-frequency (beta) activity in comparison with the control group. However, the spatial pattern of differences was dependent on the type of method used. Comparative analysis has shown that increased EEG power in schizophrenia patients apparently concerns both widely spatially distributed components and local components of signal. Furthermore, the observed differences in the delta and theta range can be described mainly by the local components, and those in the beta range mostly by spatially widely distributed ones. The possible nature of the widely distributed activity is discussed.

Are Single-Item Global Ratings Useful for Assessing Health Status?

The research performance of the single-item self-rating In general, would you say your health is: excellent, very good, good, fair, or poor? was evaluated relative to the SF-36 General Health Scale that contains this item, using data for a sample of psychiatric outpatients who had co-occurring chronic physical conditions (N = 177). The scale was more robust than the single-item in cross-sectional validity tests and for predicting 2-year outcomes, but the single-item had stronger discriminant validity as a measure of physical health, especially in post-baseline analyses. Single-item and scale were both sensitive enough to detect change in perceived health over 2 years and a conditional experimental effect on health self-perceptions in a randomized trial. These findings demonstrate that a global single-item can be as valid, reliable, and sensitive as a multi-item scale for longitudinal research purposes, even if the scale performs better in cross-sectional surveys or as a screening measure.

Are Single-Item Global Ratings Useful for Assessing Health Status?

The research performance of the single-item self-rating In general, would you say your health is: excellent, very good, good, fair, or poor? was evaluated relative to the SF-36 General Health Scale that contains this item, using data for a sample of psychiatric outpatients who had co-occurring chronic physical conditions (N = 177). The scale was more robust than the single-item in cross-sectional validity tests and for predicting 2-year outcomes, but the single-item had stronger discriminant validity as a measure of physical health, especially in post-baseline analyses. Single-item and scale were both sensitive enough to detect change in perceived health over 2 years and a conditional experimental effect on health self-perceptions in a randomized trial. These findings demonstrate that a global single-item can be as valid, reliable, and sensitive as a multi-item scale for longitudinal research purposes, even if the scale performs better in cross-sectional surveys or as a screening measure.

Predictors of Job Accommodations for Individuals With Psychiatric Disabilities

The empirical literature on the impact of psychiatric disability on employment outcomes has consistently shown that individuals with psychiatric disabilities are more likely than those without to experience adverse labor market outcomes. One strategy invoked to address barriers to employment has been reasonable job accommodations, developed originally through the Americans With Disabilities Act legislation. However, little is known about the factors associated with the request for reasonable job accommodations among those with serious psychiatric disabilities. Data for this study come from a longitudinal multisite demonstration project funded by the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration. Accommodations were reported by individuals with serious mental health disabilities who became employed. Results from logistic regression analysis found that those who disclosed their disability to their employers, who were more severely disabled, and who had positive social relationships were more likely to request accommodations. This study advances our knowledge of the factors that influence the decision of individuals with serious mental health disabilities to seek accommodation in the work environment and offers a framework for guiding rehabilitation counselors in ways that might help to enhance employment outcomes for this population.

Employment program for patients with severe mental illness in Malaysia: a 3-month outcome

OBJECTIVE

This study aimed to examine the rate and predictive factors of successful employment at 3 months upon enrolment into an employment program among patients with severe mental illness (SMI).

METHODS

A cross-sectional study using universal sampling technique was conducted on patients with SMI who completed a 3-month period of being employed at Hospital Permai, Malaysia. A total of 147 patients were approached and 126 were finally included in the statistical analyses. Successful employment was defined as the ability to work 40 or more hours per month. Factors significantly associated with successful employment from bivariate analyses were entered into a multiple logistic regression analysis to identify predictors of successful employment.

RESULTS

The rate of successful employment at 3 months was 68.3% (n=81). Significant factors associated with successful employment from bivariate analyses were having past history of working, good family support, less number of psychiatric admissions, good compliance to medicine, good interest in work, living in hostel, being motivated to work, satisfied with the job or salary, getting a preferred job, being in competitive or supported employment and having higher than median scores of PANNS on the positive, negative and general psychopathology. Significant predictors of employment, from a logistic regression model were having good past history of working (p<0.021; OR 6.12; [95% CI 2.1-11.9]) and getting a preferred job (p<0.032; [OR 4.021; 95% CI 1.83-12.1]).

CONCLUSION

Results showed a high employment rate among patients with SMI. Good past history of working and getting a preferred job were significant predictors of successful employment.

Accuracy of self-report, biological tests, collateral reports and clinician ratings in identifying substance use disorders among adults with schizophrenia

Identifying substance use disorders among adults with schizophrenia presents unique challenges but is critical to research and practice. This study examined: (a) the accuracy of assessments completed using various approaches in identifying substance use disorders, (b) their ability to discriminate between disorders of abuse and dependence, and (c) the benefits of using multiple indicators to identify substance use disorders. Data are from the Clinical Antipsychotic Trials of Intervention Effectiveness study. The sample comprised 1,460 community-based adults with schizophrenia, 15.8% (n = 230) of whom were positive for a current (past month) drug or alcohol use disorder using the Structured Clinical Interview for DSM-IV Disorders (SCID). Clinician ratings, self-report, collateral reports, and results of hair and urine tests were compared to SCID diagnoses. Congruence with SCID diagnoses was good across approaches and evidence for superiority of one approach over another was limited. No approach discriminated between abuse and dependence. There was limited benefit of using multiple indicators. Findings suggest that the decision regarding the "best" approach for identifying substance use disorders among adults with schizophrenia may be made through consideration of practical issues and assessment purpose, rather than selection of the approach that yields the most accurate diagnostic assessment.

Clinical and cognitive correlates of employment among patients with schizophrenia: a cross-sectional study in Malaysia

BACKGROUND

Gainful employment is one major area of functioning which is becoming an important goal in psychiatric rehabilitation of patients with schizophrenia. Studies in western countries are pointing to evidence that certain sociodemographic and clinical factors may contribute to employment outcomes in this group of people. However, the area is still largely unexplored in Malaysia. The aim of this study was to examine the sociodemographic, clinical and cognitive correlates of employment status among patients with Schizophrenia.

METHODS

This was a cross-sectional study. All participants who fulfilled the requirements of the study according to the inclusion and exclusion criteria were enrolled. Study instruments included a demographic data questionnaire, Positive and Negative Symptom Scale (PANSS), Trail Making Tests, Rey's Auditory Verbal Learning Test (RAVLT) and Digit Span. Bivariate analyses were done using chi-square for categorical data and t-test for continuous data and multiple logistic regression analysis was done to identify predictors of employment status.

RESULTS

A total of 95 participants who fulfilled the inclusion criteria were enrolled into the study. Among the sociodemographic, clinical and cognitive variables studied marital status, educational level, mean scores of negative symptoms, Digit Span and RAVLT and Trail Making Tests were found to show significant association with employment status on bivariate analyses. However, when entered into a logistic regression model, only cognitive variables ie. Trail A and B, Digit Span and RAVLT were significant predictors of employment status.

CONCLUSIONS

The results from this study support the role of cognitive function, particularly, attention, working memory and executive functioning on attaining and maintaining employment in persons with schizophrenia as measured by the RAVLT, Digit Span and Trail Making Tests. These findings may act as preliminary evidence suggesting the importance of integrating cognitive rehabilitation in the psychosocial rehabilitation program for patients with schizophrenia in Malaysia.

The psychometric properties of the Illness Management and Recovery scale: client and clinician versions

The present study examined the psychometric properties of the clinician and client versions of the Illness Management and Recovery (IMR) scale. Using a 5-point behaviorally anchored response format, these scales were designed to tap the critical illness management and recovery domains targeted by the IMR program. This program is a curriculum-based approach to helping persons with a serious mental illness (SMI) acquire the knowledge and skills they need to manage their illness effectively and to achieve personal recovery goals. Two hundred and ten persons with a diagnosis of a SMI and their 13 clinicians filled-out the client and clinician versions of the IMR questionnaire. The clients also responded to measures of coping efficacy and social support. While indicating limitations of the IMR scales and pointing to how they could be improved, this study provided some support for the construct and concurrent validity of the client and clinician versions of the IMR questionnaire. Moderate reliabilities were uncovered for these parallel versions of the questionnaire. Client responses to the client IMR scale and clinician responses to the clinician IMR scale were shown to be characterized by similar major components of the IMR intervention.

When programs benefit some people more than others: tests of differential service effectiveness

Practitioners need to know for whom evidence-based services are most or least effective, but few services research studies provide this information. Using data from a randomized controlled comparison of supported employment findings for two multi-service psychiatric rehabilitation programs, we illustrate and compare procedures for measuring program-by-client characteristic interactions depicting differential program effectiveness, and then illustrate how a significant program-by-client interaction can explain overall program differences in service effectiveness. Interaction analyses based on cluster analysis-identified sample subgroups appear to provide statistically powerful and meaningful hypothesis tests that can aid in the interpretation of main effect findings and help to refine program theory.

WHEN PARENTS WITH SEVERE MENTAL ILLNESS LOSE CONTACT WITH THEIR CHILDREN: ARE PSYCHIATRIC SYMPTOMS OR SUBSTANCE USE TO BLAME?

This study compared parental psychiatric symptom severity, and the absence or presence of severe substance abuse, as predictors of contact with minor children for a representative sample of adults with diagnoses of serious mental illness (N = 45). Child contact and psychiatric symptom severity were measured during regularly scheduled 6-month research interviews over a total 30-month period following each participant's entry into the project. Severe substance abuse was documented as present or absent for the 6-month interval preceding each interview. Results revealed that incidence of severe substance abuse was repeatedly associated with less frequent parent-child contact, even after controlling for psychiatric symptoms, diagnosis, gender, age, ethnicity, and socioeconomic status. Neither psychiatric diagnosis nor symptom severity predicted frequency of child contact when substance abuse was taken into account. Mental health agencies offering parenting classes for adults with serious mental illness should incorporate substance use interventions to reduce loss of child custody and strengthen parent-child relationships.

Stress and coping responses to a natural disaster in people with schizophrenia

Investigations of how individuals with schizophrenia differ from non-patients in their responses to stressful life events are subject to the criticism that any between-group differences might merely reflect differences in the types of stressful events that each group experiences. This report presents new analyses of data collected from schizophrenia patients (n=96), bipolar disorder patients (n=18), and healthy controls (n=18) immediately after the Northridge Earthquake that struck Southern California in 1994, a natural experiment that confronted all groups with the same stressful event. Participants completed the Impact of Events Scale (IES; [Horowitz, M.J., Wilner, N., Alvarez, W., 1979. Impact of Events Scale. A measure of subjective stress. Psychosomatic Medicine 41, 209-218]) at 1 week and 5 weeks post-earthquake. At the 5-week follow-up, measures of coping, social support, and self-esteem were also completed. Both patient groups reported higher IES avoidance symptoms than controls immediately after the earthquake. The schizophrenia group also reported lower approach coping, self-esteem, and social support than controls, with the bipolar group reporting intermediate levels. Within the schizophrenia group, higher levels of avoidance coping predicted higher residual stress symptoms at follow-up. Results support the validity of prior reports of altered responses to stressful life events in schizophrenia and demonstrate the clinical relevance of individual differences in coping among affected individuals.

Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models

OBJECTIVE

In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services.

METHODS

Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt.

RESULTS

Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay.

CONCLUSIONS

Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.

Clinical factors associated with employment among people with severe mental illness: findings from the employment intervention demonstration program

Research has shown that supported employment programs are effective in helping psychiatric outpatients achieve vocational outcomes, yet not all program participants are able to realize their employment goals. This study used 24 months of longitudinal data from a multisite study of supported employment interventions to examine the relationship of patient clinical factors to employment outcomes. Multivariate random regression analysis indicated that, even when controlling for an extensive series of demographic, study condition (experimental versus control), and work history covariates, clinical factors were associated with individuals' ability to achieve competitive jobs and to work 40 or more hours per month. Poor self-rated functioning, negative psychiatric symptoms, and recent hospitalizations were most consistently associated with failure to achieve these employment outcomes. These findings suggest ways that providers can tailor supported employment programs to achieve success with a diverse array of clinical subpopulations.

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

Utility of the Time-Line Follow-Back to assess substance use among homeless adults

Assessing substance use of homeless persons is a critical task. This study examines the test-retest reliability, concurrent validity, and sensitivity to change of the Time-Line Follow-Back interview, a calendar instrument used to assess days and quantities of alcohol use and days of illicit drug use, in the multisite Collaborative Program to Prevent Homelessness (CPPH). The Time-Line Follow-Back was reliable for assessing use during the past month and the recent 6 months. Results from the Time-Line Follow-Back were correlated with other self-reports of use, with research diagnoses of substance use disorder, and with clinician ratings of severity of substance abuse. The Time-Line Follow-Back detected changes in clients with severe mental illness and in those with less severe psychiatric problems.

Social network correlates among people with psychiatric disabilities

This study explores three social network characteristics as they relate to demographic, clinical, and quality of life factors. The sample consists of 219 participants with serious mental illness. Results indicate that clients' social networks were small, and that network size is robustly related to symptoms and other measures of clinical and cognitive functioning, as well as with quality of life and self-esteem. The expected relation between network density and either the demographic variables or quality of life was not found. Moderate levels of network density, however, were associated with fewer psychiatric symptoms and higher IQ. Network multiplexity was most highly associated with demographic variables, such as ethnic minority status, less education, never being married, and living with family.