Predictors of vocational recovery among young people with first-episode psychosis: findings from a randomized controlled trial

Shaping tomorrow's support: baseline clinical characteristics predict later social functioning and quality of life in schizophrenia spectrum disorder

PURPOSE

We aimed to explore the multidimensional nature of social inclusion (mSI) among patients diagnosed with schizophrenia spectrum disorder (SSD), and to identify the predictors of 3-year mSI and the mSI prediction using traditional and data-driven approaches.

METHODS

We used the baseline and 3-year follow-up data of 1119 patients from the Genetic Risk and Outcome in Psychosis (GROUP) cohort in the Netherlands. The outcome mSI was defined as clusters derived from combined analyses of thirteen subscales from the Social Functioning Scale and the brief version of World Health Organization Quality of Life questionnaires through K-means clustering. Prediction models were built through multinomial logistic regression (ModelMLR) and random forest (ModelRF), internally validated via bootstrapping and compared by accuracy and the discriminability of mSI subgroups.

RESULTS

We identified five mSI subgroups: "very low (social functioning)/very low (quality of life)" (8.58%), "low/low" (12.87%), "high/low" (49.24%), "medium/high" (18.05%), and "high/high" (11.26%). The mSI was robustly predicted by a genetic predisposition for SSD, premorbid adjustment, positive, negative, and depressive symptoms, number of met needs, and baseline satisfaction with the environment and social life. The ModelRF (61.61% [54.90%, 68.01%]; P =0.013) was cautiously considered outperform the ModelMLR (59.16% [55.75%, 62.58%]; P =0.994).

CONCLUSION

We introduced and distinguished meaningful subgroups of mSI, which were modestly predictable from baseline clinical characteristics. A possibility for early prediction of mSI at the clinical stage may unlock the potential for faster and more impactful social support that is specifically tailored to the unique characteristics of the mSI subgroup to which a given patient belongs.

Measures of Social and Occupational Function in Early Psychosis: A Systematic Review and Meta-analysis

Deficits in social and occupational function are widely reported in psychosis, yet no one measure of function is currently agreed upon as a gold standard in psychosis research. The aim of this study was to carry out a systematic review and meta-analysis of functioning measures to determine what measures were associated with largest effect sizes when measuring between-group differences, changes over time, or response to treatment. Literature searches were conducted based on PsycINFO and PubMed to identify studies for inclusion. Cross-sectional and longitudinal observational and intervention studies of early psychosis (≤5 years since diagnosis) that included social and occupational functioning as an outcome measure were considered. A series of meta-analyses were conducted to determine effect size differences for between-group differences, changes over time, or response to treatment. Subgroup analyses and meta-regression were carried out to account for variability in study and participant characteristics. One hundred and sixteen studies were included, 46 studies provided data (N = 13 261) relevant to our meta-analysis. Smallest effect sizes for changes in function over time and in response to treatment were observed for global measures, while more specific measures of social and occupational function showed the largest effect sizes. Differences in effect sizes between functioning measures remained significant after variability in study and participant characteristics were accounted for. Findings suggest that more specific measures of social function are better able to detect changes in function over time and in response to treatment.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

Evaluating Educational and Employment Services for Young People With Psychiatric Conditions: A Systematic Review

OBJECTIVE

The authors conducted a systematic review of studies evaluating vocational interventions for young people with psychiatric conditions to determine the extent to which services were adapted for young people and whether services promoted gains in postsecondary education and employment.

METHODS

Five databases (PubMed, PsycINFO, Web of Science, Academic Search Premier, and ERIC) were searched. Sources eligible for inclusion were controlled studies published between 2000 and mid-2020 that evaluated a vocational intervention and examined postsecondary educational or employment outcomes for youths or young adults (ages 14-35 years) with psychiatric conditions.

RESULTS

Ten studies met the inclusion criteria. Several of the studies evaluated services that were adapted for young people, including through the incorporation of educational supports. The most consistent finding was that services based on the individual placement and support (IPS) model improved employment outcomes more effectively than did comparison approaches and treatment as usual. Fewer studies assessed educational outcomes, and they yielded mixed results; however, recent findings from a controlled trial indicate that an enhanced IPS intervention that included well-specified supported education and skills training led to significantly superior outcomes in both education and employment.

CONCLUSIONS

These results provide support for the efficacy of IPS-based services to improve employment outcomes among young people with psychiatric conditions and suggest that adapting IPS to include comprehensive educational supports and skills training may be important for efforts to improve postsecondary educational outcomes. Additional well-controlled intervention studies that examine educational and longer-term outcomes should further inform the development and delivery of vocational services for this population.

Trajectories of Vocational Recovery Among Persons with Severe Mental Illness Participating in a Randomized Three-Group Superiority Trial of Individual Placement and Support (IPS) in Denmark

PURPOSE

To investigate longitudinal trajectories of vocational recovery (VR) among individuals with severe mental illness (SMI) who participated in the Danish Individual Placement and Support (IPS) trial, and whether the IPS intervention, socio-demographic and disease-specific characteristics predicted trajectory membership.

METHODS

In an observational study design, we used previously collected data from the Danish IPS trial (N = 720). VR was defined as 'weeks in competitive employment or education in the past 6 months and was measured after 0.5, 1, 1.5, 2 and 2.5 years, using data from the Danish Register for Evaluation of Marginalization (DREAM) database. Latent growth mixture modelling in Mplus statistical software (version 7) was applied to identify trajectories of VR. Multinomial logistic regression analyses were used to estimate predictors for trajectory membership.

RESULTS

Four trajectories were identified: 'Low VR' (61.3%), 'Low Increasing VR (8.2%), 'Increasing Decreasing VR' (7.2%) and 'High VR' (23.4%). Receiving the IPS intervention increased odds of membership in 'High VR' compared to 'Low VR' (OR = 2.18; 95% CI 1.37-3.48) and so did higher education (OR = 2.25; 95% CI 1.39-3.64), higher cognitive function (OR = 1.17; 95% CI 1.02-1.35), higher motivation to change (OR = 1.04; 95% CI 1.02-1.05) and previous work history (OR = 1.64; 95% CI 1.09-2.46). Higher age decreased odds of membership in the 'High VR' (OR = 0.95; 95% CI 0.93-0.98) compared to 'Low VR'.

CONCLUSION

There was high heterogeneity in the identified VR trajectories, despite that all participants expressed a desire for work and education at baseline. Improvements of the IPS intervention are needed to support specific groups in achieving and retaining employment.

Psychosocial interventions for people with a first episode psychosis: between tradition and innovation

PURPOSE OF REVIEW

Assessing recent evidence on psychosocial interventions for people with first episode psychosis (FEP).

RECENT FINDINGS

Family interventions (FI) reduce relapse rates, whilst cognitive behavioural therapy (CBT) shows a moderate effect in improving positive psychotic symptoms. Vocational interventions (VI) appear to be worthy of implementation within early intervention for psychosis (EIP) teams, but it is still unclear what is the most cost-effective strategy for their delivery. Promising interventions, which need more careful evaluation, focus on substance misuse, physical health comorbidities, improvement of social participation, peer support and the potential of new technologies.

SUMMARY

The first five years after the onset of psychotic symptoms are a 'critical period' in which psychosocial interventions can be particularly influential in determining prognosis. Traditional EIP interventions have different effectiveness profiles, i.e., FI reduce relapse rates, CBT has a moderate effectiveness on overall and positive symptoms and VI can improve educational and employment-related functioning. Newer interventions show promise on important targets for FEP treatment but require higher-quality evaluations. Decisions on which interventions to implement within EIP teams should be informed by high-quality evidence, but difficult choices will have to be made based on costs, professionals and technologies available, and local priorities.

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.

Global Child Mental Health Research: Time for the Children

Although 9 of 10 of the world's children live in low- and middle-income countries (LMICs), and children constitute nearly half of the populations of these countries, far too little research has focused on child mental health in LMICs.¹ The expansion of research in global health and global mental health over the past several decades has not yet been matched by new research in child and adolescent mental health in LMICs.² It is time for that to change. New research should include a focus on social drivers and the mechanisms by which they contribute to mental illnesses.

Depressive symptoms during first episode psychosis and functional outcome: A systematic review and meta-analysis

OBJECTIVES

First episode psychosis (FEP) is associated with functional decline. Existing evidence was synthesised to explore the influence of depressive symptoms during FEP on future social, occupational and global functioning.

METHODS

Medline, Embase, PsychINFO, Cochrane Library, Open Grey, NICE Evidence and Web of Science were searched from inception to May 2018. Longitudinal studies of FEP patients were included. Study quality was assessed using the Downs and Black instrument. Two meta-analyses were performed using random effect models. The first meta-analysis correlates depressive symptoms during FEP with follow-up Global Assessment of Functioning (GAF) scores. The second meta-analysis shows the odds of long-term functional remission if depressive symptoms are present during FEP.

RESULTS

4751 unique abstracts were found. 36 articles were included. The first meta-analysis included 7 studies (932 participants) and showed depressive symptoms during FEP were negatively correlated with follow-up GAF scores (r = -0.16, 95% CI: -0.24 to -0.09, p < 0.001). The second meta-analysis of 9 studies (2265 participants) showed weak evidence of an association between the presence of depressive symptoms in FEP and reduction in functional remission (OR = 0.87, 95% CI: 0.68 to 1.13, p = 0.294).

CONCLUSION

Depressive symptoms during FEP are associated with poorer long-term global functioning and may be associated with a reduced chance of achieving functional remission. Clinical trials are needed to identify efficacious management of depressive symptoms in early psychosis.

Work-focused interventions that promote the labour market transition of young adults with chronic disabling health conditions: a systematic review

Objective

Young adulthood is an important transitional life phase where careers are established. Young adults with chronic disabling health conditions are underrepresented in the labour market. Our study aims to examine the effectiveness of work-focused interventions that support the labour market transition of young adults with chronic disabling health conditions; and to examine whether the effectiveness of work-focused interventions differ across work transition phase (eg, preparation, entry and sustaining work, employment advancement) and disability type.

Methods

A systematic review of articles published between January 1990 and July 2018 was conducted. Medline, EMBASE and PsycInfo were searched, and titles/abstracts and full texts of articles were reviewed for eligibility. Relevant articles were appraised for methodological quality. A best evidence synthesis was applied to medium-quality/high-quality studies to develop recommendations.

Results

5816 articles were identified; 10 articles were relevant and of moderate–high methodological quality. Six intervention categories were identified which focused on young adults with mental health or intellectual/learning disabilities (n=3) and addressed employment preparation (n=10) and/or work entry (n=9). No interventions addressed at-work issues or career advancement. Strong evidence existed for tailored supported employment (SE) interventions having a positive impact on preparation and entry into competitive employment. Also, moderate evidence existed for the positive impact of SE on preparation and entry into competitive employment for young adults with mental health conditions.

Conclusions

Tailored SE is recommended to foster preparation and entry into the labour market. Evidence-based interventions are needed to facilitate sustained work and career advancement of young adults living with different disabling health conditions.

Barriers and facilitators to employment for young adults with mental illness: a scoping review

OBJECTIVES

The issue of gaining employment for those with mental illness is a growing global concern. For many in the young adult population, who are at a transitional age, employment is a central goal. In response, we conducted a scoping review to answer the question, 'What are the barriers and facilitators to employment for young adults with mental illness?'

DESIGN

We conducted a scoping review in accordance to the Arksey and O'Malley framework. We performed a thorough search of Medline, EMBASE, CINAHL, ABI/INFORM, PsycINFO and Cochrane. We included studies that considered young adults aged 15-29 years of age with a mental health diagnosis, who were seeking employment or were included in an employment intervention.

RESULTS

Our search resulted in 24 research articles that focused on employment for young adults with mental illness. Four main themes were extracted from the literature: (1) integrated health and social services, (2) age-exposure to employment supports, (3) self-awareness and autonomy and (4) sustained support over the career trajectory.

CONCLUSIONS

Our review suggests that consistent youth-centred employment interventions, in addition to usual mental health treatment, can facilitate young adults with mental illness to achieve their employment goals. Aligning the mental health and employment priorities of young adults may result in improved health and social outcomes for this population while promoting greater engagement of young adults in care.

Challenges to recovery following early psychosis: Nursing implications of recovery rate and timing

Early intervention in first episode psychosis is based on an indicated prevention approach that has early illness identification and timely recovery as primary goals. Nurses are instrumental in helping individuals and families achieve both aims. To better understand recovery following a first episode, a prospective cohort of 260 individuals participating in a three-year early intervention program was monitored for achievement of recovery outcomes. Two outcome measures were used to examine the recovery rate and timing of the cohort: (1) partial recovery was comprised of two criteria: (a) symptom control (psychosis and mania), and (b) daily functioning, and 2) comprehensive recovery was measured by three criteria: (a) symptom control; (b) daily functioning; and, (c) quality of life. Survival analysis, including the Kaplan-Meier statistic, and Cox hazard regression were used to examine the cohort's rate and timing for both measures. One hundred and seventy-four individuals attained partial recovery with half (51.1%) reaching the target within nine months. Comprehensive recovery was achieved by 59 individuals (22.7%), primarily in year two and three of treatment. Issues impacting quality of life delayed recovery for the majority of program participants. The gap between psychosis remission and satisfaction/fulfillment with one's everyday life is troubling, but could be improved with stronger nursing support and influence. Sharing the recovery experience with individuals and families that supports their life goals and the discovery of meaning, hope and purpose in the face of illness is the work of nurses. Suggestions for strengthening nursing's impact are considered.

A meta-analysis of factors associated with quality of life in first episode psychosis

OBJECTIVE

Improving quality of life for people with first episode psychosis is an important aspect of recovery. Our objective was to review the associative factors on quality of life in first episode psychosis. A meta-analysis was conducted on the associations between quality of life, symptom severity, and duration of untreated psychosis.

METHOD

Fifty-one articles were identified (published through 08/29/2016) that provided data on the relationship between quality of life and at least one other outcome measure of interest in first episode psychosis. Of those studies, 21 were included in a meta-analysis (n = 3992) of the relationship between quality of life, severity of psychosis, and duration of untreated psychosis.

RESULTS

Meta-analysis identified significant negative correlations between quality of life and severity of symptoms (total symptom scores: r = -0.32, p < 0.001) and quality of life and duration of untreated psychosis (r = -0.21, p < 0.001). Heinrich's quality of life scale emerged as being more sensitive to the presence of psychotic symptoms than other measures of quality of life.

CONCLUSIONS

Associations were found between certain disease specific variables and quality of life in first episode psychosis, highlighting the relationship between symptom presentation and quality of life and the need for early intervention. Proper assessment of quality of life is important to promote improved quality of life in patients with first episode psychosis. Future research is needed to examine the interacting effects of symptom presentation, duration of untreated psychosis, and other variables, such as neurocognition, on quality of life.

Early Intervention in Mental Health for Adolescents and Young Adults: A Systematic Review

OBJECTIVE. The purpose of this systematic review was to describe the evidence for the effectiveness of early intervention to improve and maintain performance in occupations for youths with or at risk for serious mental illness (SMI).

METHOD. Titles and abstracts of 670 articles were reviewed, 234 were retrieved for full review, and 30 met inclusion criteria.

RESULTS. Moderate to strong evidence supports cognitive remediation (CR) and mixed evidence supports cognitive–behavioral therapy (CBT) as an adjunct modality to improve general functioning. Moderate to strong evidence supports use of supported employment and supported education (SE/E) to improve social and occupational outcomes in employment and academics. Strong evidence supports family psychoeducation (FPE) to prevent relapse and rehospitalization and improve problem-solving skills and general functioning.

CONCLUSION. Occupational therapy practitioners should integrate CR, SE/E, and FPE into early intervention with youth with or at risk for SMI. In addition, CBT is an effective modality for use with this population.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Youth mental ill health and secondary school completion in Australia: time to act

AIM

This paper reviews the evidence of youth mental ill health and its impact on secondary school educational attainment.

METHODS

This narrative review presents the current research related to the mental ill health of young people in urban and rural Australia, their educational attainment and the effectiveness of mental health strategies implemented in secondary schools.

RESULTS

The prevalence of mental ill health is high for Australian young people and the onset of depression, anxiety, substance-use disorders and first episode psychosis (FEP) commonly occurs when the individual is at school. The prevalence is reported to be higher for rural young people and barriers to treatment exist. Current evidence suggests that 40% of young people experiencing depression or anxiety disorders are not completing secondary school. Further evidence shows that over 50% of individuals who experience FEP do not finish secondary school. Current mental health promotion strategies employed in secondary schools have not been shown to reduce rates of depression or anxiety in adolescence nor identify prodromal or acute FEP. These strategies have not led to interventions that assist young people with mental ill health to finish school.

CONCLUSIONS

Not completing secondary school can limit employment options, lead to severe levels of disadvantage and increased burden on welfare and healthcare systems. All young people, including those in rural areas, have the right to education and should not be disadvantaged in their educational aspirations because they have an emerging or current mental illness.

Confirmatory factor analysis of the quality of life scale and new proposed factor structure for the quality of life scale-revised

The Quality of Life Scale (QLS) is a frequently used semistructured interview for the assessment of functional outcomes in schizophrenia. Despite the use of the QLS for over 30years, the original 4-factor structure of the instrument (Interpersonal Relations, Instrumental Role, Intrapsychic Foundations, and Common Objects and Activities) has not been rigorously examined. Exploratory factor analyses (EFAs) and confirmatory factor analyses (CFAs) were used to evaluate the factor structure of the QLS in two independent datasets, including a mixed diagnostic sample of multi-episode participants (N=247), and a sample of individuals with a first episode of psychosis (N=337). A CFA with the first dataset indicated a poor fit for the 4-factor model of the QLS. Subsequent EFAs on this dataset led to a more promising 3-factor solution including 16/21 of the QLS items, which were similar to the first 3 of 4 factors originally proposed for the QLS. CFAs on the same dataset indicated that the 3-factor model for the QLS-Revised (QLS-R) fit the data well. This factor structure was evaluated with the second dataset using CFA and was also found to be fit the data well. The results support the robustness of the 3-factor model of the QLS-R in schizophrenia and mixed diagnostic samples. Future research should evaluate the validity of the 3-factor model of the QLS-R, and consider the merits of changing the name of the Intrapsychic Foundations factor to Motivation.

A review of job tenure under the Job in Jeopardy programme in first episode psychosis

Introduction

This paper explores what happens to young people with psychosis who have competitive employment when they first engage in treatment.

Method

11 of 39 (28%) of programme participants of an individual placement and support programme who received vocational assistance under the Job in Jeopardy funding were identified. A prospective observational design was used to evaluate programme outcomes over a minimum of 6 months.

Results

It is of interest that the majority of young people who were at risk of losing their job and were receiving assistance did not manage to sustain employment. At the completion of data collection only two people continued to be engaged in competitive employment.

Conclusion

Although the sample is very small, there appears to be a clear trend demonstrating that being engaged in competitive employment at the point of experiencing a first episode of psychosis does not protect an individual against losing that job. It is evident that staff involved with this group of clients need to assist those with employment to maintain it. There is the potential for occupational therapists to play a key role in assisting these young people to secure and maintain meaningful occupation.

A systematic review of mental health outcome measures for young people aged 12 to 25 years

BACKGROUND

Mental health outcome measures are used to monitor the quality and effectiveness of mental health services. There is also a growing expectation for implementation of routine measurement and measures being used by clinicians as a feedback monitoring system to improve client outcomes. The recent focus in Australia and elsewhere targeting mental health services to young people aged 12-25 years has meant that outcome measures relevant to this age range are now needed. This is a shift from the traditional divide of child and adolescent services versus adult services with a transitioning age at 18 years. This systematic review is the first to examine mental health outcome measures that are appropriate for the 12 to 25 year age range.

METHODS

MEDLINE and PsychINFO databases were systematically searched to identify studies using mental health outcome measures with young people aged 12 to 25 years. The search strategy complied with the relevant sections of the PRISMA statement.

RESULTS

A total of 184 published articles were identified, covering 29 different outcome measures. The measures were organised into domains that consisted of eight measures of cognition and emotion, nine functioning measures, six quality of life measures, and six multidimensional mental health measures. No measures were designed specifically for young people aged 12 to 25 years and only two had been used by clinicians as a feedback monitoring system. Five measures had been used across the whole 12 to 25 year age range, in a range of mental health settings and were deemed most appropriate for this age group.

CONCLUSIONS

With changes to mental health service systems that increasingly focus on early intervention in adolescence and young adulthood, there is a need for outcome measures designed specifically for those aged 12 to 25 years. In particular, multidimensional measures that are clinically meaningful need to be developed to ensure quality and effectiveness in youth mental health. Additionally, outcome measures can be clinically useful when designed to be used within routine feedback monitoring systems.

The impact of premorbid adjustment, neurocognition, and depression on social and role functioning in patients in an early psychosis treatment program

OBJECTIVE

Functional impairments are debilitating concomitants of psychotic disorders and are present early in the illness course and, commonly, prior to psychosis onset. The factors affecting social and role functioning in early psychosis (EP) following treatment are unclear. We evaluated whether six months of participation in the PREP(R), Boston, EP treatment program, part of a public-academic community mental health center, was related to improvements in social and role functioning and whether premorbid adjustment in adolescence, baseline neurocognition, and depression symptoms predicted functional improvement.

METHOD

The Global Functioning Social and Role scales, MATRICS neurocognitive battery, and Calgary Depression Scale were assessed at baseline and six months during naturalistic treatment, while premorbid adjustment was measured at baseline. All participants were psychotic disorder patients in PREP(R) (n = 46 with social functioning and 47 with role functioning measures at both time points).

RESULTS

Large improvements were observed in role functioning (d = 0.84) and medium to large improvements were observed in social functioning (d = 0.70). Models consisting of adolescent premorbid adjustment and change in depression symptoms predicted social and role functioning change, whereas neuropsychological functioning did not.

CONCLUSIONS

Substantial improvements in social and role functioning were observed among this sample participating in a recovery-based EP program. The impact of clinical factors on social and role functioning was highlighted. Further studies of premorbid adjustment in adolescence and the treatment of depression in EP programs in controlled treatment trials are needed to confirm these findings.

Intervention précoce pour la psychose : concepts, connaissances actuelles et orientations futures

Cet article fournit un survol de la logique de l’intervention précoce pour psychose, de ses fondements théoriques et de la littérature essentielle sur le concept. L’intervention précoce repose sur l’hypothèse de la période critique, qui vient accentuer l’importance des premiers stades de la maladie, et sur les résultats d’études dans le domaine, qui suggère que la durée d’une psychose non traitée en influence le pronostic. L’intervention précoce facilite l’accès à un traitement spécialisé adapté à la phase de la maladie par un processus de recommandations médicales plus ouvert, des délais rapides et l’éducation du public et des praticiens sur la psychose. L’intervention précoce, qui dure généralement deux ans à partir du dépistage, comprend une prise en charge intensive et des médicaments antipsychotiques à faible dose. L’accent est mis sur le fonctionnement social, l’intervention familiale, l’attention précoce aux troubles connexes ainsi qu’une alliance thérapeutique entre le jeune et sa famille. Selon les données scientifiques disponibles, une telle intervention donne de meilleurs résultats que les soins typiquement offerts. Les critiques du concept visent la qualité des études en sa faveur, sa mise en oeuvre, la répartition des ressources en intervention précoce et son utilité pour les personnes présentant un risque élevé de psychose. En termes de disponibilité et d’élaboration de politiques en intervention précoce, le Royaume-Uni détient une avance certaine, alors que le Canada se situe au milieu, et les États-Unis au bas de l’échelle. Au Québec, les résultats varient et d’autres études et investissements sont nécessaires. Récemment, le concept d’intervention précoce a servi d’exemple à des mesures plus importantes visant la transformation des soins de santé mentale des jeunes, ce qui constitue une toute nouvelle percée au Canada.

Cognitive deficit and mental health in homeless transition-age youth

BACKGROUND AND OBJECTIVES

There is increasing recognition of the cognitive consequences of socioeconomic adversity during childhood, which can impair learning and negatively affect social and emotional development. However, there is a paucity of research on cognitive functioning and mental health among transition-age homeless youth. This study aimed to address this knowledge gap by examining the prevalence and functional significance of cognitive impairment and mental health disorders in a sample of 18- to 22-year-old homeless youth.

METHODS

Participants (N = 73) were recruited from a vocational support program at Covenant House New York, a care agency for homeless youth. Assessments included diagnostic assessment for mental health disorders and evaluation of neurocognition and vocational outcomes.

RESULTS

Youth demonstrated histories of academic instability, academic achievement below expectation, and high rates of untreated psychiatric disorders, the most prominent of which were anxiety, substance use, and mood disorders. Of those who had a mental health diagnosis, more than half demonstrated cognitive deficits. Performance on measures of working memory and verbal memory was <70% of that of the age-matched normative population. Cognitive impairment was associated with a significant risk for making a wage insufficient for independent living.

CONCLUSIONS

These data confirm the need to focus on cognitive as well as emotional and physical health in transition-age youth. Comprehensive intervention at this later developmental stage has the potential to facilitate the acquisition of skills needed for academic, vocational, and independent living success in adulthood.

An update on supported employment for people with severe mental illness

PURPOSE OF REVIEW

Individual Placement and Support (IPS) is an effective intervention for helping people with severe mental illness obtain competitive employment, yet it has not been widely implemented. This review will examine and summarize the latest research on IPS.

RECENT FINDINGS

As the effectiveness of IPS has been well established in the literature, newer research is exploring nonvocational outcomes, such as quality of life and mental health services utilization and expanding the reach of IPS to include different countries and different population groups. There is also a growing literature exploring the cost-effectiveness of IPS compared with traditional vocational services, which has favored IPS. By far, the area of research that has expanded the most is aimed at enhancing IPS outcomes, at both the intervention level and the client level. Researchers are exploring the variance in IPS outcomes as a means of increasing competitive employment rates with IPS.

SUMMARY

Although the field of research continues to expand, it is clear that many barriers remain to broad implementation of IPS. The solution goes beyond further research and involves policies and practices that support a recovery oriented mental healthcare system.

The relative contribution of neurocognition and social cognition to 6-month vocational outcomes following Individual Placement and Support in first-episode psychosis

AIMS

To examine whether baseline neurocognition and social cognition predict vocational outcomes over 6 months in patients with first-episode psychosis (FEP) enrolled in a randomised controlled trial of Individual Placement and Support (IPS) versus treatment as usual (TAU).

METHODS

135 FEP participants (IPS n=69; TAU n=66) completed a comprehensive neurocognitive and social cognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying cognitive structure of the battery. Setwise (hierarchical) logistic and multivariate linear regressions were used to examine predictors of: (a) enrolment in education and employment; and (b) hours of employment over 6 months. Neurocognition and social cognition factors were entered into the models after accounting for premorbid IQ, baseline functioning and treatment group.

RESULTS

Six cognitive factors were extracted: (i) social cognition; (ii) information processing speed; (iii) verbal learning and memory; (iv) attention and working memory; (v) visual organisation and memory; and (vi) verbal comprehension. Enrolment in education over 6 months was predicted by enrolment in education at baseline (p=.002) and poorer visual organisation and memory (p=.024). Employment over 6 months was predicted by employment at baseline (p=.041) and receiving IPS (p=.020). Better visual organisation and memory predicted total hours of paid work over 6 months (p<.001).

CONCLUSIONS

Visual organisation and memory predicted the enrolment in education and duration of employment, after accounting for premorbid IQ, baseline functioning and treatment. Social cognition did not contribute to the prediction of vocational outcomes. Neurocognitive interventions may enhance employment duration in FEP.