Economic, Labor, and Regulatory Moderators of the Effect of Individual Placement and Support Among People With Severe Mental Illness: A Systematic Review and Meta-analysis

Factors Associated with the Prevalence of Psychiatric Disorders Among Saudi Adults in the Eastern Region and Their Health Implications

BACKGROUND/OBJECTIVES

The present study examined the link between sociodemographic variables, anthropometric indices, and psychiatric disorders among patients in Saudi Arabia's Eastern Region (Al-Hassa), as well as health outcomes, including basic hematological and biochemical markers.

METHODS

The patients included 89 females and 79 males with psychiatric disorders, with ages ranging from 19 to 59. Sociodemographic characteristics, anthropometric proxies, and fundamental hematological and biochemical markers were assessed.

RESULTS

The sociodemographic characteristics of the patients were poor and varied within and between sexes. This study observed that male psychiatric patients had greater anthropometric proxies, particularly those who were overweight or obese, than females. Most of the patients' hematological and biochemical parameters were below the normal level, with some higher than normal. Moreover, anemia was identified in 40.51% of the male participants in the study, with a higher percentage among those diagnosed with depressive disorders (Dep-d, 57.14%) and schizophrenia spectrum and other psychotic disorders (SsP-d, 32.43%), and 49.44% of the female participants, with a higher percentage among those diagnosed with depressive disorders (52.50%) and other psychotic disorders (46.15%). Furthermore, to confirm the link between sociodemographic variables, anthropometric indices, and psychiatric disorders among patients, the Spearman correlation coefficient and simple regression analysis of such variables was carried out. The results revealed that the majority of sociodemographic characteristics were either favorably or adversely correlated with patients' anthropometrics and type of depression in both sexes.

CONCLUSION

Low sociodemographic characteristics and high anthropometric variables may be risk factors for people with psychotic disorders, which have been linked to negative health consequences.

Predictors of return to work in people with major depression: Results from a supported employment program in Germany

BACKGROUND

Depression is a common mental disorder and is associated with work disability. For the implementation of evidence-based interventions, such as Individual Placement and Support (IPS) for people with depression in Germany, the aim of this study was to investigate client variables that predict return to work.

METHODS

The sample consisted of 129 participants, initially treated in a psychiatric hospital due to major depression, who participated in IPS as part of a German clinical trial. Baseline demographic (age, sex, education, sickness absence days, employment status), psychiatric (symptom severity, comorbidity, general physical and mental health, disability), and neuropsychological (self-rated deficits, test performance) variables were included. Return to work within one year was predicted using separate and overall binary logistic regression analyses.

RESULTS

A total of 70 participants (56 %) returned to work within the one-year follow-up period. >100 days of sick leave in the year prior to study entry (vs. <100 days) and higher self-rated cognitive deficits were significantly associated with reduced odds of return to work within one year of IPS.

LIMITATIONS

The sample consisted of participants with a relatively good work history who were assigned to IPS by the treatment team, thus, the generalizability of the results is limited.

CONCLUSIONS

People with depression who participate in IPS interventions might benefit from specifically targeting perceived cognitive deficits. Factors associated with prolonged sick leave due to depression and their role in return to work with IPS need further investigation.

Impact of Individual Budgets on Work and Financial Well-Being of Supported Employment Recipients With Serious Mental Illness

OBJECTIVE

The authors sought to determine whether providing recipients of supported employment with individual budgets from which they could purchase employment-related goods and services would improve employment and financial outcomes.

METHODS

Sixty study participants were recruited from an individual placement and support (IPS) program and randomly assigned (1:1) to receive IPS services only (N=32) or IPS services with a 12-month $950 flexible fund called a career account (N=28). Participants receiving IPS and a career account met with staff who helped them identify employment goals and create a budget for purchases directly tied to these goals. The primary outcome was competitive employment; secondary outcomes included job tenure, days worked, total earnings, and financial well-being. Outcomes were analyzed by using adjusted generalized linear models (GLMs) with binary logistic, negative binomial, and linear distributions.

RESULTS

The proportion of participants who achieved competitive employment was largely similar for those in the career account+IPS group (54%) and in the IPS-only group (47%). However, the GLM analysis revealed that career account+IPS participants had significantly longer job tenure, more total days of employment, and higher total earnings than IPS-only participants. Feelings of financial well-being increased significantly among career account participants, whereas financial well-being declined among control participants. The amount of career account dollars participants spent was positively and significantly associated with longer job tenure, more days employed, and higher total earnings.

CONCLUSIONS

Combining flexible funds with IPS-supported employment achieved some superior outcomes compared with IPS only. Further research is needed to assess the longer-term effects of this practice and its cost-effectiveness.

The Danish Ibbis Trials for Sickness Absentees with Common Mental Disorders: A Phase 4 Prospective Study Comparing Randomized Trial and Real-World Data

Introduction

In two randomized controlled trials (RCT) we tested the efficacy of a novel integrated vocational rehabilitation and mental healthcare intervention, coined INT, for sickness absentees with common mental disorders. The aim was to improve vocational outcomes compared to Service As Usual (SAU). Contrary to expectations, the delivered intervention caused worse outcomes within some diagnostic groups and some benefits in others. In this phase 4 study, we examined the effectiveness of the intervention in real-world practice.

Method

In this prospective intervention study, we allocated adult sickness absentees with either depression, anxiety, or adjustment disorder to receive INT in a real-world setting in a Danish Municipality. We compared the vocational outcomes of this group to a matched group who received INT as a part of the RCTs, after randomization to the intervention group herein. Primary outcome was return to work at any point within 12 months.

Results

In the real-world group, 151 participants received INT during 2019. From the randomized trials, 302 matched participants who received INT between 2016-2018 were included. On the primary outcome - return to work within 12 months - the real-word group fared worse (48.3 vs 64.6 %, OR 0.54 [95%CI: 0.37-0.79], p = 0.001). Across most other vocational outcomes, a similar pattern of statistically significant poorer outcomes in the real-world group was observed: Lower number of weeks in work and lower proportion in work at 12 months (42.3% vs. 58.3% (p = 0.002)).

Discussion

The real-word group showed significantly worse vocational outcomes. Like in many other studies of complex interventions, implementation was difficult in the original randomized trials and perhaps even more difficult in the less structured real-world setting. Since the intervention was less effective for some groups compared to SAU in the original trial, this negative effect may be even more pronounced in a real-world setting.

Supported employment interventions with people who have severe mental illness: Systematic mixed-methods umbrella review

BACKGROUND/AIMS

Primary and review studies show that supported employment interventions showed promise in assisting people with severe mental illness (SMI) in achieving successful employment and health-related outcomes. This umbrella review synthesises evidence from across review studies on supported employment interventions for individuals with SMI, to identify key findings and implementation challenges in relation to five key outcomes: (1) employment, (2) quality of life, (3) social functioning, (4) clinical/service utilisation, and (5) economic outcomes.

METHODS

A systematic search of eleven databases and registers (CINAHL, Cochrane, EmCare, JBI EBP, ProQuest, PsycINFO, PubMed, Scopus, and Web of Science, and Prospero and Campbell) was conducted to identify meta-analyses and systematic reviews on supported employment interventions for individuals with SMI, peer reviewed and published in English. Quality assessment and data extraction were performed using standardised Joanna Briggs Institute (JBI) tools. A mixed-methods synthesis approach was employed to integrate both quantitative and qualitative evidence.

RESULTS

The synthesis of 26 review studies primarily focused on the Individual Placement and Support (IPS) model among various supported employment interventions. Overall, combining supported employment with targeted interventions such as neurocognitive therapy and job-related social skill training showed a positive effect on employment (including job retention) and non-employment outcomes (e.g., health, quality of life, social functioning) relative to standard forms of supported employment for people with SMI. Contextual factors (intervention fidelity, settings, systemic barriers) were important considerations for intervention implementation and effectiveness.

DISCUSSION

Significant overlap of primary studies across 26 review studies exposed considerable variations in interpretation and conclusions drawn by authors, raising questions about their reliability. High volume of overlap reporting from the USA on IPS interventions in review studies is likely to have biased perceptions of effectiveness. There is no one-size-fits-all solution for supporting individuals with SMI in obtaining and maintaining employment. Tailoring strategies based on individual needs and circumstances appears crucial to address the complexity of mental health recovery. We propose creating centralised registries or databases to monitor primary studies included in reviews, thus avoiding redundancy.

OTHER

This umbrella study was registered with PROSPERO (No. CRD42023431191).

Mental Health Outcomes for Young People Accessing Individual Placement Support Services: A Cohort Study

OBJECTIVE

Mental health problems and vocational disengagement are often linked for young people in a self-reinforcing cycle. Integrated Individual Placement and Support (IPS) services can help to not only overcome educational/vocational challenges but also improve mental wellbeing.

METHODS

In a matched cohort study, we compared improvement rates in mental health and wellbeing outcomes for young people aged 15 to 25 who had received at least two integrated IPS services with those who had received standard youth mental health services only. Data came from headspace, Australia's National Youth Mental Health Foundation. The sample comprised 2128 participants: 544 received integrated IPS services; 1584 received standard mental health services.

RESULTS

Four out of five IPS clients (81%) achieved positive outcomes on at least one of three mental health measures, a significantly higher proportion than matched clients who received standard services (75%). Logistic regressions estimated a 22% to 36% higher likelihood of achieving significant improvement for IPS clients. Greater improvements were evident for quality of life and potentially psychosocial functioning, but not psychological distress.

CONCLUSIONS

Integrating an IPS program within a clinical setting not only achieves positive vocational outcomes, but also supports improvements in quality of life, psychosocial functioning and psychological distress that are greater or equal to the outcomes achieved through standard clinical care.

Individual placement and support: History, current status, and future directions

Over the past three decades, Individual Placement and Support (IPS) has emerged as a robust evidence-based approach to helping people with severe mental illnesses, such as schizophrenia, bipolar disorder, and major depression, to obtain and succeed in competitive employment. This review addresses the history, principles, research, and future directions of IPS. It covers current evidence on employment outcomes, cost-effectiveness, and nonvocational outcomes. It also describes current attempts to extend IPS to new populations. The authors provide an overview of numerous systematic reviews and meta-analyses of randomized controlled trials involving people with serious mental illness. For studies addressing nonvocational outcomes and new populations, the review uses best available evidence. Published reviews agree that IPS enables patients with serious mental illness in high-income countries to succeed in competitive employment at a higher rate than patients who receive other vocational interventions. Within IPS programs, quality of implementation, measured by standardized fidelity scales, correlates with better outcomes. Employment itself leads to enhanced income, psychosocial outcomes, clinical improvements, and decreased mental health service use. As IPS steadily spreads to new populations and new settings, research is active across high-income countries and spreading slowly to middle-income countries. IPS is an evidence-based practice for people with serious mental illness in high-income countries. It shows promise to help other disability groups also, and emerging research aims to clarify adaptations and outcomes.

Examination of Adaptations to the Evidence Based Supported Employment Model: Individual Placement and Support

Individual Placement and Support (IPS) is a long-standing and innovative employment service for individuals with mental illness with dozens of clinical trials demonstrating effectiveness. Little is known, however, about intentional adaptations to IPS, especially those outside of the context of research studies. Using an implementation science framework, we conducted an exploratory study to better understand the characteristics of stakeholder-reported adaptions to IPS, the impetus for their development, and perceived impacts. We conducted qualitative interviews to analyze and describe these adaptations. Numerous adaptations of IPS were found that address the needs of new and underserved populations both within and outside of the mental health field. Programs reported adapting IPS because of the dearth of other evidence-based employment services, to serve diverse populations in need, and based on financial incentives. Benefits of adaptations were weighed against impacts on fidelity. As evidence-based practices (EBPs) are adapted, developers of EBPs should determine how fidelity of a program or service can be assessed or preserved in light of adaptations. This is critical with the increase in different service delivery methods, new populations, new service recipient needs, and new settings in need of EBPs.

Access, retention, and effectiveness of individual placement and support in the US: Are there racial or ethnic differences?

BACKGROUND: Increased federal attention to advancing racial equity and support for underserved communities suggests the need for data on racial and ethnic differences in evidence-based employment services for people with serious mental illness. Individual Placement and Support (IPS) is an evidence-based model of supported employment for this population. OBJECTIVE: The objective was to identify differences based on race and ethnicity in IPS services. METHODS: This narrative review examined the empirical literature on IPS services in the U.S., assessing evidence of differences in access, retention, and outcomes for Black and Hispanic IPS clients, relative to non-Hispanic Whites. RESULTS: We identified 12 studies examining racial and ethnic differences in access (4 studies), retention (3 studies), and effectiveness (6 studies). The findings for access to IPS were mixed, with two studies showing no differences, one finding less access for Blacks, and another finding greater access for Blacks but less access for Hispanics. Three studies found better retention rates for clients enrolled in IPS regardless of race or ethnicity. Compared to clients receiving usual vocational services, all studies found better employment outcomes for IPS clients regardless of race or ethnicity. CONCLUSION: Unlike for most of health care, few racial and ethnic differences have been found for IPS employment services in the U.S. Access to IPS is inadequate for all groups, with conflicting evidence whether Blacks and Hispanics have even less access. Based on the available evidence, Black and Hispanic clients have comparable retention and employment outcomes in IPS as non-Hispanic White clients. State and local mental health leaders responsible for monitoring IPS outcomes should routinely report statistics on race and ethnicity. They should also give active attention to client needs and equity. Research designs should answer multifaceted questions regarding disparities for historically underserved populations.

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.

Job Retention and Reintegration in People with Mental Health Problems: A Descriptive Evaluation of Supported Employment Routine Programs

PURPOSE

Striking evidence supports the effectiveness of supported employment (SE) in achieving competitive employment in individuals with mental health problems. Yet, little is known whether SE is effective to maintain employment in individuals at risk of job loss. We aimed to descriptively compare SE for employed clients (SE-retention) and unemployed clients (SE-integration) regarding competitive employment.

METHODS

We used administrative data from January 2017 to October 2021 provided by a vocational rehabilitation center in Switzerland including all individuals (≥ 18yrs.) with mental health problems who participated either in SE-retention or SE-reintegration. The outcome was the proportion with competitive employment at discharge. Logistic regression was used to assess time trends and to descriptively compare SE-treatments. We used propensity score weighting, including personal, clinical and program-specific information to reduce group differences.

RESULTS

A total of 556 participants primarily diagnosed with mood/stress-related, schizophrenia and personality disorders were included (n = 297 SE-retention, n = 259 SE-reintegration) with median age 41 years and 57% female gender. The overall weighted comparison favored SE-retention over SE-reintegration OR 4.85 (95%-CI 3.10 to 7.58, p < 0.001) with predicted employment of 67.3% and 29.9% for SE-retention and SE-reintegration, respectively. While success for SE-reintegration remained stable over time, SE-retention showed an increase in more recent years.

CONCLUSION

SE-retention provides an approach for early work-related support that can prevent labor market exclusion. In contrast, reintegration is likely to require more efforts to achieve employment and may result in less favorable outcomes. It is therefore necessary that further research includes appropriate comparison groups to evaluate the effectiveness of SE-retention programs as well as the economic and individual benefits.

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.

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.

Transition to Labor Market among Young Adults with Serious Mental Illness

Background: The research on job attainment and retention among young adults with serious mental illness (SMI) is limited. The objective of this study was to investigate the contributions of emotional, cognitive, motor, demographic, and work-related factors to the transition into supported employment (SE) and retention. Methods: This cross-sectional study included young adults with SMI involved in prevocational (N = 21) services or those who have transferred to SE (N = 21) following prevocational services. Work-related self-efficacy, executive functions, and motor skills were approached with standard and well-established tools. Results: There was a significant difference between groups in most dimensions of work-related self-efficacy, job history and experience, cognitive strategies, and general independence in daily life. The multivariate analysis demonstrates that holding a profession, experiencing self-efficacy in general work skills, cognitive strategies, and independence in living situations explained the between-group differences (χ2(4) = 34.62, p < 0.001; correct classification−90.2%). Conclusions: The study identifies the factors contributing to a sustainable transition to employment among young adults with SMI, suggesting the importance of a comprehensive approach to address a range of personal factors in an integrative way. The augmentation of prevocational training with continued employment support may be beneficial to meet the unique needs of young adults with SMI.

Implementing individual placement and support (IPS): the experiences of employment specialists in the early implementation phase of IPS in Northern Norway. The IPSNOR study

BACKGROUND

For decades there has been a continuous increase in the number of people receiving welfare benefits for being outside the work force due to mental illness. There is sufficient evidence for the efficacy of Individual Placement and Support (IPS) for gaining and maintaining competitive employment. Yet, IPS is still not implemented as routine practice in public community mental health services. Knowledge about implementation challenges as experienced by the practitioners is limited. This study seeks to explore the experiences of the front-line workers, known as employment specialists, in the early implementation phase.

METHODS

Qualitative data were collected through field notes and five focus group interviews. The study participants were 45 IPS employment specialists located at 14 different sites in Northern Norway. Transcripts and field notes were analysed by thematic analyses.

RESULTS

While employment specialists are key to the implementation process, implementing IPS requires more than creating and filling the role of the employment specialist. It requires adjustments in multiple organisations. The new employment specialist then is a pioneer of service development. Some employment specialists found this a difficult challenge, and one that did not correspond to their expectations going into this role. Others appreciated the pioneering role. IPS implementation also challenged the delegation of roles and responsibilities between sectors, and related legal frameworks related to confidentiality and access. The facilitating role of human relationships emphasised the importance of social support which is an important factor in a healthy work environment. Rural areas with long distances and close- knit societies may cause challenges for implementation.

CONCLUSION

The study provides increased understanding on what happens in the early implementation phase of IPS from the employment specialists' perspective. Results from this study can contribute to increased focus on job satisfaction, turnover and recruitment of employment specialists, factors which have previously been shown to influence the success of IPS. The greatest challenge for making "IPS efficacy in trials" become "IPS effectiveness in the real world" is implementation, and this study has highlighted some of the implementation issues.

The effects of supported employment interventions in populations of people with conditions other than severe mental health: a systematic review

AIM

To assess the effectiveness of supported employment interventions for improving competitive employment in populations of people with conditions other than only severe mental illness.

BACKGROUND

Supported employment interventions have been extensively tested in severe mental illness populations. These approaches may be beneficial outside of these populations.

METHODS

We searched PubMed, Embase, CINAHL, PsycInfo, Web of Science, Scopus, JSTOR, PEDro, OTSeeker, and NIOSHTIC for trials including unemployed people with any condition and including severe mental illness if combined with other co-morbidities or other specific circumstances (e.g., homelessness). We excluded trials where inclusion was based on severe mental illness alone. Two reviewers independently assessed risk of bias (RoB v2.0) and four reviewers extracted data. We assessed rates of competitive employment as compared to traditional vocational rehabilitation or waiting list/services as usual.

FINDINGS

Ten randomised controlled trials (913 participants) were included. Supported employment was more effective than control interventions for improving competitive employment in seven trials: in people with affective disorders [risk ratio (RR) 10.61 (1.49, 75.38)]; mental disorders and justice involvement [RR 4.44 (1.36,14.46)]; veterans with posttraumatic stress disorder (PTSD) [RR 2.73 (1.64, 4.54)]; formerly incarcerated veterans [RR 2.17 (1.09, 4.33)]; people receiving methadone treatment [RR 11.5 (1.62, 81.8)]; veterans with spinal cord injury at 12 months [RR 2.46 (1.16, 5.22)] and at 24 months [RR 2.81 (1.98, 7.37)]; and young people not in employment, education, or training [RR 5.90 (1.91-18.19)]. Three trials did not show significant benefits from supported employment: populations of workers with musculoskeletal injuries [RR 1.38 (1.00, 1.89)]; substance abuse [RR 1.85 (0.65, 5.41)]; and formerly homeless people with mental illness [RR 1.55 (0.76, 3.15)]. Supported employment interventions may be beneficial to people from more diverse populations than those with severe mental illness alone. Defining competitive employment and increasing (and standardising) measurement of non-vocational outcomes may help to improve research in this area.

Vocational Interventions to Improve Employment Participation of People with Psychosocial Disability, Autism and/or Intellectual Disability: A Systematic Review

Objective: To systematically review interventions aimed at improving employment participation of people with psychosocial disability, autism, and intellectual disability. Methods: We searched MEDLINE, Embase, PsycINFO, Web of Science, Scopus, CINAHL, ERIC, and ERC for studies published from 2010 to July 2020. Randomized controlled trials (RCTs) of interventions aimed at increasing participation in open/competitive or non-competitive employment were eligible for inclusion. We included studies with adults with psychosocial disability autism and/or intellectual disability. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias II Tool. Data were qualitatively synthesized. Our review was registered with PROSPERO (CRD42020219192). Results: We included 26 RCTs: 23 targeted people with psychosocial disabilities (n = 2465), 3 included people with autism (n = 214), and none included people with intellectual disability. Risk of bias was high in 8 studies, moderate for 18, and low for none. There was evidence for a beneficial effect of Individual Placement and Support compared to control conditions in 10/11 studies. Among young adults with autism, there was some evidence for the benefit of Project SEARCH and ASD supports on open employment. Discussion: Gaps in the availability of high-quality evidence remain, undermining comparability and investment decisions in vocational interventions. Future studies should focus on improving quality and consistent measurement, especially for interventions targeting people with autism and/or intellectual disability.

Vocational rehabilitation via social firms: a qualitative investigation of the views and experiences of employees with mental health problems, social firm managers and clinicians

BACKGROUND

Employment within social firms in the UK is under-developed and under-researched, but a potentially beneficial route to vocational rehabilitation for people with mental health problems. This study explores the views and experiences of employees with mental ill-health, managers of social firms and mental health clinicians, in order to understand the potential value of social firms for the vocational rehabilitation, employment and well-being of people with mental health problems.

METHODS

Semi-structured interviews were conducted with 23 employees with mental health problems in 11 social firms in England. A focus group and individual interviews were conducted with 12 managers of social firms. Two focus groups were held with 16 mental health clinicians. Data were analysed using thematic analysis.

RESULTS

Most employees expressed very positive views about working in a social firm. In responses from both employees and social firm managers, an overarching theme regarding the supportive ethos of social firms encompassed several related features: openness about mental health issues; peer, team and management support; flexibility; and support to progress and develop skills over time. Managers identified benefits of employing people with mental health problems who were sufficiently recovered. Knowledge of social firms within clinician focus groups was very limited, although clinicians thought they could be a welcome additional vocational resource.

CONCLUSIONS

High levels of job satisfaction among social firm employees may be explained by the supportive ethos of these working environments. Social firms have potential to be a helpful addition to the range of vocational pathways available for people with mental ill-health. Further mixed methods investigations of experiences and outcomes in order to understand who engages with and benefits from this form of vocational rehabilitation would be valuable in informing decisions about scaling up the model.

Australia's Disability Employment Services Program: Participant Perspectives on Factors Influencing Access to Work

Disability employment programs play a key role in supporting people with disability to overcome barriers to finding and maintaining work. Despite significant investment, ongoing reforms to Australia's Disability Employment Services (DES) are yet to lead to improved outcomes. This paper presents findings from the Improving Disability Employment Study (IDES): a two-wave survey of 197 DES participants that aims to understand their perspectives on factors that influence access to paid work. Analysis of employment status by type of barrier indicates many respondents experience multiple barriers across vocational (lack of qualifications), non-vocational (inaccessible transport) and structural (limited availability of jobs, insufficient resourcing) domains. The odds of gaining work decreased as the number of barriers across all domains increased with each unit of barrier reported (OR 1.22, 95% CI 1.07, 1.38). Unemployed respondents wanted more support from employment programs to navigate the welfare system and suggest suitable work, whereas employed respondents wanted support to maintain work, indicating the need to better tailor service provision according to the needs of job-seekers. Combined with our findings from the participant perspective, improving understanding of these relationships through in-depth analysis and reporting of DES program data would provide better evidence to support current DES reform and improve models of service delivery.

Predictive Association of Low- and High-Fidelity Supported Employment Programs with Multiple Outcomes in a Real-World Setting: A Prospective Longitudinal Multi-site Study

PURPOSE

The individual placement and support (IPS) model of supported employment is a leading evidence-based practice in community mental health services. In Japan, individualized supported employment that is highly informed by the philosophy of the IPS model has been implemented. While there is a body of evidence demonstrating the association between program fidelity and the proportion of participants gaining competitive employment, the association between fidelity and a wider set of vocational and individual outcomes has received limited investigation. This study aimed to assess whether high-fidelity individualized supported employment programs were superior to low-fidelity programs in terms of vocational outcomes, preferred job acquisition, and patient-reported outcome measures (PROMs).

METHODS

A prospective longitudinal study with 24-month follow-up analyzed 16 individualized supported employment programs. The Japanese version of the individualized Supported Employment Fidelity scale (JiSEF) was used to assess the structural quality of supported employment programs (scores: low-fidelity program, ≤ 90; high-fidelity program, ≥ 91). Job acquisition, work tenure, work earnings, job preference matching (e.g., occupation type, salary, and illness disclosure), and PROMs such as the INSPIRE and WHO-Five Well-being index were compared between groups.

RESULTS

There were 75 and 127 participants in the low-fidelity group (k = 6) and high-fidelity group (k = 10), respectively. The high-fidelity group demonstrated better vocational outcomes than the low-fidelity group, i.e., higher competitive job acquisition (71.7% versus 38.7%, respectively, adjusted odds ratio (aOR) = 3.6, p = 0.002), longer work tenure (adjusted mean difference = 140.8, p < 0.001), and better match for illness disclosure preference (92.6% versus 68.0%, respectively, aOR = 5.9, p = 0.003). However, we found no differences between groups in other preference matches or PROM outcomes.

CONCLUSION

High-fidelity individualized supported employment programs resulted in good vocational outcomes in a real-world setting. However, enhancing service quality to increase desired job acquisition and improve PROMs will be important in the future.

CLINICAL TRIAL REGISTRATION

UMIN000025648.

An Integrative Review of Recovery Services to Improve the Lives of Adults Living with Severe Mental Illness

There is an increasing call for recovery-oriented services but few reviews have been undertaken regarding such interventions. This review aims to synthesize evidence on recovery services to improve the lives of adults living with severe mental illness. An integrative review methodology was used. We searched published literature from seven databases: Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, Web of Science, and Scopus. Mixed-methods synthesis was used to analyse the data. Out of 40 included papers, 62.5% (25/40) used quantitative data, 32.5% used qualitative and 5% (2/40) used mixed methods. The participants in the included papers were mostly adults with schizophrenia and schizoaffective disorder. This review identified three recovery-oriented services—integrated recovery services, individual placement services and recovery narrative photovoice and art making. The recovery-oriented services are effective in areas such as medication and treatment adherence, improving functionality, symptoms reduction, physical health and social behaviour, self-efficacy, economic empowerment, social inclusion and household integration. We conclude that mental health professionals are encouraged to implement the identified recovery services to improve the recovery goals of consumers.

Leipzig - Individual Placement and Support for people with mental illnesses (LIPSY): study protocol of a randomized controlled trial

BACKGROUND

Individuals receiving means-tested benefits are at a higher risk of being diagnosed with a psychiatric illness compared to those who are employed, and the rate of those working in the first labor market is low. The intervention (Individual Placement and Support, IPS) aims at maintaining or regaining working ability and at facilitating reintegration into the (first) labor market following a "first place, then train"-approach. The objective of the study is to conduct the first RCT in Germany that addresses a broad group of long-term unemployed individuals with severe mental illnesses that receive means-tested benefits, and to test the effectiveness of the IPS intervention.

METHODS

In this randomized controlled trial, about 120 eligible participants aged between 18 years and local retirement age will be randomly allocated to an intervention group (IG) or to an active control group (CG) using a parallel arm design. The IG will receive IPS + high quality treatment as usual (TAU), the active CG will receive TAU + a booklet on integration measures. A block-randomization algorithm with a targeted assignment ratio of 1:1 for participants in IG and active CG will be used, stratified by sex and three age groups. Assessments will take place before the intervention at baseline (t0), and 6 (t1), 12 (t2), and 18 (t3) months later. Primary outcome will be the proportion of participants having worked at least 1 day in competitive employment since baseline, as assessed at t3. Secondary outcomes will be related to employment/ vocation and mental health. In addition, there will be a process evaluation. Treatment effects on outcomes will be tested using appropriate panel-data regression models, and acceptability, uptake and adherence will be evaluated using descriptive statistics and appropriate inference testing.

DISCUSSION

The results of this trial are expected to generate a better understanding of the efficiency, feasibility, acceptance, and relevance of the IPS intervention in a German setting. They could be a first step towards the implementation of the method and towards improving the situation of long-term unemployed individuals with severe mental health problems.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00023245 ), registered on 22.02.2021.

Assessing stable validity and reliability of the Japanese version of the individualized supported employment fidelity scale: A replication

Background

The Japanese version of the individualized Supported Employment Fidelity scale (JiSEF) was developed by modifying the 25‐item Individual Placement and Support Fidelity Scale (IPS‐25). While a preliminary study partly confirmed the concurrent validity with vocational outcomes, this replication study aimed to examine the stability of the concurrent validity and the inter‐rater reliability of the JiSEF and to test its convergent validity with IPS‐25.

Methods

Fidelity assessments were conducted in 2016 (n = 17), 2017 (n = 13), and 2018 (n = 18) to examine the employment rate and the fidelity scores at the agency level. We also evaluated the fidelity scores for the IPS‐25 in 2018. We examined the associations between the fidelity scale scores and vocational outcomes for the concurrent validity and between the fidelity scales for convergent validity. The inter‐rater reliability was examined in the 2016 and 2017 assessments.

Results

High intraclass correlation coefficients (0.93 in 2016 and 0.92 in 2017) were obtained for the inter‐rater reliability. The JiSEF score in each year was associated with the agency employment rate (r = 0.710, P = 0.001 in 2016; r = 0.722, P = 0.005 in 2017; and r = 0.665, P = 0.003 in 2018). A supplementary longitudinal data analysis also confirmed the association between the JiSEF score and the employment outcomes. Additionally, the JiSEF was significantly correlated with the IPS‐25 (r = 0.760, P < 0.001).

Conclusions

This study stably replicated good inter‐rater reliability and concurrent validity of the JiSEF. Additionally, the convergent validity was confirmed. Further studies with large samples are needed to confirm these findings.

This study stably replicated a good inter‐rater reliability and concurrent validity of the Japanese version of the individualized Supported Employment Fidelity scale (JiSEF).

[Implementation of the principle of supported employment in Germany : Position paper of a task force of the DGPPN]

The effects of mental diseases on the employment and working situation can be substantial. They are one of the main reasons for inability to work and reduced earning capacity. Against this background the question arises about suitable occupational reintegration measures for people with severe mental illnesses. In recent years, the principle of supported employment has been internationally shown to be increasingly more successful. In this context mentally ill people are primarily placed at a position of the first employment market and supported on-site by a job coach. This concept is inclusive, individual and evidence based. Despite proven effectiveness, it has so far been insufficiently implemented in German-speaking regions. In the future it will be a matter of considering the individual needs for assistance of mentally ill people more intensively than previously and to respond with functional and in a best-case scenario, multiprofessional and flexible offers.

Employment in people with severe mental illnesses receiving public sector psychiatric services in India

The limited literature on employment in people with severe mental illnesses (SMI) in developing countries suggests higher rates than in developed countries. The present study explored rates and associated characteristics of work in people receiving public psychiatric services. Semi-structured interviews were conducted with 150 individuals with SMI (90% schizophrenia-spectrum) receiving public outpatient psychiatric services in an urban district in western India to evaluate employment. Forty percent of participants were employed, most for independent employers (86.7%), and were working an average of 53 hours/week. Earning money was reported as the primary motivation to work. A high proportion (92.2%) of unemployed participants wanted to work. Common barriers to work for unemployed participants who were interested in working were psychological (e.g., stress), mental illness (e.g., symptoms), and work-related factors (e.g., difficulty finding a job). Help finding a job and managing mental illness were the primary desired supports. Rates of employment in people with SMI living in urban areas in India are higher than in developed countries, but much lower than the general population. The high interest in work coupled with specific barriers and desired supports point to the need for vocational rehabilitation for improving the employment functioning of people with SMI in India.

A cross-sectional survey of stigma towards people with a mental illness in the general public. The role of employment, domestic noise disturbance and age

INTRODUCTION

Stigmatization impedes the social integration of persons recovering from mental illnesses. Little is known about characteristics of the stigmatized person that lessen or aggravate public stigma.

PURPOSE

This study investigates which characteristics of persons with mental illnesses (i.e. with a depression or a psychotic disorder) might increase or decrease the likelihood of public stigma.

METHODS

Over 2,000 adults read one of sixteen vignettes describing a person with a depressive disorder or a psychotic disorder and answered a set of items measuring social distance.

RESULTS

The person who was employed (vs. unemployed), or whose neighbors did not experience domestic noise disturbance (vs. disturbance) elicited significantly less social distance. Also persons with a depressive disorder elicited less social distance, vs. persons with a psychotic disorder.

CONCLUSION

Employment and good housing circumstances may destigmatize persons coping with mental illnesses. Mental health and social services should encourage paid employment, quality housing and other paths to community integration.

Employment functioning in people with severe mental illnesses living in urban vs. rural areas in India

PURPOSE

Research on employment in people with severe mental illnesses (SMI) in developing countries is sparse and largely limited to employment rates. We conducted a comprehensive study of work, interest in work, and perceived benefits and barriers to work in people with SMI in India.

METHODS

Semi-structured interviews were conducted with 550 individuals with SMI receiving private psychiatric outpatient services in two districts in western India, one urban (Pune) and the other rural (Ahmednagar).

RESULTS

More than half of the participants were employed, with significantly more men working (79.4%) than women (35.9%). Higher rates of work were found in rural areas (77.8%), where most work was in family agricultural businesses, than in urban areas (48.9%), where most work was for independent employers. Participants in rural areas worked fewer hours and earned less money, and reported fewer benefits and fewer problems related to work than urban participants. Over 45% of participants working for independent employers found jobs with help from families and extended social networks. Most unemployed participants wanted to work, and desired a variety of supports, including assistance with job finding and illness management.

CONCLUSIONS

Gender-specific social role expectations and families play an important role in work in people with SMI in India. Despite higher rates of work in this sample than most studies from developed countries, a significant subgroup was unemployed but wanted to work. Persons with SMI in developing countries may benefit from the adaptation of validated vocational rehabilitation approaches in developed countries to their cultural context.

Fidelity and IPS: does quality of implementation predict vocational outcomes over time for organizations treating persons with severe mental illness in the Netherlands?

PURPOSE

Individual placement and support (IPS) is an evidence-based supported employment intervention. Quality of IPS implementation is assessed using a validated fidelity scale. Previous studies found a positive association between fidelity and employment outcomes at a single time-point. This study examines the longitudinal associations between IPS fidelity scores and employment outcomes.

METHODS

We examined fidelity and employment outcome data for 27 IPS programs in the Netherlands providing IPS. These programs received at least one fidelity assessment and reported quarterly employment outcomes for at least one year to a central registry between 2014 and 2019. We first examined changes over time for fidelity and employment outcome. Then we analyzed the longitudinal associations between the quarterly employment outcomes and the IPS fidelity assessments on multiple time-points using a mixed-model analysis for the 17 programs with at least two fidelity assessments.

RESULTS

Both IPS fidelity and employment outcomes improved over time, with the largest improvement in employment outcomes achieved after 18 months of implementation. We found a significant positive longitudinal association between IPS-fidelity and employment.

CONCLUSIONS

Improvement of fidelity is associated with improvement of employment outcomes over time. Future research should be focused on the improvement of specific elements of IPS implementation and their influence on employment outcomes.

Employment is a critical mental health intervention

employment is critically important in mental health care. Unemployment worsens mental health and gaining employment can improve mental health, even for people with the most serious mental illnesses. In this editorial, we argue for a new treatment paradigm in mental health that emphasises employment, because supported employment is an evidence-based intervention that can help the majority of people with mental health disability to succeed in integrated, competitive employment. Unlike most mental health treatments, employment engenders self-reliance and leads to other valued outcomes, including self-confidence, the respect of others, personal income and community integration. It is not only an effective short-term treatment but also one of the only interventions that lessen dependence on the mental health system over time.

A structured mixed method process evaluation of a randomized controlled trial of Individual Placement and Support (IPS)

Background

Individual Placement and Support (IPS) is an evidence-based work rehabilitation program helping people with moderate to severe mental illness to obtain ordinary employment. Although IPS has proven superior to other work rehabilitation programs, in many studies, the majority of the participants remain unemployed. Structured process evaluations of IPS that use mixed methods are scarce, although they could identify implementation aspects that may enhance its effect. The aim of the current study is to assess reach, fidelity, and identify barriers and facilitators to implement IPS.

Methods

The process evaluation was conducted alongside a randomized controlled trial including six IPS centers, comparing IPS with treatment as usual in a population of patients in treatment for moderate to severe mental illness. Mixed methods were used in the process evaluation, including focus group interviews with service providers, individual interviews and survey data from participants, and fidelity reviews using the validated IPS Fidelity Scale.

Results

The intervention reached the intended target group. All centers reached fair to good fidelity according to the IPS Fidelity Scale within the project period (range 97–109, SD 8.1) (see Table 5). Certain fidelity items indicated implementation issues related to employer contact, community-based services, and integration with health services. Survey data showed that less than half of the participants regarded their illness as a barrier for participating in IPS and that freedom of disclosure was important. Participant interviews gave further insight into the role of the IPS specialist, emphasizing their availability and consistent job focus.

Conclusions

Indications of implementation challenges across centers during the first year suggest special attention should be given to these aspects in an early phase to ensure higher fidelity from the start and thus enhance the effectiveness of IPS. The IPS specialist played an important role for participants and was described as positive, pushing in a positive way, and encouraging. More knowledge on the characteristics of successful IPS specialists could further enhance the effectiveness of the intervention.

Trial registration

The study was registered on clinicaltrials.gov prior to the inclusion period (reg.no: NCT01964092, registered 17/07/2013).

Supplementary information

Supplementary information accompanies this paper at 10.1186/s43058-020-00083-9.

Disability Evaluation and Treatment for Patients With Psychiatric Disorders

Primary care physicians (PCPs) are often asked to perform disability evaluations for patients with psychiatric disorders, which are now a leading cause of disability worldwide. After acknowledging the limitations of disability assessments for all conditions, this review aims to provide PCPs with practical knowledge to inform their assessments and interventions with a focus on patients with depression. After the disability definitions and programs in the United States are reviewed, a pragmatic approach to assessing function and discussing return to work is offered. Individualized assessment is key, and functional recovery rather than symptom relief should be prioritized. Finally, evidence-based interventions for enhancing the likelihood of return to work are considered. We believe the principles of functional assessment and recovery lend themselves to ready adaptation for use in other psychiatric conditions and chronic somatic syndromes, including chronic pain. The key principles of this approach are as follows: 1) a patient is not categorically disabled, but has specific limitations in specific contexts; 2) graded, work-oriented rehabilitation with tailored problem-solving strategies are essential; 3) involving a multidisciplinary team in coordinated care optimizes functional recovery; 4) return to work is an iterative process aimed at restoring meaningful function in a stepwise fashion; and 5) the relationship between symptoms and function is bidirectional. PCPs can use these principles to plan optimal recovery paths for psychiatrically ill patients presenting with a wide array of biopsychosocial realities.

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).

INdividual Vocational and Educational Support Trial (INVEST) for young people with borderline personality disorder: study protocol for a randomised controlled trial

Background

The clinical onset of borderline personality disorder (BPD) usually occurs in young people (aged 12–25 years) and commonly leads to difficulty achieving and maintaining vocational (education and/or employment) engagement. While current psychosocial interventions lead to improvements in psychopathology, they have little effect upon functioning. Individual Placement and Support (IPS) is a client-driven model that assists individuals with severe mental illness to engage with education and/or employment appropriate to their personal goals, and that provides ongoing support to maintain this engagement. The objective of the INdividual Vocational and Educational Support Trial (INVEST) is to evaluate the effectiveness of adding IPS to an evidence-based early intervention programme for BPD, with the aim of improving vocational outcomes.

Methods/design

INVEST is a single-blind, parallel-groups, randomised controlled trial (RCT). The randomisation is stratified by gender and age and uses random permuted blocks. The interventions are 39 weeks of either IPS, or ‘usual vocational services’ (UVS). Participants will comprise 108 help-seeking young people (aged 15–25 years) with three or more DSM-5 BPD features and a desire to study or work, recruited from the Helping Young People Early (HYPE) early intervention programme for BPD at Orygen, in Melbourne, Australia. All participants will receive the HYPE intervention. After baseline assessment, staff who are blind to the intervention group allocation will conduct assessments at 13, 26, 39 and 52 weeks. At the 52-week primary endpoint, the primary outcome is the number of days in mainstream education/employment since baseline. Secondary outcomes include the cost-effectiveness of the intervention, quality of life, and BPD severity.

Discussion

Current treatments for BPD have little impact on vocational outcomes and enduring functional impairment is prevalent among this patient group. IPS is a targeted functional intervention, which has proven effective in improving vocational outcomes for adults and young people with psychotic disorders. This trial will investigate whether IPS is effective for improving vocational (employment and educational) outcomes among young people with subthreshold or full-syndrome BPD.

Trial registration

Australian New Zealand Clinical Trials Registry, ID: ACTRN12619001220156. 13 September 2019.

Employment in Personality Disorders and the Effectiveness of Individual Placement and Support: Outcomes from a Secondary Data Analysis

Purpose Personality disorders (PDs) are associated with severe functional impairment and subsequent high societal costs, increasing the need to improve occupational functioning in PD. Individual placement and support (IPS) is an effective, evidence-based method of supported employment, which so far has been tested in various mixed patient populations with severe mental illness (SMI, including PDs). However, the effectiveness of IPS for PDs per se remains uninvestigated. Methods Data from the SCION trial were used, including 31 SMI patients with PDs and 115 SMI patients with other primary diagnoses (primarily psychotic disorders). First, the interaction effect of diagnosis (PD vs other SMI) and intervention (IPS vs traditional vocational rehabilitation) was studied. Second, in the IPS condition, difference between diagnostic groups in time to first job was studied. Results We did not find evidence of a moderating effect of PD diagnosis on the primary effect of IPS (proportion who started in regular employment) (OR = 0.592, 95% CI 0.80-4.350, p = 0.606) after 30 months. Also, PD diagnosis did not moderate the effect of time until first job in IPS. Conclusions From the present explorative analysis we did not find evidence for a moderating effect of PD diagnosis on the effectiveness of IPS among PD participants. This indicates that IPS could be as effective in gaining employment in participants with PD as it is in participants with other SMI. Future studies, implementing larger numbers, should confirm whether IPS is equally effective in PDs and study whether augmentations or alterations to the standard IPS model might be beneficiary for PD.

Contents and Intensity of Services in Low- and High-Fidelity Programs for Supported Employment: Results of a Longitudinal Survey

OBJECTIVE

Little is known about the association between service intensity and fidelity scale score in supported employment programs. This study compares service contents and intensity in low- and high-fidelity programs and examines the validity of the Japanese version of the individualized Supported Employment Fidelity Scale.

METHODS

The vocational outcomes and service provision data for 51 individuals with schizophrenia in 13 supported employment programs were collected over a 12-month study period. Outcomes, service contents, and service intensity were compared between the low-fidelity group (seven programs; N=29) and the high-fidelity group (six programs; N=22).

RESULTS

In both groups, 70% of the total services (hours) were provided in the first 6 months. The high-fidelity group, which was associated with better vocational outcomes than the low-fidelity group (employment rate, 68% versus 38%, respectively), made the greatest effort in job development outside of the agency, whereas the low-fidelity group spent more time on group services. In addition, before the client obtained a job, high-fidelity programs provided outreach services (B=7.2, p=0.043) and agency-based individual services (B=5.7, p<0.001) at greater intensity than did low-fidelity programs. However, no significant between-group difference was found in service intensity once clients were employed.

CONCLUSIONS

Supported employment programs with a high fidelity score focus more intensely on providing individual services in and outside of the agency, particularly before clients obtain a job. However, clarification of the relationships among service quality at the structure level, amount of follow-up services, and individual needs in supported employment programs is a future issue.

A meta-regression of the impact of policy on the efficacy of individual placement and support

OBJECTIVE

Individual placement and support (IPS) has shown consistently better outcomes on competitive employment for patients with severe mental illness than traditional vocational rehabilitation. The evidence for efficacy originates from few countries, and generalization to different countries has been questioned. This has delayed implementation of IPS and led to requests for country-specific RCTs. This meta-analysis examines if evidence for IPS efficacy can be generalized between rather different countries.

METHODS

A systematic search was conducted according to PRISMA guidelines to identify RCTs. Overall efficacy was established by meta-analysis. The generalizability of IPS efficacy between countries was analysed by random-effects meta-regression, employing country- and date-specific contextual data obtained from the OECD and the World Bank.

RESULTS

The systematic review identified 27 RCTs. Employment rates are more than doubled in IPS compared with standard vocational rehabilitation (RR 2.07 95% CI 1.82-2.35). The efficacy of IPS was marginally moderated by strong legal protection against dismissals. It was not moderated by regulation of temporary employment, generosity of disability benefits, type of integration policies, GDP, unemployment rate or employment rate for those with low education.

CONCLUSIONS

The evidence for efficacy of IPS is very strong. The efficacy of IPS can be generalized between countries.

Employment Status and Personal Income Before and After Onset of a Severe Mental Disorder: A Case-Control Study

OBJECTIVE

Individuals with severe mental disorders have an impaired ability to work and are likely to receive income transfer payments as their main source of income. However, the magnitude of this phenomenon remains unclear. Using longitudinal population cohort register data, the authors conducted a case-control study to examine the levels of employment and personal income before and after a first hospitalization for a serious mental disorder.

METHODS

All individuals (N=50,551) who had been hospitalized for schizophrenia, other nonaffective psychosis, or bipolar disorder in Finland between 1988 and 2015 were identified and matched with five randomly selected participants who were the same sex and who had the same birth year and month. Employment status and earnings, income transfer payments, and total income in euros were measured annually from 1988 to 2015.

RESULTS

Individuals with serious mental disorders had notably low levels of employment before, and especially after, the diagnosis of a severe mental disorder. Their total income was mostly constituted of transfer payments, and this was especially true for those diagnosed as having schizophrenia. More than half of all individuals with a serious mental disorder did not have any employment earnings after they received the diagnosis.

CONCLUSIONS

The current study shows how most individuals in Finland depend solely on income transfer payments after an onset of a severe mental disorder.

IPS in Supported Housing: Fidelity and Employment Outcomes Over a 4 Year Period

Background: People with severe mental illness have difficulties finding and maintaining competitive employment. This is particularly so for those living in supported housing who, by definition, have significant day-to-day support needs: in the Netherlands only 3 to 5% of people with serious mental health problems who live in supported housing are competitively employed. To support these people in finding and maintaining competitive employment, Individual Placement, and Support (IPS) was introduced within supported housing services in the Netherlands in 2015. As this is the first country that broadly implemented IPS in supported housing settings, this paper will focus on the first results regarding feasibility and effects on employment in clients of IPS in this sector. Methods: We investigated the feasibility and employment outcomes of delivering IPS in supported housing services using fidelity assessments and quarterly employment outcomes on IPS program level within eight supported housing organizations, and compared these with 21 mental health treatment organizations in the Netherlands over a 4 year period. We investigated possible reasons for our findings and their implications through qualitative evaluations of the IPS fidelity assessors' notes and additional focus groups with IPS specialists and coordinators from supported housing services and fidelity assessors. Results: The overall fidelity scores indicated reasonable implementation of the IPS model within both supported housing services and mental health services. However, there were differences between services with regard to specific fidelity items; mental health treatment organizations scored higher for team integration, whereas supported housing services scored higher for rapid job search and caseload size, diversity of jobs, and employers. Our qualitative data suggested that the difference in team integration between the two sectors was due to differences in their organizational and financial structures, as well as in the specific needs of their clients. Conversely, supported housing services had better connections with employers which facilitated more rapid job searching and greater diversity in employment opportunities. The average total client employment rate did not significantly differ; and was 25.8% per quarter in supported housing services and 29.6% in mental health treatment services. Conclusion: Implementing IPS in supported housing settings is both feasible and effective.

An Examination of the Community Participation Interests of Young Adults with Serious Mental Illnesses

Participation in various aspects of community life (e.g., education, employment) plays a critical role in fostering young adult development and health. To support behavioral health services in addressing a broader array of meaningful community participation areas, the current study examined the participation interests of young adults with serious mental illnesses via a literature review and focus groups interviews. Literature review results revealed a range of community participation areas of interest to these individuals, including employment, education, religion and spirituality, social networking (e.g., using social media), volunteering activities, socializing, and civic and artistic participation (e.g., attending a political event, playing music). Focus group participants named many of these same areas, but also mentioned unique areas of participation that have not been the focus of previous research (i.e., playing games, sports, exploration of other communities (e.g., traveling), hanging out, and nature-based participation). Implications for future research and behavioral health practice are discussed.

Barriers and facilitators to the implementation of individual placement and support (IPS) for patients with offending histories in the community: The United Kingdom experience

Introduction

We aimed to identify the barriers and facilitators to the implementation of a high fidelity individual placement and support service in a community forensic mental health setting.

Method

In-depth interviews were conducted with clinical staff ( n = 11), patients ( n = 3), and employers ( n = 5) to examine barriers and facilitators to implementation of a high fidelity individual placement and support service. Data was analysed using thematic analysis, and themes were mapped onto individual placement and support fidelity criteria.

Results

Barriers cited included competing interests between employment support and psychological therapies, perceptions of patients’ readiness for work, and concerns about the impact of returning to work on welfare benefits. Facilitators of implementation included clear communication of the benefits of individual placement and support, inter-disciplinary collaboration, and positive attitudes towards the support offered by the individual placement and support programme among stakeholders. Offences, rather than mental health history, were seen as a key issue from employers’ perspectives. Employers regarded disclosure of offending or mental health history as important to developing trust and to gauging their own capacity to offer support.

Conclusions

Implementation of individual placement and support in a community mental health forensic setting is complex and requires robust planning. Future studies should address the barriers identified, and adaptations to the individual placement and support model are needed to address difficulties encountered in forensic settings.

The association between early-onset schizophrenia with employment, income, education, and cohabitation status: nationwide study with 35 years of follow-up

PURPOSE

Individuals with schizophrenia have been reported to have low employment rates. We examined the associations of schizophrenia with employment, income, and status of cohabitation from a work life course perspective.

METHODS

Nationwide cohort study including all individuals (n = 2,390,127) born in Denmark between 1955 and 1991, who were alive at their 25th birthday. Diagnosis of schizophrenia (yes/no) between ages 15 and 25 was used as an exposure. Employment status, annual wage or self-employment earnings, level of education, and cohabitant status from the age of 25-61 (years 1980-2016) were used as outcomes.

RESULTS

Schizophrenia diagnosis between ages 15 and 25 (n = 9448) was associated with higher odds of not being employed (at the age of 30: OR 39.4, 95% CI 36.5-42.6), having no secondary or higher education (7.4, 7.0-7.8), and living alone (7.6, 7.2-8.1). These odds ratios were two-to-three times lower and decreasing over time for those individuals who did not receive treatment in a psychiatric inpatient or outpatient clinic for schizophrenia after the age of 25. Between ages 25-61, individuals with schizophrenia have cumulative earning of $224,000, which is 14% of the amount that the individuals who have not been diagnosed with schizophrenia earn.

CONCLUSIONS

Individuals with schizophrenia are at high risk of being outside the labour market and living alone throughout their entire life, resulting in an enormous societal loss in earnings. Individuals with less chronic course of schizophrenia had a gradual but substantial improvement throughout their work life.

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.

Job- and schoolprescription: A local adaptation to individual placement and support for first episode psychosis

AIM

Individual placement and support (IPS) for first episode psychosis (FEP) has proven effective for employment and education, but yields differing results across geographical regions. Local adaptations may be necessary for various reasons, such as regional differences in employment- and welfare services; in educational opportunities and job markets. The aim of this study was to investigate the efficacy of an adapted Norwegian intervention offering early IPS for education and employment to persons with FEP.

METHOD

Matched control (N = 66) study with a 1-year early IPS intervention and a 2-year follow up. A rating of fidelity to the IPS model was conducted.

RESULTS

Fidelity was "good." Adaptations to the model included the use of internships and flexible combinations of education and employment. Thirty out of 33 participants completed the intervention. Fourteen were in competitive employment >20 h/wk post intervention, compared to 2 in the control group. Fifteen participants were enrolled in education >20 h/wk, 10 of whom also had employment >20 h/wk and 3 < 20 h/wk, compared to 5 in the control group, with 2 having employment <20 h/wk on the side. Symptom levels did not predict outcome.

CONCLUSION

The School- and JobPrescription adaptation of IPS, allowing for temporary internships as a step towards obtaining the goal of paid competitive employment and facilitating flexible combinations of employment and education, showed encouraging results. These were however not sustained after closure of the intervention. At the 2-year follow up, Job- and SchoolPrescription advantages had waned, underscoring the point in IPS that support should be time-unlimited.

Expanding Individual Placement and Support to Populations With Conditions and Disorders Other Than Serious Mental Illness

OBJECTIVE

A systematic review of studies of individual placement and support (IPS) for populations other than those with serious mental illness was conducted.

METHODS

The authors searched three electronic databases (PubMed, Web of Science, and Scopus) for studies of IPS and modified IPS. Eligibility criteria for the systematic review included randomized controlled trials with prospective data collection on competitive employment rate and at least 10 study participants from a well-defined population other than people with serious mental illness. Results were compiled for competitive employment rates, IPS fidelity, and other outcomes.

RESULTS

Three clinical groups other than people with serious mental illness have been studied: people with psychiatric disorders other than serious mental illness, people with substance use disorders, and people with musculoskeletal or neurological disorders. Nine controlled trials with a total of 2,902 participants included six trials with people who had psychiatric disorders other than serious mental illness, two with people who had substance use disorders, and one with people who had spinal cord injuries. In eight studies, results for competitive employment rates significantly favored IPS. Meta-analysis yielded an overall weighted odds ratio of 2.23 (95% confidence interval=1.53-3.24, p<.001). Findings for other employment outcomes also favored IPS, but findings on symptom reduction and quality of life were inconsistent. The strongest (and only replicated) findings were for veterans with posttraumatic stress disorder (PTSD). Methodological limitations included small samples, major modifications to IPS fidelity, and short follow-up periods.

CONCLUSIONS

IPS, often with modifications, is a promising employment intervention for several populations in addition to people with serious mental illnesses. The strongest evidence pertains to veterans with PTSD. IPS should be offered to these veterans. Research on other populations, including people with anxiety, depression, substance use disorder, musculoskeletal or neurological conditions, or pain syndromes, needs development, amplification, and replication.

Effectiveness of supported employment in non-trial routine implementation: systematic review and meta-analysis

PURPOSE

While supported employment (SE) programs for people with mental illness have demonstrated their superiority in randomized controlled trials (RCTs) and meta-analyses, little is known about the effectiveness of non-trial routine programs. The primary objective of this study was to estimate a pooled competitive employment rate of non-trial SE programs by means of a meta-analysis. A secondary objective was to compare this result to competitive employment rates of SE programs in RCTs, prevocational training programs in RCTs and in routine implementation.

METHODS

A systematic review and a random-effects meta-analysis of proportions were conducted. Quality assessment was provided. Moderator analyses by subgroup comparisons were conducted.

RESULTS

Results from 28 samples were included in the meta-analysis. The pooled competitive employment rate for SE routine programs was 0.43 (95% CI 0.37-0.50). The pooled competitive employment rates for comparison conditions were: SE programs in RCTs: 0.50 (95% CI 0.43-0.56); prevocational programs in RCTs: 0.22 (95% CI 0.16-0.28); prevocational programs in routine programs: 0.17 (95% CI 0.11-0.23). SE routine studies conducted prior to 2008 showed a significantly higher competitive employment rate.

CONCLUSION

SE routine programs lose only little effectiveness compared to SE programs from RCTs but are much more successful in reintegrating participants into the competitive labor market than prevocational programs. Labor market conditions have to be taken into account when evaluating SE programs.

Supported employment: Meta-analysis and review of randomized controlled trials of individual placement and support

Supported employment is a treatment whereby those with severe mental illness (or other disabilities) receive aid searching for competitive employment and mental health (or other) treatments concurrently. The most popular implementation of supported employment is individual placement and support (IPS). We conducted meta-analytic analyses of the randomized controlled trials of IPS. We found that subjects in IPS, compared to usual treatment conditions, had better vocational outcomes (obtained any competitive employment: RR = 1.63, 95%CI = [1.46, 1.82]; job tenure: d = 0.55, 95%CI = [0.33, 0.79]; job length: d = 0.46, 95%CI = [0.35, 0.57]; income: d = 0.48, 95%CI = [0.36, 0.59]) Non-vocational outcomes estimates, while favoring IPS, included the null (quality of life: d = 0.30, 95%CI = [-0.07, 0.67]; global functioning: d = 0.09, 95%CI = [-0.09, 0.27]; mental health: d = 0.03, 95%CI = [-0.15, 0.21]). Analysis of the expected proportion of studies with a true effect on non-vocational outcomes with d>0.2 showed some reason to expect a possible improvement for quality of life for at least some settings (Prop = 0.57, 95%CI = [0.30, 0.84]).

Development of a scale to assess motivation for competitive employment among persons with severe mental illness

BACKGROUND

The employment rate among people with severe mental illness has recently increased, though it is still low. The motivation to work appears to be an important role as an intermediate outcome measure in vocational rehabilitation programs. In addition, measuring the work motivation for people with severe mental illness appears to be essential to identify candidates who are likely to benefit and monitor candidates' motivation in a supported employment program. This study aimed to develop a new measure for assessing both intrinsic and extrinsic motivation to work among people with severe mental illness, as there are currently no well-established instruments of this kind.

METHODS

A focus group interview and review of previous qualitative research were used to identify possible items for inclusion in the new scale. A provisional scale was constructed and further refined for content and format based on feedback from a researcher and also three peer workers with severe mental illness. The resulting provisional 38-item version of the scale was completed by 136 respondents with severe mental illness, and we performed exploratory factor analysis to identify latent constructs within the new measure. The finalized scale was analyzed for test-retest reliability, internal consistency, and convergent validity.

RESULT

An exploratory factor analysis yielded a four-factor scale with 23 items. The finalized 23 items had high internal consistency (Cronbach's alpha = 0.91) and relatively high test-retest reliability (ICC = 0.83). The four subscales had fair internal consistency (Cronbach's alpha ≥ 0.69) and good test-retest reliability (ICC ≥ 0.61). Convergent validity was weakly supported by the significant positive correlations with the overall question on motivation to work (r ≥ 0.19, p < 0.01). Besides these correlations, only the "Pressure from others" subscale was negatively and significantly correlated with the negative symptoms evaluated using the Positive and Negative Syndrome Scale (r = -0.18, p = 0.04).

CONCLUSIONS

This study used factor analysis to develop a new multidimensional scale assessing motivation for competitive employment among persons with severe mental illness. The scale showed acceptable levels of reliability and factor-based and convergent validity. The new measure can be used for measuring the motivation for competitive employment among people with severe mental illness, and it would be useful to identify candidates who are likely to benefit from a certain supported employment program, and to monitor interim progress of the state of participants' motivation in a program.

The Place of Social Recovery in Mental Health and Related Services

This article looks at the place of social recovery in mental health and social care services, alongside personal recovery. Despite its conceptual and practice centrality to the new meaning of recovery, social recovery has remained a relatively neglected dimension. This article attempts to provide an updated critical commentary based on findings from fifty nine studies, including a variety of research methodologies and methods. Definitions of social recovery within the new meaning of recovery are looked at. This is followed by outlining the development and significance of this dimension as reflected in the key areas of shared decision making, co-production and active citizenship, re-entering employment after experiencing mental ill health, being in employment, poverty and coping with poverty, the economic and the scientific cases for social recovery. The article highlights the connections between service users’ experiencing mental health and social care systems, and the implications of ideologies and policies reflecting positions on social recovery. The complexity of social recovery is indicated in each of these areas; the related conceptual and methodological frameworks developed to research this dimension, and key achievements and barriers concerning everyday practice application of social recovery. The summary indicates potential future development perspectives of this dimension.

Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) often interferes with a person's ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income.

OBJECTIVE

To determine whether individual placement and support (IPS)-supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment.

DESIGN, SETTING, AND PARTICIPANTS

The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed.

INTERVENTIONS

Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community.

MAIN OUTCOMES AND MEASURES

A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period.

RESULTS

A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004).

CONCLUSIONS AND RELEVANCE

This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01817712.