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

Optimism, Lifetime Financial Stressors, and Mental Health Among Racially, Sexually, and Gender Minoritized Emerging Adults

BACKGROUND

Although racially, sexually, and gender minoritized (RSGM) persons experience chronic and sometimes severe financial life stressors that increase their risk of mental health problems across the life course, no studies in this population have examined psychological resilience factors, such as optimism, that may mitigate these negative effects.

PURPOSE

To investigate how exposure to financial stressors is associated with symptoms of anxiety, depression, and somatization, and whether optimism moderates these associations.

METHOD

Two hundred and eighty-five RSGM emerging adults (Mage = 25.18, SD = 1.94) completed the Stress and Adversity Inventory and Brief Symptom Inventory online. Participants were Black (22.1%), Latinx (57.9%), and biracial Black-Latinx (20%), and they primarily identified as male (94.7%) and gay (74.2%).

RESULTS

As hypothesized, multiple regression analyses with interaction terms indicated that more frequent and severe acute and chronic lifetime financial stressors were related to greater anxious, depressive, and somatic symptoms. Moreover, greater optimism was associated with fewer mental health symptoms. Additionally, greater optimism was associated with fewer somatic symptoms than lower optimism when exposed to more financial stressors. Similarly, greater optimism attenuated the negative effects of greater financial stressors' severity on depressive symptoms.

CONCLUSIONS

Financial stressors are related to worse mental health among RSGM emerging adults, and optimism may mitigate these effects. Screening for lifetime financial stressors and bolstering optimism may help reduce mental health disparities related to financial stressors in this population.

Long-term health conditions and UK labour market outcomes during the COVID-19 pandemic

BACKGROUND

Long-term health conditions can affect labour market outcomes. COVID-19 may have increased labour market inequalities, e.g. due to restricted opportunities for clinically vulnerable people. Evaluating COVID-19's impact could help target support.

AIM

To quantify the effect of several long-term conditions on UK labour market outcomes during the COVID-19 pandemic and compare them to pre-pandemic outcomes.

METHODS

The Understanding Society COVID-19 survey collected responses from around 20,000 UK residents in nine waves from April 2020-September 2021. Participants employed in January/February 2020 with a variety of long-term conditions were matched with people without the condition but with similar baseline characteristics. Models estimated probability of employment, hours worked and earnings. We compared these results with results from a two-year pre-pandemic period. We also modelled probability of furlough and home-working frequency during COVID-19.

RESULTS

Most conditions (asthma, arthritis, emotional/nervous/psychiatric problems, vascular/pulmonary/liver conditions, epilepsy) were associated with reduced employment probability and/or hours worked during COVID-19, but not pre-pandemic. Furlough was more likely for people with pulmonary conditions. People with arthritis and cancer were slower to return to in-person working. Few effects were seen for earnings.

CONCLUSION

COVID-19 had a disproportionate impact on people with long-term conditions' labour market outcomes.

Longitudinal outcomes of a work inclusion program in mental health departments in the city of Milan

BACKGROUND

Work functioning impairment is a key diagnostic and prognostic criterion in patients with psychiatric disorders and work inclusion is a major goal of their therapeutic pathway. Since 2009, the Regional Innovative Program (PIR) TR106, promoted by ASST Fatebenefratelli-Sacco of Milan in collaboration with other Departments of Mental Health and Addictions (DSMDs) in the town of Milan (Italy), has been developing the employment inclusion of psychiatric patients.

AIMS

The objective of this study is to evaluate its outcomes over 8 years of observation.

METHOD

We reported the results of a retrospective epidemiologic analysis on 2,142 interventions on 1,066 patients recruited, investigating PIR TR106 outcomes per year focusing on different subgroups. We focused on 'positive', 'negative', and 'other' outcomes.

RESULTS

We preliminary calculated job maintenance interventions (5%, 107) and excluded these interventions from the overall. We observed 29 job firing (1.4%) and 15 job resignations (0.7%) as negative results (equal to 2.2% of the total) and 388 job hiring (16.6%), 647 traineeships (31.8%), and 413 work formation (20.3%) as positive outcomes (equal to 68.75%). In other outcomes (29.1%) we found 305 dismissals from PIR TR 106 (15%) and transitory outcomes (14.1%).Job hiring increased from 8.9% in 2012 to 23.8 % in 2019 (p < .001), while the dismissals diminished from 26.7% to 13.3% (p < .001). The effectiveness of traineeships in terms of job hiring increased in the ratio of annual job hiring versus job traineeship (+48.8%). The majority of hired patients (15.1%) were affected by a psychotic disorder. A significant hiring increase was observed in patients with psychotic disorders and personality disorders (p < .005).

CONCLUSIONS

PIR-TR106 represents a territorial employment inclusion program with progressively increasing effectiveness and specificity, as suggested by changes in outcomes during the 8-year observation. The adaptive capacity and sustainability of the intervention are worth further investigation.

Experiences of returning to work in patients with schizophrenia after treatment: A longitudinal qualitative study

BACKGROUND

Returning to work (RTW) has always been regarded as one of the important indicators to evaluate the therapeutic effect of patients with schizophrenia. The existing studies on RTW in patients with schizophrenia are mostly focused on intervention measures, and the qualitative research on RTW is very limited. The purpose of this study was to evaluate the experience of the RTW after treatment in patients with schizophrenia.

METHOD

A longitudinal qualitative study was conducted involving 24 patients with schizophrenia in China. The interviews were held at three time-points during their RTW process, (1) when patients had improved and were close to discharge, (2) within 1 month post-discharge, and (3) 6 months post-discharge. The interview recordings were transcribed by the research team, and transcripts were independently analyzed by two independent coders using reflexive thematic analysis.

RESULTS

A total of 24 patients with schizophrenia participated in 72 personal interviews. The thematic framework based on the experience of patients with schizophrenia reveals a three-phases of the process of RTW: improved, being at a loss, and job crisis. The study identified one theme of the first phase: the expectation and optimism. Two themes in the second phase: (1) psychological distress of upcoming work; (2) expectation of assistance pre-work. And four themes in the third phase: (1) tremendous pressure of RTW; (2) lack of medical and social support; (3) social status and interpersonal relationships change; and (4) high level of financial pressure.

CONCLUSION

The experience of RTW is a dynamic process with great challenges in each phase, patients with schizophrenia have been deeply affected by what they have experienced. There is an urgent need to ensure that existing community and social support is integrated into daily care to support patients with schizophrenia to RTW successful. The findings of this study also suggest relevant departments and employers should be aware of the barriers to RTW for patients with schizophrenia, and take certain measures to change the current situation.

An RCT of Virtual Reality Job Interview Training for Individuals With Serious Mental Illness in IPS Supported Employment

OBJECTIVE

Virtual Reality Job Interview Training (VR-JIT) is a computerized interview simulator with efficacy at enhancing interview skills and employment outcomes. A randomized controlled trial assessed VR-JIT effectiveness for participants in individual placement and support (IPS), in which approximately 55% of individuals with serious mental illness obtain employment.

METHODS

Ninety participants with serious mental illness were randomly assigned to IPS+VR-JIT (N=54) or IPS as usual (N=36), completing pretest-posttest assessments and an employment evaluation at 9 months. Intent-to-treat chi-square analysis, multivariable logistic regression, Cox proportional hazards models, and mixed-effects linear regressions were conducted. Fifty-one percent were IPS nonresponders (i.e., no employment within the first 90 days of IPS).

RESULTS

IPS+VR-JIT participants did not have significantly higher employment rates, compared with IPS-as-usual participants (43% versus 28%). IPS nonresponders (N=46) in the IPS+VR-JIT group had greater odds of obtaining employment (odds ratio [OR]=5.82, p=0.014) and shorter time to employment (hazard ratio=2.70, p=0.044) compared with IPS nonresponders in the IPS-as-usual group. Intent-to-treat mixed-effects linear analyses indicated that IPS+VR-JIT, compared with IPS as usual, significantly improved interview skills (p=0.006), interview confidence (p=0.013), and interview anxiety (p=0.019).

CONCLUSIONS

VR-JIT's potential benefits (increased employment in a shorter time) appeared to be specific to IPS nonresponders, whereas employment outcomes for recent IPS enrollees were not affected. VR-JIT could be a valuable resource for employment specialists to support IPS nonresponders, because 47% of participants engaged in mock interview training with their specialist. Future research should focus on evaluating the effectiveness and implementation of VR-JIT among IPS nonresponders.

Work Patterns and Support Needs of People with Serious Mental Illness

People with serious mental illness (SMI) are frequently unemployed, despite their willingness to work. Several employment interventions approaches have proven efficacy; however, work integration rates for people with SMI continue to be low. In total, 145 participants with a SMI completed a survey, answering questions regarding their personal information, work history, whether they received supports towards work integration, and their functional level. In addition, clinical records were accessed to verify and complete clinical history. A quantitative descriptive approach was used to analyze the data. No significant differences were found between those who were working and who were not, based on age, gender, educational level, living situation, and suicide risk. Those who were working presented higher levels of functional capacity than those who were not working. Factors associated with employment outcomes continue to remain unclear, adding value to the role that the different supports towards work integration may have.

Measuring, Modeling, and Forecasting the Mental Wealth of Nations

The COVID-19 pandemic has exposed the deep links and fragility of economic, health and social systems. Discussions of reconstruction include renewed interest in moving beyond GDP and recognizing "human capital", "brain capital", "mental capital", and "wellbeing" as assets fundamental to economic reimagining, productivity, and prosperity. This paper describes how the conceptualization of Mental Wealth provides an important framing for measuring and shaping social and economic renewal to underpin healthy, productive, resilient, and thriving communities. We propose a transdisciplinary application of systems modeling to forecast a nation's Mental Wealth and understand the extent to which policy-mediated changes in economic, social, and health sectors could enhance collective mental health and wellbeing, social cohesion, and national prosperity. Specifically, simulation will allow comparison of the projected impacts of a range of cross-sector strategies (education sector, mental health system, labor market, and macroeconomic reforms) on GDP and national Mental Wealth, and provide decision support capability for future investments and actions to foster Mental Wealth. Finally, this paper introduces the Mental Wealth Initiative that is harnessing complex systems science to examine the interrelationships between social, commercial, and structural determinants of mental health and wellbeing, and working to empirically challenge the notion that fostering universal social prosperity is at odds with economic and commercial interests.

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.

Supported employment programme for persons with severe mental disorders in India: A feasibility study

BACKGROUND

A number of persons with severe mental illnesses are unable to prepare for, find or keep a job due to factors linked to their illness as well as psychosocial issues.

AIM

To test the feasibility of a supported employment programme to help persons with severe mental disorders obtain and sustain employment.

METHODS

A supported employment programme was developed for persons with severe mental disorders with components of (a) assessment of vocational potential, (b) vocational counselling, (c) networking and liaison with prospective employers, (d) job-related training and placement and (e) continued support for 6 months. Job placement status, social occupational functioning and disability (quantitative data) and benefits of enrolling in the employment programme (qualitative data) were assessed.

RESULTS

A total of 40 employers were liaised with for providing job placement and reasonable accommodation. Out of 63 participants recruited into the study, 32 (50.8%) participants were placed in competitive jobs, placement was actively attempted for 17 (27.0%) participants, 7 (11.1%) were referred for skill training and 7 (11.1%) dropped out from the study. The disability score significantly reduced and socio-occupational functioning significantly improved in those who were placed over a period of 6 months.

CONCLUSION

The supported employment programme was found to be feasible as it showed good placement rates and improvement in socio-occupational functioning and disability scores.

Level of functioning, perceived work ability, and work status among psychiatric patients with major mental disorders

Background:

Major mental disorders are highly disabling conditions that result in substantial socioeconomic burden. Subjective and objective measures of functioning or ability to work, their concordance, or risk factors for them may differ between disorders.

Methods:

Self-reported level of functioning, perceived work ability, and current work status were evaluated among psychiatric care patients with schizophrenia or schizoaffective disorder (SSA, n = 113), bipolar disorder (BD, n = 99), or depressive disorder (DD, n = 188) within the Helsinki University Psychiatric Consortium Study. Correlates of functional impairment, subjective work disability, and occupational status were investigated using regression analysis.

Results:

DD patients reported the highest and SSA patients the lowest perceived functional impairment. Depressive symptoms in all diagnostic groups and anxiety in SSA and BD groups were significantly associated with disability. Only 5.3% of SSA patients versus 29.3% or 33.0% of BD or DD patients, respectively, were currently working. About half of all patients reported subjective work disability. Objective work status and perceived disability correlated strongly among BD and DD patients, but not among SSA patients. Work status was associated with number of hospitalizations, and perceived work disability with current depressive symptoms.

Conclusions:

Psychiatric care patients commonly end up outside the labour force. However, while among patients with mood disorders objective and subjective indicators of ability to work are largely concordant, among those with schizophrenia or schizoaffective disorder they are commonly contradictory. Among all groups, perceived functional impairment and work disability are coloured by current depressive symptoms, but objective work status reflects illness course, particularly preceding psychiatric hospitalizations.

Integrating Israeli Defense Force (IDF) veterans with disabilities into the workforce: characteristics and predictors

BACKGROUND

According to the ICF Model, the central goal of rehabilitation is the returning of persons with disabilities to an active and fruitful life within society. The Israel Ministry of Defense Rehabilitation Department's occupational rehabilitation program includes assessment, professional guidance, training, and assistance integrating into employment.

AIM

Examining predictors for the integration of Israel Defense Force veterans with disabilities into the workforce.

METHODS

All 1416 male veterans with disabilities who served in the military, were injured during their service, and were treated by the Israel Ministry of Defense Rehabilitation Department between 2001 and 2006 were included in this study. Data collection was based on computerized administrative data in the Ministry of Defense. The data was collected with no identifying details. Predictive variables were: health condition, personal factors, participation factors, level of functioning and structure, and variables relating to the local environment.

RESULTS

Compared to a physical disability, mental and mixed (physical and mental) disabilities reduce the odds for integration into the workforce. Higher education at the time of the injury is an additional predictor for integration into the workforce. Participation in a rehabilitation track for further education to acquire a profession is one of the main predictors for integration into the workforce.

CONCLUSION

The results may enable developing more accurate intervention plans, with more efficient use of resources, including consolidation of existing information systems and monitoring the processes and outcomes of rehabilitation.

An Integrative Review of the Barriers to Job Acquisition for People With Severe Mental Illnesses

This integrative review analyses and synthesizes specialized literature of 20 years up to 2017 studying barriers/obstacles to employment for people with severe mental illnesses. The inclusion and exclusion criteria led to 35 experimental and nonexperimental studies. Results of the prospective studies were analyzed with the evidence synthesis method to isolate the most salient obstacles. Six main themes emerged from the findings, grouped into personal and environmental barriers. Environmental barriers were related to disability benefits and other physical resources, to stigma and social support, and to vocational services. Individual barriers included those related to illness, to work experience and skills, and to self-perception, fears, and motivation. The most prominent obstacles are lack of work experience and lack of use of effective strategies toward employment. Systematically identifying barriers to employment for people with severe mental illnesses will enable employment specialists to better support their clients in overcoming them, thus facilitating their work integration.

Modified Work Behavior Inventory assessment: Evaluation of psychometric properties

The Work Behavior Inventory (WBI) is a widely used and validated assessment of work functioning in people with schizophrenia. WBI ratings are based on workplace observation and interview with work supervisors. Workplace observation may not be acceptable in all employment settings. A WBI assessment based only on supervisor interview may offer more utility. The current study evaluated the psychometric properties of a modified WBI among individuals with schizophrenia participating in VA vocational rehabilitation programs – similar to the original WBI validation study. Results suggest evidence for reliability, validity and sensitivity to change for an interview only format. Limitations and future research directions are discussed.

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

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

Regularity of self-reported daily dosage of mood stabilizers and antipsychotics in patients with bipolar disorder

BACKGROUND

Polypharmacy is often prescribed for bipolar disorder, yet medication non-adherence remains a serious problem. This study investigated the regularity in the daily dosage taken of mood stabilizers and second generation antipsychotics.

METHODS

Daily self-reported data on medications taken and mood were available from 241 patients with a diagnosis of bipolar disorder who received treatment as usual. Patients who took the same mood stabilizer or second generation antipsychotic for ≥ 100 days were included. Approximate entropy was used to determine serial regularity in daily dosage taken. Generalized estimating equations were used to estimate if demographic or clinical variables were associated with regularity.

RESULTS

There were 422 analysis periods available from the 241 patients. Patients took drugs on 84.4% of days. Considerable irregularity was found, mostly due to single-day omissions and dosage changes. Drug holidays (missing 3 or more consecutive days) were found in 35.8% of the analysis periods. Irregularity was associated with an increasing total number of psychotropic drugs taken (p = 0.009), the pill burden (p = 0.026), and the percent of days depressed (p = 0.049).

CONCLUSION

Despite low missing percent of days, daily drug dosage may be irregular primarily due to single day omissions and dosage changes. Drug holidays are common. Physicians should expect to see partial adherence in clinical practice, especially with complex drug regimens. Daily dosage irregularity may impact the continuity of drug action, contribute to individual variation in treatment response, and needs further study.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Correlates of employment interest among adults with schizophrenia

Background/Aims:

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

Methods:

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

Findings:

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

Conclusions:

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

Views of people with schizophrenia and their caregivers towards the needs for psychiatric rehabilitation in urban and rural areas of mainland China

This qualitative study explores and compares the views of the individuals with schizophrenia and their caregivers in the urban and rural areas of Wuxi towards the needs for psychiatric rehabilitation. The results may more precisely guide the government and policy makers to tailor the corresponding strategies and services. With interview guides, individual face-to-face semi-structured interviews were conducted among a total of 16 participants (four people with schizophrenia and their caregivers in the urban areas and in the rural areas, respectively). All interviews were audio-recorded, transcribed, and analyzed using an inductive approach. The findings revealed commonalities and discrepancies on their views about the needs of rehabilitation interventions and community care, the healthcare resources for medication, the major factors of employment, and the support to caregivers for facilitating recovery. Some policy and service implications to promote psychiatric rehabilitation of the people with schizophrenia and their caregivers in Wuxi are discussed. With careful consideration of the possible socio-cultural differences, the findings may also serve as references for the related researchers and clinicians in other regions in China.

Work Accommodations and Natural Supports for Employees with Severe Mental Illness in Social Businesses: An International Comparison

Little is known about the types of work accommodations and natural supports that are useful for people experiencing severe mental illness working in social businesses. We conducted an exploratory, descriptive and cross-sectional investigation in Australia, Canada and Italy to study the nature of work accommodations and natural supports available in social businesses. Study findings are drawn from survey responses of a convenience sample of 90 employees with self-reported psychiatric disabilities. Results showed that, regardless of the country, social businesses provide many work accommodations and natural supports, especially those linked to schedule flexibility and support, while work accommodations related to training and schedule flexibility were linked to longer job tenure. Overall, this study advances our knowledge about the spectrum of work accommodations and natural supports that are available in social businesses for people with severe mental illness. Also, it highlights the type of work accommodations that are likely to support this population to sustain employment.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Predictors of Acquisition of Competitive Employment for People Enrolled in Supported Employment Programs

This study aims at assessing the relative contribution of employment specialist competencies working in supported employment (SE) programs and client variables in determining the likelihood of obtaining competitive employment. A total of 489 persons with a severe mental illness and 97 employment specialists working in 24 SE programs across three Canadian provinces were included in the study. Overall, 43% of the sample obtained competitive work. Both client variables and employment specialist competencies, while controlling for the quality of SE programs implementation, predicted job acquisition. Multilevel analyses further indicated that younger client age, shorter duration of unemployment, and client use of job search strategies, as well as the working alliance perceived by the employment specialist, were the strongest predictors of competitive employment for people with severe mental illness, with 51% of variance explained. For people with severe mental illness seeking employment, active job search behaviors, relational abilities, and employment specialist competencies are central contributors to acquisition of competitive employment.

The impact of psychotic disorders and co-morbid substance abuse on vocational rehabilitation: results from an Australian national survey of psychosis

Introduction

It is unclear from prior research whether or not substance abuse co-morbid with psychosis is an added barrier to success in vocational rehabilitation. The aim of this study was to examine the relationships among three types of co-morbid substance abuse or dependence, by type of employment assistance received (disability employment services, mainstream unemployment services, other government programmes, and own resources), and by type of employment attained (competitive and non-competitive).

Method

Data were drawn from the Australian National Survey of High Impact Psychosis ( N = 1825). The survey was conducted in seven Australian catchment areas March to December 2010. Descriptive statistics and logistic regression methods were used.

Results

There were no added effects of lifetime substance abuse or dependence on any employment. However, there were some minor substance-specific effects. Past year cannabis use was negatively associated, while alcohol use was positively associated with being employed. All categories of lifetime substance abuse or dependence were associated with reduced utilisation of intensive forms of employment assistance.

Conclusion

At a population level, lifetime substance abuse or dependence had no added impact on current employment status. Those with psychosis co-morbid with lifetime substance abuse or dependence could benefit from greater utilisation of evidence-based supported employment.

Psychological Predictors of Vocational Success for People with Psychotic Illness

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

Reasons for job separations in a cohort of workers with psychiatric disabilities

We explored the relative effects of adverse working conditions, job satisfaction, wages, worker characteristics, and local labor markets in explaining voluntary job separations (quits) among employed workers with psychiatric disabilities. Data come from the Employment Intervention Demonstration Program in which 2,086 jobs were ended by 892 workers during a 24 mo observation period. Stepped multivariable logistic regression analysis examined the effect of variables on the likelihood of quitting. Over half (59%) of all job separations were voluntary while 41% were involuntary, including firings (17%), temporary job endings (14%), and layoffs (10%). In multivariable analysis, workers were more likely to quit positions at which they were employed for 20 h/wk or less, those with which they were dissatisfied, low-wage jobs, non-temporary positions, and jobs in the structural (construction) occupations. Voluntary separation was less likely for older workers, members of racial and ethnic minority groups, and those residing in regions with lower unemployment rates. Patterns of job separations for workers with psychiatric disabilities mirrored some findings regarding job leaving in the general labor force but contradicted others. Job separation antecedents reflect the concentration of jobs for workers with psychiatric disabilities in the secondary labor market, characterized by low-salaried, temporary, and part-time employment.

Separation from supported employment: a retrospective chart review study

PURPOSE

The objective of this study was to examine job separations from supported employment (SE). The aim was to identify the types and nature of separations and precipitating events leading to the separation.

METHODS

A retrospective chart review methodology was utilized. The study was conducted in a metropolitan area in the Southeast United States by a university-based SE program. Participants were 47 SE clients who had been placed into and separated from 67 jobs. Using a coding form, information regarding the type of separation and issues that preceded the separation were recorded. Data were aggregated using descriptive statistics.

RESULTS

The largest number of separations was due to termination, followed by resignation and mutual consent of the employer and employee. The mean number of issues leading to the separation was 2.2, ranging from one to five. Only eight positive issues were found (compared to 116 negative and 20 neutral), the most prevalent being entry into an educational or training program. Common negative issues included poor work performance, attendance and punctuality problems, conflicts with the supervisor, and social and behavioral issues.

CONCLUSIONS

The findings of this study illustrate the need to address job retention issues during the job development process, finding the most appropriate person-job fit and workplace culture for each client. The findings also support the need for vigilant and regular communication between the SE program and employers to intervene quickly when problems arise.

IMPLICATIONS FOR REHABILITATION

Separation from Supported Employment (SE) SE is an evidence-based employment practice that has been shown effective across multiple disability groups. Studying job separations can provide valuable information for improving service. Locating the best person-job fit, as well as frequent contract with employers, can help prevent unnecessary job loss.

Evaluating the Psychometric Properties of a Clinical Vocational Rehabilitation Outcome Measurement: The Assessment of Work Performance (AWP)

This study examined the validity and reliability of the Assessment of Work Performance (AWP) using Rasch analysis. The AWP was administered to 365 clients with a variety of work-related problems. Rasch analysis and principal component analysis were used to examine the appropriateness of the rating scales and unidimensionality of AWP items. The person-response validity, internal consistency, targeting appropriateness, and differential item function were also analyzed. The Rasch analysis confirmed the 4-point rating scale, and the item set met the criteria of unidimensionality. The AWP exhibited satisfactory person-response validity and internal consistency. Among the three subdomains, the targeting of item-difficulty was sufficient in the motor skills and process skills subdomains. Differential item functioning was found across gender and diagnoses. This study presented evidence to support that the AWP functioned as a reliable and valid assessment in assessing work performance. [OTJR: Occupation, Participation and Health 2013;33(3):125-133.].

Functional remission and employment among patients with schizophrenia in Malaysia

OBJECTIVE

The study aimed to determine the rates of functional remission and employment as well as the factors associated with functional remission among patients with Schizophrenia, receiving community psychiatric service in an urban setting in Malaysia.

METHODS

From a total of 250 patients randomly selected, 155 fulfilled the study requirement and were assessed on their functional remission status using the Personal and Social Performance Scale. The relationships between functional remission and socio-demographic factors, clinical factors, social support, symptom remission and rates of hospitalization were examined.

RESULTS

The results revealed that 74% (n=115) of the respondents had functional remission with only 20% (n=31) currently employed. Functional remission was found to be significantly associated with good social support (84.4% versus 36.4% p<0.001, OR=9.487 [95% CI=4.008-22.457]); shorter illness duration of less than 10 years (81.2% versus 66.7% p=0.038, OR=2.167 [95% CI=1.035-4.535]); good medication compliance (79.1% versus 50.0% p=0.002, OR=3.778 [95% CI=1.570-9.090]); hospital admissions of lower than 3 per year (80.5% versus 44.4% p<0.001 OR=5.150 [95% CI=2.145-12.365]) and; symptomatic remission (87.3% versus 37.4% p<0.001 [95% CI=0.070 (0.029-0.168]). A multiple regression analysis revealed only social support, lower hospitalization rate and symptom remission, as significant predictors of functional remission.

CONCLUSION

A majority of patients with Schizophrenia in this study achieved functional remission, however, only a small percentage of them were employed. Functional remission was influenced by severity of illness and levels of social support in these patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Cognitive function and competitive employment in schizophrenia: relative contribution of insight and psychopathology

PURPOSE

This study investigated the relationships among insight, psychopathology, cognitive function, and competitive employment in order to determine whether insight and/or psychopathology carried the influence of cognitive function to competitive employment.

METHODS

We recruited 253 outpatients with stable schizophrenia and we further divided our sample into two groups of patients (unemployed and competitive employment subjects). Clinical and neuropsychological assessments were performed. All clinical variables significantly different between the two groups of subjects were subsequently analyzed using a binary logistic regression to assess their independent contribution to competitive employment in the two patients' groups. On the basis of the regression results two mediation analyses were performed.

RESULTS

Verbal memory, general psychopathology, and awareness of mental illness were significantly associated with competitive employment in our sample. Both awareness of mental illness and general psychopathology had a role in mediating the verbal memory-competitive employment relationship.

CONCLUSIONS

Taken together, these findings confirmed the importance of cognitive function in obtaining competitive employment. Our results also highlighted the independent role of general psychopathology and awareness of illness on occupational functioning in schizophrenia. Thus, a greater attention must be given to the systematic investigation of insight and general psychopathology in light of an amelioration of vocational functioning in stable schizophrenia.

Supported employment outcomes for transition age youth and young adults

TOPIC

Supported Employment (SE) can help transition age youth and young adults to obtain employment and develop meaningful careers and financial security.

PURPOSE

The purpose of this analysis is to examine the role of SE in achieving employment outcomes for youth (ages 18-24) and young adults (ages 25-30), compared to outcomes for older adults. Given the importance of employment to the quality of life of young people in establishing work histories and starting careers, it is important to have a better understanding of what client and program characteristics result in better employment outcomes.

SOURCES USED

Data are from the Employment Intervention Demonstration Program (EIDP), a multisite randomized controlled trial of SE among 1,272 individuals with psychiatric disabilities in 7 states.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Among all study participants, youth and young adults had significantly better outcomes in terms of any employment and competitive employment than older (>30 years) adults. However, in multivariable models of participants randomly assigned to SE, young adults had significantly better outcomes than youth or older adults. Other significant predictors of employment and competitive employment were future work expectations, not receiving Supplemental Security Income, and receipt of more hours of SE services. Characteristics of youth, young adults and SE programs that enhance employment are discussed in terms of policy and practice.

Intrinsic motivation as a predictor of work outcome after vocational rehabilitation in schizophrenia

Intrinsic motivation is a construct commonly used in explaining goal-directed behavior. In people with schizophrenia, intrinsic motivation is usually subsumed as a feature of negative symptoms or underlying neurocognitive dysfunction. A growing literature reflects an interest in defining and measuring motivational impairment in schizophrenia and in delineating the specific role of intrinsic motivation as both an independent predictor and a mediator of psychosocial functioning. This cross-sectional study examined intrinsic motivation as a predictor of vocational outcomes for 145 individuals with schizophrenia and schizoaffective disorder participating in a 6-month work rehabilitation trial. Correlation and mediation analyses examined baseline intrinsic motivation and negative symptoms in relation to work hours and work performance. Data support a significant relationship between intrinsic motivation and negative symptoms and significant correlations with outcome variables, such that lower negative symptoms and greater intrinsic motivation were associated with better work functioning. Moreover, in this sample, intrinsic motivation fully mediated the relationships between negative symptoms, work productivity, and work performance. These results have significant implications on the design of work rehabilitation interventions for people with schizophrenia and support a role for targeting intrinsic motivation directly to influence vocational functioning. Future directions for research and intervention are discussed.

The role of motivation for treatment success

Learning during skills-based psychosocial treatments for schizophrenia is influenced by the motivating properties of the treatment context and the motivational orientation of the client. Given that motivational impairment is a core feature of schizophrenia with significant functional implications, intervention strategies emphasizing extrinsic and/or intrinsic goals may be prescribed to enhance skill learning and treatment outcomes. The purpose of this article is to consider the role that motivation plays in treatment success by evaluating the relationship between motivation and learning during cognitive remediation for schizophrenia. As intrinsic motivation (IM) is most often associated with learning, we will integrate research findings which address 3 main questions: (1) is IM in schizophrenia static or dynamic, (2) is it possible to manipulate the state of being intrinsically motivated and if so do manipulations of IM affect learning? and (3) can motivation theory be translated into clinical practice? This knowledge can facilitate treatment strategies to address the low base rate of IM that is characteristic of schizophrenia and can be applied to cognitive remediation as well as other psychosocial interventions which require learning for treatment success.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Who benefits from supported employment: a meta-analytic study

AIMS

This meta-analysis sought to identify which subgroups of clients with severe mental illness (SMI) benefited from evidence-based supported employment.

METHODS

We used meta-analysis to pool the samples from 4 randomized controlled trials comparing the Individual Placement and Support (IPS) model of supported employment to well-regarded vocational approaches using stepwise models and brokered services. Meta-analysis was used to determine the magnitude of effects for IPS/control group differences within specific client subgroups (defined by 2 work history, 7 sociodemographic, and 8 clinical variables) on 3 competitive employment outcomes (obtaining a job, total weeks worked, and job tenure).

RESULTS

The findings strongly favored IPS, with large effect sizes across all outcomes: 0.96 for job acquisition, 0.79 for total weeks worked, and 0.74 for job tenure. Overall, 90 (77%) of the 117 effect sizes calculated for the 39 subgroups exceeded 0.70, and all 117 favored IPS.

CONCLUSIONS

IPS produces better competitive employment outcomes for persons with SMI than alternative vocational programs regardless of background demographic, clinical, and employment characteristics.

Illness self-management assessment in psychiatric vocational rehabilitation

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

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

Examining the Validity of the Model of Human Occupation Screening Tool: Using Classical Test Theory and Item Response Theory

Introduction:

This study examined the psychometric properties of the Model of Human Occupation Screening Tool, using both item response theory and classical test theory.

Method:

One hundred and one people with mental health problems, aged 18–65 years, were recruited. The Chinese version of the Model of Human Occupation Screening Tool, the National Taiwan University Hospital Symptom Checklist, the Volitional Questionnaire, the Assessment of Communication and Interaction Skills, and the Mini Mental State Examination were administered. Rasch analysis and correlational analysis were used to examine the construct, convergent, divergent validity and known group validity.

Results:

Rasch analysis confirmed that there were six subscales within the Chinese version of Model of Human Occupation Screening Tool. The Volitional Questionnaire strongly correlated with the volition subscale (r = 0.583). The Assessment of Communication and Interaction Skills strongly correlated with the communication and interaction subscale (r = 0.815). The Mini Mental State Examination was moderately correlated with the process subscale (ρ = 0.334) and the symptomatology was not associated with any of the subscales as expected. There were significant differences on selected subscale scores across four known groups of participants.

Conclusion:

The Chinese version of the Model of Human Occupation Screening Tool was valid when applied to people with mental health problems.

The Effectiveness of Supported Employment in People With Dual Disorders

OBJECTIVE: This study compared the effectiveness of the Individual Placement and Support (IPS) model of supported employment to control vocational rehabilitation programs for improving the competitive work outcomes of people with a severe mental illness and co-occurring substance use disorder. METHODS: A secondary data analysis was conducted drawing from four randomized controlled trials comparing IPS supported employment to conventional vocational rehabilitation programs for severe mental illness, and focusing on the 106 clients with a recent (past 6 months) substance use disorder. Competitive work outcomes were tracked across an 18-month follow-up period. Analyses compared the IPS and comparison vocational programs on cumulative work over the 18 months, including attainment of work, hours and weeks worked, job tenure, wages earned, and days to first job. RESULTS: In the total study group, clients who participated in IPS had better competitive work outcomes than those who participated in a comparison program, with cumulative employment rates of 60% vs. 24%, respectively. Among clients who obtained work during the study period, those receiving IPS obtained their first job significantly more quickly and were more likely to work 20 or more hours per week at some point during the 18-month follow-up. CONCLUSIONS: The IPS model of supported employment is more effective than alternative vocational rehabilitation models at improving the competitive work outcomes of clients with a dual disorder.

Client predictors of employment outcomes in high-fidelity supported employment: a regression analysis

Research on vocational rehabilitation for clients with severe mental illness over the past 2 decades has yielded inconsistent findings regarding client factors statistically related to employment. The present study aimed to elucidate the relationship between baseline client characteristics and competitive employment outcomes-job acquisition and total weeks worked during an 18-month follow-up-in Individual Placement and Support (IPS). Data from 4 recent randomized controlled trials of IPS were aggregated for within-group regression analyses. In the IPS sample (N = 307), work history was the only significant predictor for job acquisition, but receiving Supplemental Security Income-with or without Social Security Disability Insurance-was associated with fewer total weeks worked (2.0%-2.8% of the variance). In the comparison sample (N = 374), clients with a diagnosis of mood disorder or with less severe thought disorder symptoms were more likely to obtain competitive employment. The findings confirm that clients with severe mental illness interested in competitive work best benefit from high-fidelity supported employment regardless of their work history and sociodemographic and clinical background, and highlight the needs for changes in federal policies for disability income support and insurance regulations.

A qualitative investigation of individual and contextual factors associated with vocational recovery among people with serious mental illness

Most people with serious mental illness (SMI) experience difficulty in fulfilling a vocational role, with many being unemployed or underemployed. Given the profound social and economic costs of this level of work impairment, researchers have investigated ways to enhance "vocational recovery," or the processes through which people with SMI regain their role as workers and reintegrate into the workforce. Using data collected from a larger qualitative study of 23 individuals who had progressed to an advanced stage of recovery from SMI, this study explored respondents' perspectives on employment and its relationship to their vocational recovery. Text passages describing employment were analyzed inductively by a diverse team of researchers. Seven themes were identified as being important in helping participants return to work or remain employed following the onset of a serious psychiatric disability: having the confidence to work, having the motivation to work, possessing work-related skills, assessing person-job fit, creating work opportunities, receiving social support, and having access to consumer-oriented programs and services. Implications of these findings on the development of interventions and policies to improve the vocational outcomes of people with SMI are discussed.

Creation of a measure to assess knowledge of the individual placement and support model

OBJECTIVE

This article describes the development and psychometric evaluation of the IPS-Q, a quiz assessing practitioner knowledge of the Individual Placement and Support (IPS) model.

METHODS

Using multiple resources, including the IPS Fidelity Scale and publications about the IPS model, a 30-item multiple-choice quiz covering fundamental IPS principles and key components was developed. Ratings by eight IPS experts supported its content validity. To examine the IPS-Q's psychometric properties, 107 practitioners from high-fidelity IPS programs and 59 practitioners from non-IPS vocational programs were administered the IPS-Q via a web-based survey tool.

RESULTS

The measure displayed good internal consistency (Cronbach's alpha = .89) and a difficulty level consistent with that of typical job knowledge tests. The IPS-Q did not correlate with demographic variables that were considered extraneous to knowledge of IPS and did correlate with self-reported supported employment familiarity. However, contrary to our hypothesis, the quiz was not significantly correlated with exposure to supported employment. The IPS-Q significantly discriminated between practitioners working in high-fidelity IPS programs and non-IPS vocational programs. Furthermore, supervisors from high-fidelity IPS programs scored significantly higher on the measure than vocational workers from high-fidelity IPS programs.

CONCLUSIONS

The IPS-Q is a valid measure of IPS knowledge and might prove useful for assessment, research, and training purposes. Practitioners sometimes assume that they understand a program model when in fact they have misconceptions. The IPS-Q provides an objective way to gauge practitioner knowledge.

Neurocognitive enhancement therapy with vocational services: work outcomes at two-year follow-up

Neurocognitive enhancement therapy (NET) is a remediation program for the persistent and function-limiting cognitive impairments of schizophrenia. In a previous study in veterans, NET improved work therapy outcomes as well as executive function and working memory. The present study aimed to determine whether NET could enhance functional outcomes among schizophrenia and schizoaffective patients in a community mental health center receiving community-based vocational services.

METHOD

Patients (N=72) participated in a hybrid transitional and supported employment program (VOC) and were randomized to either NET+VOC or VOC only. NET+VOC included computer-based cognitive training, work feedback and a social information information-processing group. VOC only also included two weekly support groups. Active intervention was 12 months with 12 month follow-up. Follow-up rate was 100%.

RESULTS

NET+VOC patients worked significantly more hours during the 12 month follow-up period, reached a significantly higher cumulative rate of competitive employment by the sixth quarter, and maintained significantly higher rates of employment.

CONCLUSION

NET training improved vocational outcomes, suggesting the value of combining cognitive remediation with other rehabilitation methods to enhance functional outcomes.

Physical wellness and employment status among adults with serious mental illness

This study examined whether concurrent medical status contributes to employment outcomes among those with psychiatric disabilities. Thirty-five percent (n = 70) of the 200 participants reported being currently employed. Sixty-three percent (n = 127) reported one or more co-occurring medical conditions; thirty-six percent (n = 71) reported two or more, and twenty-one percent (n = 41) reported three or more co-occurring medical conditions. Individuals with higher self-ratings of physical health functioning were more likely to be employed. Neither the number of co-occurring medical conditions nor any specific medical condition was related to employment status. Recommendations to enhance existing models of supported employment programs with physical health and wellness promotion components are offered.