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

Struggling with Fitting in: Clients Mixed Experiences of Receiving Job Support and Getting a Job When Participating in Individual Placement and Support in Norway

PURPOSE

To explore clients' experiences of receiving job support from employment specialists (ESs) working with individual placement and support (IPS) in Norway. IPS is developed to help people with severe mental illness (SMI) into competitive employment as an integral component of mental health services.

METHODS

Using a hermeneutic phenomenological methodology, this study comprises individual semi-structured interviews with ten participants engaged in IPS at two districts psychiatric centers. Data analysis was conducted according to systematic text condensation.

RESULTS

Three themes emerged: (1) ES-a door opener? (2) Striving to sidestep a "spider web" of triggers at and away from work; and (3) Calling for a safer route.

CONCLUSION

This study highlights the importance of ESs offering IPS clients' opportunities to try out diverse jobs and focusing more on assessing the work environment in the jobs they place people into. Our findings imply that ESs should spend more time on building a good working alliance with both clients and employers, and pay more attention on understanding individuals' vocational capacities and support needs at the worksite. The ES training should focus not simply on the technical processes of job development and placement, but more directly on empowering clients to stay focused on their vocational ambitions and prospects. The salutogenic model of health can help ESs to analyze whether clients experience workplaces as meaningful, manageable, and comprehensible.

A recovery-oriented day hospital in psychiatry: A springboard for reintegration

Psychiatric disorders are common and can cause psychological disabilities. While the creation of day hospitals (DHs) was intended to direct psychiatric care towards community settings, they may have paradoxically contributed to a form of chronicity. Furthermore, the heterogeneity and lack of evaluation of care within DHs prevent the availability needed to collect objective data on users outcomes. In this article, we aim to describe and measure the effects of a transformation of practice within a sector-based DH initially focused on traditional institutional psychiatry towards a rehabilitation model of care which offers different therapeutic tools, structured in three stages, and whose main objective is professional integration. This retrospective mirror study compares, before and after the transformation of this DH, several indicators including the rate of professional integration and its maintenance after two years. We found that this psychosocial rehabilitation model for care allowed a very clear increase in the professional integration rate and its maintenance at two years while reducing the length of stay to around 18 months. These promising results therefore highlight the pivotal role of DHs as "stepping stones" in addressing psychological disabilities towards recovery.

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.

Assessing the fidelity of supported education programs for first-episode psychosis to the supported employment guidelines adapted for education

INTRODUCTION

Psychotic disorders are associated with academic difficulties. Supported Employment Program (SEP) guidelines have become the gold standard to improve occupational functioning in psychotic disorders. More recently, these guidelines have been adapted to education. In Canada, several community organizations and hospital programs offer supported education to young people with psychotic disorders. However, SEP guidelines are not systematically used. The objective of this study was to assess the fidelity of 6 Canadian (Quebec) organizations offering supported education services to young people with psychotic disorders to the SEP guidelines adapted to education.

METHODS

Six sites offering educational services to young people with psychotic disorders were recruited. Semi-structured interviews were conducted with one supported education professional and one manager of each site, using the Quality of Supported Education Implementation Scale (QSEDIS). This new scale has been developed from the Quality of Supported Employment Implementation Scale. The QSEDIS assesses the fidelity of the quality of the implementation of supported education programs, using three subscales (Employees, Organization and Services).

RESULTS

Acceptable fidelity scores were observed in the three QSEDIS subscales for all six sites combined. The Services subscale received the highest score of fidelity (4.4/5), followed by the Supported Education Employee (4.1/5) and the Organization (3.7/5).

CONCLUSION

The results suggest that supported education services offered to young people with psychotic disorders in the six sites are generally consistent with SEP guidelines adapted to education. Further research is warranted to validate whether acceptable SEP guidelines fidelity according to the QSEDIS translates into educational outcomes.

Employers' perceptions of supports provided to their employees with disabilities

The employment of individuals with disabilities is significantly low. Many factors are associated with this issue; however, support and accommodations that can be provided to such individuals can improve their employment rate and outcomes. This study aimed to examine the support provided to employees with disabilities in Saudi Arabia. The descriptive approach was utilized, and a survey was used to collect the data. The sample consisted of 86 employer participants to examine the support of their employees with disabilities. Findings revealed that the support provided was high, and the participants reported that such support facilitates finding and maintaining a job. In addition, the variables were all found to have no significant differences. Providing needed and necessary support is an effective strategy that leads to competitive employment for individuals with disabilities, especially for the long term. Implications and recommendations are also discussed.

A Scoping Review on the Use of Machine Learning in Return-to-Work Studies: Strengths and Weaknesses

PURPOSE

Decisions to increase work participation must be informed and timely to improve return to work (RTW). The implementation of research into clinical practice relies on sophisticated yet practical approaches such as machine learning (ML). The objective of this study is to explore the evidence of machine learning in vocational rehabilitation and discuss the strengths and areas for improvement in the field.

METHODS

We used the PRISMA guidelines and the Arksey and O'Malley framework. We searched Ovid Medline, CINAHL, and PsycINFO; with hand-searching and use of the Web of Science for the final articles. We included studies that are peer-reviewed, published within the last 10 years to consider contemporary material, implemented a form of "machine learning" or "learning health system", undertaken in a vocational rehabilitation setting, and has employment as a specific outcome.

RESULTS

12 studies were analyzed. The most commonly studied population was musculoskeletal injuries or health conditions. Most of the studies came from Europe and most were retrospective studies. The interventions were not always reported or specified. ML was used to identify different work-related variables that were predictive of return to work. However, ML approaches were varied and no standard or predominant ML approach was evident.

CONCLUSIONS

ML offers a potentially beneficial approach to identifying predictors of RTW. While ML uses a complex calculation and estimation, ML complements other elements of evidence-based practice such as the clinician's expertise, the worker's preference and values, and contextual factors around RTW in an efficient and timely manner.

Experiences and needs of welfare benefit recipients regarding their welfare-to-work services and case workers

BACKGROUND

This study aimed to explore the experiences and needs of (ex-)welfare benefit recipients from a large urban municipality in the Netherlands regarding their welfare-to-work services and their case workers.

METHODS

Quantitative data from a client satisfaction survey that was filled out by 213 people (response rate 11%) who received welfare-to-work services was combined with results from four group interviews with a total of 15 people receiving welfare-to-work services. Verbatim transcripts from the interviews were analysed using inductive thematic analysis.

RESULTS

The survey results showed that most clients were reasonably satisfied with the welfare-to-work services they received. Four main themes emerged from the interviews: (1) experiences and needs related to the interactions between case workers and benefit recipients; (2) the need for tailored services; (3) the complicating role of the system the case workers operate within; and (4) the existence of differences between case workers regarding how strict they followed the rules and to what extent they connected with their clients on a personal level.

CONCLUSIONS

Our findings show that clients were reasonably satisfied with the welfare-to-work services provided by their municipality but that there is still room for improvement. Case workers should have good social skills to build a trusting relationship with the client, welfare-to-work services should be tailored to the individual, and clear concise information should be given to welfare benefit recipients, especially with regard to what benefit recipients can expect of the municipality and the case workers, given their dual role in supporting (re-)integration to work and monitoring benefit eligibility.

Intervention outcome preferences for youth who are out of work and out of school: a qualitative study

Background

While interventions have been developed and tested to help youth who have become disconnected from work and school, there is a paucity of research on young people’s intervention preferences. This study aims to understand young people’s preferred intervention outcomes and approaches for youth who are out of work and school.

Methods

Thirty youth participated in virtual focus groups. Transcripts were analyzed using thematic analysis.

Results

Youth want interventions and approaches that support them in (1) vocational readiness, (2) securing a job, and (3) mental health and well-being, while providing them with (4) high-contact, individualized, and integrated support.

Conclusions

Young people want interventions to be individualized and integrated, providing a high level of support for their educational and employment pursuits as well as their mental health and well-being. Incorporating youth's perspectives when designing interventions can increase intervention relevance and potentially service uptake, helping youth continue to pursue their educational and vocational goals.

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Evaluation of an implementation strategy for Individual Placement and Support in the Netherlands: a 30-month observational study

BACKGROUND

Individual Placement and Support (IPS) is an evidence-based, effective approach to help people with severe mental illness (SMI) obtain and maintain competitive employment. The aim of the present study was to examine employment outcomes and associations with an organizational and a financial factor in people with SMI who participated in Individual Placement and Support using a multifaceted implementation strategy (IPS + MIS). The goal of this strategy was to improve IPS implementation by enhancing collaboration among mental health care and vocational rehabilitation stakeholders, and realizing secured IPS funding.

METHODS

An observational cohort study including 103 participants was conducted, with a 30-month follow-up. Descriptive analyses were used to examine employment outcomes. Multivariable logistic and linear regression analyses were performed to study associations with an organizational and a financial factor: the level of experience of mental health agencies with providing IPS + MIS and the type of IPS funding (i.e. municipality funding (reference group) and the Dutch Social Security Institute: the Institute for Employee Benefits Schemes (UWV) funding).

RESULTS

Forty-six percent of the participants were competitively employed at any time during the 30-month follow-up; the median number of days until competitive job obtainment and in competitive jobs was 201 and 265, respectively. The majority of all jobs obtained (81%) were categorized as 'elementary occupations', 'clerical support workers', and 'service and sales workers'. A higher level of experience of the mental health agencies with providing IPS + MIS was found to be positively associated with job obtainment (OR = 3.83, 95% CI 1.42-10.30, p = 0.01) and the number of days worked in competitive jobs (B = 1.21, 95% CI 0.36-2.07, p = 0.01). UWV funding was found to be negatively associated with job obtainment (OR = 0.30, 95% CI 0.11-0.77, p = 0.01). No association was found for the type of IPS funding and the number of days worked in competitive jobs (B = -0.73, 95% CI -1.48-0.02, p = 0.06).

CONCLUSIONS

This study shows that almost half of the people who participate in IPS + MIS obtain a competitive job within 30 months. The results further suggest that both the level of experience of mental health agencies with providing IPS + MIS, and funding may play a role in employment outcomes.

Turnover of IPS employment specialists: Rates and predictors

BACKGROUND: There are anecdotal reports of high job turnover of Individual Placement and Support employment specialists. However, no studies have addressed this issue. OBJECTIVE: To explore whether turnover rates among employment specialists are higher compared to public sector employees along with the correlates of turnover intentions. METHODS: A repeated cross-sectional study collected data from 40 employment specialists in Norway using validated scales to measure job perceptions. Turnover intentions were the main outcome. RESULTS: Turnover rate of employment specialists (45.0%) was significantly higher than the average turnover rate of other occupations in the public sector (27.1%) in the same geographical regions (x2 = 6.5, df = 1, p = 0.01). After adjusting for potential confounders, five factors remained significantly and associated with turnover intentions in directions as expected: general job satisfaction (β= –0.33, p <  0.05), satisfaction with current work (β= –0.35, p <  0.05), satisfaction with supervision (β= –0.28, p <  0.05), work meaningfulness (β= –0.42, p <  0.05) and Negative emotionality personality trait (β= 0.58, p <  0.05). CONCLUSIONS: Addressing turnover will positively impact on productivity and job satisfaction of employment specialists along with continuity of employment support for people with mental health conditions.

How do supported employment programs work? Answers from a systematic literature review

Many studies have found that supported employment (SE) has effectively helped people with severe mental illness obtain and maintain competitive employment. However, most SE studies have asked "What works?" rather than discerning what works for whom, in what circumstances, in what respects and how. It is important to understand the outcomes of SE and identify the impact factors (contexts and mechanisms) that can trigger them. Four literature databases were searched for studies that analyzed counseling settings. Overall, 104 publications met the inclusion criteria. The review showed that most of the research on SE programs were one-dimensional, looking at either the effects of SE programs, the client or the professional, or the relationship between clients and professionals. The model reveals that impact factors are interconnected and can have a cumulative impact on the client, professionals, and the environment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10775-022-09533-3.

Characteristics of Enrollees in the Supported Employment Demonstration

OBJECTIVE

The Supported Employment Demonstration (SED), a multiyear (2016-2022), randomized controlled trial funded by the Social Security Administration, recruited a nontraditional sample of benefits applicants with self-reported or documented mental health conditions who were denied disability benefits and who expressed a desire for employment. This study describes the characteristics of the SED sample at baseline.

METHODS

The authors analyzed baseline data from the 2,960 eligible enrollees, including responses to the Composite International Diagnostic Interview, the 12-item Short-Form Health Survey (SF-12), and the Work Disability Functional Assessment Battery (WD-FAB).

RESULTS

A majority of SED enrollees self-identified as female (57%), White (56%), and non-Hispanic (87%). Many were 35 years or older (58%), reported at least a high school education (81%), lived with relatives (69%), had never married (55%), were unemployed (81%), and were poor. Median monthly household income was $1,200. Anxiety disorders (71%), personality disorders (65%), and mood disorders (61%) were prevalent. Enrollees reported a mean±SD of 2.5±1.3 mental health conditions and 3.5±2.1 general medical conditions. Health-related quality of life was low, relative to national norms: mean scores for the sample were 32.6±12.5 on the SF-12 mental component summary and 38.3±13.0 on the physical component summary. Mean scores on the WD-FAB subdomains were more than a SD below norms.

CONCLUSIONS

At baseline, the SED sample had multiple mental health and general medical conditions, low quality of life, and low functional ability. Despite these challenges, the ongoing SED intervention seeks to build on enrollees' expressed desire for employment.

Psychiatrists' Experience of Vocational Rehabilitation for Patients with Mental Illness

The aim of this study was to explore psychiatrists' experience of vocational rehabilitation for patients with mental illness. The study employed a qualitative design to explore psychiatrists' experience of vocational rehabilitation. Ten psychiatrists, five women and five men, 33-62 years of age (median 40), were interviewed. All of them worked with patients at Sahlgrenska University Hospital. The interviews were analyzed using inductive thematic analysis. All participants considered vocational rehabilitation to be of great importance for patients' well-being and health. The results were characterized by two opposite experiences: frustration and agency, these were the two main themes in the analysis. All narratives embraced both experiences, but some reflected more frustration and others more agency. In order for the psychiatrist to master the assignment, there is a need for further training and supervision. The psychiatrist's role, as well as other professional roles within the team, requires clarification, and the support from rehabilitation coordinators and occupational therapists should be enhanced. There is a need for improved cooperation with external actors.

"Navigating Between Unpredictable Icebergs": A Meta-Ethnographic Study of Employment Specialists' Contributions in Providing Job Support for People with Mental Illness

Purpose To explore and synthesize the views of Supported Employment clients, employment specialists and their supervisors on the core contributions of employment specialists to job support within the mental health field. Methods We systematically searched four databases with no time limitations and identified 16 qualitative studies published between 2006 and 2018 to be included in this meta-ethnographic study. Results The overarching metaphor of "Navigating an Unpredictable Iceberg-laden Sea" (a workplace) and seven themes were revealed: (1) "It's you and me looking," which represented the relationship between the client and ES, and (2) taking job seekers' ambitions and needs seriously, (3) mapping the route, (4) exploring the hidden, (5) being on tap, (6) avoiding crashes, and (7) bridging, which embodied the work of employments specialists. Conclusion. Our iceberg metaphor illustrates the importance of employment specialists being competent in addressing clients' work performance difficulties related not only to the individual's illness, age, gender, and cultural-related challenges, but also to psychosocial, behavioral, and environmental workplace factors. Given the effects of the specific characteristics of the working alliance developed in supported employment, we suggest that employment specialists' training and supervision be enriched by paying more attention to these important relational processes.

Hope, adaptability, and job-search intensity among individuals living with serious mental illness

BACKGROUND: Increased intensity in job-search behavior is associated with important employment outcomes like job attainment. There is evidence that work hope, and career adaptability are important antecedents of higher job-search intensity. However, there is no evidence that these relationships exist among individuals living with serious mental illness. OBJECTIVE: This study seeks to improve our understanding of factors that contribute to job-search intensity among individuals living with serious mental illness. METHODS: Eighty-five individuals living with serious mental illness completed surveys of demographics, work hope, career adaptability, and job-search intensity. Correlational and regression analysis was used to examine the primary relationships in this study. RESULTS: Education level, employment status, and use of vocational rehabilitation services were background factors related to job-search intensity. Controlling for background factors, regression analysis found that work hope positively predicted job-search intensity, and career adaptability negatively predicted job-search intensity. Our model explained 35%of the variance in job-search intensity. Additionally, individuals who were employed had significantly higher career adaptability than individuals who were unemployed. CONCLUSIONS: Work hope and career adaptability are related to important vocational outcomes among individuals living with serious mental illness.

Predictors of employment in people with moderate to severe mental illness participating in a randomized controlled trial of Individual Placement and Support (IPS)

BACKGROUND

Many people with moderate to severe mental illness have a desire to obtain ordinary employment. To aid further development of health and social services for this group, the aim of this study was to examine candidate modifiable and prognostic markers of employment, and moderating effects of group allocation in a clinical trial.

METHOD

The sample consists of 327 patients in treatment for mental illness, randomized to Individual Placement and Support (IPS) or treatment as usual (TAU) as part of a clinical trial. Psychosocial and demographic baseline characteristics were included as predictors in log binary regression analyses with employment 18 months after inclusion as the outcome, and group allocation as the moderator (IPS or TAU).

RESULTS

Directive emotional support and non-directive instrumental support seemed to positively predict employment, but effects were small. Involuntary hospitalization seemed to be a strong negative predictor of employment. Group allocation did not moderate any main effects.

CONCLUSION

Interpretation of the findings suggest that attention should be given to certain aspects of health and social services provided to this target group, and in particular the effect of receiving appropriate types of social support. The findings are novel because social support and involuntary hospitalization do not seem to have been included in previous predictor studies. The results from this study identify new topics for research on employment outcomes for this population.

Long-Term Effects of the Individual Placement and Support Intervention on Employment Status: 6-Year Follow-Up of a Randomized Controlled Trial

People with mental illness often experience difficulties with reintegration into the workplace, although employment is known to assist these individuals in their recovery process. Traditional approaches of "first train, then place" have been recently replaced by supported employment (SE) methods that carry strategy of "first place, then train." Individual placement and support (IPS) is one of the best-studied methods of SE, which core principles are individualized assistance in rapid job search with consequent placement in a paid employment position. A considerable amount of high-quality evidence supported the superiority of IPS over conventional methods in providing improved employment rates, longer job tenure, as well as higher salaries in competitive job markets. Nonetheless, our knowledge about the IPS-mediated long-term effects is limited. This non-interventional follow-up study of a previously published randomized controlled trial (RCT) called ZhEPP aimed to understand the long-term impact of IPS after 6 years since the initial intervention. Participants from the ZhEPP trial, where 250 disability pensioners with mental illnesses were randomized into either IPS intervention group or treatment as usual group (TAU), were invited to face-to-face interviews, during which employment status, job tenure, workload, and salaries were assessed. One hundred and fourteen individuals agreed to participate in this follow-up study. Although during the first 2 years post-intervention, the IPS group had higher employment rates (40% (IPS) vs. 28% (TAU), p < 0.05 at 24 months), these differences disappeared by the time of follow-up assessments (72 months). The results indicated no substantial differences in primary outcome measures between IPS and TAU groups: employment rate (36 vs. 33%), workload (10.57 vs. 10.07 h per week), job tenure (29 vs. 28 months), and salary (20.21CHF vs. 25.02 CHF). These findings provide important insights regarding the long-term effects of IPS among individuals with mental health illnesses. Further research is required to advance the current knowledge about IPS intervention and its years-long impact.

Personalized cognitive remediation therapy to facilitate return to work or to school in recent-onset psychosis

Cognitive deficits are barriers to job acquisition or return to school, and can be reduced through Cognitive remediation therapy (CRT). The main goal of this multiple case study was to investigate the effect of personalized CRT on occupational status in three participants with a recent-onset psychosis. Two cases improved their occupational status at post-treatment, and showed improvements in cognitive, psychological, and/or clinical variables. This study suggests that personalized CRT may facilitate job acquisition or return to school. However, the different pathways showed by our cases indicate that personalized CRT may influence occupational status through multiple mechanisms, underlining the relevance of treatment personalization.

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).

Defining Employment Specialist Competencies: Results of a Participatory Research Study

The preponderance of research conducted on supported employment has focused on the structure of interventions with little empirical investigation into the contribution of employment specialists to work outcomes. Using a participatory approach, we identified competencies essential to the role of the employment specialists, operationalized and refined those competencies using the perspectives of experts, service recipients, and employment specialists themselves. We conducted an online survey with 34 candidate items and n = 142 respondents. Results suggested good psychometric properties, stability and coherence of the Vocational Practices and Relationship Scale. A total of n = 23 final items tapping the working alliance coalesced into a strong factor, as did strategies for promoting vocational recovery, suggesting that the scale warrants wide-scale testing for predictive validity. We consider these constructs and competencies to be a potential blueprint for training employment specialists, not only in technical skills and strategies, but also to increase the hope for vocational recovery among those they serve.

Work Motivation and Employment Outcomes in People with Severe Mental Illness

Purpose To study associations between the level of self-reported work motivation and employment outcomes in people with severe mental illness (SMI) enrolled in a vocational rehabilitation program. Methods Data of 151 study participants, collected from a randomised controlled trial with a 30-month follow-up period, were used for a secondary data analysis. Multiple logistic regression, linear regression and cox regression analyses were performed to analyse the association between the level of work motivation at baseline and job obtainment, duration of job, and time until job obtainment during the 30-month follow-up period. Results No statistically significant associations were found between the level of work motivation and job obtainment (OR 1.83, 95% CI 0.55-6.06, p = 0.32), job duration (B = - 0.74, 95% CI - 2.37 to 0.89, p = 0.37, R-squared = 0.03), or time until job obtainment (HR = 1.53, 95% CI 0.64-3.68, p = 0.34). Conclusions The results of this study show no statistically significant associations between the level of work motivation and employment outcomes in people with SMI enrolled in a vocational rehabilitation program. These associations may be underestimated due to range restriction of the work motivation's level. Further research is recommended to increase knowledge on the associations between work motivation and employment outcomes, as it could be relevant for further understanding success in vocational rehabilitation.

Can social firms contribute to alleviating the economic burden of psychiatric disabilities for the public healthcare system?

In a number of countries, unemployment rates for people with psychiatric disabilities are much higher than in the general population. On the one hand, the expenses for mental health reach 3.5% of the total public health and social services budget in Québec. On the other hand, social firms (SFs) receive government subsidies. The objective was to compare public healthcare expenses for people with psychiatric disabilities who work in SFs with those associated with people with a similar condition who are looking for a job in the competitive labour market. This study followed a retrospective comparative design and considered two groups, namely: 122 employees working in SFs and 64 individuals participating in a supported employment program as job-seekers. Two complementary datasets were used: a self-report questionnaire and public healthcare databases. The cost analysis was performed from the perspective of the public healthcare system and included outpatient visit fees to physicians, outpatient visits to health professionals other than physicians in public healthcare centres, inpatient expenses due to hospitalisations, emergency room visits and amounts reimbursed to patients for medication. Regression analyses using generalised linear models with a gamma distribution and log link were used. Our results revealed that when controlling for sociodemographic variables (gender, age, marital status, education, physical disability), global health (EuroQol EQ-5D-5L), the severity of psychiatric symptoms (18-item Brief Symptom Inventory) and self-declared primary mental health diagnosis, annual healthcare costs paid by the public insurance system were between $1,924 and $3,912 lower for people working in SFs than for the comparison group. An explanatory hypothesis is that working in SFs could act as a substitute for medical treatments such as outpatient visits and medication use. There might be a form of compensation between supporting SFs and financing the public healthcare system, which provides valuable insights for public decision-making.

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.

Determinants of occupational outcome in recent-onset psychosis: The role of cognition

Working or studying is a common goal among people with recent-onset psychosis. Cognitive deficits have been reported to influence occupational outcome, but to date few studies have evaluated if cognitive deficits independently predict occupational outcome when taking into account other important determinants, such as self-esteem, motivation, length of time absent from employment/school, job/school search behaviours, subjective cognitive complaints and psychotic symptoms. Hence, this longitudinal study aimed to evaluate the role of cognition, as well as other key factors relevant to occupational outcome, to predict occupational status six months after baseline in people with recent-onset psychosis. A total of 27 participants receiving treatment in rehabilitation programs were included in the study. Neuropsychological, psychological, clinical and occupational measures were administered at baseline, and occupational status was collected six months later. Ordinal regression indicated that working memory and length of time absent from employment/school at baseline predicted 48.1% of the variance of occupational status at six months, with both variables showing a unique significant contribution to the model. These results suggest that working memory could be integrated in comprehensive models of occupational outcome in people with recent-onset psychosis. In addition, supported employment and education programs could target cognitive deficits and length of time absent from employment/school to help these individuals to acquire a job or return to school given their strong predictive value on occupational outcome.

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.

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.

Do individual and work-related factors differentiate work participation trajectories before and after vocational rehabilitation?

BACKGROUND

Understanding diverse labor market trajectories around vocational rehabilitation provides important insight into potential effectiveness of rehabilitation efforts. We examined factors associated with work participation trajectories before and after vocational rehabilitation.

METHODS

Using nationwide Finnish register data of 7180 vocational rehabilitees, we constructed latent trajectory groups of work participation two years before and two years after their rehabilitation episode starting in 2008-2010. We plotted changes in labor market statuses in these groups and examined other associated factors using multinomial logistic regression.

RESULTS

We identified four trajectories based on work participation levels before and after vocational rehabilitation. The "High-Resumed" group (35.6%) typically returned to full duties. The "High-to-Negligible" group (20.7%) typically transitioned to full disability retirement or unemployment. Among the "Medium-Resumed" (25.5%) and "Longstanding Negligible" (18.3%) groups, work disability and unemployment were common before rehabilitation, but afterwards those assigned to the former group often returned to full or partial duties. Overall, older age, male gender, living in areas with lower employment rates, having lower education, being employed in the private sector, and having mental diagnoses were associated with the other three trajectories than the most favorable "High-Resumed" trajectory. Furthermore, certain industrial sectors, job exposures, and less common diagnoses further separated specific trajectories.

CONCLUSIONS

Work participation trajectories around vocational rehabilitation are diverse, only partly dependent on initial levels of work participation, and determined by various individual and work-related factors. Future nationwide studies should assess the effectiveness of vocational rehabilitation taking into consideration both individual and work-related factors.

Compensatory cognitive training for people with severe mental illnesses in supported employment: A randomized controlled trial

Treatments for cognitive and functional impairments associated with severe mental illnesses are urgently needed. We tested a 12-week, manualized, Compensatory Cognitive Training (CCT) intervention targeting prospective memory, attention, learning/memory, and executive functioning in the context of supported employment for people with severe mental illnesses who were seeking work. 153 unemployed, work-seeking outpatients with schizophrenia/schizoaffective disorder (n=58), bipolar disorder (n=37), or major depression (n=58) were randomized to receive supported employment plus CCT or enhanced supported employment, a robust control group. Assessments of neuropsychological performance, functional capacity, psychiatric symptom severity, and self-reported functioning and quality of life were administered at baseline and multiple follow-up assessments over two years; work outcomes were collected for two years. Forty-seven percent of the participants obtained competitive work, but there were no differences in work attainment, weeks worked, or wages earned between the CCT and the enhanced supported employment group. ANCOVAs assessing immediate post-treatment effects demonstrated significant, medium to large, CCT-associated improvements on measures of working memory (p=0.038), depressive symptom severity (p=0.023), and quality of life (p=0.003). Longer-term results revealed no statistically significant CCT-associated improvements, but a trend (p=0.058) toward a small to medium CCT-associated improvement in learning. Diagnostic group (schizophrenia-spectrum vs. mood disorder) did not affect outcomes. We conclude that CCT has the potential to improve cognitive performance, psychiatric symptom severity, and quality of life in people with severe mental illnesses. Receiving CCT did not result in better work outcomes, suggesting that supported employment can result in competitive work regardless of cognitive status.

Predictors of Employment for People With Mental Illness: Results of a Multicenter Randomized Trial on the Effectiveness of Placement Budgets for Supported Employment

Background: Individual placement and support (IPS) has proven to be effective for vocational outcomes in people with mental illness. The original concept of IPS requires temporally unlimited provision of support. Using limited placement budgets and investigating factors that predict their effectiveness may inform decisions about resource allocation. Methods: A range of patient characteristics were tested as predictors of employment outcomes in participants who attended six outpatient psychiatric clinics in Switzerland between June 2010 and May 2011. Overall, 116 patients with the full spectrum of psychiatric conditions were randomly assigned and started an IPS intervention, which was provided by three different placement budgets. Support lasted 2 years for those who found a job, and outcomes were repeatedly assessed over 3 years. The intervention ended for those who failed to find competitive employment by the time their placement budget had run out. Results: Of the 15 variables tested, only Global Assessment of Functioning (GAF) and Clinical Global Impression (CGI) scores were predictors for obtaining work (for ≥1 day) and for maintaining it over a longer period (>3 months). Higher GAF and lower CGI scores increased the odds of obtaining employment and keeping it for at least 3 months. Functional role impairment, quality of life, self-esteem, or education level did not predict employment. Conclusion: Our data suggest that, if time-restricted budgets are offered to a wide range of patients, such as those included in this study, better functioning and lower symptom severity at baseline are predictive of better employment outcomes (finding and maintaining work) on the first (competitive) labor market in Switzerland. It remains to be investigated whether this holds true under different environmental factors. Clinical Trial Registration: ISRCTN, trial number: ISRCTN89670872.

Predictors of Sustained Employment Among Individuals With Serious Mental Illness: Findings From a 5-Year Naturalistic Longitudinal Study

Despite decades of research, understanding of the employment trajectories of individuals with serious mental illnesses remains elusive. We conducted a 5-year prospective, longitudinal study using a geographically broad sample of individuals who met established criteria for sustained competitive employment (N = 529). We collected data on an annual basis with a specifically designed survey instrument. Despite stable employment at study entry, more than half of the participants experienced work interruptions during the 5-year follow-up period. Predictors of sustained employment included the absence of a trauma diagnosis, Social Security disability income, psychiatric hospitalizations, and difficulties with daily functioning. The presence of a higher quality of life, workplace supports, and a flexible job were also predictive. Results dispel the myth that people with serious mental illnesses cannot be employed for prolonged periods. Interruptions in work trajectories, however, suggest that longer-term supports may increase individuals' capacity to maintain stable employment.

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.

Les accompagnants à l’insertion professionnelle en milieu ordinaire pour les personnes en situation de handicap psychique au sein des ESAT de transition Messidor

Les dispositifs d’aide à la réinsertion professionnelle des personnes souffrant de troubles psychiques sont peu étudiés en France bien que la littérature spécialisée souligne que ces dispositifs sont clés pour favoriser l’insertion en milieu ordinaire. Les objectifs de cette recherche étaient de décrire les rôles, tâches et compétences des conseillers d’insertion et des responsables d’unité de production qui accompagnent ce public vers le milieu ordinaire au sein des ESAT de transition Messidor. Une méthodologie qualitative a été retenue : 24 entretiens individuels et 7 groupes de discussion ont été menés auprès des deux types de professionnels de ces structures. Les résultats ont permis de définir la fonction de chaque accompagnant et une liste de 110 compétences pour les conseillers d’insertion et de 155 compétences pour les responsables de production. Ce binôme d’accompagnants complémentaires apporte un soutien à l’insertion en favorisant un changement de regard sur soi. Le conseiller d’insertion accompagne chaque travailleur à construire et réaliser un projet d’insertion, tout en assurant la liaison entre différents partenaires externes de la collectivité (ex. employeurs, équipe soignante). En parallèle, au quotidien, le responsable de production assure une formation dans un métier, propose des défis à relever, ce qui contribue à restaurer l’estime de soi professionnelle des personnes, facteur clé pour l’insertion en milieu ordinaire. Les implications cliniques de cette recherche concernent le recrutement, la formation et la supervision des personnels accompagnant vers l’emploi.

Le fonctionnement cognitif et le travail chez les personnes souffrant de troubles du spectre schizophrénique : l’apport de la Classification internationale du fonctionnement

Cet article dresse un état des lieux de l’implication du fonctionnement cognitif dans le champ de l’insertion professionnelle et du maintien en emploi des personnes qui souffrent de troubles du spectre schizophrénique (TSS). L’objectif est de visualiser comment les déficits cognitifs s’articulent avec les autres dimensions du handicap rapportées dans la Classification internationale du fonctionnement, du handicap et de la santé (CIF), dans le domaine du travail. Les données de la littérature vont dans le sens du modèle de la CIF, à savoir un plus fort impact du fonctionnement cognitif sur les limitations d’activités (LA) plutôt que sur les restrictions de participation (RP). Ce sont en effet davantage les facteurs environnementaux et personnels qui prédisent la participation au travail. En conclusion, ce cadre théorique offre de nouvelles perspectives, notamment que la prise en compte de l’interaction entre les déficits cognitifs et les limitations d’activités peut venir étayer l’accompagnement vers et dans l’emploi des personnes souffrant de TSS.

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.