Predictors of employment for people with severe mental illness: results of an international six-centre randomised controlled trial

Superiority and cost-effectiveness of Individual Placement and Support versus standard employment support for people with alcohol and drug dependence: a pragmatic, parallel-group, open-label, multicentre, randomised, controlled, phase 3 trial

Background

Individual Placement and Support (IPS) is a specialist intervention to help people attain employment in the open competitive labour market. IPS has been developed in severe mental illness and other disabilities, but it is of unknown effectiveness for people with alcohol and drug dependence. The Individual Placement and Support-Alcohol and Drug (IPS-AD) is the first superiority trial to evaluate effectiveness and cost-effectiveness.

Methods

IPS-AD was a pragmatic, parallel-group, multi-centre, randomised, controlled, phase 3 trial of standard employment support (treatment-as-usual [TAU]) versus IPS. IPS was offered as a single episode for up to 13 months. The study was done at seven community treatment centres for alcohol and drug dependence in England. Study participants were adults (18-65 years), who had been enrolled for at least 14 days in treatment for alcohol use disorder (AUD), opioid use disorder (OUD), or another drug use disorder (DUD; mostly cannabis and stimulants); were unemployed or economically inactive for at least six months; and wished to attain employment in the open competitive labour market. After random allocation to study interventions, the primary outcome was employment during 18-months of follow-up, analysed by mixed-effects logistic regression, using multiple imputation for the management of missing outcome data. There were two cost-effectiveness outcomes: a health outcome expressed as a quality adjusted life year (QALY) using £30,000 and £70,000 willingness-to-pay [WTP] thresholds; and additional days of employment, with a WTP threshold of £200 per day worked. The study was registered with ISRCTN (ISRCTN24159790) and is completed.

Findings

Between 8 May 2018 and 30 September 2019, 2781 potentially eligible patients were identified. 812 were excluded before screening, and 1720 participants were randomly allocated to TAU or IPS. In error, nine participants were randomised to study interventions on two occasions-so data for their first randomisation was analysed (modified intention-to-treat). A further 24 participants withdrew consent for all data to be used (full-analysis set therefore 1687 participants [70.1% male; mean age 40.8 years]; TAU, n = 844; IPS, n = 843 [AUD, n = 610; OUD, n = 837; DUD, n = 240]). Standard employment support was received by 559 [66.2%] of 844 participants in the TAU group. IPS was received by 804 [95.37%] of 843 participants in the IPS group. IPS was associated with an increase in attainment of employment compared with TAU (adjusted odds ratio [OR] 1.29; 95% CI 1.02-1.64; p-value 0.036). IPS was effective for the AUD and DUD groups (OR 1.48; 95% CI 1.14-1.92; p-value 0.004; OR 1.45, 95% CI 1.03-2.04, p-value 0.031, respectively), but not the OUD group. IPS returned an incremental QALY outcome gain of 0.01 (range 0.003-0.02) per participant with no evidence of cost-effectiveness at either WTP threshold-but QALY gains were cost-effective for the AUD and DUD groups at the £70,000 WTP threshold (probability 0.52 and 0.97, respectively). IPS was cost-effective for additional days of employment (probability 0.61), with effectiveness relating to the AUD group only (probability >0.99). Serious Adverse Events were reported by 39 participants (13 [1.5%] of 844 participants in the TAU group and 23 [2.7%] of 43 participants in the IPS group). There was a total of 25 deaths (1.5%; 9 in the TAU group and 16 in the IPS group)-none judged related to study interventions.

Interpretation

In this first superiority randomised controlled trial of IPS in alcohol and drug dependence, IPS helped more people attain employment in the open competitive labour market than standard employment support. IPS was cost-effective for a QALY health outcome (£70,000 WTP threshold) for the AUD and DUD groups, and for additional days of employment for the AUD group (£200 per day worked WTP threshold).

Funding

UK government Work and Health Unit.

Worker role perceptions and work participation among people with mental health issues taking part in interventions focusing on everyday life

BACKGROUND

Knowing whether interventions addressing everyday life as a whole can affect work readiness for people with severe mental health issues would be important for how to develop support.

OBJECTIVE

To compare two groups of people with mental health problems, receiving either of two types of 16-week activity-based interventions, Balancing Everyday Life (BEL) or Care as Usual (CAU), regarding work readiness in terms of perceived worker role and satisfaction with recent work experience. Changes from baseline (T1) to completed intervention (T2) and a six-month follow-up (T3) and variables of potential importance to changes were also explored.

METHODS

This cluster RCT recruited participants for BEL (n = 133) and CAU (n = 93) from specialized and community-based psychiatry. Questionnaires addressing work readiness and potentially influencing variables (sociodemographic, clinical, type of intervention, work experience, non-work activity factors, social interaction and self-esteem) were used. Mixed model regression analyses were employed.

RESULTS

Positive changes occurred for both groups in one worker role aspect (resources for a future worker role) and in satisfaction with recent work participation. Satisfaction with non-work everyday activities, having valued activities, and self-esteem were important for change in the work readiness variables, whereas intervention type, age, sex or general activity level were not.

CONCLUSION

Both interventions yielded equally positive work readiness outcomes. Support that emphasizes engagement in satisfying and valued everyday activities and boosts self-esteem would be a potential way to help people with mental health issues develop work readiness in terms of the worker role and satisfaction with work participation.

Folk psychiatry. La psichiatria fra immagine scientifica e psichiatria popolare

La ricerca scientifica in psichiatria sta creando un divario nei confronti delle nozioni di psichiatria che posseggono le persone comuni, in maniera analoga alla progressiva distanza fra psicologia scientifica e psicologia popolare e di senso comune. Vengono indagate le nozioni che la psichia-tria scientifica e quella popolare condividono, e quelle in cui si differenziano spesso con aspetti controintuitivi. Dopo aver delineato i tratti essenziali del concetto di senso comune e di psicologia popolare e delle loro teorie più rappresentative, viene sottolineato il ruolo centrale che i concetti popolari svolgono non solo nella teoria psichiatrica, in particolare nella diagnosi, ma anche nella pratica quotidiana. Questi concetti entrano poi nella immagine di sé stessi, del mondo e nelle rela-zioni interpersonali, mostrando la improponibilità di una psichiatria che miri a fare a meno del senso comune e la necessità di una attenta mediazione fra psichiatria scientifica e psichiatria popolare. Questo aspetto è ancora più importante nella psichiatria pratica che si rivela simile per molti aspetti alla psichiatria popolare.

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.

Who benefits from individual placement and support? A meta-analysis

AIMS

Individual placement and support (IPS) is an evidence-based service model to support people with mental disorders in obtaining and sustaining competitive employment. IPS is increasingly offered to a broad variety of service users. In this meta-analysis we analysed the relative effectiveness of IPS for different subgroups of service users both based on the diagnosis and defined by a range of clinical, functional and personal characteristics.

METHODS

We included randomised controlled trials that evaluated IPS for service users diagnosed with any mental disorder. We examined effect sizes for the between-group differences at follow-up for three outcome measures (employment rate, job duration and wages), controlling for methodological confounders (type of control group, follow-up duration and geographic region). Using sensitivity analyses of subgroup differences, we analysed moderating effects of the following diagnostic, clinical, functional and personal characteristics: severe mental illness (SMI), common mental disorders (CMD), schizophrenia spectrum disorders, mood disorders, duration of illness, the severity of symptoms, level of functioning, age, comorbid alcohol and substance use, education level and employment history.

RESULTS

IPS is effective in improving employment outcomes compared to the control group in all subgroups, regardless of any methodological confounder. However, IPS was relatively more effective for service users with SMIs, schizophrenia spectrum disorders and a low symptom severity. Although IPS was still effective for people with CMD and with major depressive disorder, it was relatively less effective for these subgroups. IPS was equally effective after both a short and a long follow-up period. However, we found small, but clinically not meaningful, differences in effectiveness of IPS between active and passive control groups. Finally, IPS was relatively less effective in European studies compared to non-European studies, which could be explained by a potential benefits trap in high welfare countries.

CONCLUSIONS

IPS is effective for all different subgroups, regardless of diagnostic, clinical, functional and personal characteristics. However, there might be a risk of false-positive subgroup outcomes and results should be handled with caution. Future research should focus on whether, and if so, how the IPS model should be adapted to better meet the vocational needs of people with CMD and higher symptom severity.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Models and frameworks of mental health recovery: a scoping review of the available literature

BACKGROUND

The recovery approach involves providing a holistic and integrated service that is centered on and adapts to the aspirations and needs of consumers, who are seen as the expert on their health and well-being. Evidence is needed to address the current ambiguities related to the concept of recovery and its application.

AIM

A scoping review was conducted to identify papers describing theories, models, and frameworks of recovery to delineate the central domains of recovery.

METHODS

Three literature search strategies were used: electronic database searching; hand-searching of key journals; and a reference list review of included papers. Inclusion criteria outlined theories, models and frameworks developed to support consumers' recovery and those supporting mental health professionals (MHPs) to deliver recovery-oriented services.

RESULTS

Twelve studies (eleven articles and one book) were included in the review. The dimensions of recovery were synthesized into a framework named the Consolidated Framework for Recovery-oriented Services (CFRS). There are three domains within the framework: mechanisms/strategies; recovery as an internal process; and recovery as an external process. Each of these domains, as well as their relationships, are discussed.

CONCLUSIONS

The CFRS can be used by practitioners, researchers, funders, and collaborative members to conceptualize, implement, and evaluate recovery-oriented services.

A Qualitative Study of Consumers' Experiences of the Quality of Mental Health Services in Ghana

Integrating consumers' experiences into quality mental health service assessment is relevant to improve service outcomes. Despite this, limited studies have attempted to explore consumers' experiences, particularly in developing countries, such as Ghana. This paper aims to explore consumers' subjective experiences of the quality of mental health services. A qualitative method involving in-depth interviews was used to collect data from 21 consumers of mental health services. Thematic analysis was used to analyse the data, which is discussed using a realistic evaluation approach. The study identifies four themes, 33 inductive codes and 594 references. The themes used to interpret the verbatim narratives are the available mental health services, therapeutic interaction with the professionals, competency and skills of the professionals, and the changes experienced in the consumers' lives. The study indicates that the mental health services aim to provide a range of treatments and medications as well as recovery-oriented services, using mechanisms such as ensuring an effective therapeutic relationship and improving technical competency and skills. The contextual factors and the mechanisms have helped to achieve some changes in the lives of consumers (increased satisfaction, reduced symptoms, improved functionality, feeling normal, improved living skills and self-care, work and capabilities, and social inclusion). The study concludes that policymakers and clinicians should integrate evidence-based recovery services, principles and values into the existing mental health services. The mechanisms used to promote quality of mental health services should be strengthened, through periodic monitoring and evaluation, using approaches such as sensor data capturing, to ensure good coordination and continuity.

Problemi della previsione in psichiatria

Sono esaminati vari problemi relativi alla previsione in psichiatria. I dati disponibili mostrano, in modo simile alle scienze sociali, ampi limiti nella capacità previsionale, specie per quanto riguarda il suicidio, la violenza e altri aspetti comportamentali. Vengono esaminate le difficoltà che nascono dal cercare di derivare il futuro della persona dal suo passato, la mancata coerenza fra aspetti di personalità e possibili comportamenti e il privilegio dato a strumenti psicopatologici incentrati sul singolo caso, rispetto a quelli attuariali con valutazioni testistiche e statistiche. Vengono anche evidenziati i numerosi bias cognitivi che distorcono le previsioni, in particolare l'errore fondamentale di attribuzione, che privilegia aspetti personologici rispetto a quelli situazionali. Ma altri bias hanno una importante azione distorsiva, da quelli della rappresentatività a quelli della disponibilità, da quelli statistici, al framing o al priming. Emerge una psichiatria molto legata nelle pratiche ancora al senso comune e alla folk psychology, con la ricchezza ma anche i molti errori che la caratterizzano. Di fatto esiste una modesta capacità previsionale riconosciuta alla psicologia popolare e alla psichiatria, ma è legata più a vincoli situazionali che a modelli personologici e psicopatologici e in ogni caso scarsamente affidabile per la previsione clinica in psichiatria.

"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.

Predictors of work and education among people with severe mental illness who participated in the Danish individual placement and support study: findings from a randomized clinical trial

PURPOSE

People with severe mental illness experience disproportionately high rates of unemployment. Nonetheless, a substantial amount of research has demonstrated vocational benefits of the Individual Placement and Support (IPS) model and IPS supplemented with cognitive remediation (IPSE). The present study sought to examine demographic and clinical predictors of employment or education among people with severe mental illness and to investigate if IPS or IPSE can compensate for risk factors for unemployment.

METHODS

Seven hundred twenty participants were randomly assigned to IPS, IPSE or Service as Usual. During the 18-month follow-up period participants in the two experimental groups obtained significantly more work or education. A series of univariate and multiple logistic regression analyses were conducted to assess the predictive power of demographic and clinical factors for the total population and for the three groups individually.

RESULTS

The strongest predictor for vocational recovery, besides treatment allocation, was previous work history (OR = 1.78; 95% CI = 1.28-2.47). Men had a lower probability for vocational recovery compared to women (OR = 0.71; 95% CI = 0.50-0.99) and higher age was also negatively associated with work or education (OR = 0.79; 95% CI = 0.67-0.93). Moreover, vocational recovery was predicted by higher readiness for change, measured on the readiness for change scale (OR = 1.42; 95% CI = 1.19-1.70). Participation in IPS or IPSE could not compensate for negative risk factors such as low cognitive function or negative symptoms.

CONCLUSIONS

In a multiple logistic regression analysis age, previous work history and motivation for change were statistically significant predictors of obtaining work or education among people with severe mental illness who participated in the Danish IPS trial.

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

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

Clinical and functional characteristics of a subsample of young people presenting for primary mental healthcare at headspace services across Australia

PURPOSE

Headspace services provide treatment options to young people seeking mental healthcare. To obtain a better understanding of needs and characteristics of this population, and effectively evaluate services, we require novel youth-specific outcome measures. As part of our broad research program to establish such measures, a sample of young people were recruited and assessed. The study describes (i) methodology used to obtain clinical, functioning, and substance use characteristics of young people presenting to headspace services; and (ii) an overview of these characteristics.

METHODS

Young people presenting to headspace centres were recruited. Multidimensional information was obtained relating to clinical and functional outcomes, demographic information, and lifestyle factors.

RESULTS

1107 young help-seeking individuals were recruited. Participants were most likely young adults aged M = 18.1 years, SD = 3.3, with diagnoses of depression and/or anxiety (76.6%, n = 801), engaged in work and study (84.9%, n = 890), and living with parent(s) (68.9%, n = 736). Impairments in functioning were moderate as indicated by the Social and Occupational Functioning Assessment Scale (M = 65.2, SD = 9.5), substance use was common (alcohol 62.7%, n = 665; illicit substances 30.5%, n = 324), and current suicidal ideation was reported by a third (33.6%, n = 358).

CONCLUSIONS

A broad dataset was obtained providing an insight into key clinical, functional and quality of life characteristics of these individuals. We observed that young people present with complex problems, comorbid diagnoses, moderate levels of symptomatology, impairments in functioning, substance use, and suicidal ideation. This work provides the foundation for our broader research program aiming to develop novel, relevant and youth-specific, change and outcome measures.

Moving clients forward: a grounded theory of disability employment specialists' views and practices

PURPOSE

This study sought to better understand the views and practices of disability employment specialists working with clients with mental illness. Specifically, it explored what helps and hinders employment specialists in their work.

MATERIALS AND METHODS

A constructivist grounded theory methodology was used. Semi-structured interviews with 16 disability employment specialists from four employment service providers in Victoria, Australia, were transcribed and analysed through initial coding, focused coding, and constant comparative methods.

RESULTS

Analysis led to the substantive grounded theory of "moving clients forward." The key themes included "taking a firm but fair approach," "meeting clients where they are at," "getting clients ready for work," "managing the interface between clients and employers," and as a consequence, "working under pressure."

CONCLUSIONS

These findings contribute the first grounded theory of how Australian disability employment specialists work with clients with mental illness and enhance understanding of employment specialists' notions of job readiness and their use of discretion in implementing seemingly contradictory employment-related policies. Practice tensions for these employment specialists could be reduced by modifying disability employment policies, and through training to deliver evidence-based practices that offer varied vocational services, pathways, and adjunct interventions tailored to clients' interests, needs and readiness for change.IMPLICATIONS FOR REHABILITATIONAustralian disability employment specialists experience tensions between meeting the needs of clients with mental illness and feeling pressured to adhere to performance-based funding and disability employment policies.Greater emphasis on evidence-based, individualised vocational interventions would better align with a recovery orientation and offer vocational options tailored to the needs and goals of job seekers with mental illnessFurther training and systemic support is needed for disability employment specialists to adopt evidence-based practices in their work with jobseekers with mental illness.Since Australian disability employment specialists describe considering the "job readiness" of clients in practice, the usefulness of this concept merits further investigation.

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.

Determinants of Physical Health Self-Management Behaviours in Adults With Serious Mental Illness: A Systematic Review

Behavioural interventions can support the adoption of healthier lifestyles and improve physical health outcomes, but it is unclear what factors might drive success of such interventions in people with serious mental illness (SMI). We systematically identified and reviewed evidence of the association between determinants of physical health self-management behaviours in adults with SMI. Data about American Association of Diabetes Educator's Self-Care Behaviours (AADE-7) were mapped against the novel Mechanisms of Action (MoA) framework. Twenty-eight studies were included in the review, reporting evidence on 104 determinant-behaviour links. Beliefs about capabilities and beliefs about consequences were the most important determinants of behaviour, especially for being physically active and healthy eating. There was some evidence that emotion and environmental context and resources played a role in determining reducing risks, being active, and taking medications. We found very limited evidence associated with problem solving, and no study assessed links between MoAs and healthy coping. Although the review predominantly identified evidence about associations from cross-sectional studies that lacked validated and objective measures of self-management behaviours, these findings can facilitate the identification of behaviour change techniques with hypothesised links to determinants to support self-management in people with SMI. Systematic Review Registration: PROSPERO, registration CRD42018099553.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Supplementary information

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

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).

Recovery services and expectation of consumers and mental health professionals in community-based residential facilities of Ghana

BACKGROUND

In the past decades, considerable global attention has been drawn to recovery services that seek to promote the personal recovery journey of consumers with mental illness. However, in most settings, including Ghana, limited empirical studies have attempted to explore, from the perspectives of Mental Health Professionals (MHPs) and consumers, the effectiveness of recovery services and expectation towards the recovery. This study, therefore, explored consumers' and MHPs perspectives concerning recovery services and expectations towards recovery in two community-based residential facilities in Ghana.

METHODS

A qualitative method, involving in-depth interviews and observations, were used to collect data from 24 participants (5 MHPs and 19 consumers). Thematic analysis was used to analyze the data.

RESULTS

The study identified three global themes and nine organizing themes. The global themes were recovery services offered to consumers, expectation regarding personal recovery and challenges in achieving recovery. The study found that recovery services were expected to improve the internal and external recovery processes of consumers. The internal recovery process was independent living whilst the external recovery process were management of illness, economic empowerment and social inclusion. Several systemic and consumer-related factors influenced consumers' and MHPs expectation concerning the recovery journey.

CONCLUSION

The study concludes that the government should prioritize the use of recovery services through policies, financial incentives, infrastructure support, and adequate training of MHPs.

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.

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.

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

Introduction

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

Method

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

Results

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

Conclusions

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

Occupational Therapy Interventions for Adults Living With Serious Mental Illness

Occupational therapy practitioners have education, skills, and knowledge to provide occupational therapy interventions for adults living with serious mental illness. Evidence-based interventions demonstrate that occupational therapy practitioners can enable this population to engage in meaningful occupations, participate in community living, and contribute to society. Systematic review findings for occupational therapy interventions for adults living with serious mental illness were published in the September/October 2018 issue of the American Journal of Occupational Therapy and in the Occupational Therapy Practice Guidelines for Adults Living With Serious Mental Illness. Each article in the Evidence Connection series summarizes evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. These articles illustrate how research evidence from the reviews can be used to inform and guide clinical decision making. Through a case story, this article illustrates how current evidence is applied for effective occupational therapy intervention with an adult living with serious 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.

Barriers and facilitators to employment in borderline personality disorder: A qualitative study among patients, mental health practitioners and insurance physicians

Background

Borderline personality disorder (BPD) is associated with unemployment and impaired functioning. However, a comprehensive understanding of barriers and facilitators to employment from a multidisciplinary perspective is currently lacking. Therefore, the aim of this qualitative study was to explore barriers and facilitators in gaining and maintaining employment in BPD from the perspectives of patients, mental health practitioners (MHPs) and insurance physicians (IPs).

Methods

Fifteen semi-structured interviews were conducted in patients with BPD and two focus groups were carried out among MHPs (n = 7) and IPs (n = 6) following a thematic content analysis approach.

Results

All participants described barriers and facilitators relating to three overall themes: characteristics of BPD, stigma, and support to employment. Barriers to employment mainly related to characteristics of BPD, such as low self-image, difficulty posing personal boundaries, difficulty regulating emotions, and lack of structure. MHPs and IPs additionally mentioned externalization and overestimation of competencies on the part of patients. Enhancing emotion regulation and self-reflection by successful treatment was suggested as a facilitator to enhance employment. Increasing collaboration between mental health and vocational rehabilitation services, and increasing knowledge about BPD, were suggested to increase sustainable employment and decrease stigma.

Conclusions

The present findings revealed that both facilitators and barriers are important in gaining and maintaining employment in BPD in which diminishing symptoms, examining stigma and increasing support to employment are key. As a next step, supported employment strategies that follow patient preferences and integrate employment and mental health services, should be studied in the context of BPD.

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.

Determinants of Employment Outcome for the People with Schizophrenia Using the WHODAS 2.0

Purpose Since the vocational outcomes of people with schizophrenia should be viewed in a holistic way, the second edition of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) might provide an evaluation regarding employment potential. To determine whether the WHODAS 2.0 scores can be used to predict employment status, we examined the probabilistic cut-off values of the scores and analyzed the relationship between work status and demographic characteristics. Methods We selected 31,793 people aged between 18 and 65 with schizophrenia or schizoaffective disorder from the disability evaluation database in Taiwan and separated them into two groups based on employment status (employed and unemployed). We used logistic regression to explore the association between employment and demographic characteristics. Moreover, we conducted a receiver operating characteristic (ROC) analysis to determine the cut-off point to assist in determining employment potential based on the WHODAS 2.0 score. Results Among the 31,793 participants, 3367 were employed and 18,801 were unemployed. The unemployed participants accounted for a higher percentage of disability in each domain of the WHODAS. The ROC analysis revealed that the optimal cut-off point of the WHODAS score to distinguish the people who were employed and unemployed was 25.78 (area under curve = 0.80). Conclusions The present study indicated that work status can be determined by the total score across the six domains of the WHODAS score. Furthermore, the probability of employment may be determined initially by the cut-off point of the WHODAS score in order to economize evaluation time and prepare prevocational training for those with scores above 25.78.

The relationship between the therapeutic alliance and client variables in individual treatment for schizophrenia spectrum disorders and early psychosis: Narrative review

Given the high rates of treatment disengagement and medication nonadherence in individuals with schizophrenia spectrum disorders and early psychosis, fostering a strong alliance in treatment is critical. Moreover, the role of the therapeutic alliance extends beyond that in traditional psychotherapy because of the multifaceted nature of treatment. Thus, this review provides a comprehensive discussion of the relationship between the alliance and client variables across various provider types and individual treatments. This review summarizes existing research on (a) client correlates/predictors of the therapeutic alliance and on (b) the relationship between the alliance and client treatment outcomes in individual treatment for schizophrenia spectrum disorders and early psychosis. Parallel literature searches were conducted using PubMed and PsycINFO databases, which yielded 1202 potential studies with 84 studies meeting inclusion criteria. With regard to correlates/predictors, the existing evidence suggests that better insight, medication adherence, social support, and recovery variables were related to better client-rated alliance. Better medication adherence and recovery variables as well as less severe symptoms were related to better provider-rated alliance. In terms of alliance-outcome relationships, evidence suggests that a strong provider-rated alliance was predictive of improved functioning and medication and treatment adherence. There was some limited evidence that better client-rated alliance was related to improved recovery outcomes. Despite mixed results and heterogeneity among studies, this review suggests that a strong alliance can be beneficial in individual schizophrenia treatment. Thus, training and supervision of providers should emphasize developing a positive alliance, particularly with clients for whom developing an alliance may be difficult.

Rates and correlates of employment in patients with schizophrenia: A multicenter study in Turkey

BACKGROUND

There is not enough information regarding the participation in the working life of the patients with schizophrenia in Turkey.

AIMS

The aim of this study was to examine the occupational experiences of patients with schizophrenia before and after the illness and to investigate the factors that predict work participation.

METHODS

The data on occupational life of the patients with schizophrenia, which were treated as outpatients in six different centers, were examined. The rates of participation in working life before and after the disease were evaluated. Patients with and without occupational life history after the disease were compared in terms of demographic characteristics. Factors predicting participation in work life after the disease were analyzed by logistic regression analysis.

RESULTS

Out of the 587 patients evaluated in the study, 73% were males, 73% were single, the mean age was 42, mean level of education was 9 years and the average duration of illness was 18 years. The duration of the employment before the disease was higher than that after the disease regarding expected working time. The rate of employment was 11% currently, 14% in the last year, 62% after the disease and 83% for the lifetime. While the factors that predicted to be in working life after the illness were male gender (odds ratio (OR) = 2.9), diagnosis of schizoaffective disorder (OR = 2.6), high level of education (OR = 1.2) and employment history before the onset of the illness (OR = 1.0), only the shorter duration of illness (OR = 1.1) predicted the current working status when the gender variable was excluded.

CONCLUSION

Rate of employment of patients with schizophrenia living in Turkey was low as in other countries. Good premorbid functioning seems to determine participation in occupational life after the illness.

Employment Support Needs of People with Schizophrenia: A Scoping Study

Purpose People with schizophrenia continue to encounter barriers to employment acquisition. The aim of this scoping study was to identify and synthesize existent evidence about the employment support needs of people diagnosed with schizophrenia. Methods Five relevant databases were used: CINAHL, Medline, PsycINFO, SCOPUS, and Web of Science. Additional material of potential interest was identified through the references of the retrieved articles. A manual search for publications from the 3 months immediately prior to the electronic search was carried out in specialized journals. Searches covered the period between 1945 and August 30, 2017 without language restrictions. Two approaches were used to display the data: descriptive analysis and thematic analysis. Results Twelve articles met the inclusion criteria, most of which discussed experiences of participation in individual placement and support programmes. Thematic analysis identified four support needs: developing skills, vocational intervention, support and encouragement, and a supportive work environment. Conclusions There is a paucity of literature examining and evaluating employment support needs from the perspectives of people with schizophrenia. Future research must look beyond individual factors affecting employment outcomes to consider societal attitudes, stigma and work-related legislation.

Employment Rates in Flexible Assertive Community Treatment Teams in The Netherlands: An Observational Study

We determined the proportions of clients treated in Flexible Assertive Community Treatment teams who were unemployed and gained employment and who were employed and lost employment. Secondly, we explored the demographical and clinical factors associated with employment. Data were collected during routine outcome monitoring. We calculated differences in employment rates over a year and explored differences in demographic characteristics at baseline between patient groups. Logistic regression analysis was used to estimate the role of clinical predictor variables on employment status. Over time, 10% remained employed, 5% lost their employment, 3% gained employment and 82% remained unemployed. Clients who found employment were younger, more often male, and had significantly fewer psychosocial problems and a higher subjective quality of life during follow-up than those who remained unemployed. Problems with motivation for treatment at baseline were related to losing employment or remaining unemployed. Better implementation of vocational services is very important for increasing the number of clients gaining employment.

Experiência laboral e inclusão social de indivíduos com esquizofrenia

Resumo Objetivos: compreender os aspectos positivos e negativos das experiências relacionadas ao trabalho relatadas por indivíduos com esquizofrenia, usuários de um ambulatório de especialidades envolvido em um programa de inclusão laboral. Métodos: estudo com abordagem qualitativa e observacional. Onze participantes responderam a uma pergunta norteadora aberta: “o que você percebe como aspectos positivos e negativos na sua experiência de trabalho?”. Os dados foram categorizados por meio de análise temática. Resultados: foram identificadas 4 categorias: sobrecarga e falta de informação/orientação no trabalho; a importância da remuneração; assumindo responsabilidades, esperança e superação; a vivência da doença, o cuidado com a saúde e o trabalho. O estudo mostrou a importância de buscar estratégias eficazes de inclusão laboral para indivíduos com esquizofrenia, que considerem as especificidades da doença e os fatores estressantes relacionados ao trabalho como potenciais desencadeadores de sofrimento físico e emocional. Conclusão: é fundamental investir em ações que possibilitem efetiva inclusão laboral de pessoas com esquizofrenia. Tais medidas devem contemplar os portadores de esquizofrenia, suas famílias, as empresas e os profissionais dos serviços de saúde mental. As especificidades da doença, as necessidades, os interesses e o potencial da pessoa devem ser considerados.

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.

Evidence for Occupational Therapy Intervention With Employment and Education for Adults With Serious Mental Illness: A Systematic Review

OBJECTIVE

Many of the estimated 9.8 million American adults with serious mental illness (SMI) want to engage in employment and education, yet the majority report a need for more skills training. This review presents evidence for the effectiveness of interventions that occupational therapy practitioners can provide to help people with SMI improve and maintain performance and participation in employment and education.

METHOD

Citations, abstracts, and full-text articles in databases including MEDLINE, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews were reviewed for inclusion and analysis.

RESULTS

Fifty-seven articles met criteria for inclusion. For employment, strong evidence was found for the Individual Placement and Support (IPS) model and cognitive interventions. For education, moderate evidence was found for supported education interventions.

CONCLUSION

This systematic review supports the role of occupational therapy practitioners in promoting the implementation of IPS, cognitive-based, and social skills programs to improve vocational and educational outcomes for adults with SMI.

Stakeholders' views on vocational rehabilitation programs: a call for collaboration with Occupational Health Physicians

BACKGROUND

The triple-dip recession taking place in Italy in 2008-2014 impacted negatively on health, mainly by increasing the rate of unemployment. This increased the prevalence of mental health disorders, while reducing the number of available places on vocational rehabilitation programs (VRPs) delivered by the psychiatric services.

OBJECTIVES

To explore the different points of views of stakeholders (namely, users and professionals) involved in VRPs developed inside an Italian Community Mental Health Center (CMHC).

METHODS

A sample of users, psychiatrists, educators and nurses of an Italian CMHC involved in VRPs took part in a focus group. Content analysis was performed with MAXQDA 12, by developing a hierarchical code system a posteriori (i.e., derived from the data). The respondent validation phase was carried out by means of a multiple-choice questionnaire, administered to all participants.

RESULTS

A total of 86 emerging issues were coded, divided into two macro-areas: Positive and Negative Reinforcements (48 contributions, 56%, and 38 contributions, 44%, respectively), further subdivided into three areas: professional (service) factors, personal (i.e, user-related) factors, and work environment features (including relationships in the workplace). Some contributions raised issues concerning occupational health protection (e.g. need of information about the rights and duties of the users-workers, as well as the risks they are exposed to in the workplace).

CONCLUSIONS

The analysis suggested to address specific issues concerning work and VRPs by means of psycho-education group interventions currently carried out at CMHCs, and pointed to the need to foster collaboration between mental health professionals and the occupational health physician of the company where the VRP is started and where the user might be employed.

Furthering the Evidence of the Effectiveness of Employment Strategies for People with Mental Disorders in Europe: A Systematic Review

(1) Purpose: This systematic review aims to assess the effectiveness of strategies used in the professional (re)integration of persons with mental disorders (MD) in European countries; (2) Methods: We conducted a search for scientific publications available in relevant electronic databases (Medline, PsycINFO, CDR-HTA, CDR-DARE, and Cochrane Library). The present study collected evidence on the effectiveness, from 2011 to 2016, of employment strategies for persons with MDs; (3) Results: A total of 18 studies were included, representing 5216 participants (aged 18⁻65, mean age of 38.5 years old) from 7 countries. Job access programs demonstrated effectiveness in four out of six studies. Return to work (RTW) interventions showed significant positive results in two studies, while four studies did not refer to effectiveness. There were inconsistent results in another four studies; (4) Conclusions: Our findings highlight the complexities of the implementation of employment strategies (job access and return to work). Job access strategies seem to improve employment outcomes. The effectiveness of return to work strategies remains unclear. The involvement and commitment of physicians, employment specialists, and employers, and employees capacity for self-care seem decisive for employment re-integration success. Further analyses are needed to assess the cost-effectiveness of these interventions and corroborate our results, with longer follow-ups.

Increasing the employment rate for people with longer-term mental health problems

Aims and method

To examine the effects of implementing the individual placement and support (IPS) approach within four community mental health teams (CMHTs). Demographic, clinical and vocational data were collected through a repeated cross-sectional survey. Additionally, a service user experience survey was conducted.

Results

The IPS approach appears to have a significant effect on the employment rates of service users; a higher proportion felt able to return to employment and a smaller proportion believed they were unable to work because of their mental health problems. Employment rates for service users appear to be independent of general employment rates.

Clinical implications

Implementing IPS appears to increase the employment rates in CMHTs resulting in increased service user expectations of being able to return to work.

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.

It can work: Open employment for people with experience of mental illness

BACKGROUND

Previous research has tended to focus on the barriers to employment for people with mental illness and the extra support they may need. This research contributes to the knowledge base pertaining to this population by looking at successful employment relationships in New Zealand.

OBJECTIVE

To describe factors enabling and/or sustaining the open employment of people with experience of mental illness.

METHOD

Fifteen pairs of employers and employees were interviewed individually but consecutively (using a semi-structured interview schedule) about their perceptions of the critical factors that enabled and sustained the employee's employment. Employee participants were recruited by advertisement, with employers approached through their employees. Transcripts were analysed using a thematic analysis.

RESULTS

Themes raised in the interviews included the meaning of work, disclosure of mental illness, the benefits of working, special arrangements or accommodations, the work environment and key things employers and employees do to sustain successful employment.

CONCLUSION

Four critical success factors were identified relating to disclosure, the employment relationship, freedom from discrimination and workplace flexibility.

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.

Schizophrenia and work: aspects related to job acquisition in a follow-up study

Objective:

Work is considered one of the main forms of social organization; however, few individuals with schizophrenia find work opportunities. The purpose of this study was to evaluate the relationship between schizophrenia symptoms and job acquisition.

Method:

Fifty-three individuals diagnosed with schizophrenia from an outpatient treatment facility were included in an 18-month follow-up study. After enrollment, they participated in a prevocational training group. At the end of training (baseline) and 18 months later, sociodemographic, clinical data and occupational history were collected. Positive and negative symptoms (Positive and Negative Syndrome Scale – PANSS), depression (Calgary Depression Scale), disease severity (Clinical Global Impression – CGI), functionality (Global Assessment of Functioning – GAF), personal and social performance (Personal and Social Performance – PSP) and cognitive functions (Measurement and Treatment Research to Improve Cognition in Schizophrenia – MATRICS battery) were applied at baseline and at the end of the study.

Results:

Those with some previous work experience (n=19) presented lower scores on the PANSS, Calgary, GAF, CGI and PSP scales (p < 0.05) than those who did not work. Among those who worked, there was a slight worsening in positive symptoms (positive PANSS).

Conclusions:

Individuals with less severe symptoms were more able to find employment. Positive symptom changes do not seem to affect participation at work; however, this calls for discussion about the importance of employment support.

Employment outcome and predictors of competitive employment at 2-year follow-up of a vocational rehabilitation programme for individuals with schizophrenia in a high-income welfare society

BACKGROUND

Employment is an important part of recovery for individuals with schizophrenia. The employment rate for this group is as low as 10% in Norway, and major system related barriers to employment are evident.

AIMS

This study reports the competitive employment outcome at 2-year follow-up of a vocational rehabilitation study augmented with cognitive remediation (CR) or elements from cognitive behaviour therapy (CBT) for individuals with schizophrenia spectrum disorders. It also investigates if global functioning, self-esteem, and depression at baseline predicts employment outcome, and if change in these variables during the intervention period is associated with employment outcome.

METHOD

One hundred and forty-eight participants with schizophrenia spectrum disorders in six Norwegian counties received 10 months vocational rehabilitation augmented with either CBT (n = 84) or CR (n = 64). Both competitive and sheltered workplaces were used. Participants were assessed at baseline, at the end of the intervention period, and at 2-year follow-up.

RESULTS

At 2-year follow-up, 21.2% had obtained competitive employment. A further 25.3% had work placements in competitive workplaces. Significant improvements were found in global functioning, self-esteem, and depression during the intervention period, but no significant differences between the two intervention groups. High baseline global functioning and self-esteem, as well as positive change in these variables during the intervention period, were significantly associated with higher competitive employment outcome at 2-year follow-up.

CONCLUSION

The results add to existing evidence that competitive employment is attainable for individuals with schizophrenia. High global functioning and self-esteem were strongly associated with competitive employment outcome.

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.

Association between family history of psychiatric disorders and long-term outcome in schizophrenia - The Northern Finland Birth Cohort 1966 study

Family history of psychiatric disorders has been associated with impaired outcome in schizophrenia, but very few studies have investigated its long-term social and occupational outcome. We investigated the association of family history of psychiatric disorders, especially psychosis, with long-term social, occupational, clinical and global outcome in schizophrenia. The study sample comprises of the Northern Finland Birth Cohort 1966. Cohort members with psychosis were detected by Finnish national registers. Altogether 69 individuals with schizophrenia spectrum diagnosis participated, mean age 43, after on average 17 years since onset of illness. The information regarding family history of psychiatric disorders were gathered from registers and interviews. A Strauss-Carpenter Outcome Scale, PANSS and SOFAS were conducted to assess the outcome. Results showed that the family history of any psychiatric disorder was associated with more severe positive and emotional symptoms in PANSS. The family history of psychosis was not associated with outcomes. These findings suggest that family history of psychiatric disorders has a small association with outcome in schizophrenia. Despite family history of psychosis being a strong risk factor for schizophrenia, after years of illness it does not seem to affect outcome.

Towards Employment: What Research Says About Support-to-Work in Relation to Psychiatric and Intellectual Disabilities

This article presents an overview of research about support-to-work in relation to psychiatric and intellectual disabilities. The overview shows that support-to-work services are multifaceted, and that work can be seen as a tool for individual rehabilitation or as a set of goals to achieve. Providers are presented with specific components, which are characterized by systematic, targeted, and individualized interventions. The overview illustrates a need for long-term engagement and cooperation of and between welfare services and agents within the labor market to dissolve the Gordian knot that the transition from welfare interventions to employment seems to be.