Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual

A supported education programme implemented in youth mental health services: Outcomes and lessons from the first year of COVID-disrupted delivery

AIM

Educational attainment is consistently highly valued by young people with mental ill health, yet maintenance and completion of education is a challenge. This paper reports on the implementation of a supported education programme for youth mental health.

METHODS

Between 10 October 2019 and 10 October 2020, a supported education programme was delivered within primary and tertiary youth mental health services. A description of the programme, context, and adjustments required due to COVID-19 is presented, and the educational outcomes of young people referred to the programme were explored. Two case studies are also presented.

RESULTS

The programme received 71 referrals over this period, of which 70.4% had not yet completed secondary school and 68% were experiencing multiple mental health conditions. Overall outcomes were positive, with 47.5% of the 40 young people who chose to engage with the programme maintaining or re-engaging with education. However, the remainder of those who engaged withdrew from the programme, often reporting challenges due to COVID-19 such as social isolation or increased uncertainty. Additionally, a number of young people declined or disengaged from the programme to focus on employment.

CONCLUSION

This report of the experience of integrating a supported employment programme in Australian youth mental health services reinforces the need for such support, and provides preliminary evidence for its successful implementation as part of routine care. The disengagement in response to COVID-19 highlights the real-world challenges of the pandemic, while young people's voicing of employment goals indicates the need for combined educational and vocational support-to assist transition and progression between these goals.

Comparing interventions for early psychosis: a systematic review and component network meta-analysis

Background

'Early Intervention in Psychosis' (EIP) services have been associated with improved outcomes for early psychosis. However, these services are heterogeneous and many provide different components of treatment. The impact of this variation on the sustained treatment effects is unknown.

Methods

We performed a systematic review and component network meta-analysis (cNMA) of randomised controlled trials (RCTs) that compared specialised intervention services for early psychosis. We searched CENTRAL (published and unpublished), EMBASE, MEDLINE, CINAHL, PsycINFO and Web of Science from inception to February 2023. Primary outcomes were negative and positive psychotic symptoms at 3-month and 1-year follow-up and treatment dropouts. Secondary outcomes were depressive symptoms and social functioning at 1-year follow-up. We registered a protocol for our study in PROSPERO (CRD42017057420).

Findings

We identified 37 RCTs including 4599 participants. Participants' mean age was 25.8 years (SD 6.0) and 64.0% were men. We found evidence that psychological interventions (this component grouped all psychological treatment intended to treat, or ameliorate the consequences of, psychotic symptoms) are beneficial for reducing negative symptoms (iSMD -0.24, 95% CI -0.44 to -0.05, p = 0.014) at 3-month follow-up and may be associated with clinically relevant benefits in improving social functioning scores at 1-year follow-up (iSMD -0.52, 95% CI -1.05 to 0.01, p = 0.052). The addition of case management has a beneficial effect on reducing negative symptoms (iSMD -1.17, 95% CI -2.24 to -0.11, p = 0.030) and positive symptoms (iSMD -1.05, 95% CI -2.02 to -0.08, p = 0.033) at 1-year follow-up. Pharmacotherapy was present in all trial arms, meaning it was not possible to examine the specific effects of this component.

Interpretation

Our findings suggest psychological interventions and case management in addition to pharmacotherapy as the core components of services for early psychosis to achieve sustained clinical benefits. Our conclusions are limited by the small number of studies and sparsely connected networks.

Funding

National Institute for Health and Care Research.

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

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

The temporal dependencies between social, emotional and physical health factors in young people receiving mental healthcare: a dynamic Bayesian network analysis

AIMS

The needs of young people attending mental healthcare can be complex and often span multiple domains (e.g., social, emotional and physical health factors). These factors often complicate treatment approaches and contribute to poorer outcomes in youth mental health. We aimed to identify how these factors interact over time by modelling the temporal dependencies between these transdiagnostic social, emotional and physical health factors among young people presenting for youth mental healthcare.

METHODS

Dynamic Bayesian networks were used to examine the relationship between mental health factors across multiple domains (social and occupational function, self-harm and suicidality, alcohol and substance use, physical health and psychiatric syndromes) in a longitudinal cohort of 2663 young people accessing youth mental health services. Two networks were developed: (1) 'initial network', that shows the conditional dependencies between factors at first presentation, and a (2) 'transition network', how factors are dependent longitudinally.

RESULTS

The 'initial network' identified that childhood disorders tend to precede adolescent depression which itself was associated with three distinct pathways or illness trajectories; (1) anxiety disorder; (2) bipolar disorder, manic-like experiences, circadian disturbances and psychosis-like experiences; (3) self-harm and suicidality to alcohol and substance use or functioning. The 'transition network' identified that over time social and occupational function had the largest effect on self-harm and suicidality, with direct effects on ideation (relative risk [RR], 1.79; CI, 1.59-1.99) and self-harm (RR, 1.32; CI, 1.22-1.41), and an indirect effect on attempts (RR, 2.10; CI, 1.69-2.50). Suicide ideation had a direct effect on future suicide attempts (RR, 4.37; CI, 3.28-5.43) and self-harm (RR, 2.78; CI, 2.55-3.01). Alcohol and substance use, physical health and psychiatric syndromes (e.g., depression and anxiety, at-risk mental states) were independent domains whereby all direct effects remained within each domain over time.

CONCLUSIONS

This study identified probable temporal dependencies between domains, which has causal interpretations, and therefore can provide insight into their differential role over the course of illness. This work identified social, emotional and physical health factors that may be important early intervention and prevention targets. Improving social and occupational function may be a critical target due to its impacts longitudinally on self-harm and suicidality. The conditional independence of alcohol and substance use supports the need for specific interventions to target these comorbidities.

Enhancing educational and vocational recovery in adolescents and young adults with early psychosis through Supported Employment and Education (SEEearly): study protocol for a multicenter randomized controlled trial

BACKGROUND

Psychotic disorders often develop a chronic course with devastating consequences for individuals, families, and societies. Early intervention programs for people in the first 5 years after the initial psychotic episode (early psychosis) can significantly improve the outcome and are therefore strongly recommended in national and international guidelines. However, most early intervention programs still focus on improving symptoms and relapse prevention, rather than targeting educational and vocational recovery. The aim of the present study is to explore the effects of Supported Employment and Education (SEE) following the Individual Placement and Support (IPS) model in people with early psychosis.

METHODS

The SEEearly trial compares treatment as usual (TAU) plus SEE to TAU alone in outpatient psychiatric settings. The study is a six-site, two-arm, single-blinded, superiority randomized controlled trial (RCT). Participants are randomly assigned (1:1) to the intervention or control group. Aiming to recruit 184 participants, with an assumed drop-out rate of 22%, we will be able to detect a 24% difference in the main outcome of employment/education with 90% power. We make assessments at baseline and at 6- and 12-month follow-ups. Outcome data on employment/education, medication, and current psychiatric treatment is obtained monthly through phone based short assessments. The primary outcome is steady participation for at least 50% of the 12-month follow-up in competitive employment and/or mainstream education. Secondary employment outcomes capture length of employment/education, time to first employment/education, monthly wages/educational attainment, and social return on investment (SROI). Secondary non-employment outcomes include subjective quality of life, psychopathology, substance use, relapse, hospitalization, and functional impairment. To be eligible, participants must be between 16 and 35 years, fulfill diagnostic criteria for early psychosis, and be interested in competitive employment and/or mainstream education.

DISCUSSION

In SEEearly, we hypothesize that participants with psychosis, who receive TAU plus SEE, present with better primary and secondary outcomes than participants, who receive TAU alone. Positive results of this study will justify SEE as an evidence-based strategy for clinical routine treatment in people with early psychosis.

TRIAL REGISTRATION

SEEearly was registered nationally and internationally in the German Clinical Trials Register (DRKS; identifier: DRKS00029660) on October 14, 2022.

Social and occupational recovery in early psychosis: a systematic review and meta-analysis of psychosocial interventions

BACKGROUND

Psychosis, even in its early stages, ranks highly among the causes of disability worldwide, resulting in an increased focus on improved recovery of social and occupational functioning. This study aimed to provide an estimate of the effectiveness of psychosocial interventions for improving functioning in early psychosis. We also sought evidence of superiority between intervention approaches.

METHODS

An electronic search was conducted using PubMed and PsycINFO to identify original articles reporting on trials of psychosocial interventions in early-stage psychosis, published up to December 2020 and is reported following PRISMA guidelines. Data were extracted on validated measures of functioning from included studies and pooled standardised mean difference (SMD) was estimated.

RESULTS

In total, 31 studies involving 2811 participants were included, focusing on: cognitive behavioural therapy for psychosis (CBTp), family-based therapy, supported employment, cognitive remediation training (CRT) and multi-component psychosocial interventions. Across interventions, improved function was observed (SMD = 0.239; 95% confidence interval 0.115-0.364, p < 0.001). Effect sizes varied by intervention type, stage of illness, length and duration of treatment and outcome measure used. In particular, interventions based on CRT significantly outperformed symptom-focused CBT interventions, while multi-component interventions were associated with largest gains.

CONCLUSIONS

Psychosocial interventions, particularly when provided as part of a multi-component intervention model and delivered in community-based settings are associated with significant improvements in social and occupational function. This review underscores the value of sensitively tracking and targeting psychosocial function as part of the standard provided by early intervention services.

Predictors of full recovery in patients with early stage schizophrenia spectrum disorders

To promote recovery in psychosis, targeting modifiable factors related to recovery is critical. Using more strict definition of full recovery, we examined predictors for recovery in patients with early stage schizophrenia spectrum disorders (SSD) followed up to 6.5 years. The target subjects were 375 patients with early stage SSD who had been over at least 1-year after registration and evaluated. The criteria for full recovery were having the score of the Positive and Negative Syndrome Scale (PANSS) 8-item ≤ 2 and adequate functional recovery for at least 1-year. We performed univariate Cox and stepwise Cox regression in both total and acute patients. In stepwise Cox regression, several independent predictors for recovery, i.e., negative symptoms of the PANSS, duration of untreated psychosis (DUP) and non-professional job were identified in patients with early stage SSD. In acute patients, other factors such as professional job and subjective well-being under neuroleptics were more important. The present study identified independent predictors for recovery modifiable by various psychosocial intervention and early intervention services. Moreover, it highlights the need of providing different treatment strategies depending on clinical status.

Implementing a combined individual placement and support and vocational peer work program in integrated youth mental health settings

AIM

To describe the implementation and outcomes of a combined individual placement and support (IPS) and vocational peer work program for young people with mental ill-health.

METHODS

This uncontrolled pilot study co-located IPS workers and vocational peer workers within two integrated youth mental health services (provided to clients aged 15-25 years old). Employment outcomes included job placements (working 15 hours or more per week in a paid competitive job in the open employment market) and sustained employment (employed for at least 26 weeks). Participants who required additional assistance also received peer work.

RESULTS

Of the 326 young people enrolled, 195 (59.8%) achieved competitive employment, including 157 (48.2%) in funder-approved placements. Among those in approved placements, 87 (55.4%) achieved sustained employment. For the 116 participants additionally receiving vocational peer work, 54 (46.6%) worked in funder-approved placements, of whom 27 (50.0%) achieved sustained employment. Among 210 participants who did not receive peer work, 103 (49.0%) worked in funder-approved placements, of whom 60 (58.3%) achieved sustained employment.

CONCLUSIONS

The program achieved positive vocational outcomes and good fidelity to the IPS model. Approximately half of young people had employment placements, with a relatively high proportion maintained over time. The similar proportion of placements for those who did and did not receive peer work was encouraging given the IPS team determined that the former group needed additional support. Recommendations include upskilling the workforce, a data linkage system to obtain placement evidence, and using implementation science methodologies to understand how IPS programs are successfully embedded. This demands a coordinated effort between governments and funders, policymakers, services, and professional bodies.

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

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

Meaning in life and flow experiences among people with psychiatric disabilities who are engaged in peer-helping vs. non-helping work-roles

BACKGROUND: Finding meaning in life and wellbeing through vocational work-roles are central to recovery of persons with psychiatric disabilities. However, there is a disconnect between positive concepts and vocational rehabilitation, rendering meaning and wellbeing rarely explored in vocational rehabilitation. OBJECTIVE: We assume higher meaning and wellbeing exists among individuals engaged in peer helping work-roles (meaningful role) as compared to non-helping work-roles. We examine this and additional questions to learn about relationships between positive concepts and vocational work-roles illuminating mental health recovery. METHODS: 114 individuals with psychiatric disabilities (ages 20-70) from various vocational-services participated. Sixty-nine worked in peer-helping roles (i.e. consumer-providers/peer-supporters) and 45 engaged in non-helping work-roles (vendors/clerical work, etc.). Participants filled in the Meaning in Life and Work-related Flow (assessing wellbeing at work) scales. Additionally, participants in peer-helping work-roles filled a peer-developed scale estimating their salience of peer-role characteristics. RESULTS: Individuals in peer-helping work-roles had significantly higher meaning in life levels than those in non-helping roles. Having meaning in life also predicted higher work-related flow across the sample. Finally, meaning in life positively mediated relations between salience of peer-role characteristics and work-related flow experiences. CONCLUSION: Researching meaning and wellbeing can broaden theoretical understanding and bear practical implications for enhancing vocational work-role fit and recovery.

Key service components for age-appropriate mental health service planning for young adults

AIM

To identify and describe key service components that should be incorporated into age-appropriate integrated mental health care for young adults aged 18-24 years.

METHODS

Key service components were identified through a mixed-methods approach including targeted examinations of the literature and structured discussions with experts in youth mental health.

RESULTS

Seven key components were identified as important for providing age-appropriate mental health care to young adults. Two were classified as clinical service components (structured psychological therapies; care coordination and liaison), three were classified as non-clinical service components (vocational support; youth development; peer support) and two as integrated non-clinical and clinical service components (lifestyle interventions and family and network support). Example service models for each of these key service components were identified and described.

CONCLUSIONS

This is the first study to identify and describe key service components for age-appropriate mental health care for young adults. The findings provide mental health service planners with a framework of services that should be considered when planning and resourcing services for this age range.

Use of generic social services and social integration of patients with a severe mental illness in Belgium: Individual and services network determinants

BACKGROUND

Patients with severe mental illnesses (SMI) have low levels of social integration, which could be improved if they used social services. To our knowledge, however, the extent to which they use generic social services remains unknown.

AIMS

We assessed the extent to which patients with SMI use generic social services and the factors that may drive that usage.

METHOD

In 2014, we carried out a multi-setting clustered survey of patients with severe mental disorders (n = 1,019, participation rate = 71%) and of services (n = 517, participation rate = 53%) in 19 networks of services, covering most of Belgium. On the one hand, we asked patients, amongst other, about their health condition, their social integration in the community, and their use of social services of different types. On the other hand, we asked each service to report on its relationships with other services in the services networks.

RESULTS

On average, patients' use of generic social services within the previous 6 months was low (6%-16%), with the exception of administrative services. There were few differences in usage according to the severity of patients' symptoms, but some differences according to gender and age were observed. Social integration was improved when generic social services were more central in the networks.

CONCLUSIONS

We suggest that generic social services should be more central in mental health services networks.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A randomized controlled trial of cognitive remediation and long-acting injectable risperidone after a first episode of schizophrenia: improving cognition and work/school functioning

BACKGROUND

Cognitive deficits at the first episode of schizophrenia are predictive of functional outcome. Interventions that improve cognitive functioning early in schizophrenia are critical if we hope to prevent or limit long-term disability in this disorder.

METHODS

We completed a 12-month randomized controlled trial of cognitive remediation and of long-acting injectable (LAI) risperidone with 60 patients with a recent first episode of schizophrenia. Cognitive remediation involved programs focused on basic cognitive processes as well as more complex, life-like situations. Healthy behavior training of equal treatment time was the comparison group for cognitive remediation, while oral risperidone was the comparator for LAI risperidone in a 2 × 2 design. All patients were provided supported employment/education to encourage return to work or school.

RESULTS

Both antipsychotic medication adherence and cognitive remediation contributed to cognitive improvement. Cognitive remediation was superior to healthy behavior training in the LAI medication condition but not the oral medication condition. Cognitive remediation was also superior when medication adherence and protocol completion were covaried. Both LAI antipsychotic medication and cognitive remediation led to significantly greater improvement in work/school functioning. Effect sizes were larger than in most prior studies of first-episode patients. In addition, cognitive improvement was significantly correlated with work/school functional improvement.

CONCLUSIONS

These results indicate that consistent antipsychotic medication adherence and cognitive remediation can significantly improve core cognitive deficits in the initial period of schizophrenia. When combined with supported employment/education, cognitive remediation and LAI antipsychotic medication show separate significant impact on improving work/school functioning.

Not in education, employment and training status in the early stages of bipolar I disorder with psychotic features

OBJECTIVE

There is a lack of existing research regarding young people with bipolar I disorder (BD-I) and psychotic features, who are not in education, employment, and training (NEET). Thus, the aims of the study were to: (a) establish rates of NEET at service entry to a specialist early intervention service; (b) delineate premorbid and current variables associated with NEET status at service entry and (c) examine correlates of NEET status at discharge.

METHOD

Medical file audit methodology was utilized to collect information on 118 patients with first episode psychotic mania treated at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. NEET status was determined using the modified vocation status index (MVCI). Bivariate and multivariable logistic variables were used to examine relationships between premorbid, service entry and treatment variables, and NEET status at service entry and discharge.

RESULTS

The NEET rate was 33.9% at service entry, and 39.2% at discharge. Variables associated with NEET status at service entry were premorbid functioning and polysubstance use. NEET status at service entry was the only significant correlate of NEET status at discharge. When service entry NEET was taken out of the model, substance use during treatment was predictive of NEET status at discharge.

CONCLUSIONS

NEET status at service entry was related to a history of premorbid decline, and risk factors such as substance use and forensic issues. NEET status can decline during treatment, and utility of vocational intervention programs specifically for BD, in addition to specialist early intervention, needs to be examined.

Individualized vocational and educational support and training for youth at clinical high risk for psychosis

AIM

Early intervention for psychosis has been of high interest in the past two decades. Research demonstrates that clinical high risk for psychosis (CHR-p) populations experience impairments in role functioning. Although several vocational and cognitive interventions exist for people living with psychosis, there are no known evidence-based treatments for role functioning difficulties during the CHR-p stage. There is clear evidence for a need for interventions that directly target role functioning.

METHODS

This paper describes the theoretical development and implementation of a novel intervention targeting role functioning impairments: Individualized Vocational and Educational Support and Training (InVEST). The CEDAR Clinic, a specialized CHR-p coordinated specialty care (CSC) team, has worked to develop InVEST to target core aspects of role functioning, namely executive functioning, stress sensitivity, and task initiation. The intervention is cost-efficient, as bachelor level clinicians provide the service under supervision of licensed clinicians. This summary describes InVEST, provides a disguised case example, and presents initial exploratory data (N = 135) focused on the intervention's feasibility in this CSC program.

RESULTS

Although these preliminary data are limited, available information suggests that InVEST may provide a core treatment modality within CHR-p treatment programs.

CONCLUSIONS

More research formally investigating InVEST with a larger sample would provide further evidence of the intervention's efficacy.

Psychosocial Interventions for Adults With Schizophrenia: An Overview and Update of Systematic Reviews

OBJECTIVE

The authors of this systematic review (SR) sought to provide evidence for effects of commonly used psychosocial interventions on several outcomes among adults with schizophrenia.

METHODS

MEDLINE, the Cochrane Library, and PsycINFO databases were searched through July 2020. Eligible studies were SRs and trials of at least 12 weeks duration and with ≥50 participants that compared psychosocial interventions with treatment as usual among adults with schizophrenia. Study design, year, setting, country, sample size, eligibility criteria, population, clinical and intervention characteristics, results, and funding source were extracted, along with quality criteria. The evidence was evaluated on quality and strength of evidence stratified by intervention area and outcome, according to the Evidence-Based Practice Centers Methods Guide of the Agency for Healthcare Research and Quality.

RESULTS

Nine SRs and 30 trials (N=23,921 patients) in 11 intervention areas were included. Trials were mostly of fair quality and had low-to-moderate strength of evidence. Compared with treatment as usual, most psychosocial interventions were more effective in improving intervention-targeted outcomes, including core illness symptoms. Compared with treatment as usual, assertive community treatment, cognitive-behavioral therapy (CBT), family interventions, psychoeducation, social skills training, supported employment, and early interventions for first-episode psychosis (FEP) improved various functional outcomes. CBT and early interventions for FEP improved quality of life. Family interventions, psychoeducation, illness self-management, and early interventions for FEP reduced relapse.

CONCLUSIONS

Compared with treatment as usual, most psychosocial interventions improved functional outcomes, quality of life, and core illness symptoms, and several reduced relapse frequency among adults with schizophrenia.

Specialized inpatient treatment for young people with early psychosis: acute-treatment and 12-month results

The objective of the study was to investigate the development of clinical outcomes of young people with early psychosis in a specialized inpatient treatment and assess the feasibility of such an intervention in an inpatient setting. The study was a prospective cohort study of patients with early psychosis treated at the specialized inpatient treatment "Fühinterventions-und Therapiezentrum, FRITZ" (early intervention and therapy center) in Berlin, Germany. The primary outcomes were attitudes towards psychiatric medication and patient satisfaction with treatment after 6 weeks. Secondary outcomes were clinical symptoms, functioning, remission, recovery, all-cause treatment discontinuation, and rehospitalisation at 6 and 12 months after inpatient treatment. We recruited 95 inpatients with early psychosis. Attitudes towards psychiatric medication (Δ_6weeks = 3.00, d_6weeks = 0.55; Δ_6mo = 2.15, d_6mo = 0.35; Δ_12mo = 3.03, d_12mo = 0.52) and patient satisfaction (Δ_6weeks = 0.21, d_6weeks = 0.40; Δ_6mo = 0.32, d_6mo = 0.43; Δ_12mo = 0.13, d_12mo = 0.17) changed with medium effect sizes at six weeks up to a 6- and 12-month follow-up. Clinical outcomes changed significantly with medium-to-large-effect sizes over 12 months CGI_Δ12mo = 1.64, d_12mo = -1.12; PANSS total_Δ12mo = 20.10, d_12mo = -0.76; GAF_Δ12mo = 19.58, d_12mo = 1.25). The all-cause treatment discontinuation rate was 13.69% (n = 13) at a 6-month and 35.79% (n = 34) at a 12-month follow-up. The rehospitalization rate was 30.53% (n = 29) at a 6-month and 43.16% (n = 41) at a 12-month follow-up. Patients with specialized inpatient treatment for early psychosis showed improvements in attitude towards psychiatric medication, patient satisfaction, symptoms, and functioning for up to 12 months.Trial registration: DRKS00024351, 2021/02/11 retrospectively registered.

Effects of IPS plus cognitive remediation in early psychosis: 18-month functioning outcomes of a randomized controlled trial

BACKGROUND

After a first episode of psychosis, cognitive impairments present an important barrier to successful (re-)entry into work and education. We assessed whether cognitive remediation (CR) as an add-on to Individual Placement and Support (IPS) can improve participation in regular employment and education.

METHOD

Participants with early psychosis (N = 73) were randomly assigned to receive IPS supplemented with computerized CR, or IPS plus an active control intervention (computer games). The primary outcome was the number of hours spent in competitive employment or regular education, which was assessed every month during the 18-month study period. Secondary outcomes included employment rate, cognitive functioning, mental health (assessed at baseline, 6 and 18 months), and job duration (assessed after 18 months). Both patients and assessors were blind to treatment.

RESULTS

Participants receiving IPS + CR showed greater improvement of competitive employment over time in terms of hours worked (during follow-up period: 38.5 vs. 19.6 h, B = 2.94; Wald χ² = 5.39; P = .02) and employment rate (at T2: 62.1% vs. 25.9%, χ ² = 7.39; df = 1; P = .008), compared with the IPS + control group, particularly in the longer term. The number of hours spent in regular education was lower in the IPS + CR group, with more participants having ended education for a positive reason. There was a significant beneficial effect of adjunctive CR for executive functioning, subjective cognitive functioning, and empowerment.

CONCLUSIONS

Augmenting IPS with CR has a significant impact on competitive employment in people with early psychosis, with beneficial effects being more pronounced after 18 months.

"Individual Placement and Support" boosts employment for early psychosis clients, even when baseline rates are high

AIM

Individual Placement and Support is an effective vocational intervention for increasing competitive employment for people with severe mental illness. Little is known, however, about its effectiveness in the context of early psychosis. This study assesses improvements in clients' employment in a phase of illness during which functional abilities often decline.

METHODS

The trial design is an assessor-blinded randomized clinical trial, set in the context of a population-based Early Psychosis Intervention program in British Columbia, Canada. Participants were randomized either to 1 year of employment support added to treatment-as-usual, or the latter alone. Interviews at intake captured data regarding demographics, symptom severity, and employment; assessments at 6 and 12 months repeated queries about employment activities.

RESULTS

A total of 109 clients were recruited. Employment rates in the Individual Placement and Support group increased over time, unlike the control group. Further, the number of days worked over the 12-month intervention period, compared to the 6 months prior to the study, improved for both groups, but the increase was greater among clients receiving IPS. Sensitivity analysis indicated the advantage in days worked was evident in the second half of the intervention period (6-12 months), but not the first half.

CONCLUSIONS

Employment rates, for younger clients in both early-psychosis groups, were high compared to older clients in later stages of illness. In this study, use of the Individual Placement and Support strategy further increased employment, despite the high baseline rates. Further research is needed to identify the optimal timing of employment support for these clients.

Exploring presentation differences in multi-cultural youth seeking assistance for mental health problems

Background

Mental ill-health can impact an individual’s capacity to interact with others, make decisions, and cope with social challenges. This is of particular importance for many Culturally and linguistically diverse (CALD) individuals who may be at various stages of the acculturation process. The increasing diversity of the Australian population necessitates informed and culturally relevant services that meet the needs of a changing demographic. However the extant research on the mental health needs of CALD Australians is limited. This study aimed to further our understanding of the mental health needs of young CALD Australians by exploring the mental health concerns and social factors exhibited by CALD individuals accessing community based youth mental health services in two major cities.

Methods

We performed a series of logistic regression models to ascertain if a concert of factors (i.e., clinical, socio-economic, criminal justice system involvement, child maltreatment, social support) were associated with CALD status

Results

Comparisons across factors revealed no significant differences between groups. A small number of correlates differentiated between CALD and non-CALD participants (mental illness diagnosis during childhood, family history of mental illness/suicide, sensation seeking, sensitivity to punishment, maternal overprotection) however these factors were no longer meaningful after adjustment for multiple comparisons.

Conclusions

In help-seeking mainstream youth populations, cultural differences across clinical and environmental factors appear to be minimal.

An Online Platform to Provide Work and Study Support for Young People With Mental Health Challenges: Observational and Survey Study

BACKGROUND

Young people, aged 15-25 years, are at a critical stage of life when they need to navigate vocational pathways and achieve work and study outcomes. Those with mental health problems are particularly at risk of disengagement with work and study and need effective support. The headspace Work and Study (hWS) service is an innovative online platform implemented in Australia to support young people aged 15-25 years with mental health problems to achieve work and study goals.

OBJECTIVE

This study aims to determine whether the hWS service has been implemented as planned, provides appropriate support for young people, and achieves its main goals.

METHODS

Data were collected via 2 methodologies: (1) the hWS Minimum Data Set, which includes data on all clients in the service (n=1139), services delivered, and service impact; and (2) a survey of hWS clients who volunteered to participate in an evaluation of the hWS service (n=137).

RESULTS

The service was accessed by its defined target group, young people aged 15-25 years with mental health and work and study difficulties. Young people found the online platform to be acceptable, and the assistance provided and clinical integration useful; many young people achieved positive work and study outcomes, particularly those who engaged more times with the service. More assistance was sought for work than study goals, suggesting that the transition to work may be particularly challenging for young people. One-third (298/881, 33.8%) of the sample for the service impact analyses achieved at least 1 primary work or study outcome, and this increased to 44.5% (225/506) for those who engaged with 5 or more sessions, demonstrating that greater engagement with the service produced better outcomes.

CONCLUSIONS

Critical work and study support can be effectively delivered via an online modality to young people with common mental health problems. Digital services are scaleable to reach many young people and are of particular value for those with difficulty accessing in-person services.

Individual placement and support in Italian young adults with mental disorder: Findings from the Reggio Emilia experience

AIM

Individual placement and support (IPS) has a considerable body of evidence for its effectiveness in helping people with mental disorder to achieve and maintain competitive jobs. However, little data in young adult populations are currently available, especially in Europe. Aim of this study was to assess the effect of IPS in Italian young adults with moderate-to-severe mental illness, examining the main competitive employment outcomes and drop out rates during a 3-year follow-up period.

METHODS

Participants (n = 54) were recruited from patients receiving psychiatric treatment in one of the seven adult Community Mental Health Centers of the Reggio Emilia Department of Mental Health. Together with drop out rates, we investigated job duration (total number of days worked), job acquisition (employment in the labour market for at least 1 day during the follow-up), total hours per week worked, and job tenure (weeks worked on the longest-held competitive job).

RESULTS

A crude competitive employment rate of 40.7% and a crude drop out rate of 22.2% over the 3-year follow-up period were found. However, 66% of 42 clients who remained in the program over 3 years gained competitive employment at some time during the 3-year period.

CONCLUSIONS

This research shows the feasibility of an IPS intervention model in the public mental health care system in Italy, especially for a young adult target population.

Trajectories of occupational and social functioning in people with recent-onset non-affective psychosis enrolled in specialized early intervention services across New York state

BACKGROUND

Despite the benefits of early intervention services for the initial stages of psychosis ongoing impairments in functioning are common.

AIMS

To identify 1-year trajectories of occupational and social functioning in individuals enrolled in OnTrackNY, a statewide program offering early intervention services for recent-onset psychosis in community settings.

METHOD

We included 937 persons with recent-onset psychosis enrolled at 19 programs across New York State. Demographic, social and clinical data was collected at program entry and at 3, 6, 9 and 12 months. We used growth mixture models to identify occupational and social functioning trajectories and examined the association between trajectory class, baseline factors and symptoms during 1-year follow-up.

RESULTS

Four distinct trajectory classes of occupational and social functioning were identified. The converging (58.0%) class had disparate levels of functioning at baseline (low occupational, higher social) which eventually converged. The other classes had high-stable (14.8%), moderate-stable (17.8%) and low-improving (9.4%) trajectories. Female gender, educational attainment and private insurance status were significantly associated with the trajectory characterized by higher functioning, while living alone, homelessness, a longer period from psychosis onset to program enrollment, a schizophrenia diagnosis and cannabis use at enrollment were associated with the poorest trajectory. The differences in severity of symptoms by trajectory class diminished over time.

CONCLUSIONS

Trajectories of occupational and social functioning showed substantial variation, but overall, remained stable or improved during 1-year follow-up. The relationship between symptoms and occupational and social functioning attenuated after the acute treatment phase.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Enhancing return to work or school after a first episode of schizophrenia: the UCLA RCT of Individual Placement and Support and Workplace Fundamentals Module training

BACKGROUND

This study evaluated in a rigorous 18-month randomized controlled trial the efficacy of an enhanced vocational intervention for helping individuals with a recent first schizophrenia episode to return to and remain in competitive work or regular schooling.

METHODS

Individual Placement and Support (IPS) was adapted to meet the goals of individuals whose goals might involve either employment or schooling. IPS was combined with a Workplace Fundamentals Module (WFM) for an enhanced, outpatient, vocational intervention. Random assignment to the enhanced integrated rehabilitation program (N = 46) was contrasted with equally intensive clinical treatment at UCLA, including social skills training groups, and conventional vocational rehabilitation by state agencies (N = 23). All patients were provided case management and psychiatric services by the same clinical team and received oral atypical antipsychotic medication.

RESULTS

The IPS-WFM combination led to 83% of patients participating in competitive employment or school in the first 6 months of intensive treatment, compared with 41% in the comparison group (p < 0.005). During the subsequent year, IPS-WFM continued to yield higher rates of schooling/employment (92% v. 60%, p < 0.03). Cumulative number of weeks of schooling and/or employment was also substantially greater with the IPS-WFM intervention (45 v. 26 weeks, p < 0.004).

CONCLUSIONS

The results clearly support the efficacy of an enhanced intervention focused on recovery of participation in normative work and school settings in the initial phase of schizophrenia, suggesting potential for prevention of disability.

School-Based Approaches in Youth with Psychosis

A major recovery milestone for youth affected by psychosis is reintegration back into a school setting, an important, attainable, treatment goal. The emergence of psychosis often results in either an onset or exacerbation of prior neurocognitive and learning challenges for affected students. Gold standard practice in clinical care for psychosis comprises comprehensive supportive educational services explicitly focused on successful academic reintegration and achievement. This article discusses how providers can guide school teams and their institutions to identify psychosis in their student populations along with a delineation of key educational programming that helps youth reintegrate back into school and achieve academic success.

Can antipsychotic dose reduction lead to better functional recovery in first-episode psychosis? A randomized controlled-trial of antipsychotic dose reduction. The reduce trial: Study protocol

Antipsychotic medication has been the mainstay of treatment for psychotic illnesses for over 60 years. This has been associated with improvements in positive psychotic symptoms and a reduction in relapse rates. However, there has been little improvement in functional outcomes for people with psychosis. At the same time there is increasing evidence that medications contribute to life shortening metabolic and cardiovascular illnesses. There is also uncertainty as to the role played by antipsychotic medication in brain volume changes.

AIM

The primary aim of the study is, in a population of young people with first-episode psychosis, to compare functional outcomes between an antipsychotic dose reduction strategy with evidence-based intensive recovery treatment (EBIRT) group (DRS+) and an antipsychotic maintenance treatment with EBIRT group (AMTx+) at 24-months follow-up.

METHODS

Our single-blind randomized controlled trial, within a specialist early psychosis treatment setting, will test the whether the DRS+ group leads to better vocational and social recovery than, the AMTx+ group over a 2-year period in 180 remitted first-episode psychosis patients. Additionally, we will examine the effect of DRS+ vs AMTx+ on physical health, brain volume and cognitive functioning. This study will also determine whether the group receiving DRS+ will be no worse off in terms of psychotic relapses over 2 years follow-up.

RESULTS

This paper presents the protocol, rationale and hypotheses for this study which commenced recruitment in July 2017.

CONCLUSION

This study will provide evidence as to whether an antipsychotic dose-reduction recovery treatment leads to improved functioning and safer outcomes in first-episode psychosis patients. In addition, it will be the first-controlled experiment of the effect of exposure to antipsychotic maintenance treatment on brain volume changes in this population.

Improving vocational recovery among people with psychosis: a two-pronged approach

Purpose

This paper aims to investigate the feasibility of conducting research on a two-pronged vocational intervention for people with first episode psychosis. The paper also aims to empirically examine the impact of a two-pronged vocational intervention for people with first episode psychosis by determining what effect, if any, introducing a two-pronged vocational intervention to an early intervention for psychosis service (EIPS) has on vocational outcomes using a prospective follow-up design. The approach consisted of supported employment (individual placement and support, IPS) for participants without a productive role and a job retention programme for those employed or studying.

Design/methodology/approach

Between 2010 and 2013, a supported employment specialist joined an EIPS where occupational therapy was available to all attenders. The appropriate intervention was determined by the occupational therapist on the team. Participants were interviewed at baseline and one follow-up. Ethical approval was attained. The Individual Placement and Support Fidelity Scale was used to ensure the quality of IPS implementation.

Findings

In total, 39 (20 men, 19 women) consented; 21 (54 per cent) of these participants were unoccupied; 18 (46 per cent) had a productive role; 87 per cent (n= 34) were followed up. The mean length of follow-up was 18 months. At follow-up, 50 per cent (n= 10) of unoccupied participants had attained a productive role, and 17 of the 18 participants had retained their productive role. Overall, participants were found to have spent an average of 62 per cent of the follow-up period in a productive role.

Research limitations/implications

Rates of vocational recovery among people affected by psychosis may be enhanced by a two-pronged approach that allows for the persons individual work circumstances to be taken into account.

Originality/value

This study highlights the impact of a two-progroned vocational intervention for people with first episode psychosis in Ireland. It is the first study of its kind to be published in the Republic of Ireland and the first world-wide to include a job retention element in its design.

Factors associated with vocational disengagement among young people entering mental health treatment

AIM

Most mental disorders have their onset by age 25, disrupting normative vocational engagement. Factors associated with vocational disengagement at first contact with specialist treatment are important for service planning. The aim of this paper was to investigate the association between theoretically important factors and vocational disengagement for youth entering mental health treatment.

METHODS

A file audit was used to extract vocational data of 145 young people aged 15 to 25 years entering treatment in 2011 at a public youth mental health service in Melbourne, Australia. Comparisons were made across three specialist programs for: psychosis (n = 50), mood disorders (n = 52) and borderline personality pathology (n = 43). Individual characteristics were entered into univariate and multivariate logistic regressions to investigate their associations with vocational disengagement.

RESULTS

Educational disengagement was associated with being older (OR = 4.38, P = 0.004) and not living with parents (OR = 2.87, P = 0.038). Unemployment and being NEET (Not in Education, Employment or Training) were both associated with not having commenced tertiary education (OR = 0.23, P = 0.022; OR = 0.05, P = 0.002; respectively). Being NEET was also associated with being older (OR = 6.18, P = 0.004). Primary diagnostic grouping was not associated with vocational disengagement, once accounting for other factors.

CONCLUSIONS

The likelihood of vocational disengagement did not differ across disorder groups, implying that intervention should be "transdiagnostic" and might best target education first, specifically post-secondary qualifications. Other domains or variables not measured in this study are also likely to be important, and this might include young people's support systems and symptom severity. Qualitative studies may be useful for exploring further factors relevant to vocational engagement.

The rates and determinants of disengagement and subsequent re-engagement in young people with first-episode psychosis

BACKGROUND

A core component of treatment provided by early intervention for psychosis (EI) services is ensuring individuals remain successfully engaged with the service. This ensures they can receive the care they may need at this critical early stage of illness. Unfortunately, rates of disengagement are high in individuals with a first episode of psychosis (FEP), representing a major barrier to effective treatment. This study aimed to ascertain the rates and determinants of disengagement and subsequent re-engagement of young people with FEP in a well-established EI service in Melbourne, Australia.

METHOD

This cohort study involved all young people, aged 15-24, who presented to the Early Psychosis Prevention and Intervention Centre (EPPIC) service with FEP between 1st January 2011 and 1st September 2014. Data were collected retrospectively from clinical files and electronic records. Cox regression analysis was used to identify determinants of disengagement and re-engagement.

RESULTS

A total of 707 young people presented with FEP during the study period, of which complete data were available for 700. Over half of the cohort (56.3%, N = 394) disengaged at least once during their treatment period, however, the majority of these individuals (85.5%, N = 337) subsequently re-engaged following the initial episode of disengagement. Of those who disengaged from the service, 54 never re-engaged, representing 7.6% of the total cohort. Not being in employment, education or training, not having a family history of psychosis in second degree relatives and using cannabis were found to be significant predictors of disengagement. No significant predictors of re-engagement were identified.

CONCLUSION

In this study, the rate of disengagement in young people with first-episode psychosis was higher than found previously. Encouragingly, rates of re-engagement were also high. The concept of disengagement from services might be more complex than previously thought with individuals disengaging and re-engaging a number of times during their episode of care. What prompts individuals to re-engage with services needs to be better understood.

Contribution of neurocognition to 18-month employment outcomes in first-episode psychosis

AIM

To examine whether baseline neurocognition predicts vocational outcomes over 18 months in patients with first-episode psychosis enrolled in a randomized controlled trial of Individual Placement and Support or treatment as usual.

METHODS

One-hundred and thirty-four first-episode psychosis participants completed an extensive neurocognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying structure of the battery. Setwise (hierarchical) multiple linear and logistic regressions were used to examine predictors of (1) total hours employed over 18 months and (2) employment status, respectively. Neurocognition factors were entered in the models after accounting for age, gender, premorbid IQ, negative symptoms, treatment group allocation and employment status at baseline.

RESULTS

Five neurocognitive factors were extracted: (1) processing speed, (2) verbal learning and memory, (3) knowledge and reasoning, (4) attention and working memory and (5) visual organization and memory. Employment status over 18 months was not significantly predicted by any of the predictors in the final model. Total hours employed over 18 months were significantly predicted by gender (P = .027), negative symptoms (P = .032) and verbal learning and memory (P = .040). Every step of the regression model was a significant predictor of total hours worked overall (final model: P = .013).

CONCLUSION

Verbal learning and memory, negative symptoms and gender were implicated in duration of employment in first-episode psychosis. The other neurocognitive domains did not significantly contribute to the prediction of vocational outcomes over 18 months. Interventions targeting verbal memory may improve vocational outcomes in early psychosis.

Social inclusion and its interrelationships with social cognition and social functioning in first-episode psychosis

AIM

People with psychosis are at risk of social exclusion. Research is needed in this area due to the lack of direct measurement of social inclusion, which becomes salient in adolescence and is relevant to first-episode psychosis (FEP; the onset of which typically occurs during or shortly after adolescence). Social inclusion may be impacted by impaired social cognition and social functioning, which are related features observed in psychosis. The aim of this study was to explore interrelationship(s) between social cognition, social functioning and social inclusion in FEP while controlling for symptomatology (positive, negative and depressive symptoms) and demographic characteristics.

METHODS

A series of cross-sectional hierarchical multiple regressions were conducted to examine whether: social cognition (theory of mind, emotion recognition) predicted social functioning; social functioning predicted social inclusion, and whether social functioning mediated the relationship between social cognition and social inclusion in people aged 15 to 25 (M = 20.49, SD = 2.41) with FEP (N = 146). Age, sex, premorbid IQ, positive and negative psychotic symptoms and depression were control variables.

RESULTS

Poor facial emotion recognition (β = -.22, P < .05) and negative symptoms (β = -.45, P < .001) predicted lower social functioning. Role-specific social functioning (ie, current employment) predicted greater social inclusion (β = .17, P < .05). Higher depression symptomatology predicted lower social inclusion (β = -.43, P < .001). Social functioning did not mediate the relationship between social cognition and inclusion. Psychotic symptoms were unrelated to social inclusion.

CONCLUSIONS

Employment and depression may influence social inclusion somewhat independently of psychotic symptomatology in FEP. Inferences should be viewed with caution given this study did not involve longitudinal data.

Vocational engagement among young people entering mental health treatment compared with their general population peers

AIM

To compare rates of vocational engagement for youth entering specialist mental health treatment with the general population.

METHODS

A file audit retrieved vocational data for 145 youth aged 15 to 25 entering treatment. Clinical and population data were stratified by age and sex and compared between cohorts.

RESULTS

Compared to the population, young people entering mental health treatment were less likely to have completed at least Year 11 in school (77% vs 42%, P < 0.001); and demonstrated higher rates of "Not in Education, Employment or Training" (9% vs 33%, P < 0.001). Individuals aged 15 to 18 years entering treatment experienced greater rates of educational disengagement than the population (30% vs 11%, P < 0.001), whereas people aged 19 to 25 years showed higher unemployment rates (52% vs 35%, P = 0.003).

CONCLUSIONS

Youth entering specialist mental health treatment have marked levels of vocational disengagement compared to demographically-matched peers. Early vocational intervention for these young people is essential.

Outcomes of an individual placement and support programme incorporating principles of the collaborative recovery model

INTRODUCTION

Engaging in employment enhances mental health recovery and is therefore of central focus for many occupational therapists working in mental health. Individual placement and support (IPS) is an evidence-based, supported employment model specifically designed for individuals with severe mental illness who have the desire to work. Despite strong support for IPS in Australia, implementation challenges have been encountered. This study evaluates outcomes achieved by participants engaged with WorkWell, an IPS programme delivered by a large Australian non-government organisation. In addition to following IPS principles, WorkWell was informed by principles of the collaborative recovery model (CRM).

METHOD

De-identified outcomes data for each participant were analysed by an independent research team. The proportion of individuals engaged with the programme who achieved a competitive employment placement was calculated. Average employment duration and weekly wages were calculated for individuals who achieved a competitive employment placement. Finally, the proportion of individuals who achieved some form of vocationally relevant outcome was calculated.

RESULTS

Ninety-seven participants were engaged with the programme. Forty-eight participants (49.5%) gained a competitive employment position. Average employment duration was 151 days (21.6 weeks) and average weekly wage was $478. Overall, 62 participants (63.9%) were supported to achieve some kind of vocationally relevant outcome (e.g. competitive employment, education, work trial or voluntary work) as a result of their engagement with the programme.

CONCLUSION

While the addition of CRM principles appears to have supported positive outcomes for participants, especially in terms of employment duration, results for employment placement rates were lower than expected. While the employment placement rate compares favourably to results from the international literature and numerous programmes in Australia, more development is required to increase the proportion of individuals who are supported into competitive employment positions. Future research should focus on the specific elements of CRM that most contribute to enhancing IPS processes.

"What is the efficacy of specialised early intervention in mental health targeting simultaneously adolescents and young adults?'' An HTA

OBJECTIVES

Current service organization is not adapted for youth with or at risk of mental illness. Access, engagement and continuity of care are notorious challenges, particularly during transition from adolescence to adulthood, when youths are transferred to adult services. An HTA was initiated to evaluate the efficacy of programs for which admission is not a function of the legal age of majority.

METHODS

A systematic review of systematic reviews identified literature published between 2000 and 2017 in 4 databases. To be selected, studies had to focus on specialised mental healthcare early intervention (EI) programs targeting both adolescents and young adults. Contextual and experiential data were collected through interviews with local leading experts. Article selection and quality assessment using ROBIS were conducted with inter rater agreement. The analytical framework developed includes 4 domains: access, engagement and continuity, recovery as well as meaningfulness and acceptability.

RESULTS

1841 references were identified. Following inclusion/exclusion criteria, 5 studies were selected, 3 of which focused on EI for psyschosis. EI programs alone do not seem to decrease duration of untreated psychosis. EI including a multi focus campaign were more successful. EI does, however, seem to decrease hospitalisation for psychosis. The experience of service users and professionals with inter agency collaboration and person-centred care models were analysed to identify facilitating and inhibiting implementation factors.

CONCLUSIONS

Healthcare policies need to support further research and development of EI where admission is not a function of the legal age of majority and diagnostic, particularly for youths at risk.

How to help homeless youth suffering from first episode psychosis and substance use disorders? The creation of a new intensive outreach intervention team

In Canada, about 6,000 youth are homeless every night, many of whom suffer from addiction and psychotic disorders. To facilitate the exit out of homelessness, access to care and to improve psychosis and addiction outcomes, a new intensive outreach intervention team (EQIIP SOL) was created in Montreal (2012). It offers intensive outreach services dedicated to homeless youth suffering from first episode psychosis and addiction (HYFEPA) in addition to an early psychosis intervention service (EIS) in collaboration with the Addiction Psychiatry Unit. Our aim is to describe the characteristics, clinical, functional and housing outcomes of HYFEPA followed by EQIIP SOL. This two years long prospective longitudinal study with all HYFEPA (n = 42) admitted to EQIIP SOL between 2012-2015 reports at multiple time points, clinical (CGI, GAF), functional (SOFAS, work/study, housing autonomy) and substance use disorder (DUS, AUS) outcomes and acute services use (hospitalizations, emergency room visits). We observed that, at baseline, HYFEPA showed poor prognostic factors (eg. cluster B personality, substance use disorders, legal problems, childhood trauma and lower education level). The majority reached housing stability after 6 months and their functioning and illness severity improved with time. This suggests that HYFEPA improve with an intensive outreach intervention team integrated to an EIS.

Implementation and fidelity assessment of the NAVIGATE treatment program for first episode psychosis in a multi-site study

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.

Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial

BACKGROUND

High unemployment is a hallmark of psychotic illness. Individual placement and support (IPS) may be effective at assisting the vocational recoveries of young people with first-episode psychosis (FEP).AimsTo examine the effectiveness of IPS at assisting young people with FEP to gain employment (Australian and Clinical Trials Registry ACTRN12608000094370).

METHOD

Young people with FEP (n = 146) who were interested in vocational recovery were randomised using computer-generated random permuted blocks on a 1:1 ratio to: (a) 6 months of IPS in addition to treatment as usual (TAU) or (b) TAU alone. Assessments were conducted at baseline, 6 months (end of intervention), 12 months and 18 months post-baseline by research assistants who were masked to the treatment allocations.

RESULTS

At the end of the intervention the IPS group had a significantly higher rate of having been employed (71.2%) than the TAU group (48.0%), odds ratio 3.40 (95% CI 1.17-9.91, z = 2.25, P = 0.025). However, this difference was not seen at 12- and 18-month follow-up points. There was no difference at any time point on educational outcomes.

CONCLUSIONS

This is the largest trial to our knowledge on the effectiveness of IPS in FEP. The IPS group achieved a very high employment rate during the 6 months of the intervention. However, the advantage of IPS was not maintained in the long term. This seems to be related more to an unusually high rate of employment being achieved in the control group rather than a gross reduction in employment among the IPS group.Declaration of interestNone.

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.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Rates, determinants and outcomes associated with the use of community treatment orders in young people experiencing first episode psychosis

BACKGROUND

Community treatment orders (CTOs) are a controversial form of involuntary treatment for individuals affected by mental health disorders and yet little is known about the use of CTOs in first presentations. Therefore, this study aimed to determine the rates, determinants and outcomes associated with the use of CTOs in young people with a first episode of psychosis (FEP).

METHODS

This epidemiological cohort study included all individuals aged 15-24 who presented with a FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne between 01.01.2011 and 31.12.13.

RESULTS

A total of 544 young people presented with a FEP during the study period and of these, 93 (17.3%) were subject to a CTO during their episode of care. A total of 69.7% of CTOs were commenced after the first three months of treatment and the median duration of CTOs was 168.5 days. Males, a diagnosis of a schizophrenia spectrum disorder and a concurrent substance abuse disorder were associated with the use of CTOs. Additionally, young people with more severe positive psychotic symptoms were more likely to be subject to a CTO. At the time of discharge, only 38.7% of those subject to a CTO were in education or employment compared to 65.4% of those who had not been subject to a CTO.

CONCLUSIONS

The majority of CTOs are commenced after at least three months of treatment, however the optimal timing of CTO implementation needs to be determined. The poor functioning of young people on a CTO should be the focus of future interventional studies.

The Provision of Education and Employment Support At the Outreach and Support in South London (OASIS) Service for People at Clinical High Risk for Psychosis

Clinical services for the early detection of individuals at clinical high risk of psychosis, such as Outreach and Support in South-London (OASIS), have been successful in providing psychological intervention and psychosocial support to young people experiencing emerging signs of serious mental disorders. Despite this, several studies have repeatedly shown that vocational and functional recovery in the clinical high risk for psychosis population is still low. This study aimed at evaluating the presence and nature of educational and employment focused interventions within the OASIS service, in order to inform research and clinical interventions aimed at supporting young people with early signs of psychosis on their path to vocational recovery. The specific objectives were to compare current practice i) to standards defined by the National Institute of Care Excellence guidelines; and ii) to principles defined by Individual Placement and Support (IPS). Nine standards of practice were derived. The OASIS caseload electronic records entered between January 2015 and January 2017 were manually screened. Data collected include sociodemographic, assessment of employment and educational status and support needs, interventions received, contacts with schools, employers and external vocational providers, employment, and educational status. Standards were considered as "met" if they were met for at least 90% of clients. Results suggest that, two out of nine standards were met while the remaining standards were only partially met. In particular, support provided was always focused on competitive employment and mainstream education and support was always based on people's interest. Implications for clinical and research practice are discussed.

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Career Services for Young Adults with Serious Mental Health Conditions: Innovations in the Field

This study examined careers services provided to young adults with serious mental health conditions. Based on an internet survey and key informant telephone interview of 31 programs nominated for delivering innovative practices for young adults, the state of the field for career services was described. Most programs offered supported education and supported employment along with mental health services. Detailed and written planning was a key feature. Programs emphasized working closely with families, inter-agency collaboration, and use of normative community resources. Programs provided direct skills training for school and work and other life skills. Largely, existing models are being applied. However, providers described unique adaptations including greater flexibility in service delivery, attending to the turbulence and developmental changes characteristic of this age group, use of social media, and a heightened willingness to meet young people where "they are at" both literally and figuratively.

Vocational support in mental health service delivery in Australia

BACKGROUND

Individuals experiencing severe and persistent mental illness report a desire to gain and sustain work. Individual Placement and Support (IPS) is an evidence-based approach to vocational rehabilitation to support competitive employment outcomes.

AIM/OBJECTIVE

This study aimed to evaluate whether a joint-governance management partnership, between a clinical adult mental health and an employment service, could deliver a sustained IPS program in Australia.

MATERIALS AND METHOD

The methodology entailed a Clinical Data Mining approach, to examine records from seven years of implementation of IPS in one setting within an Australian public mental health service context.

RESULTS/FINDINGS

Despite the prevalence of schizophrenia spectrum diagnoses and an older mean age (39 years), indicating that a large proportion of the cohort had experienced serious mental illness for over twenty years, findings were that 46.3% of participants achieved employment.

CONCLUSIONS

This is an excellent result and is comparable to the only randomised control trial, with adult services, in the Australian context, which found a 42.5% employment rate possible under IPS compared with just 23.5% with referral to external employment services.

SIGNIFICANCE

More extensive trialling of IPS across clinical services is required, in Australia and internationally, including fidelity protocols, for knowledge translation to be achieved.