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

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

DISCUSSION

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

OTHER

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

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effects of an interdisciplinary employment program on paid employment and mental health among persons with severe mental disorders

PURPOSE

This study evaluates the effects of the interdisciplinary employment program 'Work As Best Care (WABC)' on employment participation and mental health of persons with severe mental disorders.

METHODS

WABC is a 'work first' employment program for unemployed persons with severe mental disorders in which employment professionals work closely together with mental health professionals. In a longitudinal non-randomized controlled study, participants of WABC (n = 35) are compared with participants of the control group (n = 37), who received regular employment support. Participants were followed for 1 year and filled out questionnaires on individual characteristics and health at baseline, after 6 and 12 months. This information was enriched with monthly register data on employment status from 2015 until 2020. Difference-in-differences analyses were performed to investigate changes in employment participation among participants of WABC and the control group. A generalized linear mixed-effects model was used to compare changes in mental health (measured on 0-100 scale) between the two groups.

RESULTS

Before WABC, employment participation was 22.0%points lower among participants of WABC compared to the control group. After starting WABC, employment participation increased with 15.3%points per year among participants of WABC, compared to 5.6%points in the control group. Among all participants of WABC, no change in mental health was found (β 1.0, 95% CI - 3.4; 5.5). Only female participants of WABC showed a significant change in mental health (β 8.0, 95% CI 2.6; 13.4).

CONCLUSION

To enhance employment participation of persons with severe mental disorders, an interdisciplinary 'work-first' approach in which professionals of employment services and mental health services work in close collaboration, is of paramount importance.

A Mixed-Methods Implementation Evaluation of Virtual Reality Job Interview Training in IPS Supported Employment

OBJECTIVE

Employment rates among individuals with serious mental illness may be improved by engagement in the individual placement and support (IPS) model of supported employment. Results from a recent randomized controlled trial (RCT) indicate that virtual reality job interview training (VR-JIT) improves employment rates among individuals with serious mental illness who have been actively engaged in IPS for at least 90 days. This study reports on an initial implementation evaluation of VR-JIT during the RCT in a community mental health agency.

METHODS

A sequential, complementary mixed-methods design included use of qualitative data to improve understanding of quantitative findings. Thirteen IPS staff trained to lead VR-JIT implementation completed VR-JIT acceptability, appropriateness, and feasibility surveys. Participants randomly assigned to IPS with VR-JIT completed acceptability (N=42) and usability (N=28) surveys after implementation. The authors also conducted five focus groups with IPS staff (N=11) and VR-JIT recipients (N=13) and semistructured interviews with IPS staff (N=9) and VR-JIT recipients (N=4), followed by an integrated analysis process.

RESULTS

Quantitative results suggest that IPS staff found VR-JIT to be highly acceptable, appropriate for integration with IPS, and feasible for delivery. VR-JIT was highly acceptable to recipients. Qualitative results add important context to the quantitative findings, including benefits of VR-JIT for IPS staff as well as adaptations for delivering technology-based interventions to individuals with serious mental illness.

CONCLUSIONS

These qualitative and quantitative findings are consistent with each other and were influenced by VR-JIT's adaptability and perceived benefits. Tailoring VR-JIT instruction and delivery to individuals with serious mental illness may help optimize VR-JIT implementation within IPS.

Associations between Social Adversities and Chronic Medical Conditions in a Statewide Sample of Individuals in Treatment for Mental Illnesses

Individuals with mental illnesses experience disproportionately high rates of social adversities, chronic medical conditions, and early mortality. We analyzed a large, statewide dataset to explore associations between four social adversities and the presence of one or more, and then two or more, chronic medical conditions among individuals in treatment for mental illnesses in New York State. In Poisson regression models adjusting for multiple covariates (e.g., gender, age, smoking status, alcohol use), the presence of one or more adversities was associated with the presence of at least one medical condition (prevalence ratio (PR) = 1.21) or two or more medical conditions (PR = 1.46), and two or more adversities was associated with at least one medical condition (PR = 1.25) or two or more medical conditions (PR = 1.52) (all significant at p < .0001). Greater attention to primary, secondary, and tertiary prevention of chronic medical conditions is needed in mental health treatment settings, especially among those experiencing social adversities.

Employment Interventions for People With Intellectual and Developmental Disabilities: A Delphi Study of Stakeholder Perspectives

The purpose of this study was to examine the social validity of five different evidence-based and emerging pathways to employment (i.e., supported employment, customized employment, internships, apprenticeships, and postsecondary education) from the perspective of multiple stakeholders. A Delphi method was used to determine whether stakeholders are in consensus regarding the accessibility, affordability, acceptability, efficacy, and the cost-benefit ratio of these interventions. Findings indicated that all pathways were deemed socially valid via stakeholder consensus except for apprenticeships, which could not be determined as a result of limited stakeholder knowledge and experience with the pathway. Future efforts to improve employment outcomes for people with intellectual and developmental disabilities (IDD) should focus on better training for service providers and increased access to services.

Importance of occupational support for NHS patients with mental illness

BACKGROUND

Unemployment is a structural inequality which raises the risk of premature deaths among people with mental illness.

AIMS

This study examined whether UK National Health Service (NHS) patients with mental illness get support to find or keep a job because reducing unemployment rates can reduce the risk of premature mortality.

METHODS

This study analysed recently released data from 54 NHS trusts which randomly sampled patients for a Care Quality Commission survey. This study assessed 11 001 working-age patients with mental illness, of whom 50% are long-term service users (6+ years).

RESULTS

Perceived access to occupational support was poor with 46% of patients who wanted the support saying that they did not get help finding or returning to work. Perceived occupational support for physical co-morbidities needed improvement because 40% of patients with physical co-morbidities did not receive support for physical health needs. Twenty-five per cent said that medication side effects were not discussed, and 24% lacked medication follow-up although 87% of patients found medication beneficial to their mental health. Occupational support significantly benefited overall patient satisfaction to an equivalent extent as the main treatment (i.e. receiving medication and talking therapies), and it was a more consistent predictor of patient satisfaction than talking therapies.

CONCLUSIONS

Improved access to schemes which reduce unemployment among NHS patients with mental illness is needed (e.g. individual placement and support programmes), although limited availability might be due to funding constraints. As well as addressing unemployment, occupational support should address other risk factors for premature mortality, for example, poverty, stigma, discrimination and social exclusion.

Perspectives on implementing Individual Placement and Support (IPS) within primary health care settings for adults living in British Columbia, Canada

BACKGROUND

Individual placement and support (IPS) is an evidence-based practice (EBP) designed to help people with severe mental illness re-enter the labour market. Implementing an IPS program within a new context (e.g., primary health care setting) to support populations that are complex and multi-barriered presents a set of unique challenges and considerations. This paper provides community-based perspectives that identify implementation strengths and challenges and highlights potential strategies aimed at addressing emergent barriers.

METHODS

A case study was conducted across three community health centres in British Columbia (BC), Canada, where a novel IPS program was embedded within primary care services. Data collection consisted of open-ended surveys and focus groups with service providers directly involved in program implementation and their associated clinical and managerial support teams (n = 15). Using the updated Consolidated Framework for Implementation Research (CFIR) as a guide, we performed deductive thematic analysis to identify key areas impacting IPS implementation.

RESULTS

Integration with existing health care systems and primary health care teams and support from leadership across all levels were identified as both key facilitators and barriers to implementation. Facilitators and barriers were identified across all domains, with those within innovation and process most easily addressed. Four cross-cutting themes emerged for promoting more integrated and sustainable program implementation: investing in pre-implementation activities, supporting a dynamic and flexible program, building from community experiences, and developing a system for shared knowledge.

CONCLUSIONS

Implementing an IPS program embedded within primary health care settings is complex and requires extensive planning and consultation with community-based service providers and decision-makers to achieve full integration. Future practice and policy decisions aimed at supporting employment and well-being should be made in collaboration with communities.

Main activity trajectory clusters of unemployed people with partial work ability and cluster features

BACKGROUND

The early identification of different subgroups of individuals with partial work ability is important for the development of appropriate and effective services in order to prevent exclusion from working life and prolongation of unemployment.

AIMS

This study aimed to identify different main activity trajectory clusters of people with partial work ability before their participation in work ability support services and to examine sociodemographic, health, work ability and functioning features of the identified clusters.

METHODS

The sample consisted of clients who had participated in the Finnish Work Ability Programme during 2020-2022. Using the main activity data spanning from 2005 to 2021, optimal matching was applied to examine the similarity between the participants' main activity trajectories. Second, using cluster analysis, participants were categorised into four main activity trajectory clusters. Finally, the sociodemographic, health, work ability and functioning features of clusters were examined.

RESULTS

A total of 643 individuals participated in the study. Four clusters were identified: (a) early-onset retirement, (b) from studies to outside the workforce, (c) from employment to unemployment and (d) long-term employment. Individuals in the 'early-onset retirement' cluster had the best perceived work ability and functioning. Problems relating to health, work ability, functioning and well-being were highlighted in the 'from employment to unemployment' cluster.

CONCLUSIONS

Unemployed individuals with partial work ability form a heterogeneous population who often have several different underlying reasons for decreased work ability. Multiple data sources are needed to identify the special characteristics and needs of the people with partial work ability.

Social representations of gender and their influence in Supported Employment: employment specialists' experiences in Sweden

PURPOSE

Gender differences have been found in the outcomes of vocational rehabilitation (VR) and in Supported Employment (SE), therefore, the purpose of this study was to explore employment specialists' (ES) social representations of gender in relation to work and VR and how these social representations influence the ES's work in the VR process according to SE.

METHODS

The qualitative method of focus group discussions was employed. Ten focus groups were held with 39 ESs from four categories of SE organizations in Sweden. Topic analysis was applied to the transcribed material from the focus groups.

RESULTS

Five themes with different social representations about gender and disability in relation to VR and working life formed in the analysis: (1) differences in personal and health factors among VR-participants, (2) gender norms in society influencing VR, (3) energy-intensive environmental issues influencing VR, (4) gender-specific interactions in VR, and (5) gendered paths in the welfare system.

CONCLUSION

Social representations of higher strains on women with disabilities compared to men with disabilities both in private and working life, which reflect the lived experiences of the ESs, is a possible explanation for gender differences in VR and working life for persons with disabilities.IMPLICATIONS FOR REHABILITATIONGender differences in the outcomes of vocational rehabilitation (VR) interventions have been noticed worldwide. In this study, pervasive social representations about gender and disability in relation to VR were found, but also unconsciousness about gender among VR professionals. Therefore, awareness of gender is necessary in VR.Individualized and person-centered approaches to VR like Supported Employment, although considered best practice, might hide structures like gender, which could lead to reproducing discriminating processes and therefore not achieving gender equality in VR. Therefore, knowledge of discrimination is important in VR.Gender-sensitivity in vocational rehabilitation models with a person-centered and individualized approach is needed and there might also be a need to systematically tailor vocational rehabilitation models to reach gender equality in the outcomes of the interventions. Therefore, gender equality indicators are needed for VR models, to evaluate model effectiveness from a gender perspective.

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

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

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.

The Patient Journey of Schizophrenia in Mental Health Services: Results from a Co-Designed Survey by Clinicians, Expert Patients and Caregivers

BACKGROUND

The Patient Journey Project aims to collect real-world experiences on schizophrenia management in clinical practice throughout all the phases of the disorder, highlighting virtuous paths, challenges and unmet needs.

METHODS

A 60-item survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the patient's journey, focusing on three areas: early detection and management, acute phase management and long-term management/continuity of care. For each statement, the respondents expressed their consensus on the importance and the degree of implementation in clinical practice. The respondents included heads of the Mental Health Services (MHSs) in the Lombardy region, Italy.

RESULTS

For early diagnosis and management, a strong consensus was found; however, the implementation degree was moderate-to-good. For acute phase management, a strong consensus and a good level of implementation were found. For long-term management/continuity of care, a strong consensus was found, but the implementation level was slightly above the cut-off, with 44.4% of the statements being rated as only moderately implemented. Overall, the survey showed a strong consensus and a good level of implementation.

CONCLUSIONS

The survey offered an updated evaluation of the priority intervention areas for MHSs and highlighted the current limitations. Particularly, early phases and chronicity management should be further implemented to improve the patient journey of schizophrenia patients.

Mental health and unemployment: A systematic review and meta-analysis of interventions to improve depression and anxiety outcomes

BACKGROUND

Unemployment is associated with substantially greater depression and anxiety, constituting a considerable public health concern. The current review provides the most comprehensive synthesis to date, and first meta-analysis, of controlled intervention trials aimed at improving depression and anxiety outcomes during unemployment.

METHODS

Searches were conducted within PsycInfo, Cochrane Central, PubMed and Embase from their inception to September 2022. Included studies conducted controlled trials of interventions focused on improving mental health within unemployed samples, and reported on validated measures of depression, anxiety, or distress (mixed depression and anxiety). Narrative syntheses and random effects meta-analyses were conducted among prevention- and treatment-level interventions for each outcome.

RESULTS

A total of 39 articles reporting on 33 studies were included for review (sample sizes ranging from 21 to 1801). Both prevention and treatment interventions tended to be effective overall, with treatment interventions producing larger effect sizes than prevention interventions. The clearest evidence for particular intervention approaches emerged for prevention-level Cognitive Therapy/CBT, followed by prevention-level work-related interventions, although neither produced entirely consistent effects.

LIMITATIONS

Risk of bias was generally high across studies. Low numbers of studies within subgroups precluded any comparisons between long-term and short-term unemployment, limited comparisons among treatment studies, and reduced the power of meta-analyses.

CONCLUSIONS

Both prevention- and treatment-level mental health-focused interventions have merit for reducing symptoms of anxiety and depression among those experiencing unemployment. Cognitive Therapy/CBT and work-related interventions hold the most robust evidence base, which can inform both prevention and treatment strategies implemented by clinicians, employment services providers, and governments.

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

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

Job retention for people with bipolar disorder: A qualitative analysis

At least half of people with bipolar disorder, whose global prevalence is greater than 1% of the general population, do not have a stable occupation. The objective of this study is to identify the factors perceived by bipolar people as having an impact on retention in employment. Semi-directed individual interviews were offered to subjects with bipolar disorder, of working age, who had been seen by three different hospital departments in the south of France. These people had to be medically stable and have at least one occupational experience. Each interview was recorded and transcribed manually and then analyzed according to a thematic classification of verbatims. Nineteen people participated in the interviews. Three major themes identified were classified into intrinsic (working routine and working environment) and extrinsic (external aids) factors for the bipolar person. The majority believe that working regular hours is a balancing factor. For everyone, night work and stress factors can lead to relapses. All stressed the need to destigmatize the disease. Most believe that it is necessary to develop employment support organizations specific to mental illnesses. This research helps to inform people with bipolar disorder about the occupational factors that help balance their condition. Personalized multidisciplinary care pathways involving occupational medicine must be developed in order to promote the balance of the disease and job retention.

Predictors of return to work for people on sick leave with depression, anxiety and stress: secondary analysis from a randomized controlled trial

PURPOSE

Knowledge about predictors of return to work (RTW) in people on sick leave with common mental disorders (CMDs) may inform the development of effective vocational rehabilitation interventions for this target group. In this study, we investigated predictors of RTW at 6 and 12 months in people on sick leave with depression, anxiety disorders or stress-related disorders.

METHODS

We have performed a secondary analysis, utilizing data from two RCTs that evaluated the efficacy of an integrated health care and vocational rehabilitation intervention. Data were obtained from mental health assessments, questionnaires and registers. Using Cox regression analysis, the relationship between baseline variables and RTW was analysed at 6 and 12 months after randomization within the group of CMD as a whole and within the subgroups of depression, anxiety and stress-related disorders.

RESULTS

Symptom burden and employment status at baseline predicted RTW in the CMD group (n = 1245) and in the three diagnostic subgroups at both time points. RTW self-efficacy predicted RTW in the depression group but not in the anxiety or stress subgroups.

CONCLUSION

Many predictors of RTW were similar over time and, to some extent, across the CMD subgroups. Findings highlight the need not only to take health-related and psychological factors into account when developing vocational rehabilitation interventions but also to consider workplace strategies and options for support.

Intersectoral and multisectoral approaches to enable recovery for people with severe mental illness in low- and middle-income countries: A scoping review

The needs of people with severe mental illness are complex and require a range of services embedded in well-coordinated systems of care to enable recovery, promote well-being and optimise social integration. The concept of recovery is strongly rooted in the centrality of multi and intersectoral systems of care, and, while multi and -intersectoral dimensions of mental health systems have been highlighted in analyses focusing on high-income regions, little has been elaborated in terms of these approaches in the recovery of people with severe mental illness (SMI) in low- and middle-income countries (LMICs). The aim of this review was to identify and describe multi and intersectoral approaches underpinning community-based SMI recovery interventions in LMICs. A scoping review was carried out following the following steps: (1) Objectives for the review were developed and refined; (2) A systematic search of databases (EbscoHost, PubMed, Google Scholar) and previous reviews were undertaken from 2012 to 2022, where relevant papers were identified; (3) Papers with a focus on SMI and recovery, a specific description of an intervention, located in LMICs, with explicit linkages between sectors, and published in English, were selected for inclusion; (4) Data were extracted and charted and (5) Findings were analysed and reported thematically. Thirty-six papers were included for analysis, from 18 countries, including qualitative studies, trials, desktop and secondary data reviews and case studies. Examples of multi- and intersectoral action included collaboration between healthcare and community support systems, collaboration in providing supported housing and supportive community spaces for recovery, and linkages between biomedical and social spheres of care. Barriers included the dominance of mental health professions in delivering care, community-based stigmatising attitudes towards SMI. Multi- and intersectoral collaboration for SMI recovery requires investments in financing, education and coordination by a governing body.

Adding Cognitive Remediation to Employment Support Services: A Randomized Controlled Trial

OBJECTIVE

Individual placement and support (IPS) is an evidence-based strategy that helps individuals with mental illness obtain and maintain competitive employment. Despite the approach's overall success, almost half of IPS clients do not find work. Impairment in cognitive abilities may hamper employment and limit the benefits from rehabilitation services such as IPS. This randomized controlled trial aimed to assess the effects of adding cognitive remediation therapy (CRT) for IPS clients who had difficulties finding employment.

METHODS

At 14 mental health centers in Canada, 97 clients who had not found work after 3 months of receiving IPS services were recruited. Consenting clients were randomly assigned to either continue IPS alone or receive CRT added to IPS. The CRT used the Thinking Skills for Work protocol, a 12-week program that included computerized cognitive exercises along with coping strategies for managing cognitive challenges.

RESULTS

Participants completed on average 10 of 12 individual training sessions in coping strategies and 12 of 24 computerized training sessions. The addition of CRT to IPS resulted in significantly more participants working at the 3-month (odds ratio [OR]=2.83, 95% confidence interval [CI]=1.22-6.60) and 9-month follow-ups (OR=2.91, 95% CI=1.27-6.65). Participants who received CRT worked more hours and earned more in wages than those receiving IPS alone over the 9-month follow-up period. Both groups showed significantly improved cognitive outcomes at the 3-month follow-up, with no time × group interaction.

CONCLUSIONS

Cognitive remediation, especially skills training in coping and compensatory strategies, improves employment outcomes among individuals who do not show an early benefit of using IPS services.

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

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

Mental health professionals' expectations and efforts to include employment for people with moderate to severe mental illness in treatment settings

BACKGROUND

Research suggests that employment is an important factor for recovery and improved quality of life for people with mental illnesses. Mental health professionals often serve as gatekeepers for employment interventions, yet little is known about their expectations about employment for people with mental illness in Norway. The purpose of this study is to examine mental health professionals' expectations and efforts to include employment for people with moderate to severe mental illness in treatment settings.

METHODS

Two hundred seven mental health professionals were recruited from municipal mental health services, specialized clinics, social media, and professionals' networks across Norway. Participants completed a survey package comprising demographic questions, current practices and a revised version of the self-reported measure Expectations for the Employability of People with Serious Mental Illness (EESMI), a validated measure consisting of three subscales.

RESULTS

Results suggested overall favorable expectations of employment for people with moderate to severe mental illness. Analyses revealed that patients participating more frequently in collaborative meetings predicted more favorable expectations about employment among mental health professionals compared to less frequent meetings. In addition, findings suggest that psychiatrist hold more negative expectations about employment in comparison to the other educational groups. Lastly, more than half of mental health professionals reported that they have integrated discussions about employment, and routines to address work-oriented activity in consultations with patients, however, there are substantial variations in routines for addressing work or work-oriented activity as a topic in consultations with patients.

CONCLUSIONS

These results suggest that efforts are being made to integrate employment in treatment settings for people with mental illness in Norway; however, more work is needed to remove barriers and facilitate evidence-based approaches.

Outcomes of an interdisciplinary return to work intervention including occupational therapy for mood and adjustment disorders: A single-arm clinical trial

BACKGROUND

Mood and adjustment disorders are two major causes of long-term sick leave among employees, leading to large social losses. Therefore, a return to work (RTW) intervention was attempted, targeting patients with mood and adjustment disorders.

OBJECTIVE

This study aimed to investigate the outcome of an interdisciplinary RTW intervention including occupational therapy implemented within the Japanese healthcare framework.

METHODS

An interdisciplinary RTW intervention including occupational therapy was conducted five times a week for approximately three months, targeting individuals with mood and adjustment disorders who took a leave of absence. Their mental symptoms, cognitive functioning, job performance, temperament, social adaptation, psychosocial state, and readiness to RTW before and after the intervention were evaluated. Full-time RTW ratios at 3, 6, 12, 18, and 24 months from baseline were followed up and compared with those of prior studies.

RESULTS

A total of 30 individuals completed the intervention. After the intervention, participants' psychological symptoms, cognitive function, vocational aptitude, temperament, social adaptation, psychosocial state, and readiness to RTW improved (p≤0.001-0.0279). The ratios of RTW at 3, 6, 12, 18, and 24 months from the baseline were 6.7%, 46.7%, 73.3%, 77.8%, and 82.6%, respectively, reflecting a higher pattern than prior reports.

CONCLUSIONS

The interdisciplinary RTW intervention including occupational therapy has the potential to improve not only depressive symptoms but also cognitive functioning, job performance, social adaptation, and readiness to RTW. They can also raise RTW ratios.

Intersectional perspectives on the employment rate in Supported Employment for people with psychiatric, neuropsychiatric, or intellectual disabilities: A scoping review

BACKGROUND

Supported Employment (SE) has shown better results in the employment rate for persons with disabilities than other methods within vocational rehabilitation, but how SE affects the employment rate for subgroups in the interventions needs further attention.

OBJECTIVE

To examine previous research regarding the influence of intersecting statuses on the employment rate in SE for people with psychiatric, neuropsychiatric, or intellectual disabilities according to type of diagnosis, sex, race/ethnicity, age, level of education and previous work history.

METHODS

A systematic literature search was conducted in nine databases including peer-reviewed articles from 2000 to April 2021. Articles presenting the employment rate in SE interventions according to the intersecting statuses listed in the objective were included.

RESULTS

The searches identified 3777 unique records, of which 53 articles were included in data extraction. In most of the included articles, intersecting statuses did not affect the employment rate for people in the SE interventions with psychiatric disabilities. Few studies have examined neuropsychiatric and intellectual disabilities. A majority of the studies subjected to full-text analysis were excluded due to a lack of reporting of the effects of intersecting statuses on the employment rate. The studies that reported on the effects of intersecting statuses on the employment rate often had small samples and lacked statistical power.

CONCLUSIONS

Intersecting statuses do not appear to affect the employment rate for people receiving SE interventions, but systematic reviews with pooled samples need to be undertaken because of the low reporting rate and underpowered sample sizes in existing studies.

Psychometric properties of the mock interview rating scale for schizophrenia and other serious mental illnesses

Background

Over the past 10 years, job interview training has emerged as an area of study among adults with schizophrenia and other serious mental illnesses who face significant challenges when navigating job interviews. The field of mental health services research has limited access to assessments of job interview skills with rigorously evaluated psychometric properties.

Objective

We sought to evaluate the initial psychometric properties of a measure assessing job interview skills via role-play performance.

Methods

As part of a randomized controlled trial, 90 adults with schizophrenia or other serious mental illnesses completed a job interview role-play assessment with eight items (and scored using anchors) called the mock interview rating scale (MIRS). A classical test theory analysis was conducted including confirmatory factor analyses, Rasch model analysis and calibration, and differential item functioning; along with inter-rater, internal consistency, and test-retest reliabilities. Pearson correlations were used to evaluate construct, convergent, divergent, criterion, and predictive validity by correlating the MIRS with demographic, clinical, cognitive, work history measures, and employment outcomes.

Results

Our analyses resulted in the removal of a single item (sounding honest) and yielded a unidimensional total score measurement with support for its inter-rater reliability, internal consistency, and test-retest reliability. There was initial support for the construct, convergent, criterion, and predictive validities of the MIRS, as it correlated with measures of social competence, neurocognition, valuing job interview training, and employment outcomes. Meanwhile, the lack of correlations with race, physical health, and substance abuse lent support for divergent validity.

Conclusion

This study presents initial evidence that the seven-item version of the MIRS has acceptable psychometric properties supporting its use to assess job interview skills reliably and validly among adults with schizophrenia and other serious mental illnesses.

Clinical Trial Registration

NCT03049813.

30-Month Follow-Up of Individual Placement and Support (IPS) and Cognitive Remediation for People with Severe Mental Illness: Results from a Randomized Clinical Trial

Background

The individual placement and support (IPS) model for persons with severe mental illness has proven to be more effective than traditional vocational approaches in improving competitive work over 18 months. In this study, the longer-term effects of IPS over 30 months were investigated in a Danish setting.

Method

In a randomized clinical trial, we compared the effects of IPS, IPS enhanced with cognitive remediation and work-related social skills training (IPSE), and service as usual (SAU). At three locations in Denmark, 720 patients with serious mental illnesses were randomly assigned to the three groups. Competitive employment, education, and hospital admissions were tracked for 30 months using Danish national registers.

Results

The beneficial effects of IPS on competitive employment and education at the 18-month follow-up were sustained over the 30-month follow-up period. Participants receiving IPS or IPSE were more likely to obtain competitive employment or education than those who received service as usual (IPS 65%, IPSE 65%, SAU 53%, p = 0.006), and they worked on average more weeks competitively (IPS 25 weeks, IPSE 21 weeks, SAU 17 weeks; IPS vs. SAU p = 0.004 and IPSE vs. SAU p = 0.007). Moreover, participants in the two IPS groups had fewer outpatient visits during the 30-month follow-up. However, this was only statistically significant when comparing IPSE with SAU p = 0.017.

Conclusion

In conclusion, IPS and IPS enhanced with cognitive remediation and work-related skills training demonstrated that the vocational effects of the interventions are retrained over 30 months in a Danish context.

Efficacy and acceptability of psychosocial interventions in schizophrenia: systematic overview and quality appraisal of the meta-analytic evidence

Psychosocial interventions are recommended in schizophrenia and first-episode psychosis/early psychosis (EP). Nevertheless, literature is heterogeneous and often contradictory. We conducted an umbrella review of (network) meta-analyses of randomized controlled trials (RCTs) comparing psychosocial interventions vs treatment as usual (TAU)/active interventions(ACTIVE)/MIXED controls. Primary outcome was total symptoms (TS); secondary outcomes were positive/negative/depressive symptoms (PS/NS/DS), cognition, functioning, relapse, hospitalization, quality of life (QoL), treatment discontinuation. Standardized mean difference (SMD)/odds ratio (OR)/risk ratio (RR) vs TAU/ACTIVE/MIXED were summarized at end-of-treatment (EoT)/follow-up (FU). Quality was rated as high/medium/low (AMSTAR-PLUS). Eighty-three meta-analyses were included (RCTs = 1246; n = 84,925). Against TAU, regarding TS, Early Intervention Services (EIS) were superior EoT/FU in EP (SMD = -0.32/-0.21), cognitive behavioral therapy (CBT) in schizophrenia EoT/FU (SMD = -0.38/-0.19). Regarding secondary outcomes, in EP, EIS were superior for all outcomes EoT except cognition, and at FU for PS/NS/QoL, specific family interventions (FI-s) prevented relapse EoT; in schizophrenia, superiority emerged EoT for CBT for PS/NS/relapse/functioning/QoL; psychoeducation (EDU)/any FI for relapse; cognitive remediation therapy (CRT) for cognition/functioning; and hallucination-focused integrative treatment for PS. Against ACTIVE, in EP, mixed family interventions (FI-m) were superior at FU regarding TS (SMD = -0.61) and for functioning/relapse among secondary outcomes. In schizophrenia, regarding TS, mindfulness and social skills training (SST) were superior EoT, CBT at FU; regarding secondary outcomes superiority emerged at EoT for computerized cognitive drill-and-practice training for PS/DS, CRT for cognition/functioning, EDU for relapse, individual placement and support (IPS) for employment; and at FU CBT for PS/NS. Against MIXED, in schizophrenia, CRT/EDU were superior for TS EoT (d = -0.14/SMD = -0.33), CRT regarding secondary outcomes EoT for DS/social functioning, both EoT/FU for NS/cognition/global functioning; compensatory cognitive interventions for PS/functioning EoT/FU and NS EoT; CBT for PS at FU, and EDU/SST for relapse EoT. In conclusion, mental health services should consider prioritizing EIS/any FI in EP and CBT/CRT/any FI/IPS for schizophrenia, but other interventions may be helpful for specific outcomes.

A Systematic Review and Meta-analysis of IPS Supported Employment for Young Adults with Mental Health Conditions

Young adults with mental health conditions want to work and advance their education, but many need help attaining these goals. Individual Placement and Support (IPS), originally developed for working-age adults with serious mental illness, is an evidence-based employment model that may benefit young adults. This study is the first systematic review and meta-analysis of randomized controlled trials (RCTs) of IPS for this population. We conducted a systematic review of the effectiveness of IPS for young adults with mental health conditions, supplementing our electronic search of the published literature with secondary analyses of two published RCTs. Using meta-analysis, we evaluated employment rate, job duration, and education rate. Seven studies met the inclusion criteria. Four evaluated IPS for young adults with early psychosis and three evaluated IPS for other young adult subgroups. All found a significantly higher employment rate for IPS than the control group. Overall, 208 (58.3%) of 357 IPS participants and 110 (32.4%) of 340 control participants were competitively employed during follow-up, yielding an overall risk ratio of 1.69 (95% CI 1.43, 1.99), z = 6.24, p < 0.001. Six of the seven studies also reported longer job duration for IPS than the control group, yielding an overall g = 0.34 (95% CI 0.09, 0.58), z = 2.72, p < 0.01. None of four RCTs examining education outcomes found a significant difference favoring IPS, but the overall risk ratio was significant: 1.33 (95% CI 1.06, 1.66), z = 2.51, p < 0.01. Although the empirical literature is limited, IPS appears to be effective in helping young adults with serious mental illness or early psychosis gain and keep competitive jobs. The impact of IPS on education outcomes is unclear. Future research should evaluate the generalizability of these findings to the broad range of young adults with mental health conditions needing help with their employment goals.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical staging and the differential risks for clinical and functional outcomes in young people presenting for youth mental health care

BACKGROUND

Clinical staging proposes that youth-onset mental disorders develop progressively, and that active treatment of earlier stages should prevent progression to more severe disorders. This retrospective cohort study examined the longitudinal relationships between clinical stages and multiple clinical and functional outcomes within the first 12 months of care.

METHODS

Demographic and clinical information of 2901 young people who accessed mental health care at age 12-25 years was collected at predetermined timepoints (baseline, 3 months, 6 months, 12 months). Initial clinical stage was used to define three fixed groups for analyses (stage 1a: 'non-specific anxious or depressive symptoms', 1b: 'attenuated mood or psychotic syndromes', 2+: 'full-threshold mood or psychotic syndromes'). Logistic regression models, which controlled for age and follow-up time, were used to compare clinical and functional outcomes (role and social function, suicidal ideation, alcohol and substance misuse, physical health comorbidity, circadian disturbances) between staging groups within the initial 12 months of care.

RESULTS

Of the entire cohort, 2093 young people aged 12-25 years were followed up at least once over the first 12 months of care, with 60.4% female and a baseline mean age of 18.16 years. Longitudinally, young people at stage 2+ were more likely to develop circadian disturbances (odds ratio [OR]=2.58; CI 1.60-4.17), compared with individuals at stage 1b. Additionally, stage 1b individuals were more likely to become disengaged from education/employment (OR=2.11, CI 1.36-3.28), develop suicidal ideations (OR=1.92; CI 1.30-2.84) and circadian disturbances (OR=1.94, CI 1.31-2.86), compared to stage 1a. By contrast, we found no relationship between clinical stage and the emergence of alcohol or substance misuse and physical comorbidity.

CONCLUSIONS

The differential rates of emergence of poor clinical and functional outcomes between early versus late clinical stages support the clinical staging model's assumptions about illness trajectories for mood and psychotic syndromes. The greater risk of progression to poor outcomes in those who present with more severe syndromes may be used to guide specific intervention packages.

Past, Present, and Future Labor Market Participation Among Patients Admitted to Hospital With Concurrent Substance Use and Mental Health Disorder, and What We Can Learn From It

OBJECTIVE

The aim of the study is to investigate the labor market participation of patients with concurrent substance use and mental health disorder before treatment, as well as the strength of the barriers to re-enter the labor market.

METHODS

The study population is composed of individuals with concurrent substance use and mental health disorder at a psychiatric unit in 1996, 2001, 2006, 2011, and 2016. The number of self-supported years 20 years back in time, as well as present and subsequent employment, was calculated.

RESULTS

From 1996 to 2016, there was a decrease by 43.8% in self-supported years before treatment and by 36.4% in the fraction of patients working at the time of admission.

CONCLUSIONS

The results point to increasing difficulties with regard to labor market attachment among individuals with mental illnesses.

Total Metacognitive Capacity Predicts Competitive Employment Acquisition Across 6 Months in Adults With Serious Mental Illness Receiving Psychiatric Rehabilitation Services

Deficits in metacognitive capacity are common among people with serious mental illness (SMI), although there is a gap in knowledge regarding how these impairments predict later functioning, especially employment. This study aimed to prospectively examine the relationship between metacognitive capacity and 6-month competitive employment attainment in adults with SMI who were participating in a study testing a cognitive behavioral therapy intervention added to supported employment services. Sixty-seven participants with complete data at baseline and the 6-month follow-up comprised the sample. Data were analyzed using stepwise logistic regression covarying for work history and study assignment. Results indicate that total metacognitive capacity at baseline significantly predicted employment acquisition at 6 months; the final model correctly classified 83.3% of participants who obtained work. In conclusion, these findings suggest that better overall metacognitive capacity may be key for future work functioning. Thus, interventions that target metacognitive capacity may lead to enhancements in community outcomes.

Supported Employment and Psychiatric Intervention

This Viewpoint discusses the benefits of psychiatrists using individual placement and support to help patients find and maintain employment.

Comparing Service Use and Costs of Individual Placement and Support With Usual Vocational Services for Veterans With PTSD

OBJECTIVE

Among veterans with posttraumatic stress disorder (PTSD), supported employment that utilizes the individual placement and support (IPS) model has resulted in consistently better employment and functional outcomes than usual vocational rehabilitation services. This study aimed to compare these two approaches in terms of health services use and associated costs.

METHODS

A secondary analysis of a multisite randomized controlled trial of 541 unemployed veterans with PTSD used archival data from electronic medical records to assess the use and costs of health services of IPS and usual care (i.e., a transitional work [TW] program) over 18 months. Comparisons were also made to an 18-month postintervention period.

RESULTS

The two study groups did not differ in number of inpatient days or in utilization or cost of high-intensity services. Annual per-person costs of health services were approximately 20% higher for IPS than for TW participants (mean difference=$4,910 per person per year, p<0.05) during the intervention period, largely driven by higher utilization and costs for vocational services in the IPS group (p<0.001). These costs declined postintervention to nonsignificant differences. The mean annual per-person vocational service cost was $6,388 for IPS and $2,549 for TW (mean difference=$3,839, p<0.001) during the intervention period.

CONCLUSIONS

In keeping with IPS’s intensive case management approach, veterans receiving IPS used more vocational services and had correspondingly higher costs than veterans receiving TW. The two groups did not differ in use or cost of other types of health services. Future research should examine whether higher short-term costs associated with IPS relative to usual care result in long-term cost savings or higher quality of life for persons with PTSD.

Lessons from the pandemic: why having a good understanding of occupational psychiatry is more important now than ever before

The COVID-19 pandemic has once again highlighted the need for all psychiatrists to have a good understanding of the bi-directional relationship between mental health and a person's ability to function well at work. Ensuring patients are able to work should be a key treatment outcome for all psychiatrists.

Schizophrenia: A Narrative Review of Etiopathogenetic, Diagnostic and Treatment Aspects

Although schizophrenia is currently conceptualized as being characterized as a syndrome that includes a collection of signs and symptoms, there is strong evidence of heterogeneous and complex underpinned etiological, etiopathogenetic, and psychopathological mechanisms, which are still under investigation. Therefore, the present viewpoint review is aimed at providing some insights into the recently investigated schizophrenia research fields in order to discuss the potential future research directions in schizophrenia research. The traditional schizophrenia construct and diagnosis were progressively revised and revisited, based on the recently emerging neurobiological, genetic, and epidemiological research. Moreover, innovative diagnostic and therapeutic approaches are pointed to build a new construct, allowing the development of better clinical and treatment outcomes and characterization for schizophrenic individuals, considering a more patient-centered, personalized, and tailored-based dimensional approach. Further translational studies are needed in order to integrate neurobiological, genetic, and environmental studies into clinical practice and to help clinicians and researchers to understand how to redesign a new schizophrenia construct.

Maintaining functional working memory through job activities: A study among patients with schizophrenia enrolled in a supported employment program

BACKGROUND: Employment is crucial in rehabilitation of patients with schizophrenia. It may have positive effects on cognitive function, including working memory. OBJECTIVE: The objective of this study was to look for evidence to confirm continuous job activities could maintain functional working memory in patients with schizophrenia. METHODS: This was a cross-sectional study involving patients with schizophrenia enrolled in supported employment (SE) program. Informed consent was obtained. Socio-demographic, employment, and clinical data were acquired from interview and clinical notes. Mini International Neuropsychiatric Inventory (M.I.N.I) was used to confirm the diagnosis of schizophrenia. Working memory was evaluated using Weschler Memory Scale Third Edition -Letter-Number Span and Spatial Span. RESULTS: 118 patients were recruited with a mean age of 43.76 years old (SD = 8.96). Most were male, Malays, Muslims, single, and received at least secondary education. There was a significant association between working memory and employment outcome (χ 2 = 20.835, p <  .001), and past work history (χ 2 = 10.077, p = 0.002). Multiple logistic regression indicated that the employment outcome (adjusted OR: 12.50; 95% CI: 2.55–61.21; p = 0.002) and past work history (adjusted OR: 3.36; 95% CI: 1.05–10.70; p = 0.041) were significant predictors of working memory among patients with schizophrenia in SE program. CONCLUSION: This study indicated that continuous job activities could maintain functional working memory in patients with schizophrenia.

Evaluation of a supported education and employment program for adolescents and young adults with mental health problems: A study protocol of the StAB project

The majority of mental illnesses begins in childhood, adolescence and young adulthood before the age of 25. The transition from adolescence to adulthood is a particularly vulnerable time for adolescents with mental illness, affecting psychosocial functioning and participation in work life. Therefore, they need—in contrast to classic standard vocational interventions—a long-term, holistic and individually oriented vocational rehabilitation program. With the innovative model project "Start in education and employment (StAB)”, adolescents and young adults with mental illnesses are to be supported with regard to their vocational perspectives and participation by a new type of individualized, holistic, long-term job coaching. It follows the Individual Placement and Support (IPS) concept, as a manualized form of the Supported Employment Approach and is based on the "first place–then train" principle. In order to evaluate the effectiveness and feasibility of the StAB program, a double-centre prospective single arm evaluation study in a mixed-methods design will be conducted. The focus is on quantitative research analysing pre-post-effects of the StAB intervention in a two-year observational study. Young people between 15 and 25 years with a psychiatric diagnosis who are currently in receipt of means-tested benefits or are entitled to them will be recruited. The study will take place in two major cities in the north-western part of Germany, Bielefeld and Dortmund. We expect to contribute to gain more empirical data about the implementation of Supported Employment and Education to severely mentally ill adolescents and young adults in German settings. Moreover, these results may also provide the scientific foundation for future measures focusing the improvement of vocational rehabilitation for young people with mental illness.

The study was registered in the German Clinical Trials Register (DRKS00027576) on March 10, 2022.

A New Agenda for Optimizing Investments in Community Mental Health and Reducing Disparities

The Biden-Harris Administration's FY22 budget includes $1.6 billion for the Community Mental Health Services Block Grant program, more than double the FY21 allocation, given the rising mental health crises observed across the nation. This is timely since there have been two interrelated paradigm shifts: one giving attention to the role of the environmental context as central in mental health outcomes, the other moving upstream to earlier mental health interventions at the community level rather than only at the individual level. An opportunity to reimagine and redesign the agenda of mental health research and service delivery with marginalized communities opens the door to more community-based care interventions. This involves establishing multisector partnerships to address the social and psychological needs that can be addressed at the community level rather than the clinical level. This will require a shift in training, delivery systems, and reimbursement models. The authors describe the scientific evidence justifying these programs and elaborate on opportunities to target investments in community mental health that can reduce disparities and improve well-being for all. They select levers where there is some evidence that such approaches matter substantially, are modifiable, and advance the science and public policy practice. They conclude with specific recommendations and the logistical steps needed to support this transformational shift.

Evaluation of an Employment Intervention for Veterans Transitioning From the Military: A Randomized Controlled Trial

ABSTRACT

Military personnel face numerous challenges transitioning from military jobs to meaningful civilian employment. The Independence Project compared an innovative employment program (National Career Coach Program) with standard employment services (Local Community Resources) in a randomized controlled trial. Study participants were transitioning veterans with self-reported service-connected disabilities seeking permanent employment. The primary outcomes were paid employment and disability ratings over 1 year. Secondary outcomes included health and well-being. At 1-year follow-up, National Career Coach Program participants were significantly more likely to work, had significantly greater earnings, and reported significantly greater improvements in physical and mental health compared with participants assigned to Local Community Resources. Both groups increased in disability ratings over 12 months, with no difference between groups. Multifaceted supports delivered by the National Career Coach Program increased employment, earnings, mental health, and physical health over 1 year. These significant differences appeared even though control group participants achieved considerable employment success.

"It's a Big Family Here." Becoming and Belonging in a Service Providing Employment-Related Support for People with Mental Health Problems: An Interpretative Phenomenological Analysis

The impact of employment for individuals with mental health problems is complex. However, research suggests that when support is provided for accessing employment and gaining roles and skills that are valued by others, a positive effect can be seen on recovery. Employment-related support can take many forms and there is a need for further research into the experience of accessing different kinds of services. The current paper examines the lived experience of 11 people participating in a UK social enterprise providing work experience, training, and skills development for those with mental health problems. Although 'sheltered', the organisational ethos strongly emphasised service-user empowerment, co-production, equality with staff, provision of valued social roles and person-centred support. Phenomenological analysis revealed that participants valued a sense of belonging and authentic relationships within the service, whilst being given the opportunity to rediscover an identity that may have been lost because of their mental health problem. However, participants also discussed how, although the service improved their self-value, some feared the 'real world' outside of the service and were unsure whether they would be met with the same support. Tensions between field dominant approaches in supported employment and the experiences and values of the participants are explored. We argue that the findings highlight the importance of a nurturing working environment and the value for recovery of a range of meaningful roles, beyond competitive employment.

Predictors of competitive employment in individuals with severe mental illness: results from an observational, cross-sectional study in Germany

Background

Employment is of great importance as it is associated with various positive effects. Individuals with severe mental illness (SMI) are often excluded from competitive employment. Current data on employment of individuals with mental illness are rare, and influencing factors are under-researched. The present study examines possible predictors of competitive employment among individuals with SMI.

Methods

This was a cross-sectional and multicentered study of 300 individuals with SMI aged 18 to 65 years. The following inclusion criteria were used: (I) diagnosis of schizophrenia, schizotypal and delusional disorders (ICD-10 F2x), or affective disorders (ICD-10 F3x), (II) duration of psychiatric illness ≥ 2 years, and (III) substantial impact of illness on social functioning. Participants were interviewed by trained staff using standardised instruments. The relationship between potential predictors (age, sex, education, marital status, living situation, migration background, psychosocial functioning, age at first mental problem, physical illness, work ability) and employment was analysed using a hierarchic binary logistic regression model.

Results

Only one-third (34%) of participants were competitively employed. Almost one-third were unemployed (30%), and 28% reported early retirement due to mental illness. Psychosocial functioning was positively associated with competitive employment (OR = 1.09, 95% CI: 1.05 – 1.13, p < 0.001); concurrent chronic physical illness was negatively associated with competitive employment (OR = 0.38, 95% CI: 0.21 – 0.71, p = 0.002).

Conclusions

Findings confirm a high risk of exclusion from competitive employment among individuals with SMI. Nonetheless, a substantial proportion of individuals are employed. Findings call for efforts to maintain or enhance workforce participation among individuals with SMI. A special focus should be placed on improving physical health and strengthening psychosocial functioning.

Trial registration

The study was registered in the German Clinical Trials Register (DRKS) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

Trial-Based Economic Evaluations of Supported Employment for Adults with Severe Mental Illness: A Systematic Review

To identify, appraise, and summarize outcomes reported in trial-based economic evaluations of Individual Placement and Support programs for adults with severe mental illness. Six databases were searched, including Medline, PsycINFO, CINAHL, Cochrane, Scopus, and EconLit. Inclusion criteria were trial-based, full economic evaluations comparing Individual Placement and Support programs to traditional vocational rehabilitation programs for adults 18 years and older with severe mental illness. Study quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards statement. Of the 476 articles identified in the database search, seven were included in the review. Studies conducted across Europe (n = 4) and Japan (n = 1) suggested that Individual Placement and Support may be a cost-effective alternative to traditional vocational rehabilitation programs. Two studies conducted in the United States demonstrated that Individual Placement and Support led to better vocational outcomes, but at neutral or higher costs than traditional vocational rehabilitation, depending on the benefit measure used. Trial-based economic evaluations of supported employment for adults with severe mental illness are limited and heterogeneous. The interpretation of economic outcomes warrants consideration of factors that may impact cost-effectiveness, such as geographical location. Future studies should evaluate whether the benefits of IPS outweigh additional costs for patients and other stakeholders.

A Randomized Controlled Trial of an Employment Program for Veterans Transitioning from the Military: Two-Year Outcomes

BACKGROUND

Military personnel face numerous challenges transitioning from military jobs to meaningful civilian employment. Many veterans seek help finding employment, but few veteran employment programs have been rigorously studied. Transitioning veterans generally have access to Local Community Resources (LCR), which include the Veterans Health Administration vocational rehabilitation services, the state-federal Vocational Rehabilitation program, and the Department of Labor's American Job Centers. By contrast, the innovative National Career Coach Program (NCCP) offers intensive career coaching and financial incentives for working.

METHODS

This study used a randomized controlled design to compare the NCCP and LCR approaches for 208 transitioning service members (recent or pending transition). Researchers conducted interviews by telephone every four months for two years. Outcomes included earnings, months worked, and standardized self-report measures of health and well-being. Findings At two-year follow-up, significantly more NCCP participants had worked in paid employment than LCR participants (95% vs. 83%). NCCP participants averaged $2568 in monthly earnings compared to $1865 for LCR participants, thus averaging $16,872 more total income per participant over the two-year period. Employment outcomes significantly improved between Year 1 and Year 2. NCCP participants also reported significantly greater improvements in both physical and mental health compared to LCR participants. Average monthly earnings correlated with changes in health outcomes.

CONCLUSIONS

Veterans receiving multi-faceted employment services early in the transition from the military showed sustained benefit over a two-year period with increased earnings over time and improved mental and physical outcomes. Positive employment outcomes may have contributed to improved health outcomes.

The societal cost of treatment-seeking patients with borderline personality disorder in Germany

According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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