Cognitive training for supported employment: 2-3 year outcomes of a randomized controlled trial

Authors: 
McGurk, S. R., Mueser, K. T., & Pascaris, A.
Year Published: 
2007
Publication: 
American Journal of Psychiatry
Volume: 
164
Number: 
3
Pages: 
437-441
Publisher: 
American Psychiatric Publishing
Background: 

Supported employment has been repeatedly demonstrated to improve competitive work outcomes in people with severe mental illnesses such as schizophrenia and bipolar disorder (1). Although strong research supports the effectiveness of supported employment, and efforts are underway to increase access to these programs (2, 3), not all participants benefit from supported employment. Specifically, across most studies between 20% and 40% of patients do not find jobs (4–8), and of those who do, many have brief job tenures that end unsuccessfully, such as being fired for poor work performance. These findings have stimulated efforts to address illness-related impairments that may limit the effectiveness of supported employment for some individuals with severe mental illness.

Purpose: 

To address cognitive impairments that limit the effectiveness of supported employment services for patients with schizophrenia, a cognitive training program, the Thinking Skills for Work Program, was developed and integrated into supported employment services.

Setting: 

The setting was supported employment programs and various places of employment.

Sample: 

The sample included patients with severe mental illness (N=44) and prior histories of job failures who were enrolled in supported employment programs at two sites in New York City. The eligibility criteria was severe mental illness as by the State of New York Office of Mental Health, current unemployment, desire for employment, enrollment in supported employment, history of at least one unsatisfactory job ending (getting fired from a job held less than 3 months or walking off a job without another job in place), and willingness and capacity to provide informed consent.

Data Collection: 

Employment outcomes were aggregated by computing the total number of jobs, hours worked, and wages earned over the entire follow-up period. Potential interactions between site, treatment group, and work were evaluated by performing an analysis of variance (ANOVA), with site and treatment group (supported employment with cognitive training or supported employment alone) as the independent variables and the total number of jobs worked as the dependent variable. A chi-square analysis was conducted to compare the two treatment groups on percentage of patients who obtained work over the course of the follow-up period. Additional analysis was also done to address a variety of data factors.

Intervention: 

Patients with severe mental illness N=44 and prior histories of job failures who were enrolled in supported employment programs at two sites in New York City were randomly assigned to receive either supported employment alone or supported employment with cognitive training. Measures at baseline and 3 months included a brief cognitive and symptom assessment. Work outcomes were tracked for 2–3 years.

Control: 

The comparison condition was supported employment only.

Findings: 

Patients in the supported employment with cognitive training program demonstrated significantly greater improvements at 3 months in cognitive functioning, depression, and autistic preoccupation. Over 2–3 years, patients in the supported employment with cognitive training program were more likely to work, held more jobs, worked more weeks, worked more hours, and earned more wages than patients in the program offering supported employment alone.

Conclusions: 

The findings support the feasibility of integrating cognitive rehabilitation into supported employment programs and suggest that more research is warranted to evaluate the effects of the Thinking Skills for Work Program.

URL: 
http://www.coalitionny.org/the_center/resources/cognitive_remediation/documents/CogTrainingAmJPsychiatry0307.pdf
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Cognitive training and supported employment for persons with severe mental illness: One-year results from a randomized controlled trial

Authors: 
McGurk, S. R., Mueser, K. T., Harvey, P. D., LaPuglia, R., & Marder, J.
Year Published: 
2005
Publication: 
Schizophrenia Bulletin
Volume: 
31
Number: 
4
Pages: 
898-909
Publisher: 
Oxford University Press
Background: 

Individuals with severe mental illness have poor unemployment rates. Past research indicates supported employment can help improve employment rates among this group. However, not all person with severe mental illness have benefited from that model. For example, poor job tenure rates have been reported. Therefore, it is important to try to improve the effectiveness of these programs. One possible way to enhance outcomes may relate to improving cognitive functioning through an intervention such as cognitive training.

Purpose: 

The purpose of this study was to measure the impact of cognitive rehabilitation on employment outcomes among individuals with severe mental illness who had not been successfully employed and were receiving supported employment services.

Setting: 

The study took place at two mental health centers that provided a wide range of services including supported employment.

Sample: 

Participants included 44 individuals with severe mental illness who were receiving services from 2 mental health centers in New York. The majority were males (62%), from a minority like African American (59%), followed by Hispanic (24%) and had a diagnosis of Schizophrenia. The mean age of participants was 31 years and most had relatively low levels of education. Participants were assigned to either the cognitive training and supported employment program or supported employment.

Data Collection: 

Comprehensive employment data were collected the first year. Cognitive and psychological assessments were administered at baseline and three months later.
Diagnostic and background information were retrieved from the participants charts, interviews, and staff reports. Employment outcomes were measured through contact with the participants and staff. Seven different tests were used to measure cognitive functions (i.e.. attention and concentration, psychomotor speed, information processing speed, verbal learning and memory, executive functioning and overall cognitive functioning) at baseline and 3 month follow up.
Psychiatric symptoms were measured with interviews using the Positive and Negative Syndrome Scale. Efforts were made to get follow up employment data for the one year following randomization. Intent to treat analyses of the employment outcomes were conducted on the entire randomized sample that had some follow up data (n=44). The statistical analysis included: x2, t test and analyses of covariance. Due to skewed data Mann Whitney U tests were also used.

Intervention: 

The intervention was cognitive training titled Thinking Skills for Work and supported employment services.

Control: 

The control was supported employment services without cognitive training.

Findings: 

The rate of retention of the cognitive training program was high. The program was successfully implemented at two sites that predominantly served inner city minorities. Participant who received cognitive training showed improvements in several areas over the first 3 months of the study as well as a better overall cognitive functioning score as compared to those who received only supported employment services. They also had higher rates of employment. Notably, this group showed improvements on the PANSS depression scale.

Conclusions: 

The Thinking Skills for Work program may help individuals with severe mental illness with employment. This program was successfully implemented in a challenging inner city setting. More research is needed.

URL: 
https://academic.oup.com/schizophreniabulletin/article/31/4/898/1877695
Disabilities: 
Outcomes: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Service intensity as a predictor of competitive employment in an individual placement and support model

Authors: 
McGurk, S. R., Mueser, K. T, Feldman, K., Wolfe, R., & Pascaris, A.
Year Published: 
2011
Publication: 
Psychiatric Services
Volume: 
62
Number: 
9
Pages: 
1066-1072
Publisher: 
Psychiatric Services
Background: 

Research has been done on supported employment for people with psychiatric disorders; however, little of it has been focused "on variables that moderate the relationship between service intensity and vocational outcomes" (p. 1067)

Purpose: 

The study reviewed "four aspects of service intensity in a supported employment program" (p. 1067):
1. Average level of service intensity
2. Association between service intensity and weeks worked
3. Individual demographics and clinical variables associated with service intensity
4. Individual characteristics that moderate the relationship between service intensity and weeks worked

Setting: 

The setting included 2 Psychiatric Rehabilitation Centers located in Chicago, Illinois.

Sample: 

The sample was made up of 96 participants in the IPS group and 98 in the diversified placement approach group. Participants were randomly assigned to the two groups, and 5 discontinued IPS services within the first 3 months, which reduced the sample size for IPS to 91.

Data Collection: 

The intervention group was enrolled between 1999 and 2002, while data collection continued until 2004. Data were obtained from Threshold PsychServe system and were measured in terms of hours of support. Clients were also completed a survey, which included demographics, as well as a self-report of number of weeks worked and number of years since last employment.

The Positive and Negative Syndrome Scale was administered, as well as the number of lifetime hospitalizations and diagnosis (using DSM-IV). These were collected at baseline.

Data were analyzed using SPSS 11.0 for Windows and Hierarchical Linear Modeling. Zeroes were recorded for participants' IPS contacts for quarters when they dropped IPS.

Hypotheses were tested by totaling variables across the entire study and conducting hierarchical linear modeling regressions, as well as examining the data longitudinally by using the hierarchical linear model.

Intervention: 

The intervention was the Individual Placement and Support (IPS) model of supported employment

Control: 

The comparison condition was the Diversified Placement Approach.

Findings: 

Forty-eight participants continued IPS services for the entire two years. People who dropped out did not differ from those who continued on either demographics or clinical variables.

IPS services and mental health services declined over time; therefore, the intensity of IPS services was positively correlated with mental health services. The number of IPS contacts in one quarter was positively associated with the number of weeks worked in the following quarter.

Conclusions: 

Increasing ISP services intensity may improve employment outcomes.

URL: 
http://www.worksupport.com/kter/documents/pdf/ServiceIntensityasaPredictor.pdf
Disabilities: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Work, rehabilitation and mental health

Authors: 
McGuire, A. B., Bond, G. R., Clendenning, D. R., & Kukla, M.
Year Published: 
2000
Publication: 
Journal of Mental Health
Volume: 
9
Number: 
2
Pages: 
199-210
Background: 

Unemployment rates are high for individuals with psychiatric problems. Not working also has a negative impact on mental health. New services have evolved to assist people with mental health problems with employment particularly in the United States. The United Kingdom is moving in this direction. A key player is Northern Ireland which provides Assessment, Counseling and Coaching in Employment Placement and Training (ACCEPT) services for people with mental health issues.

Purpose: 

This study evaluated the ACCEPT services for individuals with mental health problems during their first 12 to 18 months of operation.

Setting: 

The setting included four ACCEPT centers.

Sample: 

Sixty three people participated in the study. Demographic data was presented on 74 who started the study but later 11 dropped out. Those data indicate about half or 53% were female. Mean age for men was 38 and women 36 years. Forty three percent of the men were single, and 41% of the women. A little over half of the men or 51% had a primary diagnosis of neurotic depression. The majority or 44% of the women had the same diagnosis.

Data Collection: 

An ACCEPT intake form provided a profile of the trainees. The Lancashire Quality of Life Profile was used to obtain information on perceived quality of life. A Goal Attainment Form documented the trainees top five goals or objectives. Participant views about ACCEPT quality of services was gained using an Client Evaluation Form. A Stakeholder Questionnaire was also used. T-Tests were used to examine pre and post training differences in the mean LSS scores.

Intervention: 

The intervention was Assessment, Counseling and Coaching in Employment Placement and Training (ACCEPT) services. It includes a combination of psychosocial rehabilitation and job training.

Control: 

There was no control or comparison conditions. The study used a pretest/posttest design.

Findings: 

Pre and post training assessment revealed improvements in the participants satisfaction with employment status, religion and purpose of life, social relationships and overall well being. Minor psychiatric problems also decreased after training. Participants reported positive views about ACCEPT services. At the close of the study around 50% of the participants were employed or either engaged in volunteer work or a work experience.

Conclusions: 

Mental health professionals play and important role in work oriented programs. Interagency collaboration is critical. These types of programs can contribute to therapeutic outcomes for individuals with mental health problems.

URL: 
http://www.tandfonline.com/doi/abs/10.1080/09638230050009195
Disabilities: 
Populations: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Cognitive and emotional consequences of TBI: Intervention strategies for vocational rehabilitation

Authors: 
McDonnall, M. C., & Cmar, J.
Year Published: 
2006
Publication: 
NeuroRehabilitation
Volume: 
21
Number: 
4
Pages: 
315-326
Publisher: 
IOS Press
Background: 

Traumatic Brain Injury (TBI) negatively impacts successful return to work for many individuals. Training individuals to use effective interventions to compensate for common deficits like attention, memory and executive functioning post injury should improve return to work outcomes.

Purpose: 

The purpose of this study was to describe examples of effective cognitive rehabilitation strategies through the use of 3 case studies and a review of literature. Professionals in the field need this type of information to better serve individuals with TBI who are returning to work.

Sample: 

The study sample included three people with TBI.

Data Collection: 

Various scales were used to measure improvements specifically related to the cognitive ability that was being treated (i.e.. attention deficits, memory problems, executive deficits) in each of the 3 case studies.

Intervention: 

The intervention was individualized cognitive rehabilitation interventions for four individuals with traumatic brain injury.

Findings: 

There are numerous strategies that can be taught to individuals after TBI to help them compensate for common cognitive deficits (ie. attention, memory, executive functioning). Therapists must understand the possibilities and be able to implement specific interventions for each person and be able to use effective teaching strategies to train the individual. It is also important to be aware of ways to support a person who is particularly "challenging" by becoming aware of ways to improve social behaviors and self awareness.

Conclusions: 

Intervention strategies must be individualized. Other considerations include considering the nature and degree of the disability and environmental context. Therapist must be able to think outside the box and use creative problem solving to assist individuals with TBI with using strategies to improve employment outcomes.

URL: 
http://content.iospress.com/articles/neurorehabilitation/nre00329
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Analyzing vocational outcomes of individuals with psychiatric disabilities who received state vocational rehabilitation services: A data mining approach

Authors: 
Roush, S.
Year Published: 
2007
Publication: 
International Journal of Social Psychiatry
Volume: 
53
Number: 
4
Pages: 
357-368
Publisher: 
Sage
Background: 

Poor vocational rehabilitation outcomes are seen for those with psychiatric disabilities; 80% to 85% are unemployed nationally. The authors claim that a lack of research into vocational rehabilitation services and outcomes is the cause for the high unemployment rates.

Purpose: 

The purpose of the study is to examine factors that affect vocational outcomes in the vocational rehabilitation process for people with psychiatric disabilities who received state Vocational Rehabilitation (VR) services.

Setting: 

The Rehabilitation Services Administration FY 2001 Case Service Report (RSA-911)was analyzed using data mining. This study included individuals with psychiatric disabilities served by multiple vocational rehabilitation agencies in various settings.

Sample: 

Participants in the study included only individuals who had a status code of 26 (working) or status code of 28 (not working).

Data Collection: 

The Exhaustive Chi-Square Automatic Interaction Detector (CHAID) data mining technique was used. The technique requires the use of categorical values; therefore, age and education (continuous variables) were recoded into categories. Decision trees "were used to generate rules for the classification of this dataset" (p. 360). SPSS AnswerTree 2.0 statistical software was used for the data analysis.

Intervention: 

The independent variables were: gender, age, race, severity of disability, education, benefits, rehabilitation services provided.

Control: 

The dependent variable included were the status codes 26 or 28.

Findings: 

Those who were receiving job placement and counseling services, did not receive any government benefits, attended special education in high school, graduated from high school or had college experience, and received comprehensive assessment and vocational training were the most likely to be employed. Those who did not receive job placement services but did receive counseling, restorative and transportation services, and government benefits were the most likely to remain unemployed.

Conclusions: 

An increase in the number of persons diagnosed with a psychiatric disability is expected as services are provided by public rehabilitation services rather than community-based services. Rehabilitation professionals should be made aware of the unique challenges and trained in the use of the Individual Placement and Support model.

URL: 
http://www.worksupport.com/kter/documents/pdf/AnalyzingVocationalOutcomes.pdf
Disabilities: 
Populations: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

The Menu Approach to supported employment for individuals with severe and persistent mental illness: Outcomes in an Oregon community based program

Authors: 
Salyers, M. P., Becker, D. R., Drake, R. E.,Torrey, W. C., & Wyzik, P. F.
Year Published: 
2009
Publication: 
Work: A Journal of Prevention, Assessment and Rehabilitation
Volume: 
31
Number: 
1
Pages: 
45-51
Publisher: 
IOS Press
Background: 

The employment rate for individuals with severe mental illness is poor. This is despite the fact that they have expressed an interest in work. The supported employment model developed to serve people with developmental disabilities has been adapted to serve this group. One approach is the Individual Placement and Support model of supported employment. Another one is the Menu Approach. The Individual Placement and Support approach has been thoroughly investigated and has been deemed effective. The Menu Approach has not.

Purpose: 

The goal of this study was to evaluate outcomes of a Menu approach to assist individuals with Mental Illness with gaining and maintaining employment.

Setting: 

The setting was a variety of employment sites located in the Pacific Northwest where individuals with mental illness worked.

Sample: 

The sample was taken from individuals with severe mental illness who were served by the program from 2000 to 2006. This resulted in a total of 140 people that met the study criteria.

Data Collection: 

Abacus program records were reviewed to identify individuals served during the established time frame. Then rates of successful employment and trends were identified. To ensure confidentiality each participant was randomly assigned a number during data analysis. General demographics was collect from records. Records were reviewed by the primary investigator and a graduate student. Other data collected from the file review related to employment outcomes and whether or not ongoing support was accessed. Reliability was checked using cross referencing and strengthened by having the student randomly code one fourth of the data which was compared to the primary investigators coding. Coded data was entered into the Statistical Package for the Social Sciences 15.0. The package calculated statistics that were used to develop and describe program employment outcomes.

Intervention: 

The intervention was a menu-based Supported employment approach provided by the Abacus Program, that works cooperatively with the State's Office of Vocational Rehabilitation Services.

Control: 

There was no control condition. There was a pre/post comparison only.

Findings: 

Among the 140 participants there were 83 reports of successful employment. The majority of those who went to work or 82% received ongoing support services. The mean number of weeks to obtain employment was 13.9. Job search services varied from behind the scenes help to job development. Most positions were entry level. The average number of months employed was nine. The most frequently reported reason for not going to work was client choice (40.4%); followed by physical medical issues (17.5%).

Conclusions: 

The Menu Approach lead to positive employment outcomes. Additional research is needed to determine if these outcomes were exclusive to the Abacus program or can be replicated.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/19923675
Disabilities: 
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

A ten-year follow-up of a supported employment program

Authors: 
Schene, A., Koeter, M., Kikkert, M., Swinkels, J., & Crone, P.
Year Published: 
2004
Publication: 
Psychiatric Services
Volume: 
55
Number: 
3
Pages: 
302-308
Publisher: 
American Psychiatric Association
Background: 

Supported employment is considered to be an evidence-based practice for people with psychiatric disabilities. The rate of competitive employment within supported employment programs is three times higher than those in other programs.

Purpose: 

The purpose of the study was to review the outcomes of supported employment 10 years after an initial demonstration project.

Setting: 

The setting included two rural rehabilitative day centers in New Hampshire that became Individual Placement and Support model centers.

Sample: 

The sample included 20 participants in the 1990 Lebanon group and 24 participants in the 1992 Claremont group; a total of 36 were in the follow-up study 10 years later.

Data Collection: 

A semi-structured interview was developed, which included open-ended questions. Open-ended questions were transferred into structured ratings

Intervention: 

The intervention was the Individual Placement and Support (IPS) model of supported employment.

Control: 

There was no control or comparison condition.

Findings: 

Seventy percent of the participants had had some type of competitive employment. Eighty eight percent (N=17) were employed at the time of the study.

Conclusions: 

The study concluded that supported employment is a viable option for people with psychiatric disorders. Further study is needed to determine is self-sufficiency is a realistic goal given that many people don't consider self-sufficiency as a goal to reach when obtaining competitive employment.

URL: 
http://www.worksupport.com/kter/documents/pdf/A10yearfollowupofSupportedEmployment.pdf
Disabilities: 
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Adjuvant occupational therapy for work-related major depression works: randomized trial including economic evaluation

Authors: 
Schneider, J., Slade, J., Secker, J., Rinaldi, M., Boyce, M., Johnson, R., ... & Grove, B.
Year Published: 
2007
Publication: 
Psychological Medicine
Volume: 
37
Number: 
3
Pages: 
351-362
Publisher: 
Cambridge Press
Background: 

Major depression has far-reaching consequences for work functioning and absenteeism. In most cases depression is treated by medication and clinical management. The addition of occupational therapy (OT) might improve outcome.

Purpose: 

The purpose of the study was to determine the cost-effectiveness of the addition of OT to treatment as usual (TAU).

Setting: 

Study was conducted as part of the Programme for Mood Disorders of the Department of Psychiatry on the Academic Medical Centre in Amsterdam.

Sample: 

The study sample included 62 adults. The inclusion criteria were: age above 18 years, major depressive disorder, single episode or recurrent, without psychotic features, no history of psychos, manic, hypo-manic or cyclothymic features, no history of alcohol abuse or dependence, and additional criteria.

Data Collection: 

Treatment effect of OT was tested using the t test for continuous measures and the chi-squared test for categorical variables. For longitudinal analysis, the generalized estimating equations method for dichotomous outcomes and a generalized linear model approach for continuous outcomes was used.

Intervention: 

Sixty-two adults with major depression and a mean absenteeism of 242 days were randomized to TAU (outpatient psychiatric treatment) or TAU plus OT [6 months, including (i) diagnostic phase with occupational history and work reintegration plan, and (ii) therapeutic phase with individual sessions and group sessions]. Main outcome domains were depression, work resumption, work stress and costs. Assessments were at baseline and at 3, 6, 12 and 42 months.

Control: 

Treatment as usual was the standard outpatient treatment for depression. This consisted of clinical management and antidepressants, if indicated and accepted by patients, according to standard treatment algorithm.

Findings: 

The addition of OT to TAU: (i) did not improve depression outcome, (ii) resulted in a reduction in work-loss days during the first 18 months, (iii) did not increase work stress, and (iv) had a 75.5% probability of being more cost-effective than TAU alone.

Conclusions: 

Addition of OT to good clinical practice does not improve depression outcome, improves productivity without increasing work stress and is superior to TAU in terms of cost-effectiveness

URL: 
http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=22007000440
Disabilities: 
Populations: 
Outcomes: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

SESAMI* study of employment support for people with severe mental health problems: 12-month outcomes

Authors: 
Schoenbaum, M., Unützer, J., McCaffrey, D., Duan N., Sherbourne, C., & Wells, K.
Year Published: 
2009
Publication: 
Health & Social Care in the Community
Volume: 
17
Number: 
2
Pages: 
151-158
Publisher: 
Blackwell Publishing Ltd.
Background: 

Individuals with severe mental illness are underrepresented in the workforce in the United Kingdom. A welfare to work policy was implemented. Guidelines recommend using evidenced based practices, the Individual Placement and Support model, to help people with mental health issues with gaining and maintaining work. It is important to understand what is currently going on to improve existing practices.

Purpose: 

This study was undertaken to learn about factors associated with successful employment and the impact of work on individuals with mental illness.

Setting: 

Six British agencies that specialized in providing services to individuals with mental illness.

Sample: 

One hundred and eighty two individuals with mental health problems participated in the study. Follow up interviews were conducted with 85% of this sample. The majority or 84% were White British or European. Ages ranged from 22 to 67 years with an mean of 42 years. About a third, or 32% reported depression, 25% anxiety, 25% schizophrenia, hallucinations or hearing voices, 14% bipolar and 4% other in response to being asked to describe his or her condition. Fifty five percent of the participants were unemployed, 29% were unemployed, 9% were in work placement and 5% in sheltered work.

Data Collection: 

The study questionnaire included the following measures. The Empowerment Among Users of Mental Health Services Scale; the Herth Hope Index, Perceived obstacles to work; and behaviours indicating nearness to the labour market. This questionnaire was usually completed during an approximately one hour face to face interview. The first was completed at baseline and another at follow up (12 months later).Statistically significant differences were tested. Analysis of variance was also used. SPSS 15.0 was used to analyze all data.

Intervention: 

The intervention was supported employment in the United Kingdom.

Control: 

There was no comparison or control group.

Findings: 

Eighty two percent of those working at baseline were employed one year later. Twenty five percent of those individuals who were unemployed were assisted with gaining work during this time. Financial satisfaction and self esteem increased among those who went to work. In addition, there was a tendency to work part-time.

Conclusions: 

Those who worked reported multiple benefits. The evidence from this study should inform service planning and the Individual Placement and Support model should be implemented in England.

URL: 
https://www.researchonline.org.uk/sds/search/taxonomy.do%3Bjsessionid=948B7FBF03C6A71157E4FD25729AE479?action=document&ref=A20206&pager.offset=140&taxonomy=GIN
Disabilities: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes