Systematic reviews and meta-analysis

Two trials (one RCT and one CCT) (total 80 participants) met the review criteria. Both trials scored poorly on the methodological quality assessment. There was 'insufficient evidence' for VR programs for (a competitive employment in altering rates of job retention, changes in employment, improvement in rates of re-entry into the labor force; (b) for altering work ability' by improving participants confidence in the accommodation request process, or employability maturity or job seeking activity. No evidence could be assimilated for changes in proportions of persons in supported employment or on disability pensions, nor for cost-effectiveness.

Forty percent of the articles had at least one universal design feature identified, and 60% used a device for which no UD feature was identified. Participants in the group incorporating UD features had an average PND score of 86% and those in the group not addressing UD features had an average PND score of 75%. Significant differences on PND scores emerged by level of severity of intellectual disability. Using ANOVA and post hoc analyses indicated differences between cases in which (a) participants had mild intellectual disabilities and cases in which participants had moderate or severe intellectual impairment, (b) cases in which participants had moderate intellectual disabilities and profound intellectual disability, and (c) cases in which participants had severe impairment and profound intellectual disability. No significant differences were found in PND scores by gender.

The selected studies (n = 26) were combined to produce 37 separate observations or data points. In terms of return-to-work, the 17 intervention studies generally appeared to produce higher percentages of successful adjusted return-to-work using an inclusive definition across all follow-up time points than did the 20 non-intervention studies. Using an inclusive definition increased the apparent rate of return to work by an average of 17% (SD = 12.5%). When the rate using the restricted definition for these 11 data points was aggregated and compared against the rate using the inclusive definition for the remaining 26 data points a similar finding emerged, with average return to work at 68% for the inclusive definition values and 48% for the restricted definition values. This finding approached significance. There was a negative correlation between unemployment and follow up time where the longer duration following injury led to a return to workplace or productive activity.

Among the 4 studies that meet the inclusion criteria, the intervention programs focused on improvement of physical, psychological, and social recovery. Although the majority of participants in these studies returned to work (75% to 85%) it is not clear if this would have been lower for individuals who did not receive counseling,exercise, or any other interventions, because only one study included a comparison group.

Rheumatic diseases can have a significant impact on employment. Managing this impact is often stressful for patients. Early diagnosis and treatment of rheumatic diseases may not keep people at work, working or enable return to work. Emerging evidence suggests that comprehensive work interventions can have positive psychological effects, as well as result in increased work participation.

With regard to organization and financing of services, clinical and vocational services should be integrated at the client level, which would offer the client "single team of providers who provide a consistent message" (p. 368). Disability policies actually "socialize people into disability" rather than supporting them. Increasing the quality of vocational services will address several of the areas identified in the Intervention section, in addition to learning to implement, maintain, and update supported employment programs as research becomes available. Motivating people with psychiatric disabilities to work can be difficult, especially with the overwhelming issues they face, such as treatment itself, applying for benefits, obtaining insurance, or societal stigma. Job development is critical to supported employment; none of the approaches mentioned have been studied empirically. Individuals with greater symptoms are less likely to be employed unless vocational and psychiatric services are integrated.

Improving job supports would enhance the employability of the individual, such as increasing the use of natural supports and skills training. Career development implies a pattern of growth and increasing satisfaction in employment over time. And lastly, supported employment was proven as a successful technique in the field of developmental disabilities; it is being evaluated as a technique for use with populations other than those with psychiatric disabilities.

Based on the findings from a single RCT, there is moderate evidence that inpatient rehabilitation results in successful return to work and return to duty for the majority of military service members. There were three studies that looked at vocational rehabilitation: a cost-benefit analysis, a case series, and an outcome study. Reviews of these studies revealed that there is limited evidence that vocational rehabilitation results in greater total taxpayer benefits than either total program operational costs or government costs; that after vocational rehabilitation the majority of subjects have fair or good adjusted outcome; or that individuals with the most significant cognitive impairments benefit the most from vocational rehabilitation services. One study examined the effectiveness of supported employment. Based on this there is limited evidence that supported employment improves employment outcomes particularly individuals who are older, have more education, have no prior work experience or who have suffered more severe injuries.

Supported employment models were more effective than services as usual. In addition, Experimental condition subjects were
more likely to be competitively employed (55% of experimental versus 34% of control participants), work 40 or more hours per month (51% versus 39%), and have higher earnings ($i22/month vs. $99/month) despite controlling for demographic, clinical, and work history confounds. And, the advantage that the experimental group clients had over the comparison group increased over time.

The findings strongly favored IPS, with large effect sizes across all outcomes: 0.96 for job acquisition, 0.79 for total weeks worked, and 0.74 for job tenure. Overall, 90 (77%) of the 117 effect sizes calculated for the 39 subgroups exceeded 0.70, and all 117 favored IPS.

In total 627 papers were identified and 246 remained after duplicates were removed, of which 241 were excluded at this stage (reasons are given below). References of the 5 included papers and relevant (excluded) systematic reviews were screened for potentially relevant titles, which identified a further 15 records for screening once duplicates had been removed. Of these, 6 further papers met the inclusion criteria. In total, 11 papers were included in the review and 250 papers were excluded. Averaging across the employment rates reported by four studies, enhanced IPS does appear to produce higher rates of competitive employment compared to IPS or control groups alone. The average enhanced rate of 76% would also appear to be higher than the average IPS employment rates reported in previous reviews [3], and this difference is accentuated when focusing on studies using skills training, where on average the employment rate is 25% higher. In addition, rates were moderately higher than previous reviews for studies involving cognitive training.