Rehabilitation Research Policy and Education

Authors: 
Arango-Lasprilla, J. C., da Silva Cardoso, Wilson, L. M., Romero, M. G., Chan, F., & Sung, C.
Year Published: 
2011
Publication: 
Rehabilitation Research Policy and Education
Volume: 
25
Number: 
3
Pages: 
149-162
Publisher: 
Elliott and Fitzpatrick Inc.
Background: 

Employment impacts the quality of life for individuals with spinal cord injury. Most studies that look at vocational service patterns for individuals with spinal cord injury focus on European Americans. Ethnic minority groups within the United State are growing. These changes also impact referrals to Model Spinal Cord Injury Systems. This presents new challenges to rehabilitation professionals.

Purpose: 

The purpose of this study was to identify demographic and service related patterns for Hispanics with spinal cord injury receiving services from state vocational rehabilitation agencies and examine similarities and differences in vocational rehabilitation services and employment outcomes between a group of European Americans and Hispanics with spinal cord injuries.

Setting: 

This study included individuals with SCI served by multiple vocational rehabilitation agencies in various settings.

Sample: 

Data for this study came from the Rehabilitation Services Administration Case Service report %

Control: 
There was no control or comparison condition.
Findings: 

Minor differences in case dollar expenditures and service patterns were noted between the two groups. Vocational rehabilitation services that impacted successful work outcomes included: assistive technology services, basic support services and job placement services.

Conclusions: 

Hispanic status of vocational rehabilitation clients does not affect employment outcomes. Hispanics appear to have more risk factors than European American clients. Vocational rehabilitation counselors were able to support the needs of Hispanic clients.

URL: 
http://eric.ed.gov/?id=EJ987046
Disabilities: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Methods of a multisite randomized clinical trial of supported employment amount veterans with spinal cord injury

Authors: 
Ownsworth, T., & McKenna, K.
Year Published: 
2009
Publication: 
Journal of Rehabilitation Research & Development
Volume: 
46
Number: 
7
Pages: 
919-930
Publisher: 
Department of Veterans Affairs
Background: 

Baseline data revealed that 65% of the study sample of veterans with spinal cord injury (SCI) who were seeking employment had never been employed postinjury. Nearly half (41%) of this group had received some type of prior vocational rehabilitation. This rate is consistent with veterans with SCI reported for samples in the community of individuals with SCI.

Purpose: 

This article compares evidence-based supported employment (SE) with conventional vocational rehabilitation for veterans with SCI. The researchers hypothesis was that evidence-based supported employment when compared with conventional vocational rehabilitation will significantly improve competitive employment outcomes. The secondary hypothesis was that evidence-based supported employment for veterans with SCI would be more cost-effective than standard care.

Setting: 

The study took place at multiple competitive employment sites versus standard vocational rehabilitation care at various Department of Veterans Affairs medical SCI centers.

Sample: 

Veterans with spinal cord injury consisting of 95% males with an average age of 48.3 years. More than half of the subjects were white, 35.3% African American, 5% Hispanic.

Data Collection: 

All subjects were followed for 12 months with face-to-face interviews every three months to collect data on primary employment variables and secondary outcomes measured. After this initial 12 months, the follow-up period was extended to 24 months at all sites including telephone interviews every three months. MANCOVAs were used to determine treatment group differences over time on the outcome variables (employment index, perceived barriers to employment, level of disability, quality of life, depression, and sustaining care needs), controlling for specified covariates. This included study site, sex, and age.

Competitive employment was as a primary outcome measure and measured every three months. Competitive employment is "community jobs that pay at least minimum wage (directly by the employer to the employee) that any person can apply for, including full-time and part-time jobs." General rehabilitation outcomes were measured at baseline and 3-month follow-up interviews. Standardized measures used included 1) Alcohol Use Disorders Identification test, 2)The Craig Handicap Assessment and Reporting Technique (CHART), 3) VR-36 that measures health-related quality of life in veterans, and 4) The Quick Inventory of Depressive Symptomatology Self-Report.

Demographic variables were also collected such as age, sec, race/ethnicity, employment history, previous levels of income, educational background, legal history, lifetime employment history, vocational services history, duration of SCI, level of SCE, and type of family structure.

Intervention: 

The Spinal Cord Injury Vocational Integration Program uses the principles of evidence-based supported employment. The program integrates vocational services into the SCI continuum of healthcare. The SE principles include 1) integrated treatment, 2) rapid engagement, 3)competitive employment, 4) belief that success is possible regardless of severity or type of disability, 5) ongoing support, 6) veteran preferences, 7) community-based services, and 8)personalized benefits counseling. The investigators spent 4 to 6 months recruiting and hiring staff to provide the evidence-based SE services. All vocational rehabilitation counselors (VRCs) have master's degrees and are certified rehabilitation counselors. Training consisted of 3-day workshop taught by VA faculty. VRCs received ongoing instruction and coaching by a co-investigator who has more than 30 years experience in vocational rehabilitation (VR).

Control: 

The study design was a randomized clinical trial that consisted of an experimental group and a comparison group. Interventional-site subjects were randomized to either the experimental group or the comparison group. Observational sites were selected based on similarity to the intervention site facilities with regards to subjects, communities, and VAMC culture. The observational sites were included because the researchers were considered that veterans and staff at the four intervention sites might be vicariously influenced by veterans and staff involved with the implementation study.

Findings: 

The findings of this study were preliminary. The final enrollment count for the study was 301 subjects. At the time of this publication, 93 participants had reached study completion. Some of the challenges faced included exhausting the study pool earlier than expected, staff turnover, and slow process of culture change within the centers.

Conclusions: 

This article discussed the methods of an ongoing randomized clinical trial of VR approaches among veterans with SCI. Strengths of the study design include repeated measures to evaluate employment across time, inclusion of benefits-counseling, and ongoing fidelity monitoring of the treatment conditions. Before the study, the researchers concluded that there was a lack of attention to identifying or addressing vocational issues in the treatment setting. A culture change occurred such that providers began to introduce and explore the topic. In this study, the recruitment relied on clinical providers' willingness to broaden their definition of rehabilitation to include vocational issues. The preliminary baseline data from this sample showed that the majority (72%) had never been employed postinjury.

URL: 
http://www.rehab.research.va.gov/jour/09/46/7/Ottomanelli.html
NIDILRR Funded: 
Peer Reviewed: 
Yes

Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment

Authors: 
Nygren, U., Markström, U., Svensson, B., Hansson, L., & Sandlund, M.
Year Published: 
2008
Publication: 
Psychiatric Rehabilitation Journal
Volume: 
38
Number: 
4
Pages: 
340-349
Publisher: 
American Psychological Association
Background: 

In recent years, functional outcome has become a very salient target for intervention for individuals with severe mental illnesses. In particular, supported employment has generated substantial research as a means of facilitating return to competitive jobs for individuals with schizophrenia and other severe mental illnesses. This article summarizes the design of an 18-month longitudinal study of IPS in the early course of schizophrenia. Improving and Predicting Work Outcome in Recent-Onset Schizophrenia and discusses the adaptations of the IPS model that were found important for this phase of the illness.

Purpose: 

The purpose of this study was to describe the adaptation of the Individual Placement and Support model of supported employment to individuals with a recent first episode of schizophrenia or a related psychotic disorder.

Setting: 

All study participants were receiving outpatient psychiatric treatment at the UCLA Aftercare Research Program and were participants in the third phase of the Developmental Processes in Schizophrenic Disorders Project.

Sample: 

The study sample consisted of 69 individuals that were recruited from a variety of local Los Angeles area psychiatric hospitals and psychiatric clinics and through referrals from the UCLA outpatient service at the Resnick Neuropsychiatric Hospital at UCLA.

Data Collection: 

A comparison of individuals who were randomized (n=69) to IPS or the Brokered treatment with those who were not randomized (n=18) reveals no statistically significant demographic differences between the two samples. Similarly the randomized individuals did not differ significantly from those who were not randomized in prior illness indicators or symptom severity at screening.

Intervention: 

Given that the vocational goals of persons with a recent onset of schizophrenia often involve completion of schooling rather than only competitive employment, the principles of Individual Placement and Support were extended to include supported education. This extension involved initial evaluation of the most appropriate goal for individual participants, having the IPS specialist working on placement either with the participant or directly with educational and employment settings (depending on permitted disclosure and individual need), and follow-along support that included work with teachers and aid in study skills and course planning as well as typical supported employment activities. Work with family members also characterized this application of IPS.

Control: 

The condition was Vocational rehabilitation through referral to traditional separate agencies(Brokered Vocational Rehabilitation.

Findings: 

A randomized controlled trial is comparing the combination of Individual Placement and Support and skills training with the Workplace
Fundamentals Module with the combination of brokered vocational rehabilitation and broad-based social skills training. Participants in the IPS condition have returned to school, competitive work, and combined school and work with approximately equal frequency.

Conclusions: 

Individual Placement and Support principles can be successfully extended to integrate supported education and supported employment within one treatment program. The distribution of return to school, work, or their combination in this group of individuals with recent-onset schizophrenia supports the view that an integrated program of supported education and supported employment fits this initial period of illness.

URL: 
http://psycnet.apa.org/journals/prj/31/4/340/
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

The effectiveness of supported employment in people with dual disorders

Authors: 
Mueser, K. T., Clark, R. E., Haines, M., Drake, R. E., McHugo, G. J. Bond, G. R, Essock, S. M., Becker, D. M., Wolfe, R., & Swain, K.
Year Published: 
2011
Publication: 
Journal of Dual Diagnosis
Volume: 
7
Number: 
2
Pages: 
90-102
Publisher: 
PubMed
Background: 

Competitive work is a common goal for people with a severe mental illness (e.g., schizophrenia, bipolar disorder, treatment refractory major depression) and substance use disorder (or dual disorder). Despite this fact, relatively little has been firmly established as to whether substance use problems interfere with the ability of clients with severe mental illness to work or to benefit from vocational rehabilitation programs.

Purpose: 

This study compared the effectiveness of the Individual Placement and Support (IPS) model of supported employment to control vocational rehabilitation programs for improving the competitive work outcomes of people with a severe mental illness and co-occurring substance use disorder.

Setting: 

Despite similar methods, the RCTs differed on geographic location, control group interventions, and length of follow-up. The four studies were as follows: The NH study was conducted in two mental health centers in Concord and Manchester, New Hampshire. The DC study recruited clients in an intensive case management program in Washington, DC. In the Hartford study, participants receiving services at a mental health center in Hartford, Connecticut, were randomly assigned. In the Chicago study, clients attending two day programs at a comprehensive psychiatric rehabilitation agency in Chicago, Illinois, were randomly assigned.

Sample: 

The study group consisted of study participants with co-occurring substance use disorders from four RCTs of IPS supported employment versus usual vocational services. All four studies compared a newly established IPS program to one or more well-established vocational programs. In all four studies, participants were recruited from mental health centers (or a psychiatric rehabilitation agency in the Chicago study). Participants were adults who met each state‚ criteria for severe mental illness, typically a DSM-IV Axis I or II diagnosis plus severe and persistent impairment in psychosocial functioning. All participants were unemployed at the time of study admission.

Data Collection: 

This study used archival data from four independent RCTs to determine the effect of IPS supported employment on clients with co-occurring substance use disorders. Institutional Review Boards at local sites and participating universities approved the four studies. In addition, the Institutional Review Board of Indiana University-Purdue University Indianapolis approved the data re-analyses reported here. To evaluate differences at baseline between the clients randomized to IPS compared to the comparison programs on demographic, diagnostic, clinical, and background characteristics, study computed t-tests for continuous variables and chi-square tests for categorical variables.

Intervention: 

Individual Placement and Support (IPS) model is a systematic approach to helping people with severe mental illness achieve competitive employment. It is based on eight principles: eligibility based on client choice, focus on competitive employment, integration of mental health and employment services, attention to client preferences, work incentives planning, rapid job search, systematic job development, and individualized job supports. Systematic reviews have concluded that IPS is an evidence-based practice.

Control: 

All of the comparison vocational services were highly regarded, active programs, considered at the time to be state-of-the-art. Common principles shared among these comparison groups were the emphasis on stepwise entry into competitive employment (with the exception of one subprogram in the Hartford study) and brokered services in which the vocational program was provided by a separate agency from the mental health program (with the exception of the Chicago program).

Findings: 

In the total study group, clients who participated in IPS had better competitive work outcomes than those who participated in a comparison program, with cumulative employment rates of 60% vs. 24%, respectively. Among clients who obtained work during the study period, those receiving IPS obtained their first job significantly more quickly and were more likely to work 20 or more hours per week at some point during the 18-month follow-up.

Conclusions: 

The IPS model of supported employment is more effective than alternative vocational rehabilitation models at improving the competitive work outcomes of clients with a dual disorder.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/23275763
Disabilities: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

The Hartford study of supported employment for persons with severe mental illness

Authors: 
Murphy, L., Chamberlain, E., Weir, J., Berry, A., James, D. N., & Agnew, R.
Year Published: 
2004
Publication: 
Journal of Consulting and Clinical Psychology
Volume: 
72
Number: 
3
Pages: 
479-490
Publisher: 
American Psychological Association
Background: 

High rates of unemployment persist with people with psychiatric disorders despite their desire to work. Moderate evidence suggests that people with psychiatric disorders who do work experience "modest benefits in terms of symptoms and life satisfaction" (p. 479).

Purpose: 

Three approaches to vocational rehabilitation were compared for people with psychiatric disorders. This included the Individualized Placement and Support Model(IPS), a psychosocial rehabilitation program (PSR), and standard services.

Setting: 

The setting included community mental health center in Hartford, Connecticut. The psychosocial rehabilitation program was located off-site. Standard services were offered off-site.

Sample: 

One hundred ninety-eight clients consented to participate (out of 258 who were asked): 86% were Latino(n = 64 consents/74 total), 81% were African-American (n = 91 consented/119 total), and 66% were White (n=43 consented/65 total).

Data Collection: 

Several assessments were used: diagnosis,
background information, employment outcomes, and nonvocational outcomes. Interviews were completed by one of three research staff and reliability checks were conducted on 15% of the interviews by having a 2nd person review the interviews.

Job satisfaction was rated by the Indiana Job Satisfaction Scale. PANSS was used for nonvocational outcomes and modified to be entirely client self-report.

Overall functioning was rated by the Global Assessment Scale, while social and leisure functioning was rated using one subscale from the Social Adjustment Scale-II: Social-Leisure subscale, as well as a global rating.

Social network information was rated with a variant of the Social Support and Social Network Interview and was requested at baseline, 12 months and 24 months. Quality of Life was assessed through the Brief Version of Quality of Life Interview. Substance abuse was also tracked using the Alcohol Use Scale and Drug Use Scale.

Statistical analyses were conducted as follows:
- "Intent-to-treat analyses of employment outcomes were conducted on the entire randomized sample" (p. 483).
- A second set of analyses were conducted to determine if clients differed in their vocational outcomes.
- Employment outcomes were collected over the entire 2-year period. The 3 groups on time to job were restricted to clients who obtained any work.
-Changes in non-vocational outcomes used mixed-effects regression models, using the vocational program as the independent variable.

Intervention: 

Two interventions were studied: IPS and PSR. The IPS model used "was based on the principles in the IPS manual (D.R. Becker & Drake, 1993)" (p. 481). The PSR program "incorporated transitional employment into its into its vocational rehabilitation approach" (p. 481). Clients focused on clerical and janitorial skills training with transitional jobs and later obtaining competitive employment.

Control: 

Standard services that are considered typical of most supported employment services, which included access to all other vocational services available to everyone with severe mental illness, vocational program with substandard wages, or competitive wages under contracts negotiated by the program. Two programs were evaluated: standard-supported and standard-enclave.

Findings: 

Fidelity to the IPS model (for each of the programs) was evaluated using the IPS Fidelity Scale. The programs were rated in order from highest to lowest: IPS, standard-supported, PSR, and standard-enclave.

Conclusions: 

The Individual Placement and Support model was the most effective at retaining clients and improving employment outcomes.

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

One-year outcomes from the CASAWORKS for Families intervention for substance-abusing women on welfare

Authors: 
Michalak, E., Yatham, L., Maxwell, V., Hale, S., & Lam, R.
Year Published: 
2003
Publication: 
Evaluation Review
Volume: 
27
Number: 
6
Pages: 
656-680
Publisher: 
Sage
Background: 

Drug and alcohol addictions continue to pose serious public problems for the nation, particularly in the areas of crime, overutilization of expensive health services, lost productivity, and welfare costs. The percentage of individuals receiving welfare with diagnosable substance-abuse disorders has ranged from 2% to 37% in various studies. There is general consensus that these individuals will be among the last to exit the welfare rolls.

Purpose: 

The purpose of this study was to evaluate the CASAWORKS for Families (CWF) intervention, developed by the National Center for Substance Abuse and Addiction (CASA) at Columbia University and implemented in 11 sites across the country. The CASAWORKS demonstration project was designed to reduce alcohol and drug use among substance-abusing women receiving welfare and increase independence through employment.

Setting: 

Using a recruitment process, 11 sites were selected from a pool of more than 30 applicants. Three sites were located in California, and one each in the states of Maryland, Missouri, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, and Tennessee. Five sites were located within urban cities, two were located in suburbs, and the others were in small towns.

Sample: 

The study sample consisted of 962 women referred to one of the 11 demonstration sites, of whom 673 were determined to be eligible for services. The mean age was 32 years, 38% were white, 48% African-American, and 12% Hispanic.

Data Collection: 

Repeated measures included the Addiction Severity Scale, a structured interview related to problem areas (health, transportation, finances, etc.), and six- and 12-month follow-up interviews regarding employment status. Data analysis used mixed-effects models to describe in-treatment change. These models comprise fixed effects, describing the average change over time, and random effects, describing the components of variation about that average pattern of change. For continuously distributed linear mixed-effects models were used, and for binary responses generalized linear mixed-effects models.

Intervention: 

The CWF model is a multifaceted integrative intervention strategy designed to assist recipients of TANF achieve stable employment and self-sufficiency by overcoming substance abuse and other major barriers to work. The core services of the intervention were focused on substance abuse, employment (work readiness, vocational training, and basic education), domestic violence, and parenting training. Additional as-needed services were physical health, mental health, and assistance with basic needs such as child care, transportation, shelter, and clothing.

Control: 

There was no control or comparison condition. The study used a pre/during/post intervention design.

Findings: 

Because of time limits on the evaluation, only the first 529 clients from 10 sites had an opportunity to be followed at least 12 months. Retention was relatively high in comparison to similar programs; 81%of those enrolled were still in the intervention at the 1-month point, 61% were enrolled at 3 months, 51% were enrolled at 6 months, and 38% were enrolled at 9 months. Significant improvements in drug and alcohol use were seen at the 6- and 12-month follow-ups. There were significant improvements in employment and earnings from baseline to 6-month follow-up and from 6-month to 12-month.

Conclusions: 

Although the authors note that it cannot be certain that the generally favorable results seen in this formative evaluation were actually caused by the intervention, the findings are quite consistent with the underlying CWF model under which the interventions were conceived, delivered, and evaluated. In addition, there is evidence that the intervention was appropriate for and attractive to the target population. These initial findings offer a compelling rationale for continued development and evaluation of the CWF model.

URL: 
http://erx.sagepub.com/content/27/6/656.full.pdf
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Work, recovery and comorbidity in schizophrenia: A randomized controlled trial of cognitive remediation

Authors: 
McHugo, G., Drake, R., & Becker, Dl.
Year Published: 
2009
Publication: 
Schizophrenia Bulletin
Volume: 
35
Number: 
2
Pages: 
319-335
Publisher: 
Oxford University Press
Background: 

A common theme that cuts across all definitions of recovery is work. Work is valued by most and it enables on to make a contribution to society and offers the promise of liberating consumers from financial dependence on others. In recent years, a recovery paradigm has emerged that offers a guiding vision for self-empowerment, treatment, and rehabilitation for individuals with schizophrenia and comorbid problems such as: cognitive impairment,9 substance abuse,10 and medical disorders. This study addressed the impact of comorbidity on recovery of work functioning and response to vocational rehabilitation, described strategies for minimizing its effects, and provided data from a new study targeting the problem of cognitive impairment in order to improve employment outcomes.

Purpose: 

The purpose of the study is to evaluate the impact of adding cognitive remediation to vocational rehabilitation to determine the impact on comorbid substance abuse and medical disorders on work outcomes and response to the treatment program.

Setting: 

The study took place in a vocational rehabilitation program associated with an urban medical center.

Sample: 

The study included 34 participants who were 18 years or older, had severe mental illness, expressed an interest in work, had a history of being fired or quitting employment prior to locating new work. Participants received either vocational rehabilitation plus cognitive retraining or Vocational rehabilitation only.
In both groups, the majority of subjects were male (61% and 56%) black (61% and 63%) and had never been married (78% and 75%). The primary diagnosis was Schizophrenia (75% and 60%) and most had a comorbid disorder (67% and 81%). The mean age of the group members was (46 and 42 years).

Data Collection: 

Referrals were made by therapists and work services personnel. Those interested had a baseline assessment scheduled. Consumers were not paid for assessments. Following completion of the assessments, consumers were randomized to either vocational rehabilitation alone (VR) or vocational rehabilitation and cognitive remediation (VR and CR)using a computer program. The examiners compared the groups at baseline on the demographic, clinical, and cognitive measures using t-tests (continuous variables) and v2 analyses (categorical variables). Next they computed the percentage of consumers who were exposed to the cognitive remediation program, as completing 6 or more cognitive remediation sessions, the average number of sessions completed, and the number of weeks to complete them.

Then to evaluate changes over the treatment period in cognitive functioning and clinical variables, they performed a series of analyses of covariance (ANCOVAs), with the cognitive/symptom measures at posttreatment as the dependent variables, the cognitive/ symptom measures at baseline as the covariate, and treatment group as the independent variable. Finally they looked at work outcomes. Because continuous work outcomes were highly positively skewed, main treatment effects were evaluated by performing Mann-Whitney U tests comparing the 2 treatment groups on wages earned and hours and weeks worked. To evaluate whether substance abuse directly influenced vocational outcomes or interacted with treatment group, separate analyses were performed for current drug-use disorder and alcohol-use disorder. For these analyses, the work variables were log transformed to minimize skew. For each series of analyses, analysis of variance were performed with current drug-use disorder (or current alcohol-use disorder), treatment group, and their interactions as the independent variables and the work outcomes as the dependent variables. The main effect for drug-use disorder (or alcohol-use disorder) in these analyses was a test of whether the disorder had an overall impact on vocational outcomes, whereas the drug-use disorder (or alcohol-use disorder) by treatment group interaction effect was a test of whether the outcomes of the treatment groups differed significantly as a function of the disorders.

Intervention: 

The intervention was adding cognitive remediation to a hybrid vocational rehabilitation program that combined paid internship jobs with supported employment.

Control: 

Participants were randomly assigned to either vocational rehabilitation alone or vocational rehabilitation and cognitive remediation using a computer-generated randomization program.

Findings: 

Statistical tests comparing consumers assigned to VR only or VR and CR indicated no significant differences in any demographic, diagnostic, or baseline clinical or cognitive performance measures.

The results of the ANCOVAs comparing changes over time in cognitive functioning and symptoms between consumers who received cognitive remediation and those who did not were summarized. Significant improvements favoring cognitive remediation were found for several cognitive measures. Results of the Mann-Whitney U tests comparing work outcomes for the 2 groups indicated that the VR and CR group worked significantly more internship weeks and hours and earned more wages than the VR-only group.

The VR and CR group also worked significantly more weeks than VR only, and there was a trend for them to earn more wages, although hours
worked did not differ between the groups. Number of weeks or hours of competitive work did not differ between the 2 groups nor did wages earned. Overall rates of competitive rates were 39% for the VR and CR group vs 31% for the VR-only group, which did not differ significantly. Analyses of relationship of substance-abuse disorder and medical comorbidity focused on total (log transformed) hours worked for each vocational outcome. Alcohol-use disorder was marginally significantly related to total hours worked with the absence of current alcohol-use disorder associated with more hours worked compared with the presence of an alcohol-use disorder. Drug-use disorder was also related to total hours worked, with absence of current drug-use disorder associated with more hours worked compared with the presence of a drug-use disorder.

There were no interactions between either alcohol or drug-use disorder and treatment group, suggesting that the addition of cognitive remediation to vocational services was just as helpful in the consumers with a substance-use disorder as those without. A similar analysis of total hours worked comparing consumers with high levels of medical comorbidity to those with low levels indicated that both the main effect for medical comorbidity and the interaction with treatment group were not significant. Thus, consumers with higher medical comorbidity burden appeared to have comparable vocational outcomes compared with those with less such burden. For the VR-only group, Spearman correlations between overall cognitive performance at baseline and total work over the study period were significant for total hours worked and wages earned and marginally significant for number of weeks worked, whereas for the VR and CR group, none of these correlations were significant Thus, cognitive performance at baseline was more predictive of work in the study for those in the control group than those in the cognitive remediation group.

Conclusions: 

Providing cognitive remediation in addition to vocational rehabilitation can improve cognitive functioning and employment outcomes for individuals with severe mental illness. Comorbid substance abuse impacts work outcomes while medical comorbidity does not. More research is needed to evaluate the impact of comorbidity and their interaction on treatment. More research is needed to evaluate the impact of comorbidity on work functioning in VR and its interaction with cognitive remediation.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/19269925
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Cognitive and symptom predictors of work outcomes for clients with schizophrenia in supported employment

Authors: 
McGurk,S., R., Mueser, K. T., DeRosa, T., J., & Wolfe, R.
Year Published: 
2003
Publication: 
Psychiatric Services
Volume: 
54
Number: 
8
Pages: 
1129-1135
Publisher: 
American Psychiatric Association
Background: 

Although previous research has indicated that symptoms and cognitive functioning are related to employment outcomes for clients with severe mental illness, few studies have examined the relationship between these client factors and outcomes in supported employment programs.

Purpose: 

This study examined the relationships of measures of cognitive functioning and psychiatric symptoms with work outcomes and use of vocational services for clients with schizophrenia in a supported employment program.

Setting: 

Study sample received outpatient services at a state hospital. Research team was based at Mount Sinai School of Medicine, New York, New York.

Sample: 

The study participants were 30 clients with schizophrenia or schizoaffective disorder who are receiving outpatients services at a state hospital. The clients diagnoses were made by a member of the research team on the basis of clinical interviews with the Comprehensive Assessment of Symptoms and History and information form the clients charts.

Data Collection: 

Data for the study included work outcomes, an analysis of demographic and other background predictors of work outcomes, the degree of change in clients' symptom severity and cognitive functioning over the year follow up period, and an analysis of symptom and cognitive predictors of work outcomes. Final analysis was on the relationship of symptoms and cognitive functioning with utilization of supported employment services by the clients who obtained competitive employment.

Intervention: 

The program provided at the hospital's outpatients clinics was based on the individual placement and support employment model. At entry into the program, each client was assigned an employment specialist who provided all components of supported employment, including assessment, assistance with job search, and job support. Each employment specialist functioned as a member of the client's interdisciplinary team. The supported employment program provided follow along as needed for an unlimited time, including both on- and off-site support, depending on the client's needs or preferences.

Control: 

There was no control or comparison condition.

Findings: 

Predictors of clients' work outcomes included previous work history, amount of government entitlement income received, severity of negative symptoms, involvement in sheltered work activity at baseline, and level of cognitive functioning, including scores on measures of executive functioning and verbal learning and memory. The amounts of on-job support and contact with employment specialists were predicted by the cognitive domains of executive functioning, verbal learning, attention, and psychomotor speed as well as by the severity of psychotic symptoms.

Conclusions: 

Clients with schizophrenia who have higher levels of cognitive impairment may require greater amounts of vocational support than those with lower levels of impairment. A variety of rehabilitation strategies may be required to improve vocational outcomes and reduce the amount of supported employment services needed by clients with schizophrenia.

URL: 
http://schizophreniabulletin.oxfordjournals.org/content/31/4/898.short
Disabilities: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

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