The impact of supported employment and working on clinical and social functioning: Results of an international study of individual placement and support
|Authors:||Butler, S., F.,Chiauzzi, E., & Thum, C. C.|
Concerns are frequently expressed that working might worsen the mental health of people with severe mental illness(SMI). Several studies of Individual Placement and Support (IPS), however, have found associations between working and better nonvocational outcomes. IPS has been found to double the return to work of people with SMI in 6 European countries.
To explore separately associations between IPS, returning to work, and clinical and social outcomes. The study tested 4 specific questions. (1) Are there any differences in clinical and social functioning outcomes at 18-month follow-up between the IPS and control service groups? (2) Is there any association between (a) having worked, (b) total duration of work, and (c) job tenure and clinical and social functioning outcomes at 18-month follow-up? (3) Is being in work at any given time point associated with (a) particular concurrent clinical and social functioning variables or (b) change in clinical and social functioning over the subsequent 6 months?
A randomized controlled trial comparing IPS to usual high-quality vocational rehabilitation was conducted in 6 European centers.
Patients (n=312)in a randomized controlled trial of IPS in 6 European centers were followed up for 18 months. Patients were recruited if they had a psychotic illness, were aged 18 to local retirement age, had been ill and had major role dysfunction for at least 2 years, were living in the community, had not been in competitive employment in the preceding year and wanted to enter competitive employment.
To determine whether there were any differences between the IPS and vocational service patient groups, a between-group analysis was conducted to compare the 2 on each clinical and social functioning variable at T3, along with whether they had been hospitalized during or were in remission for the last 6 months of the study. Analysis of covariance was used to compare the 2 groups in terms of the clinical and social functioning variables at T3 while controlling for the baseline level of the respective measure. Logistic regression was used to analyze the hospitalization and remission variables, controlling for the number of previous lifetime admissions and being in remission for the first 6 months of the study, respectively. These analyses were then repeated for those patients who had worked only. To determine the impact of having worked at any point during the 18-month follow-up period, patients who worked for at least one day (the study‚ primary outcome) were compared with those who did not in terms of each clinical and social functioning variable, along with whether they had been hospitalized during the final 6 months of the study and were in remission for the final 6 months. Analysis of covariance was used to compare the 2 groups (worked/not worked) in terms of the clinical and social functioning variables at T3, while controlling for the baseline level of the respective measure. Logistic regression was used to analyze the hospitalization and remission variables, controlling for the number of previous lifetime admissions and being in remission for the first 6 months of the study, respectively.
The vocational service (control service) at each center was the best alternative vocational rehabilitation service available locally, with a structured program conducted mostly in day facilities (although mostly residential in Ulm). Each was based on the more traditional principles of train and place providing vocational training and job preparation before the client proceeded to seek competitive employment. Each vocational service had to guarantee taking patients into the service within 2 months of randomization.
There were no differences in clinical and social functioning between IPS and control patients at 18 months. Those who worked had better global functioning, fewer symptoms, and less social disability at final follow-up; greater job tenure was associated with better functioning. Working was associated with concurrently better clinical and social functioning, but this contrast was stronger in the control up, suggesting that IPS was better than the control service at helping more unwell patients into work. Working was associated with having been in remission and out of hospital for the previous 6 months. It was also associated with a slight decrease in depression and with being in remission over the subsequent 6 months.
Concerns among clinicians about possible detrimental effects of working and supported employment have been misplaced. Although some of the associations found may have been selection effects, there is sufficient evidence of work having beneficial effects on clinical and social functioning to merit further exploration.
|Populations||Male & Female|
|Outcomes||Employment acquisition | Increase in tenure | Wages|
|Research Design||Randomized Controlled Trials (RCTs)|