Integration of psychiatric and vocational services: a multisite randomized, controlled trial of supported employment
|Authors:||Cook, J. A., Mulkern, V., Grey, D. D., Burke-Miller, J., Blyler, C. R., Razzano, L. A., ... & Steigman, P. A.|
|Publication||American Journal of Psychiatry|
|Publisher||American Psychiatric Publishing|
Research has tested the efficacy of vocational rehabilitation service model programs,that have established supported employment as an evidenced based practice for individuals with psychiatric disabilities. However the randomized controlled trial design has its drawbacks related to replicating model programs under varying environmental conditions with diverse populations in a variety of organizational settings. Implementation effectiveness trials can be used to evaluate models with established efficacy by testing them in reals world setting with vary program implementation and participant acceptance. One of the features of evidenced based supported employment is the integration of psychiatric and vocational services. No studies have looked at the effects of types and amounts of vocational services on employment outcomes taking into account service integration and patient demographic and clinical characteristics.
The study pool was 10,653, from this group 2,883, were contacted about participation and 1,750 agreed to do so. From this group 1,655 completed the first interview and 1,648 were randomly assigned. Among this group 375 were excluded. A total of 1,273 people were included in the analysis, from seven different States.
Dependent variables were two vocational outcome measures: competitive employment and work for 40 or more hours in a single month. All experimental programs integrated psychiatric treatment and vocational services. An Employment Intervention Demonstration Program measure was developed to operationalize the level of integration. In addition, the effects of the number of hours of psychiatric and vocational services were examined separately. A running cumulative total of service hours for each service was calculated monthly for each of the 24 months of study. Dichotomous variables were used for gender, minority status, and education. Age was measured in 10 year intervals. The structured Clinical Interview for DSM IV was administered at two sites while case records by treating psychiatrist were used at the other sites. Level of functioning was self rated. Receipt of public assistance was reported by the subjects. An evaluation of the Employment Intervention Demonstration Program's protocol found good to excellent validity and reliability on these measures. Of the 1,273 participants, 65% completed five interviews. Those participants were compared to others regarding model covariates. The only significant differences were gender and age. After calculation and inspection of frequency distributions and zero order relationships, outcome were visually inspected. Then random-effects logistic regression modeling, was used to address hypotheses at the multivariate level. All models included: demographics, clinical factors, time and study site.
The control condition was typical vocational services.
Approximately half of the participants were men, two thirds had a high school education and half were Caucasian. The mean and median age was 38 years. Sixty four percent reported having one or more jobs in the 5 years before baseline. The majority (72%) received some type of social security benefit. Slightly over half or 51% had a primary or secondary diagnosis of schizophrenia spectrum disorder. Results revealed that individuals who were in programs where clinical and vocational staff worked together in multidisciplinary teams at the same location using a unified case record and meeting together multiple times a weak were more likely to work competitively and work 40 or more hours a week. In addition, those who received more hours of vocational versus psychiatric services had better employment outcomes. Results support the idea that individuals who receive more vocational services supports achieve significantly better outcomes, even after control for the amount of psychiatric services they receive. This confirms earlier research.
Supported employment models with high levels of integration of psychiatric and vocational services were more effective than models with low levels of service integration.
|Populations||Male & Female|
|Research Design||Randomized Controlled Trials (RCTs)|