The effects of primary care depression treatment on patients' clinical status and employment

Authors: 
Schonebaum, A., Boyd, J., & Dudek, K.
Year Published: 
2002
Publication: 
Health Services Research
Volume: 
37
Number: 
5
Pages: 
1145-1158
Publisher: 
John Wiley & Sons, Inc.
Background: 

Effective treatment of depression could thus have major public health benefits. Yet despite availability of efficacious treatments, that is, antidepressant medications and psychotherapies, and of national practice guidelines, rates of appropriate treatment for depression remain low nationally, particularly in primary care where only about a quarter of depressed patients receive appropriate care.

Purpose: 

The goal of this study was to evaluate the effects of depression treatment in primary care on patients' clinical status and employment, over six months.

Setting: 

The study was conducted in six diverse, non academic managed primary care organizations. Forty-six of 48 primary care practices and 181 of 183 clinicians participated. Practices were matched into blocks of three clusters, based on factors that might affect baseline quality of care or intervention response: clinician specialty mix, distribution of patient socioeconomic and demographic characteristics, and presence of onsite mental health clinicians.

Sample: 

Study staff screened 27,332 consecutive patients in participating practices over five to seven months. Patients were eligible if they intended to use the clinic during the next twelve months and screened positive for depression, using items from the World Health Organization's twelve-month Composite International Diagnostic Interview. Patients were positive if they reported at least one week of depression in the last 30 days, plus two weeks or more of depressed mood or loss of interest in pleasurable activities or persistent depression over the year.

Data Collection: 

Patient-reported clinical status, employment, health care use, and personal characteristics; health care use and costs from claims data.

Intervention: 

Observational analysis of the effects of evidence-based depression care over six months on health outcomes and employment. Selection into treatment is accounted for using instrumental variables techniques, with randomized assignment to the quality improvement intervention as the identifying instrument. One intervention supported the same nurses to provide six or twelve months of medication follow-up (randomized at the patient level) through telephone contacts or visits, and the other intervention trained local therapists in group and individual Cognitive Behavioral Therapy. These therapists were available to intervention patients at reduced copay. All patients could have other types of psychotherapy for usual copays.

Control: 

Usual care practices only received written depression treatment guidelines by mail. In all intervention conditions, patients and providers made their own treatment decisions and use of intervention resources was optional.

Findings: 

At six months, patients with appropriate care, compared to those without it, had lower rates of depressive disorder (24 percent versus 70 percent), better mental health-related quality of life, and higher rates of employment (72 percent versus 53 percent), each p<.05.

Conclusions: 

Appropriate treatment for depression provided in community-based primary care substantially improves clinical and quality of life outcomes and employment.

URL: 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464020/
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

A comparison of competitive employment outcomes for the clubhouse and PACT models

Authors: 
Secker, J., & Membrey, H.
Year Published: 
2006
Publication: 
Psychiatric services
Volume: 
57
Number: 
10
Pages: 
1416-1420
Publisher: 
Psychiatric Services
Background: 

The unemployment rate among individuals with severe mental illness is high, ranging from 67 to 85 percent. Many studies focus on job placement rates without considering job retention. Supported employment programs vary a lot and no single definition exists. Furthermore, the rapid placement guideline may mean that a lack of job readiness may be impacting an individual's success at work. The clubhouse model to employment may be able to help individuals gain and maintain work at higher rates than other approaches.

Purpose: 

The goal of this study was to determine if a clubhouse model could achieve and maintain employment rates comparable to the Program of Assertive Community Treatment model of supported employment.

Setting: 

The study was conducted in Western Massachusetts Genesis Club.

Sample: 

The study sample included 177 individuals who data was collected over a four year time period. All had a diagnosis of bipolar disorder, depression or schizophrenia and were 18 years of age or older. They were not screened for work readiness and interest in work was not required.

Data Collection: 

After acceptance into the study the Positive and Negative Syndrome Scale was conducted. Interviews were also conducted at baseline and then every 6 months over two and half years. Questions related to symptoms, jobs, hospitalizations and more. Program staff tracked job information. Employment data was also provided by staff or through interviews with participants. Each participant was followed for the study period or until he or she exited services. Time based analyses compared weekly employment and job placement rates for participants in each group. Binary employment outcomes were analyzed with generalized estimating equations of the Genmod procedure in SAS with a logit link function. Another group of job based analyses was also conducted to examine average job duration, hours and wages to compare outcomes from participants in the two groups. Spearman rank-order correlations between job duration, hours and wages were estimated to identify potential covariates in the hours and wages test model.

Intervention: 

The intervention was Supported Employment services delivered through Club Houses.

Control: 

The control was Supported Employment services delivered via Program of Assertive Community Treatment (PACT).

Findings: 

The PACT model had a 14% higher job placement rate than the clubhouse model. Participants in either approach maintained weekly employment levels at or exceeding other published reports. On average participants in more than 2 jobs during the study period and worked 20 hours a week. Clubhouse participants remained employed 2 months longer than individuals in PACT, which resulted in a 66% difference in duration.

Conclusions: 

No difference was found in job placement rates between clubhouse and PACT participants over two and half years. Clubhouse participants remained employed for more weeks and earned slightly higher wages than participants in PACT.

URL: 
http://www.fountainhouse.org/sites/default/files/C.%20Schonebaum%20article.pdf
Disabilities: 
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Efficacy of the customized employment supports(CES) model of vocational rehabilitation for unemployed methadone patients: Preliminary results

Authors: 
Strickland, D., Coles, C., & Southern, L.
Year Published: 
2004
Publication: 
Substance Use and Misuse
Volume: 
39
Number: 
13
Pages: 
2261-2285
Publisher: 
Informa Healthcare
Background: 

Methadone-maintained patients experience great difficulty with gaining and maintaining competitive employment due to personal barriers and limited vocational services. Federal and state policy reforms require substance users to obtain work or risk losing public benefits. Innovative vocational rehabilitation models need to be tested in order to improve employment outcomes for patients enrolled in addiction treatment programs.

Purpose: 

The purpose of the study was to evaluate a Customized Employment Supports (CES) model designed to improve employment outcomes for unemployed methadone-maintained patients.

Setting: 

The study was implemented at two sites in Manhattan. One is a free-standing methadone clinic operated by Greenwich House, a nonprofit social services agency. The other methadone clinic is operated by Harlem Hospital but is located separately from the hospital.

Sample: 

The study eligibility criteria for methadone patients included the following: unemployed or remarkably underemployed; stabilized on an appropriate methadone dose; negative urine toxicologies for both opiates and cocaine for last 4 tests; absence of any condition that would preclude working (e.g., serious mental illness, developmental disability, severe physical health problem, or time-intensive dependent care responsibilities) and willingness to participate and be randomly assigned to either the innovative vocational program or the clinic‚ existing vocational counseling program. The participants included at total of 135 patients: 79 at Greenwich House's methadone clinic and 56 at the Harlem Hospital's methadone clinic. Participants were randomly assigned to either the customized employment supports vocational model or the clinic's standard vocational program. The final sample included 55 in the experimental group and 66 in the control or a total of 121 patients. Some of the key characteristics of the overall sample at baseline included the following: male (58%); minority group (68%); mean age 44 years (s.d.¬º8.8 years); high school graduate/GED (65%); no paid job within last 6 months (60%); unemployed at study entry (100%); ever arrested (81%); rates own overall health as excellent, very good, or good (62%), but reports having trouble standing for long periods (67%), climbing stairs (73%) and lifting a medium weight (90%); received prior treatment for substance misuse (67%) and mental health problems (53%); has attended some form of 12-step program (79%); and has received public assistance benefits in the past year (82%).

Data Collection: 

The study collected data on patient employment and behaviors from the following sources: baseline interviews of patients prior to before random assignment; patient follow-up interviews at 6, 12, and 18 months later using the same procedure as the baseline but adding measures about the intervention; review of vocational activities log kept by both CES and standard counselors as well as employment documentation. The employment measures drew on and integrated information from these sources since no single source was completed using the combined ordinal outcome measure, the initial analysis was a cross-tabulation of the highest level of vocational activity attained by study condition using the combined ordinal outcome measure. Next, cross-tabulations were conducted between experimental condition and four separate indices of vocational outcomes. Pearson chi square provided the tests of statistical significance across the board. Since the hypotheses involving vocational outcomes were directional predictions (i.e., better outcomes were predicted for the experimental group), single-tailed significance tests were reported. Four dichotomous measures of vocational activities, which constitute the outcome measures for this analysis, were obtained at baseline and at 6-month follow-up: 1. Whether the patient attained any paid job in the previous 6 months. 2. Whether the patient attained a competitive job in the previous 6 months. 3. Whether the patient attained an informal job in the previous 6 months. 4. Whether the patient participated in any other socially constructive, vocationally relevant activity in the previous 6 months. The three basic vocational measures (i.e., competitive, informal, constructive activity) were not significantly associated with each other (p>0.05). To provide a single overall index of vocational outcomes, they were combined into a four-level, ordinal measure of highest level of vocational attainment: 1. Attained a competitive job (highest). 2. Attained an informal job. 3. Performed constructive activity other than paid employment. 4. None of the above (lowest).

Intervention: 

The intervention, the Customized Employment Supports (CES) model, is designed to help patients overcome these employment barriers and attain paid work as soon as possible. The model assigns CES counselors small caseloads so that, using intensive interventions, they can engage patients and enhance their self-efficacy. Methods used to help patients increase their self-efficacy included: role modeling, persuasion, and minimizing emotional arousal.

Control: 

The participants were randomized into intervention and control groups.

Findings: 

Consistent with the study‚ main hypothesis, the experimental group achieved significantly higher levels of vocational activities than the comparison group during the 6-month follow-up. Each of the four measures of vocational outcomes was also evaluated individually. Compared with the standard vocational services group, patients in the CES program were significantly more likely to have obtained any form of paid employment, competitive employment, and informal employment. However, the two groups did not differ significantly on engaging in constructive vocational activities other than paid work.

Conclusions: 

The preliminary results supported the hypothesis for two indices of paid employment, i.e., the CES group was more likely to obtain both competitive employment and informal paid employment. More research is needed.

URL: 
http://www.tandfonline.com/doi/abs/10.1081/JA-200034618?journalCode=isum20
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury

Authors: 
Tsang H. W, Fung K. M., Leung A. Y., Li S. M., & Cheung W. M.
Year Published: 
2010
Publication: 
Journal of Head Trauma Rehabilitation
Volume: 
25
Number: 
6
Pages: 
440-446
Publisher: 
Lippincott, Williams and Wilkins Inc.
Background: 

Brain injury has a negative impact on return to work. Past research indicates improved employment outcomes with an integrated medical/vocational case coordination system.

Purpose: 

The researchers hypothesized that individuals with brain injury who receive resource facilitation (RF) will have greater success with return to work and participation in community and home activities.

Setting: 

The setting was a large acute rehabilitation hospital, located in the Midwest.

Sample: 

The sample size included 23 individuals with brain-injury and their caregivers. To be included in the study those with brain injury had to meet the following criteria: injury in the last 12 months or less, 18 to 60 years of age, ability to speak English, had been employed and/or had been enrolled in school for 2 years prior to the injury, had a goal to return-to-work or school and had a caregiver who was willing to participate in the study.

Data Collection: 

Participants were given O-Log and the C-Log, as part of their clinical examination in the acute rehabilitation center prior to enrollment to determine the initial severity of cognitive impairment. Ratings on the Participation Index of the Mayo- Portland Adaptability Inventory (M2PI) were obtained for 11 RF participants and 11 controls before the intervention and at 6-month follow-up.

Intervention: 

All participants received standard follow up. Those assigned to the experimental group also received resource facilitation through a facilitator who was charged with assisting them with returning to work.

Control: 

Participants were assigned to either a resource facilitation group N=12 or regular follow up control conditions N=11.

Findings: 

Resource facilitation can improve work outcomes. Those who received resource facilitation were more engaged in vocational services. It also had a positive impact on participants involvement in community and home activities. Resource facilitation does not appear to affect depression.

Conclusions: 

Six months of resource facilitation, provided soon after patient discharge from acute rehabilitation, may have a powerful impact on employment post brain injury and community participation. More research is needed.

URL: 
http://journals.lww.com/headtraumarehab/Abstract/2010/11000/Prospective_Randomized_Controlled_Trial_of.6.aspx
Populations: 
Outcomes: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Tailoring a vocational rehabilitation program to the needs of people with HIV/AIDS: The Harbor-UCLA experience

Authors: 
Mateer, C. A. & Sira, C. S.
Year Published: 
2005
Publication: 
Journal of Vocational Rehabilitation
Volume: 
22
Number: 
2
Pages: 
95-103
Publisher: 
IOS Press
Background: 

New treatments introduced in the early to mid-1990s have led to improved health and quality of life for many people with HIV/AIDS. These increased health and quality of life improvements have prompted some to consider workforce reentry.

Purpose: 

The purpose of the paper is to provide an overview of the work done in the three study projects to assist people with HIV/AIDS in reentering the workforce.

Setting: 

The setting was various community mental health centers.

Sample: 

Three projects were undertaken. The first included a series of focus groups of people with HIV/AIDS that had contemplated going back to work and a survey of HIV/AIDS case management clients. The second project was a 5 year demonstration program to integrate vocational rehabilitation services, psychosocial care, and HIV treatment. The program accepted referrals from community agencies in the Long Beach area of Los Angeles County. The third project was a clinical trial of an intervention to address issues observed in the demonstration project.

Data Collection: 

Participants are followed for 24 months by a case manager to gather employment data.

Intervention: 

The intervention was vocational rehabilitation and job training services in conjunction with HIV/AIDS related services.

Control: 

The control group received standard treatment conditions available in the community.

Findings: 

Of the first forty-seven people randomized into the enhanced condition, over a third have made some measurable progress. The return to work rates of the two conditions have not been compared yet.

Conclusions: 

There is a continued need for workforce reentry services for individuals with HIV/AIDS.

URL: 
http://content.iospress.com/articles/journal-of-vocational-rehabilitation/jvr00277
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

The effectiveness of artificial intelligent 3-D virtual reality vocational problem-solving training in enhancing employment opportunities for people with traumatic brain injury

Authors: 
Marini, I., Lee, G. K., Chan, F., Chapin, M. H., & Romero, M. G.
Year Published: 
2013
Publication: 
Brain Injury
Volume: 
27
Number: 
9
Pages: 
1016-1025
Publisher: 
Informa Healthcare
Background: 

Individuals who sustain traumatic brain injuries face a myriad of cognitive and other disabilities post injury. Deficits in executive functioning are one of the major problems that impact work. Psychosocial educational interventions and computer assisted training have helped some individuals learn to problem solve. Virtual reality may also be a useful tool.

Purpose: 

This study explored whether or not participants with artificially intelligent VR based vocational problem solving skill training would show better problem solving skills and employment outcomes, than those who received conventional psychosocial program.

Setting: 

The training modules were developed at a University lab in Hong Kong. Where the study took place was not clear.

Sample: 

The study sample included 40 people from Hong Kong with mild (N=20)and moderate (N=20) traumatic brain injury. Participants were randomly assigned to one of the two study groups.

Data Collection: 

The Wisconsin Card Sorting Test and the Tower of London Test were administered to participants. In addition, the Vocational Cognitive Rating Scale was completed by the participant's case manager or supervisor of a rehabilitation facility or center. After the pretest each participant started either the virtual or psychosocial training. The content and structure of the two programs were similar. Each included an introduction to training objectives, training in specific vocational skills and practice and a review of those skills. The virtual program was interactive in nature. The psycho educational vocational training system included a training manual and was delivered under the guidance of a trainer. Post test were also conducted on the previously cited measures. Information about the participants employment status was collected at one, three and six month intervals. Statistical analysis were performed using SPSS for Windows Version 17.

Intervention: 

The intervention was an artificial intelligent virtual reality-based vocational problem solving training program. Participants took part in 12 sessions that lasted 20 to 25 minutes each.

Control: 

The control condition was traditional psycho-educational training.

Findings: 

There was no significant differences in the participants in screening criteria or baseline of outcomes between the virtual training and psycho education program. Those who participated in the virtual training showed improvements in selective cognitive functioning. However, the training did not transfer to functional real world outcomes, as indicated by limited success in vocational outcomes. The virtual training was more cost effective than workshop based training.

Conclusions: 

Virtual reality training may improve memory functioning and have other applications for vocational rehabilitation. More research is needed.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/23662639
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

An innovative job placement model for unemployed methadone patients: A randomized clinical trial

Authors: 
Major, B. S., Hinton, M. F., Flint, A., Chalmers-Brown, A., McLoughlin, K., & Johnson, S
Year Published: 
2007
Publication: 
Substance Use and Misuse
Volume: 
42
Number: 
5
Pages: 
811-828
Publisher: 
Informa Healthcare
Background: 

Methadone treatment patients, have had poorer employment outcomes than other substance users. Employment may enhance clinical outcomes for this group by reducing rates of relapse, criminality, and parole violation. Work is also associated with lower rates of drug use during treatment, as well as longer retention in treatment. Substance users have been eliminated and federal welfare reform legislation. Substance users in treatment must achieve work readiness in specific time frames. Traditional vocational services for substance users, including methadone treatment patients, have had limited positive results. Innovative vocational interventions or programs are needed to assist this group with employment.

Purpose: 

The hypothesis of this study was that patients assigned to the experimental Customized Employment Support model condition would have better employment outcomes
than those assigned to a control condition who received standard vocational counseling.

Setting: 

The study was implemented at two sites in Manhattan. One is a free-standing methadone clinic operated by Greenwich House, a nonprofit social services agency. The other methadone clinic is operated by Harlem Hospital but is located separately from the hospital.

Sample: 

The data was collected from May 2001 through April 2005. The efficacy sample for the analysis consisted of 168 patients who completed follow-up interviews. *(Note this is a follow up to the study by Staines, Blankertz, Magura et al 2004) The sample was 58% male, 75% minority group, average age 45 years, and in methadone treatment for an average of five years.

Data Collection: 

The study collected data on patient employment and behaviors from the following sources: personal interviews, vocational activities log and employment documentation. Employment measures drew on and integrated information from these sources. The major employment outcome was the attainment of a paid job.
To provide a single overall index of vocational outcomes, they were combined into a four-level, ordinal measure of highest level of vocational attainment:
1. Attained a competitive job (highest).
2. Attained an informal job.
3. Performed constructive activity other than paid employment.
4. None of the above (lowest).
CES counselors left during the study period. Patients who received no counseling (N=24) were excluded from this sample. The interview follow up rate for follow up at 12 months was 91%. The main analytical technique was multiple logistic regression with statistical significance set at p < .05 (2-tailed). Vocational intervention condition was introduced into the analysis as an indicator variable (CES=1, standard=0). The statistical control for period of intervention, as described above, is also an indicator variable (earlier cases = 1, later cases = 0). All analyses of employment outcomes included the baseline measure of the outcome variable as a covariate. Since the study had no dollar measure of earnings prior to baseline, work in the prior 6-month period was used as the covariate in the analysis of earnings as an outcome. Patient baseline variables were examined to determine whether any were significantly associated with both an employment outcome and vocational intervention assignment (CES vs. standard counseling); none were. Thus, none of these variables was a potential confounder in the regression analysis. Work in the pre-study period was included as a covariate in the multivariate analysis, however, to enable the potential independent effect of the CES intervention on employment outcomes to be determined.

Intervention: 

The intervention, the Customized Employment Supports (CES) model, is designed to help patients overcome these employment barriers and attain paid work as soon as possible. The model assigns CES counselors small caseloads so that, using intensive interventions, they can engage patients and enhance their self-efficacy. Methods used to help patients increase their self-efficacy include role modeling, persuasion, and minimizing emotional arousal.

Control: 

Participants were randomized into intervention and control groups.

Findings: 

The results supported the hypothesis for two measures of employment; i.e., the Customized Employment Support group was significantly more likely than the control group to obtain both any paid employment and informal paid employment. However, there were no significant differences for competitive employment or total earnings.

Conclusions: 

Vocational rehabilitation services for unemployed methadone patients can be improved by implementing a Customized Employment Support model.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/17613946
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models

Authors: 
Magura, S., Blankertz, L., Madison, E., Friedman, E., & Gomez, A.
Year Published: 
2006
Publication: 
Psychiatric Services
Volume: 
57
Number: 
10
Pages: 
1406-1415
Publisher: 
American Psychiatric Association
Background: 

Supported employment for individuals with mental illness is recognized as an evidenced based practice. One of the highlights of this approach is rapid job placement which does not necessitate a need for job readiness training or sheltered work. Some individuals have used this approach to gain work but do not maintain employment. Some individuals do not need the intensity of services offered in a SE approach, but may benefit from a clubhouse approach.

Purpose: 

This study had two purposes. These included to examine the relationship between the working alliance and the employment outcomes of individuals with severe mental illness who were receiving vocational services. The study also looked at whether working alliance differences existed between client receiving evidenced based supported employment service and those receiving traditional vocational rehabilitation services (DPA). This is a highly regarded team model organized within a day program where individuals get ready to work, then work with a group and overtime progress through a series of placements and eventually move into competitive work. The hypotheses was individuals receiving supported employment services would have a stronger working alliance with their IPS vocational provider than those receiving traditional vocational services (DPA).

Setting: 

The setting included a number of different job sites across 5 states and DC where individuals with mental illness received supported employment services. Services were provided by 5 different experimental programs that adopted the individual placement and support model of supported employment.

Sample: 

The participants included 310 individuals with mental illness who were unemployed, 18 years of age or older and who did not have a diagnosis of severe mental retardation. Each person was randomly assigned to the ACT or the Clubhouse programs. Most participants were white males with a schizophrenia diagnosis.

Data Collection: 

The research measures included participant characteristics and employment. Control variables included: age, severity of psychiatric symptoms, severity of physical health problems and active substance use. Gender was also added.
Psychiatric symptoms were measured using the Positive and Negative Syndrome Scale. Physical health problems were measured through PANSS probes, Medicaid claims, and interviews. Substance abuse was identified through records, reports and interviews. Two motivational control variable were collected related to interest in working at baseline and match of random assignment to participant preference. The programs kept the same service logs and other records.
The data analysis plan included benchmark comparisons of program performance by using published outcome data from exemplary SE programs. A comparison of ACT and clubhouse outcomes was completed using a services of hierarchical regression analyses.

Intervention: 

The intervention was the Individual Placement and Support(IPS)model of supported employment delivered through Assertive Community Treatment programs.

Control: 

There was no control condition as supported employment has already been identified as an evidenced based practice. Comparison services were delivered through Clubhouse programs.

Findings: 

The results included a comparison with benchmark employment outcomes. Club house participants had higher earnings and hours worked as compared to participants in exemplary supported employment programs. Earnings and work hours for ACT participants was greater than two of those programs. A comparison of ACT and clubhouse outcomes found ACT program had better service engagement. There was no difference in time to obtain a first job. Club house participants were employed longer and for more hours and earned more than than ACT participants. Background variables were predictive of receipt of job search services, which predicted higher employment rates. Wage was an incentive for employment success. A few participants in transitional employment, had about the same job tenure as other participants.
ACT participants received services faster than clubhouse participants. The strong integration of vocational and clinical services, provided by ACT, appeared to be especially helpful to participants with co-occurring disorders.

Conclusions: 

The authors concluded that adding supported employment into multiservice programs like ACT and clubhouses, is a way to provide more services to individuals with mental illness, without compromising quality of those services. Although, a cost analysis was not presented, it is suspected that this may also be a cost effective approach to providing supported employment services.

URL: 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759891/
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Enhanced cognitive behavioral therapy for vocational rehabilitation in schizophrenia: Effects on hope and work

Authors: 
Macias, C., Rodican, C. F., Hargreaves, W. A., Jones, D. R., Barreira, P. J., & Wang, Q.
Year Published: 
2005
Publication: 
Journal of Rehabilitation Research & Development
Volume: 
42
Number: 
5
Pages: 
673-682
Publisher: 
Department of Veteran Affairs
Background: 

Many unemployed or disabled adults with schizophrenia spectrum disorders wish to work again yet doubt their ability to succeed. As the result of factors including stigma, practitioners' negative expectations, and the deficits associated with severe mental illness, many with schizophrenia spectrum disorders view themselves as being minimally competent, of low social value, and possibly beyond help. They may believe that they have little ability to influence their lives and construct a personal narrative in which they expect social and vocational failure.

Purpose: 

To address the effects of dysfunctional cognitions on vocational outcome of people with schizophrenia spectrum disorders, the Indianapolis Vocational Intervention Program, a cognitive-behavioral program of group and individual interventions was developed.

Setting: 

The setting was various community employment sites.

Sample: 

The study sample included 50 individuals with schizophrenia or schizoaffective disorders.

Data Collection: 

Hours worked were measured weekly, and work performance was assessed biweekly with the use of the Work Behavior Inventory. Hope and self-esteem were assessed at baseline and at 5 months with the Beck Hopelessness Scale and the Rosenberg Self-Esteem Schedule.

Intervention: 

The intervention was the Indianapolis Vocational Intervention Program.

Control: 

The condition was standard support services.

Findings: 

Analysis of variance (ANOVA) revealed that the IVIP group worked significantly more weeks and had better average work performance than the standard support group. Repeated measures ANOVA of baseline and follow-up scores indicated that the Indianapolis Vocational Intervention Program. group sustained baseline levels of hope and self-esteem through follow-up, while the standard support group experienced declines.

Conclusions: 

Results provide initial evidence of the effectiveness of the Indianapolis Vocational Intervention Program.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/16586193
Disabilities: 
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Improving employment outcomes for persons with severe mental illnessesImproving employment outcomes for persons with severe mental illnesses

Authors: 
Levack, W., McPherson, K., & McNaughton, H.
Year Published: 
2002
Publication: 
Archives of General Psychiatry
Volume: 
59
Number: 
2
Pages: 
165-172
Publisher: 
American Medical Association
Background: 

Unemployment remains a major consequence of schizophrenia and other severe mental illnesses. This study assesses the effectiveness of the Individual Placement and Support model of supportive employment relative to usual psychosocial rehabilitation services for improving employment among inner-city patients with these disorders.

Purpose: 

This study evaluates the Individual Placement and Support model among a population of high-risk inner-city patients with severe mental illnesses, extending previously published work that compared the IPS model with an enhanced vocational rehabilitation program among a similar population. In our study, men and women with severe mental illnesses were randomly assigned to either an IPS program or a comparison psychosocial rehabilitation program, the predominant mode of rehabilitation services offered in Maryland and many other states. This comparison program includes, but does not emphasize, enhanced vocational services.

Setting: 

The setting was a university-run community mental health agency in Baltimore, Maryland and various employment sites.

Sample: 

Two hundred nineteen outpatients with severe mental illnesses, 75% with chronic psychoses, from an inner-city catchment area were randomly assigned to either the Individual Placement and Support program or a comparison psychosocial rehabilitation program. Participants completed a battery of assessments at study enrollment and every 6 months for 2 years. Employment data, including details about each job, were collected weekly.

Data Collection: 

The cumulative measures of employment, total hours worked, and wages earned during the study period were analyzed with fixed-effect procedures. Logistic regression was used to test whether the participant worked during the study, and an analysis of variance was used to test log hours worked and log wages earned. The probability of working over time by treatment group was analyzed as a repeated binary measure using generalized estimating equations to adjust SEs. This secured an estimate of the "population-averaged" effect of working over time for the 2 treatment groups.

Intervention: 

Individual Placement and Support (IPS) 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: 

The comparison psychosocial rehabilitation program provided an array of services, including evaluation and skills training, socialization, access to entitlements, transportation, housing supports, counseling, and education. Vocational services included in-house evaluation and training for individuals who staff believed were not yet fully prepared for competitive employment. Training focused on improving specific work readiness skills, such as work endurance, appropriate social interaction in the workplace, and acceptance of supervision. In-house sheltered work and factory enclave projects were also available. For those ready for competitive employment, the psychosocial program either provided in-house assistance in securing employment or referred participants to city-based rehabilitation or vocational service programs.

Findings: 

Individual Placement and Support program participants were more likely than the comparison patients to work (42% vs 11%; P<.001; odds ratio, 5.58) and to be employed competitively (27% vs 7%; P<.001; odds ratio, 5.58). Employment effects were associated with significant differences in cumulative hours worked (t(211) = -5.0, P =.00000003) and wages earned (t = -5.5, P =.00000003). Among those who achieved employment, however, there were no group differences in time to first job or in number or length of jobs held. Also, both groups experienced difficulties with job retention.

Conclusions: 

As hypothesized, the Individual Placement and Support program was more effective than the psychosocial rehabilitation program in helping patients achieve employment goals. Achieving job retention remains a challenge with both interventions.

URL: 
http://archpsyc.jamanetwork.com/article.aspx?articleid=206027
Disabilities: 
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes