The effectiveness of supported employment in people with dual disorders
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.
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.
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.
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.
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.
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.
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).
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.
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.