Work rehabilitation for middle-aged and older people with schizophrenia: a comparison of three approaches

Authors: van den Hout, J. H. C., Vlaeyen, J. W. S., Heuts, P. H. T. G., Zijlema, J. H. L., & Wijnen, J. A. G.
Year Published 2005
Publication The Journal of Nervous and Mental Disease
Volume 193
Number 9
Pages 596-601
Publisher Lippencott, Williams, and Wilkins

There are increasing numbers of middle-aged and older people with schizophrenia-spectrum disorders, most of whom are unemployed. Across all age groups, rates of paid employment among people with these disorders are less than 15%. Yet the potential benefits of employment (e.g., increased income, activity, structure, socialization, and self-esteem) could improve symptoms, everyday functioning, and overall health. Many older people with severe mental illness (SMI) want to work. However, work rehabilitation programs usually do not target older patients, and no published studies have addressed work rehabilitation specifically in middle-aged and older people with SMI.


To examine employment outcomes among middle-aged and older clients with schizophrenia in three work rehabilitation programs that varied in their emphasis on conventional vocational rehabilitation (train-then-place) versus supported employment principles (place-then-train). We analyzed retrospective data from 36 veterans receiving VA Wellness and Vocational Enrichment Clinic (WAVE) services and prospective data from a randomized controlled trial of 30 subjects receiving Department of Rehabilitation/Employment Services (DOR) or Individual Placement and Support (IPS).


Study settings were three separate programs: (a) the VA San Diego Healthcare System's Wellness and Vocational Enrichment Clinic (WAVE), (b) the Department of Rehabilitation/Employment Services (DOR), and (c) IPS. The WAVE Clinic provides conventional vocational rehabilitation (CVR) with some elements of SE. The DOR provides CVR services, as do most of the federally funded state agencies across the United States.


Participants were 40 years of age or older and had DSM-IV (American Psychiatric Association, 1994) diagnosis of schizophrenia or schizoaffective disorder made by their treating psychiatrists and confirmed by a diagnostic chart review by trained research staff. Exclusion criteria were alcohol or substance dependence within the past month and presence of dementia or other major neurological disorders.

Data Collection

All participants were classified as working (including volunteering) at any point in the study or nonworking for the analyses. Three IPS subjects and three DOR subjects decided not to pursue work and dropped out of the prospective study, but these subjects were included in the analyses. We used analysis of variance, [chi]2, and logistic regression techniques to analyze the data. All variables were distributed normally. The [alpha] for significance was set at p < 0.05, and all tests were two-tailed.


Two Comparison Conditions:
(1) WAVE: The WAVE Clinic assists veterans in achieving work readiness by providing prevocational classes and job contracts with various community employers. WAVE services are consistent with CVR, but unlike most CVR programs, the vocational services are integrated with psychiatric services.
(2)Department of Rehabilitation: In San Diego, vocational rehabilitation services for clients with mental illness are contracted to an organization called Employment Services. Individuals first become DOR clients and are then referred to Employment Services. To become a DOR client, the individual must first attend an orientation session and then attend an intake appointment with a DOR counselor. Following the intake appointment, the DOR has 60 days to determine eligibility for services.
Once eligibility has been approved, clients are referred to Employment Services and assigned a vocational counselor (a bachelor's-level or master's-level provider with a typical caseload of 35 clients). Job development and job coaching are provided by additional staff members. The DOR uses a train-then-place approach; individuals receive job readiness coaching and attend pre-vocational classes before their job search begins.


Across interventions, half the subjects obtained volunteer or paid work. IPS participants, those with schizophrenia (versus schizoaffective disorder), and those with more education were more likely to work or volunteer. Rates of volunteer or paid work were 81% in IPS, 44% in WAVE, and 29% in DOR. Rates of competitive/paid work only were highest in IPS (69%), followed by DOR (29%) and WAVE (17%).


Although they are typically written off as having little potential to return to work, especially paid work, middle-aged and older people with severe mental illnesses can obtain employment. Furthermore, they are more likely to do so in the context of a supported employment intervention than with traditional vocational services.

Disabilities Emotional disturbance
Populations Hispanic or Latino | Black / African American | White / Caucasian | Male & Female
Outcomes Employment acquisition
Research Design Mixed methods, Randomized Controlled Trials (RCTs)
Peer Reviewed Yes