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Improving Employment Outcomes for Persons With Severe Mental Illnesses
Anthony F. Lehman, MD, MSPH;
Richard Goldberg, PhD;
Lisa B. Dixon, MD, MPH;
Scot McNary, PhD;
Leticia Postrado, PhD;
Ann Hackman, MD;
Karen McDonnell, PhD
Arch Gen Psychiatry. 2002;59:165-172.
ABSTRACT
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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.
Methods 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.
Results 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 (t211 = -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.
INTRODUCTION
WORK represents an important goal for many people with severe mental
illnesses. Gainful employment addresses practical needs by improving economic
independence and therapeutic needs by enhancing self-esteem and overall functioning.1-4 Several
recent forces have again raised employment as an outcome priority. The advent
of new pharmacologic agents has raised hopes that overall outcomes may improve
and that patients may be better able to take advantage of rehabilitation efforts.5 Consumer and family advocacy has created an imperative
to develop treatments that enhance functional status and quality of life.6-8 The government has responded
with efforts to eliminate disincentives to work among persons with disabilities,
such as the Ticket to Work and Work Incentives Improvement Act (1999), enabling
disabled individuals to join the workforce without the fear of losing their
Medicaid coverage.9
Despite these advances, it seems that most persons with severe mental
illnesses do not have vocational services included as part of their treatment
plans.10-11 A recent National
Alliance for the Mentally Ill report12 concluded
that efforts of the Federal-State Vocational Rehabilitation System to serve
this population have been inadequate. However, promising recent randomized
controlled trials have reported greatly improved vocational and psychosocial
outcomes for supported employment models. These models emphasize a rapid search
in competitive jobs and supports from employment specialists within a continuous
mental health treatment team.13-17
The Individual Placement and Support (IPS) model studied herein emphasizes
competitive employment in integrated work settings with follow-along support,
bypassing the traditional stepwise approaches to vocational rehabilitation.17-18 Findings from studies11, 13, 19-21
of IPS programs are encouraging in showing increased rates of competitive
employment.
This study evaluates the IPS model among a population of high-risk inner-city
patients with severe mental illnesses, extending previously published work
by Drake and colleagues,13 who 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. The study tests the hypothesis that patients
assigned to the IPS program will be more likely to work, to be competitively
employed, and to accumulate more hours worked and more wages earned than the
comparison patients.
PARTICIPANTS AND METHODS
PARTICIPANTS
The sample includes patients with severe mental illnesses receiving
outpatient psychiatric care from 3 continuous-care teams within a university-run
community mental health agency serving inner-city Baltimore, Md. All participants
were recruited between March 1, 1996, and April 30, 1998. Standard written
informed consent was obtained from participants at baseline and reviewed at
each follow-up interview. Participants received $20 for the baseline interviews,
$10 for each of the next 2 follow-up interviews, and $15 each for the 18-
and final 24-month interviews.
All participants met the criteria for severe mental illness based on
diagnosis, duration of illness, and level of disability using the following
hierarchical criteria.22-23 Patients
were automatically eligible if they were receiving Supplemental Security Income,
Social Security Disability Income, or 100% Veterans Affairs disability benefits
because of a mental disorder (other than substance use only) or if they had
a diagnosis in the schizophrenia spectrum using DSM-IV
criteria. Those not meeting this criterion were eligible if they had another
Axis I mental disorder (other psychotic, major affective, or anxiety disorder)
or an extensive prior hospitalization history ( 2 prior psychiatric hospitalizations
of >21 days within the prior 3 years, a total of at least 42 days before a
current hospitalization; or 90 total days in a psychiatric hospital or nursing
home during the past 3 years). Finally, people not meeting either of the first
2 criteria were eligible if they had a history of mental disorder lasting
for at least the past year, during which they were unable to spend at least
75% of their time in some gainful activity owing to the mental disorder. Enrollment
was restricted to those who were unemployed for at least 3 months before joining
the study.
The target sample based on power analysis was 220 patients, taking into
account anticipated follow-up attrition. To avoid selection bias in approaching
patients, the patient rosters of the treatment teams were placed in randomized
order, with screening for recruitment beginning at the top of the random-order
list. The medical records of 540 patients served by these teams were screened.
Of these patients, 103 were subsequently determined to be ineligible. An additional
68 patients were excluded because they were too disabled to provide informed
consent or to participate safely in the study. Another 55 eligible patients
could not be located during the recruitment period. Hence, a total of 314
of those screened from the random-order list represented the final eligible
pool approached for participation. Of these 314 patients, 219 (70%) enrolled
and 95 (30%) refused to enroll. While there were no sex or diagnostic differences
between those who enrolled and those who refused to enroll, white patients
were more likely than African American patients and other minorities to refuse
(36% vs 25%;  21 = 4.07; P
= .04). 2 And t test analyses indicated
no significant differences in the samples assigned to the 2 conditions.
INTERVENTIONS
Using pre-prepared sealed envelopes, participants were randomly assigned
to either (1) the IPS program or (2) the comparison psychosocial rehabilitation
program. Regardless of condition assignment, all participants received their
psychiatric clinical services within a single treatment system, thus allowing
for assessment of the 2 interventions under comparable clinical treatment
conditions. Most participants were part of a continuous treatment team that
provided mobile, multidisciplinary, comprehensive, 24-hour continuous (inpatient/outpatient)
care with a 1-stop approach to service delivery. Remaining participants were
recruited from the general outpatient clinic serving the same catchment area.
Experimental Condition
The IPS model involves integrating an employment specialist into the
clinical treatment team. This model focuses on a rapid job search with continued
follow-along support. The IPS program seeks employment opportunities that
are consistent with participants' preferences, skills, and abilities. Ongoing
supervision and consultation were provided by the developers of the IPS program17 and by local experts in the use of supported employment
models. Fidelity ratings, completed by the IPS program developer who served
as a consultant to our project, were made twice yearly using the IPS Fidelity
Scale.24 The program received high ratings
of implementation fidelity across all review periods (69-71 of a possible
75 points).
Comparison Condition
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.
MEASURES
Assessments completed at study enrollment included the Structured Clinical
Interview for DSM-IV25
and a structured interview assessing quality of life, self-esteem, work motivation,
medication attitudes, general health, and social network. All instruments
except the Structured Clinical Interview for DSM-IV
were readministered at 6-, 12-, 18-, and 24-month follow-up points. Logs of
all vocational and nonvocational services were also summarized for all participants.
Employment data, including details about each job (start date, end data,
salary, hours worked, benefits, and level of mainstream integration), were
collected weekly using a standardized employment report form completed by
case managers or vocational specialists. These data were used to define the
vocational outcomes for this study, including percentage of participants working
at all, percentage working in competitive jobs, hours worked, and wages earned.
Competitive employment was defined as a job in which (a) the worker earned at least minimum wage, (b)
the worker had no contact with disabled workers and at least some contact
with nondisabled workers (alternatively, no contact with any other employees,
ie, works alone), and (c) the job had not been set
aside for a disabled person.26 Vocational outcomes
were further conceptualized in 2 ways. Dichotomous indicators of whether a
participant worked (or worked competitively) at any time during the study
were used as cumulative measures of job starts. Longitudinal measures were
created to monitor change over time, specifically, whether a participant was
working each month of participation and the average number of hours worked
and the wages earned.
DATA ANALYSES
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 equations27 to adjust SEs. This secured an estimate of the "population-averaged"
effect28 of working over time for the 2 treatment
groups. Hours worked and wages earned were log transformed to improve the
fit of the models to the data and were analyzed with fixed-effect analyses
of variance with correlated errors (SAS PROC MIXED; SAS Institute Inc, Cary,
NC). For binary and continuous repeated measures, correlated errors were modeled
with a 1-lag autoregressive correlation structure (ar[1]). A Bonferroni correction
was applied to control the type I error rate among the treatment contrasts
in cumulative and longitudinal models. The  value was set at .05/8
= .006 for the 8 treatment group contrasts (2 groups x 4 employment
outcomes). Job characteristics were analyzed using 2-sample nonparametric
tests.
RESULTS
INTERVENTION IMPLEMENTATION
The patterns of vocational and clinical services for the 2 intervention
groups were determined as a manipulation check of program fidelity. In this
effectiveness trial, patients were offered, but not required to accept, services.
While 93% of the IPS program group received vocational services (including
vocational assessments, job development assistance, vocational skills training,
and vocational counseling/support), only 33% of those enrolled in the comparison
program received such services. Clinical services, on the other hand, were
received in equal (and high) numbers across the 2 groups (Table 1).
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Table 1. Receipt of Vocational and Clinical Services: Differences in
the Proportion of Each Treatment Group Receiving a Service*
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FOLLOW-UP RATES AND ATTRITION
The completion rates for assessments across the 2-year period for the
2 treatment conditions were similar: 6 months, IPS program vs comparison program,
92% vs 89%; 12 months, IPS program vs comparison program, 87% vs 84%; 18 months,
IPS program vs comparison program, 81% vs 75%; and 24 months, IPS program
vs comparison program, 74% vs 60%. There were no statistically significant
differences in demographics (sex: 2 = 1.76, P = .19; race: 2 = .07, P
= .79; education: 2 = .05, P = .82;
age: t = 1.24, P = .22),
diagnosis (2 = 3.18, P = .07), current
substance abuse status (2 = 1.42, P
= .23), or treatment condition (2 = 2.49, P = .11) between those who did (n = 151) and those who did not (n =
68) complete the 24-month assessments.
OVERALL EMPLOYMENT OUTCOMES
The proportion of patients who worked at all during any given month,
the proportion who worked competitively, the average hours worked per month,
and the average wages earned per month were all greater for the patients in
the IPS program than for those in the comparison program during the entire
intervention period (Figure 1, Figure 2, Figure 3, and Figure 4,
respectively). Participants in the IPS program (47 [42%] of 113) were more
likely than participants in the comparison program (12 [11%] of 106) to work
at all during the study (21 = 25.5; P<.001; odds ratio, 5.58; 95% confidence interval, 2.75-11.3). Patients
in the IPS program (31 [27%] of 113) were also more likely than the comparison
patients (7 [7%] of 106) to be competitively employed (21 = 15.1; P<.001). In multivariate analyses,
the odds of working at all and working competitively, and the average hours
worked and wages earned, were greater for the patients in the IPS program
(Table 2). Employment outcomes
were worse among patients with psychotic diagnoses and those with active substance
use disorders (Table 2).
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Figure 1. Mean proportion of participants
working at all over time by treatment group. IPS indicates Individual Placement
and Support.
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Figure 2. Mean proportion of participants
working competitively over time by treatment group. IPS indicates Individual
Placement and Support.
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Figure 3. Mean time worked per month over
time by treatment group. IPS indicates Individual Placement and Support.
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Figure 4. Mean wages earned per month over
time by treatment group. IPS indicates Individual Placement and Support.
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Table 2. Cumulative and Longitudinal Work Outcomes by Treatment Group*
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Analyses of the longitudinal patterns of employment outcomes (Table 2) clarify how this treatment effect
operated. In all 4 work outcomes, the longitudinal models showed significant
main effects for treatment group during the entire study, favoring the IPS
program. Time effects were similar for both groups across all 4 outcomes;
a rapid increase in job starts (significant linear effect) was followed by
a leveling-off period in the last 12 months of a participant's study membership.
This latter effect is indicated by the significant (time)2 quadratic
effect.
JOB CHARACTERISTICS
The 47 IPS program patients who achieved employment held 94 jobs during
the 2-year follow-up period, including 50 competitive jobs. In contrast, the
12 comparison group patients who achieved employment held 22 jobs during the
same period, including 12 that were competitive. For those patients who obtained
at least some employment during the intervention period, there were no treatment
group differences in the number of jobs per person, the length of time jobs
were held, hourly wages earned, hours worked, the length of time participants
held those jobs, or time to first job (Table 3).
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Table 3. Job Characteristics by Treatment Condition*
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COMMENT
As hypothesized, the patients in the IPS program were more likely than
the comparison patients to achieve employment and to work competitively during
the intervention period. As a result, in aggregate, the patients in the IPS
program worked more hours and earned more wages (Figure 1, Figure 2, Figure 3, and Figure 4 and Table 2).
Subjects in the IPS program moved more quickly into employment (Figure 1 and Figure 2),
consistent with the philosophy of the IPS program's place-and-train approach.
Nearly half (42%) of the patients in the IPS program achieved employment,
compared with only 11% of the comparison patients. This rate of employment
among the patients in the IPS program approaches that reported by Drake and
colleagues13 (61%) in their study of the IPS
program in inner-city Washington, DC. The rates of employment among these
2 inner-city IPS program samples are substantially lower than that reported
by Drake and colleagues19-20 in
their New Hampshire studies (78%). An important variation between this study
and the studies by Drake et al is the method for screening and enrolling patients.
Drake et al used an "induction group" before consent, requiring that prospective
patients attend 1 or 2 orientation sessions before consent to demonstrate
their motivation to participate. We did not use an induction group to be as
inclusive as possible. Hence, it is likely that our study enrolled some poorly
motivated patients who would have been excluded from the studies by Drake
et al, and this may have contributed to the lower overall employment rates
in our sample.
Most striking, however, is the low rate of employment among our comparison
patients. The employment rate for the comparison patients in the Washington
study by Drake et al13 was 46%. The low rate
of employment among our comparison group relative to the study by Drake et
al likely reflects 2 influences, the severe levels of disability and disadvantage
among the sample in this project and differences in the comparison conditions.
Although our sample is similar in many ways to the inner-city sample (Table 4) studied by Drake et al, the rate
of current substance abuse among our sample was considerably higher (40% vs
24%). Multivariate analyses (Table 2)
revealed that substance abuse was a negative predictor of employment outcomes.
Furthermore, our sample had high levels of prior hospitalizations, averaging
more than 11 in their lifetimes (Table 4).
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Table 4. Sample Characteristics*
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Another factor possibly accounting for the low rate of employment in
our comparison group is the nature of the comparison condition. Our comparison
patients were offered a comprehensive psychosocial rehabilitation program,
only a component of which was a vocational service. The comparison patients
often opted not to use these services (Table 1), and that program did not reach out assertively to engage
patients. In contrast, the comparison group in the Washington study by Drake
et al13 was provided traditional vocational
rehabilitation services coordinated by an on-site vocational coordinator,
who also provided outreach. We hypothesize that the low rate of employment
in our comparison group is attributable to the high level of disability of
the sample and to their failure to access vocational services. Regardless
of the reasons, this low employment rate among the comparison patients underscores
the effectiveness of the IPS program in helping such disabled and disadvantaged
patients in this experiment.
Consistent with other studies8, 11
of supportive employment, the types of jobs obtained by our patients in the
IPS program were short-term, entry-level, part-time jobs (Table 3). More sobering is the finding that job retention for the
patients in the IPS program was problematic. After initial success in obtaining
work, the monthly employment rate for the patients in the IPS program leveled
off in the range of 15% to 20% (Figure 1), despite the ongoing job supports. For those patients who achieved employment,
there were no between-group differences in the length of employment, hourly
wages, or hours worked (Table 3). Clearly, a better understanding of how to enhance job retention is needed.
Job retention is a more challenging outcome than job initiation. We hypothesize
that underlying illness processes, especially neurocognitive impairment and
impaired interpersonal skills, may play a major role in job retention.9 We plan to test this hypothesis with further analysis
of our results. If such factors play significant roles in job retention, then
cognitive rehabilitation, social skills training, better pharmacotherapies,
and additional environmental supports may all be needed to enhance vocational
outcomes.
There are important limitations to this study. The generalizability
of the results, particularly the rates of employment, is limited to similar
highly disabled inner-city populations who face multiple disadvantages and
limited local job markets. As with many research demonstration projects, the
intervention period included the initial start-up of the IPS program and,
hence, the results reflect the combined effects of an initial start-up period
and a more mature program phase. Such start-up periods are characterized by
initial staff turnover and efforts to achieve program fidelity, which affect
program effectiveness. This may explain in part why some patients in the IPS
program entered noncompetitive jobs, a finding contrary to the intent of the
IPS program. In this effectiveness trial, many comparison patients opted out
of the comparison intervention. While this is a real effect, it limits generalizing
to other psychosocial rehabilitation programs that are more effective at engaging
patients in services.
Nevertheless, this study adds to the growing literature on the effectiveness
of the IPS program and related supported employment programs in promoting
employment among persons with severe mental illnesses. It also highlights
the challenges that remain in helping most patients achieve sustained employment
even with assertive efforts to help them achieve work.
AUTHOR INFORMATION
Accepted for publication September 11, 2001.
This study was supported by cooperative grant UD7-SM51824 from the Center
for Mental Health Services, Substance Abuse and Mental Health Services Administration,
Department of Health and Human Services, Rockville, Md, as part of the Employment
Intervention Demonstration Project; grant P50-MH4370 from the National Institute
of Mental Health, Rockville; and the Mental Illness Research Education and
Clinical Center, Veterans Affairs Integrated Service Network 5, Baltimore,
Md.
The contents of this publication are solely the responsibility of the
authors and do not necessarily represent the official views of the Center
for Mental Health Services, the Substance Abuse and Mental Health Services
Administration, the Department of Health and Human Services, or other Employment
Intervention Demonstration Project collaborators.
Corresponding author and reprints: Anthony F. Lehman, MD, MSPH, Department
of Psychiatry, University of Maryland, 701 W Pratt St, Suite 388, Baltimore,
MD 21201 (e-mail: alehman{at}psych.umaryland.edu).
From the Department of Psychiatry, University of Maryland (Drs Lehman,
Goldberg, Dixon, McNary, Postrado, and Hackman); the Mental Illness Research
Education and Clinical Center, Veterans Affairs Integrated Service Network
5 (Drs Lehman, Goldberg, and Dixon); and The Johns Hopkins School of Hygiene
and Public Health (Dr McDonnell), Baltimore, Md.
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A Randomized Clinical Trial of Vocational Rehabilitation for People With Psychiatric Disabilities
Rogers et al.
Rehabil Couns Bull 2006;49:143-156.
ABSTRACT
Randomized Trial of Supported Employment Integrated With Assertive Community Treatment for Rural Adults With Severe Mental Illness
Gold et al.
Schizophr Bull 2006;32:378-395.
ABSTRACT
| FULL TEXT
Predictors of Physical Functioning Among Adults With Severe Mental Illness
Chafetz et al.
Psychiatr. Serv. 2006;57:225-231.
ABSTRACT
| FULL TEXT
Supported employment interventions are effective for people with severe mental illness
Becker and Drake
Evid. Based Ment. Health 2006;9:22-22.
FULL TEXT
Employment status and occupational care planning for people using mental health services
Bertram and Howard
Psychiatr. Bull. 2006;30:48-51.
ABSTRACT
| FULL TEXT
Predictors of HIV and Hepatitis Testing and Related Service Utilization Among Individuals With Serious Mental Illness
Goldberg et al.
Psychosomatics 2005;46:573-577.
ABSTRACT
| FULL TEXT
Effects of Job Development and Job Support on Competitive Employment of Persons With Severe Mental Illness
Leff et al.
Psychiatr. Serv. 2005;56:1237-1244.
ABSTRACT
| FULL TEXT
The Effectiveness of Skills Training for Improving Outcomes in Supported Employment
Mueser et al.
Psychiatr. Serv. 2005;56:1254-1260.
ABSTRACT
| FULL TEXT
Cognitive Training and Supported Employment for Persons With Severe Mental Illness: One-Year Results From a Randomized Controlled Trial
McGurk et al.
Schizophr Bull 2005;31:898-909.
ABSTRACT
| FULL TEXT
Components of a modern mental health service: a pragmatic balance of community and hospital care: Overview of systematic evidence
Thornicroft and Tansella
Br. J. Psychiatry 2004;185:283-290.
ABSTRACT
| FULL TEXT
Rehab Rounds: Supplementing Supported Employment With Workplace Skills Training
Wallace and Tauber
Psychiatr. Serv. 2004;55:513-515.
ABSTRACT
| FULL TEXT
The Cost of High-Fidelity Supported Employment Programs for People With Severe Mental Illness
Latimer et al.
Psychiatr. Serv. 2004;55:401-406.
ABSTRACT
| FULL TEXT
Cognitive and Symptom Predictors of Work Outcomes for Clients With Schizophrenia in Supported Employment
McGurk et al.
Psychiatr. Serv. 2003;54:1129-1135.
ABSTRACT
| FULL TEXT
Does having been on a 'section' reduce your chances of getting a job?
Fenton et al.
Psychiatr. Bull. 2003;27:177-178.
ABSTRACT
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Cost-Effectiveness of Two Vocational Rehabilitation Programs for Persons With Severe Mental Illness
Dixon et al.
Psychiatr. Serv. 2002;53:1118-1124.
ABSTRACT
| FULL TEXT
Cognitive Correlates of Job Tenure Among Patients With Severe Mental Illness
Gold et al.
Am. J. Psychiatry 2002;159:1395-1402.
ABSTRACT
| FULL TEXT
Other Articles Noted
Evid. Based Ment. Health 2002;5:72-72.
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