ArticlesThe effectiveness of supported employment for people with severe mental illness: a randomised controlled trial
Introduction
Unemployment for people with mental-health disorders is very high, with rates of up to 95% for those with severe mental illness.1 In the UK, the contribution of mental-health problems to absence from work due to sickness has substantially increased over the past decade,2 and people with mental-health disorders represent the largest group (40%) who claim incapacity benefit.3 A European study4 reported that mental-health problems are a rising cause of sickness, absenteeism, and work disability pensions. Traditional rehabilitation, increasingly referred to as the train-and-place model, has addressed deficits related to illness and training in job skills to prepare patients for a return to employment. This approach remains the most widespread but has had very little success, and many patients obtain employment only in sheltered workshops.5 Developments in the USA emphasise direct job placements, often in simple entry-level occupations, plus support to patient and employer. This model is called place-and-train.
The most intensively studied place-and-train or supported employment intervention is individual placement and support (IPS), which emphasises rapid job search on the basis of patient preference and continuing support to patient and employer from an employment specialist working as an integral member of the mental-health service contributing to treatment planning and delivery.6 Results from several randomised trials and two meta-analyses7, 8 have shown the effectiveness of the programme in the USA, where this intervention is now the recommended evidence-based practice.9 There are almost 20 experimental and quasi-experimental studies of IPS. Several of these studies investigated combined interventions (eg, IPS and assertive community treatment10) or examined specific aspects of the intervention (such as degree of IPS integration for agencies, teams, and individual providers11). Results from randomised trials10, 12, 13, 14, 15, 16 have shown that rates for competitive employment on the open job market for patients using IPS were more than doubled, and a large scale implementation trial in eight sites with locally-determined supported employment and control services noted much the same degree of clinical effectiveness.17
Europe differs greatly from the USA in both its employment practices (varying amounts of employment protection compared with a hire and fire culture in the USA) and in having more generous welfare systems. Such systems might generate a benefit trap, in which there could be perceived or real financial disincentives to returning to work—eg, loss of housing benefits or high disability payments.18 Differences in both labour markets and welfare systems might reduce the effectiveness of IPS. Moreover, welfare systems and job markets vary considerably across Europe,19 and there are substantial differences in unemployment rates.
Our aim was to assess the effectiveness of IPS compared with existing good quality rehabilitation and vocational services for people with severe mental illness in terms of open employment outcomes (in the competitive labour market), and to examine its effectiveness in different European welfare systems and labour markets.
Section snippets
Study design
We undertook a randomised trial in six European centres—London (UK), Ulm-Guenzburg (Germany), Rimini (Italy), Zürich (Switzerland), Groningen (Netherlands), and Sofia (Bulgaria). Patients were included if they were diagnosed with severe mental illness (psychotic illness, including bipolar disorder), were aged between 18 years and local retirement age (ie, between 60 and 65 years), had been ill and had major role dysfunction for at least 2 years, were living in the community at baseline, had not
Results
Figure 1 shows the trial profile. Table 1 shows baseline sociodemographic characteristics of the two groups. Data for the primary outcome measure (in competitive employment for at least 1 day) were available for the whole sample. Of these patients, 252 (81%) completed the final follow-up interview. There were no systematic differences in any baseline characteristics between those who dropped out (did not complete the final interview) and those who remained, nor between the number dropping out
Discussion
This study clearly shows the effectiveness of IPS, since the rate of obtaining competitive employment for people with severe mental illness who were motivated to work was doubled compared with usual, high quality, vocational rehabilitation. Not only did patients assigned to IPS obtain competitive employment more often than did those assigned to vocational services, but they also kept their jobs for longer and worked for more hours. We noted that a high rate of employment did not have a
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Collaborators listed in full at end of article