Elsevier

The Lancet

Volume 370, Issue 9593, 29 September–5 October 2007, Pages 1146-1152
The Lancet

Articles
The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(07)61516-5Get rights and content

Summary

Background

The value of the individual placement and support (IPS) programme in helping people with severe mental illness gain open employment is unknown in Europe. Our aim was to assess the effectiveness of IPS, and to examine whether its effect is modified by local labour markets and welfare systems.

Methods

312 patients with severe mental illness were randomly assigned in six European centres to receive IPS (n=156) or vocational services (n=156). Patients were followed up for 18 months. The primary outcome was the difference between the proportions of people entering competitive employment in the two groups. The heterogeneity of IPS effectiveness was explored with prospective meta-analyses to establish the effect of local welfare systems and labour markets. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, with the number NCT00461318.

Findings

IPS was more effective than vocational services for every vocational outcome, with 85 (55%) patients assigned to IPS working for at least 1 day compared with 43 (28%) patients assigned to vocational services (difference 26·9%, 95% CI 16·4–37·4). Patients assigned to vocational services were significantly more likely to drop out of the service and to be readmitted to hospital than were those assigned to IPS (drop-out 70 [45%] vs 20 [13%]; difference −32·1% [95% CI −41·5 to −22·7]; readmission 42 [31%] vs 28 [20%]; difference −11·2% [−21·5 to −0·90]). Local unemployment rates accounted for a substantial amount of the heterogeneity in IPS effectiveness.

Interpretation

Our demonstration of the effectiveness of IPS in widely differing labour market and welfare contexts confirms this service to be an effective approach for vocational rehabilitation in mental health that deserves investment and further investigation.

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

References (26)

  • KT Mueser et al.

    A prospective analysis of work in schizophrenia

    Schizophr Bull

    (2001)
  • M Henderson et al.

    Long term sickness absence

    BMJ

    (2005)
  • Incapacity benefit and severe disablement allowance quarterly summary statistics: February, 2005

  • J Jarvisalo et al.

    Mental disorders as a major challenge in prevention of work disability. European Commission Social Security and Health Reports, No 66, Brussels, 2005

  • AF Lehman et al.

    The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003

    Schizophr Bull

    (2004)
  • DR Becker et al.

    A working life for people with severe mental illness

    (2003)
  • RE Crowther et al.

    Helping people with severe mental illness to obtain work: systematic review

    BMJ

    (2001)
  • EW Twamley et al.

    Vocational rehabilitation in schizophrenia and other psychotic disorders: a literature review and meta-analysis of randomized controlled trials

    J Nerv Ment Dis

    (2003)
  • GR Bond et al.

    Implementing supported employment as an evidence-based practice

    Psychiatric Services

    (2001)
  • PB Gold et al.

    Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness

    Schizophr Bull

    (2006)
  • JA Cook et al.

    Integration of psychiatric and vocational services: a multi-site randomized implementation effectiveness trial of supported employment

    Am J Psychiatry

    (2005)
  • RE Drake et al.

    The New Hampshire study of supported employment for people with severe mental illness

    J Consult Clin Psychol

    (1996)
  • RE Drake et al.

    A randomized clinical trial of supported employment for inner-city patients with severe mental disorders

    Arch Gen Psychiatry

    (1999)
  • Cited by (464)

    View all citing articles on Scopus

    Collaborators listed in full at end of article

    View full text