Unemployment is the main psychosocial disability of people with psychotic illnesses such as schizophrenia. Not only is unemployment costly to society, it reinforces social and economic marginalisation, can exacerbate symptoms, increases risk of homelessness, and persists after other symptoms have resolved (Rinaldi et al, 2010).
Psychotic illnesses have their peak onset in the late teens and early twenties, which is a stage in normal development when young people finish school and enter the workforce. Because the onset of mental illness can be extremely disruptive, basic employment skills, such as job searching and interviewing are not learned and these individuals do not develop a history of work experience. Evidence suggests that for young people in particular, periods of unemployment can have ‘scarring’ effects on future employment opportunities (Marks et al, 2003).
Most people with severe mental illness say they would like to work (Secker et al, 2001), yet despite this, only a small proportion (estimates 4-27%) of people with schizophrenia are employed (Marwaha et al, 2004).
The costs of lost employment due to mental health problems are substantial. In England in 2007, it was estimated that these amounted to nearly £20 billion (McCrone et al, 2008).
The key message of the government Work, Recovery and Inclusion (Perkins et al, 2009) report is that “work is good for mental health and is central to recovery for people with mental health conditions”. Indeed, a central theme of a number of recent mental health reviews (Perkins et al, 2009; Government HMs, 2009) is that we need to be doing more to help people with severe mental illness gain and maintain employment.
Employment interventions have been trialled in people with severe mental illness, including psychosis, with varying success (for review see Crowther et al, 2001). The strongest evidence has been shown for Individual Placement and Support (IPS), which focuses on supporting competitive job searching in all clients who want to return to work regardless of measures of work-readiness or symptom severity. IPS is significantly better on all employment outcome measures than various control conditions, and in first episode psychosis, patients receiving IPS gain significantly more jobs, earn significantly more money, and work longer (Crowther et al, 2001).
It therefore seems unnecessary to conduct yet another trial of IPS in early psychosis; we know that it works, it just needs to be rolled out across early intervention services. However, actually doing this has proved difficult, not because patients are ambivalent but because key clinicians discourage their clients from participating because they fear that work will precipitate a relapse. In this context, then, Craig and colleagues have conducted a trial of IPS in conjunction with motivational interviewing training for staff (Craig et al, 2014).
This was a cluster-randomised controlled trial at four early intervention teams (two in London and two in the Midlands). All teams included a trained vocational specialist to deliver IPS, and two teams (one each in London and the Midlands) received additional training “in motivational techniques aimed at addressing staff concerns about the value and risks of a return to open (i.e. competitive) employment.”
Participants were patients of the services, aged between 18 and 35, and not currently in work or full-time education.
The primary outcome was the proportion of patients in open paid employment at 12 month follow-up.
- Of the 300 eligible participants across the four sites, 160 consented to involvement (1 later withdrew and asked that all his data be removed). The remaining 159 generally expressed a strong desire to return to work, but thought it unlikely they would be able to do so.
- By the twelve-month time point, 24 participants had been lost to follow-up.
- Of those still in the study:
- 29 of 68 patients in the IPS + MI group were employed
- As opposed to 12 of 66 in the IPS along group
- A significant advantage for the intervention group (p=0.006).
- This was confirmed by a random effects logistic regression accounting for clustering by care coordinator, and adjusted for participants’ gender, ethnicity, educational and employment history and clinical status scores:
- This indicated that those in the intervention arm were four times more likely to be in employment at 12 months (odds ratio=4.3, 95% CI 1.5 to 16.6)
- A similar advantage for the intervention arm was found for formal education (odds ratio=2.4, 95% CI 1.1 to 5.6).
Interestingly, the advantage for the intervention was lost when voluntary or short term ‘cash-in-hand’ positions were included in the ‘employed’ category (38/68 vs 28/66, p=0.12).
Strengths and weaknesses
- Motivational interviewing was offered to the entire clinical team, not just key workers, and was attended by all care coordinators at the two centres.
- IPS was well implemented across all sites.
- Sites covered a range of urban/rural areas.
- MI attendance was not good amongst psychologists and psychiatrists (just one of three clinical psychologists attended any training session).
- Only half the available population of young people consented to participation, potentially biasing the study.
This study provides evidence that a major reason for the poor vocational outcomes experienced by young people with psychosis is the lack of encouragement from and low expectations of staff at early intervention services. The negative views of staff, although well-meaning, are unfortunately hugely misplaced; prolonged inactivity is actually more likely to have negative outcomes than a return to work is to provoke relapse (Burns et al, 2009).
The strong implication of the study is that staff in early intervention services need to be encouraged to support the desires of their clients, rather than be over-protective of them.
Craig T, Shepherd G, Rinaldi M, Smith J, Carr S, Preston F, Singh S. Vocational rehabilitation in early psychosis: cluster randomised trial. Br J Psychiatry. 2014 May 22. pii: bjp.bp.113.136283. [Epub ahead of print] [PubMed abstract]
Burns T, Catty J, White S, Becker T, Koletsi M, Fioritti A, et al. The impact of supported employment and working on clinical and social functioning: results of an international study of individual placement and support. Schizophr Bull 2009; 35: 949–58. [PubMed abstract]
Crowther R, Marshall M, Bond GR, Huxley P. Vocational rehabilitation for people with severe mental illness. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD003080. DOI: 10.1002/14651858.CD003080.
Government HMs: Work, Recovery and Inclusion: Employment support for people in contact with secondary care mental health services (PDF). London, 2009.
Government HMs: New horizons: a shared vision for mental health (PDF). London, 2009.
Marks GN, Hillman K, Beavis A, Australia. Dept. of Education S, Training: Dynamics of the Australian youth labour market: the 1975 cohort, 1996-2000, Australian Council for Educational Research; 2003. [Abstract]
Marwaha S, Johnson S. Schizophrenia and employment. Social psychiatry and psychiatric epidemiology. 2004;39:337-349. [Abstract]
McCrone P, Dhanasiri S, Patel A, Knapp M, Lawton-Smith S. Paying the price: the cost of mental health care in England to 2026 (PDF). London, The King’s Fund; 2008.
Perkins R, Farmer P, Litchfield P. Realising ambitions: Better employment support for people with a mental health condition (PDF). Department of Work and Pensions 2009.
Rinaldi M, Killackey E, Smith J, Shepherd G, Singh SP, Craig T. First episode psychosis and employment: a review. International Review of Psychiatry. 2010;22:148-162. [PubMed abstract]
Secker J, Grove B, Seebohm P. Challenging barriers to employment, training and education for mental health service users: the service users perspective. Journal of Mental Health. 2001;10:395-404. [Abstract]