Long-term unemployment is more likely for those suffering from mental health problems, particularly when the illness is more severe and enduring. There is considerable stigma and wariness from employers towards recruiting individuals with a history of poor mental health. What’s more, the mental ill health and treatments can cause difficulties with social interactions and concentration, which can further compound the issue.

Employment is a crucial protective factor in maintaining mental health, and contributes massively towards recovery (HM Government 2009). Unemployment can be devastating, and leads to worse outcomes, and is costly to both the NHS and broader society. With a growing emphasis of recovery in mental health services, and the need to gain meaningful employment from a broader societal perspective, schemes which enable a route back into work are vital.

There are a variety of schemes which support/encourage routes to employment; one of these schemes known as individual placement and support (IPS) seems to have a growing international evidence base.

The key principles of IPS are:

1. Focus on competitive employment
2. No exclusion criteria
3. Rapid job search
4. Integration with mental health team
5. Attention to client’s job preferences
6. Time-unlimited support
7. Benefits counselling
8. Active job development

This all makes for a costly and time consuming intervention.

The authors of a recent study (Burns et al, 2015) wanted to see if a ‘light’ version of IPS was equally as effective. Their aim was to test whether introducing a time limit for IPS would significantly alter its clinical effectiveness and consequently its potential cost-effectiveness.

Methods

The authors used an unblinded randomised controlled trial comparing IPS with IPS-LITE.

The primary outcome measure was employment for 1 day in an 18 month follow-up period. A range of other measures (vocational, social and clinical) were also collected.

It was not clear from the paper whether there were any exclusion criteria.

Results

• Trial participants were randomised to one of two possible treatments:
  • IPS standard (n=61)
  • IPS-LITE (n=62)
• There was no difference in time to employment between the two groups (HR=0.90, CI=0.51 to 1.58, P=0.71)
• The median time to first job was 137 days, and duration of employment was 65 days
  • However duration of employment was 44 days for IPS-LITE and 74 days for IPS
• There were no significant differences in clinical or social outcomes between the two groups
• Modelling suggested that IPS-LITE potentially could be 17% more efficient

Author’s conclusion

However, the figures we obtain with a potential 17% increase in number of jobs with the same resource would suggest that IPS-LITE may be more cost-effective than routine IPS. A larger and longer trial would be needed to test this definitively…

Our study confirms the growing international literature that IPS is a highly successful form of vocational rehabilitation for individuals with enduring mental health disorders. It also confirms that this can be successfully delivered within non-statutory services that provide adequate staff training and support. A limit of the duration of support to 9 months appears not to significantly reduce the number obtaining employment.

Discussion

Enabling services users to gain employment is incredibly important, however, enabling a service user to remain in and support their employment is arguably more so. The primary outcome measure was a day in employment. Indeed the modelling only focused on employment, not long-term follow-up. The value of such should be questioned in terms of meaningful recovery or therapeutic value. But also the quality of the employment also needs to be examined.

Recent government policy such as ‘welfare to work’ has been criticised for cherry picking those easiest into employment for financial reward (payments by results) leaving those least likely to gain employment on benefits. It could be argued that the same is true here; for example, did those with psychosis (58% of the sample) gain more from support than those without? Those employed later on (post 9 months) could have produced greater individual and societal benefits in the longer term. As with all healthcare provision the rationing through time limiting an intervention requires careful consideration.

The timing and the location of the study was also of interest, it would be good to explore whether these results could be replicated in areas more affected by the recent recession, with long standing long-term unemployment such as parts of the North of England.

Links

Primary paper

Burns T, Yeeles K, Langford O, Vazquez Montes M, Burgess J, Anderson C. (2015) A randomised controlled trial of time-limited individual placement and support: IPS-LITE trial. The British Journal of Psychiatry Jun, DOI: 10.1192/bjp.bp.114.152082

Other references

Coutts, P. (2007) Mental Health, Recovery and Employment. SRN Discussion Paper Series. Report No.5. Glasgow, Scottish Recovery Network

HM Government (2009) Work, Recovery and Inclusion: Employment support for people in contact with secondary care mental health services. Best Practice Guidance, London.