The employment rate amongst people with severe mental illness such as schizophrenia or bipolar disorder is extremely poor (Marwaha et al., 2007). Re-entering the workforce after suffering mental illness can be daunting, whether due to stigma in the workplace, poor educational attainment, or the distress caused by symptoms themselves (Glozier, 1998).
Nonetheless, people with severe mental illness consistently show a desire to work, and the benefits of employment to such individuals are considerable. Benefits include improved self-esteem and general wellbeing, a sense of social support and independence, and reduced use of mental health services (Bush et al., 2015).
Sadly, mental health services are accused of focusing too much on symptom reduction, and too little on helping people regain employment (Secker, 2001). Traditional models of work rehabilitation emphasise lengthy training before work placement. This delay may exacerbate feelings of social exclusion (Waghorn et al., 2009). A more modern approach, supportive employment, rapidly places individuals into work while providing support and training alongside. The most successful iteration of supportive employment is ‘Individual Placement and Support’ (IPS). IPS places competitive employment as the primary goal by integrating vocational and clinical services towards this end. IPS is at its most successful when fidelity to its principles are high (Drake et al., 2012).
IPS is now seen as the ‘gold standard’, but only in the USA. There has been doubt as to whether IPS can generalise to other countries, given variation in economic growth, availability of employment, and health services (Boardman & Rinaldi, 2013). Published in the British Journal of Psychiatry, a recent study examined whether IPS is effective in different countries by carrying out a meta-analysis of available international studies (Modini et al., 2016).
Two researchers independently identified relevant studies from medical databases, and one author extracted the following data for analysis: sample characteristics, country of origin, length of follow-up and rate of competitive employment achieved for the experimental and control groups.
Only randomised controlled trials (RCTs) were included, although true masking of group allocation for all involved was impossible given the nature of IPS. Only studies scoring moderate to high on an IPS fidelity scale were selected. Study quality rated as ‘poor’ resulted in exclusion. Severe mental disorders included schizophrenia, bipolar, and depression with psychotic features.
Three meta-analyses were carried out using the random effects model, which assumes that the true effect varies across studies. This was appropriate given the large variation in populations and socioeconomic factors.
The first was to determine the effectiveness of IPS compared with traditional rehabilitation. Meta-regressions analysed associations between IPS and region of origin, unemployment rate and GDP (gross domestic product) growth (total value of goods produced and services provided in a country annually, obtained from World bank database).
The second and third meta-analyses determined whether IPS effects would remain stable over a 2-year period. Main outcome was measured as binary (yes/no), so could be calculated as Risk Ratios (RRs). This essentially calculated the likelihood of successfully entering competitive employment using IPS relative to traditional rehabilitation models.
- In total, 19 studies were included:
- 4 studies in Asia and Australia
- 6 studies in Europe
- 9 studies in North America
- Two authors found that two studies were of ‘fair’ quality, and 17 were ‘good’, with good inter-rater reliability (Cohen’s Kappa=0.74)
- GDP growth ranged from 0.7% to 6.6% across countries, indicating a wide variability
- A funnel plot used to visualise publication bias (i.e. when only positive results get published), found some slight bias, with smaller studies showing greater estimates of the effectiveness of IPS than is likely
- Meta-analysis 1:
- Pooled risk ratio (PRR) for gaining competitive employment for IPS compared with traditional vocational rehabilitation = 2.40 (95% CI 1.99 to 2.90)
- Meta-regressions did not indicate that unemployment rate or geographic region accounted for this finding, although IPS was relatively more effective in higher GDP growth (b=0.13, s.e.=0.59 95% CI 0.00 to 0.25, P= 0.045)
- However, even when only including low GDP growth studies, IPS remained more effective, with PRR of 1.82 (95% CI 1.37 to 2.40)
- Meta-analysis 2:
- PRR for gaining employment within first year after IPS started, compared with traditional vocational rehabilitation was 2.59 (95% CI 1.88 to 3.56)
- Meta-analysis 3:
- PRR for gaining competitive employment within the second year was 2.41 (95% CI 1.96 to 2.97).
This is the first meta-analysis examining the effectiveness of IPS in different countries and economies. Overall, Individual Placement and Support was effective in helping individuals with severe mental illness to gain competitive employment across multiple settings. In fact, those in the IPS group were more than twice as likely to get employment, regardless of country, unemployment rate, or GDP. Furthermore, these effects remained stable over a 2-year period. Although IPS was slightly less effective during times of economic downturn, it still remained significantly more effective than traditional rehabilitation.
Individuals do not need to be symptom-free before returning to work. The longer someone is out of work the less likely they are to return, partly due to deterioration in skills, but more likely owing to increased anxiety and perceived vulnerability (Henderson et al., 2011). IPS emphasises getting people back to work quickly with support from both clinical and employment services. Current barriers to the wider uptake of IPS include unhelpful attitudes by clinicians and employers, the way in which labour market and welfare are structured, and how mental health services are organised (Boardman, 2013). The authors argue these results should give ammunition to stakeholders wishing to pressure policy-makers into addressing these barriers.
The authors conclude that:
This study provides strong evidence that IPS is effective in a variety of international settings… policy-makers and clinicians need to begin addressing the barriers preventing wide-scale use of supported employment principles, to ensure access to high-fidelity IPS is made available to those with severe mental illness regardless of where they live or the prevailing economic conditions.
Strengths and limitations
- This is the first study to examine the effectiveness of supported employment internationally
- There was variation in what each study deemed a sufficient length of employment as a successful outcome, ranging from 1 day to 1 month
- Study selection was limited to those investigating high fidelity IPS, so no data on less efficient implementation of IPS was examined
- Some publication bias was present in smaller studies; sadly this is an issue across all research
- No successful blinding/masking of anyone involved in each study was possible due to nature of IPS
- It is unclear at present exactly which components of IPS are the most effective.
Modini M, Tan L, Brinchmann B, Wang M-J, Killackey E, Glozier N, Mykletun A, Harvey SB. (2016) Supported employment for people with severe mental illness: systematic review and meta-analysis of the international evidence. The British Journal of Psychiatry, bjp. bp. 115.165092. [Abstract]
Boardman J, Rinaldi M. (2013) Difficulties in implementing supported employment for people with severe mental health problems (Editorial). The British Journal of Psychiatry, 203(4), 247-249.
Bush PW, Drake RE, Xie H, McHugo GJ, Haslett WR. (2015) The long-term impact of employment on mental health service use and costs for persons with severe mental illness. Psychiatric Services. [Abstract]
Drake RE, Bond GR, Becker DR. (2012) Individual placement and support: an evidence-based approach to supported employment: Oxford University Press. [OUP book page]
Glozier N. (1998) Workplace effects of the stigmatization of depression. Journal of Occupational and Environmental Medicine, 40(9), 793-800. [PubMed abstract]
Henderson M, Harvey S, Øverland S, Mykletun A, Hotopf M. (2011). Work and common psychiatric disorders (PDF). Journal of the Royal Society of Medicine, 104(5), 198-207.
Marwaha S, Johnson S, Bebbington P, Stafford M, Angermeyer MC, Brugha T, Azorin J-M, Kilian R, Hansen K, Toumi M. (2007) Rates and correlates of employment in people with schizophrenia in the UK, France and Germany. The British Journal of Psychiatry, 191(1), 30-37.
Secker BG, Patience Seebohm J. (2001). Challenging barriers to employment, training and education for mental health service users: The service user’s perspective. Journal of Mental Health, 10(4), 395-404. [Abstract]
Waghorn G, Lloyd C, Clune A. (2009) Reviewing the theory and practice of occupational therapy in mental health rehabilitation (PDF). The British Journal of Occupational Therapy, 72(7), 314-323.
Supported employment for people with severe mental illness https://t.co/5gWReT5aGI #MentalHealth https://t.co/1EtjkRnI0D
New @Mental_Elf blog on evidence that IPS is better at getting #mentalhealth service users into work than trad model https://t.co/K1Dw1ScSuB
SR: IPS significantly more effective than traditional rehab, even in hard economic times https://t.co/vq0EIxqquW https://t.co/3GVN2lGlcT
@Mental_Elf IPS is good, but needs to address the paradox of work that degrades the quality and meaning of life.
@Mental_Elf broken link? It refers to COBRA trial…
@ACLDrake Thanks ? #PostBankHoliday #BrainFog This link should work for you https://t.co/vq0EIxqquW
MT @Mental_Elf: Supported employment for people with severe mental illness https://t.co/luM4Gj0zo6 #PlaceAndTrainWorks #NewEvidence
Supported #employment for people with severe #mentalillness https://t.co/5KZVIPVfJY @Mental_Elf on #evidence from a new #metaanalysis
El empleo con apoyos es más de dos veces más probable que conduzca a un empleo competitivo que la rehabilitación https://t.co/95pNTUgiTV
#IPS is effective in supporting ppl with severe mental illness into work via @Mental_Elf https://t.co/Ra1djonSmW #healthatwork #mentalhealth
Further research needed to ascertain which components of Individual Placement and Support are most effective https://t.co/vq0EIxqquW
Supported employment for people with severe mental illness
@Mental_Elf what types of jobs were people given? Could they choose? Were they low wage entry level jobs?
@Mental_Elf more importantly what were service users’ experiences of the programmes. Did they think it worked? Figures don’t tell u that
@Mental_Elf successful outcomes measured between 1 day & 1 month employment!!! We need sustainable employment.
It’s important to have better supported employment programs for people with smi who can work. However, there is now an overemphasis on these programs and meanwhile there is a lack of attention on the needs of people whose illnesses prevent them from participating in competitive employment. Many NIMH funded research projects document the common cognitive losses that accompany schizophrenia. These include difficulties with focusing, short term and working memory, problem solving and judgement. We need services that recognize and address these problems. The overemphasis on supported employment programs led to the elimination of the supported volunteer program that meant so much to my daughter.
Supported employment for people with severe mental illness
Individual Placement and Support more than twice as likely to lead to competitive employment https://t.co/wDgs8uS5gY
Supported employment for people with severe mental illness https://t.co/1GCcu5ugAo
Promising results: Supported employment for people with severe mental illness https://t.co/pAhFv5v1nr
“Mental health services are accused of focusing too much on symptom reduction, and too little on helping people rega…https://t.co/VYlZB3Ds2h
Individual Placement and Support may help those with #mentalillness return to work https://t.co/tYWm6fsqi5
Love this idea https://t.co/GIK0RKaXpc
RT @Mental_Elf: SR: IPS significantly more effective than traditional rehab, even in hard economic times https://t.co/luM4Gj0zo6
MT @Mental_Elf: Further research needed to ascertain which parts of Individual Placement & Support most effective https://t.co/luM4Gj0zo6
Supported employment for people with severe mental illness https://t.co/umRhFmdg9X via @sharethis
I’m confused as to why the common cognitive losses associated with schizophrenia are not acknowledged in this article. NIMH has written that these losses are the biggest factor in the ongoing disability of people with schizophrenia. By only mentioning stigma, poor educational attainment or “distress caused by symptoms themselves” as the barriers to employment, the actual obstacles for many people don’t receive the attention that is needed.
These common cognitive problems include difficulties with working and short term memory, reasoning, sequencing, judgment, problem solving and social skills.
The current emphasis on competitive employment has reduced investment in supported volunteer programs. My daughter was benefitting from this service in Vancouver. However, the implementation of the Recovery Model led to a drastic reduction in these opportunities and my daughter’s program was cut.