Journal Club 20 th Feb 2007 The Effectiveness of Supported Employment for People With Severe Mental Illness: Randomised Controlled Trial’ Dr J Romain
The Lancet, Vol 370, September 2007, 1146-52. Burns T., Catty J., Becker T., Drake R E., et al
Method and Results
People with severe mental health disorders suffer high unemployment rates
Often seen as a vicious circle
40% of people claiming incapacity benefit claim due to mental health issues
Substantially increased over last decade
How are we getting patients back to work?
Traditional methods referred as ‘train-and-place’ model
- addresses deficits related to illness
- train in job skills
- once trained, placed in vocational job, often low skilled and poorly paid
- direct job placement on basis of patient preference
- Often in simple entry level occupations
- no period of training required
- ‘on the job’ support for both employer and employee from an employment specialist working as part of the mental health team
Individual Placement and Support (IPS)
The most intensively studied ‘place-and-train’ model
Very popular and effective in USA, now recommended evidence based practice
- Randomised trials; rates for competitive employment on open job market more than doubled
Europe and USA Differ Greatly in Employment Practices
Hire and fire culture
Varying amounts of employment protection
More generous welfare systems- DLA, IS, housing benefits…
IPS in Europe
Therefore would IPS be as effective as it had been in the USA?
Europe itself contains a lot of variations when looking at welfare systems, job markets and unemployment rates.
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.
To examine its effectiveness in different European welfare systems and labour markets
Patients assigned to IPS more likely to obtain open employment than the control group.
Proportion of people entering competitive employment (working for at least 1 day)
Secondary outcomes; number of hours worked, days employed, job tenure of employed patients, drop-out from service and admissions to hospital.
Six European Centres- UK, Germany, Italy, Switzerland, Netherlands and Bulgaria.
Patient inclusion criteria
- severe mental illness
- aged 18 to local retirement age (60-65)
- major role dysfunction for at least 2 years
- living in the community at baseline
- not been in competitive employment for the past year
Recruited from April 1 st 2003- May 30 th 2004. Follow-up ended on Nov 30 th 2005.
Patients randomly allocated to IPS or vocational (control) service.
Randomisation centrally done with MINIM. Researcher recruited patients and submitted to statistician for randomisation.
Once services assigned, researchers unable to be blind.
Identify patients wanting to work in competitive market
Worker helps them to develop realistic goals and seek appropriate employment directly. All IPS workers are novices. Assessed using ‘IPS fidelity scale’.
No training phase
Network of employers willing to accept patients
Worker offers open-ended support to both employee and employer with a caseload of 25 pts
Best alternative vocational rehabilitation service available locally.
Based on ‘train-and-place’ model
Assessed patients rehab needs
Provision of structured training programme concentrating on deficits related to illness.
Training in appropriate work skills such as reintroducing daily routine, time management, IT skills
Vocational services questionnaire (VSQ) designed to capture the nature of service offered and its distinctiveness from IPS
Patients followed for 18 months, interviews at 6, 12 and 18 months
Data on vocational outcomes, hospital admission and service use by interview
Inter-rater reliability assessed periodically with videotaped interviews
Job satisfaction and hours worked done by questionnaire
95% confidence intervals were calculated for primary and other binary outcomes.
Continuous vocational outcomes analysed by presenting bootstrapped estimates for differences in means and their 95% confidence intervals as they were positively skewed
Prospective meta-analyses used to explore effect of labour market and welfare system factors on the heterogeneity of the effectiveness of IPS and returning to competitive employment. Done to account for variability in the primary employment outcome across the 6 centres.
Variability caused by certain factors;
- local unemployment rate
- percentage change in GDP
- benefit trap
- indirect income redistribution
Cochran’s Q test used to examine heterogeneity in outcomes between the centres
252 pts (81%) completed final follow up interview
No difference in baseline characteristics of groups
IPS workers maintained fair levels of fidelity throughout study. No vocational services achieved near fair level
VSQ confirmed substantial differences in aims and scope of the different models
IPS more effective than vocational services for every vocational outcome
- 85 (55%) of IPS pts worked for at least 1 day compared to 43 (28%) of vocational
(difference 26.9%, 16.4 - 37.4)
- IPS pts maintained these jobs for longer (214 days vs 108 days)
IPS pts worked more hours and were employed for more days
Table Summary of Results -4.3 (-8.40 to -0.59) 141 8.9 (20.08) 148 4.6 (13.56) % of time spent in hospital -11.2% (-21.5 to -0.90) 141 42 (31%) 148 28 (20%) Admission -32.1% (-41.5 to -22.7) 156 70 (45%) 156 20 (13%) Drop-out from service 104.9 (56.03 to 155.04) 39 108.4 (111.95) 83 213.6 (159.42) Job Tenure (days) 99.8 (70.71 to 129.27) 152 30.5 (80.07) 154 130.3 (174.12) Number of days employed 308.7 (189.22 to 434.17) 138 119.1 (311.94) 143 428.8 (706.77) Number of hours worked 26.9% (16.4 to 37.4) 156 43 (28%) 156 85 (55%) Worked for at least 1 day Difference (95% CI) n Vocational n IPS