A working reality: Evaluating enhanced intersectoral links in supported employment for people with psychiatric disabilities

Background/aim: Supported employment (SE) program‐mes have been found to improve the rates of competitive employment for people with severe mental illness. Evidence has suggested that the most effective SE model is one in which the employment specialist is co‐located with mental health services. However, this may not always be achievable. The aim of this study was to investigate the effectiveness of the enhanced intersectoral links approach to SE. Methods: A total of 43 people with a mental illness participated in the programme in which formal links were created between a community mental health team and three employment services. The outcomes of the programme were evaluated over 24 months. Results: Of all participants, 77% achieved a competitive employment outcome, with 60.6% remaining in employment at the end of the evaluation period. The average duration of employment was 44.8 weeks. For those who were unable to maintain a job, the average period of employment was 14.2 weeks. The study found that participants with less severe symptoms at baseline were more likely to obtain employment and those who had worked in the year preceding entry into the programme were employed for a higher proportion of time. The factors related to job loss were the short‐term nature of the position, cognitive difficulties and social skills. Conclusions: The study found that the enhanced intersectoral links approach was effective in achieving outcomes consistent with international studies of SE programmes and may offer a viable alternative to the co‐location of employment specialists with community mental health teams.     

The economic benefits of supported employment for persons with mental illness

BACKGROUND: Policies and programs that emphasize employment for persons with mental illness are often promoted with the goals of improving economic self-sufficiency and reducing dependence on public welfare programs. At present, there is little empirical evidence about the actual effect of vocational interventions on economic self-sufficiency or on use of public benefits by persons with mental illness. STUDY AIMS: This study provides a preliminary look at how participating in supported employment, a form of vocational rehabilitation emphasizing ongoing support in competitive jobs, affects the amount that participants earn from work and the total amount of income they receive from all sources. Further, we examine the extent to which receiving public benefits affects the amount earned from private employment, taking into consideration other factors that might be associated with benefit status. METHODS: Data are from a randomized trial of supported employment interventions. This analysis followed 137 of those study participants with severe mental illness for 18 months after they enrolled in either of two supported employment programs. Income from various sources was estimated based on interviews with study participants upon study entry and at six-month intervals thereafter. Changes in income from work, government and other sources were analyzed using paired Wilcoxon matched-pairs signed-ranks tests and t-tests. Using ordinary least-squares regression, we analyzed the effect of benefit status on changes in earnings, taking into account diagnosis, work history, education, program type, site of program, psychiatric symptoms, global functioning and previous earnings. RESULTS: Estimated total income increased by an average of $134 (US) per month after enrolling in supported employment. More than three-quarters of this increase was from government sources, such as Social Security and educational grants. The increase in government income was largely due to participants applying for and getting cash benefits for the first time. Social Security payments for those receiving benefits before enrollment did not change significantly. A small group of persons (n = 22) who did not receive Social Security benefits before or after enrolment earned significantly more from competitive employment after enrolling than did those who received benefits. This finding persisted after taking into acount differences in work history, clinical and functional variables and education. LIMITATIONS: Because of the relatively small sample size and the lack of continuous measures of income these results should be considered preliminary. CONCLUSIONS: Supported employment, one of the more effective forms of vocational rehabilitation for persons with mental illness, did not reduce dependence on government support. Receiving government benefits was associated with lower earnings from work. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These findings suggest that most persons in treatment for severe mental illness need continued public financial support even after enrolling in vocational rehabilitation programs. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Undoubtedly increased labor force participation can benefit persons with mental illness in a number of ways. However, policy makers should be careful about justifying increased access to vocational programs on the basis of reduced spending for income support. Further, targeting such programs only to persons receiving income support may overlook the clients who can benefit most: those who are not currently receiving benefits. IMPLICATIONS FOR FURTHER RESEARCH: Policy makers need a better understanding of how vocational interventions and income support programs affect the income and well-being of persons with mental illness. Studies similar to this one should be repeated with larger, more diverse samples that will allow use of instrumental variables statistical techniques.     

Job Acquisition for People with Severe Mental Illness Enrolled in Supported Employment Programs: A Theoretically Grounded Empirical Study

Introduction The main purpose of this study was to test a conceptual model based on the theory of planned behaviour (TPB) to explain competitive job acquisition of people with severe mental disorders enrolled in supported employment programs. Methods Using a sample of 281 people with severe mental disorders participating in a prospective study design, the authors examined the contribution of the TPB in a model including clinical (e.g., severity of symptoms), psychosocial (e.g., self-esteem) and work related variables (e.g., length of time absent from the workplace) as predictors of job acquisition. Path analyses were used to test two conceptual models: (1) the model of job acquisition for people with mental illness adapted from the TPB, and (2) the extended TPB including clinical, psychosocial, and work related variables recognized in the literature as significant determinants of competitive employment. Results Findings revealed that both models presented good fit indices. In total, individual factors predicted 26% of the variance in job search behaviours (behavioural actions). However, client characteristics explained only 8% of variance in work outcomes, suggesting that environmental variables (e.g., stigma towards mental disorders) play an important role in predicting job acquisition. About 56% (N = 157) of our sample obtained competitive employment. Conclusion Results suggest that employment specialists can be guided in their interventions by the concepts found in the extended model of work integration since most of these are modifiable, such as perceived barriers to employment, self-efficacy, and self-esteem.     

A Test of the Occupational Matching Hypothesis for Rehabilitation Clients with Severe Mental Illness

Purpose This study compared job matching rates for clients with severe mental illness enrolled in two types of employment programs. Also examined was the occupational matching hypothesis that job matching is associated with better employment outcomes. Methods The study involved a secondary analysis of a randomized controlled trial comparing evidence-based supported employment to a diversified placement approach. The study sample consisted of 187 participants, of whom 147 obtained a paid job during the 2-year follow-up. Jobs were coded using the Dictionary of Occupational Titles classification system. Match between initial job preferences and type of job obtained was the predictor variable. Outcomes included time to job start, job satisfaction, and job tenure on first job. Results Most occupational preferences were for clerical and service jobs, and most participants obtained employment in these two occupational domains. In most cases, the first job obtained matched a participant’s occupational preference. The occupational matching hypothesis was not supported for any employment outcome. The occupational matching rate was similar in this study to previous studies. Conclusions Most clients who obtain employment with the help of evidence-based supported employment or diversified placement services find jobs matching their occupational preference, and most often it is a rough match. Occupational matching is but one aspect of job matching; it may be time to discard actuarial classification systems such as the Dictionary of Occupational Titles as a basis for assessing job match.     

Perspectives on barriers to employment for job seekers with mental illness and additional substance‐use problems

This paper examines the barriers to employment faced by job seekers (JS) with mental illness and additional substance‐use issues. Semi‐structured interviews concerning barriers to employment for JS with mental illness and substance‐use problems and strategies to improve employment outcomes were conducted with stakeholders associated with an employment service provider specialising in mental illness (n = 17). Stakeholders were JS, family members who provide significant support to JS [support persons (SP)] and staff [employment staff (ES)]. Data were collected between May and August 2009 at the premises of the employment service provider in metropolitan Sydney. Thematic analysis of transcribed interview data was conducted to develop a meaningful data framework. The expectations of JS and SP regarding employment outcomes were higher than those of ES. Length of time unemployed was perceived as the most important barrier to future employment associated with mental illness, and substance‐use problems were associated with lower, more variable motivation, restrictions on the environments where JS could work and more negative community and employer perceptions. The findings are consistent with studies from non‐vocational settings and provide direction for meeting the needs of clients with mental illness and additional substance‐use problems. Ensuring alignment between JS and ES concerning service goals and expected timeframes may improve JS motivation, satisfaction with service delivery and ultimately, employment outcomes.     

The contributions of persons in the work environment to the self‐identity of persons with mental health problems: a study in Israel

This study explores the contribution of others in the workplace to the self‐identity and job integration of persons with severe mental health problems. Thematic content analysis of in‐depth, semi‐structured interviews conducted in 2009 with 15 Israelis with severe mental health problems who work in a variety of frameworks (protected and supported employment and open market) revealed three main themes: (i) dissatisfaction with the protected work settings in which they were initially employed; (ii) the importance they attributed to their relationships with others in their workplace; and (iii) the change in self‐identity they underwent from persons defined by their mental health problems to persons who had worth, abilities and being beyond their illness. The findings underscore the important role of managers and colleagues in integrating persons with mental health problems at work and in strengthening the self‐identity of those individuals.     

Caring hours and possible need for employment support among primary carers for adults with mental illness: Results from an Australian household survey

Intensive unpaid caring is associated with greater likelihood of not being employed, but impacts for mental health carers specifically remain unknown. This study aimed to: (a) examine the association between caring intensity and not being employed for primary mental health carers, (b) ascertain whether this relationship differs from that for other disability carers, (c) enumerate Australian primary mental health carers with a possible need for employment support and (d) describe these carers’ unmet support needs and barriers to employment. Co‐resident, working age primary mental health (n = 137) and other disability carers (n = 821) were identified in the Survey of Disability, Ageing and Carers (collected July‐December 2015). Multiple logistic regression analyses examined associations between levels of caring intensity (1–9, 10–19, 20–39, 40+ hr/week) and not being employed. A ‘possible need for employment support’ indicator was derived from information about current employment status, caring hours, past impact of caring on employment and desire for more work or workplace accommodations. After controlling for demographic and caring role factors, mental health carers providing 40+ hr of care weekly had greater odds of not being employed compared to carers providing <10 hr (AOR 13.38, 95% CI: 2.17–82.39). For other disability carers, the odds of not being employed were also higher among those providing 20–39 hr of care (AOR 3.21, 95% CI: 2.18–4.73). An estimated 54.1% (95% CI: 43.1–64.8) of carers had a possible need for employment support, with the proportion increasing as level of caring intensity increased. Of carers who were not employed, 42.2% (95% CI: 30.3–55.0) reported a desire to work, and the main reported barrier was no alternative care arrangements or disruption to the person supported. Findings suggest that improving employment participation for mental health carers requires a greater balance between unpaid care and access to formal services for people with mental illness.     

Predictors and course of vocational status, income, and quality of life in people with severe mental illness: a naturalistic study

Due to high unemployment rates, people with mental illness are at risk of poverty and are deprived of the social and psychological functions of work, such as the provision of social support, structuring of time, and self-esteem, with a negative effect on their perceived quality of life (QoL). Two distinct processes are held responsible for the low work force participation of people with mental illness: 'Social underachievement' and 'social decline'. Social underachievement signifies that, due to early illness onset, the educational attainment of people with mental illness is low and entry to the labor market fails. Social decline, on the other hand, describes the loss of competitive employment after illness onset, followed by prolonged periods of unemployment and difficulties to re-enter the labor market. This study examines how social underachievement and decline are reflected in the course of vocational status, income, and QoL of people with severe mental illness in the years after a psychiatric admission in a naturalistic longitudinal design. A total of 176 participants diagnosed with schizophrenia or affective disorders were interviewed during an index hospitalization in two large psychiatric hospitals in Zurich. Follow-up interviews were conducted 12 and 30 months after. Random coefficient models (multilevel models) were used to examine simultaneously the predictors and course of the variables of interest. A low number of psychiatric hospitalizations, a higher educational degree, a diagnosis of schizophrenia, and years of work experience predicted a higher vocational status. Vocational status decreased in first-admission participants with prolonged hospitalizations during the follow-up period. Income did not change over time and was positively influenced by a higher age of illness onset, competitive employment, higher education, and not having had a longer hospitalization recently. Subjective QoL significantly improved and was rated higher by people with any kind of employment than by participants without a job. Participants with an affective disorder, those with few hospitalizations but a recent inpatient stay of longer duration, showed lower QoL. Including employment issues early in treatment is especially important for people with an early illness onset and those with more severe forms of psychiatric disorder. A life course perspective enhances the understanding of patients' vocational potential and needs for support.     

Serious health events following involuntary job loss in New Zealand meat processing workers

BACKGROUND: The association between unemployment and poor health outcomes is well documented. Significant debate exists as to whether unemployment causes ill health or whether those with poor health find it harder to obtain and maintain employment. Factory closure studies are well placed to comment on causation. The objective of this study was to investigate associations between involuntary job loss, mortality and serious illness. METHODS: An 8-year follow-up of workers from two meat-processing plants in the Hawkes Bay region of New Zealand. A cohort (n = 1945) made redundant in 1986 was compared with a cohort (n = 1767) from the neighbouring plant that remained open until 1994. Incidence rates for mortality, cancer registrations and admissions to public hospitals were derived from record linkage with routinely collected national data. RESULTS: Follow-up for the period 1986-1994 was 96% complete for both plants. Among the cohort made redundant in 1986, there was an increased risk of serious self-harm which led to hospitalization or death (adjusted for age, sex and ethnicity relative risk [RR] = 2.47; 95% CI: 1.04-5.89) compared to the employed cohort. The RR of admission to hospital with a mental health diagnosis was 1.17 (95% CI: 0.68-2.01). There were no other statistically significant findings. CONCLUSIONS: This study has most of the features of an 'ideal' factory closure study, in that it achieved near-complete follow-up of a large workforce made redundant and a similar employed workforce for 8 years. We found that exposure to involuntary job loss increased the risk of mental distress leading to serious self-harm. No other association was found.     

Employing persons with serious mental illness

Data from various national surveys find that approximately half the population with mental disorders is gainfully employed across the entire range of occupations; such persons have an employment rate of about two-thirds that of the general population. More than a third of persons with serious mental illness also work, and many hold high-status positions. Among those with schizophrenia, a diagnosis associated with high impairment, only slightly more than a fifth are at work, and 12 percent are working full time. Approximately two-thirds are enrolled in federal disability insurance programs. Our analyses indicate considerable diversity of jobs among persons with various mental disorders. Most persons with mental illness want to work, and some with even the most serious mental disorders hold jobs requiring high levels of functioning. Educational attainment is the strongest predictor of employment in high-ranking occupations among both the general population and persons with mental disorders.     

Needs-based planning for persons with serious mental illness residing in intermediate care facilities

This study examined the association of clinical status to mental health service use among persons with mental illness living in residential care. Two hundred residents with a chart diagnosis of schizophrenia were randomly selected from four intermediate care facilities. The severity of psychiatric illness-community mental health (SPI-CMH) scale was used to assess clinical status and symptom severity according to three dimensions: symptoms and functioning, risk behaviors, and complication to illness. Lower levels of severity of psychiatric illness were associated with participation in workshops, family contact, and admitting to mental health problems. Results suggest that residents of the intermediate care facilities have clinical needs consistent with habilitation and rehabilitation services. While residents infrequently engage in high-risk behavior such as suicide and violence, they have considerable living skills and vocational needs. Future research should consider the relationship over time of mental health service utilization, severity of psychiatric illness, and psychosocial factors.     

The impact of atypical employment on individual wellbeing: evidence from a panel of British workers

This study explores the relationship between individual wellbeing and atypical employment, which includes both temporary and part-time employment schemes. Individual wellbeing is measured in terms of subjective indicators of mental health, general health status, life satisfaction, and job satisfaction. It addresses four questions: (1) Are workers on a temporary contract more likely to report poor health and poor life and job satisfaction than those who are employed in permanent jobs? (2) Is this the case for part-time workers compared to those who are in a full-time job? (3) Do changes in employment profiles (e.g., from a fixed-term contract to a permanent job, or from part-time employment to full-time employment) affect individuals' health and life satisfaction? (4) Are there differences in such relationships between men and women? To answer these questions, logistic regression models were used to analyse a panel of almost 7000 male and female workers from the first 10 waves of the British Household Panel Survey, 1991-2000. Controlling for background characteristics, atypical employment does not appear to be associated with adverse health consequences for either men or women, when both health and employment are measured at the same time. However, there is evidence that job satisfaction is reduced for seasonal/casual workers and is higher for part-timers. Taking account of selection issues does not change the general picture: the chances of poor mental and physical health and low life satisfaction are unaffected by atypical employment and some of the effects of job satisfaction persist. In addition, very few employment transitions appear to be consequential for a worsening in health outcomes, which tends to be observed in the case of job satisfaction. Although the pattern of results suggests that atypical forms of employment do not have durable adverse health consequences on workers, public policies that aim at improving the working conditions of workers in weak bargaining positions should give special attention to equity issues, including the possible health effects of experience of work in atypical employment arrangements.     

Prevalence and patterns of major depressive disorder in the United States labor force

BACKGROUND AND AIMS OF THE STUDY: In this paper, we identify the 12-month and lifetime prevalence of major depressive disorder in and out of the labor force, and among the employed and unemployed. We examine whether prevalence by labor force and employment status varies by gender and over the life cycle. Finally, we examine whether people can "recover" from depression with time by identifying patterns of labor force participation and employment as time since most recent episode passes. METHODS: We examine data collected as part of the National Comorbidity Survey, a survey representative of the population of the United States designed to identify the prevalence of major mental illnesses. The National Comorbidity Study identified cases of major depression via the Composite International Diagnostic Interview. Using these data, we estimate univariate and bivariate frequency distributions of major depressive disorder. We also estimate a set of multivariate models to identify the effect of a variety of dimensions of major depression on the propensity to participate in the labor force, and be employed if participating. RESULTS: Lifetime and 12-month prevalence rates of depression are similar in and out of the labor force. Within the labor force, however, depression is strongly associated with unemployment. The negative relationship between depressive disorder and employment is particularly strong for middle age workers. Depression and the number of depressive episodes have a differing pattern of effects on labor market outcomes for men and women. We find evidence that labor force participation and employment rates for people with a history of depression increase significantly over time in the absence of additional depressive episodes. DISCUSSION: Labor market status represents an important dimension along which prevalence of major depression varies. The relationship between depression and employment status is particularly strong for middle aged persons, but becomes weaker as time passes since the last depressive episode. Continued exploration of the association between work (or lack of work) and depression may ultimately help in the prediction, treatment and assessment of the illness. IMPLICASIONS FOR PRACTICE AND POLICY: These results present a basic set of facts about the relationship between major depressive disorder and labor market outcomes. We have not, however, attempted to sort out the complexities of this relationship here. These complexities arise at almost every turn. For instance, the high level of prevalence of depression among the unemployed may be due to the possibility that the stresses associated with unemployment trigger depressive episodes or to the possibility that workers who are depressed are more likely to be fired or quit. IMPLICATIONS FOR FURTHER RESEARCH: Our continuing research attempts to address these problems. Understanding when and how depression affects labor market outcomes and when and how labor market outcomes affect depression is an important endeavor for those interested in treating the disease and understanding its consequences.     

Effects of Psychiatric Disorders on Labor Market Outcomes: A Latent Variable Approach Using Multiple Clinical Indicators

In this paper, we estimate the effect of psychiatric disorders on labor market outcomes using a structural equation model with a latent index for mental illness, an approach that acknowledges the continuous nature of psychiatric disability. We also address the potential endogeneity of mental illness using an approach proposed by Lewbel (2012) that relies on heteroscedastic covariance restrictions rather than questionable exclusion restrictions for identification. Data come from the US National Comorbidity Survey – Replication and the National Latino and Asian American Study. We find that mental illness adversely affects employment and labor force participation and also reduces the number of weeks worked and increases work absenteeism. To assist in the interpretation of findings, we simulate the labor market outcomes of individuals meeting diagnostic criteria for mental disorder if they had the same mental health symptom profile as individuals not meeting diagnostic criteria. We estimate potential gains in employment for 3.5 million individuals, and reduction in workplace costs of absenteeism of $21.6 billion due to the resultant improvement in mental health. Copyright © 2015 John Wiley & Sons, Ltd.     

Women's mental health: an overview

Women often have different outcomes and experiences with mental illness compared to men. However, there is still a ‘gender-blind’ approach to the understanding and development of new treatments for mental illness. The emphasis is on: women and schizophrenia, depression in women and existing sex differences in anxiety disorders (including phobias, agoraphobia, panic disorder, generalised anxiety disorder and post-traumatic stress disorder). Utilizing gender differences in the onset, course and outcomes of mental illness may enable a better development of best outcomes for women with mental illness.     

Profile of cognitive problems in schizophrenia and implications for vocational functioning

Aim:  This literature review attempts to profile specific areas of cognition that have shown unique and consistent evidence of dysfunction among people with schizophrenia. In addition, their impact on vocational functioning is illustrated, so as to highlight the importance of managing these cognitive difficulties in vocational rehabilitation.
Methods:  Literature search was carried out on seven key cognitive domains identified by the National Institute of Mental Health in the USA. Their impact on vocational function was also reviewed.
Results:  It is found that attention, declarative and working memory, reasoning, problem-solving and social cognition are areas of impairment that have great impact on vocational functioning. Attention and memory problems affect learning of new work tasks. Executive function is particularly crucial in determining supported and open employment outcomes, as executive dysfunction cannot be easily compensated. Lastly, social cognition plays a major role in determining the success of workplace social exchanges.
Conclusion:  Occupational therapists need to have a good understanding of the profile of cognitive problems among people with schizophrenia, in order to tailor our intervention according to their cognitive strengths and difficulties. Several cognitive remediation strategies and programs have been designed specifically for people with mental illness. Equipping ourselves with skills in conducting such programs will augment our expertise in vocational rehabilitation.     

Employment and Mental Health Service Utilization in Washington State

This study examined employment among individuals utilizing publicly funded mental health services in Washington State during a 2-year period through the analysis of archival administrative data. The mean income found in this study was higher than that reported in the supported employment literature. This difference likely reflects the inclusion of individuals with less severe mental illness and ongoing employment who are typically excluded from studies of supported employment. Individuals in this study were employed in all industrial sectors in a distribution similar to the general population, although somewhat over-represented in service industries. Employment rates varied from 15% to 21% over a 3-year period and did not appear to increase after treatment. Employment rates tended to decline after the receipt of public support. Among individuals who lost employment, service utilization was found to increase prior to the loss of employment. Policy implications are discussed.Judy Hall, PhD, is a research director for the Washington State Department of Social and Health Services, Mental Health Division, 14th and Jefferson, PO Box 45320, Olympia 98504-5320, WA, USA. Phone: +1-360-9020874. Fax: +1-360-9027691. E-mail: HallJJ@dshs.wa.gov.     

Employment Specialist Competencies for Supported Employment Programs

Purpose Supported employment (SE) programs are evidence-based programs offered to people with severe mental illness to facilitate obtaining and keeping competitive work. However, significant variations in individuals’ vocational success may be partly explained by differences in their employment specialists’ competencies. Aim The main objectives of this study were to develop a questionnaire measuring the behaviors, attitudes and knowledge of employment specialists working in SE programs and to link specific competencies to vocational outcomes. Methods A total of 153 employment specialists working in Canadian and Dutch supported employment programs completed the Behaviors, Attitudes, and Knowledge in Employment Specialists (BAKES) questionnaire and provided information about their clients’ vocational outcomes. Results Exploratory Factor Analyses results found 90 items over 12 subscales (e.g., Relationships with employers and supervisors). Regression analyses indicated that the two most useful subscales for predicting vocational success were: (1) Relationships with employers and supervisors, and (2) support and client-centered approach. Conclusion Employment specialists require specific competencies to help people with severe mental illness obtain and maintain competitive employment. Validating the BAKES will better define the broad range of competencies expected for this position, and this tool may facilitate training of employment specialists.     

Work and health in a contemporary society: demands, control, and insecurity

OBJECTIVE: To examine independent associations of job strain (high demands and low control) and job insecurity with mental and physical health outcomes. DESIGN: Cross sectional general population study conducted in 2000 using a self completed questionnaire. SETTING: Two adjoining cities in south east Australia. SUBJECTS: 1188 employed professionals, aged 40-44 years, 55% (n = 655) male. MAIN OUTCOME MEASURES: Depression, anxiety, physical, and self rated health (SRH). RESULTS: Adverse job conditions were relatively prevalent as 23% of the sample reported high job strain, while 7.3% and 23% reported high and moderate job insecurity respectively. Associations between job conditions and health persisted after adjustment for gender, education, marital status, employment status, major life events, and negative affectivity (personality). When adjusted for job strain, high job insecurity was independently associated with a greater than threefold increase in odds for poor SRH, depression and anxiety (OR (95% confidence intervals) poor SRH: 3.72 (1.97 to 7.04) depression: 3.49 (1.90 to 6.41), anxiety: 3.29 (1.71 to 6.33)), and a twofold increase for physical health 2.19 (1.21 to 3.95). High job strain also showed significant independent associations with depression: 2.54 (1.34 to.4.75) and anxiety: 3.15 (1.48 to 6.70). CONCLUSION: In this relatively privileged socioeconomic group, insecure employment and high job strain showed independent, consistent, and strong associations with physical and mental health. These adverse job conditions are on the increase, particularly insecure employment, and the influence of these two work conditions are an important focus for future public health research and their prevalence and impact should be examined in other occupations.