Employment services as an early intervention for young people with mental illness

Aim: To examine the service characteristics and effectiveness of a segregated employment service assisting young clients with mental illness in New Zealand. Methods: The service assisted both youth and adults with severe mental illness to find and keep competitive employment. A retrospective case study method was used to examine service effectiveness with respect to employment outcomes attained by 49 clients aged 16–25 years over a 2-year period (2005–2007). These results were compared with recent national and international benchmarks. Results: As a service segregated from public mental health services, there were no formal arrangements with local mental health teams, limiting coordination of services and reducing fidelity to evidence-based practices in supported employment. Despite an inability to collaborate closely with local community mental health services and a contract not specifically targeting youth, the service was high performing on a range of employment outcome variables. Conclusions: Subject to some study design and benchmarking limitations, these results support the continuing use of evidence-based practices in supported employment and supported education as important early interventions for young people with mental illnesses.     

Economic impacts of supported employment for persons with severe mental illness.

BACKGROUND: Most persons with severe mental illness prefer competitive to sheltered vocational settings. Supported employment (SE) has become a clearly defined model for helping people with severe mental illness to find and maintain competitive jobs. It involves individualized and rapid placement, ongoing support and assessment, and integration of vocational and mental health staff within a single clinical team. Previous studies show that SE secures competitive employment much more effectively than do other approaches. This review focuses on its economic impacts. METHODS: Studies reporting some service use or monetary outcomes of adding SE programs were identified. These outcomes were tabulated and are discussed in narrative form. RESULTS: Five nonrandomized and 3 randomized studies compare SE programs with day treatment or transitional employment programs. The introduction of SE services can result in anything from an increase to a decrease in vocational service costs, depending on the extent to which they substitute for previous vocational or day treatment services. Overall service costs tend to be lower, but differences are not significant. Earnings increase only slightly on average. CONCLUSIONS: Converting day treatment or other less effective vocational programs into SE programs can be cost-saving or cost-neutral from the hospital, community centre, and government points of view. Investments of new money into SE programs are unlikely to be materially offset by reductions in other health care costs, by reductions in government benefit payments, or by increased tax revenues. Such investments must be motivated by the value of increasing the community integration of persons with severe mental illness.     

Issues in Medicaid policy and system transformation: recommendations from the President's Commission

Efforts to ensure that people with disabilities participate fully in their communities have raised awareness of current Medicaid policies that impede provision of best-practice mental health services. The author summarizes issues that were examined by the Medicaid Subcommittee of the President's New Freedom Commission and its recommendations in four areas: access, service delivery, service coordination, and quality. Because of Medicaid's substantial role as a payer for mental health services, more creative and flexible program policies can promote system transformation. Current eligibility rules and time-consuming procedures can inhibit timely access to Medicaid coverage for people with mental illness. Medicaid benefit plans may create financial incentives for maintaining more traditional but less effective models of care. Some policies impede states' ability to coordinate Medicaid funding with other sources of funding to create systems of community-based care. Medicaid does not provide specific requirements to ensure that individuals with depression are identified and offered informed choices about treatment through primary or specialty care providers. Action steps to address these and other issues include use of presumptive eligibility and parity, retention of coverage as enrollees enter the workplace, guidance to states on evidence-based practices and service coordination with other agencies, more flexible financing mechanisms, improved data collection and reporting, and enhanced integration of primary and mental health care.     

Inpatient Hospitalizations and Emergency Service Visits Among Participants in an Individual Placement and Support (IPS) Model Program

Supported employment (SE) is considered an "evidence-based" practice for people with serious mental illness. We examined inpatient hospitalizations and emergency service visits among clients in a SE program based on the Individual Placement and Support (IPS) model in comparison to a propensity score matched group of clients who did not participate in IPS. A significant interaction showed that only IPS/SE clients who were also high in regular mental health services had fewer hospitalizations and emergency service visits than matched controls. The interaction effect was moderate, even when we controlled for client functioning. These findings provide support for the integration of mental health and vocational rehabilitation services, a key feature of evidence-based SE services.     

The Role of State Mental Health Authorities in Managing Change for the Implementation of Evidence-Based Practices

The evidence-based practice demonstration for services to adults with serious mental illness has ended its pilot stage. This paper presents the approaches states employed to combine traditional policy levers with more strategic/institutional efforts (e.g., leadership) to facilitate implementation of these practices. Two rounds of site visits were completed and extensive interview data collected. The data were analyzed to find trends that were consistent across states and across practices. Two themes emerged for understanding implementation of evidence-based practices: the support and influence of the state mental health authority matters and so does the structure of the mental health systems.     

Making the Case for IPS Supported Employment

Individual Placement and Support (IPS) is an evidence-based practice for helping people with severe mental illness (SMI) gain competitive employment, yet those who could benefit often find it difficult to obtain IPS services. We summarize the evidence supporting the effectiveness of IPS and the benefits of working, discuss the barriers to implementing IPS in the U.S., and suggest policy changes that could expand its access.     

Vocational rehabilitation in psychiatry: a re-evaluation

OBJECTIVE: To highlight the vocational gap in the provision of psychiatric rehabilitation, to outline the goals and conceptual framework of psychiatric rehabilitation, and to discuss rehabilitation interventions with specific reference to vocational rehabilitation and the evidence base for supported employment. CONCLUSIONS AND SERVICE IMPLICATIONS: Vocational psychiatric rehabilitation has been a neglected area of practice in Australian psychiatry. Psychiatric treatment needs to adopt a more balanced approach in the provision of a range of services, including vocational rehabilitation, in order to improve long-term outcomes for people suffering from psychiatric disability. A vocational focus should be included in psychiatric rehabilitation and better integration between mental health services and vocational services needs to take place. Supported employment is an evidence-based practice that is designed to help people with psychiatric disabilities participate as much as possible in the competitive job market.     

Enabling all young Australians to grow up safe, happy, healthy and resilient: a Collaboration for Young People, Technology and Wellbeing

OBJECTIVE: This paper describes a framework for a multi-disciplinary collaboration to investigate the role of technology for improving young Australians' mental health and wellbeing. RESULTS: The poor mental health of young Australians poses a significant challenge to Australia's future. Half of all Australians will experience a mental health difficulty in their lifetime and 75% of mental illness has its onset before age 25. Cross-sectoral collaboration is critical for meeting this challenge. In order to establish a world-first multi-partner collaboration, leading researchers and institutes, commercial, non-profit and end-user organization and young people were identified and invited to participate. Together we have developed an international research framework that explores the role of technologies in young people's lives, their potential and how this can be harnessed to address challenges facing young people. This research framework will: (i) conduct empirical research that tests the utility of technology across mental health promotion, prevention, early intervention and treatment and, (ii) translate existing and new knowledge into products and services that help create a generation of safe, happy, healthy and resilient young people. Research undertaken by the Collaboration will be the most comprehensive investigation of technologies' potential to improve the wellbeing of young people ever conducted, leading to significant benefits for Australian young people and their mental health.     

Integrierte psychotherapeutische Behandlung von schwer psychisch Kranken

Psychiatric care for severe and persistent mentally ill individuals has considerably changed over the last three decades. Striving for improvement in services provision for these patients has led to the emergence of various specialized community services, suited housing and supported work offers. Moreover, community-based treatment is also offered during acute episodes of mental illness. At the same time a range of evidence-based psychotherapeutic approaches targeting treatment needs of people with severe mental illness were developed in a process independent of the rise of community psychiatry. At present, however, a sufficient level of coordination of psychiatric services and integration of evidence-based psychological treatment into psychiatric care has not been achieved. Thus, these issues represent important steps in the further development.This paper discusses recent developments in psychiatric care of people with severe mental illness and reviews the evidence-based psychotherapy approaches suited to fit the needs of patient-centered integrated care.     

Outreach services to clients with severe mental illness in the Okayama Prefectural Mental Health and Welfare Center

The community mental health system in Japan is being adversely affected by diminishing public mental health services, including those provided by public healthcare centers and the mental health divisions of municipal governments. It seems reasonable to expect that this will lead to the inadequate detection, assessment, and treatment of the population with mental health problems, and thus to the flooding of psychiatric hospitals with excessive numbers of severely mentally ill patients. In this article, the author suggests the utility of a 'network-based outreach team' as a possible remedy for the current situation. The Okayama Prefectural Mental Health & Welfare Center is running a network-based outreach team on a trial basis to work with individuals with serious mental illness who are disengaged from mental health services. The team is composed of members from the Mental Health & Welfare Center, public mental health services, and human service agencies. The main aims of this team are two-fold: to enhance support for clients with severe mental illness who are overwhelmed with multiple complex problems, through collaborative intervention within the framework of a network-based outreach team; and to develop the qualities and skills of public mental health service and human agency personnel in order that they better assist people with severe mental illness, by providing joint training with mental health specialists of the Mental Health & Welfare Center in community settings. The author suggests that the team structure of the network-based outreach team will benefit public mental health services by reintegrating currently fragmented services into coordinated ones.     

Employment supports: Perceptions of people with severe mental disorders

Professional rehabilitation of people with severe mental illness is a field of research often left aside. Despite the aspiration of people with severe mental illness to employment, their presence in the job market remains low. Lack of supports appears to be one explanation. Thus, the aim of this study was to identify the types of necessary supports to maintain these people in employment. Six (6) participants have been recruited following a qualitative methodology. Ten types of supports have been identified and classified according to their direct association to work or to the residential or community environment. To conclude, the authors suggest a greater involvement from mental health workers in the identification and development of supports that favour maintaining these people in employment.     

Making progress in mental health policy in conservative times: one step at a time

Progress in mental health services has been made incrementally in a sequence of policy steps. In recent years, in spite of political conservatism, progressive changes have advanced new principles of service delivery. Reports from the surgeon general and the President's New Freedom Commission on Mental Health advanced these principles, including recovery and evidence-based practices. Both of these high-level reports were influenced by the findings of the Schizophrenia Patient Outcomes Research Team (PORT). The Schizophrenia PORT established the effectiveness of mental health treatments and supports, which provided a scientific foundation for the optimistic focus on recovery and its expectation of improved outcomes for individuals with severe mental disorders. The PORT study also established the gap between treatment recommendations and actual services. Concern about this gap has motivated efforts to transform services by implementing evidence-based practices. Advances in broad mental health and social policy, coupled with continued advances in science, have the potential to improve the care of individuals who experience severe mental disorders, such as schizophrenia.     

Critical review of world policies for mental healthcare for children and adolescents

PURPOSE OF REVIEW: Policy development is essential for the development of child and adolescent mental health services. The gaps in policy and knowledge on how to develop policy have hindered the development of sustainable services. RECENT FINDINGS: The WHO has now objectively identified gaps in child and adolescent mental health policy and services worldwide through its Atlas project. Others have identified the need to use evidence-based interventions in developing services and the need for ongoing evaluation. These latter elements are essential for effective policy implementation. SUMMARY: Data are now available worldwide to move forward with advocacy for child and adolescent mental health policy development.     

The Australian experience of deinstitutionalization: interaction of Australian culture with the development and reform of its mental health services

OBJECTIVE: To describe the Australian experience of deinstitutionalization of the Australian National Mental Health Strategy in the context of the history of mental health services in Australia, and of Australian culture. METHOD: The development of Australian Mental Health Services is described with reference to developments in both psychiatric intervention research and Australian culture. The effects and achievements of national mental health reforms are described and critically examined. RESULTS: The relationship in Australia between the development of mental health services and the development of Australian society includes the stories of colonization, gold rush, suppression of indigenous peoples' rights, incarceration of mentally ill people, and incompatible state service systems. Mental health services required reform to provide consistent services and support for full citizenship and rights for such individuals who are still on the margins of society. Recent national developments in service models and service system research have been driven by the Australian National Mental Health Strategy. The translation of national policy into state/territory mental health service systems has led to a 'natural' experiment between states. Differing funding and implementation strategies between states have developed services with particular strengths and limitations. CONCLUSION: The effects of competition for limited resources between core mental health service delivery and the shift to a population-based public health approach (to prevention of mental illness and promotion of mental health), leaves our services vulnerable to doing neither particularly well. The recent loss of momentum of these reforms, due to failure of governments to continue to drive and fund them adequately, is causing the erosion of their considerable achievements.     

Rehab rounds: use of the Americans with Disabilities Act by young adults with schizophrenia

Introduction by the column editors: People with mental illness have consistently identified employment as a strong unmet need, yet only one in five people with schizophrenia has been able to work in full-time competitive employment and less than 50 percent work at all, despite the advent of evidence-based services, such as supported employment (1,2). However, there are compelling developmental, clinical, and economic reasons for people with mental illnesses to pursue competitive employment as they attempt to normalize and reconstruct their lives (3). Even with a mainstreaming ideology that encourages everyone who wants work to seek it, the real challenges are to organize supportive employment services, match people to jobs, and sustain clients in a continuum of work rehabilitation (4).Several Rehab Rounds columns have focused on programs aimed at enhancing the work functioning of people with serious mental disorders by using supported employment (5), increasing work readiness (6), and teaching fundamental workplace skills (7). In this month's column, Deborah Gioia and John S. Brekke describe the impact of the Americans With Disabilities Act on the work experience of young adults with schizophrenia.     

Expert ratings on the critical ingredients of supported employment for people with severe mental illness

BACKGROUND: Supported employment is identified as an evidence-based practice for people with severe mental illness, with Individual Placement and Support (IPS) emerging as the clearest articulation of this practice. Yet throughout the U.S., programs labeled as supported employment operate in a wide variety of ways, with different staffing patterns, organizational features, and services. Consensus on critical ingredients is crucial for establishing standards for evidence-based services, guiding implementation of new programs, and fostering communication in the literature. The current study examined the degree of agreement on the critical ingredients of supported employment among experts and practitioners. METHODS: The expert sample (n=19) consisted primarily of university-based researchers, while the practitioner sample (n=55) was a convenience sample generated from lists provided by state leaders in 2 Western, 2 Central, and 2 Eastern states. Using multiple sources, including published guidelines and 3 supported employment fidelity scales, we developed a 59-item survey checklist. Respondents rated items on a 7-point importance scale and indicated ideal specifications in 11 areas. FINDINGS: We found strong agreement on the critical ingredients of supported employment within the expert and practitioner groups. On most items, the two groups had similar mean ratings of importance. Experts rated 4 items reflecting evidence-based principles and 2 items related to outcome monitoring as more important than did practitioners, while practitioners rated as more important 10 items reflecting pragmatic concerns (e.g., funding, accreditation). Comparing survey responses on the 15 items from the IPS Fidelity Scale suggested general endorsement of IPS principles, except in the area of staffing. Ideal model specifications included caseload size of 16 and twice weekly supervision. Respondents also suggested critical ingredients not measured by the IPS Fidelity Scale, such as benefits counseling, supported education, a cultivation of employers. CONCLUSIONS: This survey shows a growing consensus within the psychiatric rehabilitation field on IPS principles while suggesting additional strategies endorsed by experts and practitioners.