Supported employment for adults with severe mental illness

People with mental health problems experience high rates of unemployment. There are various schemes delivering support to people with mental health problems who are trying to find employment. Supported employment tries to place people into competitive jobs. People are placed quickly in normal work settings where they receive intensive support and training from ‘job coaches’.

Individual placement and support (IPS) is a more specified scheme that includes: finding local jobs; a rapid job search; customer choice in what they want from the employment service; close working between employment and mental health teams; attention to people’s preferred job, their strengths and work experience; ongoing and, if necessary, long-term individual support; and the benefits of counselling. Employment specialists act to identify people’s job interests, assist with job finding, give job support and engage other support services. IPS uses assertive outreach to deliver training, advice and vocational support in the community. Augmented supported employment is where employment support is given with other supplementary techniques, such as social skills training, motivational classes and various types of rehabilitation. Other approaches are many and varied, including: job workshops; job counselling; peer support; partnerships with business; and the Clubhouse model, which involves training, work experience, peer support and transitional employment and IPS because they do not search for immediate and competitive employment. However, all approaches involve periods of preparation, education and on-the-job training.

This review compares supported employment and IPS with other approaches for finding employment. Drawing from a total of 2259 people with mental health problems in 14 studies, the review has two main findings: 1) Supported employment increases the length and time of people’s employment; 2) People on supported employment find jobs quicker. Supported employment and IPS are better than other approaches in these two respects, but there is limited information or measurable differences on other important issues for service users.

For example, there is little information on issues such as improving quality of life, impact on people’s mental health, days in hospital and costs. Furthermore, the review built its main findings on limited statistical evidence drawn mainly from studies carried out in North America and Europe. Future studies should address a fuller range of information and outcomes. Longer studies are needed to see how long the effects of supported employment last.

This plain language summary has been written by a consumer Ben Gray from RETHINK.

Authors' conclusions: 

The limited available evidence suggests that supported employment is effective in improving a number of vocational outcomes relevant to people with severe mental illness, though there appears to exist some overall risk of bias in terms of the quality of individual studies. All studies should report a standard set of vocational and non-vocational outcomes that are relevant to the consumers and policy-makers. Studies with longer follow-up should be conducted to answer or address the critical question about durability of effects.

Read the full abstract...
Background: 

People who suffer from severe mental disorder experience high rates of unemployment. Supported employment is an approach to vocational rehabilitation that involves trying to place clients in competitive jobs without any extended preparation. The Individual placement and support (IPS) model is a carefully specified form of supported employment.

Objectives: 

1. To review the effectiveness of supported employment compared with other approaches to vocational rehabilitation or treatment as usual.
2. Secondary objectives were to establish how far:
(a) fidelity to the IPS model affects the effectiveness of supported employment,
(b) the effectiveness of supported employment can be augmented by the addition of other interventions.

Search strategy: 

We searched the Cochrane Schizophrenia Group Trials Register (February 2010), which is compiled by systematic searches of major databases, handsearches and conference proceedings.

Selection criteria: 

All relevant randomised clinical trials focusing on people with severe mental illness, of working age (normally 16 to 70 years), where supported employment was compared with other vocational approaches or treatment as usual. Outcomes such as days in employment, job stability, global state, social functioning, mental state, quality of life, satisfaction and costs were sought.

Data collection and analysis: 

Two review authors (YK and KK) independently extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% (CI). We employed a fixed-effect model for analyses. A random-effects model was also employed where heterogeneity was present.

Main results: 

A total of 14 randomised controlled trials were included in this review (total 2265 people). In terms of our primary outcome (employment: days in competitive employment, over one year follow-up), supported employment seems to significantly increase levels of any employment obtained during the course of studies (7 RCTs, n = 951, RR 3.24 CI 2.17 to 4.82, very low quality of evidence). Supported employment also seems to increase length of competitive employment when compared with other vocational approaches (1 RCT, n = 204, MD 70.63 CI 43.22 to 94.04, very low quality evidence). Supported employment also showed some advantages in other secondary outcomes. It appears to increase length (in days) of any form of paid employment (2 RCTs, n = 510, MD 84.94 CI 51.99 to 117.89, very low quality evidence) and job tenure (weeks) for competitive employment (1 RCT, n = 204, MD 9.86 CI 5.36 to 14.36, very low quality evidence) and any paid employment (3 RCTs, n = 735, MD 3.86 CI -2.94 to 22.17, very low quality evidence). Furthermore, one study indicated a decreased time to first competitive employment in the long term for people in supported employment (1 RCT, n = 204, MD -161.60 CI -225.73 to -97.47, very low quality evidence). A large amount of data were considerably skewed, and therefore not included in meta-analysis, which makes any meaningful interpretation of the vast amount of data very difficult.

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