NIHR Signal Supported employment helps people with severe mental illness to obtain work

Published on 3 January 2018

Adults with schizophrenia and other psychosis receiving supported employment were more than twice as likely to obtain a job in the competitive labour market as those receiving pre-job training, sheltered employment or psychiatric care only. Supported employment seemed most effective when augmented with other interventions such as social or cognitive skills training.

Many people with severe mental illnesses would like to work, and employment can improve their quality of life. This Cochrane review combined international data from nearly 50 trials comparing several different types of vocational rehabilitation.

Supported employment was mainly delivered through the Individual Placement and Support scheme, as used in the UK. It is integrated with mental health services and involves a job search guided by a helper followed by long-term support once employed.

These findings support NICE guidelines and government policy aiming to increase provision of supported employment places. Commissioners may need to address any implementation barriers. Relative costs were not directly addressed in these studies.

Supported employment helps people with severe mental illness to obtain work

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Why was this study needed?

Between 1 and 3% of the UK population have severe mental health problems, such as schizophrenia, bipolar disorder and long-term depression. It is estimated that only between 5 and 15% of people with psychosis are in employment. They are six or seven times more likely to be unemployed than the general population. Unemployment can lead to poverty, low self-esteem and social isolation.

People with enduring mental illnesses can receive different types of help to find and keep jobs. These include transitional (sheltered) employment, vocational training before looking for competitive work, and supported employment combining vocational training with mental health support.

Previous systematic reviews found positive effects for supported employment compared to other interventions and usual psychiatric care. This review was the first to use network meta-analysis, where interventions are compared directly within studies and indirectly across studies. This allows the different types of vocational help to be ranked for effectiveness.

What did this study do?

This review identified 48 randomised controlled trials involving 8,743 unemployed adults with severe mental illness. The majority of trials included people with schizophrenia or other psychosis, who were predominantly male and of average age 36 years. Most had an interest in employment and were educated to secondary level.

The interventions were supported employment (Individual Placement and Support in 24 studies), augmented supported employment (varied interventions), prevocational training (mainly job-related skills) and transitional (sheltered) employment. The majority of trials took place in North America. There were four UK studies.

The evidence was low to moderate quality for most comparisons, so better designed studies could change our conclusions. The highest risk of bias was participants and researchers being aware of the intervention given, and drop-out from trials.

See Definitions section for more details of the interventions.

What did it find?

  • In a network meta-analysis across 22 trials involving 5,233 adults, supported employment and augmented supported employment, specifically, were the most effective vocational interventions for gaining a job within a year or more.
  • Augmented schemes had the greatest effect, with 71% gaining employment compared with 19% receiving psychiatric care only (relative risk [RR] 3.81, 95% confidence interval [CI] 1.99 to 7.31, including one direct comparison trial in 256 participants). Symptom-related cognitive or social skills training were the most effective type of enhancement. Supported employment alone ranked second in effect compared with psychiatric care alone (RR 2.72, 95% CI 1.55 to 4.76, with one direct trial in 2,238 people).
  • Supported employment was also more effective than transitional employment (i.e. work in a setting solely for people with disabilities). About 60% gained a job within a year or more compared with 22% in transitional employment (RR 2.71, 95% CI 1.80 to 4.06; four direct studies in 87 people). Augmented supported employment, specifically, resulted in 85% employment (RR 3.79, 95% CI 2.34 to 6.14; two direct studies in 212 people).
  • Supported employment doubled the chances of obtaining a job compared with prevocational training (RR 2.16, 95% CI 1.59 to 2.93; nine direct trials in 1,570 adults), with a trebled chance when augmented (RR 3.02, 95% CI 1.88 to 4.87 with two direct trials in 193 people). 
  • There was little difference in the effectiveness of augmented supported employment and supported employment, which did not reach statistical significance in network meta-analyses ranking all interventions (direct comparison in three trials: RR 1.94, 95% CI 1.03 to 3.65; indirect comparison across 22 trials: RR 1.40, 95% CI 0.92 to 2.14).

What does current guidance say on this issue?

NICE recommends that people with psychosis and schizophrenia or bipolar disorder who want to find work are offered supported employment programmes. A new NICE guideline on rehabilitation in people with severe and enduring mental illness is due for publication in 2020.

NHS England’s Five Year Forward View for the Mental Health report by the Mental Health Taskforce (2016) includes an objective to double access to Individual Placement and Support places by 2020/21. The aim is to reach an extra 30,000 people living with severe mental illness so that at least 9,000 are in employment.

What are the implications?

In 2014, less than half of people with schizophrenia who were interested in looking for work said they received help towards this.

There may still be a need to overcome any barriers or stigmatisation that persist around working with people with severe mental health problems, and address any challenges in service integration. Employers also have a role to play in maximising the potential of people who have recovered from severe mental illness. NHS England will be developing a competency framework and workforce development strategy for the Individual Placement and Support employment specialists.

Effects may vary in countries with different mental health services, labour markets and social support systems. A European trial found that this type of individual support was cost-effective compared with standard employment support in London and other areas.

Citation and Funding

Suijkerbuijk YB, Schaafsma FG, van Mechelen JC, et al. Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. Cochrane Database Syst Rev. 2017;9:CD011867.

Bibliography

Boardman J. and Rinaldi M. Difficulties in implementing supported employment for people with severe mental health problems. BJPsych. 2013;203:247-49.

NHS Choices.  Returning to work after mental health issues. London: Department of Health; 2015.

NHS England. Implementing the Five Year Forward View for Mental Health. Leeds: NHS England; 2016.

NICE. Bipolar disorder: assessment and management. CG185. London: National Institute for Health and Care Excellence; 2014 (updated 2017).

NICE. Bipolar disorder in adults. QS95. London: National Institute for Health and Care Excellence; 2015.

NICE. Psychosis and schizophrenia in adults. QS80. London: National Institute for Health and Care Excellence; 2015.

NICE. Psychosis and schizophrenia in adults: prevention and management. CG178. London: National Institute for Health and Care Excellence; 2014.

Khan M and Boardman J. Employment and mental health. Occasional Paper OP101. London: Royal College of Psychiatrists; 2017.

Knapp M, Patel A, Curran C, et al. Supported employment: cost effectiveness across six European sites. World Psychiatry. 2013;12:60-68.

Why was this study needed?

Between 1 and 3% of the UK population have severe mental health problems, such as schizophrenia, bipolar disorder and long-term depression. It is estimated that only between 5 and 15% of people with psychosis are in employment. They are six or seven times more likely to be unemployed than the general population. Unemployment can lead to poverty, low self-esteem and social isolation.

People with enduring mental illnesses can receive different types of help to find and keep jobs. These include transitional (sheltered) employment, vocational training before looking for competitive work, and supported employment combining vocational training with mental health support.

Previous systematic reviews found positive effects for supported employment compared to other interventions and usual psychiatric care. This review was the first to use network meta-analysis, where interventions are compared directly within studies and indirectly across studies. This allows the different types of vocational help to be ranked for effectiveness.

What did this study do?

This review identified 48 randomised controlled trials involving 8,743 unemployed adults with severe mental illness. The majority of trials included people with schizophrenia or other psychosis, who were predominantly male and of average age 36 years. Most had an interest in employment and were educated to secondary level.

The interventions were supported employment (Individual Placement and Support in 24 studies), augmented supported employment (varied interventions), prevocational training (mainly job-related skills) and transitional (sheltered) employment. The majority of trials took place in North America. There were four UK studies.

The evidence was low to moderate quality for most comparisons, so better designed studies could change our conclusions. The highest risk of bias was participants and researchers being aware of the intervention given, and drop-out from trials.

See Definitions section for more details of the interventions.

What did it find?

  • In a network meta-analysis across 22 trials involving 5,233 adults, supported employment and augmented supported employment, specifically, were the most effective vocational interventions for gaining a job within a year or more.
  • Augmented schemes had the greatest effect, with 71% gaining employment compared with 19% receiving psychiatric care only (relative risk [RR] 3.81, 95% confidence interval [CI] 1.99 to 7.31, including one direct comparison trial in 256 participants). Symptom-related cognitive or social skills training were the most effective type of enhancement. Supported employment alone ranked second in effect compared with psychiatric care alone (RR 2.72, 95% CI 1.55 to 4.76, with one direct trial in 2,238 people).
  • Supported employment was also more effective than transitional employment (i.e. work in a setting solely for people with disabilities). About 60% gained a job within a year or more compared with 22% in transitional employment (RR 2.71, 95% CI 1.80 to 4.06; four direct studies in 87 people). Augmented supported employment, specifically, resulted in 85% employment (RR 3.79, 95% CI 2.34 to 6.14; two direct studies in 212 people).
  • Supported employment doubled the chances of obtaining a job compared with prevocational training (RR 2.16, 95% CI 1.59 to 2.93; nine direct trials in 1,570 adults), with a trebled chance when augmented (RR 3.02, 95% CI 1.88 to 4.87 with two direct trials in 193 people). 
  • There was little difference in the effectiveness of augmented supported employment and supported employment, which did not reach statistical significance in network meta-analyses ranking all interventions (direct comparison in three trials: RR 1.94, 95% CI 1.03 to 3.65; indirect comparison across 22 trials: RR 1.40, 95% CI 0.92 to 2.14).

What does current guidance say on this issue?

NICE recommends that people with psychosis and schizophrenia or bipolar disorder who want to find work are offered supported employment programmes. A new NICE guideline on rehabilitation in people with severe and enduring mental illness is due for publication in 2020.

NHS England’s Five Year Forward View for the Mental Health report by the Mental Health Taskforce (2016) includes an objective to double access to Individual Placement and Support places by 2020/21. The aim is to reach an extra 30,000 people living with severe mental illness so that at least 9,000 are in employment.

What are the implications?

In 2014, less than half of people with schizophrenia who were interested in looking for work said they received help towards this.

There may still be a need to overcome any barriers or stigmatisation that persist around working with people with severe mental health problems, and address any challenges in service integration. Employers also have a role to play in maximising the potential of people who have recovered from severe mental illness. NHS England will be developing a competency framework and workforce development strategy for the Individual Placement and Support employment specialists.

Effects may vary in countries with different mental health services, labour markets and social support systems. A European trial found that this type of individual support was cost-effective compared with standard employment support in London and other areas.

Citation and Funding

Suijkerbuijk YB, Schaafsma FG, van Mechelen JC, et al. Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. Cochrane Database Syst Rev. 2017;9:CD011867.

Bibliography

Boardman J. and Rinaldi M. Difficulties in implementing supported employment for people with severe mental health problems. BJPsych. 2013;203:247-49.

NHS Choices.  Returning to work after mental health issues. London: Department of Health; 2015.

NHS England. Implementing the Five Year Forward View for Mental Health. Leeds: NHS England; 2016.

NICE. Bipolar disorder: assessment and management. CG185. London: National Institute for Health and Care Excellence; 2014 (updated 2017).

NICE. Bipolar disorder in adults. QS95. London: National Institute for Health and Care Excellence; 2015.

NICE. Psychosis and schizophrenia in adults. QS80. London: National Institute for Health and Care Excellence; 2015.

NICE. Psychosis and schizophrenia in adults: prevention and management. CG178. London: National Institute for Health and Care Excellence; 2014.

Khan M and Boardman J. Employment and mental health. Occasional Paper OP101. London: Royal College of Psychiatrists; 2017.

Knapp M, Patel A, Curran C, et al. Supported employment: cost effectiveness across six European sites. World Psychiatry. 2013;12:60-68.

Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis

Published on 13 September 2017

Suijkerbuijk, Y. B.,Schaafsma, F. G.,van Mechelen, J. C.,Ojajarvi, A.,Corbiere, M.,Anema, J. R.

Cochrane Database Syst Rev Volume 9 , 2017

BACKGROUND: People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions. OBJECTIVES: To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness. SEARCH METHODS: In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials. SELECTION CRITERIA: We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only. DATA COLLECTION AND ANALYSIS: Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE. MAIN RESULTS: We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions. AUTHORS' CONCLUSIONS: Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.

Supported employment (“place then train”) aims for a job at a market wage in a setting not specific to people with disabilities.

Individual placement and support are based on eight principles centring on equal access for all; rapid job search related to client preferences; long-term ‘on the job’ support from skilled employment specialists; and integration with mental health services. Supported employment schemes can be augmented with help such as social and cognitive skills training, motivational coaching and psychiatric rehabilitation.

Prevocational training gives training and skill development for work before a job starts (“train then place”).

Transitional employment sometimes called sheltered employment, is in a work setting solely for people with disabilities. It may be offered before, or as a long-term alternative to competitive employment.

Expert commentary

Having a job is important to a person’s wellbeing. For a long time, employment was not regarded as a viable option for people experiencing severe mental illness.

The recovery approach changed perceptions. Initially, professionals used simple strategies, such as volunteering, but this did not lead to paid work. Supported employment turned thinking on its head about how to secure real work for people with a severe mental illness.

It is interesting that augmented support may be more effective but, as a resource-intensive intervention, service providers would also need to know if the gains secured are a cost-effective use of time.

Dr Katrina Bannigan, Associate Professor (Reader) of Occupational Therapy, Plymouth University