Abstract

Abstract Background

Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre‐vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on‐the‐job support (Supported Employment). It is unclear which approach is most effective.

To assess the effects of Pre‐vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre‐vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention.

Searches were undertaken of CINAHL (1982‐1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980‐1998), MEDLINE (1966‐1998) and PsycLIT (1887‐1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies.

Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness.

Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross‐checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta‐analysis). A sensitivity analysis was performed, excluding poorer quality trials.

Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre‐vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre‐vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre‐vocational Training. There was no evidence that Pre‐vocational Training was more effective in helping clients to obtain competitive employment than standard community care.

Supported employment is more effective than Pre‐vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre‐vocational Training is effective.

Author(s)

Ruth Crowther, Max Marshall, Gary R Bond, Peter Huxley

Abstract

Plain language summary

Vocational rehabilitation for people with severe mental illness 

A majority of severely mentally ill people would like to work and there are compelling ethical, social and clinical reasons for helping them to achieve this goal. Pre‐vocational Training and Supported Employment are two different approaches to helping severely mentally ill people obtain employment. The key principle of Pre‐vocational Training is that a period of preparation is necessary before entering competitive employment. In contrast, the key principle of Supported Employment is that placement in competitive employment should occur as quickly as possible, followed by support and training on the job. This systematic review found that people who received Supported Employment were significantly more likely to be in competitive employment than those who received Pre‐vocational Training (at 12 months 34% employed in Supported Employment compared with 12% in Pre‐vocational Training).

Author(s)

Ruth Crowther, Max Marshall, Gary R Bond, Peter Huxley

Reviewer's Conclusions

Authors' conclusions

Implications for practice

This review has suggested that Supported Employment is more effective than Pre‐vocational Training in helping mentally ill people obtain competitive employment. Although Supported Employment is growing in popularity, it is still less widely available than Pre‐vocational Training.

Finding competitive employment is a top priority for many mentally ill people, so the vocational rehabilitation agencies that serve them need to consider how to make Supported Employment more widely available. Purchasers, clinicians and clients should encourage vocational rehabilitation agencies to develop and evaluate more US‐style Supported Employment schemes.

Implications for research

The effects of Supported Employment should be examined in larger, multi‐centre trials, both within and outside of the United States. Such research is particularly indicated in countries with high rates of unemployment and more extensive welfare systems. Future trials should involve detailed analyses of the cost‐effectiveness of the various vocational rehabilitation models. The trials should also involve standard care control groups, to establish whether there is an effect on hospital admission rates. Researchers planning future trials of Supported Employment should consider standardising this intervention by adhering to the carefully specified Individual Placement and Support model. Research is also indicated to determine how far Pre‐vocational Training (including the Clubhouse approach) affects readmission/relapse rates under modern conditions. Further research is also required to determine how far mental state and social outcome may be improved by working. Methodological considerations may mean that such research may have to take place outside the framework of randomised controlled trials. Finally, there is a case for countries to survey their existing vocational rehabilitation agencies to determine the extent to which the most effective interventions are being offered.