The effectiveness of supported employment for people …ec.europa.eu/health/sites/health/files/mental_health/docs/ev... · The effectiveness of supported employment for people with

Christoph Lauber

Department of Psychiatry

The effectiveness of supported employment

for people with severe mental illness –

EQOLISE project

Promoting Social Inclusion and Combating Stigma

for better Mental Health and Well-Being

Lisbon, 8/9 November 2010

Employment in people with mental illness

• Employment on the free labour market

UK 10-20% (Perkins & Rinaldi, 2002)

F 5-10% (oral communication)

CH 20% (Lauber et al., 2005)

EU 10-20% (Michon et al., 2005; Marwaha et al., 2007)

• Reintegration into the free labour market: 5 – 10%

• >40% of the 2.7m people on long-term unemployment benefits have mental health

problems as their primary concern

• 2x risk of losing jobs compared with the general public


Proportion of employed people by health type

UK Labour Force

Survey, 2004

Difference between

physical and mental

health


Sheltered employment

Vocational training

Free labour market

Unemployment

x No supportx

Day hospital / vocational training

The situation

as per today


The new Phoenix out of the ashes

Supported

Employment


Supported Employment (SE): What is it about? (I)


• Finding „real work in the real world‟

• Immediate job search (without pre-vocational training)

The motto: First place and then train on the job

• Job coaches based in clinical teams

• Employment is an integral part of the overall care plan

SE: What is it about? (II)


• Job search driven by client„s preferences and choice

• Qualification on the job

• Real wages for real quality work

Sheltered employment

Vocational training

Free labour market

Unemployment

Free labour market

Unemployment

Secondary labour market Supported Employment

x No supportx

Day hospital / vocational training

The situation with supported employment

The TGV*

to work

* Train a Grande

Vitesse (Express

train)


SE for people with mental illness:

Individual Placement and Support (IPS)

What did we know in 2003?

• 21 studies (12 RCTs) favour IPS over “train and place”

• 20 – 60% obtain jobs in IPS

• 10 – 20% in train and place

• Accepted as the evidence based standard in USA


SE: The situation in the USA

• Unemployment rate 61-73%

• Wish to work 75%

• Successful reintegration SE: 61%

sheltered employment: 9%

• System - low unemployment rate

- low workplace security

- minimal health care

- low paid work places


SE: USA vs. Europe

• The US has tolerated levels of relative poverty that would have brought down

any European government

• European governments have tolerated levels of unemployment that would have

brought down any US government

• US „hire and fire‟ versus European employment protection and stability

• Welfare state provision: European benefits higher


EQOLISE: Design and Method (I)

1. Randomised control trial (RCT) in six European countries: UK (London),

Bulgaria (Sofia), Germany (Ulm), Italy (Rimini), NL (Groningen), Switzerland

(Zurich)

2. Patients with psychotic disorders or bipolar disorder and extensive

unemployment (>1y)

3. Living in community at baseline

4. Displaying major role dysfunction for >2 years


EQOLISE: Design and Method (II)

5. Wish to work! motivation

6. Continuous medical treatment in a community mental health centre or a local

equivalent

7. Randomisation at the patient level stratified by: centre, gender and work history

8. N=312, min. 50 in each centre


EQOLISE: Design and Method (overview)

Data assessment:

0 Mt. 6 Mt. 12 Mt. 18 Mt.312 clients

156 clients in the control group

156 clients in the experimental group


What are the most heard concerns?

• Work will worsening mental health

• Lacking support

• Low understanding of employers and staff

• Benefit review causing financial consequences

• Just getting low quality jobs



The effectiveness of supported employment for people

with severe mental illness: a randomised controlled trial

in six European countries

Tom Burns, Jocelyn Catty, Thomas Becker, Robert E. Drake,

Angelo Fioritti, Martin Knapp, Christoph Lauber, Wulf Rössler,

Toma Tomov, Jooske van Bussenbach, Sarah White, Durk Wiersma

2007; 370: 1146-1152

Effectiveness of IPS


IPS Voc rehab

• Worked for at least 1 day (%) 54.5 27.6*

• No days employed (mean) 130.3 30.5*

• Job tenure (d) 213.6 108.4*

* p<0.001

0

10

20

30

40

50

60

70

80

90

London Ulm Rimini Zurich Groningen Sofia

Perc

en

tag

e

Primary outcome: worked for at least 1 day

IPS

Vocationalservices

IPS: employment during the study period (Zurich data)

0 5 10 15 20 25

1

12

cli

en

ts

Months

Arbeitssuche

Beschäftigung

Predictors of employment


OR

Work history 2.42 (p<0.001)

Diagnosis, symptoms, social functioning, ns

QoL, needs, therapeutic relationship

Catty et al., Br J Psychiatry 2008

Predictors of job tenure


IPS p<0.01

QoL p=0.05

Diagnosis, symptoms, social functioning, ns

needs

Catty et al., Br J Psychiatry 2008

Does SE make you ill? (I)


Hospitalised (%) Time in hospital (%)

IPS 20.1 4.6

Voc rehab 31.1 8.9

p <0.05 <0.01

(Burns et al., Schizophr Bull 2009)

Does SE make you ill? (II)


Job 1 Job 2 Job 3

PANSS1

PANSS2

PANSS3

Hosp 1 Hosp 2 Hosp 3

IPS0

iPANSS

sPANSS

PANSS0Autoregressive latent trajectory (ALT): combining the latent trajectory

model and the autoregressive model for the examination of

longitudinal relationships between repeatedly measured variables

Does SE make you ill? (III)


Job1 Job2 Job3

PANSS1

PANSS2

PANSS3

Hosp1 Hosp2 Hosp3

IPS0

iPANSS

sPANSS

PANSS0

OR 0.702

OR = 2.221 OR = 2.221

OR = 2.596OR = 2.596

b = 1.717

b = 1.558

OR 1.763

OR 1.014

(Kilian et al., submitted)

What about medication? (I)


Influence medication vocational outcomes* NO

- Antipsychotics

- dosage NO

- atypical vs typical NO

- depot vs oral NO

- Antidepressants NO

- Benzodiazepines NO

- Mood stabilizers NO

* Working at least one day, number of days worked, time to employment (Lauber et al., submitted)

What about medication? (II)


Influence of vocational outcomes* on medication NO

- Antipsychotics NO

- Antidepressants NO

- Benzodiazepines YES

- Mood stabilizers NO

Change in medication dosage due to work (antipsychotics only) NO


What about clients’ preferences?


Preferences, consistency Vocational outcomes* NO

Job satisfaction NO

Employment (±preferred job) Preferences, consistency +

Consistency of clients‟ preferences

- Previous work history -

- Service allocation (IPS, control) NO


What about the costs?


IPS produced better outomces at lower cost to the health and social care system.

- Available cases: Total costs over 18 months IPS < CVR

Imputed cases: Total costs over 18 months no difference

- IPS with a much bigger decline of inpatient costs (-£2,700) in the first 6 months

- IPS with overall higher intervention costs when compared to CVR

- Incremental cost-effectiveness: effectiveness, costs

Overall IPS dominates

Site-specific IPS dominates (ex. Groningen)

Knapp et al., submitted

Summary


IPS when compared to conventional vocational rehabilitation is

• More effective

• More cost-effective

• Not making people ill

• Not related to medication

• Independent of clients‟ job preferences (incl. consistency)

• Better only in an initial phase

• Not a solution for everybody!

Thank you for your attention!

[email protected]


http://www.contacting.com/pause/index2.html

This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on thesubject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumers DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.

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The effectiveness of supported employment for people …ec.europa.eu/health/sites/health/files/mental_health/docs/ev... · The effectiveness of supported employment for people with