Article Details

Research Database: Article Details

Citation:  Cook, J., Lehman, A., Drake, R., McFarlane, W., Gold, P., Leff, H.S., et al. (2005). Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment. American Journal of Psychiatry, 162 (10), 1948-1956.
Title:  Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment
Authors:  Cook, J., Lehman, A., Drake, R., McFarlane, W., Gold, P., Leff, H.S., et al.
Year:  2005
Journal/Publication:  American Journal of Psychiatry
Publisher:  American Psychiatric Association
DOI:  https://doi.org/10.1176/appi.ajp.162.10.1948
Full text:  https://www.ncbi.nlm.nih.gov/pubmed/16199843    |   PDF   
Peer-reviewed?  Yes
NIDILRR-funded?  No
Research design:  Randomized controlled trial

Structured abstract:

Background:  Rigorous study of vocational rehabilitation for patients with schizophrenia and other severe mental illnesses has predominantly focused on testing the efficacy of model programs. Reviews of randomized, controlled trials of supported employment (1, 2) have established this approach as an evidence-based practice in returning psychiatric outpatients to competitive employment. However, the randomized, controlled trial design is subject to constraints related to the difficulties of replicating model programs under varying environmental conditions with diverse populations in a variety of organizational settings. Given prior research, this study tested two hypotheses: 1) participants in supported employment programs with highly integrated psychiatric and vocational service delivery will achieve superior vocational outcomes compared to those in programs with low levels of integration, and 2) the amount of vocational services received will be positively associated with better employment outcomes after control for the amount of psychiatric services received as well as participant demographic and clinical characteristics.
Purpose:  Although large-scale surveys indicate that patients with severe mental illness want to work, their unemployment rate is three to five times that of the general adult population. This multi-site, randomized implementation effectiveness trial examined the impact of highly integrated psychiatric and vocational rehabilitation services on the likelihood of successful work outcomes.
Setting:  The Employment Intervention Demonstration Program was funded in 1995, with the selection of eight study sites located in Maryland, Connecticut, South Carolina, Pennsylvania, Arizona, Massachusetts, Maine, and Texas. Organized under the cooperative agreement funding mechanism (Request for Applications SM 94-09), researchers and federal personnel collaborated in the development and implementation of a common protocol of research instruments, uniform data collection methods, and statistical analyses (15). This effort was led by a coordinating center based at the Department of Psychiatry at the University of Illinois at Chicago in partnership with the Human Services Research Institute located in Cambridge, Mass.At seven sites nationwide, 1,273 outpatients with severe mental illness were randomly assigned either to an experimental supported employment program or to a comparison/services-as-usual condition and followed for 24 months. Data collection involved monthly services tracking, semiannual in-person interviews, recording of all paid employment, and program ratings made by using a services-integration measure. The likelihood of competitive employment and working 40 or more hours per month was examined by using mixed-effects random regression analysis.
Study sample:  All of the study subjects met diagnosis, duration, and disability criteria for severe and persistent mental illness, as defined by the federal Center for Mental Health Services (15), along with the following inclusion criteria: age 18 years or older, interest in working, and ability to provide informed consent. At all sites, the subjects were recruited from clinical populations by provider referral, self-referral, family referral, or word of mouth. Advertisements in newspapers were also used by the Massachusetts site. Each site received approval from its local internal review board for the protection of human subjects and obtained written informed consent from all participants. The eligible pool of study participants numbered 10,653; of this group, 2,883 were contacted about participation (the numbers excluded the Massachusetts site, which was unable to provide this information). Across all sites (including Massachusetts), 1,750 individuals consented to participate in the study, 1,655 completed the first interview, and 1,648 were randomly assigned. Among those who agreed to participate but were never randomly assigned, the reasons included patient refusal, patient non-eligibility, and patient loss to follow-up.
Intervention:  At each site, the experimental condition was a form of enhanced best-practice supported employment compared to either services as usual or an unenhanced version of the experimental model. For example, The Maryland, Connecticut, and South Carolina sites tested the individual placement and support model in which multidisciplinary provider teams engage in minimal prevocational assessment, rapid job search, and placement into competitive jobs, with the provision of training and ongoing follow-along support for as long as the patient requests it.
Control or comparison condition:  As with many multisite studies, the nature of the comparison conditions varied. Arizona, Connecticut, Maryland, and South Carolina used a services-as-usual comparison condition in which the subjects received whatever services were available in the local community. Massachusetts used the Clubhouse model, in which facility-based services were provided according to a work-ordered day, with patients and staff working together on jobs within the program as well as at job placements in the community. Both Texas and Maine used an "unenhanced" version of their experimental condition (i.e., no social network services in Texas and no employer consortium in Maine).
Data collection and analysis:  Data collection involved monthly services tracking, semiannual in-person interviews, recording of all paid employment, and program ratings made by using a services-integration measure. The likelihood of competitive employment and working 40 or more hours per month was examined by using mixed-effects random regression analysis.
Findings:  Subjects served by models that integrated psychiatric and vocational service delivery were more than twice as likely to be competitively employed and almost 1½ times as likely to work at least 40 hours per month when the authors controlled for time, demographic, clinical, and work history confounds. In addition, higher cumulative amounts of vocational services were associated with better employment outcomes, whereas higher cumulative amounts of psychiatric services were associated with poorer outcomes.
Conclusions:  Supported employment models with high levels of integration of psychiatric and vocational services were more effective than models with low levels of service integration.

Disabilities served:  Chronic mental illness
Depression
Schizophrenia
Populations served:  Gender: Female and Male
Race: White / Caucasian
Interventions:  Individual Placement and Support (IPS) model of supported employment
Vocational rehabilitation
Outcomes:  Other