Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness.

Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, IOP 4 South, Charleston, SC 29425, USA.
Schizophrenia Bulletin (Impact Factor: 8.61). 04/2006; 32(2):378-95. DOI: 10.1093/schbul/sbi056
Source: PubMed

ABSTRACT Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

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    ABSTRACT: APA's Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition, was published in April 2004 (1). This watch highlights key research studies published since that date. The studies were identified by a MEDLINE literature search for meta-analyses and randomized, con-trolled trials published between 2002 and 2008, using the same key words used for the literature search performed for the 2004 guideline. With regard to pharmacotherapy, there have been sev-eral important randomized trials of antipsychotics. For chronic schizophrenia, trials include the National Insti-tute of Mental Health (NIMH) Clinical Antipsychotic Trial for Intervention Effectiveness (CATIE) and the United Kingdom–funded Cost Utility of the Latest Antipsychotics in Schizophrenia (CUtLASS). For first-episode schizophrenia, there are two industry-funded trials, the European First Episode Schizophrenia Trial (EUFEST)—funded by AstraZeneca, Pfizer, and Sanofi-Aventis—and the Comparison of Atypicals for First Epi-sode Schizophrenia (CAFE)—funded by AstraZeneca. For early-onset schizophrenia, there is one trial, the NIMH-funded Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS). These trials point to a re-consideration of treatment with the antipsychotics per-phenazine and molindone and by extension other first-generation antipsychotics, with the possible exception of haloperidol, for which some trials have shown greater rates of extrapyramidal side effects or less favorable clinical re-sponse (2). In addition, a recent population-based cohort study (3) that encompassed 11 years of follow-up showed decreased rates of mortality with perphenazine as compared with other first-and second-generation antipsychotic agents; only clozapine use was associated with lower rates of overall mortality. For the period April 2008 to August 2009, Dr. Dixon reports attending a consultation meeting for Janssen and receiving a grant from Bristol-Meyers-Squibb for investigator-initiated research, Dr. Perkins reports receiving research funding from Janssen (ended Janu-ary 2009) and reports receiving income for consulting for Dainippon (data safety monitoring board on lurasidone studies) and for serving on speakers bureaus for Eli Lilly, and Dr. Calmes reports no competing interests. The Executive Committee on Practice Guidelines reviewed this watch and found no evidence of influence from these relationships. The American Psychiatric Association's (APA's) practice guidelines are developed by expert work groups using an explicit meth-odology that includes rigorous review of available evidence, broad peer review of iterative drafts, and formal approval by the APA Assembly and Board of Trustees. APA practice guidelines are intended to assist psychiatrists in clinical decision making. They are not intended to be a standard of care. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. Guideline watches summarize significant developments in practice since publication of an APA practice guideline. Watches may be authored and reviewed by experts associated with the original guideline development effort and are approved for publication by APA's Executive Committee on Practice Guidelines. Thus, watches represent opinion of the authors and approval of the Executive Committee but not policy of the APA. This guideline watch was published in September 2009.
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    ABSTRACT: Background Roughly one third of disability pensions in Norway are issued for mental and behavioral disorders, and vocational rehabilitation offered to this group has traditionally been dominated by train-and-place approaches with assisted or sheltered employment. Based on a more innovative place-and-train approach, Individual Placement and Support (IPS) involves supported employment in real-life competitive work settings, and has shown great promise for patients with severe mental illness. Methods/design The study is a multicenter Randomized Controlled Trial (RCT) of IPS in a Norwegian context, involving an effect evaluation, a process evaluation, and a cost/benefit analysis. IPS will be compared to high quality treatment as usual (TAU), with labor market participation and educational activity at 12 months post inclusion as the primary outcome. The primary outcome will be measured using register data, and the project will also include complete follow-up up to 4 years after inclusion for long-term outcome data. Secondary outcomes include mental health status, disability and quality of life, collected through survey questionnaires at baseline, and after 6 and 12 months. Participants will include patients undergoing treatment for moderate to severe mental illness who are either unemployed or on sickness or social benefits. The estimated total sample size of 400–500 will be randomly assigned to the interventions. To be eligible, participants must have an expressed desire to work, and sufficient Norwegian reading and writing skills to fill out the questionnaires. Discussion The Effect Evaluation of Individual Placement and Support (IPS) will be one of the largest randomized controlled trials to date investigating the effectiveness of IPS on competitive employment, and the first study to evaluate the effectiveness of IPS for patients with moderate to severe mental illness within a Norwegian context. Trial registration NCT01964092. Registered October 16th, 2013.
    BMC Psychiatry 11/2014; 14(307). DOI:10.1186/s12888-014-0307-7 · 2.24 Impact Factor
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    ABSTRACT: Concerns about fragmented mental health service delivery persist, particularly for people with severe and persistent mental illness. The objective was to review evidence regarding outcomes attributed to system-level intersectoral linkages involving mental health services and non-clinical support services, and to identify barriers and facilitators to the intersectoral linkage process.
    Australian and New Zealand Journal of Psychiatry 07/2014; 48(10). DOI:10.1177/0004867414541683 · 3.77 Impact Factor

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