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: 8.45). 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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    • "Several other studies that favored IPS with regard to vocational outcomes failed to find greater improvement in non-vocational outcomes [27,37]. Nor have advantages been found for IPS in studies that specifically evaluated psychiatric symptoms [39– 42], quality of life [39,4142, self-esteem [40], global functioning404142, relapses [41], coping [41], social support [42], or substance misuse [42]. When differences on non-vocational outcomes have been identified, they have been small [20] or possibly due to baseline differences and resultant regression to the mean [42] . "
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    ABSTRACT: Supported employment, specifically individual placement and support (IPS), improves competitive employment (CE) rates for individuals with serious mental illness, but has not shown greater improvement in non-vocational outcomes than other rehabilitation approaches. The Department of Veterans Affairs offers two types of vocational services, IPS and transitional work experience (TWE), but no study has compared the effectiveness of these approaches. This secondary analysis of data from a study of homeless veterans compared 6 mo improvement in diverse outcomes for five employment patterns: never worked, worked only in TWE, worked in TWE followed by CE, worked in CE without IPS, and worked in CE with IPS referral. Veterans referred to IPS were more likely to be competitively employed. Those who worked in CE (whether following TWE or with or without IPS referral) showed the greatest increase in days worked, employment income, and total income and the greatest decrease in public support income when compared with those who worked only in TWE or not at all. Veterans in TWE showed the greatest increase in residential treatment days, but there were no other differences in non-vocational outcomes between groups. There are multiple paths to CE, but few differences in non-vocational outcomes across employment experiences.
    Preview · Article · Apr 2014 · The Journal of Rehabilitation Research and Development
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    • "During the search for relevant articles, five further studies of enhanced IPS were identified, although these were not included as they were not comparative in design and so the contribution of the enhancement could not accurately be judged. Of these studies, one was a further case study of ISE [32], one was an RCT of IPS and WFT versus standard vocational rehabilitation [33], and another study examined assertive community treatment (ACT) and IPS [34]. The latter study consisted of two staff teams: ACT and IPS, who tailored and coordinated care to address individuals' mental health and vocational needs. "
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    ABSTRACT: Topic: Additional interventions used to enhance the effectiveness of individual placement and support (IPS). Aim: To establish whether additional interventions improve the vocational outcomes of IPS alone for people with severe mental illness. Method: A rapid evidence assessment of the literature was conducted for studies where behavioural or psychological interventions have been used to supplement standard IPS. Published and unpublished empirical studies of IPS with additional interventions were considered for inclusion. Conclusions. Six published studies were found which compared IPS alone to IPS plus a supplementary intervention. Of these, three used skills training and three used cognitive remediation. The contribution of each discrete intervention is difficult to establish. Some evidence suggests that work-related social skills and cognitive training are effective adjuncts, but this is an area where large RCTs are required to yield conclusive evidence.
    Full-text · Article · May 2012
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    • "Only 1 of these 11 trials was performed in a rural setting. That study's employment outcomes were at the median, with a competitive employment rate of 64% (Gold et al., 2006). Although this result is encouraging, Bond's review nonetheless reveals that few randomized controlled trials of IPS have been conducted in rural settings. "
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    ABSTRACT: Little is known about the relationship between population density and employment rates in individual placement and support (IPS), the evidence-based approach to supported employment. Using longitudinal employment data from 87 agencies that provide IPS to clients with severe mental illness in diverse regions of the United States, we categorized and compared agencies according to population density data as metropolitan, micropolitan, or small town. We tested for an association between population density category and employment rate. Mean program-level competitive employment rates were 43% for 66 metropolitan, 49% for 14 micropolitan, and 40% for 7 small-town IPS programs. Population density of the community in which a supported employment program is located was not associated with program-level competitive employment rates. Despite differences in the number and diversity of employers, cultural norms, and other factors associated with population density, rurality does not adversely influence the effectiveness of IPS supported employment programs.
    Full-text · Article · Jul 2011 · American Journal of Psychiatric Rehabilitation
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