Severe mental illness and work: What can we do to maximise the employment opportunities for individuals with psychosis?

Background

Earlier this year, the Australian and New Zealand Journal of Psychiatry published the results of the 2010 Survey of High Impact Psychosis (SHIP) (Morgan et al., 2012). This survey provided a snapshot of how Australia’s mental health services have changed over the 12 years since the first national psychosis survey (Jablensky et al., 1999). The decreased use of inpatient admissions together with a greater use of community mental health clinics and rehabilitation services suggested Australian mental health services had shifted towards a more recovery-focused model of care, with the proportion of respondents feeling satisfied with their own level of independence rising by 23% (Morgan et al., 2012). However, this apparent shift appears to have neglected one of the key measures of social functioning, namely employment. The proportion of Australian adults with a psychotic disorder who are in employment (either part-time or full-time) remains stuck at 22%, with no improvement over the 12 years between surveys (Waghorn et al., 2012). This is despite national unemployment rates decreasing over the same period and a dramatic expansion in employment services for those with disabilities. This compares with European rates of employment in people with schizophrenia of 11.5% (France) and 30% (Germany), with very high inter-centre variability indicating that policies, services and local context have a major influence on employment rates (Kooyman et al., 2007; Marwaha et al., 2007). The failure to improve the catastrophic occupational outcomes for individuals with psychosis and other severe mental illness should prompt all of the agencies involved, including Australia’s mental health system and the relevant policymakers, to re-examine the way in which rehabilitation is organised and consider what needs to change to allow more of our patients to enjoy the benefits of work.

Why are people with severe mental illness excluded from work?

The first symptoms of mental illness often present during adolescence or young adulthood (Hatch et al., 2010; Kessler et al., 2005), which is a crucial time for education and transitions into further training or employment (Henderson et al., 2011). Only one-third of people living with psychosis in Australia complete high school, with one in five subsequently reporting reading and writing problems (Waghorn et al., 2012). As a result, those with psychosis enter the labour market with a huge educational disadvantage. This disadvantage is then compounded by the stigmatising views about mental illness found in the workplace (Glozier, 1998). One study found that 50% of employers would ‘never’ or ‘rarely’ employ someone they knew to have a psychiatric disorder (Manning and White, 1995). Case vignette studies have also shown that when a disclosure of mental illness is made, hypothetical job applications tend to receive lower employment suitability ratings (Brohan et al., 2012). Even if an individual with severe mental illness does make the transition into employment, they are more likely to end up in part-time or temporary jobs, so called ‘precarious employment’ (Bohle et al., 2004), which may be unstable, poorly remunerated, and have less access to paid sick leave (Harvey and Henderson, 2009).

Does it matter if people with severe mental illness do not work?

Within Australia and most other developed countries, individuals who are excluded from the workforce due to illness-related disability are usually able to receive welfare payments to partially offset the financial consequences of their worklessness. Given this compensation, some will suggest that those with severe and enduring mental illness may be better off not attempting to enter the employment market, especially given the extreme challenges they face gaining and maintaining employment. However, employment is associated with more than just financial benefit (Wadhell and Burton, 2006). Among individuals with psychosis, being in work is associated with improved self-esteem (Lehman, 1995) and greater social contact and independence (Bond, 2004). As a result, it is not surprising that the majority of people with severe mental illness consistently report that they want to work (Secker et al., 2001; Waghorn et al., 2012).

What can be done?

Despite the severity and complexity of barriers to employment for people with severe mental illness, there are evidence-based interventions that have proven to be remarkably effective among those with a psychotic disorder. There have been two main streams of research: (1) early intervention and (2) supported employment. Early intervention programmes for psychosis aim to reduce the period of time between the onset of psychosis and the start of effective treatment, and provide consistent and comprehensive care during the early phase of an illness (McGorry et al., 2007). A number of randomised controlled trials (RCTs) have shown that compared to standard community care, individuals assigned to early intervention programmes are more likely to be actively involved in education or work 12 and 18 months after presenting to services (Garety et al., 2006; Petersen et al., 2005).

Individual placement and support (IPS) is a form of supported employment that is based on the philosophy that anyone is capable of gaining competitive employment, provided the right job with appropriate support can be identified (Bond, 2004). The key principles of IPS are described in Box 1. IPS programmes tend to focus on finding early employment for those with severe mental illness and then providing individual support within a job. This is in contrast to more traditional models, such as clubhouse pre-vocational training or sheltered workshops, where the emphasis is on extensive training and preparation before any return to competitive employment. While they may be appropriate for some individuals, traditional models place little urgency around starting immediate competitive employment (thus delaying the positive effects of employment) and may add to the sense of exclusion from mainstream society felt by many with severe mental illness (Waghorn et al., 2009).

The effectiveness of IPS has been known for some time. A detailed Cochrane systematic review published in 2001 assessed 18 RCTs and concluded that among those with severe mental illness, the supported employment model was significantly more likely to lead to employment than more traditional types of pre-vocational training (Crowther et al., 2001). In fact, IPS has been shown to have a competitive employment rate of 61% compared to 23% for controls (Bond et al., 2008). In addition to improving job acquisition, IPS has also been shown to improve job duration, hours worked per week and wages (Bond et al., 2012), and to decrease inpatient costs for successful users by 50% over 10 years (Bush et al., 2009).

Much of the early evidence for the effectiveness of IPS originated in the US (Bond et al., 2008). Due to its success, IPS has been exported to many other countries, although some concerns have been raised as to whether the IPS model would be as successful outside of the US setting. A recent review on non-US IPS RCTs indicates that IPS continues to be effective in a variety of different countries, with an overall employment rate of 47% (Bond et al., 2012). Interestingly, although a number of characteristics, such as previous job tenure and education, are associated with higher employment rates, there is no demographic or clinical characteristic that undermines the superiority of IPS over standard care (Campbell et al., 2011). While the setting does not appear to be important in predicting the success of IPS, unlike non-IPS employment models (Marwaha et al., 2007), model fidelity is vital. A number of studies and a recent systematic review have shown that IPS services that are able to meet the key requirements as listed in Box 1, are more successful at obtaining employment for people with severe mental illness (Bond et al., 2012). Delivering complex interventions in mental health care, while achieving such fidelity, is difficult but crucial.

Australia and supported employment

Despite the increasing international evidence of the effectiveness of the IPS model, supported employment schemes have not become standard within the Australian mental health system. In June 2012, the Federal House of Representatives Standing Committee on Education and Employment produced their report on the Inquiry into Mental Health and Workforce Participation (Standing Committee on Education and Employment, 2012). One of the key recommendations was that the ‘Commonwealth Government explore ways, in partnership with the states and territories through COAG, to support Individual Support and Placement (ISP) and other service models that integrate employment services and clinical health services’.

There are, however, some structural aspects to the Australian situation which have contributed to the slow uptake of IPS and which may continue to impede any further progress. Over recent years, the delivery of disability employment services (DES) within Australia has been outsourced to a variety of different organisations, with different providers operating in each area. The results of the recent federal tender process for 2013–2018 have resulted in 475 different DES providers across the country. For a clinician working in, say, South Brisbane, there are 14 different providers of such services with which to liaise. Despite attempts by the government to monitor the practices of each organisation, the heterogeneity of services makes it difficult to ensure evidence-based methods are being used. Australian rehabilitation efforts are also limited by the physical and organisational separation between DES and clinical services. This separation is not unique to Australia, with a recent international review on mental health in the workforce highlighting the need for clinical, vocational and educational services to be integrated to increase employment outcomes (Organisation for Economic Co-operation and Development, 2012). Integration of these services, which can be achieved by enhancing the intersectoral links between the services as well as co-locating employment specialists within the community mental health team, would allow greater communication and coordination of clinical care with vocation goals (King et al., 2006). High-fidelity IPS will be impossible to obtain without such integration.

Despite these challenges, there have been a number of successful trials of IPS within Australia and New Zealand. IPS is now used at over 30 sites within Queensland and at over 50 sites within New Zealand. New South Wales has also begun using IPS, with 13 sites where local DES are selected to partner community mental health teams based on their ability to provide high-fidelity IPS. However, the establishment of IPS within these locations is the result of individual and local initiatives, rather than a comprehensive roll-out. The Federal House of Representatives Standing Committee on Education and Employment report highlighted previously will hopefully bring a new sense of urgency to decisions surrounding the vocational rehabilitation for those with severe mental illness. If we want the occupational outcomes of those with severe mental illness to improve by the time of the next national survey, Australian mental health systems will have to lobby and work closely with Federal and State policymakers and disability employment providers. The international evidence of what works must have a central place in mental health vocational rehabilitation programmes in Australia. By engaging with evidence-based programmes, mental health services can help many more sufferers of mental illness to gain the financial, personal and health benefits of work.