Employment programmes for schizophrenia and other severe mental illness in psychosocial rehabilitation: a systematic review

Abstract

Introduction

Employment programmes for people with mental illness vary widely in range, but nonetheless all share the same objectives of restoring or initiating vocational roles to promote recovery in psychosocial rehabilitation. The current interventions available usually focus on the specific vocational outcomes of the intervention rather than focusing holistically on the client’s needs.

Method

This review aimed to examine the effectiveness of intervention programmes and determine the best intervention for schizophrenia and other severe mental illness, considering both vocational and non-vocational outcomes. Searching five databases – CINAHL, Medline via Ovid, Scopus, OT Seeker and Web of Science – a total of 3108 studies was identified; 24 met the selection criteria and were reviewed. Interventions were categorised into five major programmes of supported employment, integrated supported employment, vocational rehabilitation, cognitive intervention and virtual reality-based vocational training.

Results

Integrated supported employment was found to be the most effective approach for a vocational outcome. However, evidence concerning non-vocational outcomes of employment programmes and the use of cognitive training remains unclear.

Conclusion

Clinicians are advised to consider the needs and preferences of the client before selecting the best intervention programme. More research is needed to determine the applicability and the efficacy of intervention programmes.

Keywords

Vocational rehabilitation occupational therapy integrated supported employment vocational outcomes non-vocational outcomes

Introduction

Providing vocational services is one of the significant roles of occupational therapy for psychosocial rehabilitation. Occupational therapists offer a unique role in understanding an individual’s needs and can design strategies to accommodate those needs. This includes providing job matching, individualised environment support, skills development and on-job training (Kirsh et al., 2019). Work and employment are the fundamental outcomes and predictors of recovery in psychosocial rehabilitation for severe mental illness (SMI) especially schizophrenia. Limited evidence to suggest the ‘best’ intervention approach has given researchers and healthcare workers different perspectives on rehabilitation for employment (Gere and Flowers, 2016). Clients with schizophrenia face the biggest challenge in finding, keeping and maintaining a job due to various barriers such as stigma, low self-esteem, social and cognitive incompetence and poor social support; only 10–39% manage to obtain and keep a job (Jonsdottir and Waghorn, 2015; McGurk et al., 2005; Marwaha and Johnson, 2004). Difficulty in vocational ability (choosing, getting and keeping a job in the community) is the central feature of psychiatric disorders (Massel et al., 1990).

According to Marwaha et al. (2014), meaningful employment has been shown to improve self-esteem, increase personal empowerment and social contact, social identity and status. In addition, employment reduces clinical symptoms, increases personal wellbeing and stimulates higher levels of functioning (Dunn et al., 2008; Siu et al., 2010).

Numerous studies have reported the effectiveness of employment in vocational rehabilitation programmes for persons with schizophrenia (Cook et al., 2008; Machingura and Lloyd, 2017; Nuechterlein et al., 2008). Nevertheless, most of these programmes are still lacking in assessment strategies in relation to rapid job placement for persons with schizophrenia, as clinicians lack a specific strategy to decide when to place those who want real work (Corrigan, 2001). According to a meta-analysis by Carmona et al. (2018) on employment outcomes, supported employment, when combined with other interventions that target schizophrenic-related deficits such as neurocognitive therapy and job-related social skills training, has the potential to address the multicausality of work disability. Another systematic review and meta-analysis by Modini et al. (2016) examined supported employment for people with severe mental illness. However, that review included various diagnoses including bipolar disorders, in which the outcome may differ for persons with schizophrenia. In addition, the review was limited to a comparison of individual placement and support (IPS) interventions with conventional vocational training, while other types of vocational rehabilitation were not included in the review.

Employment programmes not only overcome these challenges but also improve both the success rate of employment and of recovery from the condition. Supported employment emerged and became the widely used model developed for SMI, especially for schizophrenia, in obtaining competitive jobs (Burns et al., 2009; Corbière et al., 2010; Katz et al., 2013, Kern et al., 2008). Despite its superiority in effectiveness compared to other employment programmes, this place-and-train approach was found to have limitations by some researchers. According to Corrigan (2001), ‘place-and-train’ approaches to support employment see 40–70% of persons fail to obtain work successfully. Only about a third of the persons who did get jobs still had them a year later. The length of time that people in supported employment kept their jobs ranged from 9 to 30 weeks.

A previous similar systematic review of comparisons of IPS with other vocational programmes by Kinoshita et al. (2013) concluded that IPS is effective in some vocational outcomes, even though bias in the quality of studies was identified and suggested the need to report a standard set of vocational and non-vocational outcomes. A scoping study conducted by Carmona et al. (2018) also highlighted a few support needs in employment, including the development of skills, vocational interventions, supports and encouragement, and a supportive work environment. However, neither review deliberately highlighted the effectiveness of various employment programmes that were available in psychosocial rehabilitation, choosing instead to explore the comparison between IPS and other employment programmes.

The objective of this systematic review is to examine the effectiveness of the current employment programmes for both vocational and non-vocational outcomes and its effect on individuals with schizophrenia and other severe mental illness.

Method

Literature search

Extensive literature searches were conducted to locate available published research reporting on the effectiveness of various employment programmes as an outcome for adults with schizophrenia. Keyword searches were performed in five selected databases; namely, CINAHL, Medline via Ovid, Scopus, OT Seeker and Web of Science. The following keywords were used: (‘occupational therapy’ AND ‘schizophrenia’ AND ‘employment’ OR ‘vocational’ AND ‘outcome’) with the use of MeSH terms, Boolean operators, parenthesis and truncations whenever appropriate. Occupational therapy in the search term was used to capture employment services or programmes provided by occupational therapists or related to or within the scope of occupational therapy practice. Employment services within the scope of occupational therapy in this study are defined as interventions focusing on work and employment in vocational rehabilitation programmes for people with schizophrenia and severe mental illness, with outcomes related to vocational (employment rate, job tenure, days/hours of working and job change) and also non-vocational admission and re-admission rate, social functioning, quality of life, psychiatric symptoms, self-esteem and wellbeing. Cross referencing of the literature search was also conducted within the available systematic reviews. The search was conducted in April 2020.

Inclusion and exclusion criteria

To be included in this systematic review, studies are required to meet the specific inclusion criteria:

Participants: adults aged above 18 years with schizophrenia, typically with (a) positive symptoms including hallucinations, delusions and abnormal motor behaviour; (b) negative symptoms involving diminished emotional expression and avolition, also alogia and anhedonia as they disturb the patient’s emotions and behaviour; (c) cognitive symptoms; as the latest classification in schizophrenia includes disorganised speech, thought, and/or attention, ultimately impairing the person’s ability to communicate (Patel et al., 2014) and other severe mental illness including schizoaffective disorder, psychosis and delusional disorders.

Interventions: Vocational occupational therapy interventions or interventions related to or within the scope of occupational therapy including employment/vocational programmes, conventional vocational rehabilitation, supported employment (SE; also referred to as individual placement and support; IPS), integrated supported employment (ISE), use of cognitive intervention and virtual reality for employment/skills training.

Outcome measures: Primary outcomes: vocational-related outcomes including employment rate, job tenure, days/hours of working and job change; Secondary outcomes: non-vocational outcomes including admission and re-admission rate, social functioning, quality of life, psychiatric symptoms, self-esteem and wellbeing.

Study design: randomised controlled trials (RCTs) only.

Studies were excluded if: (a) the subjects primarily demonstrated other non-psychotic psychiatric disorders including autism spectrum disorders and intellectual disabilities; (b) they were published in languages other than English; and (c) they were published before the year 2000.

Study selection

Duplicates were removed first before undergoing the screening process. Two independent reviewers, the first and second authors, were responsible for the screening and selection of the retrieved studies, as well as assessment of the methodological properties and data extraction according to the title, abstract, subjects recruited, outcome measures and interventions provided. A manual hand search of the reference list in the included studies was also conducted to identify any further potential articles. The potential articles then underwent the same procedure for inclusion or exclusion. Any disagreements on the studies selected were resolved through discussion until consensus was achieved.

Data extraction and analysis

Included studies in the final analyses were narratively analysed. Each study was extracted based on the objective, participants, study design, intervention applied, primary and secondary outcomes found – related to both vocational (including employment rate, job tenure, days/hours of working and job change) and non-vocational outcomes of employment (including admission and re-admission rate, social functioning, quality of life, psychiatric symptoms, self-esteem and wellbeing). The intervention programmes were then reported based on their effectiveness (non-effective, mixed results, effective).

Quality appraisal of the study

The physiotherapy evidence database (PEDro) scale (Moseley et al., 2002) was employed to assess the methodological quality of the RCT studies. The PEDro is described as a scale to measure the quality of reports on a 10-point scale, examining 11 criteria of randomisation. The scale rates the quality of reports at 9–10 as excellent, 6–8 as good, 4 or 5 as fair and below 4 as poor (Zou et al., 2017). In the event of disagreement between the authors, consensus would be sought from the third and fourth authors.

Results

Study identification

The search strategies identified 3108 articles to be reviewed. A total of 2948 were identified after removing duplicates for title and abstract screening. Eighty one article was eligible for full text screening with 57 articles was excluded afterwards. Finally, only 24 studies remained fulfilling the inclusion criteria for this review. From the 24 studies, 10 studies were from authors or authors collaborating with those from an occupational therapy background (Areberg and Bejerholm, 2013; Bejerholm et al., 2015; Kopelowicz et al., 2006; Tsang and Man, 2013; Tsang and Pearson, 2001; Tsang et al., 2009, 2010; Twamley et al., 2017; Wong et al., 2008; Zhang et al., 2017). The remaining 14 studies were interventions used or related to or within the scope of occupational therapy including IPS, ISE, work skills training, cognitive behavioural therapy (CBT), neurocognitive enhancement therapy (NET), cognitive remediation augmented in job management programmes, compensatory cognitive training and virtual reality job interview training. Studies included in this review were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for reporting systematic and meta-analysis (Moher et al., 2009; Figure 1).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Methodological quality assessment of studies

Based on the PEDro scale quality assessment, one RCT was rated as excellent with a score of 9 out of 10 (Tsang and Pearson, 2001); 14 RCTs were rated as having good quality with a score of 6 to 8 out of 10 (Allott et al., 2013; Areberg and Bejerholm, 2013; Au et al., 2015; Bell et al., 2008; Burns et al., 2007; Lysaker et al., 2009; Smith et al., 2015; Tsang et al., 2009; Tsang and Man, 2013; Twamley et al., 2017; Ullevoldsæter et al., 2016; Waghorn et al., 2014; Wong et al., 2008; Zhang et al., 2017) and 10 RCTs were rated as fair, with a score of 4 or 5 out of 10 (Abi-Saab et al., 2005; Bejerholm et al., 2015; Burns et al., 2009; Evensen et al., 2017; Falkum et al., 2017; Kopelowicz et al., 2006; Rogers et al., 2006; Smith et al., 2015; Torrey et al., 2000; Tsang et al., 2010). Table 1 illustrates the scoring for each study.

Table 1.

The physiotherapy evidence database (PEDro) scale result.

Authors/questions	1.Eligibility criteria were specified	2. Subjects were randomly allocated to groups	3. Allocation was concealed	4. The groups were similar at baseline regarding the most important prognostic indicators	5. There was blinding of all subjects	6. There was blinding of all therapists who administered the therapy	7. There was blinding of all assessors who measured at least one key outcome	8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups	9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, when this was not the case, data for at least one key outcome were analysed by ‘intention to treat’	10. The results of between-group statistical comparison are reported for at least one key outcome	11. The study provides both point measures of variability for at least one key outcome	Total score
Abi-Saab et al. (2005)	–	1	0	1	0	0	0	1	0	1	1	5
Allott et al. (2013)	–	1	0	1	0	0	1	1	1	1	1	7
Areberg and Bejerholm (2013)	–	1	0	1	1	0	1	0	1	1	1	7
Au et al. (2015)	–	1	1	1	0	0	0	1	1	1	1	7
Bell et al. (2008)	–	1	1	1	0	0	0	1	1	1	1	6
Bejerholm et al. (2015)	–	1	0	1	0	0	1	0	0	1	1	5
Burns et al. (2007)	–	1	1	1	0	0	0	0	1	1	1	6
Burns et al. (2009)	–	1	0	0	0	0	0	0	1	1	1	4
Evensen et al. (2017)	–	1	0	0	0	0	0	1	1	1	1	5
Falkum et al. (2017)	–	1	0	0	0	0	0	0	1	1	1	4
Kopelowicz et al. (2006)	–	1	0	1	0	0	0	1	1	0	1	5
Lysaker et al. (2009)	–	1	0	1	0	0	1	1	1	1	1	7
Rogers et al. (2006)	–	1	0	1	0	0	0	0	1	1	1	5
Smith et al. (2015)	–	1	1	1	0	0	0	0	1	1	1	6
Torrey et al. (2000)	–	1	0	0	0	0	0	1	0	1	1	4
Tsang and Pearson (2001)	–	1	1	1	0	1	1	1	1	1	1	9
Tsang et al. (2009)	–	1	1	1	0	0	1	1	1	1	1	8
Tsang et al. (2010)	–	1	0	0	0	0	1	0	1	1	1	5
Tsang and Man (2013)	–	1	0	1	0	0	1	0	1	1	1	6
Twamley et al. (2017)	–	1	0	1	0	0	1	0	1	1	1	6
Ullevoldsæter et al. (2016)	–	1	0	1	0	0	0	1	1	1	1	6
Waghorn et al. (2014)	–	1	0	1	1	1	0	0	1	1	1	7
Wong et al. (2008)	–	1	1	1	0	0	0	1	1	1	1	7
Zhang et al. (2017)	–	1	1	1	0	0	1	0	1	1	1	7

Summary of study details

Details of the 24 included studies are presented in Table 2, which consists of: (a) intervention categories; (b) objectives; (c) diagnosis of participants; (d) number of participants; (e) age of participants; (f) outcome measures; (g interventions implemented; (h) interventions outcomes.

Table 2.

Summary of the study details.

Intervention categories	Studies	Design	Objectives	Participants	Number of participants	Age (years) (range; mean)	Gender (number) (male, female)	Outcome measure	Interventions	Results
Supported employment (IPS)	Areberg and Bejerholm (2013)	Randomised controlled trials	To investigate the effectiveness of IPS on non-vocational outcomes	Severe mental illness with psychosis or psychiatric disability on long-term basis	77	20–65; 38	67, 10	Profile of occupational engagement in people with severe mental illness (POES); worker role interview (WRI-S); empowerment scale (ES); Manchester short assessment of quality of life (MANSA)	Experimental group: IPS; Control group: Conventional vocational rehabilitation	Effective result: IPS participants showed higher scores in quality of life, empowerment and work motivation
Supported employment (IPS)	Bejerholm et al. (2015)	Randomised controlled trials	To determine effectiveness of IPS on vocational outcomes among people with severe mental illness in Swedish context	Severe mental illness with psychosis or psychiatric disability on long-term basis	77	20–65; 38	67, 10	Manchester short assessment of quality of life version 2 (MANSA), profile of occupational engagement in persons with severe mental illness (POES), brief psychiatric rating scale (BPRS), supported employment fidelity scale (SEFS)	Experimental group: IPS; Control group: conventional vocational rehabilitation	Effective result: IPS more effective than conventional vocational rehabilitation in terms of gaining employment, amount of working longer job tenure periods and income
Supported employment (IPS)	Burns et al. (2007)	Randomised controlled trials	To assess the effectiveness of IPS and to examine the effects by local labour markets and welfare systems	Severe mental illnesses (schizophrenia/ schizoaffective disorder, bipolar disorder)	248	18–65; 37.8	188, 60	Vocational outcomes	Experimental group: IPS control group: vocational service	Effective result: IPS more effective than vocational service by vocational outcome
Supported employment (IPS)	Burns et al. (2009)	Randomised controlled trials	To compare differences in the psychiatric status and social functioning of people with severe mental illness receiving 18 months of IPS compared with conventional vocational services	Severe mental illness or psychotic illnesses	251	18–retirement; (data not available)	188, 63	Global assessment of functioning symptoms and disability (GAF-S, GAF-D); positive and negative symptoms scale (PANSS); hospital anxiety and depression scale (HADS); Groningen social disability schedule (GSDS); Lancashire quality of life profile (LQoLP-EU)	Experimental group: IPS; Control group: vocational service	Non-effective: no significant differences in clinical and social functioning
Supported employment (IPS)	Rogers et al. (2006)	Randomised controlled trials	To examine differential effectiveness of psychiatric vocational rehabilitation and enhanced state vocational rehabilitation	Schizophrenia/ psychotic disorders, schizoaffective disorder	85	18–55; (data not available)	73, 12	Rosenberg self-esteem scale; change assessment scale (CAS); brief psychiatric rating scale (BPRS); Lehman quality of life interview (QOLI); vocational/educational status instruments	Experimental group: psychiatric vocational rehabilitation; Control group: enhanced state vocational rehabilitation	Non-effective: no differences were found between the two interventions on any outcomes
Supported employment (IPS)	Waghorn et al. (2014)	Randomised controlled trials	To assess effectiveness of IPS when implemented for Australia adult consumers by utilising existing service systems	Psychotic disorders	168	18–59; 32.4	144; 24	IPS fidelity scale, socially valued role classification scale, scale for the assessment of positive symptoms, assessment of negative symptoms	Experimental group: IPS control group: Treatment as usual	Effective result: IPS had 2.4 times greater odds of commencing employment than control
Supported employment (IPS)	Wong et al. (2008)	Randomised controlled trials	To examine the effectiveness and applicability of supported employment programme	Mental illness (schizophrenia spectrum)	64	18–55; 32.5	55; 9	Brief psychiatric rating scale, Hong Kong Chinese version World Health Organization quality of life	Experimental group: IPS control group: stepwise conventional vocational rehabilitation	Effective result: SE group more likely to work competitively, earned more income, worked more days, and sustained longer job tenure
Integrated supported employment (ISE)	Au et al. (2015)	Randomised controlled trials	To investigate synergistic effect of cognitive remediation training on integrated supported employment (ISE)	Schizophrenia, schizoaffective disorder	90	(18 years & older); 36.14	57, 33	Employment outcome checklist; 18-item brief psychiatric rating scale (BPRS); Chinese version, personal wellbeing index (PWI); Rosenberg self-esteem scale (RSES); Wisconsin card sorting test (WCST)	Experimental group: ISE + cognitive remediation training; Control group: ISE	Non-effective: no significant group difference was found
Integrated supported employment (ISE)	Torrey et al. (2000)	Randomised controlled trials	To examine self-esteem as outcome measure for ISE and IPS	Schizophrenia, affective disorder, personality disorders	67	20–65; (data not available)	67, 0	Rosenberg self-esteem scale (RSES); brief psychiatric rating scale (BPRS); Lehman quality of life interview (QOLI)	Experimental group: ISE & IPS; Control group: skills training group	Non-effective: working does not support improved self-esteem
Integrated supported employment (ISE)	Tsang and Pearson (2001)	Randomised controlled trials	To examine outcomes of vocational social skills training programme in improving ability to find and keep a job	Schizophrenia	97	18–50; 38.66	60, 37	Two-part measure of work-related social competence; Motivation checklist; Follow-up questionnaire	Experimental group: social skills training with follow-up support & social skills training without follow-up support; Control group: standard after-care treatment	Effective result: experimental groups statistically outperform in comparison group. Training group receiving follow-up more successfully at finding and keeping job
Integrated supported employment (ISE)	Tsang et al. (2009)	Randomised controlled trials	To examine the effectiveness of ISE with social skills training	Severe mental illness including schizophrenia, schizoaffective disorder, bipolar disorder, recurrent major depression, borderline personality disorder	126	(Data not available); 34.56	81, 45	Employment outcomes	Experimental group: ISE & IPS; Control group: conventional vocational rehabilitation	Effective result: ISE had significantly higher employment rates and longer job tenure compared to IPS and conventional vocational rehabilitation. IPS also demonstrated better vocational outcomes than conventional vocational rehabilitation
Integrated supported employment (ISE)	Tsang et al. (2010)	Randomised controlled trials	To examine and compare long-term effectiveness of ISE	Severe mental illnesses (schizophrenia, schizoaffective disorder, bipolar disorder, recurrent major depression, borderline personality disorder)	145	(Data not available); 34.94	93, 52	Employment outcome checklist; 21-item Chinese job stress coping scale (CJSC); personal well-being index (PWI); Chinese general self-efficacy scale (CGSS)	Experimental group: ISE & IPS; Control group: conventional vocational rehabilitation	Effective result: ISE obtained higher employment rate and longer job tenure compare to IPS and conventional vocational rehabilitation. Non-vocational outcomes inconclusive
Integrated supported employment (ISE)	Zhang et al. (2017	Randomised controlled trials	To investigate the effectiveness of integrated supported employment	Schizophrenia	162	(Data not available); 32.81	68, 94	Employment outcome checklist; brief psychiatric rating scale (BPRS); global assessment functioning (GAF); personal wellbeing index (PWI)	Experimental group: ISE & IPS; Control group: conventional vocational rehabilitation	Effective result: ISE group significantly found higher in employment rate and longer job tenure compare to IPS and conventional vocational rehabilitation. ISE also attained most positive psychological outcomes
Vocational rehabilitation	Falkum et al. (2017)	Randomised controlled trials	To study outcomes of vocational rehabilitation programme, the Job Management Program (JUMP) for persons with psychotic disorders based on close collaboration between health and welfare	Broad schizophrenia spectrum disorders (schizophrenia, schizoaffective disorder, other psychosis)	489	18–65; 34.29	296, 193	Work status and working hours; positive and negative symptoms scale (PANSS)	Experimental group: CBT & cognitive remediation augment in JUMP; Control group: treatment as usual	Mixed result: JUMP group showed significant differences of positive and general symptoms of psychosis. CBT and cognitive remediation interventions showed no significant difference
Vocational rehabilitation	Kopelowicz et al. (2006)	Randomised controlled trials	To determine vocational success might be a function of cognitive demands imposed by typical entry-level job tasks	Schizophrenia	120	18–64; 36.8	82, 38	Work tasks (index card filing, computer board assembly, computer use)	Experimental group: work skills training; Control group: occupational therapy	Effective result: work skills training performed significantly better – suggesting cognitive demands of work tasks
Cognitive intervention	Abi-Saab et al. (2005)	Randomised controlled trials	To differentiate memory profile groups and examine validity with respect to vocational outcomes and neuropsychological functioning	Schizophrenia, schizoaffective disorder	151	(Veterans); 42.8	120, 31	Positive and negative syndrome scale (PANSS); vocational cognitive rating scale (VCRS); work behaviour inventory (WBI); Hopkins verbal learning test – revised edition (HVLT-R)	Experimental group: work rehabilitation + neurocognitive enhancement therapy (NET); Control group: work rehabilitation	Non-effective: no clinical differences in three memory profile groups
Cognitive intervention	Allott et al. (2013)	Randomised controlled trials	To examine the baseline of neurocognition and social cognition in predicting vocational outcomes	Psychotic disorders (first episode psychosis)	135	15–25; 20.3	91, 44	Neurocognition batteries (WRAT-4; WAIS-III; TMT; RAVLT; RCFT; COWAT; & animal fluency test); social cognition batteries (PST; FBDST; DANVA-2); vocational outcomes	Experimental group: IPS; Control group: treatment as usual	Non-effective: IPS alone may not be sufficient for first episode psychosis in sustaining employment. Neurocognition not social cognition predict three vocational outcomes
Cognitive intervention	Bell et al. (2008)	Randomised controlled trials	To study functional outcomes of neurocognitive enhancement therapy (NET)	Schizophrenia, schizoaffective disorder	72	(Data not available); 39.71	39, 33	Work hours and employment rates	Experimental group: vocational rehabilitation condition + NET; Control group: vocational rehabilitation condition	Effective result: Experimental group worked significantly more hours higher cumulative rate of competitive employment
Cognitive intervention	Evensen et al. (2017)	Randomised controlled trials	To study competitive employment outcome at 2-year follow-up of vocational rehabilitation augmented with cognitive remediation or elements of cognitive behaviour therapy (CBT)	Schizophrenia, schizoaffective disorder, psychosis, delusional	148	18–65; 32.85	103, 45	Global assessment of functioning (GAF); Rosenberg self-esteem scale (RSE); Calgary depression scale for schizophrenia (CDSS)	Experimental group: CBT & cognitive remediation augment in vocational rehabilitation; Control group: no control group	Mixed result: significant improvements found in global functioning, self-esteem and depression. No significant differences between the two groups
Cognitive intervention	Lysaker et al. (2009)	Randomised controlled trials	To examine the effects of CBT with vocational outcomes	Schizophrenia, schizoaffective disorder	97	(Data not available); 49.47	85, 12	Positive and negative syndrome scale (PANSS); change assessment scale (CAS); medical outcome survey: 36 item short health form (SF-36); work behaviour inventory (WBI); revised cognitive therapy scale (CTS-R)	Experimental group: Indianapolis vocational intervention program; Control group: support service	Effective result: vocational intervention programme worked significantly greater number of weeks and hours as well as better performance than support service
Cognitive intervention	Twamley et al. (2017)	Randomised controlled trials	To study effectiveness of compensatory cognitive training in prospective of memory, attention, learning/memory and executive functioning	Severe mental illnesses (schizophrenia, schizoaffective disorder)	58	(18 years & older); 43.7	25, 33	Work outcomes, University of California performance-based skills assessment-brief (UPSA-Brief), social skills performance assessment (SSPA), Hamilton depression rating scale (HAM-D), positive and negative syndrome scale (PANSS), independent living skills survey (ILSS), quality of life interview (QOLI)	Experimental group: compensatory cognitive training Control group: enhanced supported employment (ESE)	Non-effective: No difference in work attainment, weeks worked, or wages earned between compensatory cognitive training and ESE group. No statistically significant in long-term compensatory cognitive training-associated improvement
Cognitive intervention	Ullevoldsæter et al. (2017)	Randomised controlled trials	To examine the effects of cognitive remediation combine with vocational rehabilitation compared to CBT with vocational rehabilitation	Schizophrenia, schizoaffective disorder, psychosis, delusional	131	18–65; 32.72	92, 39	Positive and negative syndrome scale (PANSS); Wechsler abbreviated scale of intelligence (WASI); MATRICS consensus cognitive battery (MCCB); occupational status	Experimental group: cognitive remediation + vocational rehabilitation; Control group: CBT + vocational rehabilitation	Mixed result: significant increase in number of participants working and hours for both groups. No significant difference between group were reported
Virtual reality-based vocational training	Smith et al. (2015)	Randomised controlled trials	To evaluate the efficacy of virtual reality job interview training at improving job interview skills and employment outcomes	Schizophrenia/ schizoaffective disorder	32	18–55; 40.22	17, 15	Positive and negative syndrome scale (PANSS); repeatable battery for the assessment of neuropsychological status; Bell–Lysaker emotion recognition tasks; treatment experience questionnaire (TEQ)	Experimental group: virtual reality job interview training; Control group: treatment as usual waitlist	Effective result: virtual reality job interview training is acceptable to trainees and may be efficacious for improving job interview skills
Virtual reality-based vocational training	Tsang and Man (2013)	Randomised controlled trials	To investigate the efficacy and effectiveness of virtual reality as cognitive intervention for enhancing vocational outcomes	Schizophrenia	75	18–55; 40.64	33, 42	Cognitive outcomes (brief neuropsychological cognitive examination; BNCE); digit vigilance test (DVT); Rivermead behavioural memory test (RBMT); Wisconsin card sorting test, computer version 4 (WCST-CV4)); work outcomes (vocational cognitive rating scale; VCRS)	Experimental group: virtual reality group; Control group: therapist-administered group and conventional group	Effective result: virtual reality group found to perform better in cognitive functioning than therapist-administered group and conventional group. Both: virtual reality group and therapist-administered group showed better work performance on on-site result

Participants

A total of 3165 individuals were involved in the 24 studies, of whom the majority were diagnosed with schizophrenia. The breakdown of diagnoses was as follows: schizophrenia (n = 1767; 55.83%); labelled as schizophrenia/schizoaffective disorders in the studies (n = 338; 10.68%); psychotic disorders/illnesses (n = 284; 8.97%); schizoaffective disorders (n = 227; 7.87%); labelled as schizophrenia/psychotic disorders (n = 216; 6.82%) (Areberg and Bejerholm, 2013; Bejerholm et al., 2015; Rogers et al., 2006); first episode psychosis (n = 135; 4.27%); chronic paranoid schizophrenia (n = 106; 3.35%; schizophrenia spectrum (n = 64; 2.02%); and, finally, labelled as delusional disorders in the studies (n = 6; 0.19%). The subjects’ age range was 18 to 65 years. There were 2216 male subjects (70.02%).

Intervention

Studies involved in the review generally implemented rehabilitation programmes including supported employment (IPS) (Areberg and Bejerholm, 2013; Bejerholm et al., 2015; Burns et al., 2007, 2009; Rogers et al., 2006; Waghorn et al., 2014; Wong et al., 2008), ISE (Au et al., 2015; Torrey et al., 2000; Tsang et al., 2009, 2010; Tsang and Pearson, 2001; Zhang et al., 2017) vocational rehabilitation (Falkum et al., 2017; Kopelowicz et al., 2006) and virtual reality-based vocational training (Smith et al., 2015; Tsang and Man, 2013) as employment interventions. Other approaches, including cognitive intervention applying NET, cognitive rehabilitation therapy, cognitive remediation and compensatory cognitive training, emerged as interventions that were not limited to employment programmes exclusively, but were proved to be beneficial in employment as augmentation (Allott et al., 2013; Bell et al., 2008; Evensen et al., 2017; Lysaker et al., 2009; Twamley et al., 2017; Ullevoldsæter et al., 2016). One further study (Abi-Saab et al., 2005) using memory profiling was also placed under cognitive intervention as it validates vocational outcomes and neuropsychological functioning. After achieving consensus with both authors, the decision was made to classify the intervention found in the studies under five categories, these are: (a) supported employment; (b) ISE; (c) vocational rehabilitation; (d) cognitive intervention; and (e) virtual reality-based vocational training.

Supported employment (IPS)

In evidence-based supported employment (IPS), also known as the place-train approach, the primary goal is competitive employment to support recovery in mental illness by implementing eight principles of IPS (Corrigan and McCracken, 2005). Seven studies were identified under this category. Six of these (Areberg and Bejerholm, 2013; Bejerholm et al., 2015; Burns et al., 2007, 2009; Waghorn et al. 2014; Wong et al., 2008) evaluated the effectiveness of IPS either in vocational or non-vocational outcomes, while one study (Rogers et al., 2006) evaluated the choose-get-keep intervention which closely approximates the IPS approach.

IPS was reported to be effective compared to the control group vocational service in the study by Burns et al. (2007). The study included relatively successful findings of 55% (n = 85) of patients working for at least one day compared to vocational service, with 28% (n = 43) employment rates, the total number of patients included was 248. The control group was also found to be more likely to drop out from the service and be re-admitted to the hospital (drop-out 45% vs. 13%; re-admission 31% vs. 20%). The PEDro quality score in Burns et al. (2007) is rated as good quality (score 6/10). Another study by Bejerholm et al. (2015) included 77 participants and also found that IPS was more effective (46% vs. 11%) and participants gained employment five times more quickly than those with conventional vocational rehabilitation. The PEDro score for that study is rated as having fair quality (score 5/10). The study by Wong et al. (2008) included 64 participants and that by Waghorn et al. (2014) included 168 participants, and they also supported effective findings for IPS, with a greater likelihood of participants working competitively (70% vs. 29% control group) and with 2.4 times greater odds of commencing employment than the control condition (42.5% vs. 23.5%), respectively. Both studies scored as good quality in PEDro (both scored 7/10).

Quality of life as a non-vocational outcome in IPS was found to have a significant change along with occupational engagement (Areberg and Bejerholm, 2013). Included in the study were 77 participants and PEDro quality was scored as having good quality (score 7/10). Clinical and social functioning outcomes were not found to be associated with IPS (Burns et al., 2009); however, work and employment in general were found to be better, with participants having fewer symptoms and seen to have less social disability. The study included 251 participants, with the PEDro scored as fair quality (score 4/10). The choose-get-keep intervention involving 85 participants in Rogers et al. (2006) was also found not to be effective in any outcomes – vocationally or non-vocationally. This study scored as fair quality in PEDro (score 5/10).

Integrated supported employment

ISE is another evidence-based vocational rehabilitation intervention in which work-related social skills training (WSST) was integrated with IPS to enhance the vocational outcomes further (Tsang and Pearson, 2001). Six studies were identified (Au et al., 2015; Torrey et al., 2000; Tsang and Pearson, 2001; Tsang et al., 2009, 2010; Zhang et al., 2017) in the review designed to examine the effectiveness of ISE on a variety of aspects including both vocational (job tenure, job keeping) and non-vocational outcomes (psychological).

ISE had been studied widely by similar researchers especially in the China region where the approach originated, mostly providing positive and promising evidence throughout. Tsang and Pearson (2001) included 97 participants and found that participants in ISE, through the use of WSST, were more successful at finding and keeping a job; this was further supported by Tsang et al. (2009), who included 126 participants and in which ISE was found to give higher employment rates (78.8%) and longer job tenures (23.84 weeks) compared to IPS and conventional vocational rehabilitation. Quality scores are excellent (score 9/10) and good (score 8/10) for the studies.

A 3-year follow-up study of ISE conducted by Tsang et al. (2010) included 145 participants, evaluated the long-term effectiveness and found higher employment rates (82.8% vs. 61.5%) and longer job tenures (49.94 weeks vs. 36.17 weeks) in ISE compared to IPS participants, with fewer interpersonal conflicts at the workplace. The PEDro score is fair in quality (score 5/10) for this study.

Zhang et al. (2017) included 162 participants and found that ISE, compared with IPS alone and vocational rehabilitation, showed significantly higher employment rates and longer job tenures (employment rate 63.0% vs. 50.0% vs. 33.3%, respectively; job tenures 29.56 weeks vs. 25.47 weeks vs. 9.91 weeks, respectively). ISE was also found to improve non-vocational outcomes such as psychiatric symptoms, social functioning and wellbeing, which also suggests some implications for occupational therapy practice in psychosocial rehabilitation. The study was rated as having good quality in PEDro (score 7/10).

ISE was furthered attempted by Au et al. (2015), with 90 participants involved, by combining with other domains related to the employment of cognitive remediation. The findings showed no difference between ISE with cognitive remediation and ISE alone. That study scored good quality in PEDro (7/10). Another effort to examine self-esteem (Torrey et al., 2000) as the non-vocational outcome of ISE and employment as a general perspective, also found it was non-effective. Also, no supporting evidence was reported in self-esteem improvement due to work. The intervention characteristics/protocols in the study were also found to be limited. That study included 67 participants with fair quality in PEDro (score 4/10).

Vocational rehabilitation

Vocational rehabilitation involves the use of vocational assessment and pre-vocational training with a sheltered environment in various work settings and groups (Tsang et al., 2010). Two studies implemented the use of vocational training, which was seen as more conventional and was commonly referred to as the train-and-place approach (Falkum et al., 2017; Kopelowicz et al., 2006). A study by Kopelowicz et al. (2006) involving 120 participants, using work skills training as an intervention, implemented six 60-minute sessions in 2 weeks, which performed significantly better than occupational training and points to the cognitive demands of work tasks. Another study by Falkum et al. (2017) involving 489 participants used the job management program (JUMP), which was effective after 10 months of training. Both studies reported that the intervention was effective in reducing non-vocational outcomes which include general symptoms of psychosis in schizophrenia participants and improved in the vocational outcome of work skills. However, both studies scored fair quality in PEDro (scores 5 and 4).

Cognitive intervention

Cognitive training interventions were developed due to an increased understanding of relationships between cognition and work to improve cognition functioning and work outcomes (Twamley et al., 2017). Cognitive interventions were examined in relation to employment as a primary outcome, which is identified in seven studies (Abi-Saab et al., 2005; Allott et al., 2013; Bell et al., 2008; Evensen et al., 2017; Lysaker et al., 2009; Twamley et al., 2017; Ullevoldsæter et al., 2016). Three of the studies reported that cognitive augmentation had positive effects on vocational outcomes. The study by Lysaker et al. (2009) involving 97 participants examined the effects of CBT through the Indianapolis vocational intervention program, which was found to report a greater number of working weeks and hours as well as better performance than the support service. The study by Allott et al. (2013) involving 135 participants found that IPS alone may not be sufficient to sustain employment when neurocognition, not social cognition, predicts selective vocational outcomes. The study by Bell et al. (2008) involving 72 participants found that NET investigated in vocational service could enhance functional and vocational outcomes among schizophrenia clients, even though the use of a token economy was involved for the participants. All three studies scored good quality in PEDro (score 7/10 in two studies and 6/10 in one study).

Ullevoldsæter et al. (2016) included 131 participants and attempted to examine participants’ occupations in a 2-year follow-up study by combining cognitive remediation and CBT in vocational rehabilitation, and found a significant increase in the number of participants’ working hours for both groups. However, no difference was found between cognitive remediation and CBT. The findings were also supported by Evensen et al. (2017) involving 148 participants; even though cognitive remediation and CBT in vocational rehabilitation were found to be significant in improving non-vocational outcomes including global functioning, self-esteem and depression, there was no difference between the two interventions. The quality scores of both studies are good and fair (score 6/10 and 5/10). Twamley et al. (2017) included 58 participants, and through the use of compensatory cognitive training also found no difference in work attainment, weeks worked, or wages earned compared to the enhanced supported employment group. One study applied memory profiling involving 151 participants (Abi-Saab et al., 2005) in an attempt to examine the implications of memory profile in vocational and neurocognitive functioning. No improvement was reported for the intervention in both vocational and non-vocational outcomes. Both studies scored good and fair in PEDro quality (6/10 and 5/10).

Virtual reality-based vocational training

Virtual reality is commonly used as a pre-vocational skills training to provide a virtual work environment with the potential of repetitions of work skills training tasks (Hodges et al., 2001). Two studies were identified implementing the use of virtual reality-based interventions (Smith et al., 2015; Tsang and Man, 2013). Tsang and Man (2013) included 75 participants and used job interview training for 10 session over 5 weeks, while Smith et al. (2015) involved 32 participants and applied the same method for 10 hours within 5 to 10 working days. Both studies reported a positive effect on the intervention applied. Cognitive functioning as a non-vocational outcome was seen to be better in Tsang and Man (2013), and an improvement in job interview skills as a vocational outcome was found to be promising in Smith et al. (2015). Both studies scored good quality in PEDro (score 6/10 in both studies).

Discussion

The best choice of intervention approach for an individual’s needs often remains unclear among complex psychosocial interventions in which there will be a need to evaluate a different number of approaches tailored to different levels of disability (Boardman et al., 2003). Preferably, individuals should have access to a range of work, training and support relevant to their constantly changing needs. Implementing the best intervention approaches not only allows individuals to be actively employed, but also promotes a more holistic recovery from the illness. The process of recovery can be achieved by contributing factors including good relationships, financial security and satisfying work (Bonney and Stickley, 2008; Davidson, 2005; Jacob, 2018; Ramon et al., 2007). This also includes providing training for skills development and supports to assist in achieving goals and dealing with periods of crisis.

This systematic review examined the evidence of RCTs on the implementation of employment programmes based on a variety of intervention approaches for schizophrenia and other severe mental illness in general. Twenty-four RCT studies were included in this review. The studies represented five main types of employment programmes including IPS, ISE, vocational rehabilitation, cognitive intervention and virtual reality-based vocational training, which was assessed based on vocational and non-vocational-related outcomes on the effectiveness of each intervention.

The breakthrough of the ISE approach emerged primarily to augment the IPS and fulfils the deficits in social and interpersonal functioning. The principle of ISE was developed by incorporating the IPS (Drake and Becker, 1996) with WSST (Tsang and Pearson, 2001) by providing social skills training related to the workplace. ISE appears to be the most commonly, yet recently, reported among the other five types of interventions. Four out of six studies reported an effective result despite the research being conducted mostly by similar researchers. Findings from the studies support the use of social elements in employment interventions. Most of the ISE studies also agreed that vocational outcomes of ISE, especially on employment rates, job tenures and hours/days/weeks of working, were effective, but the non-vocational outcomes, including psychological outcomes and self-esteem, produced mixed result.

The term IPS model developed by Drake and Becker (1996) has often been referred to simultaneously with supported employment and the place-and-train approach in much clinical research. Five studies utilising IPS reported compelling findings of the effectiveness in competitive employment rates as well as significant change in quality of life and occupational engagement. Two studies did not find significant differences in any outcomes – neither clinically nor in social functioning (Burns et al., 2009; Rogers et al., 2006). Despite the superiority of IPS over other interventions, not all individuals benefitted from IPS, when job tenure is often brief, averaging between 3 and 5 months (Drake et al., 1999; Mueser et al., 2004; Wong et al., 2004). Cook et al. (2008) also supported some researchers’ suggestions that individuals with schizophrenia may benefit less from IPS than those with other forms of severe illness (bipolar disorder and major depression), and were significantly less likely to be competitively employed. Evidently, IPS alone as a discrete intervention appears difficult to establish and is usually favoured by studies conducted in the United States, whereas health professionals urge the development of culturally relevant supplementary interventions and adaptations required to meet broader needs internationally (Bond et al., 2012; Boycott et al., 2012). A review by Arbesman and Logsdon (2011) also suggested that social skills or cognitive skills training combined in an IPS model appear to be more prominent by increasing productive occupations. The review also suggested that a combination of structured, manual-based skills development programmes in social and daily living skills training produced better living skills outcomes. Although IPS alone is effective, job sustainability was reported to be less prolonged.

The vocational rehabilitation of the two studies included in the review reported positive results and significantly better performance as well as a decrease in the positive and general symptoms of psychosis (Falkum et al., 2017; Kopelowicz et al., 2006). However, the combination of CBT and cognitive remediation in vocational rehabilitation in the study showed no significant differences. Despite the limited clinical evidence, vocational rehabilitation continued to be applied in practice to a large extent (Frøyland, 2006).

Additional research was conducted to examine the effects of cognitive domains in employment programmes: three studies reported in favour of cognitive remediation and CBT. The included studies produced mixed and inconclusive results. Lysaker et al. (2009) found significant vocational outcomes through CBT; Allott et al. (2013) suggest that IPS alone is not sufficient to sustain employment when neurocognition predicts the outcomes. Bell et al. (2008) concluded that NET could improve functional and vocational outcomes, but the participants are arguably paid minimum wages for their time on cognitive training. Combining cognitive remediation and CBT in vocational rehabilitation was found to improve vocational outcomes in global functioning, self-esteem and depression, but no difference was found between them (Evensen et al., 2017; Ullevoldsæter et al., 2016). It has been suggested, however, that cognitive functioning is related to employment outcomes in persons with severe mental illness, retrospectively, concurrently and prospectively (McGurk et al., 2005).

While IPS remains the most extensively studied model over the years, virtual reality-based interventions, especially in job interviewing skills, and other isolated approaches were also being examined. The results of two studies on virtual reality-based interventions (Smith et al., 2015; Tsang and Man, 2013) demonstrate that they are efficacious and remain promising.

From the review findings, ISE was found to be the most effective intervention providing strong evidence compared with the other interventions reported in this review. This evidence was based on the vocational outcomes of duration that reflected the long-term outcomes rather than immediate effects such as employment rates and job tenures, which can be observed as early as in 24-hour successful rates. The studies also present well-conducted RCTs, with blind assessors, a good length of follow-up and good to fair fidelity (Boycott, et al. 2012), which also translated into strong evidence based on the PEDro scale in which the ISE majority scored 8 and above. ISE studies typically ranged from 3 months of intervention and 15 to 36 months of follow-ups in which training was longer compared to IPS which ranged from 2 months with 18–24-month follow-ups. Longer training with shorter follow-ups allows confidence and better preparation for people with SMI.

Findings from this review suggested that clinicians, especially occupational therapists, should consider applying ISE as an intervention in practice. ISE has a suitable and realistic duration of implementation with outcomes on vocational, including employment rates, job tenures and hours of working compared to other approaches, and non-vocational including self-esteem and psychological outcomes. ISE addresses the clients’ holistically, which supports occupational therapy practice related to employment; emphasising the clients’ physical, cognitive, social, behavioural and emotional capacity. Longer job tenures of 46.94 versus 36.17 weeks and a higher employment rate of 82.8% versus 61.5% were seen in ISE compared to IPS (Tsang et al., 2010). This was also supported by other researchers (Becker et al., 1998; Chan et al., 2009; Mak et al., 2006), indicating that problems with job retention were usually associated with social functioning in which interpersonal difficulty is the most frequently reported job problem. Job tenure and job retention are the most effective indicators of outcomes in employment programmes. This is due to the ability to sustain the current job, composed of other general elements including symptoms reduction, interpersonal and social skills, employment rates and psychological outcomes. Positive associations were seen between employment, job tenure and job retention on interventions. Therefore, occupational therapists in psychosocial rehabilitation should continue to emphasise and focus on the clients’ capacities, interests and motivations, which is known as the core skills of occupational therapy.

Limitations

Bias assessment and meta-analysis were not conducted.

Conclusion

This systematic review examined the evidence of employment programmes available for schizophrenia or other severe mental illness in vocational and non-vocational outcomes. ISE alone (without combining with other approaches) was shown to have the best clinical evidence in this review for both vocational and non-vocational outcomes. ISE remains the strongest evidence in practice that is responsible for revolutionising vocational rehabilitation throughout. Even though ISE was proved to be the best evidence, other interventions also have their own strengths in helping different individuals at different times in their recovery and reintegration. More research is needed to fill the gaps in the literature in establishing professional roles, efficacy of approach, effectiveness of interventions and outcomes, especially for non-vocational outcomes.

Key messages

Integrated supported employment was found to be the most effective intervention for schizophrenia or other severe mental illness.

Clinicians should consider the needs and preferences of clients before selecting an intervention programme.

Footnotes

Acknowledgements

This study is part of the first author’s master’s in occupational therapy study at Universiti Kebangsaan Malaysia.

This study was registered with PROSPERO (CRD42019122130).

Research ethics

No ethics approval was needed for this review as no human participants were involved.

Consent

This systematic review did not involve any contact with humans, as such no consent was obtained.

Declaration of conflicting interests

None of the authors have any conflicts of interest in relation to this work.

Funding

No financial support was received for this review.

Contributorship

MZRZA and FWY conceptualised, designed, developed the search strategy, undertook database searches, screened for eligibility and conducted the methodological assessment of all included studies. All authors drafted the manuscript, critically reviewed the manuscript and approved the final version for publication.

ORCID iDs

Farahiyah Wan Yunus

Masne Kadar

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