Employment outcomes and their predictors among people with severe mental illness participating in an individual placement and support programme

Abstract

Background

The impact of client and programme-related variables on employment outcomes among participants of Individual Placement and Support programmes has been sub-optimally researched. We evaluated the effectiveness of an Individual Placement and Support programme and examined selected demographic, clinical, and programme-related variables associated with obtaining competitive employment.

Methods

Data were collected retrospectively from consecutive participants with severe mental illness enrolled in an Individual Placement and Support programme co-located as a partnership between a disability employment service provider and a public mental health service in Western Australia. Demographic, clinical, and service engagement characteristics of the groups that obtained and did not obtain competitive employment were collated, compared, and analysed to predict successful employment outcomes.

Results

Of the 84 participants, 36 (42.9%) secured competitive employment. The absence of psychiatric comorbidity (p = .037) and especially, shorter time between the programme commencement and first face-to-face contact (p < .001) were strongly associated with positive employment outcome.

Conclusion

Modifiable participant and programme-related characteristics can significantly impact the outcome of Individual Placement and Support services for people with severe mental illness implemented at everyday clinical settings. Managing these within clinical services and Individual Placement and Support programmes has potential to improve participant outcomes.

Keywords

individual Placement and Support supported employment: competitive employment outcome predictors of employment outcome IPS

While work is identified as an important personal goal by individuals living with severe mental illnesses (SMI) such as schizophrenia, bipolar affective disorder, and moderate to severe major depression, anxiety disorders, and personality disorders, employment rates among these people remain unacceptably low worldwide.^1,2 According to the Australian Bureau of Statistics, only 26% of people with psychosocial disabilities, particularly those with severe or complex mental health conditions, are employed, compared to 57% of people with other disabilities and 80% of those without disabilities (www.abs.gov.au/articles/psychosocialdisability#employment).

The Individual Placement and Support (IPS) model is the most widely researched form of supported employment designed to help individuals with SMI achieve competitive employment. IPS follows a ‘place-then-train’ approach grounded on eight core principles, supported by a validated fidelity scale.³ These principles include a focus on competitive employment as the goal, zero exclusion based on diagnosis or symptoms, attention to consumer preferences, integration of vocational services with mental health treatment, benefits counselling, job development based on individual interests, rapid job search, and ongoing support following job placement.³ Reviews of randomised controlled trials (RCTs) have provided robust evidence that IPS is significantly more effective than traditional vocational rehabilitation or treatment-as-usual approaches for people with SMI to obtain competitive employment.^4–6 However, the majority of these RCTs have been conducted in the United States, with relatively few studies from other geographical regions.⁷ While the efficacy of IPS has been well-established through controlled trials, pragmatic studies evaluating the effectiveness of IPS in routine clinical practice have been less common and more methodologically challenging.⁸ This is particularly true in Asia and Oceania, where research on real-world IPS implementation is limited, and both efficacy and effectiveness trials are sparse,^9–14 warranting further investigation.

Furthermore, IPS-related research has revealed that a substantial proportion of the participants with SMI across various geographical regions are not able to obtain competitive employment during their involvement with IPS.^4–7 Several factors, such as differences in demographic and clinical characteristics of the participants, IPS programme elements, skills of the employment consultants, economic and job market conditions, and regulatory frameworks, can influence employment outcomes.^15,16 A greater understanding of these factors and addressing any modifiable risk factors could enhance the outcomes of IPS programmes. However, there is a lack of comprehensive research, particularly from the Oceania and Asian regions, examining the demographic, clinical, and programme-related variables that influence employment outcomes of IPS programmes. We evaluated the employment outcomes of an IPS programme implemented in partnership between an adult community mental health service in Australia and a disability employment service provider. We examined the demographic, clinical, and service-related factors associated with successful employment outcomes among participants with severe mental illness.

Methods

Study location

This study was conducted at Bentley Health Service, Bentley, Western Australia which serves approximately a population of 300,000 people. The health service provides a comprehensive range of mental health services, including youth, adult, and older adult inpatient and community mental health services. The adult community mental health service provided clinical services to approximately 600 patients with SMI between the ages of 18 and 65 who resided in the community.

Description of the IPS programme

The health service commenced a co-located IPS programme in partnership with a disability employment service provider, Advanced Personnel Management (APM), in November 2017. The IPS team consisted of two employment consultants and a supervisor. The employment consultants and supervisor collaborated closely with the multidisciplinary clinicians of the health service, and referrals were encouraged through ongoing liaison with the clinicians. The IPS programme was implemented adhering to its eight core principles, and a fidelity review of the programme conducted in January 2022 achieved an exemplary rating. Employment consultants maintained detailed records of all referrals, including referral outcomes, services provided, employment outcomes, and duration of service involvement.

Study period and participants

This study period spanned from the commencement of the IPS programme on 30 November 2017 to 31 December 2021. The study sample comprised consecutive participants enrolled in the IPS programme during this period.

Exclusion criteria:

• Those who were not receiving social security benefit payments or National Disability Scheme Funding from the Commonwealth government.

• Those aged under 18 or over 67 years.

• Those who were assessed by Services Australia not to have capacity to work at least 8 hours per week with support.

• Those who were in in full time study or were already engaged in work at their assessed capacity.

However, no referred patients were excluded from participation in the IPS programme based on their diagnosis or symptoms.

Data collection

Data for this study were collected between February and April 2024 by a senior psychiatry trainee doctor under the supervision of a senior psychiatrist, ensuring clinical oversight. Information was sourced from the participants’ health service medical records and APM’s IPS service database. The following data was extracted from the IPS dataset maintained by APM: date of referral, date of acceptance, date of commencement of IPS, duration from commencement of IPS to first employer face-to-face contact, length of engagement in the IPS, number and nature of competitive employment positions obtained, wages earned, and the assigned funding levels from the Australian government. Funding was allocated to APM per registered participant, and levels ranged from one to five and were based on factors such as demographic characteristics, duration of unemployment, labour market conditions, identified barriers to employment, disability indicators, and functional capacity. Level 1 indicated the highest likelihood of employment and the lowest support allocation, while Level 5 indicated the lowest likelihood of gaining employment without interventions and was associated with the highest level of funding. Additional outcome-based payments were allocated to APM once participants started a job and remained employed for specific periods. These varied according to employment type, hours worked and duration of employment.

Demographic and clinical characteristics of the patients such as age, gender, accommodation, ICD-10 diagnosis, comorbidities, substance abuse, age of onset of mental illness, age at first hospitalisation, number of psychiatric hospitalisations, and participation in psychosocial interventions such as clinical psychology, occupational therapy, social work, National Disability Insurance Scheme, or intensive case management were extracted from their medical records. In addition, data on the Kessler Psychological Distress Scale (K10),¹⁷ Health of the Nation Outcome Scales (HoNOS),¹⁸ and Life Skills Profile-16 (LSP-16)¹⁹ were extracted from the electronic records. The demographic and clinical data were collected with reference to the time of the participant’s referral to the IPS programme.

The ICD-10 (International Classification of Diseases) was used for psychiatric diagnosis. Psychiatric comorbid conditions were categorised as either present or absent, except for substance use disorders. Substance use disorders were documented separately for lifetime use and current use (within the past 6 months). Medical comorbidities were identified through a detailed review of medical records, including psychiatrist notes, documentation of liaison with general practitioners or specialists, and prescribed medications.

Ethics permission and consent

The study was approved by the Royal Perth Hospital Human Research Ethics Committee and relevant Governance Committees (Project Reference Number RGS0000005270). The ethics committee provided a waiver of the need to obtain consent from individual participants.

Statistics

All statistical analyses were conducted using Jamovi open-source software (version 2.4.11). Descriptive statistics were employed to summarise the variables associated with the IPS programme, providing a clear overview of the data characteristics. A chi-square test was performed to assess the distribution of demographic and clinical variables across the various study groups. The mean score differences between groups were examined using the independent samples t test, while a non-parametric alternative, specifically the Mann–Whitney U test, was applied when the assumption of normality was violated. Furthermore, binary logistic regression analysis was employed to evaluate how well specific and clinically relevant variables predicted a positive outcome of the Individual Placement and Support (IPS) programme. An alpha level was set at 0.05 for the significance tests.

Results

Description of the sample

A total of 84 patients were accepted and enrolled in the IPS programme during the study period. The mean age of participants was 34.4 years (SD = 11.0), with an equal distribution of males and females (Table 1). Schizophrenia was the most common diagnosis (44%), and when combined with schizoaffective disorder and unspecified nonorganic psychosis, accounted for 62% of all diagnoses. Approximately, one-quarter of the sample had mood disorders. Psychiatric comorbidities were present in 62% of participants, and medical comorbidities were documented in 45%. Substance use was prevalent, with 73% reporting lifetime substance use and 43% reporting current use. The mean number of prior inpatient psychiatric admissions was 3.8 (SD = 3.9), and the mean duration of illness was 8.3 years, all indicating a population with chronic SMI. Overall, the participants exhibited mild to moderate levels of current psychological distress and functional impairment as reflected in the mean K 10 score of 23.0 (SD = 8.7), HoNOS score of 7.9 (SD = 5.0), and LSP-16 score of 9.8 (SD = 5.5).

Table 1.

Demographic and clinical characteristics of patients who participated in the IPS programme.

Variable	Descriptive statistics
Age (years) – M (SD)	34.4 (11.0)
Gender – n (%)
Male	42 (50.0)
Female	42 (50.0)
Living situation – n (%)
Independent living	49 (58.3)
Semi-independent living	27 (32.1)
Dependent/group home	8 (9.5)
ICD-10 diagnoses – n (%)
Schizophrenia	37 (44.0)
Schizoaffective disorder	11 (13.0)
Unspecified nonorganic psychosis	4 (4.8)
Major depression	7 (8.3)
Bipolar affective disorder	13 (15.5)
Personality disorders	6 (7.1)
Other disorders	6 (7.1)
Psychiatric comorbidities present – n (%)	52 (61.9)
Medical comorbidities present – n (%)	38 (45.2)
Participating in psychosocial interventions other than routine management – n (%)	57 (67.9)
Age at onset – M (SD)	25.4 (9.9)
Duration of illness (years) – M (SD)	8.3 (7.8)
Age at 1^st admission – M (SD)	27.7 (9.9)
No of lifetime psychiatric admissions – M (SD)	3.8 (3.9)
Inpatient psychiatric admission (days) – M (SD)	89 (162)
Presence of current substance abuse – n (%)	36 (42.9)
Cannabis abuse	23 (27.4)
Alcohol abuse	23 (27.4)
stimulants abuse	9 (10.7)
Opioids abuse	1 (1.2)
Benzodiazepine abuse	1 (1.2)
Lifetime substance abuse – n (%)	61 (72.6)

Comparison of clinical and demographic characteristics of patients who obtained and did not obtain competitive employment

Of the 84 patients who participated in the IPS programme, 36 (42.9%) secured competitive employment. Among those employed, the majority (83%) obtained positions in semi-skilled roles (43%), such as apprentice hairdresser, retail assistant, receptionist, barista, and security staff, or unskilled roles (40%), including cleaner and labourer positions. A smaller proportion (17%) was employed in skilled roles such as a welder or account manager. On average, employed participants worked 15.2 hours per week (SD = 8.3), with a mean hourly wage of $24.30. A comparison of clinical and demographic characteristics between the two groups is presented in Table 2. Participants who secured competitive employment were significantly younger, by an average of approximately 5 years, compared to those who did not (p = .044). While 50% of those who acquired competitive employment had a psychiatric comorbidity, this was 20% less than the group who did not (70.8%), with the difference narrowly failing to reach statistical significance (p = .052).

Table 2.

Clinical and demographic characteristics of patients who obtained and did not obtain competitive employment (CE).

Variable	Did not obtain CE n = 48	Obtained CE n = 36	Test	p-value
Age – M (SD)	36.5 (11.7)	31.6 (9.5)	2.04^a	0.044
Gender – n (%)
Male	24 (50.0)	18 (50.0)	0.00^b	1.000
Female	24 (50.0)	18 (50.0)	0.00^b	1.000
Living situation
Independent living	31 (64.6)	18 (50.0)	1.81^b	0.405
Semi-independent living	13 (27.1)	14 (38.9)
Dependent/group home	4 (8.3)	4 (11.1)
ICD-10 diagnoses – n (%)
Schizophrenia spectrum	30 (62.5)	22 (61.1)	0.02^a	0.897
Other disorders	18 (37.5)	14 (38.9)	0.02^a	0.897
Psychiatric comorbidities	34 (70.8)	18 (50.0)	3.79^b	0.052
Medical comorbidities	24 (50.0)	14 (38.9)	1.02^b	0.311
Psychosocial interventions (other than case management) provided	34 (70.8)	23 (63.9)	0.46^b	0.500
Age at onset – M (SD)	26.9 (11.4)	23.5 (7.2)	751.0^c	0.384
Duration of illness (years) – M (SD)	8.6 (8.0)	7.9 (7.7)	818.0^c	0.800
Age at 1^st admission – M (SD)	29.3 11.3)	25.3 (7.1)	395.0^c	0.177
Lifetime psychiatric admissions – M (SD)	3.7 (3.7)	3.9 (4.3)	449.0^c	0.533
Inpatient psychiatric admission (d) – M (SD)	83 (102)	96 (220)	758.0^c	0.337
Past 6 months of substance use	18 (37.5)	18 (50.0)	1.31^b	0.252
Current Tetrahydrocannabinol use	11 (22.9)	12 (33.3)	4.56^b	0.102
Current alcohol use	13 (27.1)	10 (27.8)	0.09^b	0.956
Current stimulants use	3 (6.3)	6 (16.7)	4.51^b	0.105
Current opioids use	1 (2.1)	0 (−)	0.76^b	0.683
Current benzodiazepine use	1 (2.1)	0 (−)	0.84^b	0.657
Past substance use (lifetime)	34 (70.8)	27 (75.0)	0.18^b	0.672
HoNOS – M (SD)	8.60 (5.3)	7.03 (4.4)	2.56^b	0.920
Kesler-10 - M (SD)	23.1 (8.1)	22.8 (9.5)	0.17^b	0.920
LSP-16 - M (SD)	10.2 (5.8)	9.3 (5.1)	0.36^b	0.835

^aChi-square test.

^bIndependent samples t test.

^cMann–Whitney U test.

No significant differences were observed between the groups with respect to primary psychiatric diagnosis (schizophrenia spectrum vs other disorders), presence of medical comorbidities, substance use history, duration of illness, age at onset, or psychiatric hospitalisation. Likewise, no differences were found in their engagement with psychosocial intervention and measures of symptom severity, distress, and functional ability assessed using the HoNOS, LSP-16, and K10.

Comparison of the IPS service characteristics between the two groups

The IPS service-related characteristics of the patients who obtained competitive employment and others are presented in Table 3. Patients who secured competitive employment took four times less time from the commencement of the IPS programme to their first employer face-to-face contact (p < .001). However, the two groups had no significant difference in funding levels (p = .677) or other service level parameters examined. No statistically significant differences were observed in employment outcomes achieved among the four employment specialists who worked with the programme during the study period, with placement rates of 54.5%, 52.2%, 50.0%, and 33.2%.

Table 3.

IPS service characteristics: Comparison between patients who obtained and did not obtain competitive employment (CE).

Variable	Did not obtain CE n = 48	Obtained CE n = 36	Test^a	p-value
Funding level	4.0 (2–5)	3.5 (1–5)	580.0	0.677
Time duration (days) – Median (IQR)
Referral -> acceptance	21 (0–123)	27 (0–126)	751.5	0.730
Referral -> start of IPS	70 (39–119)	48 (35–78)	655.5	0.108
Acceptance -> the start of the IPS	22 (8–75)	17 (0–34)	278.0	0.125
Start of IPS -> first face-to-face employer contact	90 (50–127)	22 (2–46)	139.0	<0.001
Duration of IPS involvement (years)	1.9 (1.1–3.0)	2.4 (1.5–3.2)	617.0	0.049

^aMann–Whitney U test.

Evaluation of prediction factors

A binary logistic regression model was used to predict a ‘good outcome’ of the IPS programme, with competitive employment as the outcome (1 = positive and 0 = negative) as the dependent variable and three independent and clinically relevant variables (age at referral, time from commencement to first employer face-to-face contact, and psychiatric comorbidity). The model was statistically significant (X² = 25.88, p < .001), explaining about 50% of the variance in good outcomes (R²_N = 0.501). Among the predictors, two variables showed a statistically significant predictive power: a shorter time between commencement and employer face-to-face contact was strongly associated with positive outcomes (OR = 0.97, p < .001). Similarly, the absence of any psychiatric comorbidity also had a statistically significant predictive value (OR = 6.2, p = .037). The model demonstrated a 77% overall prediction accuracy and an area under the curve (AUC) of 0.86, indicating solid diagnostic properties and discrimination.

Discussion

Success of the IPS programme in achieving CE

While efficacy studies of IPS from the USA among people with SMI have reported successful competitive employment outcomes among 65% of participants, studies from Europe, Asia, and Oceania have generally reported lower positive figures.⁷ Similarly, a review of the few studies on supported employment programmes implemented in routine clinical settings has reported lower success rates similar to ours.⁸ The success rate of 42.9% of IPS participants with SMI obtaining competitive employment in this study is in the middle range of research on the efficacy and effectiveness of IPS among people with SMI from other Australian settings, which have revealed successful outcomes ranging from 12% to 71.2%.^9–12 Comparable or higher success rates of 44.4% and 53.6% have been reported from Japan and Hong Kong.^13,14 The IPS programme received an exemplary fidelity rating in our study, consistent with many other studies in this area. Thus, variations in programme fidelity alone are unlikely to explain the differences in success rates across studies. Other contextual factors, such as national labour market conditions, disability policies, employment regulations, and client-related clinical and demographic factors, are known to influence IPS outcomes.^15,16

Determinants of successful employment outcomes

Despite the well-established effectiveness of IPS, relatively few studies have systematically examined the demographic, clinical, and programme-level predictors of competitive employment outcomes. Our study explored the association of several such variables with employment outcomes. The absence of psychiatric comorbidity and shorter time from programme commencement to first employer face-to-face contact emerged as significant predictors of obtaining competitive employment on logistic regression analysis. Younger age, while significant in univariate analysis, did not emerge as a significant variable in logistic regression. The role of age in obtaining competitive employment with IPS has generated inconsistent results, with some studies reporting that younger patients are more likely to obtain employment. In contrast, others have found no relationship between age or reported that older people are able to sustain obtained employment.^15,16,20

Programme engagement emerged as a robust predictor of successful employment outcomes. Participants in IPS who believed they were ready to look for work, were active in seeking work, showed interest and motivation in their employment searches, and demonstrated self-responsibility, self-efficacy, and reciprocity were more likely to find and maintain jobs.^21,22 Early face-to-face contact with employers could reflect these traits and the importance of rapid job search is a core principle of the IPS for successful outcomes. Furthermore, it is possible that comorbid psychiatric conditions such as anxiety and depression could increase the severity of symptoms and worsen motivation, self-efficacy, and drive to obtain competitive employment. Our findings highlight the importance of clinicians actively identifying and managing comorbid psychiatric conditions to ensure favourable employment outcomes.

We did not find differences between genders in obtaining competitive employment. Some researchers from Hong Kong have reported that male clients were more likely to find employment because of the physical nature of the work available in the market.²³ Cultural and labour market dynamics may influence gender disparities in employment outcomes. We did not find a significant difference in competitive employment outcomes among those with the diagnosis of schizophrenia spectrum disorders or other diagnoses. However, several authors have observed that IPS showed more favourable outcomes in studies targeting participants with SMI, such as schizophrenia and bipolar disorder, than common mental disorders, such as depression and anxiety.^15,24 Interestingly, we found no significant difference in past or recent substance use between those who obtained competitive employment and others. While some researchers have not found a negative impact on IPS outcomes with substance abuse, others support the effectiveness of IPS among those with fewer comorbid substance use problems.^25,26 There is increasing interest in the role of employment consultant characteristics in influencing IPS outcomes, with research suggesting that consultants with strong interpersonal, time management, and job development skills are more effective in obtaining competitive employment for their clients.^27–29 While no significant differences in outcomes were observed across the employment consultants in our study, the small sample size could have limited the ability to detect such effects.

Our multivariate logistic regression model, including three clinically relevant predictors: age at referral, time from commencement to first employer face-to-face contact, and presence of psychiatric comorbidity, together explained approximately 50% of the variance in competitive employment outcomes. This is consistent with the findings of Corbière et al.,²⁷ who identified predictors such as younger age, shorter unemployment, active job search strategies, and strong alliances, which accounted for 51% of the variance in successful outcomes. However, such modelling studies are relatively rare, and further research using larger, multicentre samples is needed to validate and expand on these findings.

Strengths and limitations

Studies examining a comprehensive set of demographics, clinical, and IPS programme-related variables predicting employment outcomes remain limited. In this study, data were collected by experienced psychiatrists, and the availability of well-maintained clinical and service records enabled the inclusion of multiple variables across a consecutive sample of individuals with SMI who were accepted into the IPS programme. Participants were drawn from a public community mental health service with a large catchment area, which enhances the generalisability of findings to similar clinical settings. However, this study was retrospective and involved collecting documented data from participant’s medical records and IPS databases. While we found the quality of documentation to be good, the accuracy of the data could not be cross-checked through direct patient interviews. While documentation and information extraction bias cannot be excluded, the data was collected after a comprehensive review of records. Furthermore, the sample size was modest and restricted to individuals with SMI, limiting the applicability of findings to other populations or service contexts. Additionally, this was an effectiveness study conducted in a real-world clinical setting rather than a randomised controlled efficacy trial. However, demonstrating that IPS is effective under everyday clinical conditions and ascertaining the predictors of response is important in supporting its broader implementation and sustainability.^15,16,30 This study focused specifically on competitive employment outcomes and did not assess other potential benefits of IPS participation, such as improvements in quality of life, symptomatology, or job retention.

Conclusions

Potentially modifiable demographic, clinical, and programme-related parameters can provide valuable insights into the successful outcomes of IPS programmes. The significant number of participants who do not obtain competitive employment through their participation in IPS points towards the need for prospective research involving larger, more diverse samples of people with mental illness across multiple sites and geographical locations to understand the factors associated with successful IPS outcomes.

Footnotes

Acknowledgement

we acknowledge the contributions of Samantha Cooper who worked as Employment Consultant and Manager of the IPS Programme at Bentley Health Service.

Disclosure

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical consideration

The study was approved by the Royal Perth Hospital Human Research Ethics Committee and relevant Governance Committees (Project Reference Number RGS0000005270).

Consent to participate

The HREC granted a waiver of consent, allowing the use of de-identified participant data without requiring individual consent.

ORCID iDs

Milan Dragovic

Alexander Panickacheril John

Data Availability Statement

Data related to the study is available on reasonable request to the corresponding author once permission is obtained from the ethics committee.*

Institution where the work was conducted: Bentley Health Service, Bentley, Western Australia, Australia.

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