Poor physical health: A major barrier to employment among individuals with serious mental illness

1 Introduction

The benefits of employment participation among individuals with serious mental illnesses (SMI) are well documented. Employment success is correlated with increases of financial resources, self-esteem, housing stability, quality of life, and decreases in symptom distress, substance abuse, mental health service utilization and crises (Akihito et al., 2015; Bunnings et al., 2015; Burt, 2012; Dunstan et al., 2017; Kukla et al., 2012;). On the other hand, unemployment, especially long-term unemployment, can undermine access to basic needs and health care that directly jeopardize the wellbeing of these individuals. Studies have found those who experienced prolonged unemployment reported increased levels of stress about financial resources, dependence upon public assistance, lack of access to needed health care, poorer physical health, higher occurrence of sleep loss or disturbance, greater risk of cardiovascular diseases, loss of a sense of belonging and positive self-identity, and increased levels of isolation, anxiety and depression (Gonzalez et al., 2018; Hiswals et al., 2017; Julia et al., 2017; Naslund et al., 2017, Romain et al., 2017; Premji, 2017; Sumner & Gallagher, 2017; Zandara et al., 2016).

Over the past three decades, interventions such as the Individual Placement and Support (IPS) model of Supported Employment have improved employment outcomes among many individuals with SMI (Bond et al., 2008; Drake et al., 2016). However, increasing employment participation among individuals with SMI remains challenging. In 2016, results of a national survey estimated 10.4 million adults in the United States were diagnosed with SMI (Ahrnsbrak et al., 2017; SAMHSA, 2017), representing 4.2% of the total adult population. The overall rate of employment participation among this group remains extremely low, between 10% and 20% (Bertram & Howard, 2006; National Alliance on Mental Illness, 2014; Salkever et al., 2007). At least three million working-aged adults with SMI depend on Social Security benefits - 40% of all Social Security Supplemental Security Income (SSI) recipients and 28% of all Social Security Disability Insurance (SSDI) recipients. This disability group has been rapidly growing and is now the largest subgroup of disabled adults (Colpe et al., 2010; Drake et al., 2009; Mojtabai, 2011).

Individuals with SMI face many barriers to employment success, including lack of education and job training, gaps in employment, stigma of mental illness, and lack of support. Milfort et al. (2015) identified three barriers to employment among SSDI recipients with mental disorders and more than half reported poorly controlled mental illness symptoms as the biggest barrier (55%), followed by nonengagement in supported employment (44%) and poorly controlled general health issues (33%). One barrier to employment participation among this population that has not been well reported and studied is poor physical health, despite the increasing evidence that individuals with SMI are also more likely to experience physical health related diseases when compared to the general population (Brunero & Lamont, 2010; Shuel et al., 2010). Several studies have indicated an association between SMI and several adverse health outcomes, such as type 2 diabetes, metabolic syndrome, cancer, dementia, anxiety, and premature mortality (Romain et al., 2017). Taking into consideration only obesity, for example, individuals with SMI have a prevalence nearly double that of the general population (Naslund et al., 2017, Nishi et al., 2017). The high risk of poor physical health among individuals with SMI is clear and dire, particularly when taking into account that the life expectancy of individuals with SMI may be reduced by up to 25 years (Parks et al., 2006; Shuel et.al, 2010). Some studies have suggested that employment may be a key component of improving and maintaining mental health and physical health (Bunnings et al., 2017; Schmitz, 2011). However, limited data of poor physical health as a barrier to employment engagement are available. This paper provides some detailed information for drawing attention to the issue.

2 Method

3 Results

3.1 Physical and mental health issues as a barrier to job-related activities

In each of the 10 monthly follow-ups, 10.7% to 26.1% of the participants reported their long-term physical health problems as a barrier to job-related activities, and 2.1% to 9.3% reported a short-term physical health issue as a barrier. Regarding mental health issues, 0% to 1.5% reported long-term illness as a barrier, and 3.5% to 11.6% reported a short-term illness as a barrier. Figure 1 provides detailed information.

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Fig. 1

Physical Health Condition as a Barrier to Job-related Activities.

Chi-square tests were performed, 10 for long-term physical health conditions and 10 for short-term physical health conditions. Before performing chi-square tests, tables were examined to determine whether any expected value in each cell was less than five. For the tests with expected cells less than five, Fisher’s Exact test was performed instead. The chi-square test results of 4th, 8th, 10th, and 11th month rejected the independence model between the two dichotomous variables, indicating that participants who identified long-term physical health conditions as a barrier were significantly less likely to have done job-related activities in these four months. Meanwhile, the participants who identified short-term physical health issues as a barrier were significantly less likely to have done job-related activities in the 4th month only. These results are presented in Table 2. Continuity was corrected with Yates’s correction, to reduce an error in approximation of Pearson’s chi-square statics to the continuous chi-square distribution when the table indicates discrete probability of binomial frequencies. The p-value of the 10th month result of long-term physical health condition was slightly over 0.05 when using Yates’s correction Participants’ perceptions of whether their mental health conditions was a barrier to employment were all independent of their job-related activities, suggesting no relationship between the perception of mental health conditions as a barrier and the extent of job-related activities.

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Table 2

Relationship of physical health conditions as a barrier and job-related activities

	Long-terma				Short-termb
	4th	8th	10th	11th	4th
χ2(1)	7.28**	6.51*	4.69*	12.43**
Continuity Adjusted χ2	5.94*	5.32*	3.75+	10.81**
Fisher’s Exact Test					(p < 0.01)
n	139	128	128	123	139

Note.⁺p < 0.10, ^*p < 0.05, ^**p < 0.001. Long-term^a indicates chi-square test results between job-related activities and long-term/chronic physical health conditions as a barrier. Short-term^b indicates Fisher’s Exact test result of short-term physical health conditions.

The study participants consistently reported greater role limitations due to their physical health problems than mental health issues over the 12-month study period despite after employment intervention was integrated into the Supported Housing program. Of physical health problems, long-term conditions including diabetes, chronic pain, and obesity were reported more frequently than short-term physical health problems such as having a cold, or injures from accidents. Furthermore, participants perceived that physical health conditions negatively affected their job-related activities such as job searching, submitting applications, and interviewing. More seriously, their perceptions of long-term physical health conditions as barriers were actually significantly associated with fewer job-related activities.

Unaddressed long-term physical health problems among people with SMI unquestionably contribute to the overall higher rate of physical health related diseases and premature mortality as compared to the general population (Brunero & Lamont, 2009; Romain et al., 2017; Shuel et al., 2010). Furthermore, physical health problems severely diminish their opportunities for engaging in employment activities in which they have the potential of gaining resources for and access to quality health care. The lack of employment participation also deprives these individuals of the benefits from being employed including increased financial resources, self-worth, community integration, and quality of life.

The study findings also provide more evidences for the urgent needs for integrated mental health and physical health care for the population with SMI, especially for long-term, chronic conditions. There have been some studies in recent years showed promising outcomes when integrated care was provided (Mangurian et al., 2017; Mcginty et al., 2018). On the other hand, there is still serious disparity in healthcare provision between those with SMI and the general population. Studies found unequal quality of healthcare provision contributed to excess mortality. People with SMI are less likely to receive cancer screening during routine medical checkups (Carney & Jones, 2006; Lawrence & Kisely, 2010; Xiong et al., 2008). Individuals with schizophrenia have lower rates of surgical interventions such as stenting and bypass grafting for cardiovascular diseases (Druss et al., 2001; Laursen et al., 2008). Other studies found long-term health problems are very common in people with SMI, but are usually under-recognized and under-treated (Dixon et al., 1999; McIntyre et al., 2007). Considering that when physical health problems are unaddressed, other services including employment programs might not be effective, the need for integrated care exists for people with SMI for their successful recovery and rehabilitation.

There are a few limitations of the findings. Role limitations and physical and mental health data were self-reported without corroboration from health care records or providers. The study was conducted at 11 different sites where inconsistencies of program structures and elements might have influenced the study findings. The study also includes many older participants who might have lower motivation for employment participation and usually have more physical health problems. Two different staff training models of employment services at these study sites might have affected the association between limitations due to health conditions and job-related activities. Also, alcohol or drug use can affect their physical health or job-related activities, but the data were not collected by big enough sample that catches substance use to the meaningful analysis results. Bigger sample is recommended in the future studies. Side effect of psychiatric medication also shows as physical health concerns such as weight gain (Correll et al., 2015) and they can be explored as a barrier for employment in future studies.

In sum, poor physical health among individuals with SMI is a serious, persistent, and pervasive barrier to employment participation in this population. For optimum improvement, this must be addressed with the integration of care of mental health, vocational and medical services. Without addressing physical health problems, individuals with SMI will not only continue experiencing more health problems and diseases, but fewer opportunities of employment participation to improve their quality of life.

Conflict of interest

None to report.