Supported employment in early
intervention for psychosis services
Niall Turner
Overview
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Conditions that feature psychosis
Typical employment outcomes
Early intervention
The IPS model
The DETECT Service
Trial of supported employment in the DETECT
service
Conditions that feature psychosis
……can be a sub feature of the clinical presentation
such as major depression, bipolar affective disorder or
the main feature of the condition such as with
schizophrenia, drug induced psychosis
Lifetime prevalence = 3% population = circa 120,000 in ROI
Current numbers unemployed
• International
– 95% Burns et al 2007
– 80 – 90% Marwaha and
Johnson 2004
– 85% Crowther et al 2001
• Ireland
– 73% Behan et al. 2008
(based on 2006 data)
Recovery
…know about employment outcome?
6
…their conclusions….
• Outcome poor but reviewing data difficult due to lack of detail
• Rates decline over time
• Outcome influenced by local environment: welfare system and
availability of Evidence Based Interventions
• Disruption starts prior to treatment commencing
• Many negative consequences of lack of paid employment
“Serious mental illness affects approximately 2% of the world’s
population. It results in persons having much
difficulty in fulfilling the role which they
may have set for themselves in life. Those
individuals no longer live in institutions for long periods of time;
the vast majority are in the community where they often receive
inadequate follow-up.
Even though more than 70% of these people
would like to work, only 10-12% do in fact
work, all too often in jobs that do not correspond to their liking
and capacities. In contrast, the employment rate of other forms
of disability is in the vicinity of 50%”
p.57
….page 58….
“Treatment programmes should include the capacity for correct diagnosis, remembering that often mental illness “hides
behind physical signs and symptoms”. Quick
access to and intervention by competent
medical and professional staff will be called for. Integral to quick access and early
intervention of appropriate medical treatment for individuals is reducing the stigma and shame associated with mental
health problems. As discussed, often an individual will not seek treatment or will delay seeking it because of the stigma
associated with mental illness. Furthermore, there
is a need for more easily accessible
mental health treatment programmes. Rehabilitation programmes will emphasize the
requirements for a prompt return to work by focusing on necessary accommodations to the work
situation, as well as required support to the individual”
Timeline – Early Psychosis
Deterioration
in Health and
Functioning
Receipt of
effective
Treatment
DELAYS
Onset of Psychosis
Start of Critical
Period
3 – 5 years
End of
Critical
Period
Length of Delays
2.5
years
2
1.5
1
DUP
0.5
0
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Au
lia
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A
S
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y
a
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d
a
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d
n
a
a
w
la
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n
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o
Ir
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Ca
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Research on impact of delays
Short Delay Worse
First contact
6 months
12 months
24 months
Long Delay Worse
Delay and Occupational Disruption
• shorter delays = more likely to still be
involved in employment or non labour force
work (Turner et al, 2009)
• At 3 yr follow-up length of delay was a
predictor of productive vocational activity
(Norman et al, 2007)
Development of Early Psychosis Programs
EPPIC
EI Paradigm
Early
detection
Improved
Outcome
Aggressive
treatment
in critical
period
Is earlier detection possible?
29 months to 6 months
18 months to 11 months
16 months to 8 months
12 months to 4 months
Mc Gorry et al, 1996; Melle et al, 2004 & 2008; Malla et al, 2006; Chong et al, 2005.
Interventions with evidence base
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Medication
Cognitive behavioural therapy
Cognitive remediation
Family education
Supported employment (SE)
– Individual Placement and Support Model (IPS)
IPS
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Employment specialists part of clinical service
Rapid return to employment
Ongoing support
RCTs - 11 reviewed by Bond, Drake & Becker (2008)
– Competitive employment 61% IPS vs. 23% control
– 66% attained employment of 20hrs plus per week
– Time to competitive employment 50% shorter for IPS (138
days vs. 206 days)
RCT’s of IPS in Early Intervention
Killackey et al (2012)
Nuechterlein et al
(2008)
80% vs. 40% in
education/employment
Killackey et al
(2008)
IPS group
significantly better on
level of employment,
hours worked per
week, jobs acquired
and longevity
Conducted an analysis
on predictors of
vocational recovery –
only independent
predictor was
treatment group.
Participants in
treatment group were
16.26 times more
likely to obtain
work/study
Killackey et al
(2013)
larger RCT of IPS
which showed
greater numbers
engaged in paid
work, education and
competitive
employment
however only comp
employ statistically
significant
Some caveats
• Largest RCT is from EPPIC service
• “original” Early Intervention Service
• Stand alone
• Entire care
• Attached to a large academic programme
However
• Other naturalistic studies also showing >66% of FEP
population returning to work/education when IPS present
International
Movement
iFEVR
End of Part I
An Irish Early Intervention Service
DUBLIN FIRST EPISODE
PSYCHOSIS STUDY
• 8.5 WTE Team Members
• Pop. – 385,000
Reducing Delays
7
6
5
4
3
2
1
0
Median
DUP
Treatment
• Community Mental
Health Team
– OPD, medication, acute
episode care
• DETECT
– ….group CBT
– ….one-to-one
occupational therapy
– ….group carer
education course
Additionally since 2010…..
A clinical trial of supported employment and
workplace fundamentals for people with first
episode psychotic disorders
Principles of IPS
1.
2.
3.
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6.
7.
8.
Every person who wants to work is eligible
Employment services are integrated with mental health services
Competitive employment is the goal
Benefits counselling is provided
Job search happens soon after interest is expressed
Employment specialist systemically develop relationship with
employers
Job supports are continuous
Client preferences are honoured
Workplace Fundamentals Module
• Rationale: Even with SE maintaining jobs remains problematic
• Aim of WFM: Reduce job terminations/breakdown
• Method: Training module to augment SE.
“Evening course” in employment skills
Manual & training materials developed by UCLA Psychosocial
Rehabilitation Center (Liberman and Wallace, 2000)
Skills for maintaining employment are best taught when person
in employment
Why offer WFM?
• Previous research found declining rates over
time
• If delays reduced likely to be significant
numbers still in education/work
• Preventative approach
• Address an unmet need
• Address a gap in the current knowledge base
Research Questions
Primary
Secondary
• Does augmenting an
early intervention service
with IPS and WFM
improve work outcomes?
• What relationship, if any,
does employment
outcome have with
quality of life, recovery,
social inclusion and
remission?
Methodology I
Control Group
• Recipients of
DETECT service
02/2005 – 07/2009
Experimental
Group
• Recipients of
DETECT Service
08/2009 – 12/2012
• Supported
employment specialist
joined team 06/2010
Comparison
• 1 year follow up
conducted as part of
DETECT service
evaluation
• Includes measure of
time in employment,
last worked, QoL,
recovery and mental
health
Methodology II
Baseline
• Assessment of occupational
history and Social Inclusion
Followup
• Repeat above
• Merge with measures
conducted at DETECT
baseline and 1 year follow up
• Statistical analysis
Recruitment
Recruitment
Occupational
Status
Offer
Interventions
IPS
Unemployed
DETECT
ASSESSMENT
WFM
Employed
WFM
Follow up
Once
specifically for
this research
project
Once at one
year for the
DETECT service
evaluation
Progress (to April 2012)
IPS
WFM
• 44 people offered IPS
• 42 attended initial
assessment
• 34 (81%) progressed to
education/employment/
training
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70 people offered WFM
22 agreed to attend
12 completed
11 were still employed in
December 2012
Challenges
• Recession
• Traditional concerns re people with schizophrenia
returning to work
– Clinicians
– Family
• Perceived need amongst target group
• State financial assistance
– Old habits die hard!
• Current policy – who’s responsibility is it to provide this
population with assistance to return to work
• Expertise
Tentative Conclusions
• IPS model in early intervention services has the potential to
change course of employment outcome for majority of people
affected by psychosis
• Need to consider offering assistance for those who never lose
their work role at their first episode
• There remains significant challenges to the widespread
implementation of SE for people with psychotic conditions in
Ireland
Thank You