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QUESTION: Is prevocational training (a period of preparation before entering job market) or supported employment (support on the job without extended preparation) effective for helping people with severe mental illness to obtain competitive employment?
Studies were identified by searching Medline (1966–98), CINAHL (1982–98), EMBASE/Excerpta Medica (1980–98), PsycLIT (1987–98), and the Cochrane Collaboration register of controlled clinical trials; and by scanning the reference lists of articles.
2 reviewers independently selected studies that were randomised control trials (RCTs), used intention to treat analyses, compared prevocational training or supported employment with standard care or with each other, reported outcome data for ≥50% of randomised participants, and involved people with severe mental illness who were 18–65 years of age.
2 reviewers independently extracted and cross checked data on patients, interventions, and outcomes. The main outcome was number of clients in competitive employment. The quality of study methods was assessed.
11 RCTs met the selection criteria. 5 RCTs (1204 participants) compared prevocational training with usual care. In 2 of these RCTs, groups did not differ for competitive employment rates. In 3 RCTs, prevocational training did not lead to higher rates for any employment than usual care. 1 RCT showed that supported employment combined with assertive community treatment led to higher competitive employment rates than usual care at 24 months (relative benefit increase [RBI] 8%, 95% CI 1% to 15%) and 36 months (RBI 12%, CI 4% to 18%). Supported employment led to more people in competitive employment at follow up than prevocational training at 6 months (3 RCTs, n=364), 12 months (5 RCTs, n=484), and 18 months (3 RCTs, n=364); at 24 months, the absolute difference remained between groups but the relative difference was not statistically significant (2 RCTs, n=155) (table⇓).
In people with severe mental illness, supported employment is more effective than prevocational employment for increasing competitive employment rates.
The issue of obtaining work when experiencing severe mental illness is critical to many service users who often perceive “a meaningful day” as being of greater benefit to them than other treatments (eg, medication). Contrasting with this is the fact that few treatment services offer work rehabilitation, perhaps because of the questionable efficacy of these services and their dubious history as “industrial therapy units” within large asylum type institutions. Crowther et al make a contribution to the debate by offering clear evidence of the most useful method of rehabilitation where successful outcome is defined by the number of hours worked, mean monthly earnings, and the possible link to admission rates.
The study uses clear terminology and describes the methods of interventions well. Ethical dimensions of the question are addressed and the methods are presented stage by stage, allowing readers to understand the material and become aware of the review process. The methods could be easily replicated.
The issue of generalisability is acknowledged, but could be extended to include a discussion on the difficulties in the benefit system that impede access to both types of work rehabilitation, thus limiting the effectiveness of these programmes. In addition, the social factors relating to work are not investigated, and many programmes of work rehabilitation focus on the development of social skills because they are designed to prepare the user for the competitive working environment.
Overall, I found the article clear and interesting. Workers in the field may wish to know about an electronic database for allied health professionals, the Allied and Complementary Medicine Database (AMED), which may have additional published works on this subject.
Source of funding: NHS Health Technology Assessment Programme.
For correspondence: Dr M Marshall, Academic Unit, Royal Preston Hospital, Preston PR2 9HT, UK. Fax +44 (0)1772 710772.
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