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Q How does individual placement and support compare with a psychosocial rehabilitation programme or standard services for vocational rehabilitation in people with severe mental illness?
Randomised controlled trial.
Follow up period:
Hartford, Connecticut, USA; April 1996 to May 1998.
204 people (46% African American, 30% Latino) with severe mental illness (DSM-IV Axis I diagnosis or borderline personality disorder and severe impairment of psychosocial functioning and self care) who were unemployed and lived in the inner city. Participants were required to have a desire for competitive work and be capable of giving informed consent.
Individual placement and support (IPS): employment specialists worked with case managers, psychiatrists and the client to integrate employment services with treatment. Services included vocational assessment and identifying job interests, job finding, and support, and were provided away from the mental health centre. Psychosocial rehabilitation programme (PSR): skills training was given followed by transitional employment and support for obtaining competitive work. PSR also gave social support and housing services, which were provided to all participants in the study. Standard services: access to local vocational services and a programme supplying sub-minimum wage employment in supervised janitorial positions.
Employment: type of job, hours, wages, and tenure were assessed weekly by interview with participants or in logs written by support staff. Other outcomes: psychiatric symptoms were assessed using the PANSS, functioning with the Global Assessment Scale, and social and leisure functioning with the Social-Leisure subscale and global rating from the Social Adjustment Scale II. Interviews were held every 6 months for two years.
Patient follow up:
195/204 (96%) attended at least one interview; follow up at 6 months was 86%; at 12 months, 85%; at 18 months, 85%; at 24 months, 81%.
At two years, IPS significantly improved employment outcomes compared with PSR or standard services (see http://www.ebmentalhealth.com/supplemental for table). There were no significant differences among groups for the other outcomes.
Individual placement and support is more effective for finding competitive employment for people with serious mental illness than psychosocial rehabilitation or standard services.
The Hartford study confirms that factors such as integrated support services, rapid job placement, and matching individuals with specific job preferences—as purported by the individual placement and support (IPS) model—cannot predict long term job sustainability (tenure over six months) for people with mental illnesses. Judith Cook reported similar findings for job retention for individuals participating in a non-IPS model vocational programme.1 To determine the constellation of significant factors that can lead to longer retention, programmes that exceed the job retention rate of six months for supported employment placements should be examined, as in the Chinook clubhouse study.2
The Hartford study was unique in the comparison of three different vocational rehabilitation approaches within the same geographical region. However, to suggest that one model is preferred over another as a general recommendation negates consumer choice and discounts individual needs and preferences. The IPS model may be more suited to certain individuals, such as those from Latino populations or individuals who prefer more intensive, individualised settings. Others may benefit from participating in a clubhouse where one becomes part of a community that offers an array of support including employment, education, housing, and social opportunities.
Findings in the Hartford study would have been more relevant if an IPS model had been compared to an International Center for Clubhouse Development (ICCD) certified clubhouse. Although the psychosocial rehabilitation (PSR) programme in the paper was similar to other PSR programmes in Connecticut, it is unclear whether this PSR programme would have met the criteria in the clubhouse fidelity scale.3 There seems to be an inherent misunderstanding in this study, and in psychiatric rehabilitation literature in general, with respect to the clubhouse model and transitional, supported, and independent employment.4 The authors acknowledge more research in this area is necessary. Studies that examine outcomes of existing service programmes that have not been researched extensively may prove beneficial.
Review history and Supplementary material
For correspondence: Kim T Mueser, New Hampshire-Dartmouth Psychiatric Research Center, Main Building, 105 Pleasant Street, Concord, NH 03301, USA;
Sources of funding: US Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS), National Institute of Mental Health (NIMH).
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