Supported employment is associated with significant reductions in mental
health service utilization costs by people with serious mental illness.
The finding, reported in APA's journal Psychiatric Services in
August, builds on a substantial literature and clinical lore testifying to the
dramatic benefits of employment on functioning and outcome for people with
serious mental illness. But the Psychiatric Services study is the
first to examine long-term economic benefits of employment.
"We have known for a while that once people become steady workers,
they do better in other areas of their lives," coauthor Robert Drake,
M.D., told Psychiatric News. "They feel better about themselves
and about their relationships, and they may have a little more money so they
are more independent. And they control their symptoms better and stay out of
the hospital. We have had so many patients over the years say that work is
what really helped them recover and get out of the mental health system and
have a life of their own.
"But nobody had looked at the long-term economic effects of supported
employment programs," continued Drake, a professor of psychiatry and
community and family medicine at Dartmouth Medical School.
In the study, Drake and colleagues calculated annual costs of outpatient
services and institutional stays over a 10-year period for 187 subjects in the
New Hampshire Dual-Diagnosis Program. Patients who met the following criteria
were included: long-term psychotic illness (schizophrenia, schizoaffective
disorder, or bipolar disorder), active substance use disorder within the past
six months, and absence of mental retardation.
These participants were heavy service users at baseline. They were
identified by their interest in co-occurring disorder services rather than in
employment services; however, many were exposed to supported employment during
the 10 years of follow-up, because New Hampshire implemented this service
widely during the 1990s.
Group differences in utilization and cost were examined over the follow-up
between two groups: a "steady-work group" (n=51) who averaged
5,060 hours per person over 10 years, and a "minimum-work group"
who averaged about 45 hours per person over 10 years.
Drake and colleagues found that use of outpatient services for the
steady-work group declined at a significantly greater rate than for the
minimum-work group, and that the average cost for outpatient services and
institutional stays for the minimum-work group exceeded that of the
steady-work group by $166,350 per participant over 10 years.
Statistical controls for group differences did not make the large effects
disappear, Drake told Psychiatric News. "We were shocked when
we looked at the magnitude of the effect," he said.
More education, a bipolar disorder diagnosis (versus schizophrenia or
schizoaffective disorder), work in the past year, and lower scores on the
expanded Brief Psychiatric Rating Scale predicted membership in the
"The most parsimonious explanation for this finding, consistent with
many stories of recovery, is that clients who develop independent vocational
lives outside of the mental health system decrease their use of the mental
health system," the researchers wrote.
"There are now five long-term follow-up studies showing that over
time people who are exposed to supported employment work more hours and stay
employed more of the time, over time, and consider their job a career,"
Drake told Psychiatric News. "That's interesting by itself
because it's so different from everything we have found in mental health
services, where treatment effects invariably tend to erode over time or go
away completely. That's not so with employment—people get better and
The authors acknowledged in the study that they could not rule out a
possibility that their findings resulted from subjects' being less ill, being
better motivated, or responding better to treatments than their counterparts.
However, the authors deemed these explanations unlikely for several reasons.
For example, statistical controls for age, previous work, and illness severity
did not strongly affect or eliminate the associations they found in the
Drake said that for policymakers and program administrators, the study's
message is clear—supported employment works.
"In the U.S. today, we provide supported employment for about 1
percent of people with serious mental illness, and that's because there is no
simple way to pay for this service," he said. "Programs are just
struggling to survive financially so they are going to go on providing
services paid for by Medicaid that we know are ineffective. Everyone believes
we will have this gap between needs and services until we have an obvious and
simple payment mechanism."
Drake added that there is also a positive message for the practicing
clinician. "When we do long-term follow-up with people who have done
well and become steady workers, one of the things that surprised us is that
many people say they went back to work because their psychiatrist told them
And changing medications or lowering doses to reduce side effects that can
interfere with working has also turned out to be important, he said.
He noted that in the past the conventional wisdom was that people with
psychotic illness couldn't work because employment would be too stressful.
"It turns out that it's unemployment that is stressful," Drake
"The Long-Term Impact of Employment on Mental Health Service
Use and Costs for Persons With Severe Mental Illness" is posted at<http://ps.psychiatryonline.org/cgi/content/full/60/8/1024>.▪