Study Finds Evidence Showing Supported Employment Works
Abstract
An article in a series sponsored by SAMHSA finds that supported employment of people with mental illness leads to higher rates of employment, fewer days to the first competitive job, more hours and weeks worked, and higher wages.
The evidence base for supported employment for individuals with severe mental illness is very sound, and policymakers should consider including it as a covered service.
That’s the finding of a comprehensive review of the evidence for supported employment, a direct service with multiple components designed to help adults with mental disorders or co-occurring mental and substance use disorders choose, acquire, and maintain competitive employment. The review appears in the January Psychiatric Services.
The survey of evidence for supported employment is the first in a series of 14 articles titled “Assessing the Evidence Base” (AEB) to appear in the print edition of Psychiatric Services; the series will review evidence for 14 commonly used behavioral health services for people with serious mental illness. Articles in the series began appearing online in Psychiatric Services in Advance in October 2013; all online articles in the series will be free and open to the public.
The 14 services to be included in the review are behavioral management for children and adolescents, trauma-focused cognitive-behavioral therapy for children and adolescents, recovery housing, residential treatment for individuals with substance use disorders, peer-support services for individuals with serious mental illness, peer-recovery support for individuals with substance use disorders, permanent supportive housing, supported employment, substance abuse intensive outpatient programs, skill building, intensive case management, consumer and family psychoeducation, medication-assisted treatment with methadone, and medication-assisted treatment with buprenorphine.
The literature reviews were commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA) through a contract with Truven Health Analytics and conducted and written by experts in each topic area. Each article was peer reviewed by a panel of Psychiatric Services reviewers. The target audiences are state mental health and substance abuse treatment facility directors and their senior staff, Medicaid staff, other purchasers of health care services (for example, administrators in managed care organizations and commercial insurance plans), people who use behavioral health services and their families, leaders in community health organizations, clinicians, and other interested stakeholders.
Psychiatric Services Editor Howard Goldman, M.D., told Psychiatric News that SAMHSA turned to the journal to provide an independent peer review of the papers and to guide their revision for publication in the journal. “The hope is that health insurers, particularly state Medicaid programs, will consider including these services within their plans,” Goldman said.
In the first review, Tina Marshall, Ph.D., and colleagues graded the level of research evidence for supported employment as “high” based on 12 systematic reviews and 17 randomized controlled trials of the individual placement and support model. “Supported employment consistently demonstrated positive outcomes for individuals with mental disorders, including higher rates of competitive employment, fewer days to the first competitive job, more hours and weeks worked, and higher wages,” Marshall and colleagues said. “There was also strong evidence supporting the effectiveness of individual elements of the model.”
Marshall is with Westat, a research corporation in Rockville, Md.,
In the AEB series, reviewers have graded evidence for the effectiveness of the 14 behavioral services as “high,” “moderate,” or “low” based on the strength of research designs that are found in the literature and the number of each kind of study—randomized, controlled trials, quasi-experimental designs, and case studies or single-group pre-post design—that have been published (see box).
A ranking of “high” for the evidence base associated with any of the 14 behavioral health services assessed in Psychiatric Services’ “Assessing the Evidence Base” series is given to those for which the number and quality of studies indicate confidence in the reported outcomes.
A ranking of “moderate” would suggest that there is adequate research to judge the service, though it is possible that future research could influence reported results. A ranking of “low” indicates that evidence for the service is not adequate to draw conclusions about effectiveness; there is a need for research of adequate quality on the topic, and results are likely to change based on new research.
Randomized, controlled trials (RCTs) are generally considered to provide a high level of evidence because they employ random assignment to experimental and control groups. Quasi-experimental designs are generally considered to establish a moderate level of evidence because they have nonrandomized comparison groups, which may or may not be properly matched or have statistical controls to test for differences between groups.
Studies that lack a comparison group or time-series design are generally considered to provide a low level of evidence (for example, case studies or single-group pre-post designs), because they offer no comparison of effects for the same group over time or no comparison with groups that do not receive the identified treatment.
To achieve a “high” rank, there must be at least three RCTs with adequate designs or two RCTs plus two quasi-experimental studies, all with adequate designs. A service ranked as “moderate” would have at least two quasi-experimental studies with adequate designs, one quasi-experimental study plus one RCT all with adequate designs; or at least two RCTs with some methodological weaknesses, or at least three quasi-experimental studies with some methodological weaknesses. A service ranked as having a “low” level of evidence would have nonexperimental designs only or no more than one adequately designed quasi-experimental study.
In an introduction to the series accompanying the article on supported employment, Richard Dougherty, Ph.D., and colleagues noted that although a number of practices in the series are backed by strong evidence and are effective, the overall effectiveness of a number of other services has not been validated sufficiently because of a lack of adequate research.
“The evidence for these services does not yet meet the standards found in other sectors of health care research; however, some services show promise on the basis of the limited evidence available, and they deserve further study,” they wrote. “In particular, some new recovery-oriented practices have received very positive reviews from consumers, behavioral health professionals, and payers, even though these practices currently lack a strong research evidence base. We believe it is critical for research funders to support rigorous studies of these services to rapidly obtain more information about their effectiveness.”
Dougherty is with DMA Health Strategies in Lexington, Mass.
In an editorial in the January issue of the journal, psychiatrist Robert Drake, M.D., who has been a leader in promoting implementation of evidence-based services for seriously mentally ill individuals, addressed the problem of dissemination of these services to the field.
“Getting effective interventions to those who need them, when they need them, and where they want to access them—and in a fair and equitable manner—is fundamentally an issue of productivity,” Drake said. “Thus we need to emphasize the well-known components of productivity: infrastructure, human capital, and new technology. But where is the investment in infrastructure? Are we building communications and delivery systems for the next decade? Where is the human capital? Are we educating clinicians to be adept with new technologies? And are we developing new technologies to extend effective services to the growing numbers of people around the world who will need them?” ■
“Supported Employment: Assessing the Evidence” is posted at http://ps.psychiatryonline.org/article.aspx?articleid=1778882. The introduction to the series and accompanying editorial can be accessed at http://ps.psychiatryonline.org/issue.aspx?journalid=18&issueid=929507. The articles, which began appearing online in October, can be accessed at http://ps.psychiatryonline.org/Issue.aspx?issueID=927776&direction=P&journalID=18.
