Advantages of Supported Employment Persist at Five-Year Follow-up

Benefits of supported employment for individuals with severe mental illness persist up to five years after enrollment, according to an August 13 report in AJP in Advance.

The study confirms the significant benefits—more hours of competitive work, higher pay, and diminished likelihood of hospitalization—associated with supported employment that have been found at two and three years.

Additionally, the study found that over time, the supports associated with the intervention could be removed without diminishing the benefits; recipients became less dependent on the program to stay employed.

“[The] superiority of supported employment over traditional vocational rehabilitation programs becomes even stronger over time and thus is consistent with the principle of time-unlimited support in the model,” said Holger Hoffman, M.D., of Switzerland’s University of Berne and colleagues. “Furthermore, the results show that participants who received supported employment had fewer hospitalizations, which, combined with higher earnings from competitive employment, resulted in a higher social return on investment than traditional vocational rehabilitation. This study is a further contribution to the evidence of the effectiveness and economic efficiency of supported employment, not only in the long term, but also outside the United States.”

In the study, 100 unemployed individuals with severe mental illness were randomly assigned to two vocational programs—46 to the supported employment program and 54 to traditional vocational rehabilitation. All had persistent impairments in role functioning, social functioning, or independent living/self-care skills.

The supported employment program, known as the Job Coach Project, was modeled after the individual placement and support model of supported employment. The Job Coach Project is staffed by employment specialists (job coaches) who have a maximum caseload of 15 participants. Just after enrollment, each participant is assisted in a rapid job search based on the participant’s educational background, work preferences, and previous work experience.

Once employed, participants receive on-the-job training and follow-along support to facilitate job maintenance. In the event of job loss, support and assistance are provided in securing a new job. Employment specialists had contact at least once every two weeks with participants and at least monthly with work supervisors, the treatment team, or other relevant individuals.

The results showed that participants in supported employment were more likely to obtain competitive work than those in traditional vocational rehabilitation (65 percent compared with 33 percent), work more hours and weeks, earn more wages, and have longer job tenures. Reliance on supported employment services for retaining competitive work decreased from the two-year to the five-year follow-up for participants in supported employment. Participants were also significantly less likely to be hospitalized, had fewer psychiatric hospital admissions, and spent fewer days in the hospital.

In addition, the rate of competitive employment among those in supported employment remained stable, even though the proportion of participants who received support from an employment specialist decreased from 67 percent at the two-year follow-up to 35 percent at the five-year follow-up.

These findings thus suggest that sustained employment with vocational supports enabled many participants to eventually work independently.

Robert Drake, M.D., Ph.D., of Dartmouth University, one of the founders and foremost champions of supported employment, said the findings are consistent with 21 other randomized, controlled trials in the literature. “The new findings here are that employment supports can be reduced without eroding benefits, and cost savings are great when you follow people for five years rather than 18 months, as in most U.S. trials,” he told Psychiatric News. “People want to get out of dependence on the mental health system, and so far, supported employment is the only effective strategy. The U.S. system has been narrowly focused on symptom control and short-term clinical outcomes, but patients are interested in long-term functional outcomes.”

Drake said that supported employment should be integrated with clinical care in accordance with evidence-based principles, saying it enhances the clinical care by improving patients’ motivation, independence, income, and self-esteem.

“If health plans and policymakers are truly interested in serving patients, they should include supported employment,” he continued. “The problem is that decision makers often do not recognize that employment is treatment.” ■