Vocational rehabilitation for people with severe mental illness

 

Abstract

Background

Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre-vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on-the-job support (Supported Employment). It is unclear which approach is most effective.

Objectives

To assess the effects of Pre-vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre-vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention.

Search methods

Searches were undertaken of CINAHL (1982-1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1887-1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies.

Selection criteria

Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness.

Data collection and analysis

Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross-checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta-analysis). A sensitivity analysis was performed, excluding poorer quality trials.

Main results

Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre-vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre-vocational Training. There was no evidence that Pre-vocational Training was more effective in helping clients to obtain competitive employment than standard community care.

Authors' conclusions

Supported employment is more effective than Pre-vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre-vocational Training is effective.

 

Plain language summary

Vocational rehabilitation for people with severe mental illness

A majority of severely mentally ill people would like to work and there are compelling ethical, social and clinical reasons for helping them to achieve this goal. Pre-vocational Training and Supported Employment are two different approaches to helping severely mentally ill people obtain employment. The key principle of Pre-vocational Training is that a period of preparation is necessary before entering competitive employment. In contrast, the key principle of Supported Employment is that placement in competitive employment should occur as quickly as possible, followed by support and training on the job. This systematic review found that people who received Supported Employment were significantly more likely to be in competitive employment than those who received Pre-vocational Training (at 12 months 34% employed in Supported Employment compared with 12% in Pre-vocational Training).

 

摘要

背景

嚴重精神疾患的職能復健

嚴重精神疾患患者的失業率很高，然而調查顯示大部分人都想要工作。職能復健服務是為了協助精神疾患患者找到工作。傳統上，這些服務在嘗試將個案安置於具競爭性的(如開放性的)工作之前，提供一段期間的準備(職前訓練)(Prevocational Training)。近來，有些服務開始盡快將個案安置於具競爭性的工作，並同時提供在職訓練(支持性僱用)(Supported Employment)。哪一種取向最有效則不清楚。

目標

評估職前訓練與支持性僱用(對嚴重精神疾患患者)兩者相比較的效果，也與標準照護(在醫院或社區)相比較。此外，評估(a)某類職前訓練(俱樂部模式)(Clubhouse model)與支持性僱用(個別安置與支持模式)(Individual Placement and Support model);與(b)促進每一個取向的技巧，例如：薪資或心理介入的效果。

搜尋策略

搜尋CINAHL (1982 – 1998), The Cochrane Library (第2期, 1999), EMBASE (1980 – 1998), MEDLINE (1966 – 1998) and PsycLIT (1887 – 1998)等資料庫。檢閱合格研究的參考文獻與回顧，並與此領域的研究者聯繫，以找出未發表的研究。

選擇標準

對嚴重精神疾患患者進行職能復健之隨機對照試驗。

資料收集與分析

納入的試驗是兩位評估者一致地選擇的試驗。兩位回顧者分別擷取資料，並交叉比對。與試驗的作者聯繫以取得額外的資訊。計算同質的二分變項之相對風險與95%信賴區間。對於異質的二分變項則使用隨機效果模式分析。以表格來呈現連續變項(沒有足夠的連續變項可以進行正式的後設分析)。執行一個敏感的分析，排除品質不佳的試驗。

主要結論

找到18個有品質的隨機對照試驗。主要的發現是在主要的結果變項(被僱用於具競爭性工作的人數)上，支持性僱用顯著地比職前訓練要更有效；例如，在18個月後，支持性僱用組中34%的人有工作，而職前訓練組只有12%有工作(RR 隨機效果 (失業) 0.76 95% CI 0.64 to 0.89, NNT 4.5)。支持性僱用組的個案也比職前訓練組的個案賺取較多的薪資，每個月的工作時數也較長。沒有證據顯示職前訓練組比標準社區照護更能協助個案獲得具競爭性的工作。

作者結論

在協助嚴重精神疾患患者獲得具競爭性的工作上，支持性僱用比職前訓練要更為有效。沒有清楚的證據顯示職前訓練是有效的。

翻譯人

本摘要由彰化基督教醫院陳美雀翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

嚴重精神疾患患者中大部分都想要工作，也有強烈的倫理的、社會的以及臨床的理由來協助他們達成這個目標。職前訓練與支持性僱用是兩種不同的取向，來協助嚴重精神疾患患者獲得工作。職前訓練的主要原則是在進入具競爭性的工作之前，有一段時間的準備是必須的。相對地，支持性僱用的主要原則是應該盡快將個案安置於具競爭性的工作，接著提供工作上的支持與訓練。這篇系統系的回顧發現，接受支持性僱用的個案比接受職前訓練的個案顯著有較高的機會留在具競爭性的工作(12個月後，支持性僱用組有34%有工作，而職前訓練組是12%有工作)。