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Supported employment for adults with severe mental illness

  1. Yoshihiro Kinoshita1,*,
  2. Toshi A Furukawa2,
  3. Kuni Kinoshita3,
  4. Mina Honyashiki4,
  5. Ichiro M Omori5,
  6. Max Marshall6,
  7. Gary R Bond7,
  8. Peter Huxley8,
  9. Naoji Amano9,
  10. David Kingdon10

Editorial Group: Cochrane Schizophrenia Group

Published Online: 13 SEP 2013

Assessed as up-to-date: 23 MAY 2012

DOI: 10.1002/14651858.CD008297.pub2


How to Cite

Kinoshita Y, Furukawa TA, Kinoshita K, Honyashiki M, Omori IM, Marshall M, Bond GR, Huxley P, Amano N, Kingdon D. Supported employment for adults with severe mental illness. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD008297. DOI: 10.1002/14651858.CD008297.pub2.

Author Information

  1. 1

    Shinshu University School of Medicine, Department of Psychiatry, Matsumoto, Japan

  2. 2

    Kyoto University Graduate School of Medicine / School of Public Health, Departments of Health Promotion and Behavior Change and of Clinical Epidemiology, Kyoto, Japan

  3. 3

    Akitsu-kai Nanshin Hospital, Minami-minowa, Japan

  4. 4

    Kyoto University Graduate School of Medicine / School of Public Health, Department of Health Promotion and Human Behavior, Kyoto, Japan

  5. 5

    Toyokawa City Hospital, Department of Psychiatry, Aichi, Japan

  6. 6

    The Lantern Centre, University of Manchester, Preston., Lancashire, UK

  7. 7

    Dartmouth Medical School, Department of Psychiatry, Lebanon, New Hampshire, USA

  8. 8

    University of Swansea, Applied Social Studies, Swansea, UK

  9. 9

    Shinshu University, School of Medicine, Department of Psychiatry, Matsumoto, Japan

  10. 10

    University of Southampton, Mental Health Group, Southampton, UK

*Yoshihiro Kinoshita, Department of Psychiatry, Shinshu University School of Medicine, Matsumoto, Japan. ykino@joy.hi-ho.ne.jp.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 13 SEP 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

 
Summary of findings for the main comparison. Supported employment versus other vocational approaches for adults with severe mental illness

Supported employment versus other vocational approaches for adults with severe mental illness

Patient or population: patients with adults with severe mental illness
Settings: community psychiatric/mental health service
Intervention: Supported employment versus other vocational approaches

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Other vocational approachesSupported employment

Employment - obtained any job during the study (high=better)
Follow-up: mean 18 months
Study populationRR 2.62
(2.18 to 3.16)
951
(7 studies)
⊕⊝⊝⊝
very low2,3

202 per 10001530 per 1000
(441 to 639)

Moderate

260 per 10001681 per 1000
(567 to 822)

Employment - days in competitive employment (primary outcome) - long term
Follow-up: 24 months
The mean employment - days in competitive employment (primary outcome) - long term in the control groups was
16.85 days
The mean employment - days in competitive employment (primary outcome) - long term in the intervention groups was
70.63 higher
(43.22 to 98.04 higher)
204
(1 study)
⊕⊝⊝⊝
very low4,5,6,7

Employment - days in any form of paid employment - long term
Follow-up: mean 21 months
The mean employment - days in any form of paid employment - long term in the control groups was
43.75 days
The mean employment - days in any form of paid employment - long term in the intervention groups was
84.94 higher
(51.99 to 117.89 higher)
510
(2 studies)
⊕⊝⊝⊝
very low7,8,9,10

Employment - job tenure for competitive employment (weeks) - long term
Follow-up: 24 months
The mean employment - job tenure for competitive employment (weeks) - long term in the control groups was
2.5 weeks
The mean employment - job tenure for competitive employment (weeks) - long term in the intervention groups was
9.86 higher
(5.36 to 14.36 higher)
204
(1 study)
⊕⊝⊝⊝
very low5,6,7,11

Employment - job tenure for any paid employment (weeks) - long term
Follow-up: mean 22 months
The mean employment - job tenure for any paid employment (weeks) - long term in the control groups was
15.43 weeks
The mean employment - job tenure for any paid employment (weeks) - long term in the intervention groups was
3.86 higher
(-5.66 lower to 13.38 higher)
423
(2 studies)
⊕⊝⊝⊝
very low6,7,12,13

Time (days) to first competitive employment - long term
Follow-up: 24 months
The mean time (days) to first competitive employment - long term in the control groups was
396.42 days
The mean time (days) to first competitive employment - long term in the intervention groups was
161.6 lower
(225.73 to 97.47 lower)
204
(1 study)
⊕⊝⊝⊝
very low4,5,6,7

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Median control risk across studies.
2 Risk of bias: rated 'high' - all studies were non-blind; four of the seven studies did not describe allocation concealment.
3 Inconsistency: rated 'very serious' - heterogeneity substantial Chi² = 22.87, df = 6 (P = 0.0008); I² = 74%.
4 Risk of bias: rated 'serious' - one included (Mueser 2004) study was not double-blinded nor described allocation concealment.
5 Inconsistency: rated 'very serious' - only one study presented data, the remaining six studies were presented separately due to considerable skewed data, which presented high degrees of heterogeneity when assessed together.
6 Imprecision - rated 'serious': small sample sizes; data were skewed, but as per protocol (where there were N=200 in an included study or greater) data from this one study was used.
7 Publication bias - rated 'likely': There were few included studies and might be some publication bias.
8 Risk of bias: rated 'serious' - both included (Burns 2007; Mueser 2004) studies were not double-blinded nor described allocation concealment; also unclear as to losses to follow-up.
9 Inconsistency: rated 'very serious' - only two studies presented data, the remaining eight studies were presented separately due to considerable skewed data, which presented high degrees of heterogeneity when assessed together.
10 Imprecision - rated 'serious': small sample sizes; data were skewed, but as per protocol (where there were N=200 in an included study or greater) data from this one study was used.
11 Risk of bias: rated 'serious' - one included (Mueser 2004) study was not double-blinded nor described allocation concealment; also unclear as to losses to follow-up.
12 Risk of bias: rated 'serious' - all included (Burns 2007; Lehman 2002; Mueser 2004) studies were not double-blinded nor described allocation concealment; also unclear as to losses to follow-up.
13 Inconsistency: rated 'very serious' - high degrees of heterogeneity in results; Chi² = 3.73, df = 1 (P = 0.05); I² = 73%.

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Description of the condition

People who suffer from severe mental disorder experience high rates of unemployment. A review of eight controlled trials demonstrated that employment rates for people with schizophrenia, even with optimal support, ranged from only 30% to 80%, with a median of 60% across these studies (Bond 2004). These low employment rates reflect the disability caused by severe mental illness, but they may also reflect discrimination (unemployment rates are higher than in other disabled groups) (ONS 1998) and the low priority given to employment by psychiatric services (Lehman 1995). Despite high unemployment rates amongst people with severe mental illness, surveys have consistently shown that most want to work (Hatfield 1992; Lehman 1995; Shepherd 1994). Mental health issues said to be linked to unemployment include: cognitive impairment, psychotic symptoms, negative symptoms, fear of losing benefits, stigma and lack of access to employment services (Bond 1991; Bond 2008b; Cook 2006; Rosenheck 2006; Rutman 1994).

 

Description of the intervention

Supported employment is an approach to vocational rehabilitation that involves trying to place clients in competitive jobs without any extended preparation (Bond 1992). Originally developed for people with learning disabilities, supported employment has been defined as 'paid work that takes place in normal work settings with provision for ongoing support services' (Becker 1994; Bond 1999). Proponents of supported employment had two objections to pre-vocational training, which adheres to the key principle that a period of preparation is necessary before entering competitive employment (Bilby 1992; Bond 1997a). First, they argued that it promoted dependency and deterred clients from finding competitive employment. Second, they argued that pre-vocational training was not effective in developing work skills. Instead of pre-vocational training, they proposed trying to place clients as quickly as possible in competitive employment positions, where they would receive intensive on-the-job support and training from personnel known as 'job coaches' (Anthony 1987).

The individual placement and support (IPS) model is a carefully specified form of supported employment that is based on close adherence to seven key principles (Mueser 2004). These principles are: (a) the goal is competitive employment in work settings integrated into a community's economy; (b) services are based on clients' choices; (c) clients are expected to obtain jobs directly, rather than following lengthy pre-employment training (rapid job search); (d) attention to patient preference in the job search; (e) integration between employment services and mental health treatment teams; (f) ongoing individual support; and (g) systematic benefits counselling (Bond 2008a).

Adherence to individual placement and support guidelines may be measured using a fidelity scale (Bond 1997b). In IPS, employment specialists serve on clients’ treatment teams alongside other staff, such as case managers and psychiatrists. Each employment specialist provides the full range of vocational services to each client, including engagement in services, identifying job interests and vocational assessment, job finding and job support. IPS uses assertive outreach (Stein 1998) to deliver vocational services in the community rather than at mental health or rehabilitation agencies (Bond 1997b).

 

How the intervention might work

Supported employment is defined as 'paid work that takes place in normal work settings with provision for ongoing support services' (Becker 1994; Bond 1999). It helps people with mental illness to work by placing them as quickly as possible in competitive employment positions, where they would receive intensive on-the-job support and training from personnel known as job coaches (Anthony 1987). Listed below are critical components which are common in successful supported employment programs (Bond 2001).

  1. The agency providing the services is committed to help clients with attaining competitive employment.
  2. A rapid job search rather than lengthy pre-employment assessment, training, and counselling is provided for clients.
  3. Staff and clients find individualised job placements according to client preferences, strengths, and work experiences.
  4. Follow-along supports are provided indefinitely.
  5. The program is closely integrated with the mental health treatment team.

Supported employment is also provided for clients with autism (Keel 1997), mental retardation (Walsh 1994), and traumatic brain injuries (Wehman 2003), though its effectiveness for these populations is yet to be confirmed.

 

Why it is important to do this review

A previous Cochrane review (Crowther 2001) and another systematic review (Twamley 2003) have examined the effectiveness of various types of vocational rehabilitation for individuals with severe mental illness, including supported employment, but as several new trials of supported employment have been published recently a review focusing purely on supported employment is required. These trials have been covered in two narrative reviews (Bond 2004; Bond 2008a), but there have been no formal meta-analytic summaries as yet.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

  1. To review the effectiveness of supported employment compared with other approaches to vocational rehabilitation and treatment as usual. 
  2. Secondary objectives are to establish how far:
    1. fidelity to the IPS model affects the effectiveness of supported employment;
    2. the effectiveness of supported employment can be augmented by the addition of other interventions.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomised controlled trials (RCTs) that assess the effects of supported employment in people with severe mental illness. We excluded quasi-randomised studies, such as those allocating by using alternate days of the week.

 

Types of participants

The supported employment was not designed for a specific diagnostic group nor was it applied in a diagnostic-specific way in everyday practice. Therefore, for the purpose of this review, the main requirements of participants were that they were similar to those who typically present to the supported employment services. Specific inclusion criteria were that a majority of clients in the trial were (a) of working age (normally 16 to 70 years); (b) unemployed; and (c) suffering from severe mental illness, defined as: schizophrenia and schizophrenia-like disorders; bipolar disorders; or depression with psychotic features. Trials were included where a majority of participants (more than 50%) were suffering from schizophrenia and schizophrenia-like disorders; bipolar disorders; or depression with psychotic features. Substance abuse and post traumatic stress disorder were not considered severe mental illness, but trials were eligible if participants had a problem with substance abuse and/or comorbidity of post traumatic stress disorder in addition to severe mental illness. We excluded trials where a majority of participants (more than 50%) were suffering from a learning disability as the sole psychiatric diagnosis.

 

Types of interventions

Three interventions of interest were defined: supported employment (including Individual Placement and Support (IPS), and Augmented Supported Employment), other vocational approaches and treatment as usual.

 

1. Supported employment

Supported employment is a technique designed to help mentally ill people obtain and keep competitive employment. Supported employment aims to help clients obtain competitive work as quickly as possible and provides ongoing support to help them keep their employment (Bond 2001; Mueser 2004).

 
1.1 Individual placement and support (IPS)

IPS is a carefully specified approach to supported employment that requires close adherence to the seven principles described above. Fidelity to the IPS model can be assessed using an IPS Fidelity Scale (Becker 2001). IPS is classified into two categories: (i) Low fidelity IPS and (ii) High fidelity IPS. The seven key principles described in Description of the intervention are taken into consideration to assess the fidelity (Bond 1997b). Low fidelity IPS is defined as a) the programme itself does not satisfy one or more of the seven key principles, for example, if the same personnel are in charge of employment services and clinical services; b) although the programme does satisfy all the seven criteria, the quality assessment reveals that the actual delivery of the programme did not satisfy one or more of the seven key principles; or c) the quality of the actual delivery was not assessed. High fidelity IPS is when the programme satisfies all seven criteria.

Fidelity of IPS was assessed by the following two-step procedure.

  1. Two review authors (YK and KK) independently selected RCTs that assured fidelity of IPS using the IPS scale (Bond 1997b). Trials that did not fulfil this criterion were rated as low fidelity IPS.
  2. The same two review authors checked the selected articles. If the detailed description, especially in terms of engagement and intensity, indicated low fidelity of IPS conducted in some of the RCTs, fidelity of such IPS was rated as low in this review. If not, fidelity of the IPS was classified as high. The reason for judgement for the low fidelity IPS is presented in Characteristics of included studies.

 
1.2 Augmented supported employment

Supported employment can be augmented with other interventions, such as motivational interventions, social skills training and cognitive rehabilitation (Bell 2008; Drake 2008; McGurk 2007; Mueser 2005; Tsang 2007; Wallace 2004).

 

2. Other vocational approaches

Other vocational approaches are described in detail in another Cochrane review (Crowther 2001) and include sheltered workshop; prevocational training classes; job counselling; and the Clubhouse model - this model provides (a) work experiences through clubhouse work units; (b) transitional employment (the participant works for a limited period in a paid position in a real workplace, but the position is “owned” by the employment agency rather than the participant); and (c) peer support. In this model, the participant graduates from helping to maintain a patient-led "clubhouse", to transitional employment, and finally to competitive employment; and diversified placement approach - principles of this approach are: (a) goal of paid employment including but not limited to a competitive one; (b) gradualism (members move gradually through the vocational continuum); (c) flexibility in movement between placements; (d) peer support; and (f) partnerships with the business community (Bond 2004). All of these approaches differ from supported employment in that they do not place an emphasis on an immediate search for competitive employment, but prefer a period of preparation, before seeking competitive employment. We planned to treat them as a single control intervention.

 

3. Treatment as usual

Treatment as usual is defined as standard psychiatric care for participants in the trial, without any specific vocational component. It is assumed that both intervention and control participants will be receiving treatment as usual, which would normally include: medication, medication management, case management, and supportive psychotherapy (Bond 2008c).

 

Types of outcome measures

We grouped outcomes into short term (less than six months) medium term (six months to one year) and long term (over one year: a follow-up duration of 12 months was also considered as long term)

 

Primary outcomes

 
1. Employment: days in competitive employment (long term)

 

Secondary outcomes

 
1. Employment

1.1 Days in competitive employment (medium term)
1.2 Days in any form of paid employment (such as competitive employment, transitional employment, or sheltered employment with wage)
1.3 Earnings in the first year
1.4 Job tenure (weeks/work/person: for competitive employment and any paid employment)
1.5 Time to first competitive employment

 
2. Education

2.1 Days in any form of employment or education (including training courses or full or part-time education)

 
3. Leaving the study early (i.e. number of participants who dropped-out from service)

3.1 For any reason
3.2 Specific reason (as defined by individual studies)

 
4. Global state

4.1 Relapse
4.2 Time to relapse
4.3 No clinically important change in global state
4.4 Not any change in global state

 
5. Mental state

5.1 No clinically important change in general mental state
5.2 Not any change in general mental state
5.3 Average endpoint general mental state score
5.4 Average change in general mental state scores
5.5 No clinically important change in specific symptoms
5.6 Not any change in specific symptoms
5.7 Average endpoint specific symptom score
5.8 Average change in specific symptom scores

 
6. Service Use

6.1 Mean days in hospital
6.2 Number of participants admitted to hospital/re-hospitalised

 
7. Quality of life

7.1 No clinically important change in quality of life
7.2 Not any change in quality of life
7.3 Average endpoint quality of life score
7.4 Average change in quality of life scores
7.5 No clinically important change in specific aspects of quality of life
7.6 Not any change in specific aspects of quality of life
7.7 Average endpoint specific aspects of quality of life
7.8 Average change in specific aspects of quality of life

 
8. Social/General functioning

8.1 Average endpoint general functioning score (when Global Assessment of Functioning (GAF) was rated in symptoms and disability separately, a lower score was considered as general GAF score, and extracted and integrated in a meta-analysis)
8.2 Average change in general functioning scores
8.3 No clinically important change in specific aspects of functioning, such as social or life skills
8.4 Not any change in specific aspects of functioning, such as social or life skills
8.5 Average endpoint specific aspects of functioning, such as social or life skills
8.6 Average change in specific aspects of functioning, such as social or life skills

 
9. Adverse effects

9.1 Not any general adverse effects
9.2 Average endpoint general adverse effect score
9.3 Average change in general adverse effect scores
9.4 No clinically important change in specific adverse effects
9.5 Not any change in specific adverse effects
9.6 Average endpoint specific adverse effects
9.7 Average change in specific adverse effects
9.8 Death - natural and suicide

 
10. Economic Costs (excluding housing costs)

10.1 Direct costs
10.2 Indirect costs

 
11. Summary of findings

We used the GRADE approach to interpret findings (Schünemann 2008) and used GRADE profiler (GRADEPRO) to import data from RevMan 5.1 (Review Manager) to create 'Summary of findings' tables. These tables provide outcome-specific information concerning the overall quality of evidence from each included study in the comparison, the magnitude of effect of the interventions examined, and the sum of available data on all outcomes we rated as important to patient-care and decision making. We selected the following main outcomes for inclusion in the Summary of findings table:

1. Employment - obtained any job during the study
2. Employment - days in competitive employment (primary outcome) - long term
3. Employment - days in any form of paid employment - long term
4. Employment - job tenure for competitive employment (weeks) - long term
5. Employment - job tenure for any paid employment (weeks) - long term
6. Time (days) to first competitive employment

 

Search methods for identification of studies

 

Electronic searches

The Cochrane Schizophrenia Group Trials Register (Feb 2010) was searched using the phrase:

[( *employ* or ((*supp* or *transitional*) and (*employ* or *work*) or ((*psychosocial* or *psycho-social* or *psychiatric* or *occupational or *soc* or *work* or *job* or *counsel*) and *rehab*) or *sheltered work* or *vocatio* or *fountain house* or *fountain-house* or *clubhouse* or *club-house* or *occupat* or *job* or *work therap* or *delivery of  health care* or *delivery of integrated delivery* in title, abstract and index fields in REFERENCE) or (*vocat* or work* or *employ* or * job* or *occupat* or * placem* or *rehab*) in STUDY interventions)]

This register is compiled by systematic searches of major databases, handsearches and conference proceedings (see group module).

 

Searching other resources

 

1. Reference searching

The sensitivity of the search strategy was examined by comparing the results of the search with the reference lists of the identified reviews and trials to determine how many cited trials had not been detected.

 

2. Personal contact

We contacted researchers working in the field to identify unpublished studies.

 

Data collection and analysis

 

Selection of studies

Two review authors (YK and KK) independently inspected all the citations identified by the search and requested all potentially relevant articles, contacting the trial authors where necessary. Once the full articles had been obtained, two review authors independently decided whether the studies met the inclusion criteria. In the event of a disagreement, a third reviewer adjudicated and made a final decision. If it was not possible to obtain sufficient information to judge whether a study met inclusion criteria, it was placed in the list of studies awaiting assessment until such information became available.

 

Data extraction and management

 

1. Extraction

Two review authors (YK and KK) independently extracted data from the selected trials using a double-entry method. In the event of a difference between the review authors, they sought to resolve the difference by further scrutiny of the original trial reports, and involved a third review author and/or contacted the authors for further information.

 

2. Management

We extracted data onto standard, simple forms.

 

3. Scale-derived data

We included continuous data from rating scales only if: (a) the psychometric properties of the measuring instrument had been described in a peer-reviewed journal (Marshall 2000); (b) the measuring instrument was not written or modified by one of the trialists; (c) the measuring instrument was either (i) a self-report or (ii) completed by an independent rater or relative (not the therapist).

 

Assessment of risk of bias in included studies

Review authors YK, KK and/or MH worked independently by using criteria described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) to assess trial quality. This new set of criteria is based on evidence of associations between overestimate of effect and high risk of bias of the article such as sequence generation, allocation concealment, blinding, incomplete outcome data and selective reporting.

Where inadequate details of randomisation and other characteristics of trials were provided, we contacted authors of the studies in order to obtain additional information.

We noted the level of risk of bias in both the text of the review and in the  Summary of findings for the main comparison.

 

Measures of treatment effect

 

1. Binary outcomes

Where binary outcomes (proportions) were used, we calculated fixed-effect risk ratios (RR) (Furukawa 2002), with 95% confidence intervals (CIs) for each outcome. In the event of significant heterogeneity, we used a random-effects model. The RR was chosen over the odds ratio because the latter tends to overstate effect size when event rates are high (Higgins 2011).

 

2. Continuous data

 
2.1 Summary statistic

For continuous outcomes, we estimated a mean difference (MD) between groups. We preferred not to calculate effect size measures (standardised mean difference SMD). However, if scales of very considerable similarity were used, we would have presumed there was a small difference in measurement, and would have calculated effect size and transformed the effect back to the units of one or more of the specific instruments.

 
2.2 Endpoint versus change data

Since there is no principal statistical reason why endpoint and change data should measure different effects (Higgins 2011), we used scale endpoint data which was easier to interpret from a clinical point of view. If endpoint data were not available, we used change data.

 
2.3 Skewed data

Continuous data on clinical and social outcomes are often not normally distributed. To avoid the pitfall of applying parametric tests to non-parametric data, we aimed to apply the following standards to all data before inclusion: (a) standard deviations (SDs) and means are reported in the paper or obtainable from the authors; (b) when a scale starts from the finite number zero, the SD, when multiplied by two, is less than the mean (as otherwise the mean is unlikely to be an appropriate measure of the centre of the distribution, (Altman 1996); (c) if a scale starts from a positive value (such as the Positive and Negative Syndrome Scale (PANSS) which can have values from 30 to 210), the calculation described above is modified to take the scale starting point into account. In these cases skew is present if 2SD > (S-S min), where S is the mean score and S min is the minimum score. Endpoint scores on scales often have a finite start and end point and these rules can be applied. Skewed endpoint data from studies of less than 200 participants were entered as 'other data' within the data and analysis section rather than into a statistical analysis. Skewed data pose less of a problem when looking at means if the sample size was large (over 200 participants) and they were entered into syntheses. When continuous data are presented on a scale which includes a possibility of negative values (such as change data), it is difficult to tell whether data are skewed or not, skewed change data were entered into statistical analysis.

 
2.4 Data synthesis

When standard errors instead of SDs were presented, the former were converted to SDs. If SDs were not reported and could not be calculated from available data, authors were asked to supply the data. In the absence of data from authors, the mean SD from other studies was used.

 

Unit of analysis issues

 

1. Cluster trials

Studies increasingly employ ‘cluster randomisation’ (such as randomisation by clinician or practice) but analysis and pooling of clustered data poses problems. Firstly, authors often fail to account for intra class correlation in clustered studies, leading to a ‘unit of analysis’ error (Divine 1992) whereby P values are spuriously low, confidence intervals unduly narrow and statistical significance overestimated. This causes type I errors (Bland 1997; Gulliford 1999).

Where clustering had not been accounted for in primary studies, we presented the data in a table, with a (*) symbol to indicate the presence of a probable unit of analysis error. In subsequent versions of this review we will contact first authors of studies to obtain intra class correlation coefficients (ICCs) of their clustered data and adjust for this by using accepted methods (Gulliford 1999). Where clustering had been incorporated into the analysis of primary studies, we also presented these data as if from a non-cluster randomised study, but adjusted for the clustering effect.

The binary data as presented in a report should be divided by a ‘design effect’ (Raj 2009). This is calculated using the mean number of participants per cluster (m) and the ICC [Design effect = 1+(m-1)*ICC] (Donner 2002). If the ICC had not been reported it was assumed to be 0.1 (Ukoumunne 1999).

 

2. Studies with multiple treatment groups

Where a study involved more than two treatment groups, if relevant, the additional treatment groups were presented in additional relevant comparisons. Data were not double counted. Where the additional treatment groups were not relevant, these data were not reproduced.

 

Dealing with missing data

 

1. Overall loss of credibility

At some degree of loss of follow-up, data must lose credibility (Xia 2007). Where more than 40% of data were unaccounted for, we did not reproduce these data or use them within analyses.

 

2. Binary

In the case where attrition for a binary outcome was between 0% and 40% and outcomes of these people were described, we included these data as reported. Where these data were not clearly described, data were presented on a 'once-randomised-always-analyse' basis, assuming an intention-to-treat analysis. Those lost to follow-up were all assumed to have a negative outcome. For example, for the outcome of employment, those who were lost to follow-up were all considered to be unemployed. A final sensitivity analysis was undertaken to test how prone the primary outcomes were to change when 'completed' data only were compared to the intention-to-treat to treat analysis using the negative assumption.

 

3. Continuous

In the case where attrition for a continuous outcome was between 0% and 40% and completer-only data were reported, we reproduced these.

 

4. Intention-to-treat (ITT)

Intention-to-treat (ITT) was used when available. We anticipated that in some studies, in order to undertake an ITT analysis, the method of last observation carried forward (LOCF) was employed within the study report. As with all methods of imputation to deal with missing data, LOCF introduces uncertainty about the reliability of the results. Therefore, where LOCF data had been used in the analysis, they were indicated in the review.

 

Assessment of heterogeneity

 

1. Clinical heterogeneity

We considered all included studies, hoping to use all studies together. Where clear unforeseen issues were apparent that may have added obvious clinical heterogeneity, we noted these issues, considered them in the analyses and undertook sensitivity analyses for the primary outcome.

 

2. Statistical

 
2.1 Visual inspection

We visually inspected graphs to investigate the possibility of statistical heterogeneity.

 
2.2 Employing the I2 statistic

Heterogeneity between studies was investigated by using the I2 method (Higgins 2003) and the Chi2 'P' value. The former provides an estimate of the percentage of variation in observed results thought unlikely to be due to chance. A value equal to or greater than 50% was taken to indicate heterogeneity and the reason for heterogeneity was explored. If the inconsistency was high and the clear reasons were found, the data were presented separately.

 

Assessment of reporting biases

Data from all identified and selected trials were entered into a funnel graph (trial effect versus trial size) in an attempt to investigate overt publication bias. The possible existence of small study effects was examined by Egger’s regression method (Egger 1997) as well as by visual inspection of the graph (see Results).

 

Data synthesis

In the absence of significant heterogeneity, a fixed-effect model was used. However, if significant heterogeneity was demonstrated, a random-effects model was used for analysis. Where available, the analyses were based on intention-to-treat data from the individual studies. The data from included trials were combined in a meta-analysis if they were sufficiently homogeneous, both clinically and statistically.

 

Subgroup analysis and investigation of heterogeneity

 

1. Pre-planned subgroup analyses

Subgroup analyses should be performed and interpreted with caution because multiple analyses will lead to false positive conclusions (Oxman 1992). However, we performed the following subgroup analyses, where possible, for the following a priori reasons.

(a) High fidelity IPS versus other vocational approaches.

(b) Augmented supported employment versus other vocational approaches.

 

2. Regression analyses

If we had included a sufficient number of trials (roughly nine to 11) per independent variable, meta-regression would have been performed to determine whether various study-level characteristics affect effect sizes. Possible effect modifiers to be examined in future updates of this review include: study location (USA versus other countries), study location (urban versus rural) and the local unemployment rate. STATA would have been used to perform the meta-regression (STATA 2005).

 

Sensitivity analysis

We examined the robustness of our findings by excluding (i) studies with less than 80% follow-up on the variable at the time point (ii) skewed data (iii) trials with a high risk of bias or where the overall risk of bias was unclear, and (iv) studies where IPS was augmented with other interventions.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Description of studies

See:Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

 

Results of the search

Electronic searches identified 500 references with 9 additional records identified through other sources. After duplicates were removed, we screened 509 records. 107 potentially relevant records were obtained and scrutinised and 59 of these reports did not meet the inclusion criteria (see Characteristics of excluded studies) and had to be excluded. Fourteen trials are included (Figure 1).

 FigureFigure 1. Study flow diagram.

 

Included studies

Two review authors (YK and KK) checked the strict eligibility of the identified studies. They agreed on 98 articles (91.6 %) but disagreed on eight articles. The latter were discussed with a third review author (TAF) and according to the consensus among the authors remaining discrepancies were resolved, One additional study (Bayer 2008) was written in German and judged not eligible by one review author (TAF) who can read and understand German. Forty-seven articles describing 20 studies were finally judged eligible. Of these, five trials (eight articles) (Bejerholm 2009 (SE142); McFarlane 2000; McFarlane 2008 (SE147); Michon 2010; Nuechterlein 2008) are either still underway; are being written-up; in process of publication; or required further details and therefore cannot be included in the present version of the review.

 

1. Study size

A total of 2265 participants were included from 14 trials. The median sample size per arm was 70 participants (range 20-156).

 

2. Study design

Twelve studies were two-arm studies, the remaining (Mueser 2004; Tsang 2009) were multi-arm studies.

 

3. Participants

All 14 studies recruited outpatients. Thirteen RCTs were conducted in the setting of community psychiatric/mental health service. Participants were adults with severe mental illness, with schizophrenia or schizoaffective disorder well represented. Eleven RCTs used DSM-IV (Diagnostic and Statistical Manual) or ICD 10 (International Classification of Diseases) criteria and three studies adopted DSM-III-R criteria. Two studies used other diagnostic criteria (Indiana Department of Mental Health Criteria, OPCRIT, and the Federal Center for Mental Health Services' criteria) (Burns 2007; Gold 2006). No description was given about diagnostic criteria in one RCT (Wong 2008). Men were well represented. There were insufficient data to assess representation of people from ethnic minorities.

 

4. Interventions and comparators

All included studies compared supported employment with other vocational approaches. Among these, 13 studies (Bond 2007; Burns 2007; Drake 1996; Drake 1999; Gold 2006; Howard 2010; Killackey 2008; Latimer 2006; Lehman 2002; Mueser 2004; Tsang 2009; Twamley 2008; Wong 2008) implemented individual placement and support (IPS) as supported employment and one RCT (Macias 2006) adopted supported employment, which was not defined as IPS.

Tsang 2009 consisted of integrated supported employment (ISE), IPS and traditional vocational rehabilitation, and Mueser 2004 involved IPS, standard services including supported employment, and psychosocial rehabilitation program. Only one study (Tsang 2009) implemented augmented supported employment. Detailed information of interventions adopted in each site from the Employment Intervention Demonstration Program (EIDP) (Gold 2006; Lehman 2002; Macias 2006; Mueser 2004; Blankertz 1997; Cook 2005; McFarlane 2002 (SE175); Toprac 2002) were also obtained via the Internet (EIDP website).

In terms of fidelity check of implementation of supported employment, 12 studies used the IPS fidelity scale (Bond 1997b) and two adopted other procedures defined in each study (Drake 1996; Macias 2006).

 

5. Outcomes

Of the 14 included studies, 13 reported vocational and/or non-vocational data (either as dichotomous or as continuous outcomes) that could be entered into a meta-analysis. All included studies reported attrition due to any reason; 13 studies provided data for this outcome.

 
5.1 Primary outcomes and secondary outcomes

Seven out of the 14 included studies reported data for our primary outcome of interest of days in competitive employment. At least one study provided data on each of the remaining secondary outcomes, except for time spent in education, and relapse.

5.2 Outcome scales

5.2.1 Mental state

5.2.1.1 Positive and Negative Syndrome Scale - PANSS (Kay 1987)
This is a 30-item scale, each of which can be defined on a seven-point scoring system from absent to extreme. It has three subscales for measuring the severity of general psychopathology, positive symptoms (PANSS-P), and negative symptoms (PANSS-N). A low score indicates lesser severity. Two studies (Bond 2007; Burns 2007) reported data from this scale.

5.2.1.2 Brief Psychiatric Rating Score - BPRS (Overall 1962)

This scale is used to assess the severity of abnormal mental state. A revised 18-item scale is commonly used, though the original scale has 16 items. Each item is defined on a seven-point scale varying from 'not present' to 'extremely severe', scoring from 0-6 or 1-7. Scores can range from 0-126, with high scores indicating more severe symptoms. Only one study reported this outcome (Drake 1999).

5.2.1.3 Hospital Anxiety and Depression Scale - HADS (Zigmond 1983).

This scale is a self-rating instrument for anxiety and depression in patients with both somatic and mental problems. The scale consists of 14 items on a four-point Likert scale (range 0–3). The total score is the sum of the 14 items, and for each subscale the score is the sum of the respective seven items. One study (Burns 2007) reported data from this scale.

5.2.2 Quality of Life

5.2.2.1 Quality of Life Interview - QOLI (Lehman 1982)

The scale is a self-rating instrument in which participants respond on a Likert scale for all items. Two different Likert scales were used; the first Likert scale ranged from one, “terrible” to 10 “delighted.”and the second ranged from one, “not at all” to five, “at least once a day.”The QOLI assesses objective and subjective quality of life indicators and includes such areas as leisure activities, social relationships, living situations, health, employment and vocational services, and finances. Scoring was performed by adding up scores on all items to obtain a total quality of life score. The original version consists of 143 items and the abbreviated version has thirteen sections consisting of 35 total items. Three studies (Bond 2007, Drake 1999, and Twamley 2008) reported data from this scale.

5.2.2.2 Lancashire Quality of Life Profile European version - LQoLP-EU (Gaite 2000)

This scale was originally developed from the QOLI. It is a structured interview comprising 105 items. It includes nine domains: work and education (seven items); leisure and participation (eight items); religion (four items); finances (seven items); living situation (12 items); legal status and safety (five items); family relations (seven items); social relations (six items) ; and health (10 items).The interview can also assess positive and negative affect; self-esteem; global well-being; quality of life of the patient independent of the patient's own opinion. Two studies (Burns 2007 and Howard 2010) reported data from this scale.

5.2.3 General functioning score

5.2.3.1 Global Assessment Scale - GAS or Global Assessment of Functioning - GAF (Endicott 1976)

This scale is a clinician-rated scale of overall functioning on a scale of 1-100. Lower scores indicate poorer functioning. Three studies reported data from this scale (Burns 2007; Drake 1999; Howard 2010).

 

Excluded studies

Of the 107 references retrieved for more detailed evaluation, 58 articles did not meet our inclusion criteria and were excluded. Reasons for this are presented in the 'Characteristics of excluded studies' table.

 

Awaiting classification

Two studies are considered as awaiting classification (McFarlane 2000; Michon 2010).

 

Ongoing Studies

Three studies are ongoing (Bejerholm 2009 (SE142); McFarlane 2008 (SE147); Nuechterlein 2008).

 

Risk of bias in included studies

See: Included studies, Figure 2, Figure 3.

 FigureFigure 2. 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 3. 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Our judgment about the overall risk of bias in the individual studies is illustrated in Figure 2 and Figure 3. Overall, the methodological quality of the included studies was moderate, with a high risk of bias for blinding across all included studies due to the open nature of the intervention. This type of reporting has been associated with an overestimate of the estimate of effect (Schulz 1995) and this should be considered when interpreting the results.

 

Allocation

Nine studies reported the methods of generating random sequence, in which "a computer originated schedule" was used, while enough description was not given and risk of bias was unclear with regard to sequence generation in six trials. In terms of allocation concealment, seven studies reported enough details, but risk of bias was unclear in the eight remaining studies. Therefore, we were not assured that bias was minimised during the allocation procedure in the other studies, yet the great majority of them reported that the participants allocated to each treatment group were "similar", "the same", "not significantly different", "comparable" or "matched".

 

Blinding

It is in the nature of studies for psychosocial interventions, that it is not possible for participants or those administering the intervention to be masked to the participants' allocation status. Therefore, none of the studies were double-blinded. The reported results may exaggerate estimates of treatment effect (Boutron 2004). Nevertheless, three studies reported that the rater, assessor or interviewer was blind to the assignment (Howard 2010; Tsang 2009; Twamley 2008).

 

Incomplete outcome data

Total attrition rate was moderate and ranged from 2% (Drake 1999) to 32% (Lehman 2002). In six studies, the total dropout rates were more than 20% (Bond 2007; Gold 2006; Lehman 2002; Macias 2006; Tsang 2009; Twamley 2008).

 

Selective reporting

All included studies were rated as high quality in reporting outcome with a low risk of reporting bias. In terms of the Employment Intervention Demonstration Program (EIDP), data from one of the eight RCTs which seemed eligible (Arizona site) were not available due to lack of publication (EIDP website). This might be a source of publication bias.

 

Other potential sources of bias

Relatively small sample size in many of the studies might have reduced the opportunity to have comparable groups thus threatening internal validity, and might also have resulted in under-powered studies, thus increasing chances of false positive outcomes. Moreover, the comparatively short duration of follow-up might be insufficient to answer or address the critical question about durability of effects. In one study (Gold 2006), project redesign and deviation from a pre-specified random assignment process may have compromised study validity.

 

Effects of interventions

See:  Summary of findings for the main comparison Supported employment versus other vocational approaches for adults with severe mental illness

 

COMPARISON 1: Supported employment versus other vocational approaches

 

1.1 Employment (continuous outcomes)

Eleven studies (Bond 2007; Drake 1996; Drake 1999; Gold 2006; Killackey 2008; Latimer 2006; Macias 2006; Mueser 2004; Tsang 2009; Twamley 2008; Wong 2008) reported competitive employment outcomes. All data for this outcome were skewed; however, as per our protocol, where studies had n = 200 participants or more, these were included in data synthesis. Data from the remaining studies were presented as 'Other data' in the Data and analyses section. Data demonstrate high levels of heterogeneity are presented using a random effects model.

 
1.1.1 days in competitive employment (primary outcome) - long term

For days in competitive employment, we found only one relevant trial (n = 204) (Mueser 2004) which demonstrated statistically significant favour for supported employment over other vocational approaches (MD 70.63 CI 43.22 to 98.04,  Analysis 1.1).

 
1.1.2 days in any form of paid employment - long term

In this subgroup we found two relevant trials (n = 510). There was statistically significant favour for supported employment over other vocational approaches (MD 84.94 CI 51.99 to 117.89,  Analysis 1.1); however, with moderate levels of heterogeneity (Chi2=1.85; df=1; P=0.173; I2=46%).

 
1.1.3 job tenure for competitive employment (weeks) - long term

In this subgroup we only found one relevant trial (n = 204) (Mueser 2004). There was statistically significant favour for supported employment over other vocational approaches (MD 9.86 CI 5.36 to 14.36,  Analysis 1.1).

 
1.1.4 job tenure for any paid employment (weeks) - long term

Data from two studies showed no significant difference between groups (n = 423,  Analysis 1.1), with substantial levels of heterogeneity (Chi2=3.73; df=1; P=0.054; I2=73%).

 

1.2 Employment (skewed data)

Skewed data from studies of less than n = 200 were entered as 'Other data' in the Data and analyses section; all data need interpreting with caution. Data from the majority of studies that reported employment outcomes of days in in employment and job tenure are heavily skewed, and are best inspected by viewing  Analysis 1.2.

 
1.2.1 Days in competitive employment

Data at short and medium term suggest a trend favouring supported employment over other vocational approaches for days spent in competitive employment; however these data need interpreting in light of the considerable skew present ( Analysis 1.2).

 
1.2.2 Days in any form of paid employment

There was indication that there were more days spent in any form of paid employment for supported employment at both medium and long term ( Analysis 1.2); again, data are skewed and need interpreting with caution.

 
1.2.3 Job tenure for competitive employment (weeks)

Taking into account the considerable skewed data, at medium term, results indicated more weeks of job tenure for other vocational approaches, and the opposite at long term; again, data are skewed and need interpreting with caution ( Analysis 1.2).

 
1.2.4 Job tenure for any paid employment (weeks)

Data are considerably skewed and are best inspected by viewing the 'Other data' table ( Analysis 1.2).

 
1.2.5 Earnings in the first year

Greater earnings in the first year were associated with participants receiving supported employment; again, data are skewed and need interpreting with caution ( Analysis 1.2).

 

1.3 Employment (dichotomous outcomes)

 
1.3.1 obtained competitive job during the study (high=better)

Seven studies reported data for this outcome (n = 951); there was a statistically significant difference between supported employment and other vocational approaches (RR 3.24 CI 2.17 to 4.82,  Analysis 1.2). However, data demonstrated substantial levels of heterogeneity and are analysed using a random effects model (Chi2=22.87; df=6; P=0.0008; I2=74%).

 

1.4 Time (days) to first competitive employment

 
1.4.1 long term

Again, all data for this outcome were skewed; however, as per our protocol, where studies had n = 200 participants or more, these were included in the data synthesis. Data from the remaining studies were presented using 'Other data' tables in the Data and analyses section. There was evidence that supported employment was associated with less days to first competitive employment than other vocational approaches at long term (1 RCT, n = 204, MD -161.60, 95% CI -225.73 to -97.47,  Analysis 1.4).

 

1.5 Time (days) to first competitive employment (skewed data)

Skewed data from studies of less than n = 200 were entered into 'Other data' tables in the Data and analyses section; all data need interpreting with caution ( Analysis 1.5).

 

1.6 Leaving the study early for any reason

There was no significant difference between groups for leaving the study early in the short term (1 RCT, n = 92) or medium term (2 RCTs, n = 191). By long term, there was a statistically significant difference in favour of supported employment over other vocational approaches (RR 0.66 CI 0.52 to 0.84,  Analysis 1.6) with moderate levels of heterogeneity (Chi2=13.62; df=9; P=0.137; I2=34%).

 

1.7 Mental state: Average endpoint specific symptom score (high = worse) - long term

There was no evidence that supported employment was associated with a lower or higher endpoint specific symptom score than other vocational approaches when using the BPRS, PANSS or HADS scales ( Analysis 1.7).

 

1.8 Service use: 1. Mean days in hospital (skew)

Data are considerably skewed and are best inspected by viewing the 'Other data' table ( Analysis 1.8).

 

1.9 Service use: 2. Number of participants admitted to hospital

In the long term, there was no evidence that supported employment was associated with a lower or higher rate of participants admitted to hospital/re-hospitalised than other vocational approaches at long term (2 RCTs, n = 455, RR 0.71, 95% CI 0.53 to 0.96,  Analysis 1.9).

 

1.10 Quality of Life: Average endpoint QOL-QOLI - various subscales (high = better)

There was no evidence that supported employment was associated with a lower or higher average endpoint quality of life score than other vocational approaches across the measured quality of life domains ( Analysis 1.10)

 

1.11 Global/Social functioning: Average endpoint general functioning score - GAS (high = better)

There was no evidence that supported employment was associated with a lower or higher average endpoint general functioning score than other vocational approaches at long term (3 RCTs, n = 623,  Analysis 1.11).

 

1.12 Adverse effects: Death - natural and suicide

There was no evidence that supported employment was associated with a lower or higher risk of death than other vocational approaches at long term (1 RCT, n = 312,  Analysis 1.12).

 

1.13 Economic Costs (excluding housing costs): Direct costs (GPB £, skewed)

There was no evidence that supported employment was associated with lower or higher economic costs than other vocational approaches; data are considerably skewed and need interpreting with cation ( Analysis 1.13).

 

2. Comparison 2. subgroup analysis: High fidelity IPS versus other vocational approaches

We included RCTs in which high fidelity of IPS was assured using the IPS scale (Bond 1997b) in this subgroup analysis. Though Howard 2010 fulfilled these criteria, the study was excluded from the analysis because the detailed description in the article indicated the low fidelity of IPS conducted in the RCT (See: Characteristics of included studies). Where data were considerably skewed in studies of less than n = 200, we excluded these data.

 

2.1 Employment

 
2.1.1 Days in competitive employment (primary outcome)

There was evidence that high fidelity IPS was associated with more days in competitive employment than other vocational approaches in the long term (1 RCT, n = 306, MD 99.80, 95% CI 69.50 to 130.10,  Analysis 2.1).

 
2.1.2 Job tenure for any paid employment

There was no evidence that high fidelity IPS was associated with more or less longer or shorter job tenure for any paid employment than other vocational approaches in the long term (1 RCT, n = 225,  Analysis 2.1).

 

2.2 Leaving the study early for any reason

There was no evidence that high fidelity IPS was associated with lower or higher rate of participants leaving the study early for any reason than other vocational approaches at short or medium term; however, significantly more people left the study early when receiving other vocational approaches, with moderate heterogeneity present overall (P = 0.02; I2 = 49%,  Analysis 2.2).

 

2.3 Mental state: average endpoint specific symptom score

There was no evidence that high fidelity IPS was associated with a lower or higher endpoint specific symptom score than other vocational approaches when using either the BPRS, PANSS or HAD scales ( Analysis 2.3).

 

2.4 Service Use

 
2.4.1 Number of participants admitted to hospital/re-hospitalised

There was no evidence that high fidelity IPS was associated with a lower or higher rate of participants admitted to hospital/re-hospitalised than other vocational approaches ( Analysis 2.4).

 

2.5 Quality of life: Average endpoint quality of life scores

 
2.5.1 Average endpoint QoL-QoLI - various subscales

There was no evidence that high fidelity IPS was associated with a lower or higher average endpoint quality of life score than other vocational approaches ( Analysis 2.5)

 

2.6 Global/Social functioning: Average endpoint general functioning score

There was no evidence that high fidelity IPS was associated with a lower or higher average endpoint general functioning score than other vocational approaches in the long term ( Analysis 2.6).

 

2.7 Adverse effects: Death - natural and suicide

There was no evidence that high fidelity IPS was associated with a lower or higher risk of death than other vocational approaches ( Analysis 2.7).

 

3. COMPARISON 3: subgroup analysis: Augmented supported employment versus other vocational approaches

This subgroup analysis was not conducted due to the reason described in Summary of main results.

 

4. Funnel Plot Analysis

As stated in the protocol, analyses were carried out as head-to head comparisons. Where available, the funnel plot analyses did not suggest evidence of publication bias (Figure 4, Figure 5, Figure 6), however, for many comparisons the presence of publication bias was not examined because there were insufficient trials to allow meaningful formal assessment using funnel plots.

 FigureFigure 4. Funnel plot of comparison: 1 Supported employment versus other vocational approaches, outcome: 1.1 Employment.
 FigureFigure 5. Funnel plot of comparison: 1 Supported employment versus other vocational approaches, outcome: 1.3 Employment.
 FigureFigure 6. Funnel plot of comparison: 1 Supported employment versus other vocational approaches, outcome: 1.6 Leaving the study early for any reason.

 

5. Regression Analysis

We did not conduct regression analysis because we did not have a sufficient number of trials for most variables, including the primary outcome.

 

6. Sensitivity Analysis

 
6.1 Excluding trials with less than 80% follow-up on the variable at the time point

Results from this sensitivity analysis did not materially change the main findings.

 
6.2 Excluding skewed data

No data were available for four items with regard to average endpoint specific symptom score (positive and negative symptoms of PANSS, and anxiety and depression of HADS) in this sensitivity analysis. This sensitivity analysis was not performed for the outcomes specified in the protocol 1.1 to 1.5 (days in competitive employment, days in any form of paid employment, earnings in the first year, job tenure, time to first competitive employment) and 10.1 (direct costs) (see Measures of treatment effect), because all included continuous data were skewed in terms of these outcomes. Only studies with more than n = 200 were included in data synthesis, with the remaining studies reported in separate data tables, making it difficult to draw any meaningful conclusions from the data.

 
6.3 Excluding trials with a high risk of bias or where the overall risk of bias was unclear.

This sensitivity analysis was not performed, because all included trials were with at least one risk of bias.

 
6.4 Excluding trials where IPS was augmented with other interventions.

Results from this sensitivity analysis did not materially change the main findings.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Summary of main results

A total of 14 randomised controlled trials (2265 participants) were included in this review.

 

COMPARISON 1: Supported employment versus other vocational approaches

In terms of primary outcome, employment: days in competitive employment (long term, i.e. over one year of follow-up), supported employment seems to increase the length of competitive employment when compared with other vocational approaches. However, the vast majority of the data were considerably skewed, making it impossible to draw any meaningful conclusions from these data. However, binary employment outcomes of obtaining competitive employment during the study clearly and significantly favoured supported employment over other vocational approaches.

Supported employment also showed advantage in other secondary outcomes. It seems to increase the length of any form of paid employment and job tenure for competitive employment, and decrease the time to first competitive employment. In terms of job tenure for any paid employment, no statistically significant difference was observed between supported employment and other vocational approaches.

With regard to earnings in the first year, endpoint global state, endpoint specific symptom scores, days in hospital, rate of hospitalisation, endpoint quality of life scores, endpoint global functioning score, death and direct costs, no significant difference was observed between supported employment and other vocational approaches.

 

COMPARISON 2: subgroup analysis: High fidelity Individual Placement and Support IPS) versus other vocational approaches

Results from this subgroup analysis did not materially change the main findings in COMPARISON 1 except that no data were available for direct costs.

Few data were obtained indicating that fidelity to the IPS model affects the effectiveness of supported employment.

One of the 14 included studies, Tsang 2009 adopted augmented supported employment as an experimental intervention and could contribute to a subgroup analysis including only augmented supported employment (COMPARISON 3: subgroup analysis: Augmented supported employment versus other vocational approaches). However, this subgroup analysis did not prove useful for exploring if the effectiveness of supported employment can be augmented by the addition of other interventions, because the study did not provide data about days in competitive employment (long term) and could not contribute to the primary outcome.

 

Sensitivity analysis

Results from a sensitivity analysis excluding studies with less than 80% follow-up on the variable at the time point did not materially change the main findings in COMPARISON 1, except that no statistically significant difference was observed in job tenure for competitive employment between supported employment and other vocational approaches.

 

Overall completeness and applicability of evidence

 

1. Completeness

 
1.1 Duration of follow-up

Though the majority of studies presented long-term data, i.e. over one year of follow-up, this might still not be enough to answer or address the critical question about durability of effects.

 
1.2 Coverage of outcomes

Of the 14 identified studies, 10 (71%) at maximum were able to contribute to any vocational or non-vocational outcome that we had specified in the protocol. For example, eight studies contributed to "Days in any form of paid employment" and seven studies to "Job tenure for any paid employment by weeks," whereas only one study provided data in format we were able to pool for our primary outcome "Days in competitive employment" or five studies for "Average endpoint QOL-life in general". No studies reported data on relapse except average endpoint global state score, and only one or two studies provided data for general functioning or costs. Adverse effects were not reported, except death.

 

2. Applicability

 
2.1 Origin

A percentage of 52.9% of the total number of participants included in the review were from USA, while 29.4% were from Europe.The sample also included people from Canada, Australia and China. Given that a large part of the total sample came from North America and Europe, the present review findings are still lacking applicability to developing countries and, more generally, to countries where mental health systems are not community-based.

 
2.2 People

Variability of participants recruited for trials is likely to reflect the heterogeneity of patients a clinician faces in daily practice when treating people with severe mental illness. This variability was in regard to diagnosis (where participants were affected by a wide diagnostic group including schizophrenic, affective and personality disorder). On average, studies included people with a long history of illness; only Killackey 2008 included participants with a first episode of psychosis. This fits with the concept of severe mental illness, where this label includes certain criteria relating to length of illness.

 
2.3 Interventions

All the included studies compared supported employment with other vocational approaches and there was no study comparing supported employment with treatment as usual, as defined in the protocol. This would not violate the applicability of the results, because most of current psychiatric services provide at least one type of vocational approach (supported employment or pre-vocational rehabilitations).

 

Quality of the evidence

The biggest caveat of the current data-set is that only seven out of 14 (50%) of the identified studies contributed to our primary outcome. For secondary outcomes, eight studies (57%) contributed to days in any form of paid employment but for the others typically between two and five studies only were contributory. This represents a substantial risk of outcome reporting bias (Furukawa 2007). In terms of the quality of individual studies, there also appears to exist some overall risk of bias, as illustrated in Figure 2. This would mean, therefore, a moderate risk of overestimation of positive effects in the current systematic review. Future RCTs in this area should attempt to report all clinically important outcomes, preferably in a standardised format, and also to improve quality of study methodology and its reporting.

The following pre-planned subgroup analyses did not fully answer the question explained in the secondary objectives.

(a) High fidelity IPS versus other vocational approaches.
(b) Augmented supported employment versus other vocational approaches.

Future reviews should include comparisons listed below.

(c) High fidelity IPS versus low fidelity IPS.
(d) Augmented supported employment versus supported employment without augmentation.

 

Potential biases in the review process

The present review is not exempt from some potential biases. We have worked mainly with published reports, and only in few cases with unpublished material. Only a minority of the identified trials contributed to any of the primary or secondary outcomes. This may have lead to a reporting and publishing bias. In several cases, our original protocol was not specific enough and a need for subsequent clarification arose and post hoc decisions had to be taken (see Differences between protocol and review). In some cases this could have affected the review results. Nevertheless, much information would have been lost if we chose to exclude trials where diagnoses of a part of the participants did not fulfil the definition of severe mental illness described in the original protocol.

 

Agreements and disagreements with other studies or reviews

A previous Cochrane review (Crowther 2001) and another systematic review (Twamley 2003) have examined effectiveness of various types of vocational rehabilitation for individuals with severe mental illness, including supported employment. In addition, there are two narrative reviews (Bond 2004; Bond 2008a). Their results are in line with this review. All the previous reviews indicated that supported employment could improve vocational and non-vocational conditions in this population.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

 

Implications for practice

Supported employment was found to be effective in improving a number of outcomes relevant to people with severe mental illness. Indeed, supported employment was shown to increase the likelihood of obtaining any employment and the length of both competitive employment and any form of employment. Furthermore, this type of vocational intervention was indicated to reduce time to first competitive employment and increase job tenure for competitive employment. However, the number of studies contributing to these clinically relevant outcomes was typically around two to five out of the total 14 identified through our systematic literature search. Therefore, whether supported employment is effective for people with severe mental illness is still inconclusive. Data on non-vocational outcomes including mental state, quality of life and costs were very few and difficult to interpret, as were the vast amount of considerably skewed data from the primary outcome of interest.

 
Implications for research

Studies with longer follow-up should be conducted to answer or address the critical question about durability of effects. These trials should also evaluate additional outcomes, including mental state, quality of life and effect on length of hospital stay, and should report adverse events in a more systemic manner. All the studies should report a standard set of outcomes that are relevant to the consumers and policy makers.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

We would like to thank Richard Ben Ibbotson for all his practical help and spiritual support during our review process.

We acknowledge the following authors who provided us with further information on their trials through personal communication: Bond 1986; Bond 1999; Bond 2007; Gervey unpublished; Gold 2006, Howard 2010; Michon 2010, Nuechterlein 2008; Twamley 2008.

We would like to gratefully thank the substantial contribution of Clive Adams and the staff at the Cochrane Schizophrenia Group (CSG) in Nottingham,UK, for all their practical help and spiritual support during our review process. The Cochrane Schizophrenia Group Editorial Base in Nottingham produces and maintains standard text for use in the Methods sections of their reviews. We have used this text as the basis of what appears here and adapted it as required.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
Download statistical data

 
Comparison 1. Supported employment versus other vocational approaches

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Employment3Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 days in competitive employment (primary outcome) - long term
1204Mean Difference (IV, Random, 95% CI)70.63 [43.22, 98.04]

    1.2 days in any form of paid employment - long term
2510Mean Difference (IV, Random, 95% CI)84.94 [51.99, 117.89]

    1.3 job tenure for competitive employment (weeks) - long term
1204Mean Difference (IV, Random, 95% CI)9.86 [5.36, 14.36]

    1.4 job tenure for any paid employment (weeks) - long term
2423Mean Difference (IV, Random, 95% CI)3.86 [-5.66, 13.38]

 2 Employment (skewed)Other dataNo numeric data

    2.1 days in competitive employment (primary outcome) - medium term
Other dataNo numeric data

    2.2 days in competitive employment (primary outcome) - long term
Other dataNo numeric data

    2.3 days in any form of paid employment - medium term
Other dataNo numeric data

    2.4 days in any form of paid employment - long term
Other dataNo numeric data

    2.5 job tenure for competitive employment (weeks) - medium term
Other dataNo numeric data

    2.6 job tenure for competitive employment (weeks) - long term
Other dataNo numeric data

    2.7 job tenure for any paid employment (weeks) - medium term
Other dataNo numeric data

    2.8 job tenure for any paid employment (weeks) - long term
Other dataNo numeric data

    2.9 Earnings from paid employment - CAN ($) - long term
Other dataNo numeric data

    2.10 Earnings from paid employment - USD ($) per hour - long term
Other dataNo numeric data

    2.11 Earnings from paid employment - USD ($) - long term
Other dataNo numeric data

    2.12 Earnings from paid employment - AUS ($) - medium term
Other dataNo numeric data

 3 Employment7Risk Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 obtained any job during the study (high=better)
7951Risk Ratio (M-H, Random, 95% CI)3.24 [2.17, 4.82]

 4 Time (days) to first competitive employment1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    4.1 long term
1204Mean Difference (IV, Fixed, 95% CI)-161.60 [-225.73, -97.47]

 5 Time (days) to first competitive employment (skewed)Other dataNo numeric data

    5.1 medium term
Other dataNo numeric data

    5.2 long term
Other dataNo numeric data

 6 Leaving the study early for any reason132114Risk Ratio (M-H, Random, 95% CI)0.76 [0.57, 1.01]

    6.1 short term
192Risk Ratio (M-H, Random, 95% CI)0.33 [0.01, 7.98]

    6.2 medium term
2191Risk Ratio (M-H, Random, 95% CI)1.92 [0.98, 3.76]

    6.3 long term
101831Risk Ratio (M-H, Random, 95% CI)0.66 [0.52, 0.84]

 7 Mental state: Average endpoint specific symptom score (high = worse) - long term3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    7.1 BPRS specific symptom score
1152Mean Difference (IV, Fixed, 95% CI)-1.90 [-5.71, 1.91]

    7.2 PANSS positive symptoms
2446Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.97, 0.96]

    7.3 PANSS negative symptoms
2446Mean Difference (IV, Fixed, 95% CI)-2.12 [-3.20, -1.05]

    7.4 PANSS cognitive
1194Mean Difference (IV, Fixed, 95% CI)-1.20 [-3.09, 0.69]

    7.5 PANSS specific symptom score
1194Mean Difference (IV, Fixed, 95% CI)-3.05 [-8.01, 1.91]

    7.6 PANSS emotional discomfort symptoms
1194Mean Difference (IV, Fixed, 95% CI)0.17 [-1.17, 1.51]

    7.7 PANSS hostility/excitement
1194Mean Difference (IV, Fixed, 95% CI)-0.17 [-0.80, 0.46]

    7.8 HADS anxiety
1252Mean Difference (IV, Fixed, 95% CI)-0.20 [-1.30, 0.90]

    7.9 HADS depression
1252Mean Difference (IV, Fixed, 95% CI)-0.10 [-1.20, 1.00]

 8 Service use: 1. Mean days in hospital (skewed)Other dataNo numeric data

    8.1 long term
Other dataNo numeric data

 9 Service use: 2. Number of participants admitted to hospital2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    9.1 long term
2455Risk Ratio (M-H, Fixed, 95% CI)0.71 [0.53, 0.96]

 10 Quality of Life: Average endpoint QOL-QOLI - various subscales (high = better)5Mean Difference (IV, Fixed, 95% CI)Subtotals only

    10.1 LQoLP-EU life in general
5867Mean Difference (IV, Fixed, 95% CI)0.04 [-0.10, 0.18]

    10.2 financial
1194Mean Difference (IV, Fixed, 95% CI)0.10 [-0.32, 0.52]

    10.3 job satisfaction
1152Mean Difference (IV, Fixed, 95% CI)0.0 [-0.53, 0.53]

    10.4 housing
1152Mean Difference (IV, Fixed, 95% CI)0.0 [-0.46, 0.46]

    10.5 town
1152Mean Difference (IV, Fixed, 95% CI)0.20 [-0.29, 0.69]

    10.6 leisure
2346Mean Difference (IV, Fixed, 95% CI)0.01 [-0.25, 0.28]

    10.7 services
1152Mean Difference (IV, Fixed, 95% CI)0.0 [-0.38, 0.38]

    10.8 vocational services
1152Mean Difference (IV, Fixed, 95% CI)0.0 [-0.51, 0.51]

    10.9 time spent with others
1194Mean Difference (IV, Fixed, 95% CI)-0.15 [-0.48, 0.18]

    10.10 socialisation
1194Mean Difference (IV, Fixed, 95% CI)0.16 [-0.09, 0.41]

 11 Global/Social functioning: Average endpoint general functioning score - GAS (high = better)3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    11.1 long term
3623Mean Difference (IV, Fixed, 95% CI)-0.70 [-2.82, 1.41]

 12 Adverse effects: Death - natural and suicide1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    12.1 long term
1312Risk Ratio (M-H, Fixed, 95% CI)1.5 [0.25, 8.85]

 13 Economic costs: 1. Direct costs (British £, skewed)Other dataNo numeric data

    13.1 long term
Other dataNo numeric data

 
Comparison 2. Sub-group analyses: High fidelity IPS vs other vocational approaches

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Employment2Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 days in any form of paid employment - long term
1306Mean Difference (IV, Random, 95% CI)99.80 [69.50, 130.10]

    1.2 job tenure for any paid employment - long term
1225Mean Difference (IV, Random, 95% CI)-1.16 [-8.50, 6.18]

 2 Leaving the study early for any reason132114Risk Ratio (M-H, Random, 95% CI)0.76 [0.57, 1.01]

    2.1 short term
192Risk Ratio (M-H, Random, 95% CI)0.33 [0.01, 7.98]

    2.2 medium term
2191Risk Ratio (M-H, Random, 95% CI)1.92 [0.98, 3.76]

    2.3 long term
101831Risk Ratio (M-H, Random, 95% CI)0.66 [0.52, 0.84]

 3 Mental state: Average endpoint specific symptom score (high = worse) - long term3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 BPRS specific symptom score
1152Mean Difference (IV, Fixed, 95% CI)-1.90 [-5.71, 1.91]

    3.2 PANSS positive symptoms
2446Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.97, 0.96]

    3.3 PANSS negative symptoms
2446Mean Difference (IV, Fixed, 95% CI)-2.12 [-3.20, -1.05]

    3.4 PANSS cognitive
1194Mean Difference (IV, Fixed, 95% CI)-1.20 [-3.09, 0.69]

    3.5 PANSS hostility/excitement
1194Mean Difference (IV, Fixed, 95% CI)-0.17 [-0.80, 0.46]

    3.6 PANSS emotional discomfort symptoms
1194Mean Difference (IV, Fixed, 95% CI)0.17 [-1.17, 1.51]

    3.7 PANSS specific symptom score
1194Mean Difference (IV, Fixed, 95% CI)-3.05 [-8.01, 1.91]

    3.8 HADS anxiety
1252Mean Difference (IV, Fixed, 95% CI)-0.20 [-1.30, 0.90]

    3.9 HADS depression
1252Mean Difference (IV, Fixed, 95% CI)-0.10 [-1.20, 1.00]

 4 Service use: Number of participants admitted to hospital2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    4.1 long term
2455Risk Ratio (M-H, Fixed, 95% CI)0.71 [0.53, 0.96]

 5 Quality of Life: Average endpoint QOL-QOLI - various subscales (high = better)4Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 LQoLP-EU life in general
4648Mean Difference (IV, Random, 95% CI)-0.02 [-0.19, 0.14]

    5.2 job satisfaction
1152Mean Difference (IV, Random, 95% CI)0.0 [-0.53, 0.53]

    5.3 housing
1152Mean Difference (IV, Random, 95% CI)0.0 [-0.46, 0.46]

    5.4 town
1152Mean Difference (IV, Random, 95% CI)0.20 [-0.29, 0.69]

    5.5 leisure
2346Mean Difference (IV, Random, 95% CI)0.01 [-0.25, 0.28]

    5.6 services
1152Mean Difference (IV, Random, 95% CI)0.0 [-0.38, 0.38]

    5.7 vocational services
1152Mean Difference (IV, Random, 95% CI)0.0 [-0.51, 0.51]

    5.8 time spent with others
1194Mean Difference (IV, Random, 95% CI)-0.15 [-0.48, 0.18]

    5.9 socialisation
1194Mean Difference (IV, Random, 95% CI)0.16 [-0.09, 0.41]

 6 Global/Social functioning: Average endpoint general functioning score - GAS (high = better)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    6.1 long term
2404Mean Difference (IV, Fixed, 95% CI)-0.70 [-3.08, 1.67]

 7 Adverse effects: Death - natural and suicide1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    7.1 long term
1312Risk Ratio (M-H, Fixed, 95% CI)1.5 [0.25, 8.85]

 
Comparison 3. Sensitivity analysis: Excluding trials with less than 80% follow-up on the variable at the time point

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Employment2Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 days in competitive employment (primary outcome)
1204Mean Difference (IV, Random, 95% CI)70.63 [43.22, 98.04]

    1.2 days in any form of paid employment
2510Mean Difference (IV, Random, 95% CI)84.94 [51.99, 117.89]

    1.3 job tenure for competitive employment (weeks)
1204Mean Difference (IV, Random, 95% CI)9.86 [5.36, 14.36]

    1.4 job tenure for any paid employment (weeks)
1204Mean Difference (IV, Random, 95% CI)8.56 [2.01, 15.11]

 2 Time (days) to first competitive employment1204Mean Difference (IV, Random, 95% CI)-161.60 [-225.73, -97.47]

 3 Leaving the study early for any reason61054Risk Ratio (M-H, Random, 95% CI)0.92 [0.54, 1.58]

    3.1 medium term
2191Risk Ratio (M-H, Random, 95% CI)5.27 [1.36, 20.34]

    3.2 long term
4863Risk Ratio (M-H, Random, 95% CI)0.65 [0.40, 1.05]

 4 Service use: 2. Number of participants admitted to hospital1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    4.1 long term
1312Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.44, 0.90]

 5 Quality of Life: Average endpoint QOL-QOLI - various subscales (high = better)4Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 LQoLP-EU life in general - long term
4817Mean Difference (IV, Random, 95% CI)0.04 [-0.13, 0.20]

 
Comparison 4. Sensitivity analysis: Excluding trials where IPS was augmented with other interventions

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Employment2Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 job tenure for any paid employment (weeks) - long term
2423Mean Difference (IV, Random, 95% CI)3.86 [-5.66, 13.38]

 2 Leaving the study early for any reason91364Risk Ratio (M-H, Random, 95% CI)0.89 [0.60, 1.33]

    2.1 medium term
3241Risk Ratio (M-H, Random, 95% CI)2.76 [0.62, 12.38]

    2.2 long term
61123Risk Ratio (M-H, Random, 95% CI)0.71 [0.49, 1.01]

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Last assessed as up-to-date: 23 May 2012.


DateEventDescription

16 September 2013AmendedReference corrected.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Protocol first published: Issue 1, 2010
Review first published: Issue 9, 2013


DateEventDescription

6 October 2010AmendedContact details updated.

15 February 2010AmendedContact details updated.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Yoshihiro Kinoshita - developed and wrote protocol, participated in literature searches, selected studies and extracted data, wrote report.
Toshi A Furukawa - protocol development, helped in studies selection, data extraction and writing the report.
Kuni Kinoshita - participated in studies selection and data extraction.
Mina Honyashiki - participated in studies selection and data extraction.
Ichiro M Omori - developed protocol, helped in studies selection.
Max Marshall - developed protocol.
Gary R Bond - developed protocol, helped in studies selection and data extraction.
Peter Huxley - developed protocol.
Naoji Amano - helped in writing the report.
David Kingdon - developed protocol.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Internal sources

  • Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya CityUniversity Graduate School of Medical Sciences, Japan.
  • Department of Psychiatry, University of Southampton, UK.
  • Department of Psychiatry, Shinshu University School of Medicine, Japan.

 

External sources

  • none, Not specified.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 
1. Types of participants

A sentence "Trials were included where a majority of participants (more than 50%) were suffering from schizophrenia and schizophrenia-like disorders; bipolar disorders; or depression with psychotic features." was included.

 
2. Types of interventions

A description "Fidelity of IPS was assessed by a two-step procedure explained below:

1. Two review authors (YK and KK) independently selected RCTs that assured fidelity of IPS using the IPS scale (Bond 1997b). Trials which did not fulfil this criterion were rated those with low fidelity IPS.

2. The same two review authors checked the selected articles. If detailed description, especially in terms of engagement and intensity, indicated low fidelity of IPS conducted in some of the RCTs, fidelity of such IPS was rated as low in this review. If not, fidelity of the IPS was classified as high. The reason for judgement for the low fidelity IPS is presented in Characteristics of included studies." was included.

 
3. Types of outcome measures

A description "a follow-up duration of 12 months was also considered as long term" was added.

 
4. Secondary outcomes

We renamed the outcome 1.4 "Job stability" to Job tenure and defined it.

Item 1.5 "Numbers not participating in programmes (as defined by individual studies)" was omitted.

Item 3. Leaving the study early: A description "(i.e. Number of participants who dropped-out from service)" was added.

Items 4.5 Average endpoint global state score and 4.6 Average change in global state scores were omitted because these items overlapped with items 8.1 Average endpoint general functioning score and 8.2 Average change in general functioning scores.

With regard to "8.1 Average endpoint general functioning score", we made post-hoc decision to add the following description: "When Global Assessment of Functioning (GAF) was rated in symptoms and disability separately, lower score thereof was considered as general GAF score, and extracted and integrated in a meta-analysis.

 
5. Data and analyses section

This was modified because exclusion and inclusion of skewed data seemed incomplete. For example, Mueser 2004 (n >= 200) was not included in some items of sub-group analyses "high fidelity IPS vs. other vocational approaches".

 
6. Sensitivity analysis

In a original sentence "We will examine the robustness of our findings by excluding (i) studies with less than 20% follow up on the variable at the time point...", an exclusion criterion for follow-up rate was changed from "less than 20%" to "less than 80%".

 
7. Subgroup analysis and investigation of heterogeneity
 
6.1 Pre-planned subgroup analyses

A description "(a) Excluding studies with low fidelity IPS and augmented supported employment" was substituted with "(a) High fidelity IPS versus other vocational approaches" to clarify what was done in the procedure.

A description "(b) Augmented supported employment versus treatment as usual" was substituted with "(b) Augmented supported employment versus other vocational approaches" to clarify what was done in the procedure.

 
8. Overall

Some sections of the methods text have been updated to reflect updates in the Cochrane Schizophrenia Group methods.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
Bond 2007 {published data only}
  • Bond GR, Salyers MP, Dincin J, Drake RE, Becker DR, Fraser VV, et al. A randomized controlled trial comparing two vocational models for persons with severe mental illness. Journal of Consulting and Clinical Psychology 2007;75(6):968-82.
  • Fraser VV, Jones AM, Frounfelker R, Harding B, Hardin T, Bond GR. VR closure rates for two vocational models. Psychiatric Rehabilitation Journal 2008;31(4):332-9.
  • Harding B, Torres-Harding S, Bond GR, Salyers MP, Rollins AL, Hardin T. Factors associated with early attrition from psychosocial rehabilitation programs. Community Mental Health Journal 2008;44(4):283-8.
  • Kukla M, Bond GR. The working alliance and employment outcomes for people with severe mental illness enrolled in vocational programs. Rehabilitation Psychology 2009;54(2):157-63.
  • Kukla ME. The relationship between employment status and non vocational outcomes for persons with severe mental illness enrolled in vocational programs: a longitudinal study [dissertation]. Indianapolis, Indiana: University of Purdue, 2010.
Burns 2007 {published data only}
  • Burns T. Increasing access to work for longer term community mental health team clients: the impact of a work-placement training intervention. National Research Register 2001; Vol. 1.
  • Burns T, Catty J, Becker T, Drake RE, Fioritti A, Knapp M, et al. EQOLISE Group. The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial. Lancet 2007;370(9593):1146-52.
  • Burns T, Catty J, EQOLISE Group. IPS in Europe: the EQOLISE trial. Psychiatric Rehabilitation Journal 2008;31(4):313-7.
  • Burns T, Catty J, White S, Becker T, Koletsi M, Fioritti A, et al. EQOLISE Group. The impact of supported employment and working on clinical and social functioning: Results of an international study of individual placement and support. Schizophrenia Bulletin 2009;35(5):949-58.
  • Burns T, White SJ, Catty J, EQOLISE group. Individual placement and support in Europe: the EQOLISE trial. International Review of Psychiatry 2008;20(6):498-502.
  • Catty J, Lissouba P, White S, Becker T, Drake RE, Fioritti A, et al. EQOLISE Group. Predictors of employment for people with severe mental illness: results of an international six-centre randomised controlled trial.. British Journal of Psychiatry 2008;192(3):224-31.
Drake 1996 {published data only}
  • Becker DR, Drake RE, Bond GR, Xie H, Dain BJ, Harrison K. Job terminations among persons with severe mental illness participating in supported employment. Community Mental Health Journal 1998;34(1):71-82.
  • Clark RE. Supported employment and managed care: can they coexist?. Psychiatric Rehabilitation Journal 1998;22(1):62-8.
  • Clark RE, Xie H, Becker DR, Drake RE. Benefits and costs of supported employment from three perspectives. Journal of Behavioral Health Services & Research 1998;25(1):22-34.
  • Drake RE, McHugo GJ, Becker DR, Anthony WA, Clark RE. The New Hampshire study of supported employment for people with severe mental illness. Journal of Consulting and Clinical Psychology 1996;64(2):391-9.
  • Mueser KT, Becker DR, Torrey WC, Xie H, Bond GR, Drake RE, et al. Work and non-vocational domains of functioning in persons with severe mental illness: a longitudinal analysis. Journal of Nervous and Mental Disease 1997;185(7):419-26.
  • Torrey WC, Mueser KT, McHugo GH, Drake RE. Self-esteem as an outcome measure in studies of vocational rehabilitation for adults with severe mental illness. Psychiatric Services 2000;51(2):229-33.
Drake 1999 {published data only}
  • Dixon L, Hoch JS, Clark R, Bebout R, Drake R, McHugo G, Becker D. Cost-effectiveness of two vocational rehabilitation programs for persons with severe mental illness. Psychiatric Services 2002;53(9):1118-24.
  • Drake RE, McHugo GJ, Bebout RR, Becker DR, Harris M, Bond GR, et al. A randomized clinical trial of supported employment for inner-city patients with severe mental disorders. Archives of General Psychiatry 1999;56(7):627-33.
Gold 2006 {published data only}
  • Gold JM, Goldberg RW, McNary SW, Dixon LB, Lehman AF. Cognitive correlates of job tenure among patients with severe mental illness. American Journal of Psychiatry 2002;159(8):1395-402.
  • Gold PB, Meisler N, Santos AB, Carnemolla MA, Williams OH, Keleher J. Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness. Schizophrenia Bulletin 2006;32(2):378-95.
  • Meisler N. Rural-based supported employment approaches: results from the South Carolina site of the employment intervention demonstration project. Proceedings of the155th Annual Meeting of the American Psychiatric Association; 2002 May18-23; Philadelphia, PA, USA. 2002.
Howard 2010 {published data only}
  • Heslin M, Howard L, Leese M, McCrone P, Rice C, Jarrett M, et al. Randomized controlled trial of supported employment in England: 2 year follow-up of the supported work and needs (SWAN) study. World Psychiatry 2011;10(2):132-7.
  • Howard LM, Heslin M, Leese M, McCrone P, Rice C, Jarrett M, et al. Supported employment: randomised controlled trial. British Journal of Psychiatry 2010;196(5):404-11.
  • ISRCTN96677673. RCT of individual placement and support (IPS) to improve the occupational outcomes for people with severe mental illness in South London.. http://www.controlled-trials.com/ISRCTN96677673/SWAN (accessed 06 July 2009).
  • Thornicroft G. Employment programme for patients with severe mental illness operated by status employment. National Research Register 2004; Vol. 4.
Killackey 2008 {published data only}
  • Killackey E, Jackson HJ, McGorry PD. Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual. British Journal of Psychiatry 2008;193(2):114-20.
Latimer 2006 {published data only}
  • Latimer EA, Lecomte T, Becker DR, Drake RE, Duclos I, Piat M, et al. Generalisability of the individual placement and support model of supported employment: results of a Canadian randomised controlled trial. British Journal of Psychiatry 2006;189:65-73.
Lehman 2002 {published data only}
  • Lehman AF, Goldberg R, Dixon LB, McNary S, Postrado L, Hackman A, et al. Improving employment outcomes for persons with severe mental illnesses. Archives of General Psychiatry 2002;59(2):165-72.
Macias 2006 {published data only}
  • Macias C, DeCarlo LT, Wang Q, Frey J, Barreira P. Work interest as a predictor of competitive employment: policy implications for psychiatric rehabilitation. Administration and Policy in Mental Health 2001;28(4):279-97.
  • Macias C, Rodican CF, Hargreaves WA, Jones DR, Barreira PJ, Wang Q. Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models. Psychiatric Services 2006;57(10):1406-15.
  • Schonebaum AD, Boyd JK, Dudek KJ. A comparison of competitive employment outcomes for the clubhouse and PACT models. Psychiatric Services 2006;57(10):1416-20.
Mueser 2004 {published data only}
  • Mueser KT, Becker DR, Wolfe R. Supported employment, job preferences, job tenure and satisfaction. Journal of Mental Health 2001;10(4):411-7.
  • Mueser KT, Clark RE, Haines M, Drake RE, McHugo GJ, Bond GR, et al. The Hartford study of supported employment for persons with severe mental illness. Journal of Consulting and Clinical Psychology 2004;72(3):479-90.
  • Mueser KT, Essock SM, Haines M, Wolfe R, Xie H. Posttraumatic stress disorder, supported employment, and outcomes in people with severe mental illness. CNS spectrums 2004;9(12):913-25.
Tsang 2009 {published data only}
  • Tsang HW, Chan A, Wong A, Liberman RP. Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness. Journal of Behavior Therapy and Experimental Psychiatry 2009;40(2):292-305.
Twamley 2008 {published data only}
  • Twamley EW, Narvaez JM, Becker DR, Bartels SJ, Jeste DV. Supported employment for middle-aged and older people with schizophrenia. American Journal of Psychiatric Rehabilitation 2008;11(1):76-89.
Wong 2008 {published data only}
  • Wong K, Chiu R, Tang B, Mak D, Liu J, Chiu SN. A randomized controlled trial of a supported employment program for persons with long-term mental illness in Hong Kong. Psychiatric Services 2008;59(1):84-90.

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
Alverson 1998 {published data only}
  • Alverson H, Vincente E. An ethnographic study of vocational rehabilitation for Puerto Rican Americans with severe mental illness. Psychiatric Rehabilitation Journal 1998;22:69-72.
Bayer 2008 {published data only}
  • Bayer W, Koster M, Salize HJ, Hohl W, Machleidt W, Wiedl KH, et al. Longer-term effects of inpatient vocational and ergotherapeutic measures on the vocational integration of patients with schizophrenia. Psychiatrische Praxis 2008;35(4):170-3.
Bell 1993 {published data only}
  • Bell MD, Milstein RM, Lysaker PH. Pay as an incentive in work participation by patients with severe mental illness. Hospital and Community Psychiatry 1993;44(7):684-6.
Bell 1993b {published data only}
  • Bell MD, Milstein RM, Lysaker PH. Pay and participation in work activity: clinical benefits for clients with schizophrenia. Psychosocial Rehabilitation Journal 1993;17(2):173-6.
Bell 1995 {published data only}
  • Bell M, Lysaker P. Paid work activity in schizophrenia: program costs offset by costs of rehospitalizations. Psychosocial Rehabilitation Journal 1995;18(4):25-34.
Bell 1996 {published data only}
  • Bell MD, Lysaker PH, Milstein RM. Clinical benefits of paid work activity in schizophrenia. Schizophrenia Bulletin 1996;22(1):51-67.
Bell 1997 {published data only}
  • Bell MD, Lysaker PH. Clinical benefits of paid work activity in schizophrenia: 1-year follow-up. Schizophrenia Bulletin 1997;23(2):317-28.
Bell 2001 {published data only}
  • Bell M, Bryson G, Greig T, Corcoran C, Wexler BE. Neurocognitive enhancement therapy with work therapy: effects on neuropsychological test performance. Archives of General Psychiatry 2001;58:763-8.
Bell 2001b {published data only}
  • Bell MD. Effects of work activity augmented by cognitive training. CRISP database 2001.
Bell 2002 {published data only}
  • Bell MD, Bryson G, Wexler BE. Remediating working memory in impaired and less-impaired schizophrenia.. Proceedings of the155th Annual Meeting of the American PsychiatricAssociation; 2002 May 18-23; Philadelphia, PA, USA. 2002.
Bell 2003 {published data only}
  • Bell MD, Bryson G, Greig T, Wexler B. Neurocognitive enhancement therapy in schizophrenia: durability of effects on neuropsychological test performance six months after training. Proceedings of the 9th International Congress on Schizophrenia Research; 2003 Mar 29-Apr 2; Colorado Spings, Colorado, USA. 2003.
Bell 2003b {published data only}
Bell 2005 {published data only}
  • Bell MD, Bryson G, Greig TC, Fiszdon JM, Wexler BE. Functional outcomes from a RCT of cognitive training and work therapy: 12 month follow-up. Proceedings of the 20th International Congress on Schizophrenia Research; 2005 Apr 2-6; Savannah, Georgia, USA. 2005.
Bell 2005b {published data only}
  • Bell MD, Bryson GJ, Greig TC, Fiszdon JM, Wexler BE. Neurocognitive enhancement therapy with work therapy: Productivity outcomes at 6- and 12-month follow-ups. Journal of Rehabilitation Research & Development 2005;42(6):829-38.
Bell 2007 {published data only}
  • NCT00339170. Computer-based cognitive training program to improve productivity and work performance in individuals with schizophrenia. http://clinicaltrials.gov 2007.
Bell 2007b {published data only}
  • NCT00430560. Work activity augmented by cognitive rehabilitation for schizophrenia. http://clinicaltrials.gov 2007.
Bell 2007c {published data only}
  • Bell M, Fiszdon J, Greig T, Wexler B, Bryson G. Neurocognitive enhancement therapy with work therapy in schizophrenia: 6-month follow-up of neuropsychological performance. Journal of Rehabilitation Research & Development 2007;44(5):761-70.
Bell 2007d {published data only}
  • Bell MD, Greig TC, Zito W, Wexler BW. An RCT of neurocognitive enhancement therapy with supported employment: employment outcomes at 24 months. Schizophrenia Bulletin 2007;33(2):420-1.
Bell 2008 {published data only}
Bell 2008b {published data only}
  • Bell M, Zito W, Greig T, Wexler BE. Neurocognitive enhancement therapy and competitive employment in schizophrenia: Effects on clients with poor community functioning. American Journal of Psychiatric Rehabilitation 2008;11:109-22.
Bell 2009 {published data only}
  • NCT00829400. Cognitive training to enhance VA work program outcomes. http://clinicaltrials.gov 2009.
Blankertz 1997 {published data only}
  • Blankertz LE, Keller C. The provision of long-term vocational supports for individuals with severe mental illness. American Sociological Association 1997.
Bond 1986 {published data only}
  • Bond GR, Dincin J. Accelerating entry into transitional employment in a psychosocial rehabilitation agency. Rehabilitation Psychology 1986;31(3):143-54.
Bond 1995 {published data only}
  • Bond GR, Dietzen LL, McGrew JH, Miller LD. Accelerating entry Into supported employment for persons with severe psychiatric disabilities. Rehabilitation Psychology 1995;40(2):75-94.
Briggs 1966 {published data only}
  • Briggs PF, Yater AC. Counseling and psychometric signs as determinants in the vocational success of discharged psychiatric patients. Journal of Clinical Psychology 1966;22:100-4.
Bryson 2002 {published data only}
  • Bryson G, Lysaker P, Bell M. Quality of life benefits of paid work activity in schizophrenia. Schizophrenia Bulletin 2002;28(2):249-57.
Bryson 2005 {published data only}
  • Bryson GJ, Bell MD, Greig TC, Wexler BE. Neuropsychological outcomes from a RCT of cognitive training and work therapy: 12 month follow-up. Proceedings of the 20th International Congress on Schizophrenia Research; 2005 Apr 2-6; Savannah, Georgia, USA. 2005.
Buchain 2003 (SE155) {published data only}
  • Buchain PC, Vizzotto AD, Henna Neto J, Elkis H. Randomized controlled trial of occupational therapy in patients with treatment-resistant schizophrenia. Revista Brasileira de Psiquiatria 2003;25(1):26-30.
Chandler 1996 (SE156) {published data only}
  • Chandler D, Meisel J, McGowen M, Mintz J, Madison K. Client outcomes in two model capitated integrated service agencies. Psychiatric Services 1996;47(2):175-80.
Chandler 1996 (SE159) {published data only}
  • Chandler D, Meisel J, Hu TW, McGowen M, Madison K. Client outcomes in a three-year controlled study of an integrated service agency model. Psychiatric Services 1996;47(12):1337-43.
Chandler 1997 (SE157) {published data only}
  • Chandler D, Hu TW, Meisel J, McGowen M, Madison K. Mental health costs, other public costs, and family burden among mental health clients in capitated integrated service agencies. Journal of Mental Health Administration 1997;24(2):178-88.
Chandler 1997 (SE160) {published data only}
  • Chandler D, Meisel J, Hu T, McGowen M, Madison K. A capitated model for a cross-section of severely mentally ill clients: employment outcomes. Community Mental Health Journal 1997;33(6):501-16.
Chandler 1998 (SE158) {published data only}
  • Chandler D, Meisel J, Hu T, McGowen M, Madison K. A capitated model for a cross-section of severely mentally ill clients: hospitalization. Community Mental Health Journal 1998;34(1):13-26.
Collier 2006 {published data only}
  • NCT00333177. Effectiveness of psychosocial therapy plus risperidone treatment improving work or school performance in people with recent-onset schizophrenia. http://clinicaltrials.gov (accessed 6 July 2009).
Cook 2005 {published data only}
  • Cook JA, Leff HS, Blyler CR, Gold PB, Goldberg RW, Mueser KT, et al. Results of a multi site randomized trial of supported employment interventions for individuals with severe mental illness. Archives of General Psychiatry 2005;62(5):505-12.
  • Cook JA, Lehman AF, Drake R, McFarlane WR, Gold PB, Leff HS, et al. Integration of psychiatric and vocational services: a multi site randomized, controlled trial of supported employment. American Journal of Psychiatry 2005;162(10):1948-56.
  • Cook JA, Razzano LA, Burke-Miller JK, Blyler CR, Leff HS, Mueser KT, et al. Effects of co-occuring disorders on employment outcomes in a multi site randomized study of supported employment for people with severe mental illness. Journal of Rehabilitation Research & Development 2007;44(6):837-50.
Davis 2010 {published data only}
  • Davis LL, Drebing C, Parker PE, Leon AC. Occupational recovery in persons with PTSD:? Results from clinical investigations. Proceedings of the International Society of Traumatic Stress Studies; 2010 Nov 3-5 ; Montreal, Quebec. 2010.
Drebing 2007 (SE164) {published data only}
  • Drebing CE, Van Ormer EA, Mueller L, Hebert M, Penk WE, Petry NM, et al. Adding contingency management intervention to vocational rehabilitation: outcomes for dually diagnosed veterans. Journal of Rehabilitation Research & Development 2007;44(6):851-66.
Gervey unpublished {published data only}
  • Gervey R, Bedell JR. Supported employment in vocational rehabilitation. Psychological assessment and treatment of persons with severe mental illness. Washington, DC, USA: Taylor & Francis, 1994:1151-75.
  • Gervey RG, Bedell JR, Parrish A. Supported employment versus paid pre-employment training for persons with psychiatric disabilities: A controlled study. Data on file.
Glynn 2005 {published data only}
  • NCT00261716. Motivational interviewing to improve work outcomes in schizophrenia. http://clinicaltrials.gov (accessed 6 July 2009).
Greig 2007 {published data only}
  • Greig TC, Zito W, Wexler BE, Fiszdon J, Bell MD. Improved cognitive function in schizophrenia after one year of cognitive training and vocational services. Schizophrenia Research 2007;96(1-3):156-61.
Hu 1998 (SE166) {published data only}
  • Hu TW, Jerrell JM. Estimating the cost impact of three case management programmes for treating people with severe mental illness. British Journal of Psychiatry 1998;173(Suppl 34):26-32.
Jones 2005 (SE143) {published data only}
  • Jones PB. Improving social recovery in early affective and non-affective psychosis: a randomised controlled trial of social recovery orientated cognitive behaviour (SRCBT). National Research Register 2005, issue 3.
Katz 2009 (SE144) {published data only}
  • Katz N, Keren N. Effectiveness of an occupational goal intervention (OGI) in schizophrenia for executive dysfunction and occupational outcomes: a randomized controlled trial.. Proceedings of the World Psychiatric Association International Congress; 2009 April 1-4th; Florence Italy. 2009.
Lysaker 2004 (SE170) {published data only}
  • Lysaker PH, Davis LW. Cognitive-behavioral therapy and work outcome in schizophrenia. Proceedings of the 157th Annual Meeting of the American Psychiatric Association; 2004 May 1-6; NewYork, USA. 2004.
Lysaker 2005 (SE169) {published data only}
  • Lysaker PH, Bond G, Davis LW, Bryson GJ, Bell MD. Enhanced cognitive-behavioral therapy for vocational rehabilitation in schizophrenia: Effects on hope and work. Journal of Rehabilitation Research & Development 2005;42(5):673-82.
Lysaker 2006 (SE168) {published data only}
  • Lysaker PH, Davis LW, Beattie N. Effects of cognitive behavioral therapy and vocational rehabilitation on meta-cognition and coping in schizophrenia. Journal of Contemporary Psychotherapy 2006;36(1):25-30.
Lysaker 2009 (SE167) {published data only}
  • Lysaker PH, Davis LW, Bryson GJ, Bell MD. Effects of cognitive behavioral therapy on work outcomes in vocational rehabilitation for participants with schizophrenia spectrum disorders. Schizophrenia Research 2009;107:186-91.
Malm 2003 (SE172) {published data only}
Mangrum 2006 (SE173) {published data only}
  • Mangrum LF, Spence RT, Lopez M. Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders. Journal of Substance Abuse Treatment 2006;30(1):79-84.
Marder 2005 (SE145) {published data only}
  • NCT00183625. The effectiveness of supplementing supported employment with behavioral skills training in schizophrenia patients taking risperidone or olanzapine. http://clinicaltrials.gov (accessed 6 July 2009).
McFarlane 2002 (SE175) {published data only}
  • McFarlane WR, Cook W, Balser R, Boyak C, Leavitt R. Effects of fact and an employers consortium on employment in severe mental illness. Proceedings of the 155th Annual Meeting of the American PsychiatricAssociation; 2002 May 18-23; Philadelphia, PA, USA. 2002.
McGurk 2005 (SE18) {published data only}
  • McGurk SR, Mueser KT, Pascaris A. Cognitive training and supported employment for persons with severe mental illness: one-year results from a randomized controlled trial. Schizophrenia Bulletin 2005;31(4):898-909.
McGurk 2007 (SE19) {published data only}
  • McGurk SR, Mueser KT, Feldman K, Wolfe R, Pascaris A. Cognitive training for supported employment: 2-3 year outcomes of a randomized controlled trial. American Journal of Psychiatry 2007;164(3):437-41.
McGurk 2009 (SE176) {published data only}
  • McGurk SR, Mueser KT, DeRosa TJ, Wolfe R. Work, recovery, and comorbidity in schizophrenia: a randomized controlled trial of cognitive remediation. Schizophrenia Bulletin 2009;35(2):319-35.
Mueser 2005 (SE178) {published data only}
  • Mueser KT, Aalto S, Becker DR, Ogden JS, Wolfe RS, Schiavo D, et al. The effectiveness of skills training for improving outcomes in supported employment. Psychiatric Services 2005;56(10):1254-60.
Mueser 2008 (SE180) {published data only}
  • Mueser KT, Rosenberg SD, Xie H, Jankowski MK, Bolton EE, Lu W, et al. A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology 2008;76(2):259-71.
Mueser u1 (SE179) {published data only}
  • Mueser KT, McGurk SR. 2-3 year outcomes of a randomized controlled trial of cognitive training and supported employment for people with severe mental illness. Schizophrenia Bulletin 2007;33(2):448-9.
Okpaku 1997 (SE181) {published data only}
  • Okpaku SO, Anderson KH, Sibulkin AE, Butler JS, Bickman L. The effectiveness of a multidisciplinary case management intervention on the employment of SSDI applicants and beneficiaries. Psychiatric Rehabilitation Journal 1997;20(3):34-41.
Toprac 2002 {published data only}
  • Toprac M, Hoppe SK, Daggett P, Wambach K, OnkenS, Burek S, et al. The Texas earns supported employment demonstration project. Proceedings of the 155th Annual Meeting of the American Psychiatric Association; 2002 May 18-23; Philadelphia, PA, USA. 2002.

References to studies awaiting assessment

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
McFarlane 2000 {published data only}
Michon 2010 {published data only}
  • ISRCTN87339610. SCION - Study on cost-effectiveness of individual placement and support (IPS regarding open employment in the Netherlands). http://www.controlled-trials.com (accessed 6 July 2009).
  • Michon H, van Busschbach J, van Vugt M, Stant, Kroon H, Wiersma D, et al. Effectiveness of the Individual Placement and Support (IPS) model of vocational rehabilitation for people with severe mental illnesses in the Netherlands. Psychiatr Prax. 2011; Vol. 38. [DOI: 10.1055/s-0031-1277830]

References to ongoing studies

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
Bejerholm 2009 (SE142) {published data only}
  • NCT00960024. Supported employment in a Swedish context. http://clinicaltrials.gov (accessed 6 July 2009).
McFarlane 2008 (SE147) {published data only}
  • NCT00531518. Early detection and intervention for the prevention of psychosis, a multi-site study (EDIPP). http://clinicaltrials.gov (accessed 6 July 2009).
Nuechterlein 2008 {published data only}
  • NCT00203788. Antipsychotic therapy plus a behavioral Intervention for improving work outcome in people with recent-onset schizophrenia. http://clinicaltrials.gov (accessed 06 July 2009).
  • Nuechterlein KH, Subotnik KL, Turner LR, Ventura J, Becker DR, Drake RE. Individual placement and support for individuals with recent-onset schizophrenia: integrating supported education and supported employment. Psychiatric Rehabilitation Journal 2008;31(4):340-9.
  • Nuechterlein KH, Subotnik KL, Ventura J, Gitlin MJ, Green MF, Wallace CJ, et al. Advances in improving and predicting work outcome in recent-onset schizophrenia. Proceedings of the 20th International Congress on Schizophrenia Research; 2005 Apr 2-6; Savannah, Georgia, USA. 2005.

Additional references

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
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Schulz 1995
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Schünemann 2008
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