Responding to challenges for people with psychotic illness: Updated evidence from the Survey of High Impact Psychosis.

OBJECTIVE: The objective is to summarise recent findings from the 2010 Australian Survey of High Impact Psychosis (SHIP) and examine their implications for future policy and planning to improve mental health, physical health and other circumstances of people with a psychotic disorder. METHODS: Survey of High Impact Psychosis collected nationally representative data on 1825 people with psychotic illness. Over 60 papers have been published covering key challenges reported by participants: financial problems, loneliness and social isolation, unemployment, poor physical health, uncontrolled symptoms of mental illness, and lack of stable, suitable housing. Findings are summarised under the rubric of participant-ranked top challenges. RESULTS: The main income source for the majority (85%) of participants was a government benefit. Only one-third was employed, and the most appropriate employment services for this group were under-utilised. High rates of loneliness and social isolation impacted mental and physical health. The rate of cardiometabolic disease was well above the general population rate, and associated risk factors were present from a very young age. Childhood abuse (30.6%), adult violent victimisation (16.4%) and alcohol and substance abuse/dependence (lifetime rates of 50.5% and 54.5%, respectively) complicated the clinical profile. Treatment with medication was suboptimal, with physical health conditions undertreated, a high rate of psychotropic polypharmacy and underutilisation of clozapine in chronic persistent psychotic illness. Only 38.6% received evidence-based psychosocial therapies. In the previous year, 27.4% had changed housing and 12.8% had been homeless, on average for 155 days. CONCLUSION: Money, social engagement and employment are the most important challenges for people with psychotic illness, as well as good physical and mental health. An integrated approach to recovery is needed to optimise service delivery and augment evidence-based clinical practice with measures to improve physical health and social circumstances. Meeting these challenges has the potential to reduce costs to government and society, as well as promote recovery.

Earning and learning among Australian community residents with psychiatric disorders.

At a population level the extent that psychiatric disorders and other health conditions disrupt participation in education and employment is rarely considered simultaneously and remains largely unknown. This is an important issue because policy makers are as concerned with educational attainment, school to work transitions, and workforce skills, as they are with overall labour force participation. We investigated earning or learning, and educational attainment, among Australian community residents by age group and by category of psychiatric disorder. Data files were provided by the Australian Bureau of Statistics (ABS) from a population survey conducted in 2003 using a multi-stage probability sample (N=23,787). Adults with schizophrenia, depression, and anxiety disorders were compared to (1) working age adults with other non-psychiatric health conditions and disabilities; and (2) healthy adults of working age. Participation in formal education and employment was extensively disrupted by all health conditions and by psychiatric disorders in particular. The extent of career-related disruption provides benchmarks for policy makers and service providers attempting to increase participation in formal education and in the labour force.

Labour market conditions, labour force activity and prevalence of psychiatric disorders.

BACKGROUND: At a population level, the extent that labour market conditions influence labour force activity among people with psychiatric disorders, remains equivocal. Similarly equivocal is the hypothesised relationship between economic conditions and the reported prevalence of specific psychiatric disorders. We investigated these issues by examining the extent that labour market conditions were associated with change in labour force activity among people with anxiety disorders, affective disorders, and schizophrenia, in comparison to healthy working age adults. METHODS: Data files were provided by the Australian Bureau of Statistics (ABS) from a population survey conducted in 1998 and replicated in 2003. Multi-stage probability samples were obtained in 1998 (N(1) = 37,580) and 2003 (N(2) = 36,088). Adults with schizophrenia, depression, and anxiety disorders were compared to healthy working age adults. RESULTS: Greater labour demand in 2003 was positively associated with increased labour force participation among healthy adults. The proportions actively looking for work declined among healthy adults and among those with anxiety disorders. Full-time employment significantly increased among healthy working age residents. The proportions employed part-time significantly increased in all groups except among people with schizophrenia. CONCLUSION: These results support policies which remove disincentives and increase access to the more intensive evidence-based employment programs even when labour market conditions are improving.

The challenge of integrating employment services with public mental health services in Australia: progress at the first demonstration site.

OBJECTIVE: Integrating vocational services into public mental health services is a key component of evidence-based supported employment for people with severe mental illness. While this approach has been developed in the USA, it has only recently been attempted internationally and in Australia. This report summarizes the early implementation challenges at the first Australian demonstration site. METHOD: ORYGEN Youth Health (OYH) in Melbourne established an evidence-based supported employment research project in December 2005. Challenges to service integration and fidelity were documented descriptively in order to inform other international sites attempting to implement similar evidence-based practices. RESULTS: Experiences at this demonstration site identify the major barriers to integration and suggest how these can be overcome. CONCLUSION: Successful integration of employment with youth mental health services is feasible in Australia within six months.

Comorbid physical health conditions hinder employment among people with psychiatric disabilities.

OBJECTIVE: To investigate whether comorbid physical health conditions hinder employment for people with psychiatric disabilities. METHOD: A secondary analysis of a 12-month longitudinal natural observation study. Community residents (n = 104) with schizophrenia or schizoaffective disorder were interviewed at baseline, 6 and 12 months. RESULTS: Comorbid physical health conditions were negatively associated with employment status. CONCLUSIONS: More attention to physical health conditions may improve outcomes in psychiatric vocational rehabilitation.

Musculoskeletal disorders and comorbid depression: implications for practice.

BACKGROUND: The physical demands of work have a substantial impact on the incidence of work-related musculoskeletal disorders. Depression is often associated with work-related injuries and may influence a person's success or otherwise return to work. There is pressure for occupational rehabilitation providers to produce good return-to-work outcomes in a timely and financially responsible manner. The aim was to examine current evidence for any added impact of depression on return-to-work prospects among people with work-related musculoskeletal disorders. METHODS: A review of the literature was conducted to determine the extent to which depression comorbid with musculoskeletal disorders affected labour force participation and the outcomes obtained in occupational rehabilitation. RESULTS: Australian population level data show that people of working age with depression comorbid with musculoskeletal disorders have extensive labour force disadvantage and reduced return-to-work outcomes when participating in occupational rehabilitation. CONCLUSIONS: Although more research is needed, there is already sufficient evidence to support the introduction of systems and practices to detect and integrate treatment for comorbid depression in order to prevent occupational rehabilitation failure.

Reliability of a composite measure of social inclusion for people with psychiatric disabilities.

AIM: To assess the reliability of the components of a proposed composite measure of social inclusion for people with psychiatric disabilities. METHOD: The interview covered sociodemographics, domain-specific socially valued role functioning, social support, stigma experiences, integration within the immediate psychosocial rehabilitation community, and integration within the wider neighbourhood community. Participants (n(1) = 28; n(2) = 26) were recruited from a psychosocial rehabilitation setting. The candidate measures were assessed for short-cycle test-retest reliability and internal consistency. RESULTS: Several items were identified for removal from the stigma experiences and community integration subscales because of low test-retest reliability or for having not sufficiently contributed to internal consistency. CONCLUSIONS: The promising test-retest and internal consistency results warrant continuing the psychometric development of the composite measures of social inclusion and its applicability to community residents with psychiatric disabilities.

Personal experiences of people with serious mental illness when seeking, obtaining and maintaining competitive employment in Queensland, Australia.

BACKGROUND: High non-participation in the labour force and unemployment remain challenging for adults with serious mental illness. OBJECTIVES: This study examined the personal experiences of people with serious mental illness when seeking, obtaining and maintaining competitive employment. The aim was to increase understanding of personal experiences of employment and how these experiences can be used to inform the assistance provided in support of clients' competitive employment goals. METHODS: Qualitative data from a two-year period were thematically analysed from one participating site in a multi-site trial of employment services integrated with public funded community mental health treatment and care. RESULTS: Both positive and negative themes arose. Positive themes included: Aspirations for a better life, receiving feedback on good job performance, employment displacing preoccupation with illness, and employment improving self-esteem and reducing financial stress. Negative themes included stigma experiences, stress, and health difficulties. Both positive and negative experiences did not depend on type of employment service assistance nor key client characteristics such as age, sex, and diagnostic category. CONCLUSIONS: Despite its many benefits, employment can also increase the risk of negative personal experiences. These findings suggest that employment service providers could do more to assist people who commence employment, to reduce the risk of negative personal experiences and to enhance the benefits of competitive employment.

Work-related self-efficacy among community residents with psychiatric disabilities.

A new measure of work-related self-efficacy for people with psychiatric disabilities is reported. The 37-item scale measures self-efficacy in four relevant activity domains: (1) vocational service access and career planning, (2) job acquisition, (3) work-related social skills, and (4) general work skills. The scale was developed in a 12-month longitudinal survey of urban residents diagnosed with schizophrenia or schizoaffective disorder (n=104). Results indicate validity of both a four-factor structure differentiating four core skill domains, and a single factor representing total work-related self-efficacy. The favorable psychometric properties support further research and trial applications in supported employment and psychiatric vocational rehabilitation.

Comorbidity and labor force activity among people with psychiatric disorders.

OBJECTIVE: Comorbidity among people with psychiatric disorders with respect to other health conditions is extensive yet is rarely explored in-depth in occupational studies. We investigated how other ICD-10 comorbidity impacted on the labor force activity of people with psychiatric disorders. METHODS: A secondary analysis of data files was conducted provided by the Australian Bureau of Statistics (ABS) from a 2003 population survey (N = 36,088). The reference group was working age community residents without long-term health conditions. RESULTS: Comorbidity with a broad range of ICD-10 health conditions can be characterized by both type and extent of comorbidity. Both dimensions are needed to explain impacts on labor force activity. CONCLUSIONS: Health professionals, policymakers, and administrators can utilize these results to identify people with psychiatric disorders and comorbidity profiles most likely to need more intensive vocational services.

Employment-related information for clients receiving mental health services and clinicians.

OBJECTIVE: Clients receiving public mental health services and clinicians require information to facilitate client access to suitable employment services. However, little is known about the specific employment-related information needs of these groups. This study aimed to identify employment-related information needs among clients, clinicians and employment specialists, with a view to developing a new vocational information resource. PARTICIPANTS: Employment-related information needs were identified via a series of focus group consultations with clients, clinicians, and employment specialists (n=23). METHODS: Focus group discussions were guided by a common semi-structured interview schedule. RESULTS: Several categories of information need were identified: countering incorrect beliefs about work; benefits of work; disclosure and managing personal information; impact of earnings on welfare entitlements; employment service pathways; job preparation, planning and selection; and managing illness once working. Clear preferences were expressed about effective means of communicating the key messages in written material. CONCLUSIONS: This investigation confirmed the need for information tailored to clients and clinicians in order to activate clients' employment journey and to help them make informed decisions about vocational assistance.

Labor force activity among Australians with musculoskeletal disorders comorbid with depression and anxiety disorders.

AIM: Musculoskeletal disorders (MSD) are a leading cause of work-related disability. This investigation explored the impact of MSD comorbid with depression and anxiety disorders, on labor force activity. METHODS: The Australian Bureau of Statistics provided confidentialized data files collected from a household sample of 37,580 people. MSD, affective, and anxiety disorders were identified and employment restrictions were assessed at four levels of severity. RESULTS: Anxiety and depression of six months duration was present in 12.1% of people with MSD. Comorbidity magnified the negative impacts of single conditions on labor force activity. Most at risk were people with back problems and comorbid depression, people with arthritis or other MSD and comorbid anxiety, males with MSD and comorbid depression, and females with MSD and comorbid anxiety. CONCLUSIONS: The results suggest that the occupational rehabilitation needs of people with MSD comorbid with depression or anxiety may currently be underestimated.

Work-related subjective experiences among community residents with schizophrenia or schizoaffective disorder.

OBJECTIVE: To develop a self-report scale of subjective experiences of illness perceived to impact on employment functioning, as an alternative to a diagnostic perspective, for anticipating the vocational assistance needs of people with schizophrenia or schizoaffective disorders. METHOD: A repeated measures pilot study (n(1) = 26, n(2) = 21) of community residents with schizophrenia identified a set of work-related subjective experiences perceived to impact on employment functioning. Items with the best psychometric properties were applied in a 12 month longitudinal survey of urban residents with schizophrenia or schizoaffective disorder (n(1) = 104; n(2) = 94; n(3) = 94). RESULTS: Construct validity, factor structure, responsiveness, internal consistency, stability, and criterion validity investigations produced favourable results. Work-related subjective experiences provide information about the intersection of the person, the disorder, and expectations of employment functioning, which suggest new opportunities for vocational professionals to explore and discuss individual assistance needs. CONCLUSION: Further psychometric investigations of test-retest reliability, discriminant and predictive validity, and research applications in supported employment and vocational rehabilitation, are recommended. Subject to adequate psychometric properties, the new measure promises to facilitate exploring: individuals' specific subjective experiences; how each is perceived to contribute to employment restrictions; and the corresponding implications for specialized treatment, vocational interventions and workplace accommodations.

Disability, employment and work performance among people with ICD-10 anxiety disorders.

OBJECTIVE: To ascertain at a population level, patterns of disability, labour force participation, employment and work performance among people with ICD-10 anxiety disorders in comparison to people without disability or long-term health conditions. METHOD: A secondary analysis was conducted of a probability sample of 42 664 individuals collected in an Australian Bureau of Statistics (ABS) national survey in 1998. Trained lay interviewers using ICD-10 computer-assisted interviews identified household residents with anxiety disorders. RESULTS: Anxiety disorders were associated with: reduced labour force participation, degraded employment trajectories and impaired work performance compared to people without disabilities or long-term health conditions. CONCLUSION: People with anxiety disorders may need more effective treatments and assistance with completing education and training, joining and rejoining the workforce, developing career pathways, remaining in the workforce and sustaining work performance. A whole-of-government approach appears needed to reduce the burden of disease and increase community labour resources. Implications for clinicians, vocational professionals and policy makers are discussed.

Prevalence of intellectual disability and comorbid mental illness in an Australian community sample.

OBJECTIVE: The aim of this study was to bring to light the high prevalence of Australians affected by intellectual disability and comorbid serious mental illnesses. Results from a broad scale study are used to explore the reasons for this regularly overlooked phenomenon. METHODS: This study was based on secondary analysis of data collected in the national 'Disability, Ageing and Carers Survey, 1998'. The analysed data consisted of an Australian wide sample of 42 664 individuals living at home or in cared accommodation. Classification of intellectual disability and comorbid psychosis, anxiety and depressive disorder was based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). RESULTS: The prevalence of intellectual disability in the sampled population was 1.25%. Of these people 1.3% had a psychotic disorder, 8% had a depressive disorder and 14% had an anxiety disorder that had been present for at least 6 months and was of such severity that it too was disabling. CONCLUSIONS: Findings indicate that people with intellectual disability are at high risk of developing comorbid serious mental illness. Dual diagnosis is however, often overlooked due to difficulties associated with establishing a diagnosis of a mental disorder in people with an intellectual disability, a problem which is heightened when the individual's capacity to participate in a clinical assessment is limited.