Who benefits from individual placement and support? A meta-analysis.

AIMS: Individual placement and support (IPS) is an evidence-based service model to support people with mental disorders in obtaining and sustaining competitive employment. IPS is increasingly offered to a broad variety of service users. In this meta-analysis we analysed the relative effectiveness of IPS for different subgroups of service users both based on the diagnosis and defined by a range of clinical, functional and personal characteristics. METHODS: We included randomised controlled trials that evaluated IPS for service users diagnosed with any mental disorder. We examined effect sizes for the between-group differences at follow-up for three outcome measures (employment rate, job duration and wages), controlling for methodological confounders (type of control group, follow-up duration and geographic region). Using sensitivity analyses of subgroup differences, we analysed moderating effects of the following diagnostic, clinical, functional and personal characteristics: severe mental illness (SMI), common mental disorders (CMD), schizophrenia spectrum disorders, mood disorders, duration of illness, the severity of symptoms, level of functioning, age, comorbid alcohol and substance use, education level and employment history. RESULTS: IPS is effective in improving employment outcomes compared to the control group in all subgroups, regardless of any methodological confounder. However, IPS was relatively more effective for service users with SMIs, schizophrenia spectrum disorders and a low symptom severity. Although IPS was still effective for people with CMD and with major depressive disorder, it was relatively less effective for these subgroups. IPS was equally effective after both a short and a long follow-up period. However, we found small, but clinically not meaningful, differences in effectiveness of IPS between active and passive control groups. Finally, IPS was relatively less effective in European studies compared to non-European studies, which could be explained by a potential benefits trap in high welfare countries. CONCLUSIONS: IPS is effective for all different subgroups, regardless of diagnostic, clinical, functional and personal characteristics. However, there might be a risk of false-positive subgroup outcomes and results should be handled with caution. Future research should focus on whether, and if so, how the IPS model should be adapted to better meet the vocational needs of people with CMD and higher symptom severity.

Evaluation of an implementation strategy for Individual Placement and Support in the Netherlands: a 30-month observational study.

BACKGROUND: Individual Placement and Support (IPS) is an evidence-based, effective approach to help people with severe mental illness (SMI) obtain and maintain competitive employment. The aim of the present study was to examine employment outcomes and associations with an organizational and a financial factor in people with SMI who participated in Individual Placement and Support using a multifaceted implementation strategy (IPS + MIS). The goal of this strategy was to improve IPS implementation by enhancing collaboration among mental health care and vocational rehabilitation stakeholders, and realizing secured IPS funding. METHODS: An observational cohort study including 103 participants was conducted, with a 30-month follow-up. Descriptive analyses were used to examine employment outcomes. Multivariable logistic and linear regression analyses were performed to study associations with an organizational and a financial factor: the level of experience of mental health agencies with providing IPS + MIS and the type of IPS funding (i.e. municipality funding (reference group) and the Dutch Social Security Institute: the Institute for Employee Benefits Schemes (UWV) funding). RESULTS: Forty-six percent of the participants were competitively employed at any time during the 30-month follow-up; the median number of days until competitive job obtainment and in competitive jobs was 201 and 265, respectively. The majority of all jobs obtained (81%) were categorized as 'elementary occupations', 'clerical support workers', and 'service and sales workers'. A higher level of experience of the mental health agencies with providing IPS + MIS was found to be positively associated with job obtainment (OR = 3.83, 95% CI 1.42-10.30, p = 0.01) and the number of days worked in competitive jobs (B = 1.21, 95% CI 0.36-2.07, p = 0.01). UWV funding was found to be negatively associated with job obtainment (OR = 0.30, 95% CI 0.11-0.77, p = 0.01). No association was found for the type of IPS funding and the number of days worked in competitive jobs (B = -0.73, 95% CI -1.48-0.02, p = 0.06). CONCLUSIONS: This study shows that almost half of the people who participate in IPS + MIS obtain a competitive job within 30 months. The results further suggest that both the level of experience of mental health agencies with providing IPS + MIS, and funding may play a role in employment outcomes.

It is not only competitive employment that counts: Findings from a longitudinal panel of people with severe mental illness.

OBJECTIVE: Being engaged in work and social activities is associated with a better quality of life. However, little evidence is available on the relationship between different categories of social participation and quality of life in people with severe mental illnesses. Furthermore, longitudinal studies considering this relationship in people with severe mental illnesses (SMI) are scarce. This study attempts to fill this gap by exploring whether and how different categories of social participation and quality of life were associated over a period of 4 years. METHOD: The association between social participation activities and quality of life was analyzed with linear mixed models, using data from a Dutch national panel of people with SMI. Four annual waves including self-reported measures were used. Three categories of participation were assessed: paid employment, voluntary work, outside social activities. RESULTS: From 2015 to 2018, 1.682 panel members (18-75 years old) participated in the survey. All three participation variables show a unique significant positive association with quality of life. Controlling for covariates (age, sex, and mental health) comparable regression coefficients were found: paid employment, .208, 95% CI [.090-.326], voluntary work, .210, 95% CI [.120-.300], and outside social activities, .239, 95% CI [.154-.324]. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The value of participation for people with SMI seems to be not restricted to competitive employment. Engagement in paid employment, voluntary work, and performing outside social activities each have a comparable and additional positive association with quality of life. Therefore, rehabilitation professionals should pay attention to social participation activities in a broad range. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Systematic Review of Individual Placement and Support, Employment, and Personal and Clinical Recovery.

OBJECTIVE: The objective of this review was to assess associations between Individual Placement and Support (IPS), employment, and personal and clinical recovery among persons with severe mental illness at 18-month follow-up. METHODS: A systematic literature search identified randomized controlled trials (RCTs) comparing IPS with services as usual. Outcomes were self-esteem, empowerment, quality of life, symptoms of depression, negative or psychotic symptoms, anxiety, and level of functioning. A total of six RCTs reported data suitable for meta-analyses, and pooled original data from five studies were also analyzed. RESULTS: Meta-analyses and analyses of pooled original data indicated that receipt of the IPS intervention alone did not improve any of the recovery outcomes. Participants who worked during the study period, whether or not they were IPS participants, experienced improved negative symptoms, compared with those who did not work (standardized mean difference [SMD]=-0.41, 95% confidence interval [CI]=-0.56, -0.26). For participants who worked, whether or not they were IPS participants, improvements were also found in level of functioning and quality of life (SMD=0.59, 95% CI=0.42, 0.77 and SMD=0.34, 95% CI=0.14, 0.54, respectively). CONCLUSIONS: Employment was associated with improvements in negative symptoms, level of functioning, and quality of life.

Experiences with Individual Placement and Support and employment - a qualitative study among clients and employment specialists.

BACKGROUND: Individual Placement and Support (IPS) is an evidence-based, effective approach to help people with severe mental illness (SMI) achieve competitive employment. The aim of the present study is to explore experiences with Individual Placement and Support using a multifaceted implementation strategy (IPS + MIS), and competitive employment. The goal of this strategy was to improve IPS implementation by enhancing collaboration between mental health care and vocational rehabilitation stakeholders, and realizing a secured IPS funding with a 'pay for performance' element. METHODS: A qualitative, exploratory study was performed using semi-structured interviews with IPS clients (n = 10) and two focus groups with IPS employment specialists (n = 7 and n = 8) to collect rich information about their experiences with IPS + MIS and competitive employment. Thematic content analysis was used to analyse the data. RESULTS: Themes related to experiences with IPS and the multifaceted implementation strategy were identified, including the importance of discussing the client's motivation and motives to work, facilitators and barriers to obtaining and maintaining employment, facilitators to collaboration between stakeholders, barriers to benefits counselling, organizational barriers to IPS execution and collaboration between stakeholders, financial barriers to IPS execution and experiences with the pay for performance element. CONCLUSIONS: Although the multifaceted implementation strategy seems to contribute to an improved IPS implementation, the barriers identified in this study suggest that further steps are necessary to promote IPS execution and to help people with SMI obtain and maintain competitive employment.

Vocational Outcomes of the Individual Placement and Support Model in Subgroups of Diagnoses, Substance Abuse, and Forensic Conditions: A Systematic Review and Analysis of Pooled Original Data.

PURPOSE: To investigate the effect of Individual Placement and Support (IPS) according to diagnoses of schizophrenia, bipolar disorder, major depression, substance use disorders, or forensic psychiatric conditions. METHODS: A systematic search of the literature was conducted in June 2017 and repeated in December 2020. The systematic review included 13 studies. Analyses of pooled original data were based on the six studies providing data (n = 1594). No studies on forensic psychiatric conditions were eligible. Hours and weeks worked were analyzed using linear regression. Employment, and time to employment was analyzed using logistic regression, and cox-regression, respectively. RESULTS: The effects on hours and weeks in employment after 18 months were comparable for participants with schizophrenia, and bipolar disorder but only statistically significant for participants with schizophrenia compared to services as usual (SAU) (EMD 109.1 h (95% CI 60.5-157.7), 6.1 weeks (95% CI 3.9-8.4)). The effect was also significant for participants with any drug use disorder (121.2 h (95% CI 23.6-218.7), 6.8 weeks (95% CI 1.8-11.8)). Participants with schizophrenia, bipolar disorder, and any drug use disorder had higher odds of being competitively employed (OR 2.1 (95% CI 1.6-2.7); 2.4 (95% CI 1.3-4.4); 3.0 (95% CI 1.5-5.8)) and returned to work faster than SAU (HR 2.1 (95% CI 1.6-2.6); 1.8 (95% CI 1.1-3.1); 3.0 (95% CI 1.6-5.7)). No statistically significant effects were found regarding depression. CONCLUSIONS: IPS was effective regarding schizophrenia, bipolar disorder, and substance use disorder; however, the effect on hours, and weeks worked was not statistically significant regarding bipolar disorder. For people with depression the impact of IPS remains inconclusive. Non-significant results may be due to lack of power. TRIAL REGISTRATION: PROSPERO protocol nr. CRD42017060524.

Individual placement and support in the Netherlands: Past, present, and future directions.

OBJECTIVE: This article addresses the rise of individual placement and support (IPS) within vocational services for people with severe mental illness (SMI), the current state of affairs, and future directions of IPS in the Netherlands. METHOD: Review of the literature on IPS in the Netherlands, analysis of registration data, and exploration of future avenues for IPS in Dutch mental health care. FINDINGS: In the first decade of this century, an implementation study showed that IPS was feasible in the Netherlands, and a multisite randomized controlled trial (RCT) indicated that IPS was also effective in the Dutch context. Nationwide, from the start of 2016 to the end of 2017, the number of enrolled IPS participants doubled from 1,038 to 2,100, which was largely due to the introduction of preliminary national funding of IPS. Future directions include expanding the IPS practice in terms of target groups, types of providers, goals, and added interventions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Involvement of clinicians and the employment opportunities for people with SMI have increased, which is mainly due to the successes of IPS. However, considerable efforts are still needed to make IPS more widely available. Important facilitators are regular meetings of stakeholders in mental health care and vocational rehabilitation, stakeholders' experienced ownership of IPS and collaboration, the mandate and influence of the decision makers involved, and secured IPS funding. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Work Motivation and Employment Outcomes in People with Severe Mental Illness.

Purpose To study associations between the level of self-reported work motivation and employment outcomes in people with severe mental illness (SMI) enrolled in a vocational rehabilitation program. Methods Data of 151 study participants, collected from a randomised controlled trial with a 30-month follow-up period, were used for a secondary data analysis. Multiple logistic regression, linear regression and cox regression analyses were performed to analyse the association between the level of work motivation at baseline and job obtainment, duration of job, and time until job obtainment during the 30-month follow-up period. Results No statistically significant associations were found between the level of work motivation and job obtainment (OR 1.83, 95% CI 0.55-6.06, p = 0.32), job duration (B = - 0.74, 95% CI - 2.37 to 0.89, p = 0.37, R-squared = 0.03), or time until job obtainment (HR = 1.53, 95% CI 0.64-3.68, p = 0.34). Conclusions The results of this study show no statistically significant associations between the level of work motivation and employment outcomes in people with SMI enrolled in a vocational rehabilitation program. These associations may be underestimated due to range restriction of the work motivation's level. Further research is recommended to increase knowledge on the associations between work motivation and employment outcomes, as it could be relevant for further understanding success in vocational rehabilitation.

Experiences with the implementation of Individual Placement and Support for people with severe mental illness: a qualitative study among stakeholders.

BACKGROUND: Individual Placement and Support (IPS) is an evidence-based approach to help people with severe mental illness achieve competitive employment. This article provides insight into an organizational and a financial implementation strategy for IPS in the Netherlands by exploring the perceived facilitators and barriers among participating stakeholders. The goal of this multifaceted strategy was to improve IPS implementation by improving the collaboration between all organizations involved, and realising secured IPS funding with a 'pay for performance' element. METHODS: A qualitative, explorative study among practitioners (n = 8) and decision makers (n = 7) in mental health care and vocational rehabilitation was performed using semi-structured interviews to collect rich information about the possible facilitators and barriers with regard to the organizational and financial implementation strategy for IPS. RESULTS: Important perceived facilitators were the key principles of the IPS model, regular meetings of stakeholders in mental health care and vocational rehabilitation, stakeholders' experienced ownership of IPS and collaboration, the mandate and influence of the decision makers involved and secured IPS funding. Important perceived barriers included the experienced rigidity of the IPS model fidelity scale and lack of independent fidelity reviewers, the temporary and fragmented character of the secured funding, lack of communication between decision makers and practitioners and negative attitudes and beliefs among mental health clinicians. Changes in legislation were experienced as a facilitator as well as a barrier. CONCLUSIONS: The results of this study suggest that the collaboration and IPS funding were experienced as improved by applying an organizational and a financial implementation strategy. However, considerable effort is still necessary to overcome the remaining barriers identified and to make the implementation of IPS a success in practice.

The Role of Working Alliance in Attainment of Personal Goals and Improvement in Quality of Life During Psychiatric Rehabilitation.

OBJECTIVE: A key aspect of psychiatric rehabilitation is supporting individuals with serious mental illness in reaching personal goals. This study aimed to investigate whether various aspects of the working alliance predict successful goal attainment and whether goal attainment improves subjective quality of life, independent of the rehabilitation approach used. METHODS: Secondary analyses were conducted of data from a Dutch randomized clinical trial on goal attainment by individuals supported with the Boston University approach to psychiatric rehabilitation (N=80) or a generic approach (N=76). Working alliance was measured with the Working Alliance Inventory (WAI) from the practitioner's perspective. Rehabilitation practitioners had backgrounds in social work, nursing, or vocational rehabilitation. Multiple logistic regression and multiple regression analyses explored effects of working alliance on goal attainment and of goal attainment on subjective quality of life at 24 months. Analyses were controlled for client- and process-related predictors, baseline quality of life, and rehabilitation approach. RESULTS: The WAI goal subscale predicted goal attainment at 24 months. No effect was found for the bond or task subscale. Goal attainment significantly predicted quality of life at 24 months. These effects were independent of the rehabilitation approach used. CONCLUSIONS: A good bond between client and practitioner is not enough to attain successful rehabilitation outcomes. Findings suggest that it is important to discuss clients' wishes and ambitions and form an agreement on goals. Attaining rehabilitation goals directly influenced the subjective quality of life of individuals with serious mental illness, which underscores the importance of investing in these forms of client support.

Effectiveness of individual placement and support for people with severe mental illness in The Netherlands: a 30-month randomized controlled trial.

OBJECTIVE: Whereas in the U.S. and Canada the Individual Placement and Support (IPS) model has proven to be highly effective in enhancing employment perspectives for persons with severe mental illnesses, the evidence base is less abundant in countries with a different socioeconomic climate. The aim of this study was to examine the effectiveness of IPS in the Dutch socioeconomic context. METHOD: A multisite randomized controlled trial was performed following 151 persons with severe mental illnesses expressing an explicit wish for regular employment, comparing IPS with traditional vocational rehabilitation (TVR). Primary outcome was the proportion of persons who were competitively employed over a period of 30 months. Secondary outcomes were self-reported quality of life, self-esteem and mental health. Additionally, the impact of being engaged in competitive employment on these secondary outcomes was examined. RESULTS: In 30 months, 44% of IPS participants found competitive work, compared with 25% of participants supported by TVR. No direct effect of IPS on mental health, self-esteem or quality of life was found. Being competitively employed before follow-up measurements was significantly associated with an increase in mental health, self-esteem and quality of life. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study strongly confirms that IPS is an effective method in helping people with severe mental illnesses find competitive work also in countries characterized by a relatively protective socioeconomic climate putting up unintended barriers to employment. The implementation of IPS on a larger scale seems warranted, and new studies are needed on the mechanisms through which IPS works.

Effectively working on rehabilitation goals: 24-month outcome of a randomized controlled trial of the Boston psychiatric rehabilitation approach.

OBJECTIVE: To investigate the effect of the Boston Psychiatric Rehabilitation (PR) Approach on attainment of personal rehabilitation goals, social functioning, empowerment, needs for care, and quality of life in people with severe mental illness (SMI) in the Netherlands. METHOD: A 24-month, multicentre, randomized controlled trial was used to compare the results of PR to care as usual (CAU). Patients with SMI were randomly assigned by a central randomization centre to PR (n = 80) or CAU (n = 76). The primary outcome of goal attainment was assessed by independent raters blind to treatment allocation. Measures for secondary outcomes were change in work situation and independent living, the Personal Empowerment Scale, the Camberwell Assessment of Needs, and the World Health Organization Quality of Life assessment. Effects were tested at 12 and 24 months. Data were analyzed according to intention to treat. Covariates were psychiatric centre, psychopathology, number of care contacts, and educational level of the professionals involved. RESULTS: The rate of goal attainment was substantially higher in PR at 24 months (adjusted risk difference: 21%, 95% CI 4% to 38%; number needed to treat [NNT] = 5). The approach was also more effective in the area of societal participation (PR: 21% adjusted increase, CAU: 0% adjusted increase; NNT = 5) but not in the other secondary outcome measures. CONCLUSIONS: The results suggest that PR is effective in supporting patients with SMI to reach self-formulated rehabilitation goals and in enhancing societal participation, although no effects were found on the measures of functioning, need for care, and quality of life.

Illness self-management assessment in psychiatric vocational rehabilitation.

OBJECTIVE: People with severe mental illnesses experience difficulty finding and maintaining employment, even if they are offered psychiatric vocational rehabilitation services. When service recipients are able to apply more effective illness self-management strategies, vocational rehabilitation outcomes improve. To assess the use of these strategies, the Illness Self-Management assessment instrument for Psychiatric Vocational Rehabilitation (ISM-PVR) was developed. METHODS: Experts were consulted to design the ISM-PVR instrument which was then tested by 8 vocational rehabilitation workers and 26 of their service recipients. RESULTS: This study indicated sufficient internal consistency of the ISM-PVR self-report questionnaire, especially for the subscales assessing goal related self-efficacy, perceived illness-related barriers, and four of the eight coping scales. The number of self-reported illness barriers was associated with a higher number of reported work-related coping strategies. The ISM-PVR aided the identification of specific mental illness-related barriers perceived by the service recipients. The instrument also facilitated obtaining information on individual self-management strategies that clients employed to overcome such barriers or make them manageable. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The application of the ISM-PVR in vocational rehabilitation practice warrants further research. The study suggests that this instrument is a useful add-on to existing vocational assessment and provides insight in self-management strategies that people use, and that may help those people and their job coaches make more effective vocational plans.

A multisite study of implementing supported employment in the Netherlands.

OBJECTIVE: This article reports on the implementation of the individual placement and support model of supported employment in four Dutch regions. METHODS: The authors used structured site visits, employment data, and semistructured interviews to assess fidelity, employment outcomes, and facilitators of and barriers to successful implementation. RESULTS: At 24 months, the four sites reached a mean+/-SD fidelity score of 4.1+/-.3 (possible scores range from 1 to 5, with higher scores indicating closer adherence to the model). Of the 316 persons with mental illnesses, 57 (18%) obtained competitive jobs. Barriers to implementation included lack of organizational standards, loss of vocational staff, funding problems, insufficient time for program leaders, and inadequate cooperation between the involved organizations. Important facilitators were the skills and commitment of the vocational team members and the integration of vocational and mental health staff. CONCLUSIONS: To implement evidence-based supported employment in the Netherlands will require changes in financing, organizational structures, attitudes, cultural beliefs, and labor and disability regulations.

Person-related predictors of employment outcomes after participation in psychiatric vocational rehabilitation programmes--a systematic review.

BACKGROUND: There is increasing recognition of the importance of psychiatric vocational rehabilitation (PVR) programmes in helping individuals with severe mental illnesses to find and secure jobs. However, little is known concerning the factors related to PVR outcomes. OBJECTIVE: This review identifies those person-related factors which most strongly influence employment outcomes after participation in PVR programmes. METHOD: Medline, Psychinfo, Pubmed and CINAHL were searched for studies using multivariate analysis of longitudinal data, which analysed employment outcomes after at least 6 months of programme participation, and which analysed at least three predictor domains. RESULTS: Eight studies presented in 16 publications met all the criteria. Better employment outcomes were most strongly related to better work performance measured during PVR participation and to higher work-related self-efficacy. Better social functioning during PVR participation was also significantly related to positive employment outcomes, but this relationship was generally weaker than those of the two aforementioned factors. In most studies, employment outcomes after PVR were not related to past functioning, including work history and diagnosis. Findings on the severity of psychiatric symptoms measured during PVR were mixed. In terms of contribution to outcome, severity of symptoms usually ranked below work performance, when measured concurrently. CONCLUSION: Contrary to previous reviews, this study suggests that the influence of past functioning, including work history, diagnosis and psychiatric history, is outweighed by work performance in PVR. Further prospective and controlled studies are needed to reach more definite conclusions about the individual contributions of person-related factors.

The Generic Work Behavior Questionnaire (GWBQ): assessment of core dimensions of generic work behavior of people with severe mental illnesses in vocational rehabilitation.

The purpose of this study was the development of a short self-reporting and supervisor-reporting questionnaire to assess generic work behavior of people with severe mental illnesses participating in psychiatric vocational rehabilitation. An 18-item generic work behavior questionnaire (GWBQ) was developed, which contains core dimensions derived from both supervisor scores and self-report scores. The factor structure of the GWBQ was replicated for both versions (supervisor and self reports). The GWBQ was very reliable for supervisor reports and moderately so for self-reports. Although self-report scores and supervisor scores correlated significantly, participants rated their own work behavior consistently higher than supervisors did.