1. Supported employment in early intervention for psychosis services
Niall Turner

2. Overview Conditions that feature psychosis Typical employment outcomes
Early intervention
The IPS model
The DETECT Service
Trial of supported employment in the DETECT service

3. Conditions that feature psychosis
……can be a sub feature of the clinical presentation such as major depression, bipolar affective disorder or the main feature of the condition such as with schizophrenia, drug induced psychosis
Lifetime prevalence = 3% population = circa 120,000 in ROI

4. Current numbers unemployed
International
95% Burns et al 2007
80 – 90% Marwaha and Johnson 2004
85% Crowther et al 2001
Ireland
73% Behan et al (based on 2006 data)

5. Recovery

6. …know about employment outcome?

7. …their conclusions….
Outcome poor but reviewing data difficult due to lack of detail
Rates decline over time
Outcome influenced by local environment: welfare system and availability of Evidence Based Interventions
Disruption starts prior to treatment commencing
Many negative consequences of lack of paid employment

8. “Serious mental illness affects approximately 2% of the world’s population. It results in persons having much difficulty in fulfilling the role which they may have set for themselves in life. Those individuals no longer live in institutions for long periods of time; the vast majority are in the community where they often receive inadequate follow-up.
Even though more than 70% of these people would like to work, only 10-12% do in fact work, all too often in jobs that do not correspond to their liking and capacities. In contrast, the employment rate of other forms of disability is in the vicinity of 50%”
p.57

9. ….page 58….
“Treatment programmes should include the capacity for correct diagnosis, remembering that often mental illness “hides behind physical signs and symptoms”. Quick access to and intervention by competent medical and professional staff will be called for. Integral to quick access and early intervention of appropriate medical treatment for individuals is reducing the stigma and shame associated with mental health problems. As discussed, often an individual will not seek treatment or will delay seeking it because of the stigma associated with mental illness. Furthermore, there is a need for more easily accessible mental health treatment programmes. Rehabilitation programmes will emphasize the requirements for a prompt return to work by focusing on necessary accommodations to the work situation, as well as required support to the individual”

10. Timeline – Early Psychosis
Deterioration in Health and Functioning
Onset of Psychosis
Start of Critical
Period
Receipt of effective Treatment
DELAYS
End of
Critical Period
3 – 5 years 10

11. Length of Delays 11

12. Research on impact of delays
Short Delay Worse
Long Delay Worse
First contact
6 months
12 months
24 months

13. Delay and Occupational Disruption
shorter delays = more likely to still be involved in employment or non labour force work (Turner et al, 2009)
At 3 yr follow-up length of delay was a predictor of productive vocational activity (Norman et al, 2007) 13

14. Development of Early Psychosis Programs
EPPIC 14

15. Aggressive treatment in critical period
EI Paradigm
Early detection
Aggressive treatment in critical period
Improved Outcome

16. Is earlier detection possible?
29 months to 6 months
18 months to 11 months
16 months to 8 months
12 months to 4 months
Mc Gorry et al, 1996; Melle et al, 2004 & 2008; Malla et al, 2006; Chong et al, 2005.

17. Interventions with evidence base
Medication
Cognitive behavioural therapy
Cognitive remediation
Family education
Supported employment (SE)
Individual Placement and Support Model (IPS)

18. IPS Employment specialists part of clinical service
Rapid return to employment
Ongoing support
RCTs - 11 reviewed by Bond, Drake & Becker (2008)
Competitive employment 61% IPS vs. 23% control
66% attained employment of 20hrs plus per week
Time to competitive employment 50% shorter for IPS (138 days vs. 206 days)

19. RCT’s of IPS in Early Intervention
Nuechterlein et al (2008)
80% vs. 40% in education/employment
Killackey et al (2008)
IPS group significantly better on level of employment, hours worked per week, jobs acquired and longevity
Killackey et al (2012)
Conducted an analysis on predictors of vocational recovery – only independent predictor was treatment group. Participants in treatment group were times more likely to obtain work/study
Killackey et al (2013)
larger RCT of IPS which showed greater numbers engaged in paid work, education and competitive employment however only comp employ statistically significant

20. Some caveats
Largest RCT is from EPPIC service
“original” Early Intervention Service
Stand alone
Entire care
Attached to a large academic programme
However
Other naturalistic studies also showing >66% of FEP population returning to work/education when IPS present

21. International Movement iFEVR

22. End of Part I

23. An Irish Early Intervention Service
DUBLIN FIRST EPISODE PSYCHOSIS STUDY
DETECT is a good example of the impact research can have as it was developed as a consequence of the findings of the Dublin First Episode Psychosis Study.
NEXT SLIDE……..DETECT is……

24. DETECT is……. Treatments that maximise recovery…there are 8
DETECT is…….. Treatments that maximise recovery…there are 8.5 WTE team members……
NEXT SLIDE….Service delivery….
8.5 WTE Team Members
Pop. – 385,000

25. Reducing Delays Treatment
Community Mental Health Team
OPD, medication, acute episode care
DETECT
….group CBT
….one-to-one occupational therapy
….group carer education course
DETECT has had > 1300 referrals…..the education campaign we have been running has reduced delays from a median of 6 months to 3 months…..
NEXT SLIDE there is also a programme of evaluation

26. Additionally since 2010…..

27. A clinical trial of supported employment and workplace fundamentals for people with first episode psychotic disorders

28. Principles of IPS Every person who wants to work is eligible
Employment services are integrated with mental health services
Competitive employment is the goal
Benefits counselling is provided
Job search happens soon after interest is expressed
Employment specialist systemically develop relationship with employers
Job supports are continuous
Client preferences are honoured

29. Workplace Fundamentals Module
Rationale: Even with SE maintaining jobs remains problematic
Aim of WFM: Reduce job terminations/breakdown
Method: Training module to augment SE.
“Evening course” in employment skills
Manual & training materials developed by UCLA Psychosocial Rehabilitation Center (Liberman and Wallace, 2000)
Skills for maintaining employment are best taught when person in employment

30. Why offer WFM? Previous research found declining rates over time
If delays reduced likely to be significant numbers still in education/work
Preventative approach
Address an unmet need
Address a gap in the current knowledge base

31. Research Questions Primary Secondary
Does augmenting an early intervention service with IPS and WFM improve work outcomes?
What relationship, if any, does employment outcome have with quality of life, recovery, social inclusion and remission?

32. Methodology I Control Group
Recipients of DETECT service 02/2005 – 07/2009
Experimental Group
Recipients of DETECT Service 08/2009 – 12/2012
Supported employment specialist joined team 06/2010
Comparison
1 year follow up conducted as part of DETECT service evaluation
Includes measure of time in employment, last worked, QoL, recovery and mental health

33. Methodology II Baseline
Assessment of occupational history and Social Inclusion
Follow-up
Repeat above
Merge with measures conducted at DETECT baseline and 1 year follow up
Statistical analysis

34. Recruitment Once specifically for this research project
ASSESSMENT
DETECT
Unemployed
IPS
WFM
Employed
Recruitment
Occupational
Status
Interventions
Offer
Follow up
Once specifically for this research project
Once at one year for the DETECT service evaluation

35. Progress (to April 2012) IPS WFM 44 people offered IPS
42 attended initial assessment
34 (81%) progressed to education/employment/training
70 people offered WFM
22 agreed to attend
12 completed
11 were still employed in December 2012

36. Challenges
Recession
Traditional concerns re people with schizophrenia returning to work
Clinicians
Family
Perceived need amongst target group
State financial assistance
Old habits die hard!
Current policy – who’s responsibility is it to provide this population with assistance to return to work
Expertise

37. Tentative Conclusions
IPS model in early intervention services has the potential to change course of employment outcome for majority of people affected by psychosis
Need to consider offering assistance for those who never lose their work role at their first episode
There remains significant challenges to the widespread implementation of SE for people with psychotic conditions in Ireland

38. Thank You