Supported employment in early intervention for psychosis services Niall Turner

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

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

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. 2008 (based on 2006 data)

Recovery

…know about employment outcome?

…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

“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

….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”

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

Length of Delays 11

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

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

Development of Early Psychosis Programs EPPIC 14

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

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.

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

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)

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 16.26 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

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

International Movement iFEVR

End of Part I

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……

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

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

Additionally since 2010…..

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

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

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

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

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?

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

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

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

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

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

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

Thank You