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Apr 26, 2006 - Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first-episode psychosis: employing cautious optimism.
The Royal Australian and New Zealand College of Psychiatrists? 20064011/12••••Review Article EARLY INTERVENTION AND VOCATIONAL REHABILITATIONE.J.

KILLACKEY,

H.J. JACKSON, J. GLEESON, I.B. HICKIE, P.D. MCGORRY

Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first-episode psychosis: employing cautious optimism Eoin J. Killackey, Henry J. Jackson, John Gleeson, Ian B. Hickie, Patrick D. McGorry

Objective: While there are now effective interventions for the symptoms of psychosis and schizophrenia, treatment for the functional domains of these illnesses has received less attention. A key area affected by psychotic illness is vocational functioning. This area is currently of interest to clinicians, policy-makers, politicians and patients. This paper reviews several forms of vocational intervention practised over the years and highlights the issues around adopting an early intervention approach towards vocational rehabilitation. The paper has four aims: first, to consider some of the consequences of unemployment for those with psychotic illnesses; second, to review methods that have been used to address unemployment among the mentally ill; third, to highlight the importance of vocational development at a developmentally appropriate life stage; and finally, to consider the application of evidence-based vocational rehabilitation to those with first-episode psychosis. Method: An initial broad literature search was conducted using PsychInfo and Medline databases. Further narrower searches were conducted electronically where indicated. Finally, some articles were sourced through manual searches of relevant journals. Results: People with psychotic illness have a high rate of unemployment at the outset of their illness which tends to worsen over time. This is complicated by systemic factors such as the structure of the welfare system. Approaches for assisting people with mental illness return to work have evolved over the history of psychiatry. There now exists an evidencebased method of intervention. To date this has not been trialled in a systematic way with people in the early stages of psychotic illness. Conclusions: There is cause for cautious optimism in the vocational recovery of people with psychotic illnesses. Limited evidence exists that the individual placement and support approach developed with chronic populations is very effective in early episode patients. There are a number of challenges to implementing vocational intervention in first-episode psychosis. Overcoming these obstacles will require the cooperation of clinicians, those with illness, policy-makers and politicians. However, the potential economic, health and personal gains, as well as current and future research should provide sufficient motivation to overcome these barriers.

Eoin J. Killackey, Research Fellow (Correspondence); Henry J. Jackson, Head of School Department of Psychology, The University of Melbourne, and ORYGEN Research Centre, Parkville, Melbourne, Victoria 3053, Australia. Email: [email protected] John Gleeson, Associate Professor Department of Psychology, The University of Melbourne, Melbourne, Australia

Ian B. Hickie, Executive Director Brain and Mind Institute, The University of Sydney, Sydney, Australia Patrick D. McGorry, Executive Director Departments of Psychiatry and Psychology, The University of Melbourne, and ORYGEN Research Centre, Melbourne, Australia Received 26 April 2006; accepted 27 April 2006.

© 2006 The Authors Journal compilation © 2006 The Royal Australian and New Zealand College of Psychiatrists

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Key words: first episode psychosis, early intervention, vocational rehabilitation. Australian and New Zealand Journal of Psychiatry 2006; 40:951–962

The employment of people with mental illness has become an important political topic in Australia. In 2005 the Federal Treasurer stated that people with mental illnesses were a major recipient group of disability support pensions and it would be beneficial for those people and for the country if they were assisted back to work [1]. This was followed in the Federal budget by the announcement of the Welfare to Work initiative in which over half a billion dollars was to be invested ‘to help people with disabilities into work’ [2]. People with psychiatric illness have lower rates of employment than other disability groups [3] and within the population of people with psychiatric illness, people with psychotic illnesses are least employed [4]. Psychosis has a peak onset in late adolescence and early adulthood [5,6], and this is also when several developmental tasks usually occur, for example, the completion of education and training, and the beginning of career-based employment. These processes are referred to as vocational development. The onset of psychosis in this phase of life has the potential to disrupt this development, with far-reaching and deleterious consequences. The concept of work as part of the rehabilitation of people with mental illness is not new [7–10]. Currently however, there is a new motivation, both political and clinical, for facilitating the employment of people with mental illness who wish to work [11]. In addition, new evidence-based methods of vocational rehabilitation have been developed [12]. While these approaches have been successfully evaluated in chronically unwell populations [13], little attention has been paid to those at the outset of their experience with mental illness. Early intervention in psychotic illness is now an established, recognized and recommended approach [14]. Early intervention has the capacity to slow or halt the development of illness, is associated with less iatrogenic trauma, and may significantly reduce direct effects (e.g. neural degeneration) and secondary disability (e.g. social isolation, unemployment) of the illness [6]. Early intervention requires not just the treatment of presenting symptoms but the treatment of the individual taking into account their illness, their development and their future goals [15]. Ideally, this will involve a combination of biological and psychosocial interventions, targeting both symptoms and functioning. This early phase of illness

would appear to be a largely unexplored window of opportunity to implement vocational interventions. This paper considers some of the consequences of unemployment and barriers to employment for those with psychotic illnesses. It then reviews methods that have been used to address unemployment among the mentally ill. It details the window of opportunity potentially provided by combining early intervention in psychosis with vocational rehabilitation. Finally, consideration is given to the application of evidence-based vocational rehabilitation to those suffering from firstepisode psychosis.

Method Initial searches were conducted on PsychInfo and Medline databases using combinations of the search terms vocational, rehabilitation, employment, mental illness, psychosis, schizophrenia. Further specific searches were conducted using the same databases but using the terms: supported employment, transitional employment, clubhouse, club house, fountain house, individual placement and support (IPS), industrial therapy, work therapy, social firm, and social enterprise/s (enterprize/s). The searches of social firms and enterprises were also conducted on a commerce database (EconLit) as there was some indication that this may also be a useful area to search for this subject. Electronic searches were supplemented with hand searches from 2001 to September 2005 of journals that appeared frequently in the electronically sourced literature.

Barriers to employment The Australian Bureau of Statistics recently conducted a survey of barriers to employment among the general population of Australia [16]. Of the people who wanted to either work or work more hours than they currently were, the single largest barrier they reported was a lack of either qualifications or experience. It is known that controlling for course of illness, having more education is associated with being employed for people with psychosis and schizophrenia [17]. Because of the period of life in which psychosis has its onset, secondary and post-secondary education is often disrupted. The vocational disadvantage of not completing or engaging in these educational tasks at a developmentally appropriate stage is likely to compound over time. This is another reason in favour of early vocational intervention in all mental illnesses, but particularly psychosis as the psychotic illnesses tend to lead to the worst vocational outcomes [4]. Further disincentives to work are also reported

© 2006 The Authors Journal compilation © 2006 The Royal Australian and New Zealand College of Psychiatrists

E.J. KILLACKEY, H.J. JACKSON, J. GLEESON, I.B. HICKIE, P.D. MCGORRY

both in the literature and by those attempting to work. The starkest are reported in America where in some states people face the prospect of losing access to publicly funded health care and medication if they take a minimum wage paying job. In Australia while people do not lose access to health care, they do lose entitlements such as concession cards and benefit payments at a rate which leads to an increase in costs that is greater than the gain in income creating an effect whereby people are essentially punished for working. One of the advantages in this regard in intervening in the early psychosis population is that they may have a much lower rate of accessing benefits as they are more likely to still be being supported by family. Indeed, data from people who attended our service (Early Psychosis Prevention and Intervention Centre) in 2004 shows that 71% of them were not on benefits.

Unemployment and its consequences in psychotic illness Employment and unemployment initially seem to be intuitive concepts. However, when trying to define them difficulties arise. A lay definition of employment may be ‘working in order to earn enough money to live’. However, the Australian Bureau of Statistics in calculating employment and unemployment rates defines employment as ‘all persons engaged in one or more hours of work during the reference period, as well as some persons temporarily absent from work’ [18]. Further complications arise when consideration is given to how unemployment rates are calculated, specifically the choice of population of which the unemployed constitute a subset. For example, it is known that in Australia in November 2005, the participation rate (that is those either studying, working or seeking work) was 64.4% of the labour force (those aged 15 years and over and able to participate in work in the reference period) [19]. The unemployment rate can therefore vary greatly depending on whether the participating population or the whole labour force is used as a denominator for the calculation. Many studies, admittedly often reporting employment status as a descriptive demographic variable, have frequently made arbitrary categories of employed and unemployed [20,21], while some have also added student and other roles – for example, house wife [22–24]. There is little description in many of the studies that have examined employment in psychosis as to what kind of work is engaged in, how much of it, how it was attained and how it is remunerated. As Marwaha and Johnson state ‘There is no standard method of describing employment in schizophrenia’ (p. 338) [3]. A further difficulty in the field of early psychosis and employment is that there has been less of a focus on employment in this phase of the illness than there has been in more established phases of illness. However, in working out employment and unemployment rates these studies have tended to use their entire sample size as the denominator. Even allowing for the vagaries of employment statistics, it would appear that rates of employment for people with schizophrenia are low [3,14,25] compared with the general population [25,26] and this is a finding which tends not to improve over time as demonstrated in longterm follow-up studies [27,28] and by looking at cross-sectional data collected over a period of time [3]. In a recent review Marwaha and Johnson [3] note that in the UK, studies prior to the 1990s generally reported rates of employment between 20% and 30%, whereas studies conducted after 1990 report employment rates of 4–27% for people

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with schizophrenia. Fewer studies have examined the rate of employment among first-episode psychosis patients, but the range across 11 international studies reported in Marwaha and Johnson’s review (in which first episode was defined as either first presentation or having no previous episode) is from 13% to 65% with an average of 37%. This large range may reflect the heterogenous nature of first-episode populations, or may be related to specific cultural and ethnic groups included in the review. Three studies from three countries published since Marwaha and Johnson’s review have found unemployment levels of 43% [29] in Canada, 50.2% [30] in Australia and 39% [31] in Singapore. In all three studies participants were patients attending specialized early psychosis services. The mean of 37% from the earlier studies and the findings from more recent studies accords well with unpublished data gathered recently at Early Psychosis Prevention and Intervention Centre that shows that of those with first-episode psychosis, 29% of people were in employment, 25% were in education or training and 39% were unemployed. One argument that might be made is that younger people have a higher unemployment rate than the general population anyway. In fact, in Australia where the current population unemployment level is 5.1% [19], unemployment among 15–19 years olds is 3.8% with a further 3.9% not in the labour force and among 20- to 24-year-olds 4.8% are unemployed with 8.3% not in the labour force [32]. These figures suggest that for those experiencing a first psychotic episode, the level of employment is grossly higher than in the comparable general population. As noted in Marwaha and Johnson’s review and echoed in a number of other studies [33–37], the initial employment rate tends to decline quite quickly over the first year or so post admission. A consequence of the rapid decline of employment of people with first-episode psychosis is that they then become dependent on other sources of support, which may be either public welfare, family, or, in many cases, both. In one study with 48 participants followed for 5 years after their initial presentation, seven were on public financial support at the time of admission. Throughout the follow-up period, 30 others in this cohort started to receive public financial support and the median time from admission to initiation of support was 7 months. Only two of these 30 were not receiving public assistance at the time of the 5-year followup [35]. This is reflected not only in the level of employment, but also in the downward social drift (wherein a person moves from a higher to lower socio-economic group) found in several studies in which the socio-economic status of the person with a psychotic illness has been compared either with their own earlier status or that of their parents [38–40]. The majority of people who develop psychosis do so at a time in their lives when they are just at the beginning of developing vocational interests and directions. Not surprisingly then, the experience of psychosis derails this aspect of their development and either leads or contributes significantly to the rapid fall in employment rates mentioned. There is no doubt that psychotic illnesses are also economically expensive for the community. Taking schizophrenia as an example, in Australia, with a population of just under 20 million, the total cost of schizophrenia in 2001 was nearly $2 billion or 0.3% of GDP [26]. For those with schizophrenia, there was a loss of earnings of $487.6 million due to unemployment and absenteeism, from which there was a loss to the country of $165.7 million in forgone income and sales taxes. In 2001 the cost attributed to people caring for their ill family member or friend was $88.1 million. This included money paid to carers by the government and revenue lost because these carers were unable to participate in the paid labour force due to their carer responsibilities. There

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was also $16.2 million paid in accommodation assistance. Finally, 85% of people with schizophrenia in Australia were receiving a public welfare benefit. The total cost of this was $274 million. Interestingly, of those on a public welfare benefit, only 11.8% were on a benefit that indicated they were seeking employment. All others were on a disability or illness payment [26]. Thus, the indirect cost to the nation of people with schizophrenia not working was $543.7 million in 2001. Vocational intervention in the early phase of psychotic illness would tackle some of these issues before they became entrenched and expensive problems. Being employed is desirable for individuals with psychotic illness because it leads to gains in several life domains [41,42]. These include areas directly influenced by being employed such as receiving payment, social contact and external structure, as well as indirect consequences such as increasing quality of life, reducing hospitalization, increasing sense of efficacy in management of illness, participating in the community, and having a productive and contributing role [43]. In the case of people with first-episode psychosis, being either supported in maintaining their current employment or being aided in their vocational development has the potential to lead to lasting and important functional gains [44].

before deinstitutionalization [25,47,48]. In re-examining these programs now, it can be seen that while they did provide an occupation for people and in some cases might have helped them learn new skills, they were inadequate in two ways. First, the skills taught may not have generalized to other employment situations or may not have been well suited to the occupational interests of the individual. Second, these jobs often did not offer remuneration that would have been equivalent to that earned in a similar job in the community, if indeed any financial remuneration were offered at all. It has not been possible to identify any systematic reviews of these types of programs, possibly because they belonged to a pre-evidence-based era of psychiatry. As part of the deinstitutionalization process, it was recognized that formerly institutionalized people living in the community needed to develop working skills in order to reintegrate into the social and economic life of the general community. This led to the development of two different approaches. In Europe, particularly in Italy, the concept of the social firm was developed [42]. In the US the clubhouse model of vocational rehabilitation expanded [49].

Social firms Methods to address unemployment Despite long-standing recognition of the potential to intervene on many levels early in the course of schizophrenia [45], in the period since deinstitutionalization, limited mental health services have tended to be offered to those who have chronic and established illness, whereas those in early phases of illness are ‘managed’ through their episodic crises and often discharged when ‘stabilized’ [14]. Very rarely is attention given to the functional component of recovery once symptomatic concerns are dealt with [46]. In a similar way, vocational services, which have developed from work tasks given to residents of the old institutions [12,47], have also concentrated on chronic populations. Partly, this is because these populations constitute the majority of the clients of public mental health systems. In addition, those with chronic illness are more likely to be on public benefits than the early phase group. Therefore, any increase in the proportion of the chronically unwell working is attractive to government because of reduced paid benefits as well as extra tax gained (although as discussed moving from benefits to paid work is sometimes a barrier in itself because the new income does not compensate for lost additional benefits such as concession card prices). Nonetheless, this is a classic example of shortterm thinking, seeking to fix an existing problem, rather than acting to prevent a future one. So what methods have been developed in order to address this problem? As mentioned there have been a number of approaches to the issue of unemployment for people with mental illnesses. Broadly speaking, these can be described under four headings: industrial therapy; social firms; clubhouse model (transitional employment, train and place); supported employment.

Industrial therapy Industrial or work therapy was the name given to the wide range of chores and jobs given to residents of the old institutions in the times

There are many different definitions of what constitutes a social firm, and the term itself is sometimes used interchangeably with the term ‘social enterprise’. Two bodies have developed guidelines which help define exactly what is (and isn’t) a social firm. These bodies are the Confederation of European Firms, Employment Initiatives and Social Cooperatives and Social Firms UK. Social firms are a particular kind of social enterprise [50]. They are not-for-profit businesses that are set up to provide a product or service to the public and in doing so create employment for people who may ordinarily be excluded from the labour market due to illness or disability. Social Firms UK have recently gone further and issued a Values Based Checklist against which a firm is assessed to see if it meets the criteria of a social firm. These criteria include that at least 25% of employees have the illness or disability targeted by that social firm (e.g. mental illness); that at least 50% of the turnover comes from the market activity of the company; in these positions people are paid at least award or market wages and given real responsibilities and have the potential to progress through the business [42,51,52]. While it may also be envisaged that they use skills learned in the social firm to eventually find competitive employment, it is often the case that this is not an aim of the people or organization running the business who are more likely to see themselves as investing in the training of an individual [53] with the target of developing a sustainable business [51,52]. Social firms have grown quickly in some regions of Europe, particularly Italy where the number of social firms went from one in 1973 to 5401 in 1998 [54]. However, the role of definition is seen when it was reported that there were 200 social firms in the UK in 1998 [54] and in a report developed after the development of the Values Based Checklist, Social Firms UK noted that there were 49 social firms and 70 emerging (in development) social firms in the UK in 2005 [53]. In the same report they noted that in UK social firms, 55% of employees on average had a disability and that there was very good retention of staff in the businesses with only 7% leaving in the previous 12 months. Social firms can be any type of business that provides a product or service to the public as a means of pursuing a social agenda [55]. In

© 2006 The Authors Journal compilation © 2006 The Royal Australian and New Zealand College of Psychiatrists

E.J. KILLACKEY, H.J. JACKSON, J. GLEESON, I.B. HICKIE, P.D. MCGORRY

the Social Firms UK report it was found that 83% of social firms operated in the service sector [53]. While this was a small sample, in Italy, with over 5000 social firms 58% were in the service sector, 29% in the manufacture of handicrafts and the rest in areas described as building (4%), commercial (6%) and agricultural (3%) activities [54]. In 2003 it was noted that there had not been any systematic evaluation of social firms [46]. Despite extensive searching in Medline and PsycInfo and in the commerce literature via EconLit, using combinations of the terms social, firm/s, enterprise/s, enterprize/s, and imposing no date limits, no systematic research regarding social firms appears to have been undertaken since then. Further searches through the resources pages of the Social Firms UK website similarly produced little in the way of systematic research. This is a great pity because the evidence from industry groups suggests that this is a means by which people with mental illness could find work in an environment that is accommodating to the needs of their illness. There also seems to be longevity of employment. Maintaining employment is an area of vocational rehabilitation that has received less focus than it deserves in other forms of employment intervention. At the same time, social firms are not a modern form of sheltered workshop. They are market-focused businesses which choose to pursue a social outcome instead of a purely profit outcome. The downside to social firms is that as with any business, a social firm requires a lot of time and energy just to establish, let alone run successfully. Further, having established a single social firm, it may not cater to the vocational needs of the individual. Therefore, what needs to be discussed in terms of social firms is not the establishment of one or two businesses, but the development of an employment sector. Inevitably this takes time. Organizations such as Social Firms UK, and more locally and recently, Social Firms Australia are leading this development in their respective countries. One of the reasons why Italy has experienced such large growth in this sector may have been that the Italian government mandated the development of this sector as a means to create employment for those marginalized by their illnesses, disabilities or circumstances and supported its development [54]. However, without research to explore the economic and health benefits of social firms, there is little leverage to encourage either governments or those who might be described as social venture capitalists, to invest in the development of the social firm sector. In comparison to both industrial therapy and social firms, there has been more research describing and examining two other interventions, the clubhouse model and supported employment. Clubhouse programs typically involve prevocational training and transitional employment. Supported employment on the other hand emphasizes direct job placement and ongoing support and is best defined in the IPS model of Becker and Drake [56].

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patients and would work alongside a small generalist staff in the house as equals. At the club house, as well as having meaningful social encounters, a member contributes to the club by participating in voluntary work such as cleaning, clerical, research, hiring, training, public relations, and advocacy work for example [58]. The idea being that apart from contributing to the club the member develops some of the skills necessary to succeed in employment such as punctuality, confidence and responsibility. This is known as the Work Ordered Day [59]. Following on from this the person has access to a set period of employment in a local company. This transitional employment is central to the clubhouse model [60], and involves the club and the company making an arrangement whereby the company offers a number of positions which the job club guarantees to fill. The job club may then use 12 people, working part-time to fill four full-time positions. Each member would then typically receive 6–9 months of experience of employment in a real setting, for market or award wages. Since the mid 1990s the International Center for Clubhouse Development (ICCD), requires certified clubhouses to have access to a wide range of different employment settings in order to cater to the diversity of vocational interests that is likely to exist among their members. For example, Fountain House in New York placed 400 people at 41 different companies in 1998 including law firms, financial institutions and publishers [58]. Finally, at the end of this process it would be hoped that the member would be able to generalize the skills learned through the job club and transitional employment in order to obtain competitive employment [61]. However, because membership is for life, the individual can continue to contribute to the job club and use it as a place of socialization and support. If necessary the member is also able to go back to the beginning of the process. While this has been the traditional clubhouse model of employment (and clubhouses are still misrepresented as offering only transitional employment [62]), more recently clubhouses have viewed the work ordered day and transitional employment as the first two steps of a hierarchy of vocational interventions which continues on to supported employment and then independent employment [62]. In a worldwide survey of ICCD certified clubhouses in 2000 it was found that transitional employment provided 36.6% of job placements, supported employment 26.6% and independent employment 36.8% [62,63]. The importance of accreditation was seen in a study in which Macias et al. compared 73 certified clubhouses with 48 noncertified clubhouses. While they found that both groups appeared organizationally similar and had similar resources, the certified clubhouses had a wider range of rehabilitative services and a better outcome in terms of members finding competitive employment [64].

Clubhouse studies The clubhouse model The clubhouse model was started by ex-psychiatric patients at Fountain House in New York in 1948 [49]. For the time, Fountain House had a radically rehabilitative approach towards mental illness in which it was posited that men and women with histories of mental illness could, through mutual support and encouragement, work productively and live socially satisfying lives [57]. Further, participants of Fountain House were members of a club (hence the clubhouse model) rather than

One of the acknowledged neglected areas in the development of the clubhouse model over most of the first half-century of its existence was that of research as to the effectiveness of its outcomes [58,62]. This led to a number of criticisms of clubhouses, such as the work ordered day promoting dependence, transitional placements not being as effective at building work confidence as competitive employment, and questioning the level of transition to, and tenure of, competitive employment, particularly compared with supported employment approaches [62,65– 67]. The lack of randomized controlled trials (RCTs) of transitional employment [59] has possibly also affected the way that it has been

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viewed in widely cited systematic reviews of employment interventions for people with serious mental illness [44,68]. However, due to the ICCD, criteria required of clubhouses have been made clear and researchers have begun to study clubhouse outcomes and are also beginning to compare them with outcomes of other vocational interventions. Three studies [59,62,67] have examined either ICCD clubhouse outcomes or compared them with other programs (see Table 1). One of these studies will be considered in more detail. The only study to date which actually compared ICCD certified clubhouses to another approach was reported by Macias [67]. This study (MA-EIDP) was one of eight component projects of the Employment Intervention Demonstration Project (EIDP) [69] and compared the ICCD clubhouse intervention and the Program of Assertive Community Treatment (PACT). The PACT program is an intensive mobile treatment team providing clinical and rehabilitation services in the community [67]. As opposed to other studies in the EIDP, participant’s willingness to work was not an entry criterion. Thus, 30% of the MAEIDP sample had no declared interest in working at enrolment into the study. This maintained fidelity to both the PACT and ICCD models. The final sample consisted of 175 people and analyses were conducted on an intention to treat basis. Measurements were carried out at baseline, and 6, 12, 18 and 24 months. Employment outcome data were available for 174 of the sample. In their analyses the outcome of competitive employment included transitional employment, because according to criteria determined by the US Department of Labor, transitional employment meets the definition of competitive employment, although it is not necessarily seen as competitive employment by all researchers of vocational interventions [44]. This is because of the ‘setaside’ nature of the jobs involved. In the trial PACT and ICCD had similar outcomes on a number of measures including the number of participants who started competitive work, the number participants interested in work at baseline who started competitive work, job satisfaction and the amount of time from enrolment until commencing work. The ICCD clubhouse performed better than PACT on measures of days worked, money earned, quality of jobs, hourly rate of pay, and job tenure. The PACT program performed better than the ICCD clubhouse on participant retention. One of the problems of this study is that there is no distinguishing between transitional and other forms of employment. While this may reflect a philosophical orientation of those involved with clubhouses that equates transitional, supported and independent work outcomes, it complicates comparison between the two interventions. For example, while the two programs had non-significant differences on competitive employment outcome as they defined it, it would be good to know if there were differences as it is defined by others who see transitional employment as non-competitive. A positive point of the study is that it included cost data which showed that vocational and total direct costs of the ICCD clubhouse model were cheaper than PACT – although there are no reported significance tests. It is likely that PACT’s costs are higher purely because of the assertive outreach nature of this model. Given the situation of employment programs, often placed precariously between health and employment systems, the collection and analysis of economic data should be a routine part of all investigations into the efficacy and effectiveness of these interventions. While the benefits of clubhouses extend far beyond their role in employment rehabilitation they, like social firms, are not easy to establish. Clubhouse budgets in America averaged just over US$400 000 in

1996 [49]. Apart from cost, one of the other factors that mitigate against them being established by and for young people with first-episode psychosis is that clubhouses are the result of communities forming around a common issue. Often, young people with first-episode psychosis are still coming to terms with their psychotic experiences and have not developed an identity-based around their illness, nor have they necessarily developed the networks or skills required to establish an undertaking like a clubhouse. To establish a clubhouse for young people with first-episode psychosis would likely involve such significant input from non-consumers that those with first-episode psychosis may feel little ownership over the project and this would contravene the philosophy central to the clubhouse model. There are currently 10 clubhouses in Australia (only one of which is ICCD certified), five in Queensland, two in New South Wales and one each in Victoria, South Australia and Tasmania.

Individual placement and support Supported employment is a method of vocational intervention that is differentiated from prevocational training models by its focus on rapid job search and placement and support following the acquisition of a competitive position [69]. Supported employment is most specifically defined in the IPS model, and has been developed for people with severe mental illness for just over a decade [61]. The IPS model has six defining features [56,60]: it is focused on competitive employment as an outcome; the service is open to any person with mental illness who chooses to look for work and that acceptance into the program is not determined by measures of work-readiness or illness variables; job searching commences directly on entry into the program; the IPS program is integrated with the mental health treatment team; potential jobs are chosen based on patient preference; and the support provided in the program is time-unlimited, continuing after employment is obtained, and is adapted to the needs of the individual. As opposed to both social firms and clubhouses which developed largely from collectives of people experiencing mental illnesses, the supported employment model has been adapted by researchers and clinicians from its previous use in populations with intellectual disability. Consequently it is the most studied of the various vocational interventions, and the one most supported by the research.

IPS studies In a recent review of supported employment [60] nine RCTs were considered, five of which utilized IPS, of which four are published [41,43,70,71] (see Table 2). Searches of the literature since then reveal no new RCTs of IPS. One of these studies will be considered in greater detail. Lehman et al. conducted an RCT with IPS [41]. A total of 219 participants were randomized to either IPS or to a psychosocial rehabilitation program which in regards to vocational outcomes provided work readiness skills training, sheltered work, assistance in job seeking or referral to external vocational services. Although achieving lower rates of employment in the IPS group than previous studies had, the IPS group (27%) in this study still achieved significantly more competitive employment than the comparison group (7%). When all forms

© 2006 The Authors Journal compilation © 2006 The Royal Australian and New Zealand College of Psychiatrists

1995–2001

1998–2001

Macias 2001 [67]

McKay et al. 2005 [62]

Naturalistic follow-up

RCT

Design

Interventions

Clubhouse based TE, SE & IE†

Clubhouse (n = 89) versus PACT (n = 86)

TE

1702

175

n 138

Time to job (days) Days employed Job earnings Hourly earnings Days per week Hours per week

Job Characteristics Wage per hour Weekly job hours Weeks worked Total hours worked Total earnings

Retention (at 24 months) Competitive employment Time to employment Duration of employment Total earnings Hourly earnings Tenure of position

Competitive employment

Outcomes Predictors of; TE Tenure

Clubhouse studies

TE 198 146 $2130 $6.34 3.7 13.9

Club Non-TE (n = 54) $7.48 20.8 22.3 491 $4037

Club TE (n = 21) $6.88 12.3 19.1 283 $2012 IE 204 361 $16 169 $7.59 3.88 21.1

Clubhouse 60% 59% 212 day 257 days $6052 $7.31 148 days

PACT 81% 64% 242 days 173 days $3792 $6.25 80 days

Total hours worked in TE jobs

Days worked per week Length of clubhouse membership Age

Results

SE 163 301 $9787 $6.91 3.9 18.3

PACT (n = 106) $6.24 20.8 11.8 264 $1754

p SBV & PSR ($2078 vs. $618 & $239) IPS > SBV & PSR (30 vs. 5 & 3) IPS > SBV & PSR (20 vs. 5 & 3) IPS > SBV & PSR (26 vs. 5 & 3)

IPS > PSR (27% vs. 7%) IPS > PSR (42% vs. 11%) IPS > PSR IPS > PSR 69–71 (Out of possible 75)

IPS > EVR IPS > EVR IPS > EVR IPS > EVR IPS < EVR

Significant results IPS > GST (78.1% vs. 40.3%) IPS > GST (46.6% vs. 22.4%) [607 vs. 205] IPS > GST ($3394 vs. $1077) IPS < GST (15% vs. 2%)

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© 2006 The Authors Journal compilation © 2006 The Royal Australian and New Zealand College of Psychiatrists

E.J. KILLACKEY, H.J. JACKSON, J. GLEESON, I.B. HICKIE, P.D. MCGORRY

of work are included the IPS group (42%) still significantly outperforms the comparison group (11%). As in the other studies those in the IPS group worked more hours, earned more money, and moved into employment more quickly [41]. This was the first RCT conducted after the development of a fidelity scale for IPS [72] and this study utilized the scale showing that at all points fidelity to the IPS model was maintained. In discussing their results, particularly in comparison to the Drake studies, Lehman et al. suggest that two main reasons may explain the lower employment levels in both the IPS and comparison groups in their study. First, because of a different recruiting process they suspect that they may have obtained a less motivated sample. The second reason concerns illness variables. Interestingly there was a relationship between diagnosis and working in this study in that having a psychotic diagnosis or an active substance use disorder was related to a poorer employment outcome [41]. They point out that they had nearly double the number of people with substance use problems compared with the second study of Drake et al. Important findings from the study of Lehman et al. may be that illness variables and work motivation are important factors in the success of the IPS model. This study also speculates that neurocognitive variables may be important in maintaining employment once it is gained, and that cognitive remediation may be able to facilitate this [41]. Studies of IPS show that it is, in general, a better intervention than comparison treatments. Two areas of interest that are raised but not resolved by these studies concern the tenure of positions and the role of illness variables in obtaining employment.

Vocational interventions in first-episode psychosis Vocational intervention has so far occurred exclusively with people with established mental illness. It is now generally accepted that supported employment (of which IPS is the most defined form) is the leading evidence-based vocational intervention for people with established mental illness [73–75]. To date, no published RCT of vocational interventions has been conducted in a first-episode cohort. This is unfortunate as the age at which psychosis has its peak rate of onset is also the age at which vocational development is normally being engaged in. Thus exploring work preferences and areas is a normative experience in this age group. As has been seen above, unemployment is a problem in this age group. Additionally there are going to be major changes in Australia both in the employment and welfare sectors in the coming years. A detailed discussion of these changes is beyond the scope of this paper. However, in order to reduce the potential social marginalization of young people with psychosis caused by unemployment, and to maximize the employed proportion of those who go on to experience continuing mental illness, 90% of whom may otherwise be condemned to long unemployment, it is important to examine the utility of evidence-based vocational interventions in this population. Two studies have recently examined the use of IPS-based supported employment in first-episode groups [34,76]. Rinaldi et al. reported on a repeated-measures within-subject design study of supported employment with 40 first-episode clients. The results of this study show that the IPS model is effective with firstepisode patients. Over 12 months unemployment fell from 55% to 5% and competitive employment rose from 10% to 41%. In addition, those who were in education or training at baseline were either maintained

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in their education or training across the intervention or completed it within the timeframe. Rinaldi et al. specifically mention that the vocational specialist was not only seeking out job opportunities but also helping clients maintain job or training situations [34]. Neuchterlein et al. used an IPS approach [76]. In their RCT, 51 patients were randomized to either the active intervention or a traditional vocational rehabilitation control. Participants were followed for 18 months (6 months intervention, 12 months follow-up). In the first 6 months 93% of the active condition group returned to work or study compared with 50% in the control condition (p < 0.001). In the followup period 93% in the active condition remained in school or work compared with 55% in the control condition (p < 0.008). In addition, it was noted that in this study the active condition resulted in a significantly lower rate of treatment dropout [76]. These two studies indicate that the potential of IPS in first-episode psychosis is at least as good as it would seem to be from the more extensive research in other populations with more established mental illness. It is possible that because of the different stage of life that most first-episode people are at, adaptations, specific to this age group will need to be made. The Nuechterlein study above included a focus on educational outcomes for example. Because this phase of life is naturally the beginning of career development it is possible that vocational interventions in this phase could take a long-term developmental view and seek to start establishing careers rather than merely placing people in jobs. Another challenge in this phase of illness is that people are still likely to be in contact with and thus comparing themselves to sameaged peers who have performed better at school or work which may lead to feelings of failure or shame. Combining vocational interventions with specific psychological interventions may increase the efficacy of vocational rehabilitation in this age group. These early results seem to hold some promise. It is encouraging too that the interventions described discuss not only employment outcomes, but also educational outcomes as this is especially developmentally pertinent to this age group. Based on these results and with an interest in the application of these methods to the Australian context, our group is trialling a similar intervention in our own service. We have employed a Youth Employment Specialist to work with young people as part of a RCT comparing IPS with treatment as usual.

Conclusion For most of the history of psychiatry, there has been scant attention paid to the vocational rehabilitation of people with serious mental illness. Even in recent times where there has been attention, it has generally been focused on those with long-term illness and consequent long-term unemployment, where it might be argued the potential gains are limited. Despite there being evidence that the employment situation for people with psychotic illnesses is in fact getting worse [3], there is cause for a cautious optimism. The optimism is based on the facts that, development of employment interventions for people with mental illness has, over the last 15 years, produced a model that is more effective than its predecessors in producing successful employment outcomes;

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the developing evidence that the IPS model of supported employment is at least as effective in younger, less vocationally disabled groups; having effective symptomatic interventions for psychosis has allowed clinicians to begin to really focus on the functional aspects of the recovery of their clients; and governments see youth mental health and employment of people with mental illness as policy priorities. The caution is due to the fact that there is still stigma and misunderstanding in the general community (of which employers are members) regarding mental illness [42]; that while clinicians see the value in the employment of clients, there is a gap between mental health and employment agencies, which many clients struggle to successfully cross; that often rules, surrounding welfare in the transition to work, act as economic barriers to employment and hence often social participation; that in Australia, the issue of the employment of people with mental illness falls right on the juncture between federal (employment) and state (health) funding; and that there is no psychosocial intervention which can be all things to all people. Therefore, in order to realize this optimism, there are challenges ahead for clinicians, politicians, policymakers and for people with psychotic illness. For clinicians the challenge is to implement treatment guidelines and to reject persistent erroneous mythology about people with psychosis not wanting or being able to work [77]. On the political and policy front the barriers created by the welfare system which punishes those who seek to work need to be addressed and the jurisdictional barriers between State and Federal governments and between health and employment funded sectors need to be overcome. For those with psychotic illness, the challenge is to demand effective functional as well as symptomatic interventions. In order to address the last point of caution, it is necessary that a variety of employment strategies are developed for those who may not succeed at IPS. This may include the development of the social firm sector and clubhouse-based employment initiatives. Research projects, such as the one our group is starting, will provide evidence that these interventions are possible in the Australian context. This evidence will then be able to be used by policy-makers to drive reforms and clinicians to promote cultural change. If the clinical and political goals, as well as the personal ambitions of those with psychosis are to be realized, evidenced-based supported employment such as IPS needs to be embraced as part of the early intervention paradigm. Doing this will go a long way towards providing a path for social inclusion and economic participation for people with psychotic illnesses.

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