Christoph Lauber

The effectiveness of supported employment for people with severe mental illness : a randomised controlled trial

BACKGROUND The value of the individual placement and support (IPS) programme in helping people with severe mental illness gain open employment is unknown in Europe. Our aim was to assess the effectiveness of IPS, and to examine whether its effect is modified by local labour markets and welfare systems. METHODS 312 patients with severe mental illness were randomly assigned in six European centres to receive IPS (n=156) or vocational services (n=156). Patients were followed up for 18 months. The primary outcome was the difference between the proportions of people entering competitive employment in the two groups. The heterogeneity of IPS effectiveness was explored with prospective meta-analyses to establish the effect of local welfare systems and labour markets. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, with the number NCT00461318. FINDINGS IPS was more effective than vocational services for every vocational outcome, with 85 (55%) patients assigned to IPS working for at least 1 day compared with 43 (28%) patients assigned to vocational services (difference 26.9%, 95% CI 16.4-37.4). Patients assigned to vocational services were significantly more likely to drop out of the service and to be readmitted to hospital than were those assigned to IPS (drop-out 70 [45%] vs 20 [13%]; difference -32.1% [95% CI -41.5 to -22.7]; readmission 42 [31%] vs 28 [20%]; difference -11.2% [-21.5 to -0.90]). Local unemployment rates accounted for a substantial amount of the heterogeneity in IPS effectiveness. INTERPRETATION Our demonstration of the effectiveness of IPS in widely differing labour market and welfare contexts confirms this service to be an effective approach for vocational rehabilitation in mental health that deserves investment and further investigation.

Stigma towards people with mental illness in developing countries in Asia.

Background: There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996–2006. Method: Medline search focusing on English-speaking literature. Results: Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing. Conclusion: This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization–beliefs about causes of and attitudes towards mental illness, consequences for help-seeking–have more commonalities than differences to Western countries.

Factors influencing social distance toward people with mental illness

Background: When identifying ways to reduce stigmatization because of mental illness it is crucial to understand contributing factors. Social distance—the willingness to engage in relationships of varying intimacy with a person—is an indicator of public attitudes toward persons with mental illness. Methods: Multiple linear regression analysis of the results of a vignette-based opinion survey conducted on a representative population sample in Switzerland (n = 594). Results: The level of social distance increases if situations imply ‘social closeness.’ The vignette describing a person with schizophrenia, attitudes to general aspects of mental health (lay helping, community psychiatry), emotions toward those affected, and the attitude toward consequences of mental illness (medical treatment, medication side effects, negative sanctions, e.g. withdrawal of the driver license) were found to predict social distance. Demographic factors such as age, gender, and the cultural background influence social distance. The explained variance (R2) is 44.8%. Conclusions: Social distance is a multifaceted concept influenced by, e.g., socio-economic and cultural factors, but also by the respondents general attitude toward (mental) health issues. These results suggest that more knowledge about mental illnesses, especially schizophrenia, may increase social distance. The findings presented here may help to focus anti-stigma campaigns not only on transmission of knowledge, but on integrating different approaches.

Do people recognise mental illness? Factors influencing mental health literacy

Abstract.Background:Mental health literacy has been defined as the public’s knowledge and the beliefs about mental disorders enhancing the ability to recognise specific disorders.Aims:Firstly, to determine whether the public recognises a person depicted in a vignette as mentally ill or as experiencing a crisis. Secondly, to reveal the factors influencing the correct recognition.Methods:Multiple logistic regression analysis of an opinion survey conducted in a representative population sample in Switzerland (n=844).Results:The depression vignette was correctly recognised by 39.8% whereas 60.2% of the respondents considered the person depicted as having a ‘crisis.’ The schizophrenia vignette was correctly identified by 73.6% of the interviewees. A positive attitude to psychopharmacology positively influenced the recognition of the two vignettes whereas a positive attitude to community psychiatry had the inverse effect. Moreover, for the depression vignette previous contact to mentally ill people had a positive influence on the recognition. For the schizophrenia vignette instead, rigidity and interest in mass media had a negative influence, respectively.Conclusions:The low knowledge about mental disorders, particularly depression, confirms the importance and the need to increase mental health literacy. Furthermore, professionals must openly discuss illness models with their patients, especially emphasising the differences between illness and crisis.

Do mental health professionals stigmatize their patients

Objective:  Assessing stereotypes towards people with mental illness among mental health professionals, comparing their view to the Swiss general population and analysing the influence of demographic factors, profession and work place variables (type of ward, employment time and professional experience).

The Impact of Supported Employment and Working on Clinical and Social Functioning: Results of an International Study of Individual Placement and Support

BACKGROUND Concerns are frequently expressed that working might worsen the mental health of people with severe mental illness (SMI). Several studies of Individual Placement and Support (IPS), however, have found associations between working and better nonvocational outcomes. IPS has been found to double the return to work of people with SMI in 6 European countries. AIMS To explore separately associations between IPS, returning to work, and clinical and social outcomes. METHODS Patients (n = 312) in a randomized controlled trial of IPS in 6 European centers were followed up for 18 months. RESULTS There were no differences in clinical and social functioning between IPS and control patients at 18 months. Those who worked had better global functioning, fewer symptoms, and less social disability at final follow-up; greater job tenure was associated with better functioning. Working was associated with concurrently better clinical and social functioning, but this contrast was stronger in the control group, suggesting that IPS was better than the control service at helping more unwell patients into work. Working was associated with having been in remission and out of hospital for the previous 6 months. It was also associated with a slight decrease in depression and with being in remission over the subsequent 6 months. CONCLUSIONS Concerns among clinicians about possible detrimental effects of working and supported employment have been misplaced. Although some of the associations found may have been selection effects, there is sufficient evidence of work having beneficial effects on clinical and social functioning to merit further exploration.

Predictors of employment for people with severe mental illness : results of an international six-centre randomised controlled trial

BACKGROUND An international six-centre randomised controlled trial comparing individual placement and support (IPS) with usual vocational rehabilitation for people with serious mental illness found IPS to be more effective for all vocational outcomes. AIMS To determine which patients with severe mental illness do well in vocational services and which process and service factors are associated with better outcomes. METHOD Patient characteristics and early process variables were tested as predictors of employment outcomes. Service characteristics were explored as predictors of the effectiveness of IPS. RESULTS Patients with previous work history, fewer met social needs and better relationships with their vocational workers were more likely to obtain employment and work for longer. Remission and swifter service uptake were associated with working more. Having an IPS service closer to the original IPS model was the only service characteristic associated with greater effectiveness. CONCLUSIONS The IPS service was found to be more effective for all vocational outcomes. In addition, maintaining high IPS fidelity and targeting relational skills would be a valuable focus for all vocational interventions, leading to improved employment outcomes. Motivation to find work may be decreased by satisfaction with current life circumstances.

Lay recommendations on how to treat mental disorders

Background Beliefs about the helpfulness of interventions are influencing the individual help-seeking behavior in case of mental illnesses. It is important to identify these beliefs as professional helpers are asked to consider them in their treatment recommendations. Objective Assessing lay proposals for an appropriate treatment of mental illnesses. Methods We conducted a representative opinion survey in Switzerland. Eighteen treatment proposals were presented with respect to a vignette either depicting schizophrenia or depression. Respondents were asked to indicate the proposals considered to be helpful for treatment and those considered to be harmful, respectively. Results‘Psychologist,’‘general practitioner,’‘fresh air,’ and ‘psychiatrist’ were mostly proposed as being helpful. Among several psychiatric treatment approaches ‘psychotherapy’ was favored, while psychopharmacological treatment and electroconvulsive therapy were only proposed by less than one-fourth of the interviewees. Especially psychotropic drugs were considered to be harmful. Treatment by a psychiatrist was regarded as being more helpful for schizophrenic individuals than for depressive persons. For a person experiencing a life crisis, treatment by a psychiatrist and psychological treatment were viewed as being harmful, and non-medical interventions were preferred. However, for persons thought to be mentally ill, psychiatric and psychopharmacological treatments were recommended. Conclusion Mental health professionals are regarded as being helpful although their treatment methods are seen as being less helpful. A clear distinction is made between lay proposals for depression and schizophrenia. However, the perception of whether a condition is considered to be an illness or a life crisis has significantly more influence on lay treatment proposals than the cited diagnosis in the vignette.

The mental health of female sex workers.

Rössler W, Koch U, Lauber C, Hass A‐K, Altwegg M, Ajdacic‐Gross V, Landolt K. The mental health of female sex workers.

Lay beliefs about causes of depression

Objective:  Assessing lay beliefs about causes of depressive behaviour and analysing the influence of labelling and demographic factors on causal attributions.