Jocelyn Catty

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.

Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression

Objectives To explain why clinical trials of intensive case management for people with severe mental illness show such inconsistent effects on the use of hospital care. Design Systematic review with meta-regression techniques applied to data from randomised controlled trials. Data Sources Cochrane central register of controlled trials, CINAHL, Embase, Medline, and PsychINFO databases from inception to January 2007. Additional anonymised data on patients were obtained for multicentre trials. Review methods Included trials examined intensive case management compared with standard care or low intensity case management for people with severe mental illness living in the community. We used a fidelity scale to rate adherence to the model of assertive community treatment. Multicentre trials were disaggregated into individual centres with fidelity data specific for each centre. A multivariate meta-regression used mean days per month in hospital as the dependent variable. Results We identified 1335 abstracts with a total of 5961 participants. Of these, 49 were eligible and 29 provided appropriate data. Trials with high hospital use at baseline (before the trial) or in the control group were more likely to find that intensive case management reduced the use of hospital care (coefficient −0.23, 95% confidence interval −0.36 to −0.09, for hospital use at baseline; −0.44, −0.57 to −0.31, for hospital use in control groups). Case management teams organised according to the model of assertive community treatment were more likely to reduce the use of hospital care (coefficient −0.31, −0.59 to −0.03), but this finding was less robust in sensitivity analyses and was not found for staffing levels recommended for assertive community treatment. Conclusions Intensive case management works best when participants tend to use a lot of hospital care and less well when they do not. When hospital use is high, intensive case management can reduce it, but it is less successful when hospital use is already low. The benefits of intensive case management might be marginal in settings that have already achieved low rates of bed use, and team organisation is more important than the details of staffing. It might not be necessary to apply the full model of assertive community treatment to achieve reductions in inpatient care.

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.

A new scale to assess the therapeutic relationship in community mental health care: STAR

BACKGROUND No instrument has been developed specifically for assessing the clinician-patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction. METHOD A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction, test-retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden. RESULTS New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test-retest reliability was r=0.76 for STAR-P and r=0.68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit. CONCLUSIONS STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care.

Working with mental health problems: clients’ experiences of IPS, vocational rehabilitation and employment

AbstractBackgroundAlthough the effectiveness of individual placement and support (IPS) has been well established, little is known about clients’ perceptions of the model compared to usual vocational rehabilitation, nor about their experiences of searching for and returning to work with this kind of support. This qualitative study aimed to explore clients’ views of the difficulties of obtaining and maintaining employment, their experiences of the support received from their IPS or Vocational Service workers and the perceived impact of work on clients’ lives.MethodSemi-structured interviews were conducted with 48 people with psychotic disorders participating in a six-centre international randomised controlled trial of IPS compared to usual vocational rehabilitation. To assess their experiences of the services and the perceived effects of working, two IPS and two Vocational Service clients at each centre who had found work during the study period were interviewed, along with two IPS and two Vocational Service clients at each centre who had not.ResultsIPS clients reported having received more help seeking and maintaining employment, whereas Vocational Service clients reported having received more help in finding sheltered employment or placements. Clients who had worked associated this with financial stability, improved social lives, increased self-esteem, integration into society and amelioration of their symptoms, as well as reduced feelings of boredom and isolation, but also reported increased levels of stress. IPS clients as well as Vocational Service ones reported not receiving enough follow-up support, despite this being proposed as a key feature of the model.ConclusionFindings from the in-depth interviews reflect differences in service models that have also been tested quantitatively but further work in disaggregating the IPS model and assessing the impact of each component would be valuable.

A review of instruments developed to measure outcomes for carers of people with mental health problems.

Objective:  Community‐based care for mental disorders places considerable burden on families and carers. Measuring their experiences has become a priority, but there is no consensus on appropriate instruments. We aimed to review instruments carers consider relevant to their needs and assess evidence for their use.

Continuity of care in mental health: understanding and measuring a complex phenomenon.

BACKGROUND Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness. METHOD A multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care. RESULTS Factor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors, Experience and Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close but not identical to the original theoretical model. CONCLUSIONS We confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.

Developing a user-generated measure of continuity of care: brief report

Objective:  This paper describes a measure of continuity of care, establishes its reliability and tests it in a field trial sample for evidence of its validity. In contrast to others, this measure has been generated from the perspectives of service users. As continuity of care is a concern particularly for those with severe mental illness, we have confined our work to this population group.

The therapeutic relationship in secondary mental health care: a conceptual review of measures.

Objective: The study aimed to determine the conceptual basis of measures of the patient–professional relationship used in routine mental health services research by reviewing their face, content and construct validity.