Matthew Modini

Supported employment for people with severe mental illness: systematic review and meta-analysis of the international evidence

BACKGROUND Individual placement and support (IPS) is a vocational rehabilitation programme that was developed in the USA to improve employment outcomes for people with severe mental illness. Its ability to be generalised to other countries and its effectiveness in varying economic conditions remains to be ascertained. AIMS To investigate whether IPS is effective across international settings and in different economic conditions. METHOD A systematic review and meta-analysis of randomised controlled trials comparing IPS with traditional vocational services was undertaken; 17 studies, as well as 2 follow-up studies, were included. Meta-regressions were carried out to examine whether IPS effectiveness varied according to geographic location, unemployment rates or gross domestic product (GDP) growth. RESULTS The overall pooled risk ratio for competitive employment using IPS compared with traditional vocational rehabilitation was 2.40 (95% CI 1.99-2.90). Meta-regressions indicated that neither geographic area nor unemployment rates affected the overall effectiveness of IPS. Even when a countrys GDP growth was less than 2% IPS was significantly more effective than traditional vocational training, and its benefits remained evident over 2 years. CONCLUSIONS Individual placement and support is an effective intervention across a variety of settings and economic conditions and is more than twice as likely to lead to competitive employment when compared with traditional vocational rehabilitation.

Severe mental illness and work: What can we do to maximise the employment opportunities for individuals with psychosis?

Earlier this year, the Australian and New Zealand Journal of Psychiatry published the results of the 2010 Survey of High Impact Psychosis (SHIP) (Morgan et al., 2012). This survey provided a snapshot of how Australia’s mental health services have changed over the 12 years since the first national psychosis survey (Jablensky et al., 1999). The decreased use of inpatient admissions together with a greater use of community mental health clinics and rehabilitation services suggested Australian mental health services had shifted towards a more recovery-focused model of care, with the proportion of respondents feeling satisfied with their own level of independence rising by 23% (Morgan et al., 2012). However, this apparent shift appears to have neglected one of the key measures of social functioning, namely employment. The proportion of Australian adults with a psychotic disorder who are in employment (either part-time or full-time) remains stuck at 22%, with no improvement over the 12 years between surveys (Waghorn et al., 2012). This is despite national unemployment rates decreasing over the same period and a dramatic expansion in employment services for those with disabilities. This compares with European rates of employment in people with schizophrenia of 11.5% (France) and 30% (Germany), with very high inter-centre variability indicating that policies, services and local context have a major influence on employment rates (Kooyman et al., 2007; Marwaha et al., 2007). The failure to improve the catastrophic occupational outcomes for individuals with psychosis and other severe mental illness should prompt all of the agencies involved, including Australia’s mental health system and the relevant policymakers, to re-examine the way in which rehabilitation is organised and consider what needs to change to allow more of our patients to enjoy the benefits of work.

Multimorbidity and depression: a systematic review and meta-analysis

BACKGROUND Multimorbidity, the presence of two or more chronic conditions, is increasingly common and complicates the assessment and management of depression. The aim was to investigate the relationship between multimorbidity and depression. METHOD A systematic literature search was conducted using the databases; PsychINFO, Medline, Embase, CINAHL and Cochrane Central. Results were meta-analysed to determine risk for a depressive disorder or depressive symptoms in people with multimorbidity. RESULTS Forty articles were identified as eligible (n = 381527). The risk for depressive disorder was twice as great for people with multimorbidity compared to those without multimorbidity [RR: 2.13 (95% CI 1.62-2.80) p<0.001] and three times greater for people with multimorbidity compared to those without any chronic physical condition [RR: 2.97 (95% CI 2.06-4.27) p<0.001]. There was a 45% greater odds of having a depressive disorder with each additional chronic condition compared to the odds of having a depressive disorder with no chronic physical condition [OR: 1.45 (95% CI 1.28-1.64) p<0.001]. A significant but weak association was found between the number of chronic conditions and depressive symptoms [r = 0.26 (95% CI 0.18-0.33) p <0.001]. LIMITATIONS Although valid measures of depression were used in these studies, the majority assessed the presence or absence of multimorbidity by self-report measures. CONCLUSIONS Depression is two to three times more likely in people with multimorbidity compared to people without multimorbidity or those who have no chronic physical condition. Greater knowledge of this risk supports identification and management of depression.

Psychometric evaluation of self-report measures of binge-eating symptoms and related psychopathology: A systematic review of the literature.

OBJECTIVE Binge eating is a symptom common to bulimia nervosa, anorexia nervosa (binge/purge subtype), and binge eating disorder. There are many self-report measures available to aid the assessment of eating disorders symptoms, but there has not yet been a systematic review of the literature to identify the most valid and reliable measures for use in assessment and treatment of binge eating. METHOD A systematic review of the psychometric properties of self-report measures that assess binge eating symptoms and psychopathology was conducted. Two independent raters assessed the psychometric properties of each measure using a standardized quality analysis tool. RESULTS Of the 2,927 studies identified, 72 studies met the inclusion criteria and described the psychometric properties of 29 different self-report measures, and nine specific subscales within these. Results from the quality analysis tool utilized in this study indicated that none of the included measures currently meet all nine criteria of adequate psychometric properties. DISCUSSION Most of the included measures had evidence for some adequate psychometric properties. Two measures received six out of nine positive ratings for the assessed psychometric properties, the BITE and the BULIT-R, and thus appear to be the measures with the most evidence of their validity and reliability. Overall, our findings implicate a need for further investigation of the psychometric properties of the available self-report questionnaires in this field.

A framework to create more mentally healthy workplaces: A viewpoint:

Mental illness is now the leading cause of long-term sickness absence among Australian workers, with significant costs to the individual, their employers and society more broadly. However, to date, there has been little evidence-informed guidance as to what workplaces should be doing to enhance their employees’ mental health and wellbeing. In this article, we present a framework outlining the key strategies employers can implement to create more mentally healthy workplaces. The five key strategies outlined are as follows: (1) designing work to minimise harm, (2) building organisational resilience through good management, (3) enhancing personal resilience, (4) promoting early help-seeking and (5) supporting recovery and return to work. A narrative review is utilised to outline the theoretical evidence for this framework and to describe the available research evidence for a number of key example interventions for each of the five strategies. While each workplace needs to develop tailored solutions, the five strategy framework proposed in this review will hopefully provide a simple framework for employers and those advising them to use when judging the adequacy of existing services and considering opportunities for further enhancements.

Processes and pathways mediating the experience of social anxiety and negative rumination

Negative rumination in social anxiety disorder (SAD) occurs in anticipation of a social event (pre-event rumination) and in its aftermath (post-event rumination). Both are proposed to be key maintaining factors of the vicious cycle of social anxiety. Despite this, there is a dearth of research investigating the processes that mediate the relationship between social anxiety and pre-event rumination and uncertainty regarding the cognitive and attentional processes that mediate the relationship between social anxiety and post-event rumination. To investigate this further, the current study utilised a clinical sample of participants with SAD to determine the hypothesised mediators of a social anxiety and pre-event model (N = 239) and a social anxiety and post-event rumination model (N = 216). Results from path analyses were broadly consistent with cognitive models of SAD that posit several interrelated processes mediate the relationship between social anxiety and pre- and post-event rumination. Results also indicated slightly different processes showed stronger prediction of pre-event rumination (i.e., biased performance appraisals) and post-event rumination (i.e., negative attentional focus). Treatment recommendations that aim to address the maladaptive role of negative rumination in social anxiety are made in keeping with the inter-connected and dynamic role played by cognitive and attentional processes in heightening social anxiety.

Modelling the relationship between changes in social anxiety and rumination before and after treatment

Pre- and post-event rumination have been proposed to be key processes involved in the maintenance of social anxiety disorder. While the importance of addressing rumination in treatment is becoming increasingly clear, factors that mediate the relationship between changes in social anxiety and changes in rumination have yet to be investigated. Individuals with social anxiety disorder (N = 82) completed measures that assessed key cognitive and attentional processes of social anxiety, including pre- and post-event rumination, before and after cognitive behavioural treatment. Following treatment there were significant reductions in pre- and post-event rumination in addition to other cognitive and attentional aspects of social anxiety. Mediation analyses revealed that changes in state anxiety and performance and threat appraisals mediated the relationship between changes in social anxiety and pre-event rumination, while only changes in threat appraisals mediated the relationship between changes in social anxiety and post-event rumination. It appears that key cognitive and attentional processes have differing importance when anticipating feared social situations and when reflecting on it afterwards. This suggests that treatment that aims to reduce the role of pre-event rumination needs to consider multiple factors, while threat appraisals particularly need to be addressed when addressing post-event rumination.