Robert E. Drake

Individual Placement and Support: An Evidence-Based Approach to Supported Employment

Employment is the highest priority for many people with severe mental illness and it is a central aspect of recovery. Over the past two decades, the Individual Placement and Support (IPS) model of supported employment has emerged as the prominent evidence-based approach to vocational rehabilitation. This comprehensive monograph synthesizes the research and experience on IPS supported employment: historical context, core principles, effectiveness, long-term outcomes, non-vocational outcomes, cost-effectiveness, generalizability, fidelity, implementation, policy, and future research. In tracing the evolution of IPS, readers are equipped with an elegant example of the transition from needs assessment, to model development, to testing, and to dissemination.

Technology and behavioural health: an implementation challenge

As the world’s population and wealth expand rapidly, two overarching issues have emerged in behavioural health care: (1) how to address the rapidly increasing awareness of mental health and addiction disorders, especially in the poorer strata of population in highincome countries and in lowand middle-income countries and (2) how to leverage new technologies to expand access to effective services. Because these two issues converge on productivity, the solution must necessarily involve technology. Addressing these issues by expanding infrastructure and workforce would be expensive, unaffordable and insufficient. (Witness the common dilemma of countries with meager resources investing in training mental health professionals who then move to wealthy countries to increase income!) The following two essays by leaders in the behavioural health technology field, Ben-Zeev (2014) and Kane (2014), provide in this issue of EPS a view into the enormous potential of existing and developing technologies. Implementing and integrating these tools in many contexts will, however, present a new set of challenges. For mental health patients (or for people with mental health needs who choose not to be patients), technology will reinforce and drive the movement towards self-determination and self-management. People are increasingly seeking information, finding treatment providers and buying health care tools on the internet. Worldwide, the availability of electronic health communications outpaces the expansion of services several-fold. In developing countries, technological communications regarding health will precede the development of a professional workforce by years and perhaps decades. But the validity dilemma looms large: for example, nearly all of the tens of thousands of smart phone health applications now available are entirely untested and probably ineffective. How do people know if the information is unbiased and evidence-based? How do they know if the products are competently designed and effective rather than merely promotional? And how do they know if they should use these tools independently or only in conjunction with a relationship with a health care provider? Researchers must address these problems before industry once again develops solutions that meet their needs for profits at the expense of the public’s need for health. Families of people with mental health problems have greater access to information than ever before, but they are more likely to be overwhelmed or misled than educated because of the generally poor quality of health information on the internet. Even when families are able to find high-quality websites, the information may not answer their questions, which tend to be specific to the circumstances of their relatives. Unlike effective family psycho-education programmes, current websites do not train families to be care managers, educate them about environmental and social processes, explain how to provide an optimal environment and handle crises and connect them for support to other families living with similar concerns. These services can and should be available as part of a comprehensive behavioural health programme. Researchers must develop appropriate technology programmes and learn how to integrate them into clinical services. Relying on industry to do so will further bias families towards overvaluing medications and undervaluing psychological, social and environmental interventions. Clinicians, whether professionals or local health workers working under ‘task-shifting’ arrangements, will need to develop expertise with specific technology tools as well as with information technologies in general. How will they identify optimal technologies for specific groups? How will they tailor the tools for specific patients? How will they use technology to augment their reach and capacity? And who will back them up on technology problems as well as clinical problems? Educators and researchers need to solve these problems before dissemination outpaces knowledge. Another possibility is that a new type of * Address for correspondence: Dr Robert E. Drake, Dartmouth Psychiatric Research Center, Rivermill Commercial Center, 85 Mechanic Street, Suite B4-1, Lebanon, NH 03766, USA. (Email: Robert.E.Drake@Dartmouth.EDU) Epidemiology and Psychiatric Sciences (2014), 23, 313–315.