Toma Tomov

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

BACKGROUNDnThe 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.nnnMETHODSn312 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.nnnFINDINGSnIPS 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.nnnINTERPRETATIONnOur 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.

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

BACKGROUNDnConcerns 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.nnnAIMSnTo explore separately associations between IPS, returning to work, and clinical and social outcomes.nnnMETHODSnPatients (n = 312) in a randomized controlled trial of IPS in 6 European centers were followed up for 18 months.nnnRESULTSnThere 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.nnnCONCLUSIONSnConcerns 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

BACKGROUNDnAn 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.nnnAIMSnTo determine which patients with severe mental illness do well in vocational services and which process and service factors are associated with better outcomes.nnnMETHODnPatient characteristics and early process variables were tested as predictors of employment outcomes. Service characteristics were explored as predictors of the effectiveness of IPS.nnnRESULTSnPatients 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.nnnCONCLUSIONSnThe 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.

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.n

Therapeutic relationships in vocational rehabilitation: Predicting good relationships for people with psychosis

Therapeutic relationships between clients and vocational rehabilitation workers have been shown to predict entering competitive employment. We aimed to determine predictors of good relationships, using data from an international randomized controlled trial of supported employment (n=312). Baseline predictors of early therapeutic relationships with vocational workers were assessed, along with the impact of vocational status and changing clinical and social functioning variables on relationship ratings over time. Associations between client and professional relationship ratings were also explored. Better early client-rated therapeutic relationship was predicted by better baseline relationship with the clinical keyworker, being in the Individual Placement and Support (IPS) service, the absence of work history and a greater proportion of care needs being met, whereas over time it was predicted by being in the IPS service. Professional-rated early relationship was predicted by social disability and remission, while over time it was predicted by being the same sex as the client, duration of the relationship and the clients increasing anxiety. Client and professional ratings were positively associated but clients ratings were higher than professionals, particularly in the IPS service. Relationships were better where clients may have been more motivated to engage, including by their prior experience of a good therapeutic relationship with the clinical keyworker.

The relationships between employment, clinical status, and psychiatric hospitalisation in patients with schizophrenia receiving either IPS or a conventional vocational rehabilitation programme

PurposePositive relationships between employment and clinical status have been found in several studies. However, an unequivocal interpretation of these relationships is difficult on the basis of common statistical methods.MethodsIn this analysis, a structural equation model approach for longitudinal data was applied to identify the direction of statistical relationships between hours worked, clinical status and days in psychiatric hospital in 312 persons with schizophrenia who participated in a multi-centre randomised controlled trial comparing the effectiveness of Individual Placement and Support (IPS) with conventional vocational services in six study settings across Europe. Data were analysed by an autoregressive cross-lagged effects model, an autoregressive cross-lagged model with random intercepts and an autoregressive latent trajectory model.ResultsComparison of model fit parameters suggested the autoregressive cross-lagged effects model to be the best approach for the given data structure. All models indicated that patients who received an IPS intervention spent more hours in competitive employment and, due to indirect positive effects of employment on clinical status, spent fewer days in psychiatric hospitals than patients who received conventional vocational training.ConclusionsResults support the hypothesis that the IPS intervention has positive effects not only on vocational but also on clinical outcomes in patients with schizophrenia.

Therapeutic relationships: their specificity in predicting outcomes for people with psychosis using clinical and vocational services

ObjectiveTo determine the distinctions between the client–keyworker relationship and the client–vocational worker relationship by assessing their impact on clinical outcomes and exploring the associations between the two.MethodsAs part of an international randomised controlled trial of supported employment (nxa0=xa0312), client–keyworker relationship and client–vocational worker relationship were each tested against clinical and social functioning 6xa0months later. Associations between the two relationships over time were explored.ResultsClient–keyworker relationship predicted quality of life, while client–vocational worker relationship, as rated by the client, did not predict any clinical or social functioning outcomes. Vocational worker-rated relationship predicted reduced depression. The client–keyworker and client–vocational worker relationships were correlated, but this did not change over time.ConclusionThe impact of the client–vocational worker is likely to be on the shared task of finding employment, rather than on clinical and social functioning. Good client–vocational worker relationships do not detract from client–keyworker relationships.

Pyronin G as fluorescent probe for quantitative determination of the membrane potential of mitochondria

Added to mitochondrial suspension, pyronin G changes the intensity of its fluorescence depending on the membrane potential (energy state) of the mitochondria. The mechanism of this effect is studied and a dependence is obtained between the membrane potential and the fluorescence intensity. This permits quantitative determination of the membrane potential by the changes in the fluorescence of the suspension. A method is proposed for measuring the membrane potential of vesicles in the -120 to -220 mV interval.

Electrodelivery of Drugs into Cancer Cells in the Presence of Poloxamer 188

In the present study it is shown that poloxamer 188, added before or immediately after an electrical pulse used for electroporation, decreases the number of dead cells and at the same time does not reduce the number of reversible electropores through which small molecules (cisplatin, bleomycin, or propidium iodide) can pass/diffuse. It was suggested that hydrophobic sections of poloxamer 188 molecules are incorporated into the edges of pores and that their hydrophilic parts act as brushy pore structures. The formation of brushy pores may reduce the expansion of pores and delay the irreversible electropermeability. Tumors were implanted subcutaneously in both flanks of nude mice using HeLa cells, transfected with genes for red fluorescent protein and luciferase. The volume of tumors stopped to grow after electrochemotherapy and the use of poloxamer 188 reduced the edema near the electrode and around the subcutaneously growing tumors.

Effective production by electrofusion of hybridomas secreting monoclonal antibodies against Hc-antigen of Salmonella

Abstract Hybridomas secreting monoclonal antibodies (Mab) were generated by electrofusion of splenic lymphocytes from Balb/c mice immunized with Hc-antigen of Salmonella with mouse myeloma cells (x63-Ag8.653). The fusion efficiency was expressed by the number of antibody secreting hybridomas/106 lymphocytes. The results obtained show that: (1) the number of antibody secreting hybridomas produced by electrofusion is one order of magnitude higher than with the polyethylene glycol (PEG) technique; (2) pretreatment of lymphocytes with electrical pulses leads to an additional increase in the fusion yield; (3) treatment with protease does not change the yield; (4) electrofusion resulted in both IgG- and IgM-secreting hybridomas. It is supposed that the increased fusion efficiency when using lymphocytes pretreated with electrical pulses is due to their increased “fusogenicity”.