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. 2001;2001(2):CD003080.
doi: 10.1002/14651858.CD003080.

Vocational rehabilitation for people with severe mental illness

R Crowther  1 , M Marshall, G Bond, P Huxley
Affiliations

Vocational rehabilitation for people with severe mental illness

R Crowther et al. Cochrane Database Syst Rev. 2001.

Abstract

Background: Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre-vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on-the-job support (Supported Employment). It is unclear which approach is most effective.

Objectives: To assess the effects of Pre-vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre-vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention.

Search strategy: Searches were undertaken of CINAHL (1982-1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1887-1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies.

Selection criteria: Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness.

Data collection and analysis: Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross-checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta-analysis). A sensitivity analysis was performed, excluding poorer quality trials.

Main results: Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre-vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre-vocational Training. There was no evidence that Pre-vocational Training was more effective in helping clients to obtain competitive employment than standard community care.

Reviewer's conclusions: Supported employment is more effective than Pre-vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre-vocational Training is effective.

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Conflict of interest statement

Ruth Crowther, Max Marshall and Peter Huxley have no conflict of interest. Gary Bond has collaborated with Robert Drake and Debbie Becker (developers of the Individual Placement and Support Model), and their colleagues at Dartmouth on a series of studies and papers related to this model. He is co‐author on one IPS trial (Drake‐Washington) and is currently funded to complete a 5‐year randomised controlled trial comparing IPS to a Pre‐vocational Training model. Bond is also the primary author on two other trials reviewed in this group: Bond‐Chicago1 and Bond‐Indiana.

Figures

1.1
1.1. Analysis
Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 1 Not in competitive employment (at 8 months).
1.2
1.2. Analysis
Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 2 Not in any form of employment (at 8 months).
1.3
1.3. Analysis
Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 3 Not participating in program (excluding employed).
1.4
1.4. Analysis
Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 4 Not discharged from hospital (at 8 months).
2.1
2.1. Analysis
Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 1 Not in competitive employment.
2.2
2.2. Analysis
Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 2 Not in any form of employment.
2.3
2.3. Analysis
Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 3 Not participating in program (excluding employed).
2.4
2.4. Analysis
Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 4 Admitted to hospital (by 1 year).
3.1
3.1. Analysis
Comparison 3 SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE, Outcome 1 Not in competitive employment (at 24 months).
3.2
3.2. Analysis
Comparison 3 SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE, Outcome 2 Not in any form of employment.
3.3
3.3. Analysis
Comparison 3 SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE, Outcome 3 Admitted to hospital in first year of study.
4.1
4.1. Analysis
Comparison 4 MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 1 Not in any form of employment (at 6 months).
4.2
4.2. Analysis
Comparison 4 MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 2 Not participating in program.
4.3
4.3. Analysis
Comparison 4 MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 3 Admitted to hospital during first year of study.
5.1
5.1. Analysis
Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 1 Not in competitive employment.
5.2
5.2. Analysis
Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 2 Not in any form of employment.
5.3
5.3. Analysis
Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 3 Not in any form or employment or training or education at end of study.
5.4
5.4. Analysis
Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 4 Not participating in program.
6.1
6.1. Analysis
Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 1 Not in competitive employment.
6.2
6.2. Analysis
Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 2 Not in any form of employment (at 15 months).
6.3
6.3. Analysis
Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 3 Numbers not participating in program.
6.4
6.4. Analysis
Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 4 Number readmitted to hospital (at about 15 months).
7.1
7.1. Analysis
Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 1 Not in competitive employment.
7.2
7.2. Analysis
Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 2 Not in any form of employment.
7.3
7.3. Analysis
Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 3 Numbers not participating in program.
7.4
7.4. Analysis
Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 4 Numbers admitted to hospital during study.
8.1
8.1. Analysis
Comparison 8 SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING, Outcome 1 Not in competitive employment.
8.2
8.2. Analysis
Comparison 8 SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING, Outcome 2 Not in any form of employment.
8.3
8.3. Analysis
Comparison 8 SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING, Outcome 3 Numbers not participating in program.
9.1
9.1. Analysis
Comparison 9 SUB‐ANALYSIS 2: INDIVIDUAL PLACEMENT & SUPPORT (TYPE OF SUPPORTED EMPLOYMENT) versus PRE‐VOCATIONAL TRAINING, Outcome 1 Not in competitive employment.
9.2
9.2. Analysis
Comparison 9 SUB‐ANALYSIS 2: INDIVIDUAL PLACEMENT & SUPPORT (TYPE OF SUPPORTED EMPLOYMENT) versus PRE‐VOCATIONAL TRAINING, Outcome 2 Numbers not participating in program.
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