Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness

Abstract

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

Fig. 1.

Participant Flow—Random Assignment Through End of 24-Month Participation Period. Note: Numbers (percentages) for all variables refer to service receipt and job activity within each of the 4 6-month intervals. “Active sample remaining” (i.e., the inverse of attrition) is defined as the percentage of participants in each program with any form of continuing study involvement through each succeeding 6-month interval (i.e., receipt of vocational or mental health services or employed as reported directly by study providers). SEP = Supported Employment Program, ACT-IPS = Assertive Community Treatment–Individual Placement and Support Program, IPS = Individual Placement and Support.