Niall Turner Supported employment in early intervention for psychosis services.

Niall Turner

Supported employment in early intervention for psychosis

services

Overview• Conditions that feature psychosis• Typical employment outcomes• Early intervention• The IPS model• The DETECT Service• Trial of supported employment in

the DETECT service

Conditions that feature psychosis

……can be a sub feature of the clinical

presentation such as major depression,

bipolar affective disorder or the main

feature of the condition such as with

schizophrenia, drug induced psychosisLifetime prevalence = 3% population = circa 120,000 in ROI

Current numbers unemployed

• International

– 95% Burns et al

2007

– 80 – 90% Marwaha

and Johnson 2004

– 85% Crowther et al

2001

• Ireland

– 73% Behan et al.

2008 (based on 2006

data)

Recovery

6

…know about employment outcome?

…their conclusions….

• Outcome poor but reviewing data difficult due to

lack of detail

• Rates decline over time

• Outcome influenced by local environment:

welfare system and availability of Evidence Based

Interventions

• Disruption starts prior to treatment commencing

• Many negative consequences of lack of paid

employment

“Serious mental illness affects approximately 2%

of the world’s population. It results in

persons having much difficulty in

fulfilling the role which they may have

set for themselves in life. Those

individuals no longer live in institutions for long

periods of time; the vast majority are in the

community where they often receive inadequate

follow-up.

Even though more than 70% of these

people would like to work, only 10-

12% do in fact work, all too often in jobs

that do not correspond to their liking and

capacities. In contrast, the employment rate of

other forms of disability is in the vicinity of 50%”

p.57

….page 58….“Treatment programmes should include the capacity for correct diagnosis, remembering that

often mental illness “hides behind physical signs and symptoms”. Quick access to and

intervention by competent medical and professional staff will be

called for. Integral to quick access and early intervention of appropriate medical

treatment for individuals is reducing the stigma and shame associated with mental health

problems. As discussed, often an individual will not seek treatment or will delay seeking it

because of the stigma associated with mental illness. Furthermore, there is a need for

more easily accessible mental health treatment programmes.

Rehabilitation programmes will emphasize the requirements for a prompt return

to work by focusing on necessary accommodations to the work situation, as well as

required support to the individual”

Timeline – Early Psychosis

Deterioration in Health and Functioning

Receipt of effective Treatment

End of Critical Period3 – 5 years

DELAYS

Length of Delays

0

0.5

1

1.5

2

2.5

years

DUP

Research on impact of delaysLong Delay WorseShort Delay Worse

First contact

6 months

12 months

24 months

Delay and Occupational Disruption

• shorter delays = more likely to still be involved in employment or non labour force work (Turner et al, 2009)

• At 3 yr follow-up length of delay was a predictor of productive vocational activity (Norman et al, 2007)

Development of Early Psychosis Programs

EPPIC

EI Paradigm

Early detection

Aggressive

treatment in critical

period

Improved Outcome

Is earlier detection possible?

Mc Gorry et al, 1996; Melle et al, 2004 & 2008; Malla et al, 2006; Chong et al, 2005.

29 months to 6 months

18 months to 11 months

16 months to 8 months

12 months to 4 months

Interventions with evidence base

• Medication• Cognitive behavioural therapy• Cognitive remediation• Family education• Supported employment (SE)

– Individual Placement and Support Model (IPS)

IPS

• Employment specialists part of clinical service

• Rapid return to employment• Ongoing support• RCTs - 11 reviewed by Bond, Drake & Becker

(2008)– Competitive employment 61% IPS vs. 23%

control– 66% attained employment of 20hrs plus per

week– Time to competitive employment 50% shorter

for IPS (138 days vs. 206 days)

RCT’s of IPS in Early Intervention

Nuechterlei

n et al (2008)

80% vs. 40% in

education/employment

Killackey et al (2008)IPS group

significantly better on level

of employment, hours worked per week, jobs acquired and

longevity

Killackey et al (2012)

Conducted an analysis on

predictors of vocational recovery –

only independent

predictor was treatment

group. Participants in

treatment group were 16.26 times

more likely to obtain

work/study

Killackey et al (2013)

larger RCT of IPS which showed greater

numbers engaged in paid work, education

and competitive employment however only comp employ statistically significant

Some caveats• Largest RCT is from EPPIC service• “original” Early Intervention Service• Stand alone• Entire care• Attached to a large academic programme

However• Other naturalistic studies also showing >66% of

FEP population returning to work/education when IPS present

International

Movement

iFEVR

End of Part I

An Irish Early Intervention Service

DUBLIN FIRST EPISODE PSYCHOSIS STUDY

• 8.5 WTE Team Members

• Pop. – 385,000

Reducing Delays• Community Mental

Health Team – OPD, medication,

acute episode care

• DETECT– ….group CBT– ….one-to-one

occupational therapy

– ….group carer education course

Pre20

0620

0720

0820

0920

1020

110

1

2

3

4

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7 Me-dian...

Treatment

Additionally since 2010…..

A clinical trial of supported employment and workplace

fundamentals for people with first episode psychotic disorders

Principles of IPS1. Every person who wants to work is eligible2. Employment services are integrated with mental

health services3. Competitive employment is the goal4. Benefits counselling is provided5. Job search happens soon after interest is

expressed 6. Employment specialist systemically develop

relationship with employers7. Job supports are continuous 8. Client preferences are honoured

Workplace Fundamentals Module

• Rationale: Even with SE maintaining jobs remains problematic

• Aim of WFM: Reduce job terminations/breakdown

• Method: Training module to augment SE.

“Evening course” in employment skills

Manual & training materials developed by UCLA Psychosocial Rehabilitation Center (Liberman and Wallace, 2000)

Skills for maintaining employment are best taught when person in employment

Why offer WFM?• Previous research found declining

rates over time• If delays reduced likely to be

significant numbers still in education/work

• Preventative approach• Address an unmet need• Address a gap in the current

knowledge base

Research QuestionsPrimary

• Does augmenting an early intervention service with IPS and WFM improve work outcomes?

Secondary

• What relationship, if any, does employment outcome have with quality of life, recovery, social inclusion and remission?

Methodology I

Control Group

• Recipients of DETECT service 02/2005 – 07/2009

Experimental Group• Recipients of

DETECT Service 08/2009 – 12/2012

• Supported employment specialist joined team 06/2010

Comparison• 1 year follow up

conducted as part of DETECT service evaluation

• Includes measure of time in employment, last worked, QoL, recovery and mental health

Methodology II

Baseline• Assessment of occupational history and

Social Inclusion

Follow-up

• Repeat above• Merge with measures conducted at

DETECT baseline and 1 year follow up• Statistical analysis

Recruitment

DETECT ASSESSMENT

Unemployed

IPS

WFM

Employed

WFM

Recruitment

OccupationalStatus

OfferInterventions

Follow up

Once specifically for this research project

Once at one year for the DETECT service evaluation

Progress (to April 2012)IPS

• 44 people offered IPS

• 42 attended initial assessment

• 34 (81%) progressed to education/employment/training

WFM

• 70 people offered WFM

• 22 agreed to attend• 12 completed• 11 were still employed

in December 2012

Challenges• Recession• Traditional concerns re people with schizophrenia

returning to work– Clinicians– Family

• Perceived need amongst target group• State financial assistance

– Old habits die hard!

• Current policy – who’s responsibility is it to provide this population with assistance to return to work

• Expertise

Tentative Conclusions• IPS model in early intervention services has the

potential to change course of employment outcome

for majority of people affected by psychosis

• Need to consider offering assistance for those who

never lose their work role at their first episode

• There remains significant challenges to the

widespread implementation of SE for people with

psychotic conditions in Ireland

Thank You