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Preventing Unemployment and Disability Benefit Receipt Among PeopleWith Mental Illness: Evidence Review and Policy Significance

Bonnie O’Day, Rebecca Kleinman, Benjamin Fischer, Eric Morris, and Crystal BlylerMathematica Policy Research, Washington, DC

Objective: We identify effective services to assist 3 groups of people with mental illnesses become orremain employed and prevent dependence on disability cash benefits: (a) individuals, including youth,who are experiencing an initial episode of psychosis; (b) employed individuals at risk of losing jobs dueto mental illness; and (c) individuals who are or may become long-term clients of mental health servicesand are likely to apply for disability benefits. Method: We searched for articles published between 1992and 2015 using key word terminology related to employment support services and each subgroup, andprioritized articles by study design. Results: The individual placement and support model of supportedemployment is more effective than traditional vocational programs in helping people with serious mentalillnesses who are engaged in treatment or receiving disability benefits obtain competitive employment.Some early intervention programs effectively serve people who experience a first episode of mentalillness, but more research is needed to demonstrate long-term outcomes. Less is known about theeffectiveness of employment interventions in preventing unemployment and use of disability benefitsamong individuals at risk for job loss or long-term mental illness. Conclusions and Implications forPractice: States can fund employment supports to help prevent the need for disability benefit receipt bycreatively combining federal sources, but the funding picture is imperfect. Medicaid expansion and otherprovisions of the Affordable Care Act may fund employment supports and assist in reducing dependenceon disability benefits.

Keywords: supported employment, early intervention, mental illness, employment, funding for supportedemployment

Compared with the general population, people with mentalillnesses are disproportionately unemployed or underemployedand overrepresented among long-term recipients of federal disabil-ity and social safety-net programs, such as Social Security Dis-ability Insurance (SSDI) or Supplemental Security Income (SSI).Participation by people with mental illnesses in these programs hasgrown considerably within the last decade (Bailey & Hemmeter,2014). Many people report that they want to work but are unableto do so; a common fear is the loss of benefits, particularly healthinsurance if they attempt work.

Expansion of health coverage under the Affordable Care Act(ACA) may reduce barriers to employment and expand employ-ment supports for people with mental illnesses and thereforereduce new applications for cash benefit programs, but we knowlittle about what services and supports promote employment forthose likely to apply for benefits due to a mental illness. Muchresearch has been conducted over the past 25 years regarding the

effectiveness of supported employment (SE), particularly the In-dividual Placement and Support (IPS) model, but IPS has beenprimarily used for people who are not working and who alreadyreceive public disability cash benefits. Little is known about theeffectiveness of this model for those who are currently employedand at risk of job loss, or those who have not yet applied fordisability cash benefits.

In an attempt to identify programs that prevent job loss orsupport employment among those with mental illnesses mostlikely to apply for SSI and SSDI benefits, the Office of theAssistant Secretary for Planning and Evaluation (ASPE) of theU.S. Department of Health and Human Services funded the Im-proving Employment Outcomes for People with Psychiatric Dis-orders project. The purpose of the project was to identify effectiveservices that might help individuals with mental illnesses that aremost likely to apply for SSI and SSDI find and retain employment.ASPE was particularly interested in learning what supports willassist the following subgroups of people with psychiatric disorderswho, without intervention, are at risk for long-term unemploymentand likely to apply for disability cash benefits:

1. Individuals, including youth, who are experiencing aninitial episode of psychosis and require early interventionservices. Over the past 20 years, a substantial literaturehas emerged regarding early intervention to prevent psy-chosis. The main concern in early stages of psychosis iswith preventing full-blown psychosis, and theory positsthat functional deterioration and concomitant unemploy-

This article was published Online First April 3, 2017.Bonnie O’Day, Rebecca Kleinman, Benjamin Fischer, Eric Morris, and

Crystal Blyler, Mathematica Policy Research, Washington, DC.This research was supported in part by the U.S. Department of Health &

Human Services, Office of the Assistant Secretary for Planning and Eval-uation.

Correspondence concerning this article should be addressed to RebeccaKleinman, Mathematica Policy Research, 1100 1st Street, NE, 12th Floor,Washington, DC 20002. E-mail: [email protected]

Psychiatric Rehabilitation Journal © 2017 American Psychological Association2017, Vol. 40, No. 2, 123–152 1095-158X/17/$12.00 http://dx.doi.org/10.1037/prj0000253

123

mailto:[email protected]

http://dx.doi.org/10.1037/prj0000253

ment and long-term dependence on disability cash ben-efits can be prevented or ameliorated with early interven-tion (Centers for Medicare and Medicaid Services[CMS], 2015; McFarlane et al., 2012).

2. Currently employed individuals at risk of losing jobs dueto mental illness. Little is known about interventions thathelp workers who experience mental illness to remainemployed and off of the disability benefit rolls. Depres-sion is common among workers and is among the leadingcauses of disability (Adler, McLaughlin, Rogers, Chang,Lapitsky, & Lerner, 2006). Most people who experiencedepression are treated in primary care or through private-sector mental health services and, therefore, do not re-ceive SE (which is concentrated in the public sector).Workers who experience severe depression or other psy-chiatric disorders may lose their jobs and apply for cashbenefits if they do not receive effective intervention(Lerner, Allaire, & Reisine, 2005).

3. Individuals who currently are or are expected to be long-term clients of mental health services and are likely toapply or are in the process of applying for disability cashbenefits. This group includes those who previously ex-perienced illness episodes but were not diagnosed orreceiving treatment, and those who have long been diag-nosed and receiving mental health services but not re-ceiving disability cash benefits. A significant proportionof people in this group are likely to have been previouslyemployed, including those previously employed by themilitary. Others in this group may have been formerTemporary Assistance to Needy Families (TANF) recip-ients, those who are homeless, or those leaving prison.

Each of the above groups faces unique challenges that must beaddressed in effective interventions. Our study targeted the fol-lowing research questions:

• What services are most effective in helping people withmental illnesses in these three subgroups find and keepemployment and potentially avoid application for disabil-ity cash benefit programs?

• How can employment services for people with mentalillnesses be funded through the ACA and other sources?

In this article, we summarize our review of 20 years of evidence(1992–2012; O’Day et al., 2014), update the review to presentevidence through 2015, and present tables summarizing the evi-dence from the studies we reviewed. Because many of the studieswe reviewed are based upon SE, we begin with a brief reviewof studies assessing the effectiveness of SE. It is the mostevidence-based practice and therefore most likely to addressunemployment for the populations in question. We follow withevidence of programs to promote employment targeted to thethree subgroups mentioned above. We then discuss fundingoptions for employment services for these subgroups and policyimplications for moving forward. We use the term “mentalillness” unless the study we cite uses an alternative term ordescribes a specific condition, such as schizophrenia or bipolardisorder.

Method

In consultation with a library information specialist, we identi-fied the suite of relevant databases and indexes to search, includingOvid MEDLINE, PsycInfo, Cochrane Database of Systematic Re-views, Scopus, and CINAHL. We narrowed the field to articlespublished in English between 1992 and 2015 to capture almost 25years of evidence.

We then selected appropriate key word terminology for eachsubgroup (see Table 1). We also searched for reviews summarizingthe extensive literature on SE. The search for each subgroupincluded general terms for (a) disability type, including psychoticdisorders, mental disorders, severe mental illness, and schizophre-nia; and (b) employment terms, such as employment outcomes,employment supports, and work supports. To these key words weadded language specific to each subgroup.

We then reviewed abstracts to assign each study to a subgroupand exclude articles that did not focus on mental illness or em-ployment or did not provide study results. Remaining articles weresorted by study design: systematic review, nonsystematic review,randomized clinical trial (RCT), quasi-experimental design, pre-post design, implementation study, and other. We also searched forgray literature and other suitable studies by conducting searches onwebsites of key agencies, obtaining articles and reports of dem-onstration and research projects known to the authors, and con-tacting study authors. We summarized each study in separatetables for each study group, including study identifiers, studydescription, research methodology, study population, sample size,results, and limitations. We provide a summary of this informationin Tables 2 through 6.

Results

Evidence for Supported Employment (SE)

SE is a strategy for helping people with disabilities participate inthe labor market, in a job of their choosing, with professionalsupport (Bond et al., 2001). The term “Individual Placement andSupport (IPS)” has been coined to refer specifically to SE servicesthat adhere to a full set of evidence-based principles, including afocus on competitive employment in the community, rapid jobsearch, adherence to client preferences, integration of mentalhealth and employment services, and time-unlimited individual-ized support after job placement (Bond, 2004; Bond, Drake, &Becker, 2008; Twamley, Jeste, & Lehman, 2003). Properly imple-mented, IPS programs are formally assessed regarding adherence,or fidelity, to these evidence-based principles. We report programnames as they appear in the studies, using the term “IPS,” forexample, when study authors report to have implemented IPS. Weuse the term “SE” when programs are described as simply sup-ported employment models, and to refer to the category of differ-ent SE models (inclusive of IPS).

Tables 2 and 3 document studies that demonstrate some positiveoutcomes for individuals with mental illness who receive SEservices (Bond et al., 2008; Campbell, Bond, & Drake, 2011;Kinoshita et al., 2013; Marshall et al., 2014; Twamley et al., 2003),particularly in rates of competitive employment (such as in La-timer et al., 2006; Lehman et al., 2002). SE programs, includingIPS, have also shown some positive employment results when

124 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER

tested in combination with other interventions, such as AssertiveCommunity Treatment (Chandler, Meisel, Hu, McGowen, & Mad-ison, 1996; Cook et al., 2005; Gold et al., 2006; Macias et al.,2006; McFarlane et al., 2000; McFarlane, Dushay, Stastny,Deakins, & Link, 1996) and systematic medication managementand complete health insurance with no out-of-pocket expenses(Frey et al., 2011). Marshall et al. (2014) graded the researchevidence for SE as high, based on 12 systematic reviews, whichincluded 17 RCTs of the IPS model. However, based on 14 RCTs,Kinoshita et al. (2013) rated the evidence for IPS as very low touncertain in quality. Although Kinoshita et al. found studies of IPSto report improvements in employment outcomes, these authorspoint out that effectiveness of IPS is uncertain due to a low numberof studies reporting any well-defined outcome, high participantattrition rates, and, in some cases, small sample sizes.

The duration of most SE studies is also relatively short, raisingthe question of whether any advantages to SE can be sustainedover time. There is room for optimism. One long-term study thatcompared SE with traditional vocational rehabilitation services inSwitzerland found that beneficial effects of SE on work at 2 yearswere sustained over the 5-year follow-up period (p � .001; Hoff-mann et al., 2012, 2014). Reliance on SE services for retainingcompetitive work decreased between 2 and 5 years. Results ofanother study were mixed but overall favored SE. Cook, Burke-Miller, and Roessel (2016) followed a subsample of randomlyassigned SE and control participants for 13 years posttreatment,from 2000 through 2012. SE participants were almost three timesas likely as controls to have any earnings over the entire 13-year

period (odds ratio � 2.89, p � .022), controlling for other factors,and were more likely to have been suspended or terminated fromSSI or SSDI benefits due to work (odds ratio � 12.99, p � .001).Yet, total average earnings over the 13 years were low: $7,855 forthe full SE group and $22,145 for SE earners, with large standarddeviations around the means, and the benefits of SE diminishedover time. By 2012, about 5% of both groups were employed.

Even with the positive outcomes most SE studies report, roomfor improvement remains. After 12 to 18 months, only about onehalf to two thirds of treatment participants found competitivework. For those who did, jobs were part-time, job duration wasshort, and earnings were relatively low (Bond et al., 2008; Mar-shall et al., 2014; Twamley et al., 2003). Frey et al. (2011), forexample, reported that among treatment participants who workedat least one competitive job, gaining employment took sevenmonths and participants worked, on average, approximately 20 hra week for 9 months, earning $200 a week, or about $11.36 perhour. Among those with any positive earnings (59%), 8% earnedmore, on average, than the Social Security Administration (SSA)threshold for substantial gainful activity (SGA; $1,000 per month),a rate equivalent in the control group. This rate is consistent withresearch on the general SSDI population that finds very few peopleleave the disability rolls by working at jobs with earnings aboveSGA (Stapleton, Liu, Phelps, & Prenovitz, 2010). These limita-tions raise the question of how SE could be enhanced to improveemployment outcomes for those with serious and persistent mentalillness, and direct researchers and policymakers to those whose

Table 1Search Terms and Results of Literature Review

Area or population subgroup Search termsNumber of unduplicated

articles identifiedNumber of articles

includeda

Supported employment Supported employment; systematic reviews; reviews 133 28First episode First episode; onset of psychosis; onset of

schizophrenia; adolescents; young adults; psychoticdisorders; mental disorders; serious emotionaldisturbances; supported employment; job support;employment outcomes; employment supports; worksupports; individual placement; vocationalrehabilitation; wrap-around services

105 9

Risk of job loss Employer disability insurance; employee assistanceprograms; mental health parity; reasonableaccommodations; job retention; job tenure; jobsupport; depression; workplace; risk of job loss;mental health friendly workplace; return to work;employment outcomes; supported employment;vocational rehabilitation; mental disorders

�650 13

Long-term users of mental healthservices

Serious mental illness; schizophrenia; bipolar disorder;psychiatric disability; post-traumatic stress disorder;depression; employment outcomes; vocationaloutcomes; job outcomes; work supports;employment supports; job supports; disabilitysupports; vocational services; employment services;disability services; Social Security DisabilityInsurance; Supplemental Security Income; veterans;military; Temporary Assistance for Needy Families(TANF); homeless; criminal justice; immigrants;economic recession

207 10

Note. Excludes articles used for background material. Most of the articles identified through the initial search terms were eliminated during the abstractreview stage because they did not meet the review criteria.a This number includes articles identified through other sources, such as reference lists of literature reviews or reports.

125PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY

Tab

le2

Evi

denc

efo

rIm

prov

ing

Em

ploy

men

tO

utco

mes

Thr

ough

Supp

orte

dE

mpl

oym

ent:

Stud

ies

Incl

uded

inSy

stem

atic

Rev

iew

s

Syst

emat

icre

view

sour

ce(s

)St

udy

auth

orSt

udy

desi

gna

Inte

rven

tion

(sam

ple

size

)bC

ompa

riso

n(s

ampl

esi

ze)b

Not

able

sam

ple

char

acte

rist

icsb

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)a

Tw

amle

yet

al.

(200

3)B

ond

etal

.(1

995)

RC

TSE

(n�

74,

incl

.bo

thT

and

Cgr

oups

)4

mon

ths

prev

ocat

iona

ltr

aini

ng,

follo

wed

bySE

Avg

.ag

e:35

Dur

ing

12m

onth

sSc

hizo

phre

nia

spec

trum

:66

%�

HS

educ

atio

n:59

%

Com

petit

ivel

yem

ploy

ed:

56%

vs.

29%

(e.s

.�

.58)

Ann

ualiz

edw

eeks

wor

ked:

9vs

.3

Wag

esea

rned

:$1

,525

vs.

$574

SEsi

mila

rto

cont

rol

grou

pin

reho

spita

lizat

ion

rate

Bon

det

al.

(200

8);

Kin

oshi

taet

al.

(201

3);

Mar

shal

let

al.

(201

4)

Bon

det

al.

(200

7)R

CT

IPS

(n�

92)

Div

ersi

fied

plac

emen

tap

proa

ch(n

�95

)A

vg.

age:

40D

urin

g24

mon

ths

Schi

zoph

reni

asp

ectr

um:

63%

Com

petit

ivel

yem

ploy

ed:

75%

vs.

34%

c

Day

sto

firs

tco

mpe

titiv

ejo

b:15

6vs

.19

3A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely:

16vs

.8

Ann

ualiz

edw

eeks

wor

ked

com

petit

ivel

yam

ong

thos

ew

how

orke

d:22

vs.

24W

eeks

wor

ked

atlo

nges

tco

mpe

titiv

ejo

b:37

vs.

33C

ompe

titiv

ely

empl

oyed

�20

hr/w

k:47

%vs

.23

%T

wam

ley

etal

.(2

003)

Bon

dan

dD

inci

n(1

986)

RC

T“A

ccel

erat

ed”

tran

sitio

nal

empl

oym

ent

(im

med

iate

plac

emen

tin

paid

wor

kgr

oup;

n�

107

acro

ssT

and

Cgr

oups

)

“Gra

dual

”tr

ansi

tiona

lem

ploy

men

tA

ge:

68%

�21

Dur

ing

15m

onth

sSc

hizo

phre

nia

spec

trum

:55

%C

ompe

titiv

ely

empl

oyed

:20

%vs

.7%

(e.s

.�

.39)

�H

Sed

ucat

ion:

80%

Any

empl

oym

ent:4

1%vs

.25

%(e

.s.

�.3

6)W

eeks

wor

ked

duri

ngm

onth

s9–

15:

11vs

.7

Wag

esea

rned

duri

ngm

onth

s9–

15:

$790

vs.

$494

SEsi

mila

rto

cont

rol

grou

pin

reho

spita

lizat

ion

rate

Bon

det

al.

(200

8);

Kin

oshi

taet

al.

(201

3);

Mar

shal

let

al.

(201

4)

Bur

nset

al.

(200

7)R

CT

IPS

(n�

156)

Tra

ditio

nal

voca

tiona

lse

rvic

es(n

�15

6)N

otre

port

edin

syst

emat

icre

view

Dur

ing

18m

onth

sC

ompe

titiv

ely

empl

oyed

:55

%vs

.28

%c

Tw

amle

yet

al.

(200

3)C

hand

ler

etal

.(1

996)

RC

TA

CT

�vo

catio

nal

spec

ialis

t(n

�10

2ur

ban,

115

rura

l)

Com

mun

itym

enta

lhe

alth

serv

ices

asus

ual

(n�

108

urba

n,11

4ru

ral)

Age

:30

%ov

erag

e45

Dur

ing

36m

onth

sSc

hizo

phre

nia

spec

trum

:61

%A

nyem

ploy

men

t,ur

ban

site

:73

%vs

.15

%(e

.s.

�1.

37)

Any

empl

oym

ent,

rura

lsi

tes:

29vs

.11

%(e

.s.

�.3

6)


Tab

le2

(con

tinu

ed)

Syst

emat

icre

view

sour

ce(s

)St

udy

auth

orSt

udy

desi

gna

Inte

rven

tion

(sam

ple

size

)bC

ompa

riso

n(s

ampl

esi

ze)b

Not

able

sam

ple

char

acte

rist

icsb

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)a

Tw

amle

yet

al.

(200

3);

Bon

det

al.

(200

8);

Kin

oshi

taet

al.

(201

3);

Mar

shal

let

al.

(201

4)

Dra

keet

al.

(199

6)R

CT

IPS

(n�

73)

Non

inte

grat

edgr

oup

skill

str

aini

ng(n

�67

)

Avg

.ag

e:37

Schi

zoph

reni

asp

ectr

um:

47%

�H

Sed

ucat

ion:

74%

Dur

ing

18m

onth

sC

ompe

titiv

ely

empl

oyed

:78

%vs

.40

%(e

.s.

�.8

4)c

Wee

ksw

orke

dat

long

est

com

petit

ive

job:

10vs

.10

Hou

rsw

orke

dco

mpe

titiv

ely:

607

vs.

205

(e.s

.�

.60)

Com

petit

ivel

yem

ploy

ed�

20hr

/wk:

47%

vs.

22%

Com

petit

ive

wag

esea

rned

:$3

,394

vs.

$1,0

78(e

.s.

�.5

5)IP

Sm

ean

hour

lyw

ages

:$5

.59/

hrIP

Ssi

mila

rto

cont

rol

grou

pin

nonv

ocat

iona

lou

tcom

es.

Tw

amle

yet

al.

(200

3);

Bon

det

al.

(200

8);

Mar

shal

let

al.

(201

4)

Dra

keet

al.

(199

9)R

CT

IPS

(n�

74)

Shel

tere

dw

orks

hop

(n�

76)

Part

icip

ants

wer

efr

oman

inne

rci

tyA

vg.

age:

39Sc

hizo

phre

nia

spec

trum

:67

%�

HS

educ

atio

n:50

%

Dur

ing

18m

onth

sC

ompe

titiv

ely

empl

oyed

:61

%vs

.9%

(e.s

.�

1.29

)c

Any

empl

oym

ent:

74%

vs.

89%

(e.s

.�

�.4

0)D

ays

tofi

rst

com

petit

ive

job:

126

vs.

293

Ann

ualiz

edw

eeks

wor

ked

com

petit

ivel

y:10

vs.

.8A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely

amon

gth

ose

who

wor

ked:

17vs

.9

Com

petit

ivel

yem

ploy

ed�

20hr

/wk:

46%

vs.

5%IP

Sm

ean

job

dura

tion:

16.5

wee

ksPS

mea

nw

age:

$5.8

2/hr

IPS

sim

ilar

toco

ntro

lgr

oup

inno

nvoc

atio

nal

outc

omes

Bon

det

al.

(200

8);

Kin

oshi

taet

al.

(201

3);

Mar

shal

let

al.

(201

4)

Gol

det

al.

(200

6)e

RC

TIP

S�

AC

Td

(n�

66)

Shel

tere

dw

orks

hop

(n�

77)

Age

:77

%ag

es26

–45

(T),

64%

(C)

Schi

zoph

reni

asp

ectr

um:

74%

(T),

62%

(C)

�H

Sed

ucat

ion:

52%

Dur

ing

24m

onth

sC

ompe

titiv

ely

empl

oyed

:64

%vs

.26

%c

Day

sto

firs

tco

mpe

titiv

ejo

b:13

3vs

.32

2A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely:

10vs

.3

Ann

ualiz

edw

eeks

wor

ked

com

petit

ivel

yam

ong

thos

ew

how

orke

d:16

vs.

11W

eeks

wor

ked

atlo

nges

tco

mpe

titiv

ejo

b:19

vs.

20

Mar

shal

let

al.

(201

4)H

eslin

etal

.(2

011)

RC

TIP

S(n

�93

)U

sual

care

(n�

95)

Dat

ano

tre

port

edIP

Spa

rtic

ipan

tsw

ere

sign

ific

antly

mor

elik

ely

toob

tain

com

petit

ive

empl

oym

ent

(tab

leco

ntin

ues)


Tab

le2

(con

tinu

ed)

Syst

emat

icre

view

sour

ce(s

)St

udy

auth

orSt

udy

desi

gna

Inte

rven

tion

(sam

ple

size

)bC

ompa

riso

n(s

ampl

esi

ze)b

Not

able

sam

ple

char

acte

rist

icsb

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)a

Mar

shal

let

al.

(201

4)H

offm

ann

etal

.(2

012)

RC

TIP

S(n

�46

)T

radi

tiona

lvo

catio

nal

reha

bilit

atio

n(5

4)A

vg.

age:

33.5

Schi

zoph

reni

a:39

%76

%co

mpl

eted

voca

tiona

ltr

aini

ngor

have

colle

gede

gree

58.7

%of

SEgr

oup

wer

eev

erco

mpe

titiv

ely

empl

oyed

,co

mpa

red

with

25.9

%of

cont

rol

InY

ear

2,SE

grou

pem

ploy

edfo

r24

.5w

eeks

vs.

10.2

for

cont

rols

At

24m

onth

s,45

.7%

ofSE

grou

pw

ere

still

com

petit

ivel

yem

ploy

edvs

.16

.7%

ofco

ntro

lsK

inos

hita

etal

.(2

013)

How

ard

etal

.(2

010)

RC

TIP

S(n

�10

9)E

xist

ing

psyc

ho-s

ocia

lre

hab

and

day

care

(n�

110)

Avg

.ag

e:38

.3R

esul

tsno

tre

port

edse

para

tely

.A

utho

rsal

sono

teth

atfi

delit

yto

IPS

was

low

due

tolo

wra

teof

enga

gem

ent

Eth

nici

ty:

37.4

%W

hite

,42

.9%

Bla

ckD

urat

ion

ofSM

I:ov

er2

year

sB

ond

etal

.(2

008)

;K

inos

hita

etal

.(2

013)

;M

arsh

all

etal

.(2

014)

Lat

imer

etal

.(2

006)

RC

TIP

S(n

�75

)T

radi

tiona

lvo

catio

nal

serv

ices

(n�

74)

Avg

.ag

e:40

Schi

zoph

reni

asp

ectr

um:

68%

intr

eatm

ent,

84%

inco

ntro

l�

12ye

ars

educ

atio

n:43

%

Dur

ing

12m

onth

sC

ompe

titiv

ely

empl

oyed

:47

%vs

.18

%c

Day

sto

firs

tco

mpe

titiv

ejo

b:84

vs.

89A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely:

17vs

.14

Ann

ualiz

edw

eeks

wor

ked

com

petit

ivel

yam

ong

thos

ew

how

orke

d:25

vs.

27W

eeks

wor

ked

atlo

nges

tco

mpe

titiv

ejo

b:15

vs.

13B

ond

etal

.(2

008)

;K

inos

hita

etal

.(2

013)

;M

arsh

all

etal

.(2

014)

;T

wam

ley

etal

.(2

003)

Leh

man

etal

.(2

002)

eR

CT

IPS

(n�

113)

Psyc

hoso

cial

reha

bilit

atio

n(w

ithvo

catio

nal

serv

ices

for

33%

;n

�10

6)

Avg

.ag

e:42

Dur

ing

24m

onth

sSc

hizo

phre

nia

spec

trum

:75

%C

ompe

titiv

ely

empl

oyed

:27

%vs

.7%

(e.s

.�

.54)

c

�H

Sed

ucat

ion:

51%

Any

empl

oym

ent:

42%

vs.

11%

(e.s

.�

.73)

Day

sto

firs

tco

mpe

titiv

ejo

b:16

4vs

.28

7A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely:

6vs

.1.

6A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely

amon

gth

ose

who

wor

ked:

14vs

.14

Wee

ksw

orke

dat

long

est

com

petit

ive

job:

22vs

.23

IPS

mea

njo

bdu

ratio

n:14

.4w

eeks

IPS

mea

nw

age:

$5.0

7/hr

Tw

amle

yet

al.

(200

3)M

cFar

lane

etal

.(1

996)

RC

TFA

CT

(n�

37)

AC

T�

cris

isfa

mily

inte

rven

tion

(n�

31)

Avg

.ag

e:30

Dur

ing

24m

onth

sSc

hizo

phre

nia

spec

trum

:10

0%C

ompe

titiv

eem

ploy

men

t:10

%vs

.10%

�H

Sed

ucat

ion:

51%

Any

empl

oym

ent:

32%

vs.

19%

(e.s

.�

.52)


Tab

le2

(con

tinu

ed)

Syst

emat

icre

view

sour

ce(s

)St

udy

auth

orSt

udy

desi

gna

Inte

rven

tion

(sam

ple

size

)bC

ompa

riso

n(s

ampl

esi

ze)b

Not

able

sam

ple

char

acte

rist

icsb

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)a

Tw

amle

yet

al.

(200

3)M

cFar

lane

etal

.(2

000)

RC

TFA

CT

�vo

catio

nal

spec

ialis

t(p

rovi

ded

for

firs

t1–

2m

onth

s;n

�37

)

Enh

ance

dV

R(c

ouns

elor

ensu

red

and

mon

itore

dse

rvic

eus

e;n

�32

)

Avg

.ag

e:33

Schi

zoph

reni

asp

ectr

um:

65%

�H

Sed

ucat

ion:

89%

Dur

ing

18m

onth

sC

ompe

titiv

ely

empl

oyed

:46

%vs

.19

%(e

.s.

�.6

0)A

nyem

ploy

men

t:84

%vs

.57

%(e

.s.

�.4

3)M

edia

nco

mpe

titiv

ejo

bdu

ratio

n:12

vs.

4.5

mon

ths

(n.s

.)W

ages

earn

ed:

$755

vs.

$214

FAC

Tm

ean

wag

e:$6

.34/

hrA

mon

gsc

hizo

phre

nia

patie

nts,

SEsi

mila

rto

cont

rol

grou

pin

reho

spita

lizat

ion

rate

and

med

icat

ion

adhe

renc

eM

arsh

all

etal

.(2

014)

Mic

hon

etal

.(2

011)

RC

TIP

S(n

�71

)T

radi

tiona

lvo

catio

nal

serv

ices

(n�

80)

Dat

ano

tre

port

edIP

Spa

rtic

ipan

tssi

gnif

ican

tlym

ore

likel

yto

find

com

petit

ive

wor

kan

dw

ork

mor

ew

eeks

Bon

det

al.

(200

8);

Kin

oshi

taet

al.

(201

3);

Mar

shal

let

al.

(201

4)

Mue

ser

etal

.(2

004)

eR

CT

IPS

(n�

68)

(i)

Bro

kere

dSE

,(i

i)Ps

ycho

soci

alre

hab,

or(i

ii)gr

oups

(i)

and

(ii)

com

bine

d(n

�13

6)

Avg

.ag

e:42

Dur

ing

24m

onth

sSc

hizo

phre

nia

spec

trum

:77

%C

ompe

titiv

ely

empl

oyed

:74

%vs

.(i

)28

%an

d(i

i)18

%c

Day

sto

firs

tco

mpe

titiv

ejo

b:19

7vs

.(i

ii)27

7A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely:

15vs

.2

Ann

ualiz

edw

eeks

wor

ked

com

petit

ivel

yam

ong

thos

ew

how

orke

d:20

vs.

10W

eeks

wor

ked

atlo

nges

tco

mpe

titiv

ejo

b:26

vs.

4C

ompe

titiv

ely

empl

oyed

�20

hr/

wk:

34%

vs.

(iii)

9%T

wam

ley

etal

.(2

003)

Okp

aku

etal

.(1

997)

RC

TC

ase

man

agem

ent

�vo

catio

nal

spec

ialis

t(p

rovi

ded

for

firs

t4

mon

ths;

n�

73)

Serv

ices

asus

ual

(n�

79)

All

part

icip

ants

wer

eap

plyi

ngfo

ror

rece

ivin

gSS

I/D

I.A

vg.

age:

37Sc

hizo

phre

nia

spec

trum

:38

%A

vg.

educ

atio

n:11

.5ye

ars

Dur

ing

24m

onth

sA

nyem

ploy

men

t:51

%vs

.35

%(n

.s.)

Bon

det

al.

(200

8);

Kin

oshi

taet

al.

(201

3);

Mar

shal

let

al.

(201

4)

Tw

amle

yet

al.

(200

8)R

CT

IPS

(n�

28)

Ref

erra

lto

VR

(n�

22)

Avg

.ag

e:50

Dur

ing

12m

onth

sA

llpa

rtic

ipan

tsw

ere

45or

olde

rC

ompe

titiv

ely

empl

oyed

:57

%vs

.27

%c

Schi

zoph

reni

asp

ectr

um:

100%

Kin

oshi

taet

al.

(201

3)T

sang

etal

.(2

009)

RC

TIn

tegr

ated

SE(n

�52

);IP

S(n

�56

)T

radi

tiona

lvo

catio

nal

reha

bilit

atio

n(n

�55

)

Avg

.ag

e:34

.6R

esul

tsno

tre

port

edse

para

tely

SMI

unem

ploy

edan

dw

illin

gto

wor

k;co

mpl

eted

prim

ary

educ

atio

n(t

able

cont

inue

s)


Tab

le2

(con

tinu

ed)

Syst

emat

icre

view

sour

ce(s

)St

udy

auth

orSt

udy

desi

gna

Inte

rven

tion

(sam

ple

size

)bC

ompa

riso

n(s

ampl

esi

ze)b

Not

able

sam

ple

char

acte

rist

icsb

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)a

Bon

det

al.

(200

8);

Kin

oshi

taet

al.

(201

3);

Mar

shal

let

al.

(201

4)

Kin

Won

get

al.

(200

8)R

CT

IPS

(n�

46)

Step

wis

eco

nven

tiona

lvo

catio

nal

serv

ices

(n�

46)

Avg

.ag

e:33

Dur

ing

18m

onth

sSc

hizo

phre

nia

spec

trum

:32

%C

ompe

titiv

ely

empl

oyed

:70%

vs.

29%

c

�H

Sed

ucat

ion:

22%

Day

sto

firs

tco

mpe

titiv

ejo

b:72

vs.

118

Ann

ualiz

edw

eeks

wor

ked

com

petit

ivel

y:13

vs.

7A

nnua

lized

wee

ksw

orke

dco

mpe

titiv

ely

amon

gth

ose

who

wor

ked:

19vs

.25

Not

e.R

esul

tsba

sed

onsu

bsam

ples

ofth

ose

who

wor

ked

com

petit

ivel

yar

elik

ely

bias

edup

war

ds.U

nles

sot

herw

ise

indi

cate

d,K

inos

hita

etal

.(20

13),

Mar

shal

let

al.(

2014

),B

ond

etal

.(20

08),

and

Tw

amle

yet

al.(

2003

)di

dno

tre

port

stat

istic

alsi

gnif

ican

ce.N

/A�

not

appl

icab

le;

RC

T�

rand

omiz

edco

ntro

lled

tria

l;SE

�su

ppor

ted

empl

oym

ent;

HS

�hi

ghsc

hool

;IP

S�

Indi

vidu

alPl

acem

ent

and

Supp

ort;

AC

T�

asse

rtiv

eco

mm

unity

trea

tmen

t;FA

CT

�Fa

mily

-Aid

edA

sser

tive

Com

mun

ityT

reat

men

t;V

R�

voca

tiona

lre

habi

litat

ion;

SSI

�Su

pple

men

tal

Secu

rity

Inco

me;

DI

�So

cial

Secu

rity

Dis

abili

tyIn

sura

nce;

SMI

�se

riou

sm

enta

lill

ness

;e.

s.�

effe

ctsi

ze;

n.s.

�di

ffer

ence

isno

tsi

gnif

ican

t.a

We

did

not

obta

inan

dre

view

mos

tof

the

indi

vidu

alar

ticle

sin

clud

edin

the

syst

emat

icre

view

s.W

ere

port

data

for

each

stud

yas

repo

rted

inth

ere

view

.Inf

orm

atio

non

stud

yde

sign

and

resu

ltsar

esh

own

asre

port

edby

Mar

shal

let

al.

(201

4),

Kin

oshi

taet

al.

(201

3),

Bon

det

al.

(200

8),

and/

orT

wam

ley

etal

.(2

003)

.W

ere

view

edst

udie

sfo

cuse

don

the

thre

egr

oups

ofin

tere

stan

dre

port

resu

ltsin

Tab

les

4th

roug

h6.

bSa

mpl

esi

zes

and

nota

ble

char

acte

rist

ics

not

repo

rted

inM

arsh

all

etal

.(2

014)

,K

inos

hita

etal

.(2

013)

,B

ond

etal

.(2

008)

,an

dT

wam

ley

etal

.(2

003)

wer

eex

trac

ted

from

the

orig

inal

artic

les.

cB

ond

etal

.(2

008)

repo

rted

that

the

trea

tmen

t-co

ntro

ldi

ffer

ence

was

sign

ific

ant

but

did

not

repo

rtth

ele

vel

ofsi

gnif

ican

ce(p

-val

ue).

dG

old

etal

.(2

006)

iden

tifie

sth

ein

terv

entio

nas

IPS

with

AC

T.

eT

his

stud

yis

part

ofth

eE

IDP;

resu

ltsfo

rth

efu

llst

udy

are

repo

rted

inT

able

3.


Tab

le3

Evi

denc

efo

rIm

prov

ing

Em

ploy

men

tO

utco

mes

Thr

ough

Supp

orte

dE

mpl

oym

ent:

Stud

ies

Rev

iew

edby

Aut

hors

Stud

yau

thor

Stud

yde

sign

Inte

rven

tion

(sam

ple

size

)C

ompa

riso

n(s

ampl

esi

ze)

Not

able

sam

ple

char

acte

rist

ics

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)

Frey

etal

.(2

011)

RC

TIP

S�

med

icat

ion

man

agem

ent

(n�

1,00

4)

Lis

tof

avai

labl

elo

cal

and

natio

nal

serv

ices

(n�

1,05

1)

Part

icip

ants

wer

eD

Ibe

nefi

ciar

ies

with

schi

zoph

reni

a,bi

pola

rdi

sord

er,

orde

pres

sion

betw

een

18an

d55

year

sof

age

resi

ding

with

ina

30-m

ilera

dius

ofon

eof

23st

udy

site

s.A

vg.

age:

47Sc

hizo

phre

nia

spec

trum

:30

%�

HS

educ

atio

n:88

%

Dur

ing

24m

onth

sC

ompe

titiv

ely

empl

oyed

:53

%vs

.33

%(p

�.0

01)

Tot

alm

onth

sem

ploy

ed:

6.2

vs.

3.7

(p�

.001

)W

eekl

yea

rnin

gsat

mai

njo

b:$1

17vs

.$7

6(p

�.0

01)

Am

ong

thos

ew

how

orke

dco

mpe

titiv

ely

Tot

alm

onth

sem

ploy

ed:

9.3

vs.

8.4

(p�

.017

)M

onth

sto

firs

tjo

b:7.

7vs

.7.

2(p

�.1

07)

Hou

rsw

orke

dpe

rw

eek

atm

ain

job:

20vs

.19

(p�

.097

)W

eekl

yea

rnin

gsat

mai

njo

b:$2

01vs

.$1

93(p

�.0

60)

Hig

hest

hour

lyw

age:

$11.

36vs

.$1

1.54

(p�

.645

)H

offm

ann

etal

.(2

014)

RC

T:

5-ye

arfo

llow

-up

toH

offm

ann

etal

.(2

012)

cite

dab

ove

IPS

(n�

46)

Oth

ervo

catio

nal

serv

ices

(n�

54)

Avg

.ag

e:33

.5Sc

hizo

phre

nia:

39%

76%

com

plet

edvo

catio

nal

trai

ning

orha

veco

llege

degr

ee

Ana

lyze

dat

5ye

arfo

llow

-up:

IPS

�39

,co

ntro

l�

49

Am

ong

thos

eem

ploy

edat

leas

t50

%13

0w

eeks

inco

mpe

titiv

eem

ploy

men

t:43

%vs

.11

%(p

�.0

01)

Still

empl

oyed

at5

year

s:I3

7%vs

.9%

(p�

.001

)M

acia

set

al.

(200

6)R

CT

SE�

AC

T(n

�63

)C

lubh

ouse

(n�

58)

Sam

ple

char

acte

rist

ics

and

resu

ltsre

pres

ent

the

part

icip

ants

who

expr

esse

din

tere

stin

wor

king

Avg

.ag

e:36

year

sol

din

AC

T,

40ye

ars

old

incl

ubho

use

Schi

zoph

reni

asp

ectr

um:

60%

AC

T,

43%

club

hous

e�

HS

educ

atio

n:61

%

Dur

ing

24m

onth

sC

ompe

titiv

ely

empl

oyed

:64

%in

AC

Tan

d47

%in

club

hous

e(n

.s.

atp

�.0

5)

Am

ong

thos

ew

how

orke

dco

mpe

titiv

ely

Day

sem

ploy

edco

mpe

titiv

ely:

173

vs.

264

(mea

n);

98vs

.19

9(m

edia

n)(p

�.0

5)T

otal

hour

sw

orke

dco

mpe

titiv

ely:

592

vs.

784

(mea

n);

234

vs.

494

(med

ian)

(p�

.05)

Com

petit

ive

wag

esea

rned

:$3

,948

vs.

$6,2

02(m

ean)

;$1

,252

vs.

$3,4

56(m

edia

n)(p

�.0

5)(t

able

cont

inue

s)


Tab

le3

(con

tinu

ed)

Stud

yau

thor

Stud

yde

sign

Inte

rven

tion

(sam

ple

size

)C

ompa

riso

n(s

ampl

esi

ze)

Not

able

sam

ple

char

acte

rist

ics

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)

Coo

ket

al.

(200

5)Su

mm

ary

ofcr

oss-

site

resu

ltsfr

omst

udie

sof

EID

P,a

larg

e,m

ultis

iteR

CT

Seve

ral

SEm

odel

sin

clud

ing

IPS,

FAC

T,

AC

T,

and

club

hous

e

Serv

ices

asus

ual

orw

eake

rve

rsio

nsof

the

inte

rven

tion

1,27

3pa

rtic

ipan

tsw

ere

rand

omly

assi

gned

inse

ven

stat

esA

vg.

and

med

ian

age:

38Sc

hizo

phre

nia

spec

trum

:�

50%

�H

Sed

ucat

ion:

�67

%

Dur

ing

24m

onth

sC

ompe

titiv

ely

empl

oyed

:55

%vs

.34

%(p

�.0

01)

Wor

ked

�40

hrpe

rm

onth

:51

%vs

.39

%(p

�.0

01)

Mon

thly

earn

ings

:$1

22vs

.$9

9(p

�.0

4)

Ina

sam

ple

ofD

I-qu

alif

ied

part

icip

ants

,4%

earn

eden

ough

toco

mpl

ete

thei

rtr

ial

wor

kpe

riod

and

exit

DI.

Fact

ors

sign

ific

antly

asso

ciat

edw

ithbe

tter

wor

kou

tcom

esin

clud

eD

emog

raph

icfa

ctor

s:be

ing

youn

ger,

fem

ale,

His

pani

c/L

atin

o,be

tter

wor

khi

stor

y,a

high

scho

olor

colle

geed

ucat

ion.

Clin

ical

fact

ors:

high

self

-ra

ted

func

tioni

ng,

few

erre

cent

psyc

hiat

ric

hosp

italiz

atio

ns,

low

erle

vels

ofps

ychi

atri

csy

mpt

oms.

SEse

rvic

efa

ctor

s:jo

b-de

velo

pmen

tse

rvic

es;

high

degr

eeof

inte

grat

ion

with

clin

ical

serv

ices

;on

goin

gjo

bsu

ppor

tw

asno

tas

soci

ated

with

the

tota

lnu

mbe

rof

hour

sw

orke

d,bu

tw

asas

soci

ated

with

sign

ific

antly

long

erte

nure

for

afi

rst

com

petit

ive

job.


Tab

le3

(con

tinu

ed)

Stud

yau

thor

Stud

yde

sign

Inte

rven

tion

(sam

ple

size

)C

ompa

riso

n(s

ampl

esi

ze)

Not

able

sam

ple

char

acte

rist

ics

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)

Bon

det

al.

(200

8)a

Syst

emat

icre

view

with

met

a-an

alys

isIP

SC

ontr

olgr

oups

rece

ived

trea

tmen

tas

usua

l(t

ypic

ally

refe

rral

toV

R)

oral

tern

ativ

evo

catio

nal

mod

els;

2st

udie

sco

mpa

red

IPS

tono

nint

egra

ted

SE

Rev

iew

ed11

RC

Ts

with

high

mod

elfi

delit

yR

esul

tsfr

ompo

oled

anal

ysis

(stu

dype

riod

sdi

ffer

ed)

Elig

ibili

tycr

iteri

aac

ross

stud

ies:

adul

tsw

hom

etcr

iteri

afo

rSM

I,un

empl

oyed

atin

take

,ex

pres

sed

desi

reto

wor

k(i

nal

lbu

ton

eof

the

stud

ies)

,ab

senc

eof

sign

ific

ant

med

ical

cond

ition

Com

petit

ivel

yem

ploy

edin

11R

CT

s:61

%vs

.23

%�

Day

sto

firs

tco

mpe

titiv

ejo

bin

seve

nR

CT

s:13

8vs

.20

6A

nnua

lized

wee

ksw

orke

din

seve

nR

CT

s:12

vs.

5A

nnua

lized

wee

ksw

orke

dam

ong

thos

ew

hoob

tain

edco

mpe

titiv

eem

ploy

men

tin

seve

nR

CT

s:19

vs.

19W

orke

d�

20hr

per

wee

kin

four

RC

Ts:

44%

vs.

14%

Wee

ksw

orke

dat

long

est

com

petit

ive

job

insi

xR

CT

s:22

vs.

16C

ampb

ell

etal

.(2

011)

aN

onsy

stem

atic

revi

eww

ithm

eta-

anal

ysis

IPS

(n�

307)

Gro

upsk

ills

trai

ning

,en

hanc

edV

R,

psyc

hoso

cial

reha

bilit

atio

n,or

dive

rsif

ied

plac

emen

t(n

�37

4)

Rev

iew

edfo

urR

CT

sof

high

-fi

delit

yIP

Sm

odel

sE

ffec

tsi

zes

calc

ulat

edba

sed

on13

dem

ogra

phic

orcl

inic

alch

arac

teri

stic

sfo

rth

ree

outc

omes

rang

edfr

om:

.67–

1.42

for

com

petit

ive

empl

oym

ent;

.50–

1.06

for

wee

ksw

orke

d;an

d.4

7–1.

09fo

rjo

bte

nure

.E

ffec

tsi

zes

wer

esi

gnif

ican

t(p

�.0

5)fo

ral

lbu

ttw

osu

bgro

ups—

thos

ew

hoar

em

arri

edor

livin

gw

itha

part

ner,

and

thos

ew

hoar

edi

vorc

ed,

sepa

rate

dor

wid

owed

—an

dm

ost

wer

eco

nsid

ered

larg

e(�

.70)

The

rew

ere

few

inst

ance

sin

whi

chon

esu

bgro

upap

pear

edto

bene

fit

mor

efr

omIP

Sth

anan

othe

rgr

oup.

For

exam

ple,

thos

ew

hoha

dm

ore

than

ahi

ghsc

hool

degr

eesh

owed

less

impr

ovem

ent

with

IPS

than

thos

ew

ithle

ssed

ucat

ion

(tab

leco

ntin

ues)


conditions are not yet severe or chronic but who might be on thepath toward long-term disability.

Evidence for Services to Individuals, Including Youth,Experiencing a First Episode of Psychosis and Likelyto Require Early Intervention Services

With financial support from the community mental health ser-vices block grant program administered by the Substance Abuseand Mental Health Services Administration, a growing number ofU.S. states—32 as of late 2015—are implementing coordinatedearly intervention programs to treat individuals before or soonafter a first episode of psychosis (Insel, 2015). Functional andclinical recovery, and avoidance of long-term disability or vulner-ability, are the typical goals (McFarlane et al., 2012). Programstend to adapt standard community mental health services designedfor those with chronic mental illness to identify and appeal to ayounger and nonchronic population. Many comprehensive earlyintervention models incorporate interdisciplinary teams of earlyintervention specialists and offer recovery-oriented psychotherapy,family psychoeducation and support, pharmacotherapy, primarycare coordination, case management, and SE and supported edu-cation (CMS, 2015).

Limited evidence favors early intervention services with anemployment component over generic community mentalhealth services. Four studies (see Table 4) compared early in-tervention specialty services to generic services targeting the gen-eral population of mental health service users (which may or maynot offer employment support). The results overall favor compre-hensive early intervention, but not overwhelmingly so. First, animportant new study from the National Institute of Mental Health’sRecovery After an Initial Schizophrenia Episode (RAISE) demon-stration compared comprehensive early intervention services withSE and education to usual community care (Kane et al., 2016). TheRAISE study is significant for its scale and rigor: a clusteredrandomized trial that randomized 34 community mental healthcenters with more than 400 individuals in 21 states. Among thetreatment group, the proportion of participants in any school orwork grew from approximately 32% to 45% from baseline to the24-month follow-up, compared with gains from approximately41% to 44% among the control group. Although the gains weresignificantly greater for the treatment group, significantly fewertreatment group members were attending school at baseline. Thepositive impact on schooling or employment at follow-up, there-fore, may be a reflection of the baseline differences. A long-termfollow-up study will report on 5-year outcomes.

Garety et al. (2006) found that individuals who were random-ized to receive early intervention services were significantly morelikely to spend 6 months or more of the 18-month follow-up periodengaged in work or education compared with controls (49% vs.29%). However, at 18-month follow-up, only one third of the earlyintervention group was employed or in school full-time, and thisrate was not significantly higher than that of the control group.

The Early Detection, Intervention, and Prevention of PsychosisProgram (EDIPPP) expanded a psychosis-prevention model to sixsites around the U.S. EDIPPP offered family aided assertive com-munity treatment (FACT) modified for early intervention (McFar-lane et al., 2015). Family intervention was the principal treatmentcomponent, but the treatment package also included supportedT

able

3(c

onti

nued

)

Stud

yau

thor

Stud

yde

sign

Inte

rven

tion

(sam

ple

size

)C

ompa

riso

n(s

ampl

esi

ze)

Not

able

sam

ple

char

acte

rist

ics

Res

ults

(int

erve

ntio

nvs

.co

mpa

riso

n)

Tw

amle

yet

al.

(200

3)a

Syst

emat

icre

view

with

met

a-an

alys

isSE

,IPS

Prev

ocat

iona

ltr

aini

ng,

skill

str

aini

ng,

shel

tere

dw

orks

hop,

voca

tiona

lre

hab

Rev

iew

edsi

xR

CT

sof

SER

esul

tsfr

ompo

oled

anal

yses

(stu

dype

riod

sdi

ffer

ed)

Com

petit

ivel

yem

ploy

edin

five

stud

ies:

51%

vs.

18%

(wei

ghte

dm

ean

e.s.

�.7

9)SE

part

icip

ants

wer

efo

urtim

esm

ore

likel

yto

obta

inco

mpe

titiv

eem

ploy

men

t(O

dds

ratio

�4.

14,

95%

CI

[1.7

3to

9.93

]).

Not

e.U

nles

sot

herw

ise

indi

cate

d,st

atis

tical

sign

ific

ance

was

notr

epor

ted.

Res

ults

base

don

subs

ampl

esof

thos

ew

how

orke

dco

mpe

titiv

ely

are

likel

ybi

ased

upw

ards

.N/A

�no

tapp

licab

le;R

CT

�ra

ndom

ized

cont

rolle

dtr

ial;

IPS

�In

divi

dual

Plac

emen

tand

Supp

ort;

DI

�Su

pple

men

talS

ecur

ityD

isab

ility

Insu

ranc

e;SE

�su

ppor

ted

empl

oym

ent;

AC

T�

asse

rtiv

eco

mm

unity

trea

tmen

t;E

IDP

�E

mpl

oym

ent

Inte

rven

tion

Dem

onst

rato

nPr

ogra

m;

FAC

T�

Fam

ily-A

ided

Ass

ertiv

eC

omm

unity

Tre

atm

ent;

HS

�hi

ghsc

hool

;V

R�

voca

tiona

lre

habi

litat

ion;

SMI

�se

riou

sm

enta

lill

ness

;e.

s.�

effe

ctsi

ze;

QE

D�

quas

i-ex

peri

men

tal

desi

gn.

aT

wam

ley

etal

.(20

03)

and

Bon

det

al.(

2008

)re

view

edth

ree

ofth

esa

me

stud

ies,

and

all

four

stud

ies

revi

ewed

inC

ampb

ell

etal

.(20

11)

are

repo

rted

inB

ond

etal

.(20

08).

Bec

ause

ofth

isov

erla

p,po

oled

resu

ltssh

ould

beco

nsid

ered

age

nera

lpi

ctur

eof

evid

ence

and

not

thou

ght

ofas

who

llydi

stin

ctfi

ndin

gs.

�Si

gnif

ican

t;p-

valu

eno

tre

port

ed.


Tab

le4

Evi

denc

efo

rIm

prov

ing

Em

ploy

men

tO

utco

mes

Aft

era

Fir

stE

piso

deof

Psy

chos

isT

hrou

ghE

arly

Inte

rven

tion

Stud

ySt

udy

desi

gnSe

rvic

ety

pe(s

ampl

esi

ze)

Com

pari

son

(sam

ple

size

)N

otab

leba

selin

esa

mpl

ech

arac

teri

stic

sR

esul

ts(i

nter

vent

ion

vs.

com

pari

son)

Com

preh

ensi

veE

Iw

itha

voca

tiona

lco

mpo

nent

vs.

gene

ric

com

mun

itym

enta

lhe

alth

serv

ices

Kan

eet

al.

(201

6)C

lust

erR

CT

(clu

ster

edby

clin

ic)

Com

preh

ensi

veE

Ise

rvic

esw

ithSE

/E(N

AV

IGA

TE

;n

�17

site

s,22

3in

divi

dual

s)

Usu

alco

mm

unity

men

tal

heal

thse

rvic

es(1

7si

tes,

181

indi

vidu

als)

Avg

.ag

e:23

Schi

zoph

reni

asp

ectr

um:

89%

NA

VIG

AT

E,

90%

com

pari

son

Med

ian

dura

tion

ofun

trea

ted

psyc

hosi

s:66

wee

ksN

AV

IGA

TE

,88

wee

ksco

mpa

riso

n

Any

wor

kor

scho

oldu

ring

the

24-m

onth

inte

rven

tion

Bas

elin

e:�

32%

vs.

�41

%12

mon

ths

late

r:�

39%

vs.

�43

%24

mon

ths

late

r:�

45%

vs.

�44

%G

ains

wer

esi

gnif

ican

tlygr

eate

rfo

rN

AV

IGA

TE

(gro

upby

time

inte

ract

ion:

p�

.044

).H

owev

er,

sign

ific

antly

few

erN

AV

IGA

TE

mem

bers

wer

eat

tend

ing

scho

olat

base

line.

Gar

ety

etal

.(2

006)

RC

TC

ompr

ehen

sive

EI

serv

ices

w/o

ccup

atio

nal

ther

apis

t(L

ambe

thE

arly

Ons

ette

am;

n�

67)

Gen

eric

com

mun

itym

enta

lhe

alth

serv

ices

with

occu

patio

nal

ther

apis

t(n

�65

)

Avg

.ag

e:26

18m

onth

sla

ter

Schi

zoph

reni

asp

ectr

um:

69%

Em

ploy

edFT

orin

educ

atio

nFT

:33

%vs

.21

%(p

�.1

49)

Em

ploy

edor

ined

ucat

ion

�6

mon

ths:

49%

vs.

29%

(p�

.019

)A

vg.

mon

ths

empl

oyed

orin

educ

atio

n:6.

9vs

.4.

2(p

�.0

08)

McF

arla

neet

al.

(201

5)Q

ED

(RD

D)

FAC

Tw

ithSE

/E(n

�17

0)M

onth

lyph

one

mon

itori

ngan

dus

ual

com

mun

ityse

rvic

es(n

�57

)

Avg

.ag

e:17

Bas

elin

eIn

scho

olon

ly:

70%

vs.

70%

Em

ploy

edon

ly:

3%vs

.7%

Insc

hool

and

empl

oyed

:11

%vs

.11

%

24m

onth

sla

ter

Insc

hool

only

:54

%vs

.53

%E

mpl

oyed

only

:11

%vs

.18

%In

scho

olan

dem

ploy

ed:

18%

vs.

9%(t

able

cont

inue

s)


Tab

le4

(con

tinu

ed)

Stud

ySt

udy

desi

gnSe

rvic

ety

pe(s

ampl

esi

ze)

Com

pari

son

(sam

ple

size

)N

otab

leba

selin

esa

mpl

ech

arac

teri

stic

sR

esul

ts(i

nter

vent

ion

vs.

com

pari

son)

Fow

ler

etal

.(2

009)

QE

DC

ompr

ehen

sive

EI

serv

ices

with

occu

patio

nal

ther

apis

t(S

Em

entio

ned)

(“E

I”n

�10

2)

Gen

eric

com

mun

itym

enta

lhe

alth

serv

ices

(“no

EI”

n�

82);

and

gene

ric

men

tal

heal

thco

uple

dw

ithan

SEw

orke

r(“

part

ial

EI”

n�

69).

No

voca

tiona

lsu

ppor

tm

entio

ned.

Avg

.ag

es:

22,

23,

25,

for

“EI,

”“N

oE

I,”

and

“Par

tial

EI”

Schi

zoph

reni

asp

ectr

um:

69%

in“E

I,”

43%

in“N

oE

I”(“

Part

ial

EI”

not

repo

rted

)

1ye

arla

ter

(as

mea

sure

ddu

ring

asse

ssm

ent

mon

th)

Em

ploy

ed,

volu

ntee

ring

,or

insc

hool

�8

hr/w

eek:

40%

EI

vs.

24%

part

ial

EI

(p�

.05)

2ye

ars

late

r(a

sm

easu

red

duri

ngas

sess

men

tm

onth

)C

ompe

titiv

ely

empl

oyed

�15

hr/w

eek

orin

educ

atio

nFT

:44

%E

Ivs

.15

%N

oE

I(p

�.0

01)

Em

ploy

ed,

volu

ntee

ring

,or

ined

ucat

ion

8–15

hr/w

k:8%

EI

vs.

0%

No

EI

(p�

.001

)

Com

preh

ensi

veE

Iw

itha

voca

tiona

lco

mpo

nent

vs.

com

preh

ensi

veE

I,no

voca

tiona

lco

mpo

nent

Kill

acke

y(2

012)

RC

TC

ompr

ehen

sive

EI

serv

ices

with

IPS

(EPP

IC;

n�

73at

base

line,

68at

6m

onth

s)

Com

preh

ensi

veE

Ise

rvic

es(E

PPIC

;n

�73

atba

selin

e,59

at6

mon

ths)

Avg

.ag

e:20

Bas

elin

eSc

hizo

phre

nia:

38%

IPS,

37%

com

pari

son

Em

ploy

ed:

22%

vs.

11%

Ined

ucat

ion

(PT

orFT

):16

%vs

.19

%

Dur

ing

6-m

onth

inte

rven

tion

peri

odE

mpl

oyed

:72

%vs

.48

%(p

�.0

05)

Ined

ucat

ion:

54%

vs41

%(p

�.1

49)

Em

ploy

edan

d/or

ined

ucat

ion:

88%

vs.

72%

(p�

.023

)


Tab

le4

(con

tinu

ed)

Stud

ySt

udy

desi

gnSe

rvic

ety

pe(s

ampl

esi

ze)

Com

pari

son

(sam

ple

size

)N

otab

leba

selin

esa

mpl

ech

arac

teri

stic

sR

esul

ts(i

nter

vent

ion

vs.

com

pari

son)

Dud

ley

etal

.(2

014)

QE

DC

ompr

ehen

sive

EI

serv

ices

with

IPS

(n�

76at

base

line,

104

at12

mon

ths,

104

at18

mon

ths)

�(�

Sam

ple

size

sin

crea

sed

over

time

due

toth

een

tran

ceof

new

part

icip

ants

and

exit

ofot

hers

)

Com

preh

ensi

veE

Ise

rvic

es(n

�79

atba

selin

e,90

at12

mon

ths,

101

at18

mon

ths)

Avg

.ag

e:24

EI

�IP

S,25

EI

Bas

elin

eE

mpl

oyed

FT:

8%vs

.4%

Em

ploy

edPT

:4%

vs.

3%In

educ

atio

nFT

orPT

:12

%vs

.18

%T

otal

empl

oyed

,in

educ

atio

nor

volu

ntee

ring

:25

%vs

.24%

12m

onth

sla

ter

(at

end

ofin

terv

entio

n)E

mpl

oyed

FT:

13%

vs.

12%

Em

ploy

edPT

:5%

vs.

1%In

educ

atio

nFT

orPT

:17

%vs

.9%

Tot

alem

ploy

ed,

ined

ucat

ion

orvo

lunt

eeri

ng:

38%

vs.2

2%(p

�.0

2)

18m

onth

sla

ter

(6m

onth

spo

stin

terv

entio

n)E

mpl

oyed

FT:

7%vs

.9%

Em

ploy

edPT

:7%

vs.

5%In

educ

atio

nFT

orPT

:11

%vs

.13

%T

otal

empl

oyed

,in

educ

atio

nor

volu

ntee

ring

:26

%vs

.29

%(p

�.6

9)M

ajor

etal

.(2

010)

QE

DC

ompr

ehen

sive

EI

serv

ices

with

SE/E

(VIB

E;

n�

44,

incl

udin

gfo

urw

hode

clin

edV

IBE

trea

tmen

t)

Com

preh

ensi

veE

Ise

rvic

es,

novo

catio

nal

supp

ort

men

tione

d(n

�70

)

Avg

.ag

e:24

Schi

zoph

reni

asp

ectr

um:

63%

Bas

elin

eC

ompe

titiv

ely

empl

oyed

:14

%vs

.14

%In

educ

atio

n:14

%vs

.17

%

Dur

ing

past

12m

onth

sC

ompe

titiv

ely

empl

oyed

:36

%vs

.19

%In

educ

atio

n:20

%vs

.24

%(t

able

cont

inue

s)


Tab

le4

(con

tinu

ed)

Stud

ySt

udy

desi

gnSe

rvic

ety

pe(s

ampl

esi

ze)

Com

pari

son

(sam

ple

size

)N

otab

leba

selin

esa

mpl

ech

arac

teri

stic

sR

esul

ts(i

nter

vent

ion

vs.

com

pari

son)

Acc

ess

toV

IBE

was

asi

gnif

ican

tpr

edic

tor

ofat

tain

ing

empl

oym

ent/e

duca

tion

inm

ultiv

aria

tere

gres

sion

(OR

�3.

53,

95%

CI

[1.2

5,10

.00]

,p

�.0

18),

asw

ased

ucat

ion

beyo

nda

seco

ndar

yle

vel

and

bein

gem

ploy

edor

ined

ucat

ion

atba

selin

e;hi

gher

base

line

func

tioni

ngsc

ore

and

adi

agno

sis

othe

rth

ansc

hizo

phre

nia

wer

eno

tsi

gnif

ican

t

IPS

vs.

gene

ric

com

mun

itym

enta

lhe

alth

serv

ices

Nue

chte

rlei

n,Su

botn

ik,

Tur

ner,

etal

.(2

008)

and

Nue

chte

rlei

n,Su

botn

ik,

Ven

tura

,et

al.

(200

8)

RC

TIP

S�

grou

ptr

aini

ngin

wor

ksk

ills,

with

outp

atie

ntps

ychi

atri

ctr

eatm

ent

(n�

69)

Ref

erra

lto

VR

�gr

oup

trai

ning

inm

edic

ine

man

agem

ent

and

com

mun

icat

ion,

and

outp

atie

ntps

ychi

atri

ctr

eatm

ent

(n�

18)

Avg

.ag

e:25

Schi

zoph

reni

asp

ectr

um:

100%

Avg

.du

ratio

nof

illne

ss,

incl

udin

gpr

odro

mal

sym

ptom

s:25

mon

ths

Dur

ing

the

firs

t6

mon

ths

Em

ploy

edor

ined

ucat

ion:

83%

vs.

41%

(p�

.001

)

At

18-m

onth

follo

w-u

p(1

2m

onth

sla

ter)

Em

ploy

edor

ined

ucat

ion:

72%

vs.

42%

Not

e.U

nles

sot

herw

ise

indi

cate

d,st

atis

tical

sign

ific

ance

was

notr

epor

ted.

EPP

IC�

Ear

lyPs

ycho

sis

Prev

entio

nan

dIn

terv

entio

nC

entr

e;E

I�

earl

yIn

terv

entio

n;R

CT

�ra

ndom

ized

cont

rolle

dtr

ial;

SE/E

�su

ppor

ted

empl

oym

ent

and

supp

orte

ded

ucat

ion;

FT�

full

time;

QE

D�

quas

i-ex

peri

men

tal

desi

gn;

RD

D�

regr

essi

ondi

scon

tinui

tyde

sign

;FA

CT

�Fa

mily

-Aid

edA

sser

tive

Com

mun

ityT

reat

men

t;SE

�su

ppor

ted

empl

oym

ent;

IPS

�In

divi

dual

Plac

emen

tan

dSu

ppor

t;PT

�pa

rttim

e;V

R�

voca

tiona

lre

habi

litat

ion.


Tab

le5

Evi

denc

efo

rIm

prov

ing

Em

ploy

men

tO

utco

mes

ofIn

divi

dual

sat

Ris

kof

Job

Los

s

Stud

ySt

udy

desi

gnSe

rvic

ety

pe(s

ampl

esi

ze)

Com

pari

son

(sam

ple

size

)N

otab

lesa

mpl

ech

arac

teri

stic

sR

esul

ts

Ler

ner

etal

.(2

012)

RC

TT

hest

udy

exam

ined

abr

ief

tele

phon

icpr

ogra

mut

ilizi

ngvo

catio

nal,

med

ical

,an

dps

ycho

logi

cal

stra

tegi

esto

impr

ove

wor

kfu

nctio

ning

ofem

ploy

ees

with

depr

essi

on(N

�59

).

Usu

alca

re(N

�27

)Pa

rtic

ipan

tsw

ere

adul

tst

ate

gove

rnm

ent

empl

oyee

sin

Mai

ne;

empl

oyed

15hr

orm

ore

per

wee

k;di

agno

sed

with

maj

orde

pres

sive

diso

rder

and/

ordy

sthy

mia

;an

dha

dat

-wor

kpr

oduc

tivity

loss

of5%

orm

ore

intw

ow

eeks

prio

rto

enro

llmen

t.

For

inte

rven

tion

part

icip

ants

scor

eson

the

WL

Qas

sess

men

tof

the

impa

ctof

heal

thpr

oble

ms,

wor

kab

senc

em

easu

res,

and

ade

pres

sion

seve

rity

mea

sure

,w

ere

sign

ific

antly

impr

oved

,w

here

assc

ores

for

cont

rol

part

icip

ants

wer

ew

orse

orno

tsi

gnif

ican

tlych

ange

dfr

omba

selin

e.In

addi

tion,

the

mag

nitu

deof

the

chan

ge(i

mpr

ovem

ent)

inal

lei

ght

outc

omes

was

sign

ific

antly

larg

erin

the

trea

tmen

tgr

oup

than

inth

eus

ual

care

grou

p.

Nie

uwen

huijs

enet

al.

(200

8)SR

The

revi

ewex

amin

edw

ork-

and

wor

ker-

dire

cted

inte

rven

tions

for

redu

cing

wor

kdi

sabi

lity

ofde

pres

sed

wor

kers

.

11R

CT

sN

ow

ork-

dire

cted

inte

rven

tions

wer

ein

clud

ed.

Inte

rven

tions

wer

eph

arm

acol

ogic

al(f

our

stud

ies)

,ps

ycho

logi

cal

(tw

o),

and

com

bina

tions

ofth

etw

o(f

ive)

.

The

auth

ors

coul

dno

tfi

ndan

yhi

ghqu

ality

stud

ies

ofem

ploy

er-l

evel

inte

rven

tions

.T

here

view

foun

dlim

ited

evid

ence

that

clin

ical

inte

rven

tion

can

redu

cesi

ckne

ssab

senc

efr

omw

ork

inde

pres

sed

peop

le.

The

auth

ors

conc

lude

that

depr

esse

dem

ploy

ees

requ

ire

wor

ksu

ppor

tsan

dac

com

mod

atio

nsin

addi

tion

tocl

inic

trea

tmen

tin

orde

rto

impr

ove

empl

oym

ent

outc

omes

.K

rupa

(200

7)N

SRT

here

view

exam

ined

empl

oym

ent

inte

rven

tions

for

indi

vidu

als

who

expe

rien

cem

enta

lill

ness

.

The

auth

orde

velo

ped

afr

amew

ork

ofin

divi

dual

-lev

elin

terv

entio

nca

tego

ries

.

Em

ploy

er-l

evel

inte

rven

tions

incl

ude

rout

ine

scre

enin

gs,

educ

atio

n/aw

aren

ess

cam

paig

ns,

and

deve

lopi

ngor

gani

zatio

nal

fram

ewor

ksco

nduc

ive

togo

odm

enta

lhe

alth

.

The

auth

ordi

dno

tfi

ndhi

gh-l

evel

evid

ence

for

empl

oyer

-lev

elin

terv

entio

ns.

The

rew

asm

ore

supp

ort

for

indi

vidu

al-l

evel

inte

rven

tions

,in

clud

ing

clin

ical

trea

tmen

t,so

cial

-net

wor

kde

velo

pmen

t,an

dre

ason

able

job

acco

mm

odat

ions

.

Lau

ber

and

Bow

en(2

010)

NSR

The

revi

ewex

amin

edin

terv

entio

nsto

prom

ote

keep

ing

peop

lew

ithaf

fect

ive

diso

rder

sw

orki

ngor

tohe

lpth

emre

turn

tow

ork.

The

stud

yre

view

edin

terv

entio

nsfo

rpe

ople

infi

veca

tego

ries

:m

enta

lhe

alth

,pe

ople

with

anex

istin

gw

orkp

lace

,pe

ople

with

out

aw

orkp

lace

,em

ploy

er-l

evel

inte

rven

tions

,an

dpe

ople

with

othe

rth

anm

enta

lhe

alth

prob

lem

s.

Inte

rven

tions

incl

uded

clin

ical

trea

tmen

t,ca

sem

anag

ers

prov

idin

gem

ploy

ees

with

appr

opri

ate

supp

orts

,su

perv

isor

supp

ort,

soci

alsu

ppor

t,an

ded

ucat

ion

and

trai

ning

.

The

auth

ors

foun

da

wea

lthof

stud

ies

repo

rtin

gon

inte

rven

tions

toas

sist

empl

oyee

sw

ithaf

fect

ive

diso

rder

s,bu

tfe

wth

atre

port

empl

oym

ent

outc

omes

.T

here

sear

chis

even

wea

ker

for

empl

oyer

-lev

elin

terv

entio

ns.

The

auth

ors

conc

lude

ther

eis

ala

rge

gap

inth

ere

sear

chev

iden

ceon

this

topi

c. (tab

leco

ntin

ues)


Tab

le5

(con

tinu

ed)

Stud

ySt

udy

desi

gnSe

rvic

ety

pe(s

ampl

esi

ze)

Com

pari

son

(sam

ple

size

)N

otab

lesa

mpl

ech

arac

teri

stic

sR

esul

ts

Boh

man

etal

.(2

011)

RC

TT

hest

udy

exam

ined

Tex

as’

DM

IEpr

ogra

m“w

rapa

roun

d”he

alth

serv

ices

(N�

888)

.

Reg

ular

heal

thca

reth

roug

hT

exas

’H

arri

sC

ount

yH

ospi

tal

Dis

tric

t(N

�69

7)

Part

icip

ants

wer

elo

w-

inco

me,

wor

king

adul

ts;

pred

omin

atel

yfe

mal

e(7

7%),

mid

dle-

aged

(mea

nag

eof

47),

and

min

ority

(40%

Afr

ican

Am

eric

an,

30%

His

pani

c);

11%

diag

nose

dw

ithse

riou

sm

enta

lill

ness

.

Inte

rven

tion

part

icip

ants

wer

etw

ice

aslik

ely

tom

ake

any

men

tal

heal

thvi

sit

(12%

vs.

6%,

sign

ific

ant

at.0

1),

and

less

likel

yto

rece

ive

SSI/

DI

(6%

vs.

8%).

Inte

rven

tion

part

icip

ants

disp

laye

dno

sign

ific

ant

diff

eren

cein

empl

oym

ent,

earn

ings

outc

omes

,or

mea

nSF

-12

MC

Ssc

ores

.

Lin

kins

etal

.(2

011)

RC

TT

hest

udy

exam

ined

Min

neso

ta’s

DM

IEpr

ogra

m:

aco

mpr

ehen

sive

set

ofhe

alth

,be

havi

oral

heal

th,

and

empl

oym

ent-

supp

ort

serv

ices

,co

ordi

nate

dth

roug

ha

navi

gato

r(N

�88

8).

Usu

alca

re(N

�26

7)Pa

rtic

ipan

tsw

ere

wor

king

atle

ast

40hr

/mon

th,

had

men

tal

illne

ssdi

agno

sis,

and

wer

eno

tel

igib

lefo

rot

her

stat

e-sp

onso

red

publ

icpr

ogra

ms.

The

inte

rven

tion

grou

pm

aint

aine

dor

impr

oved

AD

Lfu

nctio

ning

com

pare

dto

the

cont

rol

grou

p.T

here

was

nosi

gnif

ican

tdi

ffer

ence

inem

ploy

men

tou

tcom

esbe

twee

ngr

oups

,al

thou

ghlo

wer

-fun

ctio

ning

part

icip

ants

from

the

cont

rol

grou

pdi

spla

yed

low

erea

rnin

gsth

anlo

wer

-fun

ctio

ning

trea

tmen

t-gr

oup

mem

bers

.Pa

rtic

ipan

tsin

the

inte

rven

tion

who

wer

em

ore

enga

ged

with

the

prog

ram

disp

laye

dsi

gnif

ican

tim

prov

emen

tsin

men

tal

heal

thst

atus

.R

ost

etal

.(2

004)

RC

TT

his

stud

yex

amin

edw

heth

erim

prov

ing

prim

ary

care

depr

essi

onm

anag

emen

tim

prov

esem

ploy

men

tou

tcom

esov

er2

year

s(N

�15

8).

Usu

alca

re(N

�16

8)Pa

rtic

ipan

tsw

ere

empl

oyed

patie

nts

who

pres

ente

dfo

rro

utin

evi

sits

atco

mm

unity

prim

ary

care

prac

tices

acro

ssth

eU

nite

dSt

ates

and

scre

ened

posi

tive

for

maj

orde

pres

sion

.Pa

rtic

ipan

tsw

ere

prim

arily

fem

ale

(85.

0%),

Whi

te(8

6.8%

),an

dem

ploy

edfu

lltim

e(7

7.8%

).

The

inte

rven

tion

grou

pre

port

ed6.

1%gr

eate

rpr

oduc

tivity

and

22.8

%le

ssab

sent

eeis

mov

erth

est

udy

peri

od.

The

seef

fect

sin

crea

sed

to8.

2%an

d28

.4%

,re

spec

tivel

y,fo

rpa

rtic

ipan

tsw

how

ere

cons

iste

ntly

empl

oyed

over

this

time.

The

auth

ors

estim

ate

anan

nual

econ

omic

bene

fit

asso

ciat

edw

ithth

ein

crea

sein

prod

uctiv

ityfo

rth

eco

nsis

tent

lyem

ploy

edof

$1,9

82pe

rde

pres

sed

FTE

.Fo

rth

issa

me

grou

p,th

eau

thor

ses

timat

ean

econ

omic

bene

fit

asso

ciat

edw

ithre

duct

ion

inab

sent

eeis

mof

$619

per

depr

esse

dFT

E.

Wan

get

al.

(200

7)R

CT

The

stud

yex

amin

eda

tele

phon

icde

pres

sion

outr

each

,ca

rem

anag

emen

t,an

dps

ycho

ther

apy

prog

ram

onw

orkp

lace

outc

omes

(N�

304)

.

Usu

alca

re(N

�30

0)D

epre

ssed

wor

kers

18or

over

enro

lled

ina

man

aged

care

prog

ram

who

wor

ked

for

seve

ral

larg

eem

ploy

ers.

Scor

eson

the

Qui

ckIn

vent

ory

ofD

epre

ssed

Sym

ptom

olog

yw

ere

sign

ific

antly

low

eram

ong

trea

tmen

tgr

oup

mem

bers

at6

and

12m

onth

s;sy

mpt

omim

prov

emen

tw

assi

gnif

ican

tat

12m

onth

s(3

0.9%

vs.

21.6

%).

Hou

rsw

orke

dw

ere

sign

ific

antly

high

er,

prim

arily

due

tojo

bre

tent

ion

(92.

6%vs

.88

.0%

).


Tab

le5

(con

tinu

ed)

Stud

ySt

udy

desi

gnSe

rvic

ety

pe(s

ampl

esi

ze)

Com

pari

son

(sam

ple

size

)N

otab

lesa

mpl

ech

arac

teri

stic

sR

esul

ts

Wha

len

etal

.(2

012)

RC

TT

heD

MIE

prog

ram

,in

terv

entio

nspr

ovid

ing

med

ical

bene

fits

and

fina

ncia

las

sist

ance

for

heal

thca

re,

alth

ough

the

spec

ific

pack

ages

ofse

rvic

esva

ried

inea

chof

four

stat

es(N

�2,

125)

.O

nly

Min

neso

taan

dT

exas

inte

ntio

nally

focu

sed

onpe

ople

with

men

tal

heal

th.

Usu

alca

re,

alth

ough

cont

rol

cond

ition

sva

ryby

stat

e(N

�1,

299)

.U

sual

care

,al

thou

ghco

ntro

lco

nditi

ons

vary

byst

ate

(N�

1,29

9).

Sam

ple

char

acte

rist

ics

vari

edby

stat

e.Pa

rtic

ipan

tsin

all

stat

esw

ere

prim

arily

fem

ale.

Min

neso

ta,

whi

chfo

cuse

dsp

ecif

ical

lyon

indi

vidu

als

with

men

tal

heal

this

sues

,ha

dth

elo

wes

tm

ean

men

tal

SF-

12sc

ore

(35.

0).

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eval

uatio

nof

the

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mas

aw

hole

foun

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ific

ant

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eren

ces

betw

een

the

perc

ent

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eatm

ent

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ppa

rtic

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tsan

dco

ntro

lgr

oup

part

icip

ants

not

empl

oyed

byth

een

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the

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ype

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(whi

chw

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ther

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.T

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Min

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icip

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ific

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thor

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teth

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ates

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atis

tical

lysi

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ican

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ence

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rven

tions

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ms.

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riet

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(201

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stud

yex

amin

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-com

pany

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ning

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ithth

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ncin

gca

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agem

ent,

men

tal

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th,

and

job

rete

ntio

n(N

�36

9).

Prin

ted

info

rmat

ion

abou

tca

reer

and

heal

th-r

elat

edis

sues

(N�

349)

Part

icip

ants

wer

eem

ploy

ees

atm

ediu

m-

and

larg

e-si

zed

orga

niza

tions

.M

ean

age

was

50.1

year

s,88

%w

ere

fem

ale,

and

mos

tha

da

degr

eebe

yond

high

scho

ol(6

0%).

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the

7-m

onth

follo

w-u

ppe

riod

,th

ein

terv

entio

ngr

oup

disp

laye

dsi

gnif

ican

tlyde

crea

sed

depr

essi

vesy

mpt

oms

and

inte

ntio

nsto

retir

eco

mpa

red

with

the

cont

rol

grou

p.

Adl

eret

al.

(200

6)O

ST

his

was

a3-

year

long

itudi

nal

obse

rvat

iona

lst

udy

of28

6pa

tient

sw

ithD

SM-I

Vm

ajor

depr

essi

vedi

sord

eran

d/or

dyst

hym

ia.

The

com

pari

son

grou

pin

clud

ed93

indi

vidu

als

with

rheu

mat

oid

arth

ritis

,an

d19

3de

pres

sion

-fre

ehe

alth

yco

ntro

lsu

bjec

ts.

At

base

line,

25%

ofth

ede

pres

sion

grou

pm

etth

esc

reen

ing

crite

ria

for

dyst

hym

iaan

d75

%m

etcr

iteri

afo

rm

ajor

depr

essi

vedi

sord

eran

ddo

uble

depr

essi

on.

Mea

nnu

mbe

rof

sym

ptom

sw

as2.

9fo

rth

edy

sthy

mia

grou

p,4.

8fo

rm

ajor

depr

essi

vedi

sord

er,

and

4.6

for

doub

lede

pres

sion

.

Em

ploy

ees

unde

rgoi

ngtr

eatm

ent

for

depr

essi

onha

dw

orse

job-

perf

orm

ance

scor

esth

anhe

alth

yem

ploy

ees

even

afte

rde

mon

stra

ting

clin

ical

impr

ovem

ents

insy

mpt

omse

veri

ty.

Spec

ific

ally

,th

est

udy

iden

tifie

dpe

rsis

tent

defi

cits

inpe

rfor

man

ceof

men

tal-

inte

rper

sona

lta

sks,

time

man

agem

ent,

outp

ut,

and

phys

ical

task

s.T

hest

udy

conc

lude

sth

at,

alth

ough

clin

ical

inte

rven

tions

impr

ove

men

tal

heal

th,

addi

tiona

lw

orkp

lace

inte

rven

tions

may

bere

quir

edto

impr

ove

the

perf

orm

ance

ofde

pres

sed

empl

oyee

s.

Bur

ton

etal

.(2

007)

OS

Thi

sw

asa

retr

ospe

ctiv

eob

serv

atio

nal

coho

rtst

udy

of2,

112

empl

oyee

sw

itha

new

epis

ode

oftr

eatm

ent

with

anan

tidep

ress

ant

med

icat

ion.

1,30

1em

ploy

ees

adhe

red

toac

ute-

phas

etr

eatm

ent,

and

966

rem

aine

dad

here

ntto

cont

inua

tion-

phas

etr

eatm

ent.

The

popu

latio

nw

as76

%fe

mal

ean

d87

%C

auca

sian

;1.

8%of

all

empl

oyee

sha

da

shor

t-te

rmdi

sabi

lity

even

tdu

eto

depr

essi

on/a

nxie

tyin

pre-

inde

xpe

riod

.

Adh

eren

tem

ploy

ees

wer

esi

gnif

ican

tlyle

sslik

ely

toha

vean

ysh

ort-

term

disa

bilit

yab

senc

e(8

.8%

)co

mpa

red

with

nona

dher

ent

empl

oyee

s(1

2.7%

).In

the

cont

inua

tion

phas

e,96

6em

ploy

ees

wer

ead

here

ntan

d1,

146

wer

eno

nadh

eren

t.A

dher

ent

empl

oyee

sw

ere

less

likel

yto

have

any

shor

t-te

rmdi

sabi

lity

abse

nce

than

nona

dher

ent

empl

oyee

s(8

.4%

com

pare

dw

ith12

%).

Adh

eren

tem

ploy

ees

wer

eal

sole

sslik

ely

toha

vem

ultip

lesh

ort-

term

disa

bilit

yab

senc

es(.

9%)

than

nona

dher

ent

empl

oyee

s(2

.1%

).(t

able

cont

inue

s)


education and employment, along with elements of assertive com-munity treatment and psychotropic medication. Treatment andcomparison groups were formed through a risk-based allocationdesign (also known as regression-discontinuity). Individuals iden-tified at baseline as being at higher risk of psychosis were assignedto receive FACT, and those at lower risk at baseline were assignedto receive standard community care. Thirty-seven percent of thecomparison group received SE or supported education as part ofstandard care, potentially attenuating the results. Still, outcomesslightly favored the FACT group. Participation in either school,work, or both stayed level after 24 months for the FACT group(from 84% to 83%) but fell by nine percentage points (from 88%to 79%) for the comparison group (significance not reported).These averages, which are relatively high for both groups, masksubstantial improvement for some and decline for others. Betweenbaseline and 24 months, 21% of the treatment group started workor school or both, compared with 7% among controls.

Results were more promising in Fowler et al. (2009), whichcompared comprehensive early intervention with (a) generic men-tal health services and (b) SE added to the generic team. One-yearpostreferral, 40% of the early intervention cohort was competi-tively working or in school more than 15 hr per week during theassessment month, compared with significantly fewer (24%) ofthose who received SE with generic services. Two-years postre-ferral, 44% of the early intervention cohort were engaged in workor school more than 15 hr per week, significantly more than thosein the generic-only group (15%).

Comprehensive early intervention with SE may lead to higheremployment levels than early intervention alone. Three studiesfound promising results when they examined the addition of SEspecialists into a comprehensive early intervention model. Existingearly intervention services, which may or may not offer noninte-grated vocational supports, served as the comparisons. First, Kil-lackey (2012) found that during a 6-month randomized trial forindividuals experiencing a first episode of psychosis, employmentamong those receiving comprehensive early intervention plus IPSwas 72%, compared with 48% among those receiving usual com-prehensive early intervention services (p � .005). Significantlymore treatment group members were also participating in a com-bination of employment and education during the 6-month inter-vention (88% vs. 72%), although these rates are high for bothgroups. The trial also conducted assessments at 12 and 18 months,but we could not locate published results from those assessments.

Major et al. (2010) also found support for the added benefit ofSE. At any time during the first 12 months of intervention, 56% ofpeople receiving integrated early intervention were competitivelyemployed or in school, compared with 43% in the standard earlyintervention group. Access to early intervention with SE was asignificant predictor of attaining employment or education in amultivariate regression that controlled for other tested significantpredictors.

Examining how individuals fare after the removal of the em-ployment support is highly policy-relevant. Immediate posttestoutcomes were positive but not sustained in Dudley, Nicholson,Stott, and Spoors (2014), which compared early intervention withIPS offered in one service center to early intervention aloneoffered in a similar service center. After offering IPS for 12months, significantly more people than in the comparison groupT

able

5(c

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nued

)

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(200

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are

tros

pect

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obse

rvat

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lco

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stud

yof

1,28

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atth

ree

maj

orC

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fina

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com

pani

es.

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yex

amin

edad

here

nce

totr

eatm

ent

prot

ocol

.

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uded

empl

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sha

dde

pres

sion

-re

late

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ddi

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than

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stud

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pula

tion

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over

whe

lmin

gly

fem

ale

(88%

),ha

da

mea

nof

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depr

essi

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mpt

oms,

and

46.5

%ha

dad

ditio

nal

men

tal

heal

thco

nditi

ons

besi

des

depr

essi

on.

Em

ploy

ees

who

retu

rned

tow

ork

full

time

orpa

rttim

ere

port

edsi

gnif

ican

tlyfe

wer

sym

ptom

sth

anth

ose

who

left

empl

oym

ent

orw

ent

onlo

ng-t

erm

disa

bilit

ybe

nefi

ts.

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ploy

ees

who

wen

ton

long

-ter

mdi

sabi

lity

bene

fits

wer

esi

gnif

ican

tlyle

sslik

ely

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llan

yan

tidep

ress

ant

pres

crip

tions

duri

nga

shor

t-te

rmep

isod

e(2

7.7%

)th

anth

ose

who

retu

rned

tow

ork

(47.

3%)

orth

ose

who

left

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kan

ddi

dno

tgo

onto

long

-ter

mdi

sabi

lity

bene

fits

(42.

7%).

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ordi

nary

leas

tsq

uare

sre

gres

sion

mod

elfo

und

that

earl

yin

terv

entio

nw

assi

gnif

ican

tlyas

soci

ated

with

are

duce

dle

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ofdi

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lity

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(��

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ys).

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ized

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Tab

le6

Evi

denc

efo

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prov

ing

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ploy

men

tO

utco

mes

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ong-

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yau

thor

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sign

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type

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ple

size

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n(s

ampl

esi

ze)

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able

sam

ple

char

acte

rist

ics

Res

ults

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Til

etal

.(2

013)

SRIn

terv

entio

nsto

max

imiz

ere

inte

grat

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ofw

orke

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ithm

enta

ldi

sord

ers

into

the

wor

kfor

ce.

97ob

serv

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nal

orex

peri

men

tal

stud

ies.

32of

97st

udie

sco

ncer

ned

rein

tegr

atio

n;10

ofth

emw

ere

cond

ucte

din

popu

latio

nsof

vete

rans

.

Lim

ited

know

ledg

eex

ists

abou

tho

wto

rein

tegr

ate

peop

lew

ithm

enta

ldi

sord

ers

into

ane

ww

orkp

lace

afte

ran

abse

nce

ofm

ore

than

aye

ar.

Kno

wle

dge

spec

ific

tove

tera

nsis

even

mor

elim

ited.

Dav

iset

al.

(201

2)R

CT

IPS

mod

elde

scri

bed

inA

Wor

king

Lif

efo

rP

eopl

eW

ith

Seve

reM

enta

lIl

lnes

s(n

�42

).

Stan

dard

VR

prog

ram

(n�

43)

Vet

eran

sat

the

Tus

calo

osa

Vet

eran

sA

ffai

rsM

edic

alC

ente

rag

es19

–60

with

adi

agno

sis

ofPT

SD,

am

edic

alcl

eara

nce

tow

ork,

and

who

are

curr

ently

unem

ploy

edan

din

tere

sted

inco

mpe

titiv

eem

ploy

men

t.

The

stud

ygr

oup

was

2.7

times

mor

elik

ely

toga

inco

mpe

titiv

eem

ploy

men

t.O

ther

empl

oym

ent

outc

omes

,in

clud

ing

time

wor

ked

and

tota

lea

rnin

gs,

also

favo

red

the

stud

ygr

oup.

The

sefi

ndin

gsw

ere

stat

istic

ally

sign

ific

ant

and

are

cons

iste

ntw

ithpr

evio

usly

repo

rted

adva

ntag

esof

IPS

over

trad

ition

alV

Rpr

ogra

ms.

Mic

halo

poul

oset

al.

(201

1)an

dW

eath

ers

and

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ley

(201

4)

RC

TD

Ibe

nefi

ciar

ies

with

nohe

alth

insu

ranc

ere

ceiv

edhe

alth

insu

ranc

e,m

edic

alca

rem

anag

emen

t,em

ploy

men

tan

dbe

nefi

tsco

unse

ling

and

PGA

Pfo

rne

wD

Ire

cipi

ents

;n

�61

1;22

%ha

dm

enta

ldi

sord

ers,

incl

udin

gin

divi

dual

sw

ithps

ychi

atri

cdi

sabi

litie

s.

AB

grou

pre

ceiv

edon

lyhe

alth

bene

fits

pack

age

(n�

400)

and

new

DI

reci

pien

tsw

ithno

inte

rven

tion

(n�

986)

.

New

lyen

title

dD

Ibe

nefi

ciar

ies

who

wer

eap

prov

edat

thei

rin

itial

med

ical

dete

rmin

atio

nag

es18

–54

with

atle

ast

18m

onth

sbe

fore

the

star

tof

thei

ren

title

men

tto

Med

icar

ean

dw

hore

side

din

one

ofth

e53

met

ropo

litan

area

sin

clud

edin

the

dem

onst

ratio

n.

The

AB

Plus

grou

ppa

rtic

ipat

edin

voca

tiona

lse

rvic

esat

agr

eate

rra

tedu

ring

all

3ye

ars

offo

llow

-up,

and

was

empl

oyed

ata

grea

ter

rate

and

earn

edm

ore

onav

erag

edu

ring

the

seco

ndye

araf

ter

rand

omas

sign

men

t.T

hese

resu

ltsdi

sapp

eare

dat

the

thir

dye

arfo

llow

-up.

Res

ults

wer

est

atis

tical

lysi

gnif

ican

t.(t

able

cont

inue

s)


Tab

le6

(con

tinu

ed)

Stud

yau

thor

Stud

yde

sign

Serv

ice

type

(sam

ple

size

)C

ompa

riso

n(s

ampl

esi

ze)

Not

able

sam

ple

char

acte

rist

ics

Res

ults

Bur

t(2

012)

QE

DH

ousi

ngas

sist

ance

,em

ploy

men

tca

sem

anag

emen

t,ca

seco

ordi

natio

nby

anem

ploy

men

tsp

ecia

list,

wor

ksu

ppor

tssu

chas

trai

ning

and

unif

orm

s,an

dlin

kage

sto

wor

kfor

cede

velo

pmen

tce

nter

spr

ovid

edat

one

ofth

ree

Los

Ang

eles

Cou

nty

com

mun

itym

enta

lhe

alth

cent

ers

(n�

56).

Hom

eles

sin

divi

dual

sw

ithse

riou

sm

enta

lill

ness

rece

ivin

gno

npro

gram

serv

ices

aton

eof

the

othe

r15

Los

Ang

eles

Cou

nty

com

mun

itym

enta

lhe

alth

cent

ers

(n�

415)

.

All

part

icip

ants

qual

ifie

dfo

rco

unty

men

tal

heal

thse

rvic

es,

usua

llyw

itha

diag

nosi

sof

schi

zoph

reni

aor

affe

ctiv

edi

sord

er,

and

wer

eho

mel

ess

aten

rollm

ent.

Prop

ensi

tysc

ore

mat

chin

gw

asus

edto

com

pare

grou

ps.

The

trea

tmen

tgr

oup

had

anem

ploy

men

tpa

rtic

ipat

ion

rate

(57%

vs.

22%

)an

dco

mpe

titiv

eem

ploy

men

tra

te(2

7%vs

.13

%)

mor

eth

ando

uble

that

ofth

eco

mpa

riso

ngr

oup.

Tre

atm

ent-

grou

ppa

rtic

ipan

tsw

ere

mor

elik

ely

tow

ork

full

time

rath

erth

anpa

rttim

ean

dle

sslik

ely

toha

veha

dno

empl

oym

ent

atal

lw

hile

inth

epr

ogra

m.

Of

thos

ew

hodi

dga

inem

ploy

men

t,th

etr

eatm

ent

grou

pto

okfe

wer

days

todo

soan

dw

orke

dm

ore

days

inco

mpe

titiv

eem

ploy

men

taf

ter

they

did.

App

roxi

mat

ely

half

ofth

eov

eral

lda

ysw

orke

dby

trea

tmen

t-gr

oup

part

icip

ants

wer

ein

com

petit

ive

empl

oym

ent.

Som

ebu

tno

tal

lof

the

obse

rved

empl

oym

ent

outc

omes

may

,in

fact

,be

attr

ibut

able

toim

prov

edho

usin

gou

tcom

esra

ther

than

toa

spec

ific

empl

oym

ent

inte

rven

tion.

Gao

etal

.(2

009)

Pre-

post

In-h

ouse

SEse

rvic

es(n

�60

)n/

aC

lient

sw

ithSM

Iat

asu

ppor

tive

hous

ing

agen

cyin

New

Jers

ey,

incl

udin

gin

divi

dual

sw

ithlo

nghi

stor

ies

ofho

spita

lizat

ions

.

The

com

petit

ive

empl

oym

ent

rate

doub

led

to26

%af

ter

12m

onth

san

dre

mai

ned

abov

e50

%af

ter

24m

onth

s.A

noth

er18

%ha

dre

turn

edto

scho

olor

part

icip

ated

injo

btr

aini

ngat

the

end

of3

year

s.


Tab

le6

(con

tinu

ed)

Stud

yau

thor

Stud

yde

sign

Serv

ice

type

(sam

ple

size

)C

ompa

riso

n(s

ampl

esi

ze)

Not

able

sam

ple

char

acte

rist

ics

Res

ults

Ros

enhe

ckan

dM

ares

(200

7)Pr

e-po

st/im

plem

enta

tion

stud

y.IP

S(n

�32

1)Se

rvic

esre

ceiv

edpr

ior

toim

plem

enta

tion

ofIP

S(n

�30

8).

Hom

eles

sve

tera

nsw

how

ere

not

rece

ivin

gV

Ahe

alth

serv

ices

,ex

pres

sed

inte

rest

inse

ekin

gco

mpe

titiv

eem

ploy

men

t,an

dw

ere

diag

nose

das

havi

nga

psyc

hiat

ric

orsu

bsta

nce-

abus

epr

oble

m.

Con

trol

ling

for

base

line

diff

eren

ces,

the

post

-im

plem

enta

tion

grou

pen

gage

din

anav

erag

eof

15%

mor

eda

ysof

com

petit

ive

empl

oym

ent

over

the

2-ye

arfo

llow

-up

peri

od.

The

stud

y’s

auth

ors

conc

lude

that

alo

w-i

nten

sity

trai

ning

appr

oach

can

succ

essf

ully

impl

emen

tan

IPS

prog

ram

ina

syst

empr

evio

usly

unfa

mili

arw

ithth

eap

proa

chan

dsh

owim

prov

edem

ploy

men

tou

tcom

es.

Ant

hony

(200

6)D

escr

iptiv

eSE

(n�

37)

Indi

vidu

als

with

seve

rean

dpe

rsis

tent

men

tal

illne

ssw

hore

ceiv

edSE

serv

ices

but

had

nofo

rens

icin

volv

emen

t(n

�1,

236)

.

No

sign

ific

ant

back

grou

nddi

ffer

ence

sbe

twee

nth

ose

with

rece

ntfo

rens

icin

volv

emen

tan

dth

ose

with

out.

Tho

sew

ithfo

rens

icin

volv

emen

tw

ere

mor

elik

ely

toha

vew

orke

din

the

prev

ious

5ye

ars,

less

likel

yto

have

adi

agno

sis

ofsc

hizo

phre

nia,

and

toha

veha

dsi

gnif

ican

tlyhi

gher

leve

lsof

posi

tive

and

gene

ral

sym

ptom

s.

Inth

isun

publ

ishe

dan

dex

plor

ator

yan

alys

is,

fore

nsic

invo

lvem

ent

was

ano

nsig

nifi

cant

indi

cato

rfo

ral

lem

ploy

men

tou

tcom

esfo

rin

divi

dual

sw

ithse

vere

and

pers

iste

ntm

enta

lill

ness

rece

ivin

gSE

serv

ices

inth

eE

IDP.

The

impl

icat

ion

isth

atSE

may

bean

effe

ctiv

eem

ploy

men

tin

terv

entio

nfo

rth

efo

rens

ical

lyin

volv

edbe

caus

eth

atpo

pula

tion

enjo

yed

the

sam

eem

ploy

men

tga

ins

inth

eE

IDP

asth

ose

with

out

fore

nsic

invo

lvem

ent.

Mar

rron

e(2

005)

Des

crip

tive

Ble

ndof

SEan

dA

CT

(n�

791)

n/a

Hom

eles

sin

divi

dual

sin

Van

couv

er,

Was

hing

ton,

iden

tifie

din

shel

ters

and

attr

ansi

tiona

lho

usin

gsi

tes

with

a“z

ero

reje

ct”

appr

oach

.

The

goal

for

the

5-ye

arpr

ogra

mw

asto

enga

ge25

0cl

ient

s,de

velo

p17

5pe

rson

alca

reer

plan

sor

voca

tiona

lpr

ofile

s,an

dhe

lp75

part

icip

ants

secu

reem

ploy

men

t.A

fter

39m

onth

s,79

1cl

ient

sha

dbe

enen

gage

d,54

3vo

catio

nal

prof

iles

deve

lope

d,an

d12

9pa

rtic

ipan

tsha

dse

cure

dem

ploy

men

t.(t

able

cont

inue

s)


were employed, in education, or volunteering, but the impactdisappeared 6 months after services ended.

Another study found benefits to SE while calling into questionthe necessity of early intervention specialty care (Nuechterlein,Subotnik, Turner, et al., 2008; Nuechterlein, Subotnik, Ventura, etal., 2008). The study examined the effectiveness of integrating SEinto generic community mental health services for patients expe-riencing a first episode. Individuals with a first episode or recentonset of psychosis were randomly assigned to receive SE and agroup-based work skills training, while the controls received re-ferrals to traditional vocational rehabilitation services provided bya number of agencies, group-based communication skills, andmedication management. During the first 6 months of the program,significantly more individuals in the SE group had obtained orreturned to employment or school than in the control group (83%vs. 41%). At the end of the 18-month intervention, at which pointtreatment intensity had faded, 72% of the SE group was employedor in school, compared with 42% of controls. However, this is justone study and because our review did not consider the clinicalbenefits of early intervention, this conclusion should not be inter-preted as evidence against the effectiveness of early intervention.

Evidence for Services to Prevent Job Loss Due toMental Illness

Individuals with mental illness face several challenges in theworkforce that healthy workers may not encounter. For theseemployees, the ability to modify job tasks, work flexible hours,and reduce work-related stress may be essential to maintaininglong-term employment (Nieuwenhuijsen et al., 2008). A variety ofsupports may be put in place to help such workers maintain theircurrent employment and avoid entry into SSA disability benefitprograms. Strategies to implement these supports generally fallinto two categories: (a) individual or worker level interventions inwhich treatments are geared toward helping the individual and (b)employer-level interventions, which are intended to be imple-mented by employers and focus on how the workplace itself can beconstructed to promote mental health and prevent work disability(Krupa, 2007). This section reports on the literature pertaining tosuch interventions (see Table 5).

A federal demonstration did not improve the earnings ofworkers with mental illness but did reduce the incidence ofSSA disability benefit receipt. The CMS Demonstration toMaintain Independence and Employment (DMIE) was establishedto determine whether health-related early intervention strategiesimplemented by states could delay or prevent reliance on disabilitybenefits and reduce job loss for working adults with disabilities.These RCT demonstrations enrolled adults aged 18 to 62 whoworked at least part-time and were not receiving SSI or SSDIbenefits. The DMIE was implemented in four states, two of whichfocused on individuals with mental illness. In Minnesota, 888intervention participants received care coordination, job place-ment, intensive employment-needs assessment and other employ-ment services. In Texas, the intervention participants receivedenhanced mental health services, substance-abuse assessment andreferral services, and enhanced medical services. Employment andearnings outcomes did not significantly differ between the inter-vention and control groups, with few exceptions. In Minnesota,low-functioning control group members reported a decrease inT

able

6(c

onti

nued

)

Stud

yau

thor

Stud

yde

sign

Serv

ice

type

(sam

ple

size

)C

ompa

riso

n(s

ampl

esi

ze)

Not

able

sam

ple

char

acte

rist

ics

Res

ults

Tw

amle

yet

al.

(201

3)D

escr

iptiv

eSE

(n�

1,69

4)V

eter

ans

with

men

tal

illne

ssor

TB

Iw

hore

ceiv

edno

-SE

voca

tiona

lse

rvic

es(n

�4,

651)

Vet

eran

sof

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ratio

nsIr

aqi

Free

dom

and

End

urin

gFr

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mw

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depr

essi

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I.

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san

alys

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two

larg

eV

Aad

min

istr

ativ

eda

tase

tsfo

und

that

SEha

sa

stat

istic

ally

sign

ific

ant

effe

cton

empl

oym

ent

outc

omes

inco

mpa

riso

nto

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rvo

catio

nal

inte

rven

tions

for

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popu

latio

n.

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ew;

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income, suggesting that the intervention may have ameliorated adecline among low-functioning participants. In Texas, interventiongroup members who were more engaged with the program weresignificantly less likely to receive SSDI benefits than participantswho were less engaged (Bohman et al., 2011; Linkins et al., 2011).The pooled analysis of Minnesota and Texas intervention partici-pants showed some evidence that the medical services DMIEprovided decreased the adverse effect of mental illness on earningsfor highly engaged, low functioning individuals. Members of theintervention group were significantly less likely than those in thecontrol group to be receiving SSI 1 year after DMIE enrollment(1.8% vs. 3.2%), but no significant difference in annual earningswas found between the groups (Whalen, Gimm, Ireys, Gilman, &Croake, 2012).

Studies of individual-level clinical interventions for workerswith depression show limited evidence of improving employ-ment outcomes. Nieuwenhuijsen et al. (2008) conducted a sys-tematic review of 11 RCTs to improve occupational health inworkers with depression. The only intervention found to havepositive effects on work absence due to sickness was psychody-namic therapy in combination with tricyclic antidepressant medi-cation when compared to medication alone.

We identified two RCTs of telephonic programs to improvemental health and work outcomes in employees with depression(see Table 5). The first RCT enrolled 604 workers with clinicaldepression at several large companies served by a managed careorganization in a telephonic outreach and care management pro-gram that encouraged them to enter outpatient therapy or useantidepressant medication. Participants reluctant to enter treatmentwere offered structured telephone cognitive–behavioral psycho-therapy. Combining data across 6- and 12-month assessments,participants had significantly lower depression severity, signifi-cantly higher job retention, and significantly more hours workedthan usual care subjects (Wang et al., 2007). In the second RCT, 86Maine state government employees who screened positive formajor depression and at-work limitations were enrolled in a brieftelephonic program to improve work functioning. Treatment wasoffered during 1-hour visits every 2 weeks and consisted of workcoaching and modification, care coordination with primary carephysicians or other prescribing professionals, and cognitive–behavioral therapy strategies. Intervention participant scores onhealth problems, work absence measures, and a depression sever-ity measure were all significantly improved, and the magnitude ofthe improvement on all outcomes was significantly greater than thecontrol subjects (Lerner et al., 2012).

Two studies arrived at differing conclusions about the effect ofdepression treatment on health and occupational outcomes. In onestudy (Rost, Smith, & Dickinson, 2004), participants who screenedpositive for major depression received high-quality depressioncare from their primary care physicians. The intervention groupreported greater work productivity and less absenteeism. However,the treatment did not significantly impact depression severity oremotional role functioning. Conversely, the second study (Adler etal., 2006) found that employees undergoing treatment for depres-sion had worse job performance scores than healthy employeeseven after demonstrating clinical improvements in symptom se-verity. We also identified two retrospective observational studiesthat investigated the relationship between guideline-recommendedantidepressant use and short-term disability absences. Both studies

found that adherence to antidepressant treatment criteria was sig-nificantly associated with reduced frequency and length of disabil-ity absences, although neither study provided information abouteffects on job loss (Burton et al., 2007; Dewa, Hoch, Lin, Paterson,& Goering, 2003).

Evidence that interventions directed at the entire employeepool are effective for workers with mental illness is limited.Employer-level interventions often take the form of untargetedinterventions, in which organizational changes are directed at theentire employee pool. These interventions typically focus on pro-viding a supportive work environment, engaging in stress-reduction activities, and offering employees the opportunity tofully engage in the workplace (Lauber & Bowen, 2010). In aFinnish RCT (Vuori, Toppinen-Tanner, & Mutanen, 2012) thatfocused on company-wide training programs in which individualsvolunteered to participate, the intervention group received a1-week group training workshop on enhancing career-managementskills. The control group received a literature package on basiccareer management information. At the 7-month follow-up, theintervention group displayed significantly decreased depressivesymptoms and intentions to retire compared with the controlgroup.

Evidence for Individuals Who Are or Are Expected toBe Long-Term Clients of Mental Health Services andAre Likely to Apply or Are in the Process of Applyingfor Disability Cash Benefits

We also reviewed the literature on services for people who arenow or who are expected to be long-term clients of mental healthservices who may be at risk of long-term unemployment anddisability (see Table 6). We considered research on specific sub-populations who may not currently receive SSA disability benefitsbut may do so in the future, including people who are homeless,military veterans, TANF recipients, and exoffenders with mentalillness. We also considered research on new SSA disability ben-eficiaries for whom employment interventions might be particu-larly effective in preventing long-term disability.

Vocational and other support services provided along withhealth insurance may improve short-term employment out-comes for new SSDI beneficiaries with mental illness; provid-ing health insurance alone had no impact. The AcceleratedBenefits (AB) demonstration project, funded by SSA, tested theeffects of providing Medicare to new SSDI beneficiaries withouthaving to wait the required 24 months before becoming eligible.Demonstration participants were randomly assigned into an ABgroup who received health insurance (N � 400); an AB Plus groupwho received health insurance plus case management, employmentand benefits counseling services, and other services (N � 611); ora control group (N � 983). The AB Plus group participated inemployment or vocational rehabilitation services at a significantlygreater rate (p � .005) at 1 and 2 years after random assignmentthan either the AB group or the control group. Providing healthinsurance alone (AB group) had no impact but, relative to thecontrol group, the AB Plus program led to nearly a 50% increasein employment and an $831 increase in annual earnings in thesecond calendar year following enrollment. Among AB Plus mem-bers who had any earnings (16%), average annual earnings were$10,187 during this period, about $2,300 more than the control


group (a meaningful, but not statistically significant difference).The significant effects observed for the full AB Plus group weresmaller and no longer statistically significant in Year 3, either dueto SSA work disincentives, the end of program services, or wors-ening of beneficiaries’ health conditions (Michalopoulos et al.,2011; Weathers & Bailey, 2014). Findings for the 22% of the studysample with mental illness mirrored these patterns.

Limited evidence suggests that providing SE along withhousing supports may improve employment outcomes for peo-ple with mental illness who are homeless. We identified threepromising approaches that assist people with mental illness whoare homeless to find employment. The most rigorously evaluatedof these, Los Angeles’ HOPE, provided SE, supportive housing,and direct payment for such items as vocational classes, workclothing, and equipment to people with mental illness who wereformerly homeless. Los Angeles County designated three of its 18programs for supportive services and housing assistance as LosAngeles HOPE sites. The overall employment rate for Los Ange-les’s HOPE clients was more than double that of the comparisongroup who received housing services at other sites (57% vs. 22%),as was the competitive employment rate (27% vs. 13%; Burt,2012). The other two approaches have not been rigorously evalu-ated but suggest similar results (Gao, Waynor, & O’Donnell, 2009;Marrone, Foley, & Selleck, 2005).

Limited evidence suggests that SE may be effective forveterans with mental illness. A systematic review suggestslimited knowledge of how to reintegrate veterans with mentalillness into a new workplace after an absence of more than a year(Van Til et al., 2013). The review concluded that although SE hasthe strongest evidence base for facilitating workplace reintegrationfor individuals with mental illness, the literature dealing withreintegration, especially for veterans, is sparse. Of the 97 studies ofprograms for people with mental illness reviewed, 10 were studiesof veterans.

The most promising study included in the review was a RTCfocused on veterans with posttraumatic stress disorder (PTSD;Davis et al., 2012). Eighty-five veterans with PTSD were ran-domly assigned to receive either SE or the standard vocationalrehabilitation program provided through the U.S. Department ofVeterans Affairs (VA), which provided work therapy throughset-aside temporary jobs. Veterans in the SE group were signifi-cantly more likely to gain competitive employment, be competi-tively employed more quickly, work in a competitive job moreweeks, and earn higher wages.

A study of the IPS model of SE for homeless veterans withpsychiatric or addiction disorders, not covered in the systematicreview, showed similar results (Rosenheck & Mares, 2007). Theintervention tested a low-intensity teleconference training ap-proach to implementing SE at nine VA programs. Veterans whoreceived IPS engaged in significantly more days of competitiveemployment, higher levels of competitive employment, and earnedhigher wages than the control group over the 2-year follow-upperiod.

A recent analysis of VA administrative data also supports SE’seffectiveness as an intervention for veterans with PTSD, substanceuse disorder, depression, or traumatic brain injury sequelae.Twamley et al. (2013) analyzed two national VA databases ofveterans with mental health conditions from Operation Iraqi Free-dom and Operation Enduring Freedom. They found that whereas

only 2.2% of the veterans in the sample received SE, 51% of thosewho did found competitive employment as compared to 21% ofveterans in the sample who did not receive SE but received someother form of vocational services, such as transitional work expe-rience, incentive therapy, or general vocational services. The com-parative effect on number of days worked and days of enrollmentin vocational services was similarly large and significant (p �.001).

We found no studies examining the effectiveness of employ-ment interventions for exoffenders and TANF recipients.Individuals with mental illness are overrepresented in the criminaljustice system (Schnittker, Massoglia, & Uggen, 2012), and havinga criminal record presents additional challenges for finding em-ployment upon release from jail or prison. Without supports to aidin overcoming these challenges, exoffenders with mental illnessmay seek SSI or SSDI as a source of income support and a routeto health insurance. Promising efforts are demonstrating the effec-tiveness of cooperation between the criminal justice and mentalhealth systems to provide services to individuals with mentalillness upon their release (Osher, D’Amora, Plotkin, Jarrett, &Eggleston, 2012). Consistent with the findings of Anthony (2006)and Osher and Steadman (2007), however, we were not able toidentify any published studies regarding the effectiveness of em-ployment supports for this population. Our search also retrieved noarticles meeting our criteria regarding effective interventions forTANF recipients with mental illnesses.

Discussion

Policymakers are increasingly interested in services aimed atpreventing long-term unemployment and disability for people ex-periencing a first episode of psychosis; workers at risk of job loss;and those who are, or are at risk of becoming, long-term users ofmental health services who are newly or not yet enrolled in SSAdisability programs. We identified interventions that support em-ployment for individuals in these groups. Although one of the moststudied interventions, SE (particularly the standardized IPSmodel), appears to be effective in helping individuals who vary incharacteristics such as age, gender, diagnosis or education levelachieve higher rates of competitive employment than those incontrol groups who have the same characteristics, Kinoshita et al.(2013) point out that study sizes are relatively small and data maybe skewed due to high attrition rates. Furthermore, evidence on SEhas mixed success at improving job retention and earnings. Muchof the research on SE has focused on adults with mental illnesswho are already eligible for disability benefits. For these individ-uals, SE typically has not raised earnings enough to facilitate exitfrom disability rolls, even among those who have achieved em-ployment. More evidence is needed on the effectiveness of SE forindividuals who have not joined the disability rolls.

Some early intervention programs for people in the early stagesof psychosis provide services that include an SE component. Thegoal is to help prevent full-blown mental illness and long-terminvolvement with the mental health and disability systems. Evi-dence for the efficacy of these programs in improving employmentand work disability outcomes is limited but positive, and work inthis field continues to be an important priority for researchers andpolicymakers. More research is needed, particularly to demon-strate medium- and long-term outcomes. Similarly, the occupa-


tional outcomes of interventions for workers with mental illnessesat risk of job loss are not well established. Few high quality studieshave evaluated interventions that help workers who acquire amental illness remain at work. Effective interventions for individ-uals with depression and other mental health conditions who arestill working are critical because they may reduce the need forentrance onto the disability rolls.

Several strategies have been used to improve employment out-comes for individuals who are now or who are expected to belong-term clients of traditional mental health services and may belikely to apply for disability benefits in the future. Althoughidentifying this group before they become attached to disabilitybenefits is difficult, the population is of interest to policymakersbecause after they begin receiving benefits, the likelihood of theirreturning to work is minimal. SSA’s AB demonstration showedthat providing vocational and other support services along withhealth insurance may lead to improved short-term employmentoutcomes for new SSDI beneficiaries with mental health impair-ments. In addition, a growing body of evidence suggests that SEmay improve employment outcomes for veterans with mentalillness. More research is needed to establish a strong evidence basefor the effectiveness of these services, as well as for services toother distinct target groups, such as exoffenders and TANF recip-ients. Although the cost of providing employment supports mayexceed the average earnings gained (Michalopoulos et al., 2011),the benefits of preventing long-term disability may accumulate tosubstantially exceed program costs. This is the promise of preven-tive interventions, although more research is needed to test thishypothesis.

States can develop comprehensive approaches for funding em-ployment programs by creatively combining federal sources, suchas Medicaid and SAMHSA’s Community Mental Health ServicesBlock Grant. For example, although in fiscal years 2014 through2015, SAMHSA required that states set aside five percent of theirblock grant allocation for early intervention (CMS, 2015), blockgrant funding can be used to support elements of such programsnot covered by insurance even without the set-aside. State Med-icaid programs can reimburse employment services and supportsand early intervention through a variety of optional benefit cate-gories authorized under Section 1905(a), including targeted casemanagement, preventive, rehabilitative, and other licensed practi-tioner services, as well as through the mandatory early and peri-odic screening, diagnosis, and treatment program (CMS, 2015;O’Day et al., 2014). SE and other employment supports are notthemselves mandatory or optional Medicaid services, but statesmay cover most of their components under 1915(c) and 1915(i)Home and Community Based Services (HCBS) authority (CMS,2011; Siegwarth & Blyler, 2014).

The ACA can also serve as a means to expand current paymentoptions for SE and other employment supports. This important lawcontains several provisions that may improve the health and em-ployment potential of individuals with mental illness and lessenthe degree to which lack of health care coverage may incentivizepeople to seek public health and disability benefits. These provi-sions include the Medicaid expansion and the introduction of thestate-based health insurance exchanges, the establishment of men-tal health and substance use disorder services as “essential healthbenefits,” coverage up to age 26 on a parent’s plan, and theestablishment of health homes for individuals with chronic illness.

Because these provisions have the potential to expand access tocoverage, the ACA is a significant step toward breaking the linkbetween SSA disability enrollment and availability of affordablehealth insurance. Further, the ACA may support workers, newSSDI beneficiaries, and others with mental illness who may be atrisk of long-term disability by expanding availability of vocationaland other support services along with health insurance, leading toimproved short-term employment outcomes and, perhaps, lessdependence on disability benefits in the future.

Despite these improvements, funding availability for early in-tervention and SE for people with mental illness is imperfect.States have cobbled together funding from various Medicaid pro-visions, their own state vocational rehabilitation agencies, the SSATicket to Work program and Plans for Achieving Self Support,American Job Centers funded by the U.S. Department of Labor,and grants from federal agencies and other sources. Yet, the mostcommon funding sources have stringent eligibility requirementsand many people find accessing early intervention, SE, and otheremployment services difficult or impossible. Medicaid-funded SEservices, for example, typically require individuals to have chronicserious mental illness plus meet their state’s financial eligibilityrules, which excludes those who have experienced a first episode(Karakus, Frey, Goldman, Fields, & Drake, 2011).

In conclusion, our literature review found that the IPS model ofSE provides the strongest evidence for helping people with seriousmental illness find work. Yet, the employment and earnings out-comes of SE participants may still fall short of individual andpolicy goals. More research is needed on long-term effects onemployment and receipt of disability benefits, as well as on modelsfor preventing unemployment and disability among those withnewly emerging mental illnesses, workers, and those with or at riskfor long-term mental illness who are at risk of applying fordisability benefits. Employment consistently declines as early asthree years before SSDI receipt (Honeycutt et al., 2014). Interven-tions targeting individuals during this downward employment pathare worthy of further study. Medicaid expansion and other provi-sions of the ACA provide new avenues for supporting the employ-ment goals of Americans with mental illnesses and, thereby, mayassist in reducing dependence on disability benefits, which toooften results in a lifetime of poverty.

Limitations

This review has several limitations. First, we did not evaluateeach study’s methodology, particularly when relying on studiesreported in other systematic literature reviews. Neither did we usean instrument (such as the Cochrane AMSTAR tool) to determinethe quality of systematic reviews used in this study. We includedstudies even if possible threats to internal validity existed, includ-ing high attrition or lack of attrition data, and in some cases, lackof a comparison group or data demonstrating group equivalence.We prioritized RCTs and quasi-experimental designs to mitigatethese threats, and did not include studies with very small sizes(N � 40). Similarly, we did not assess threats to external validity.Several of the studies we reviewed were conducted abroad, wherethe health systems, insurance systems, and institutionalization ofearly intervention or other practices may differ from those in theU.S., potentially producing results that are less generalizable to theU.S. Nor did we consider the representativeness of U.S.-based


samples. In addition, we combined evidence across studies toformulate overall conclusions about efficacy, despite differences ingroup characteristics and a lack of consistency in outcome mea-sures, intervention durations, and assessment periods. Reportingguidelines to standardize these approaches would greatly improvefuture research and society’s ability to draw conclusions aboutefficacy.

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Received February 8, 2016Revision received January 3, 2017

Accepted January 3, 2017 �


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