Niall Turner Supported employment in early intervention for psychosis services.
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Transcript of Niall Turner Supported employment in early intervention for psychosis services.
Niall Turner
Supported employment in early intervention for psychosis
services
Overview• Conditions that feature psychosis• Typical employment outcomes• Early intervention• The IPS model• The DETECT Service• Trial of supported employment in
the DETECT service
Conditions that feature psychosis
……can be a sub feature of the clinical
presentation such as major depression,
bipolar affective disorder or the main
feature of the condition such as with
schizophrenia, drug induced psychosisLifetime prevalence = 3% population = circa 120,000 in ROI
Current numbers unemployed
• International
– 95% Burns et al
2007
– 80 – 90% Marwaha
and Johnson 2004
– 85% Crowther et al
2001
• Ireland
– 73% Behan et al.
2008 (based on 2006
data)
Recovery
6
…know about employment outcome?
…their conclusions….
• Outcome poor but reviewing data difficult due to
lack of detail
• Rates decline over time
• Outcome influenced by local environment:
welfare system and availability of Evidence Based
Interventions
• Disruption starts prior to treatment commencing
• Many negative consequences of lack of paid
employment
“Serious mental illness affects approximately 2%
of the world’s population. It results in
persons having much difficulty in
fulfilling the role which they may have
set for themselves in life. Those
individuals no longer live in institutions for long
periods of time; the vast majority are in the
community where they often receive inadequate
follow-up.
Even though more than 70% of these
people would like to work, only 10-
12% do in fact work, all too often in jobs
that do not correspond to their liking and
capacities. In contrast, the employment rate of
other forms of disability is in the vicinity of 50%”
p.57
….page 58….“Treatment programmes should include the capacity for correct diagnosis, remembering that
often mental illness “hides behind physical signs and symptoms”. Quick access to and
intervention by competent medical and professional staff will be
called for. Integral to quick access and early intervention of appropriate medical
treatment for individuals is reducing the stigma and shame associated with mental health
problems. As discussed, often an individual will not seek treatment or will delay seeking it
because of the stigma associated with mental illness. Furthermore, there is a need for
more easily accessible mental health treatment programmes.
Rehabilitation programmes will emphasize the requirements for a prompt return
to work by focusing on necessary accommodations to the work situation, as well as
required support to the individual”
Timeline – Early Psychosis
Deterioration in Health and Functioning
Receipt of effective Treatment
End of Critical Period3 – 5 years
DELAYS
Length of Delays
0
0.5
1
1.5
2
2.5
years
DUP
Research on impact of delaysLong Delay WorseShort Delay Worse
First contact
6 months
12 months
24 months
Delay and Occupational Disruption
• shorter delays = more likely to still be involved in employment or non labour force work (Turner et al, 2009)
• At 3 yr follow-up length of delay was a predictor of productive vocational activity (Norman et al, 2007)
Development of Early Psychosis Programs
EPPIC
EI Paradigm
Early detection
Aggressive
treatment in critical
period
Improved Outcome
Is earlier detection possible?
Mc Gorry et al, 1996; Melle et al, 2004 & 2008; Malla et al, 2006; Chong et al, 2005.
29 months to 6 months
18 months to 11 months
16 months to 8 months
12 months to 4 months
Interventions with evidence base
• Medication• Cognitive behavioural therapy• Cognitive remediation• Family education• Supported employment (SE)
– Individual Placement and Support Model (IPS)
IPS
• Employment specialists part of clinical service
• Rapid return to employment• Ongoing support• RCTs - 11 reviewed by Bond, Drake & Becker
(2008)– Competitive employment 61% IPS vs. 23%
control– 66% attained employment of 20hrs plus per
week– Time to competitive employment 50% shorter
for IPS (138 days vs. 206 days)
RCT’s of IPS in Early Intervention
Nuechterlei
n et al (2008)
80% vs. 40% in
education/employment
Killackey et al (2008)IPS group
significantly better on level
of employment, hours worked per week, jobs acquired and
longevity
Killackey et al (2012)
Conducted an analysis on
predictors of vocational recovery –
only independent
predictor was treatment
group. Participants in
treatment group were 16.26 times
more likely to obtain
work/study
Killackey et al (2013)
larger RCT of IPS which showed greater
numbers engaged in paid work, education
and competitive employment however only comp employ statistically significant
Some caveats• Largest RCT is from EPPIC service• “original” Early Intervention Service• Stand alone• Entire care• Attached to a large academic programme
However• Other naturalistic studies also showing >66% of
FEP population returning to work/education when IPS present
International
Movement
iFEVR
End of Part I
An Irish Early Intervention Service
DUBLIN FIRST EPISODE PSYCHOSIS STUDY
• 8.5 WTE Team Members
• Pop. – 385,000
Reducing Delays• Community Mental
Health Team – OPD, medication,
acute episode care
• DETECT– ….group CBT– ….one-to-one
occupational therapy
– ….group carer education course
Pre20
0620
0720
0820
0920
1020
110
1
2
3
4
5
6
7 Me-dian...
Treatment
Additionally since 2010…..
A clinical trial of supported employment and workplace
fundamentals for people with first episode psychotic disorders
Principles of IPS1. Every person who wants to work is eligible2. Employment services are integrated with mental
health services3. Competitive employment is the goal4. Benefits counselling is provided5. Job search happens soon after interest is
expressed 6. Employment specialist systemically develop
relationship with employers7. Job supports are continuous 8. Client preferences are honoured
Workplace Fundamentals Module
• Rationale: Even with SE maintaining jobs remains problematic
• Aim of WFM: Reduce job terminations/breakdown
• Method: Training module to augment SE.
“Evening course” in employment skills
Manual & training materials developed by UCLA Psychosocial Rehabilitation Center (Liberman and Wallace, 2000)
Skills for maintaining employment are best taught when person in employment
Why offer WFM?• Previous research found declining
rates over time• If delays reduced likely to be
significant numbers still in education/work
• Preventative approach• Address an unmet need• Address a gap in the current
knowledge base
Research QuestionsPrimary
• Does augmenting an early intervention service with IPS and WFM improve work outcomes?
Secondary
• What relationship, if any, does employment outcome have with quality of life, recovery, social inclusion and remission?
Methodology I
Control Group
• Recipients of DETECT service 02/2005 – 07/2009
Experimental Group• Recipients of
DETECT Service 08/2009 – 12/2012
• Supported employment specialist joined team 06/2010
Comparison• 1 year follow up
conducted as part of DETECT service evaluation
• Includes measure of time in employment, last worked, QoL, recovery and mental health
Methodology II
Baseline• Assessment of occupational history and
Social Inclusion
Follow-up
• Repeat above• Merge with measures conducted at
DETECT baseline and 1 year follow up• Statistical analysis
Recruitment
DETECT ASSESSMENT
Unemployed
IPS
WFM
Employed
WFM
Recruitment
OccupationalStatus
OfferInterventions
Follow up
Once specifically for this research project
Once at one year for the DETECT service evaluation
Progress (to April 2012)IPS
• 44 people offered IPS
• 42 attended initial assessment
• 34 (81%) progressed to education/employment/training
WFM
• 70 people offered WFM
• 22 agreed to attend• 12 completed• 11 were still employed
in December 2012
Challenges• Recession• Traditional concerns re people with schizophrenia
returning to work– Clinicians– Family
• Perceived need amongst target group• State financial assistance
– Old habits die hard!
• Current policy – who’s responsibility is it to provide this population with assistance to return to work
• Expertise
Tentative Conclusions• IPS model in early intervention services has the
potential to change course of employment outcome
for majority of people affected by psychosis
• Need to consider offering assistance for those who
never lose their work role at their first episode
• There remains significant challenges to the
widespread implementation of SE for people with
psychotic conditions in Ireland
Thank You