In the spotlight

Employment Supports Show Long-term Benefit for Employees with Mental Disorders

By April Banerjee, PWDF Program Manager for Public Awareness and Education

Being employed not only provides income, it is also an important part of mental health recovery in and of itself.  Studies have shown supported employment to be an effective model for people with severe mental illness (SMI) to return to work.  Within the last year, the American Journal of Psychiatry published results from two controlled trials of supported employment, both of which showed a substantial increase in employment.[1]  The first of the two studies reported that 60.3% of participants with employment supports returned to paid employment as compared with 40.2% in the control group over a 2-year period.  The second study demonstrated similar results and showed that supported employment can be successful over a longer period.  In addition to higher levels of employment, both studies found that the groups who received employment support interventions reported mental health benefits, including fewer psychiatric hospitalizations, than the control group.  Unfortunately, lack of financing is a major barrier to obtaining supported employment services for people with mental illnesses even though preliminary analyses indicate that supported employment is more cost-effective than traditional vocational rehabilitation.

SSDI Study

The SSDI study enrolled 2,238 beneficiaries of the Social Security Disability Insurance (SSDI) program with a primary diagnosis of schizophrenia or a mood disorder (bipolar or major depression).  Participants were divided into two groups: the “intervention” group and the control group.  The intervention group received supported employment according to the IPS model, systematic medication management, and other behavioral health services for the 2-year study period.  The program also removed “obvious barriers” to employment for the intervention group:  SSA provided complete health insurance coverage and suspended continuing disability reviews for 3 years, “because these reviews may deter efforts to return to work.”[8]  The study showed significantly higher rates of both paid employment (i.e., any type of earnings) and competitive employment for the intervention group as compared with the control group.  The intervention group had a paid employment rate of 60.3% versus 40.2% for the control group and a competitive employment rate of 52.4% versus a 33.0% rate for the control group.   The intervention group also had better outcomes for length of employment.   The study defined competitive employment as “mainstream jobs in integrated work settings at usual wages with regular supervision.”

Long-term Swiss Study

The long-term study followed 100 participants (total number for intervention plus control group) for a 5-year period.  Participants had ICD-10 psychiatric diagnoses combined with persistent impairment in one of several areas; the majority of participants had a schizophrenia spectrum disorder and/or an affective disorder (mood disorder).  The intervention group received job coaching through the IPS model; this included assistance by an employment specialist (a “job coach”) in finding and maintaining competitive employment.  The job coaches had contact with participants at least once every 2 weeks and monthly with work supervisors.  Employers of participants in the intervention group received some incentives.  (The study does not indicate what these incentives were.)  The control group received traditional vocational rehabilitation.  It defined competitive employment as holding a job paying at least minimum wage for at least 2 weeks on the open labor market.

Intervention group participants maintained higher levels of competitive employment for a longer period.  Approximately twice as many intervention group participants obtained competitive employment over the 5-year period as the control group (65.2% vs. 33.3%).  Intervention group participants who obtained competitive employment had higher rates of sustaining employment to the end of the 5‑year period.  Interestingly, the average percentage of intervention group participants who were competitively employed remained relatively stable from the 2-year follow-up to the 5-year follow-up even though the percentage who received employment supports decreased during that period.  The authors of the study concluded that “the findings suggest that . . . . sustained employment with vocational supports enabled many participants to eventually work independently.”[9]  The study found that the “superiority of supported employment over traditional vocational rehabilitation programs becomes even stronger over time” and that it is consistent with the principle of providing support as long as it is needed.[10]

Both studies noted the impact of motivated employees.  The SSDI study noted that the findings may be specific to beneficiaries who are highly motivated to work.  The long-term study by design only included motivated employees in both the intervention and the control groups.

Reduction in Use of Mental Health Services if Working

Both the SSDI and the long-term study also documented mental health benefits of the respective employment support program. The SSDI study showed that the intervention group had a small, but consistent pattern of lower use of health and mental health services.  I.e., the supported employment group reported fewer days in the hospital, fewer psychiatric emergency visits, etc., and other measures of health services.  The exception was an increase in routine outpatient clinic or mental health provider visits, which the authors presumed was a direct result of participating in the program.  The authors concluded that the results indicated that the intervention program shifted participants away from “episodic, crisis-oriented services and toward ongoing management of their disorders on an outpatient basis.”[11]

The long-term study showed similar results: participants with supported employment reported significantly fewer psychiatric hospital admissions and fewer days in the hospital than those who received traditional vocational rehabilitation. The authors noted that the lower levels of psychiatric treatment were significant over the 5-year period, but the difference had not been significant at the 2-year follow-up and posited that the longer follow-up period enabled the “cumulative benefits of competitive work on reducing vulnerability to relapse and hospitalization” to become apparent.[12]

Economic Analyses

Both studies included some type of economic analysis of their respective programs.  The SSDI study evaluated whether intervention group participants were able to work enough to be “graduated” from the SSDI program, resulting in monetary savings to the Social Security Trust Fund.  It found that intervention group earnings were not high enough to meet the criteria that would terminate participants from the SSDI program because of part-time work patterns and modest earnings.  The study’s authors noted that fear of losing benefits might have been a deterrent to participation in the study and that it was unknown whether SSDI beneficiaries would work at higher levels if health insurance were completely separated from disability status.

The long-term study performed a social return on investment cost-benefit analysis, which compares “the value of the social benefits created . . .  to the relative cost of achieving those benefits,”[13] over the 5-year period.  While the supported employment model cost slightly more to implement, the mental health treatment costs per participant were lower.  Overall it was more cost-effective than traditional vocational rehabilitation due to higher participant earnings and decreased mental health care services costs.  The study’s authors recommended that future research be done on the impact of supported employment on mental health services and costs.

According to a 2011 study commissioned by the US Health and Human Services (HHS), the IPS model has been shown to be cost-effective compared with other vocational programs.[14]

Funding for Employment Supports

The 2011 HHS study identified lack of financing as the main barrier to obtaining supported employment services for people with mental illnesses and examined federal financing mechanisms for employment supports.  It identified a variety of methods that several states are using to fund supported employment, including state general funds, vocational rehabilitation funds, mental health block grants, and Medicaid funds (rehabilitation option and/or through waivers).[15]  The study found that coordination among state agencies for mental health, vocational rehabilitation, and Medicaid is crucial in developing a successful plan for supported employment.  In general, federal funding mechanisms that could support these services were found not to result in available services because the vocational rehabilitation funds were not viable at the state and local level.

More recently, provisions of the Affordable Care Act may increase funding options for employment supports for people with mental illness.[16]

Conclusion

Supported employment of persons with mental disorders is a proven method of increasing employment among this population and studies indicate that it appears to have significant mental health benefits.  The largest barrier to increasing the availability of supported employment is lack of funding, in spite of the fact that preliminary economic analyses suggest that it may be more cost-effective than traditional vocational rehabilitation services and may reduce mental health care costs.  Funding to state vocational rehabilitation counselors, including job coaches and independent living skills trainers, in particular is a barrier.  PWDF urges policymakers to consider solutions to increase availability of supported employment for people with mental and/or developmental disabilities and enact changes to funding mechanisms that will enable more people to benefit from supported employment.

PWDF Profile

Who We Are

People With Disabilities Foundation is an operating 501(c)(3) nonprofit organization based in San Francisco, California, which focuses on the rights of the mentally and developmentally disabled.

Services

Advocacy: PWDF advocates for Social Security claimant’s disability benefits in eight Bay Area counties. We also provide services in disability rights, on issues regarding returning to work, and in ADA consultations, including areas of employment, health care, and education, among others. There is representation before all levels of federal court and Administrative Law Judges. No one is declined due to their inability to pay, and we offer a sliding scale for attorney’s fees.

Education/Public Awareness: To help eliminate the stigma against people with mental disabilities in society, PWDF’s educational program organizes workshops and public seminars, provides guest speakers with backgrounds in mental health, and produces educational materials such as videos.

Continuing Education Provider: State Bar of California MCLE, California Board of Behavioral Sciences Continuing Education, and Commission of Rehabilitation Counselor Certification.