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Niall Turner

Supported employment in early intervention for psychosis services. Niall Turner. Overview. Conditions that feature psychosis Typical employment outcomes Early intervention The IPS model The DETECT Service Trial of supported employment in the DETECT service.

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Niall Turner

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  1. Supported employment in early intervention for psychosis services Niall Turner

  2. Overview Conditions that feature psychosis Typical employment outcomes Early intervention The IPS model The DETECT Service Trial of supported employment in the DETECT service

  3. Conditions that feature psychosis Lifetime prevalence = 3% population = circa 120,000 in ROI ……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 psychosis

  4. 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)

  5. Recovery

  6. …know about employment outcome?

  7. …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

  8. “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

  9. ….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”

  10. Timeline – Early Psychosis DELAYS End of Critical Period 3 – 5 years

  11. Length of Delays

  12. Research on impact of delays Short Delay Worse Long Delay Worse First contact 6 months 12 months 24 months

  13. 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)

  14. Development of Early Psychosis Programs EPPIC

  15. EI Paradigm

  16. Is earlier detection possible? McGorry et al, 1996; Melle et al, 2004 & 2008; Malla et al, 2006; Chong et al, 2005.

  17. Interventions with evidence base • Medication • Cognitive behavioural therapy • Cognitive remediation • Family education • Supported employment (SE) • Individual Placement and Support Model (IPS)

  18. 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)

  19. RCT’s of IPS in Early Intervention

  20. 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

  21. International MovementiFEVR

  22. End of Part I

  23. An Irish Early Intervention Service DUBLIN FIRST EPISODE PSYCHOSIS STUDY

  24. 8.5 WTE Team Members • Pop. – 385,000

  25. Treatment Reducing Delays • Community Mental Health Team • OPD, medication, acute episode care • DETECT • ….group CBT • ….one-to-one occupational therapy • ….group carer education course

  26. Additionally since 2010…..

  27. A clinical trial of supported employment and workplace fundamentals for people with first episode psychotic disorders

  28. Principles of IPS Every person who wants to work is eligible Employment services are integrated with mental health services Competitive employment is the goal Benefits counselling is provided Job search happens soon after interest is expressed Employment specialist systemically develop relationship with employers Job supports are continuous Client preferences are honoured

  29. 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 Workplace Fundamentals Module

  30. 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

  31. Research Questions Primary Secondary What relationship, if any, does employment outcome have with quality of life, recovery, social inclusion and remission? • Does augmenting an early intervention service with IPS and WFM improve work outcomes?

  32. Methodology I

  33. Methodology II

  34. Recruitment Once specifically for this research project Once at one year for the DETECT service evaluation

  35. Progress (to April 2012) IPS WFM 70 people offered WFM 22 agreed to attend 12 completed 11 were still employed in December 2012 • 44 people offered IPS • 42 attended initial assessment • 34 (81%) progressed to education/employment/training

  36. 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

  37. 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

  38. Thank You

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