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
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)
126 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
127PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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)
128 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
129PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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.
130 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
131PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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.
132 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
133PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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.
134 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
135PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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
)
136 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
137PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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.
138 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
139PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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%
).
140 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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).
The
eval
uatio
nof
the
DM
IEpr
ogra
mas
aw
hole
foun
dno
sign
ific
ant
diff
eren
ces
betw
een
the
perc
ent
oftr
eatm
ent
grou
ppa
rtic
ipan
tsan
dco
ntro
lgr
oup
part
icip
ants
not
empl
oyed
byth
een
dof
the
stud
ype
riod
(whi
chw
asei
ther
12or
24m
onth
s,de
pend
ing
onth
est
ate)
.T
heco
mbi
natio
nof
Min
neso
taan
dT
exas
part
icip
ants
saw
anin
sign
ific
ant
incr
ease
inem
ploy
men
tof
.2pe
rcen
t.T
heau
thor
sno
teth
atth
eon
lyst
ates
tosh
owst
atis
tical
lysi
gnif
ican
tre
duct
ions
inde
pend
ence
onSS
Abe
nefi
tsfo
cuse
dth
eir
inte
rven
tions
ona
popu
latio
nw
ithbe
havi
oral
heal
thpr
oble
ms.
Vuo
riet
al.
(201
2)R
CT
The
stud
yex
amin
edin
-com
pany
trai
ning
prog
ram
for
empl
oyee
sof
17or
gani
zatio
nsw
ithth
ego
alof
enha
ncin
gca
reer
man
agem
ent,
men
tal
heal
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%).
At
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)
141PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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
onti
nued
)
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
Dew
aet
al.
(200
3)O
ST
his
was
are
tros
pect
ive
obse
rvat
iona
lco
hort
stud
yof
1,28
1em
ploy
ees
atth
ree
maj
orC
anad
ian
fina
ncia
lan
din
sura
nce
com
pani
es.
The
stud
yex
amin
edad
here
nce
totr
eatm
ent
prot
ocol
.
Incl
uded
empl
oyee
sha
dde
pres
sion
-re
late
dab
senc
esfr
omw
ork,
used
thei
rpr
escr
iptio
ndr
ugbe
nefi
tdu
ring
the
stud
ype
riod
,an
ddi
dno
tha
vem
ore
than
one
shor
t-te
rmdi
sabi
lity
epis
ode
1ye
arpr
ior
toba
selin
e.
The
stud
ypo
pula
tion
was
over
whe
lmin
gly
fem
ale
(88%
),ha
da
mea
nof
4.1
depr
essi
onsy
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.
Em
ploy
ees
who
wen
ton
long
-ter
mdi
sabi
lity
bene
fits
wer
esi
gnif
ican
tlyle
sslik
ely
tofi
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
wor
kan
ddi
dno
tgo
onto
long
-ter
mdi
sabi
lity
bene
fits
(42.
7%).
An
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
ngth
ofdi
sabi
lity
epis
ode
(��
�24
.1da
ys).
Not
e.R
CT
�ra
ndom
ized
cont
rolle
dtr
ial;
WL
Q�
Wor
kL
imita
tions
Que
stio
nnai
re;S
R�
syst
emat
icre
view
;NSR
�no
nsys
tem
atic
revi
ew;D
MIE
�D
emon
stra
tion
toM
aint
ain
Inde
pend
ence
and
Em
ploy
men
t;SS
I/D
I�
Supp
lem
enta
lSec
urity
Inco
me
orSo
cial
Secu
rity
Dis
abili
tyIn
sura
nce;
SF-1
2M
CS
�Sh
ortF
orm
12It
emH
ealth
Surv
ey,m
enta
lhea
lthco
mpo
site
sum
mar
y;A
DL
�A
ctiv
ities
ofD
aily
Liv
ing;
FTE
�fu
ll-tim
eeq
uiva
lent
;SS
Abe
nefi
ts�
Soci
alSe
curi
tyA
dmin
istr
atio
ndi
sabi
lity
bene
fits
;O
S�
obse
rvat
iona
lst
udy;
DSM
-IV
�D
iagn
ostic
and
Stat
istic
alM
anua
lof
Men
tal
Dis
orde
rs-
4th
editi
on;
QE
D�
quas
i-ex
peri
men
tal
desi
gn;
EID
P�
Em
ploy
men
tIn
terv
entio
nD
emon
stra
tion
Prog
ram
.
142 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
Tab
le6
Evi
denc
efo
rIm
prov
ing
Em
ploy
men
tO
utco
mes
ofL
ong-
Ter
mC
lien
tsof
Tra
diti
onal
Men
tal
Hea
lth
Serv
ices
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
Van
Til
etal
.(2
013)
SRIn
terv
entio
nsto
max
imiz
ere
inte
grat
ion
ofw
orke
rsw
ithm
enta
ldi
sord
ers
into
the
wor
kfor
ce.
97ob
serv
atio
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
Bai
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)
143PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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.
144 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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)
145PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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
Ope
ratio
nsIr
aqi
Free
dom
and
End
urin
gFr
eedo
mw
ithPT
SD,
depr
essi
on,
SUD
,or
TB
I.
Thi
san
alys
isof
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
othe
rvo
catio
nal
inte
rven
tions
for
the
sam
ple
popu
latio
n.
Not
e.SR
�sy
stem
atic
revi
ew;
RC
T�
rand
omiz
edco
ntro
lled
tria
l;IP
S�
Indi
vidu
alPl
acem
ent
and
Supp
ort;
VR
�vo
catio
nal
reha
bilit
atio
n;PT
SD�
post
trau
mat
icst
ress
diso
rder
;D
I�
Supp
lem
enta
lSe
curi
tyD
isab
ility
Insu
ranc
e;PG
AP
�Pr
ogre
ssiv
eG
oal
Atta
inm
ent
Prog
ram
;A
B�
Acc
eler
ated
Ben
efits
dem
onst
ratio
npr
ojec
t;Q
ED
�qu
asi-
expe
rim
enta
lde
sign
;SE
�su
ppor
ted
empl
oym
ent;
SMI
�se
riou
sm
enta
lilln
ess;
VA
�V
eter
ans
Aff
airs
;EID
P�
Em
ploy
men
tInt
erve
ntio
nD
emon
stra
tion
Prog
ram
;AC
T�
Ass
ertiv
eC
omm
unity
Tre
atm
ent;
TB
I�
trau
mat
icbr
ain
inju
ry;
SUD
�su
bsta
nce
use
diso
rder
;IC
M�
inte
nsiv
eca
sem
anag
emen
t;H
WV
P�
Hom
eles
sW
omen
Vet
eran
Prog
ram
.
146 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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
147PREVENTING UNEMPLOYMENT: EVIDENCE AND POLICY
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-
148 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER
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
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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 �
152 O’DAY, KLEINMAN, FISCHER, MORRIS, AND BLYLER