Dr Geoffrey Waghorn

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Dr Geoffrey Waghorn Queensland Centre for Mental
Health Research E-mail geoff_waghorn_at_qcmhr.uq.ed
u.au
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Acknowledgments

• Professor Harvey Whiteford (Director) and Dr
  David Chant (Statistician) of the Queensland
  Centre for Mental Health Research
• www.qcmhr.uq.edu.au

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Providing evidence-based employment assistance to
people with psychiatric disabilities

• This presentation summarises research covering
• labour force activity by Australians with
  psychiatric disabilities in 1998
• employment restrictions and labour force activity
• evidence-based ingredients of effective
  employment services
• implications for policy makers and service
  providers

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Main data source

• The Australian Bureau of StatisticsSurvey of
  Disability Ageing and Carers, 1998
• Sampled 1 per 400 households in Australia, and
  37 580 individuals.
• Multistage stratified sampling strategies.
• Secondary analyses were conducted using multiple
  logistic regression.

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Data source cont. 2

• Completed interviews were obtained from 35 569
  persons or 94.4 of the total sample.
• Non-responses included refusals 0.1
  non-contacts 0.1 and language problems, death,
  illness or other, less than 0.05.
• Trained lay interviewers used ICD-10 computer
  assisted interviews

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Data source cont. 3

• People of labour market age (15-64 years) were
  compared
• ICD-10 anxiety disorders (n  716)
• ICD-10 depression (including co-morbid anxiety,
  n  370)
• ICD-10 psychotic disorders (n 169).
• Healthy controls (n  19 956)
• Application of ABS population weights revealed
  965,520 people of working age with these mental
  disorders, including over 210,000 people with
  psychotic disorders.

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Other data sources 5, 9

• National Survey of Mental Health and Wellbeing.
  Report 4. People Living with Psychotic Illness
  1998 An Australian Study. Canberra Commonwealth
  Department of Health and Aged Care. (This survey
  involved 850 in-depth interviews of community
  residents with psychotic disorders).
• A series of reviews of international evidence
  identifying the ingredients of evidence-based
  practices by Professor Gary Bond.

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Table 1. How mental disorders impact on labour
force activity - Australia 1998
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Reasons for non-participation in the labour force
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Employment restrictions (self-reported)
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How big is the problem?

• Australians with a primary psychiatric or
  psychological disability represent
• Approx. 26 of 706,000 people receiving DSP
  (183,560) If 70 want to work (128,000), and 50
  need ongoing support, then approx. 64,000 new
  intensive places are needed just for DSP
  recipients.
• 25-30 of clients of CRS Australia and Disability
  open employment services in 2002.
• 12.2 of employment commencements by open
  employment service clients in 2002.
• the lowest durable work outcomes in 2002.

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Note severity of employment restrictions

• Employment restrictions were assessed at four
  levels of severity (profound, severe, moderate,
  and mild). Profound was defined as unable to
  perform employment or a core activity, or always
  needing assistance. Severe was defined as needing
  assistance to perform employment or a core
  activity. Moderate referred to not needing
  assistance, but having difficulty. Mild referred
  to having no difficulty, but using aids or
  equipment because of disability.

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Some conclusions about LF activity in Australia

• The ageing population drives the economic need to
  optimise LF participation in all groups across
  the working life.
• The greatest difference can be made at the
  beginning and end of the working life, at 15-24
  years, and at 55-64 years.
• Mental disorders (even without employment
  restrictions) have a large impact on LF activity,
  despite 6 years of disability reform 1992-1998.
• Unlike healthy Australians, youth with mental
  disorders were seldom not in the LF for study
  reasons. Education outcomes appear just as
  important for youth as employment..

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Evidence-based employment services for people
with psychiatric disabilities

• We expect our GPs to provide the latest
  evidence-based treatments for our health
  conditions.
• So why do we settle for less when it comes to
  psychosocial rehabilitation?
• There is now a large and rigorous body of
  international evidence that needs to influence
  Welfare to Work policy in Australia.

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Gary Bond Open Employment for People with Severe
Mental Illness (PSMI) in the USA (The problem)

• Say they want to work 55-70
• Are currently working lt10 (16 in Australia)
• Current access to SE lt5 (unknown in Australia)
• Sources Rogers, 1991 McQuilken, 2003 Mueser,
  2003 Harris 2002 Hall 2003 West, 2005

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Gary Bond Traditional Vocational Services
Typical Features

• Stepwise Training or sheltered work first
• Work readiness criterion Clients screened for
  acceptance or placement
• Brokered Different agencies provide vocational
  and mental health services
• Short-term Services curtailed once job is found

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Bonds (1992) Review of 24 RCTs of Traditional
Vocational Approaches
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Conclusions from Bonds 1992 Review

• Most programs poorly defined
• No approach stood out as best
• Traditional psychiatric rehabilitation programs
  do not prepare clients for competitive
  employment, but instead help clients adjust to
  various agency-sponsored employment options.

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What works Supported Employment (SE, in USA)
nearest term is Open Employment in Australia

• An Evidence-Based Practice

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Supported Employment7 evidence-based principles

• Eligibility is based on consumer choice
• Supported employment is integrated with treatment
• Competitive employment is the goal
• Rapid job search is used within 4 weeks
• Job finding is individualized
• Follow-along supports are continuous
• Personalized benefits planning is provided

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Primary Evidence for US IPS (Integrated Open
Employment)

• Conversion studies of 6 day treatment programs
• 12 randomized controlled trials
• There is also specific evidence supporting each
  principle (Bond, 2004).

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Similar Results in All 6 Day Treatment
Conversions

• Large increase in employment rates
• No negative outcomes (e.g., relapses)
• Consumers, families, staff liked change
• Overall, all former day treatment clients got out
  into community more
• Resulted in cost savings

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Mean Competitive Employment Rates in 6 Day
Treatment Conversions
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Competitive Employment Rates in 12 RCTs of
Supported Employment
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Conclusions Randomized Controlled Trials of
Supported Employment

• In 12 of 12 studies, SE had significantly better
  competitive employment outcomes than controls
• Mean across studies of consumers working
  competitively at some time
• 59 for supported employment
• 21 for controls

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Why these ingredients are important
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Professor Gary Bond The Primary Goal is Open
and competitive employment

• Regular community job
• Pays at least minimum wage
• Work setting includes people who are not disabled
• Not temporary or voluntary
• Includes self-employment

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Eligibility is based on consumer choice

• Any one who says they want to work should be
  given a chance.

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Research findings

• Clients generally do better in SE than in other
  voc programs, regardless of
• Demographics (e.g., age, gender, ethnicity)
• Educational level
• Work history and abilities
• Clinical factors (diagnosis, symptoms)
• Substance use

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Individual job preferences are paramount for job
retention. (Ack Schultz)
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Supported Employment integrated with mental
health treatment

• Employment specialists meet frequently with the
  mental health treatment team.

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Problems encountered by brokered arrangements

• Referral process works poorly
• Breakdowns in communication
• Meetings hard to schedule
• Clients perceived differently
• Meds, housing out of sync with job
• Responsibility for follow-up unclear
• Employment staff may get caught up in crisis work
  (case manager role)

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Consumers Prefer Rapid Job Search

• Bond (1995) Consumer preferences on entering
  supported employment
• 73 immediate job search
• 4 prevocational training
• 22 no preference

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Evidence for Rapid Job Search

• 9 experimental studies comparing
• Rapid Job Search
• Stepwise Approach (e.g., skills training,
  prevocational preparation)
• 8 of 9 showed better employment for Rapid Job
  Search

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Vermont Work Incentive Initiative (Tremblay, 2004)

• Benefits counselors
• Deployed throughout state
• Worked closely with supported employment programs
• Personalized benefits counseling
• Pre-post outcomes
• Per-client earnings doubled from 500 to 1000
  per 3-month period

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Follow-Along Supports Are Continuous and
Time-Unlimited

• Supported employment staff continue to stay in
  regular contact with consumer and/or employer
  without arbitrary time limits.

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Findings from Long-Term Outcomes from Supported
Employment

• General finding Positive long-term outcomes
  when consumers receives consistent, job-specific
  support.
• McHugo study

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Long-Term SE Follow-up Study (Salyers, 2004)

• 10 Years After Switch to SE
• CMHC still maintaining contact
• 86 consumers receiving services
• Consumer outcome at follow-up
• 92 had worked during follow-up
• 47 currently working
• 33 worked at least 5 years

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A way forward

• Funding policies should be determined by what
  works, not by historical reasons or generic
  policy frameworks.
• The availability (not always the supply) of
  on-going support to retain employment is critical
  for people with psychiatric disabilities.
• New funding can be linked to the provision of
  evidence based practices.

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A way forward cont. 2

• Federal and state governments can help link
  treatment and employment services by negotiating
  the allocation of funding places to specific
  health sites.
• The health sector can contribute to costs in
  partnership with an employment service because
  employment contributes to recovery and patient
  exits.

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A way forward cont. 3

• Consider accredited training in work-related
  mental health literacy and psychiatric
  vocational rehabilitation.
• Involve all stakeholders in the establishment of
  local evidence-based services.

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References

• 1. Australian Bureau of Statistics. (1999).
  Survey of Disability, Ageing and Carers,
  Australia. Technical Paper. Confidentialised Unit
  Record File 1998. Canberra Commonwealth
  Government.
• 2. Waghorn, G., Chant, D., White, P.,
  Whiteford, H. (2004). Delineating disability,
  labour force participation, and employment
  restrictions among persons with psychosis. Acta
  Psychiatrica Scandinavica, 109, 279-288.
• 3. Waghorn, G, Chant, D., White, P., Whiteford,
  H. (2005). Disability, employment and work
  performance among persons with ICD-10 anxiety
  disorders. Australian and New Zealand Journal of
  Psychiatry, 39(1), 55-66.
• 4. Waghorn, G, Chant, D. (in press) Labour
  force activity by people with depression and
  anxiety disorders a population level second
  order analysis. Acta Psychiatrica Scandinavica.
• 5. Jablensky A, McGrath J, Herrman H, et al.
  (1999). National Survey of Mental Health and
  Wellbeing. Report 4. People Living with Psychotic
  Illness An Australian Study. Canberra
  Commonwealth Department of Health and Aged Care.

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References cont. 2

• 6. Waghorn, G., Chant, D., Jaeger, J. (in
  review, 2005). Employment functioning among
  community residents with bipolar affective
  disorder results from an Australian community
  survey. Bipolar Disorders.
• 7. Waghorn, G., Chant, D. Whiteford, H. (2002).
  Clinical and non-clinical predictors of
  vocational recovery for Australians with
  psychotic disorders. Journal of Rehabilitation,
  68(4), 40-51.
• 8. Waghorn, G., Chant, D. Whiteford, H. (2003).
  The strength of self-reported course of illness
  in predicting vocational recovery for persons
  with schizophrenia. Journal of Vocational
  Rehabilitation, 18(1), 33-41.
• 9. Bond, G. (2004). Supported Employment
  evidence for an evidence-based practice.
  Psychiatric Rehabilitation Journal, 27(4),
  345-359.
• 10. Waghorn, G. (2005). Work-related subjective
  experiences, work-related self-efficacy and
  vocational status among community residents with
  schizophrenia or schizoaffective disorder.
  Doctoral Thesis. Brisbane The University of
  Queensland.

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References cont. 3

• 11. Waghorn, G., Chant, D., King, R. (2005).
  Work-related subjective experiences among
  community residents with schizophrenia or
  schizoaffective disorder. Australian and New
  Zealand Journal of Psychiatry, 39, 88-99.
• 12. Waghorn, G., Chant, D., King, R. (in
  press). Work-related self-efficacy among
  community residents with psychiatric
  disabilities. Psychiatric Rehabilitation Journal.

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Contact details

• For further information geoff_waghorn_at_qcmhr.uq.ed
  u.au
• Tel. [phone]