Risk adjustment for physical health is essential when setting performance standards or cost expectations for mental health treatment. Excluding persons with chronic health problems from mental health service evaluations restricts generalizability of research findings and may promote interventions that are inappropriate for many persons with serious mental illness.
Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.
Objective-In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services.Methods-Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt.Results-Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay.Conclusions-Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.Supported employment is designed to help adults with serious mental illness obtain jobs in socially integrated settings that pay at least minimum wage (1-3). Randomized controlled trials have established supported employment as an evidence-based practice on the basis of higher employment rates for specialized supported employment teams compared with interventions NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript that do not provide supported employment (4-9). The effectiveness of supported employment has been partially attributed to rapid job placement, which bypasses prevocational training, trial jobs, and sheltered work (9-12).However, being hired does not guarantee success on the job. Enrollees express interest in employment when entering a supported employment program, yet typically average only a few months of employment after finding a job (1,8,11,(13)(14)(15)(16). One explanation for brief work tenure is the failure of many supported employment specialists to work closely with treating clinicians (17). Encouraging integration of supported employment with case management and other rehabilitation services, such as supported housing or supported education, also seems beneficial (18,19). Research suggests...
Random assignment to a preferred experimental condition can increase service engagement and enhance outcomes, while assignment to a less-preferred condition can discourage service receipt and limit outcome attainment. We examined randomized trials for one prominent psychiatric rehabilitation intervention, supported employment, to gauge how often assignment preference might have complicated the interpretation of findings. Condition descriptions, and greater early attrition from services-as-usual comparison conditions, suggest that many study enrollees favored assignment to new rapid-job-placement supported employment, but no study took this possibility into account. Reviews of trials in other service fields are needed to determine whether this design problem is widespread. © Springer Science+Business Media, LLC 2009Correspondence to: Cathaleene Macias. NIH Public Access Author ManuscriptAdm Policy Ment Health. Author manuscript; available in PMC 2009 December 20. The validity of research in any field depends on the extent to which studies rule out alternative explanations for findings and provide meaningful explanations of how and why predicted outcomes were attained (e.g., Bickman 1987;Lewin 1943;Shadish et al. 2002;Trist and Sofer 1959). In mental health services research, participants' expectations about the pros and cons of being randomly assigned to each experimental intervention can offer post hoc explanations for study findings that rival the explanations derived from study hypotheses. Unlike most drug studies that can 'blind' participants to their condition assignment, studies that evaluate behavioral or psychosocial interventions typically tell each participant his or her experimental assignment soon after randomization, and being assigned to a non-preferred intervention could be disappointing, or even demoralizing (Shapiro et al. 2002), and thereby reduce participants' interest in services or motivation to pursue service goals (Cook and Campbell 1979;Shadish 2002). On the other hand, if most participants randomly assigned to one experimental condition believe they are fortunate, this condition may have an unfair advantage in outcome comparisons.Reasons for preferring assignment to a particular experimental condition can be idiosyncratic and diverse, but as long as each condition is assigned the same percentage of participants who are pleased or displeased with their condition assignment, then there will be no overall pattern of condition preferences that could explain differences in outcomes. The greater threat to a valid interpretation of findings occurs when most study enrollees share a general preference for random assignment to one particular condition. Greater preference for one experimental condition over another could stem from general impressions of relative service model effectiveness, or from information that is tangential, e.g., program location on a main bus route or in a safer area of town. Even if random assignment distributes service preferences in equal proportions across conditi...
Objective-This study examined whether the situational factors that contribute to severe grief in the general population predicted the severity of grief in a sample of persons who had diagnoses of serious mental illness.Method-Research participants who had a diagnosis of a serious mental illness and who reported the death of a close friend or family member during a five-year service evaluation project were asked to detail the circumstances that surrounded the death and to rate how the death affected their lives. Key research measures included the self-rated measurement of the impact of the death, the self-rated measurement of the duration of the reported grief, and scores on a psychiatric symptom assessment in the six months after the death. A regression analysis tested the cumulative count of four situational factors-residing with the close friend or family member at the time of the death, the suddenness of the death, having low social support, and having concurrent stressors-as a predictor of severe and prolonged grief.Results-In the sample of 148 individuals with serious mental illness, 33 (22 percent) reported the death of a close friend or family member as a significant life event that resulted in relatively acute and brief grief (15 individuals, or 10 percent) or severe and prolonged grief (18 individuals, or 12 percent). The regression analysis confirmed that the more situational factors that occurred at the time of the death, the more severe the grief reaction was, irrespective of psychiatric symptomatology.Conclusions-Mental health services for persons with serious mental illness should begin to incorporate preparation for parental death and bereavement counseling as essential services, and such interventions should approach bereavement as a normal rather than a pathological response to interpersonal loss.Severe grief in response to the death of a close friend or family member is associated with a variety of physical and mental disorders (1-3) as well as with persistent depressive symptoms (4,5). Although the estimated incidence of prolonged, intense grief in the general population is only 11 to 15 percent (6-8), a study found that nearly a third of the psychiatric outpatients who were surveyed were currently experiencing intense grief that had already lasted an average of ten years (9).A bereaved individual with a preexisting psychiatric disorder is especially vulnerable to depression and depression-related physical illnesses (10,11). However, the etiology of chronic, severe grief appears to be more circumstantial than psychiatric in nature. Maladaptive cognitions-for example, denial, self-blame, and ambivalence-do not appear to lengthen the grieving process (12-15), but situational factors do. Circumstances that predict prolonged grief include a strong dependence on the close friend or family member before the death, the suddenness of the death, a lack of social support, and co-occurring other stressors (16-27). Cooccurring factors that can intensify grief or lengthen the time of grief include...
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