Randomized Trial of Supported Employment Integrated With Assertive Community Treatment for Rural Adults With Severe Mental Illness

Abstract

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

Employment outcomes for people with schizophrenia spectrum disorder: A meta-analysis of randomized controlled trials

“…One control group treatment did not focus on employment [47], although it did target the acquisition of skills to cope with job stress. Other control interventions provided a structured system targeting competitive job [48] or paid employment [39]. Risk ratio (RR) values greater than 1 indicate better treatment efficacy in the intervention group relative to the control groups.…”

Health and well-being of homeless veterans participating in transitional and supported employment: Six-month outcomes

“…Nor have advantages been found for IPS in studies that specifically evaluated psychiatric symptoms [39-42], quality of life [39,[41][42], self-esteem [40], global functioning [40][41][42], relapses [41], coping [41], social support [42], or substance misuse [42]. When differences on non-vocational outcomes have been identified, they have been small [20] or possibly due to baseline differences and resultant regression to the mean [42].…”

Assertive community treatmentIssues from scientific and clinical literature with implications for practice

“…Consistent evidence exists that ACT is a reliable vehicle for delivering vocational interventions and achieving truly competitive employment in this population [41][42][43][44]. Two major studies, one with a matched comparison group [45] and the other a rural study with a randomized control group [46], demonstrated superior outcomes for ACT integrated with individual placement and support (IPS) vocational intervention. Such integration usually entails meeting the fidelity criterion by "embedding" at least two vocational specialists as regular members of the ACT team.…”