Adults with schizophrenia and other psychosis receiving supported employment were more than twice as likely to obtain a job in the competitive labour market as those receiving pre-job training, sheltered employment or psychiatric care only. Supported employment seemed most effective when augmented with other interventions such as social or cognitive skills training.
Many people with severe mental illnesses would like to work, and employment can improve their quality of life. This Cochrane review combined international data from nearly 50 trials comparing several different types of vocational rehabilitation.
Supported employment was mainly delivered through the Individual Placement and Support scheme, as used in the UK. It is integrated with mental health services and involves a job search guided by a helper followed by long-term support once employed.
These findings support NICE guidelines and government policy aiming to increase provision of supported employment places. Commissioners may need to address any implementation barriers. Relative costs were not directly addressed in these studies.
Why was this study needed?
Between 1 and 3% of the UK population have severe mental health problems, such as schizophrenia, bipolar disorder and long-term depression. It is estimated that only between 5 and 15% of people with psychosis are in employment. They are six or seven times more likely to be unemployed than the general population. Unemployment can lead to poverty, low self-esteem and social isolation.
People with enduring mental illnesses can receive different types of help to find and keep jobs. These include transitional (sheltered) employment, vocational training before looking for competitive work, and supported employment combining vocational training with mental health support.
Previous systematic reviews found positive effects for supported employment compared to other interventions and usual psychiatric care. This review was the first to use network meta-analysis, where interventions are compared directly within studies and indirectly across studies. This allows the different types of vocational help to be ranked for effectiveness.
What did this study do?
This review identified 48 randomised controlled trials involving 8,743 unemployed adults with severe mental illness. The majority of trials included people with schizophrenia or other psychosis, who were predominantly male and of average age 36 years. Most had an interest in employment and were educated to secondary level.
The interventions were supported employment (Individual Placement and Support in 24 studies), augmented supported employment (varied interventions), prevocational training (mainly job-related skills) and transitional (sheltered) employment. The majority of trials took place in North America. There were four UK studies.
The evidence was low to moderate quality for most comparisons, so better designed studies could change our conclusions. The highest risk of bias was participants and researchers being aware of the intervention given, and drop-out from trials.
See Definitions section for more details of the interventions.
What did it find?
- In a network meta-analysis across 22 trials involving 5,233 adults, supported employment and augmented supported employment, specifically, were the most effective vocational interventions for gaining a job within a year or more.
- Augmented schemes had the greatest effect, with 71% gaining employment compared with 19% receiving psychiatric care only (relative risk [RR] 3.81, 95% confidence interval [CI] 1.99 to 7.31, including one direct comparison trial in 256 participants). Symptom-related cognitive or social skills training were the most effective type of enhancement. Supported employment alone ranked second in effect compared with psychiatric care alone (RR 2.72, 95% CI 1.55 to 4.76, with one direct trial in 2,238 people).
- Supported employment was also more effective than transitional employment (i.e. work in a setting solely for people with disabilities). About 60% gained a job within a year or more compared with 22% in transitional employment (RR 2.71, 95% CI 1.80 to 4.06; four direct studies in 87 people). Augmented supported employment, specifically, resulted in 85% employment (RR 3.79, 95% CI 2.34 to 6.14; two direct studies in 212 people).
- Supported employment doubled the chances of obtaining a job compared with prevocational training (RR 2.16, 95% CI 1.59 to 2.93; nine direct trials in 1,570 adults), with a trebled chance when augmented (RR 3.02, 95% CI 1.88 to 4.87 with two direct trials in 193 people).
- There was little difference in the effectiveness of augmented supported employment and supported employment, which did not reach statistical significance in network meta-analyses ranking all interventions (direct comparison in three trials: RR 1.94, 95% CI 1.03 to 3.65; indirect comparison across 22 trials: RR 1.40, 95% CI 0.92 to 2.14).
What does current guidance say on this issue?
NICE recommends that people with psychosis and schizophrenia or bipolar disorder who want to find work are offered supported employment programmes. A new NICE guideline on rehabilitation in people with severe and enduring mental illness is due for publication in 2020.
NHS England’s Five Year Forward View for the Mental Health report by the Mental Health Taskforce (2016) includes an objective to double access to Individual Placement and Support places by 2020/21. The aim is to reach an extra 30,000 people living with severe mental illness so that at least 9,000 are in employment.
What are the implications?
In 2014, less than half of people with schizophrenia who were interested in looking for work said they received help towards this.
There may still be a need to overcome any barriers or stigmatisation that persist around working with people with severe mental health problems, and address any challenges in service integration. Employers also have a role to play in maximising the potential of people who have recovered from severe mental illness. NHS England will be developing a competency framework and workforce development strategy for the Individual Placement and Support employment specialists.
Effects may vary in countries with different mental health services, labour markets and social support systems. A European trial found that this type of individual support was cost-effective compared with standard employment support in London and other areas.
Citation and Funding
Suijkerbuijk YB, Schaafsma FG, van Mechelen JC, et al. Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. Cochrane Database Syst Rev. 2017;9:CD011867.
Boardman J. and Rinaldi M. Difficulties in implementing supported employment for people with severe mental health problems. BJPsych. 2013;203:247-49.
NHS England. Implementing the Five Year Forward View for Mental Health. Leeds: NHS England; 2016.
NICE. Bipolar disorder: assessment and management. CG185. London: National Institute for Health and Care Excellence; 2014 (updated 2017).
NICE. Bipolar disorder in adults. QS95. London: National Institute for Health and Care Excellence; 2015.
NICE. Psychosis and schizophrenia in adults. QS80. London: National Institute for Health and Care Excellence; 2015.
NICE. Psychosis and schizophrenia in adults: prevention and management. CG178. London: National Institute for Health and Care Excellence; 2014.
Khan M and Boardman J. Employment and mental health. Occasional Paper OP101. London: Royal College of Psychiatrists; 2017.
Knapp M, Patel A, Curran C, et al. Supported employment: cost effectiveness across six European sites. World Psychiatry. 2013;12:60-68.
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