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Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial

  • Eóin Killackey (a1), Kelly Allott (a2), Henry J. Jackson (a3), Rosanna Scutella (a4), Yi-Ping Tseng (a4), Jeff Borland (a5), Tina-Marie Proffitt (a6), Sally Hunt (a7), Frances Kay-Lambkin (a8), Gina Chinnery (a9), Gennady Baksheev (a10), Mario Alvarez-Jimenez (a11), Patrick D. McGorry (a12) and Susan M. Cotton (a13)...

Abstract

Background

High unemployment is a hallmark of psychotic illness. Individual placement and support (IPS) may be effective at assisting the vocational recoveries of young people with first-episode psychosis (FEP).

Aims

To examine the effectiveness of IPS at assisting young people with FEP to gain employment (Australian and Clinical Trials Registry ACTRN12608000094370).

Method

Young people with FEP (n = 146) who were interested in vocational recovery were randomised using computer-generated random permuted blocks on a 1:1 ratio to: (a) 6 months of IPS in addition to treatment as usual (TAU) or (b) TAU alone. Assessments were conducted at baseline, 6 months (end of intervention), 12 months and 18 months post-baseline by research assistants who were masked to the treatment allocations.

Results

At the end of the intervention the IPS group had a significantly higher rate of having been employed (71.2%) than the TAU group (48.0%), odds ratio 3.40 (95% CI 1.17–9.91, z = 2.25, P = 0.025). However, this difference was not seen at 12- and 18-month follow-up points. There was no difference at any time point on educational outcomes.

Conclusions

This is the largest trial to our knowledge on the effectiveness of IPS in FEP. The IPS group achieved a very high employment rate during the 6 months of the intervention. However, the advantage of IPS was not maintained in the long term. This seems to be related more to an unusually high rate of employment being achieved in the control group rather than a gross reduction in employment among the IPS group.

Declaration of interest

None.

Copyright

Corresponding author

Correspondence: Eóin Killackey, Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia. Email: eoin@unimelb.edu.au

References

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2Waghorn, G, Saha, S, Harvey, C, Morgan, VA, Waterreus, A, Bush, R, et al. ‘Earning and learning’ in those with psychotic disorders: the second Australian national survey of psychosis. Aust N Z J Psychiatry 2012; 46: 774–85.
3Rinaldi, M, Killackey, E, Smith, J, Shepherd, G, Singh, SP, Craig, T. First episode psychosis and employment: a review. Int Rev Psychiatry 2010; 22: 148–62.
4Scott, J, Fowler, D, McGorry, P, Birchwood, M, Killackey, E, Christensen, H, et al. Adolescents and young adults who are not in employment, education, or training. BMJ 2013; 347: f5270.
5Department of Education, Employment and Workplace Relations. Evaluation of Disability Employment Services Interim Report, Reissue March 2012. Australian Government, 2012.
6Bond, G. Evidence for the Effectiveness of the Individual Placement and Support Model of Supported Employment. IPS Works, 2018 (https://ipsworks.org/index.php/evidence-for-ips/).
7Modini, M, Tan, L, Brinchmann, B, Wang, M-J, Killackey, E, Glozier, N, et al. The effectiveness of supported employment vocational programs for people with severe mental illness: a systematic review and meta-analysis of the international literature. Br J Psychiatry 2016; 209: 1422.
8Nuechterlein, KH, Subotnik, KL, Turner, LR, Ventura, J, Becker, DR, Drake, RE. Individual placement and support for individuals with recent-onset schizophrenia: integrating supported education and supported employment. Psychiatr Rehabil J 2008; 31: 340–9.
9Killackey, E, Jackson, HJ, McGorry, PD. Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual. Br J Psychiatry 2008; 193: 114–20.
10Killackey, E, Allott, K, Cotton, SM, Jackson, H, Scutella, R, Tseng, YP, et al. A randomized controlled trial of vocational intervention for young people with first-episode psychosis: method. Early Interv Psychiatry 2013; 7: 329–37.
11Drake, R, Bond, G, Becker, D. Individual Placement and Support: An Evidence-Based Approach to Supported Employment (Evidence-Based Practice). Oxford University Press, 2012.
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23Hoffmann, H, Jäckel, D, Glauser, S, Mueser, KT, Kupper, Z. Long-term effectiveness of supported employment: 5-year follow-up of a randomized controlled trial. Am J Psychiatry 2014; 171: 1183–90.
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Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial

  • Eóin Killackey (a1), Kelly Allott (a2), Henry J. Jackson (a3), Rosanna Scutella (a4), Yi-Ping Tseng (a4), Jeff Borland (a5), Tina-Marie Proffitt (a6), Sally Hunt (a7), Frances Kay-Lambkin (a8), Gina Chinnery (a9), Gennady Baksheev (a10), Mario Alvarez-Jimenez (a11), Patrick D. McGorry (a12) and Susan M. Cotton (a13)...
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eLetters

Response letter: Killackey et al, 2019 ‘Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial.’ British Journal of Psychiatry 214:2 pp 76-82

Benjamin Janaway, CT1 Psychiatry, Barnet, Enfield and Haringey Mental Health Trust
Mukesh Kripalani, Consultant Psychiatrist
16 April 2019

First Author: Dr BM Janaway at benjamin.janaway@nhs.net. Second Author: Dr Mukesh Kripalani at mukesh.kripalani1@nhs.net.

It was with interest we read the results of the recent paper evaluating the efficacy of Individual Placement and Support (IPS) in First Episode Psychosis (FEP) measured toward vocational outcomes and were excited to see positive results at earlier outcome points (Killackey et al, 2019). The authors kindly offer multiple explanations of a loss of significance of such interventions at later end points, which we would like to contrast and expand upon.

The authors concluded that the research demonstrated a case for IPS in helping those with FEP return to work, despite this is not maintained at later time points. However, this may be optimistic given the key demographics examined, could be potentially an overestimation.

Firstly, the method of selection and randomisation denotes generous selection criteria but fails to fully account for an unequal distribution of affective presentations between group strata and self-selection of willing participants, suggesting a lower baseline functional impairment.

The evidence provided suggests short term efficacy of IPS in motivated individuals of native language, with less severe symptoms, within a ‘schizonormative’ group and within a well-funded system. This is in keeping with previous research, but provides a relatively narrow margin for intervention, which does not clearly explain how and why it would be effective in those failing to make vocational recovery during usual treatment.

We would consider that those failing in usual treatment arm may lie outside of the actionable group demonstrated, attributable to the co-existence of affective subtypes, more severe disease (omitted from study) reduced language efficacy or other factors. Although some of his has evened out at later end points, this may be due to other factors (remission of anergia, efficacy of pharmacological intervention.) Would we please request the authors to address the above assertion?

Although the study does demonstrate some efficacy with those with a mood-affective component, as well as comorbid anxiety and PTSD, unless further information is made available, it does not extrapolate the relevance of these factors into short- or long-term outcomes in a comprehensive way. We note that the control group included more affective presentations, which we hope has been accounted for.

The authors also comment that due to previous work, those operating in clinics may have been previously upskilled in IPS, which may also explain the high vocational rates ascribed to the treatment as usual arm and could have nullified significance at later end points. We would proffer an additional explanation, where some observer biases inherent in those clinics sharing both intervention and test cases would inspire more supportive treatment.

Finally, the measure of a successful outcome used may overestimate the success of the project, and attenuation of employment in the intervention arm may further explain the loss of significance at later end points. We posit this could potentially empower the government in to seeking more zero hour contracts in the UK as evidence of employment. However, far from being a negative, it does suggest that IPS, and work around it does favour positive outcomes, and this has been reflected in long term follow up in similar study in Switzerland (Hoffman, H et al 2014) and shown to improve outcomes This suggests moreover that a team approach to support, regardless of vocational expert inclusion, may be the real successful intervention.

It may be that these programmes would present a viable intervention if tailored to adjust for affective symptoms, be maintained beyond 6 months, be 1:1 (Holt, RIG et al 2018) account for heterogeneity in comorbid substance use, account for patient aspirations, and allow for differences between AUS and UK service structure and funding prospects and include a team-based approach to service delivery.

Key Paper

Killackey et al, 2019 ‘Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial.’ British Journal of Psychiatry 214:2 pp 76-82

References

• Hoffmann H, et al (2014): Long-term effectiveness of supported employment: 5-year follow-up of a randomized controlled trial. Am J Psychiatry 2014; 171:1183–1190

• Holt RIG, et al (2019) Structured lifestyle education for people with schizophrenia, schizoaffective disorder and first-episode psychosis (STEPWISE): randomised controlled trial. Br J Psychiatry. Feb;214(2):63-73. doi: 10.1192/bjp.2018.167. Epub 2018 Sep 25

Declarations: No conflicts of interest to declare.
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Conflict of interest: None declared

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