In this section, we discuss EI employment supports offered to individuals before or soon after a FE of psychosis and for TAY, which is commonly defined as ranging from 14-25 years old or 16-30 years old. The EI programs we reviewed are generally similar, with slight deviations along four dimensions: stage of illness, whether providers specialize in EI, the degree to which SE is integrated with mental health services, and the degree to which mental health services are comprehensive. The models tend to be adaptations of existing models used for populations with chronic mental illness, tailored to identify and appeal to people who are younger and whose conditions are not chronic. Functional and clinical recovery is the typical goal (Appendix A, Table A.5 and Table A.6).
EI models vary in the array of services offered and whether they are delivered by EI specialists. Most EI models offer multi-element services often through an interdisciplinary team. Many of the more comprehensive service models have modified the existing system of community mental health services (CMHS) for FE populations by forming interdisciplinary teams of EI specialists. Still other interventions are focused primarily on SE and do not include comprehensive, EI-specialist teams. Among the comprehensive models, services generally entailed a mix of medication management, cognitive therapy, social skills training, SE, and family intervention (family psychoeducation, for example) or family counseling. Some of the comprehensive, EI-specialist models have incorporated the IPS model as their vocational component. The psychosocial and vocational interventions are usually adapted to the age-specific needs of FE individuals by emphasizing education in addition to immediate job placement (Bird et al. 2010). Models commonly used for people with chronic SMI may be adapted in other ways as well; for example by emphasizing stress-reduction as a way of avoiding symptomatic and functional deterioration. Additionally, EI interventions are increasingly incorporating cognitive remediation (McFarlane et al. 2012).
1. Limited evidence suggests that individuals who experience a FE benefit more from comprehensive treatment services provided by EI specialists than from generic services designed for people with chronic mental illness.
Two studies compared comprehensive services provided by EI specialists and targeted to individuals experiencing FEs to generic (non-EI focused) services targeting the general population of mental health service users. Garety et al. (2006) randomized individuals in their 20s (with a mean age of 26) to comprehensive EI services provided by an EI team or generic services provided by a traditional mental health center without an integrated EI team and found that individuals who received EI services were significantly more likely to spend six months or more of the 18-month follow-up period engaged in work or education compared with controls (49 percent versus 24 percent). However, only one-third of the EI group was employed or enrolled in school full-time at follow-up and this rate was not significantly higher than that of the control-group. Fowler et al. (2009) compared participants in generic services provided by mental health centers (with teams of a psychiatrist and a case worker) to participants in "partial EI programs", which added EI specialists to the generic team from 1998 to 2002. In 2003, funds became available to implement a full service model, which added additional case managers and a vocational counselor to the team. Fowler added these participants to the study. Fowler found significant improvement among an EI group. One year post-referral, 40 percent of the EI cohort was competitively working or in school more than 15 hours per week during the assessment month, compared with significantly fewer (24 percent) of those who received "partial EI". Two years post-referral, 44 percent of the EI cohort were engaged in work or school more than 15 hours per week, significantly more than those in the "no-EI" group that received only generic services (15 percent).
2. Results suggest that individuals who receive comprehensive EI with integrated SE experience higher levels of employment.
Two small studies found promising results when they examined the issue of medical, vocational, and SE service integration. Researchers integrated an SE specialist or team into an existing EI service team. Existing EI services, which may or may not offer non-integrated vocational supports served as the comparison intervention. The interventions adapted SE for younger participants by providing supported education in addition to job placement.
Killackey et al. (2008) found that six months after enrollment, 13 out of 20 individuals experiencing FE randomized to comprehensive EI plus evidence-based SE found or retained employment, compared with two in the control-group. Major et al. (2010) found that at any time during the first 12 months of intervention, 36 percent of integrated EI treatment-group members gained or retained competitive employment and 20 percent began or remained in education, compared with 19 percent and 24 percent, respectively, in the standard EI group. Although these findings were significant, the sample sizes were quite small (20 and 44 respectively) and conclusions should be interpreted with caution.
3. One study suggests SE is also associated with positive outcomes when delivered outside of comprehensive EI services.
We identified one study that examined employment outcomes for individuals with FE or recent-onset psychosis receiving SE. This RCT differs from those discussed above in that SE was integrated into standard, generic CMHS. Those randomly assigned to the SE group additionally received a group-based work skills training, while the controls received referrals to VR, group-based communication skills, and medication management (Nuechterlein et al. 2008a). During the first six months of the program, significantly more individuals in the SE group had obtained or returned to employment or school than in the control-group (83 percent versus 41 percent). At the end of the 18-month intervention, by which time treatment intensity had faded, 72 percent of the SE group was employed or in education, compared to 42 percent of controls (Nuechterlein et al. 2008b).
4. Few studies reported the duration of employment or school enrollment. In those that did, participants were engaged in these activities only a small proportion of the time.
Of the nine studies reviewed, only two indicated the amount of time participants were engaged in work or school. In one of these, 49 percent of all EI individuals spent at least six months out of the 18-month study period employed or in an educational activity, which was significantly higher than the 29 percent among controls (Garety et al. 2006). In the other, those in the EI group who found employment worked, on average, significantly more weeks than those in the control-group: nine weeks compared to four weeks of the 26-week study period (Killackey et al. 2008). In this study, employment was substantial enough to significantly reduce reliance on Social Security disability or other cash benefits as a primary source of income (from 80 percent to 55 percent) but the majority of individuals remained on benefits (Killackey et al. 2008).5
5. Research on the effectiveness of SE for TAY is limited to one rigorous study, which showed promising results for young adults.
We identified two studies of SE with findings specific to TAY, but only one met our requirements for rigorous research (Burke-Miller et al. 2012). Results from that study were positive for older youth and mixed for younger ones. The authors analyzed subgroup results from EIDP to discern the effects of SE by age and determine how youth (ages 18-24) and young adults (ages 25-30) fared in comparison to adults ages 31 and older. They found that young adults in SE were significantly more likely to find competitive employment than were young adults who received services-as-usual or weaker forms of the intervention. In this study, about 70 percent of young adults found competitive employment, compared with about 40 percent who received services-as-usual or weaker versions of SE. Young adults in SE were also significantly more likely to find competitive employment than older adults in SE. Among youth ages 18-24, however, competitive employment rates did not significantly differ between those who received SE and those who received traditional services or weaker versions of SE, with about 45 percent of youth in both groups finding competitive employment.
6. More evidence is on the horizon.
We identified two new initiatives that will yield important evidence about the effectiveness of SE for people experiencing their FE of psychosis. Most notably, the National Institute of Mental Health is funding the Recovery after an Initial Schizophrenia Episode (RAISE) demonstration to test the clinical and cost-effectiveness of providing specialized FE care to individuals experiencing the early stages of schizophrenia. The RAISE demonstration consists of two complementary projects: an implementation study of delivering high quality FE care in clinics in New York and Maryland, and an RCT assessing the effect of providing an array of targeted services and supports early on to those with FE schizophrenia in 34 sites across the United States. The objective is to develop interventions that can be tested and readily adopted if they prove successful. The treatment models focus on intervening as soon as possible after the first symptoms or episode of schizophrenia and integrate medication, psychosocial therapies, family involvement, rehabilitation services, and SE. Results are expected in 2014.
The Early Detection, Intervention, and Prevention of Psychosis (EDIPP) Program, sponsored by the Robert Wood Johnson Foundation, expands a psychosis-prevention model to multiple sites around the country. EDIPP offers family-aided assertive community treatment (FACT) modified for EI to individuals at clinical high risk for psychosis. FACT includes psychoeducational multifamily group therapy, community-based treatment, SE and education, and psychotropic medication. Most of those in the comparison group, which consists of lower-risk youth, receive standard community clinical or psychosocial treatment, and some also receive supported education or employment (McFarlane et al. 2012). The results of EDIPP have not yet been published.