In this section, we summarize findings on the current state of knowledge on interventions to improve employment outcomes among workers with mental illness at risk of job loss. Following a framework established by Nieuwenhuijsen et al. (2008) and Krupa (2007), our review divides interventions into two main groups: individual or worker level interventions and employer-level interventions. Individual-level interventions are typically directed to the worker, such as EI, assessment, counseling, coping skills training, return-to-work (RTW) planning, and job accommodation. These interventions are geared toward helping the individual, but some may be designed to alter organizational behavior--offering improved depression screening and treatment training to primary care physicians and nurses, for example. Employer-level interventions are implemented by employers and focus on how the workplace itself can be constructed to promote mental health and prevent work disability. They typically involve modified work (such as offering employees with mental illnesses flexible work schedules), establishing a supportive work environment, or organization-wide mental health screening and training for human resources and supervisory staff to help them work with employees experiencing depression (Appendix A, Table A.4).
1. Individual-Level Studies
a. CMS' Demonstration to Maintain Independence and Employment (DMIE) did not improve the employment and earnings of workers with mental illness, but members of the intervention group were significantly less likely to receive Social Security disability benefits.
The DMIE was established to determine whether health-related EI strategies implemented by states could delay or prevent reliance on disability benefits and reduce job loss for working adults with disabilities. These RCT demonstrations enrolled adults aged 18-62 who worked at least part-time and were not receiving SSI or SSDI benefits. The DMIE was implemented in four states, which developed various service packages to provide medical benefits and financial assistance for health care (Whalen et al. 2012). Two states, Minnesota and Texas, focused on workers with behavioral health problems. We report on both the individual and pooled state results for these two states below.
In Minnesota, intervention participants (N=888) received such employment supports as care coordination, job placement, intensive employment-needs assessment, career counseling, worker support/coaching, Americans with Disabilities Act (ADA) disclosure training, and referrals to a workforce center. The control-group consisted of 267 individuals. With the exception of certain subgroups of participants, at one year follow-up, employment and earnings outcomes did not significantly differ between the intervention and control-groups; however, in contrast to similar participants in the intervention group, control-group members scoring below 50 on the Global Assessment of Functioning reported a decrease in income, suggesting that the intervention may have ameliorated a decline among low-functioning participants. Intervention group members who were more engaged with the program were significantly less likely to receive SSDI benefits than participants who were less engaged (Linkins et al. 2011).
Texas offered 888 randomly selected intervention participants enhanced mental health services and substance abuse assessment and referral services, dental and vision care, expedited clinic appointments, fully subsidized prescriptions and medical visits, durable medical equipment, podiatry, case management services, and transportation assistance at no cost. Another 697 individuals were randomly selected for the control-group. As in Minnesota, the evaluation found no significant differences in employment or earnings between the intervention and control-group members, but intervention participants were significantly less likely to receive SSI/SSDI (6 percent versus 8 percent) at follow-up (Bohman et al. 2011).
The pooled analysis of Minnesota and Texas intervention participants did not find an effect on the likelihood of employment but did show some evidence that the medical services DMIE provided decreased the adverse effect of mental illness on earnings for highly engaged, low-functioning individuals. Members of the intervention group were significantly less likely than those in the control-group to be receiving SSI disability benefits one year after DMIE enrollment (1.8 percent versus 3.2 percent), but no significant difference in annual earnings were found between the groups (Whalen et al. 2012). Because employment was examined for only one year after enrollment, long-term impacts are unknown.
b. Studies of individual-level clinical interventions for people with depression show limited evidence of improving employment outcomes.
Depression is the most studied mental illness with regard to the effect of interventions on employment outcomes. Nieuwenhuijsen et al. (2008) conducted a systematic review of interventions to improve occupational health in people with depression. The search returned 11 RCTs, all of which described worker-initiated, individual interventions. The only intervention found to have positive effects on sickness absence was psychodynamic therapy in combination with tricyclic antidepressant medication when compared to medication alone. The review did not find evidence of reduced sickness absence from the use of selective serotonin reuptake inhibitors, a computerized form of cognitive behavioral therapy, problem-solving therapy, enhanced primary care, or occupational therapy.
We identified two retrospective observational studies that used administrative data to examine the effects of antidepressant use on occupational outcomes. In the first study, Dewa et al. (2003) examined two years of administrative data on 1,281 employees from three large Canadian financial and insurance companies. They found that employees who went on long-term disability benefits were significantly less likely to fill any antidepressant prescriptions during a short-term episode. Moreover, EI (defined as guideline-recommended medication use within 30 days of short-term disability benefit start) was significantly associated with a reduced length of disability episode. In the second study, Burton et al. (2007) assembled a data set consisting of company personnel files, pharmacy claims records, and short-term disability claims for 2,112 employees at an American financial services company. Those who met antidepressant treatment adherence criteria during the three-month acute-phase follow-up period were significantly less likely to have any short-term disability absence. In the continuation-phase, adherent employees were less likely to have any short-term disability absence and less likely to have multiple short-term disability absences than non-adherent employees. Because those who were terminated during follow-up were excluded, the study does not provide information about the effect of adherence or short-term disability absences on job loss.
Adler et al. (2006) found that employees undergoing treatment for depression had worse job performance scores than healthy employees even after demonstrating clinical improvements in symptom severity. The study concluded that, although clinical interventions improve mental health, additional workplace interventions may be required to improve the performance of depressed employees.
2. Employer-Level Studies
a. There is limited evidence that interventions directed at the entire employee pool are effective for workers with mental illness.
Employer-level interventions often take the form of untargeted interventions, in which organizational changes are directed at the entire employee pool. These interventions typically focus on providing a supportive work environment, engaging in stress-reduction activities, and offering employees the opportunity to fully engage in the workplace (Lauber & Bowen 2010). Mental health education and awareness training programs are assumed to improve co-worker and supervisor support of colleagues with psychiatric disabilities (Krupa 2007), and there is evidence that strong supervisor and workplace social network supports produce positive effects on health outcomes and job performance (Lauber & Bowen 2010).
We identified one study with limited evidence of the effectiveness of interventions designed to increase awareness of mental health issues in the workplace. In a recent Finnish study (Vuori et al. 2012), an in-company training program was provided to employees of 17 medium-sized and large-sized organizations, with the goal of enhancing career-management, mental health, and job retention. Over the course of the study, 718 participants filled out a baseline questionnaire (which included questions on mental health status) and volunteered to participate in the program. Participants were randomized into intervention and comparison groups. The intervention group received a one-week group-training workshop focused on the enhancement of career-management skills. The comparison group received a literature package on basic career-management information. At the seven-month follow-up, the intervention group displayed significantly decreased depressive symptoms and intentions to retire compared with the comparison group. Although the study appears promising, its non-representative sample and lack of replication may limit its generalizability.
b. Although the extent to which employer provision of reasonable accommodations helps individuals remain employed is not well researched, accommodations may improve such employment outcomes as hours worked and job tenure and reduce job loss for individuals with psychiatric disabilities. However, disclosing one's disability during the process of requesting a reasonable accommodation bears some risk.
A literature review found 11 generally accepted categories of reasonable accommodations for people with psychiatric disabilities. But the benefits and risks inherent to employee disclosure of disability should be taken into account when evaluating the policy implications of employer-level interventions. The literature reveals little consensus on if, when, or how employees should disclose their disabilities to employers. The benefits of disclosure may include obtaining eligibility for protection against discrimination under the ADA, receiving support from such specialists as rehabilitation professionals, and the psychological benefits related to no longer hiding one's mental health conditions. Risks of disclosure include losing a promotion or a job, discrimination, and experiencing stigma at work (MacDonald-Wilson 2005).
Our literature review (O'Day et al. 2013) did not locate any high quality RCTs or well-controlled quasi-experimental studies measuring the employment outcomes of providing reasonable accommodations for individuals with psychiatric disabilities. To close this knowledge gap, Chow (2012) compared employment outcomes of participants in the EIDP who had received reasonable accommodations to those who had not. During the study period, participants who disclosed their mental health disability tended to receive a job accommodation and those with accommodations tended to work for longer periods of time; each accommodation decreased the risk of job loss by 12.7 percent. Participants with job accommodations worked an average of 7.68 hours more per month than those without accommodations at baseline. Average job tenure for individuals in the no-accommodations group was 157.47 days, whereas the accommodations group averaged 206.96 days. However, those who reported having an accommodation at work earned almost 5 percent less than those who reported having no accommodations. The author speculates that this finding might reflect wage discrimination faced by individuals who disclosed their condition to employers. Other unobservable factors related to employment might determine whether an employee discloses a disability and receives accommodation.4 There remains a substantial need for further research into the effects of reasonable accommodations on employment outcomes for individuals with mental health issues.