by Martin Knapp and colleagues
People with severe mental illness face many challenges in securing paid work, and employment rates are low. For example, a five-country European study by Knapp et al (2002) found less than a quarter of people with schizophrenia were in paid employment, the proportion being as low as 5% in London. The economic and social impacts of employment difficulties are enormous. For individuals, it can mean long-term reliance on state welfare benefits, insecure low-paid work, and a disability trap that makes it hard to escape. For the broader society, the impacts are the risk of an almost permanently marginalized, socially excluded group of people, and high costs: productivity losses because of unemployment or absenteeism account for a large proportion of the overall cost of schizophrenia across many countries.
Not surprisingly, many public and other bodies emphasize the need to target help on these individuals. Various attempts have been made to improve access to employment for people with severe mental health problems. These include the development of sheltered work settings, clubhouse models and social firms, and, more recently, integration into competitive work settings without prior preparatory steps, following the Individual Placement and Support (IPS) approach. As macroeconomic pressures mount and public budgets face substantial cuts, it becomes all the more pressing to know whether such help is cost-effective (do the outcomes justify the costs?) and to gauge its budget impact (what is the impact on overall expenditure?).
The EQOLISE Study
IPS has emerged as an effective way to help many people with severe mental illness obtain competitive employment and could potentially contribute to social and economic inclusion. IPS seeks to place people in open paid employment, providing them with intensive and ongoing support.
A multisite randomized trial of IPS (the EQOLISE study) has been the first to directly examine the hypothesis that IPS would prove more effective than comparison services in Europe. The trial randomly assigned 312 individuals with severe mental illness (schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features, using IDC-10 criteria) to receive either IPS or standard vocational services and followed them for 18 months. The sample was drawn from six European cities: Groningen (Netherlands), London (UK), Rimini (Italy), Sofia (Bulgaria), Ulm-G€unzburg (Germany), and Zurich (Switzerland).
The EQOLISE trial found that IPS was more effective than vocational services for every vocational outcome studied: 85 (55%) of the individuals assigned to IPS worked for at least 1 day during the 18-month follow-up period compared with 43 (28%) individuals assigned to vocational services. Individuals assigned to vocational services were significantly more likely to drop out of the service (45%) and to be readmitted to hospital (31%) than people in the IPS arm of the trial (13% and 20%, respectively). The trial also found that context was important, with local unemployment rates explaining a substantial proportion of the observed variation in IPS effectiveness.
As in the United States, Canada, Australia and Hong Kong, the study found that IPS participants were much more likely to work in competitive settings and worked more hours than individuals receiving comparison services.
The study conducted a cost-effectiveness analysis with two primary outcomes: additional days worked in competitive settings and additional percentage of individuals who worked at least 1 day. Analyses distinguished country effects. A partial cost-benefit analysis was also conducted. IPS produced better outcomes than alternative vocational services at lower cost overall to the health and social care systems and would be viewed as more cost-effective than standard vocational services.
This is not merely a case of helping people move from unemployment to employment, fundamentally important though that is, but of addressing needs of people facing long-term disadvantage. Employment is both a source of income and independence and a major contributor to social inclusion, self-determination, and recovery. IPS appears to provide an effective and cost-effective means of helping many people with a serious mental illness to come closer to achieving their employment goals.
Knapp M, Patel A, Curran CM, Latimer E, Catty JC, Becker T, Drake RE, Fioritti A, Kilian K, Lauber C, Rossler W, Tomov T, Van Busschbach J, Comas-Herrera A, White S, Wiersma D, Burns T (2013) Supported employment: cost-effectiveness across six European sites, World Psychiatry, 12, 1, 60-68
Knapp M, Chisholm D, Leese M et al (2002) Comparing patterns and costs of schizophrenia care in five European countries: the EPSILON study. Acta Psychiatria Scandinavica, 105, 42-54