Strategies for improving employment outcomes for people with psychosis. Commentary on: Severe mental illness and work – What can we do to maximise employment opportunities for individuals with psychosis?

One of the disappointing findicsis (SHIP) (Morgan et al., 2012) was the low rate of employment among people with a psychotic disorder. This comprehensive survey used a two-phase sampling methodology across mental health service catchment areas covering approximately 10% of Australians aged 18–64 years in order to identify people in contact with public specialised mental health services (inpatient, outpatient, ambulatory and community services) and non-government organisations supporting people with mental illness over a 1-year period. Based on the full interviewed sample of 1825 participants, only 21.5% had been working in the week prior to interview and 32.7% at any stage in the previous year. By comparison, 72.4% of the general population aged 15–64 years were employed in July 2010 (Australian Bureau of Statistics, 2010). In the week prior to interview, the labour force participation rate among SHIP participants was estimated at 30.5%, under half that of the general population participation rate (65.3%), and the unemployment rate was estimated at 27.4%, five times that of the general population (5.0%) (Australian Bureau of Statistics, 2010).

Even more disappointing was the fact that employment outcomes had improved only marginally since the Low Prevalence Psychotic Disorders Study (LPDS), the first national psychosis survey conducted in 1997–98 (Jablensky et al., 2000). To ensure comparability across surveys, the comparison statistics presented in this paragraph are for people in contact with public specialised mental health services in the census month (n = 687 in the 1997–98 survey; n = 1211 in the 2010 survey). This differs from the statistics quoted by Harvey et al., (2013) which are based on the total survey samples and therefore raise potential issues of differences between samples. Comparing LPDS and SHIP, over the 13 year period between the two surveys, the proportion in paid employment in the week prior to interview went up from 24.3% to 30.5% and the proportion with any paid employment during the past year went up from 14.8% to 19.2% (Morgan et al., 2012). The small magnitude of these changes is surprising given the large public investment made between the two surveys in improving employment outcomes for people with a disability. It is also in contrast with marked increases in the use of rehabilitation and non-government organisation services by people with psychosis over the same period, from 22.9% to 36.8% and 18.9% to 26.5%, respectively, and a general improvement in their course of disorder, with the proportion with a continuous chronic form of illness falling from 41.2% to 33.0%.

Employment constructs a framework within which people, including those with psychosis, contribute to their community. They become part of a social network and are financially recompensed, thus gaining greater independence. Many people with psychosis want to work. For example, SHIP participants who were working part-time made up 69.0% of all employed participants. On average they worked 23 hours per week. As many as 27.5% would have preferred to work more hours; only 10.9% wanted fewer hours of work.

What are some of the things we can do to improve employment outcomes for people with psychosis?

First, given that, for many, onset of psychosis is in adolescence/early adulthood, with two-thirds (64.8%) of SHIP participants having onset under the age of 25, a period critical to the consolidation of life skills, it is vital that people with psychosis have access to supported employment/education programs as early as practicable after illness onset, as well as throughout the course of their illness, in order to be able to (re)-engage with the workforce. This is well argued by Harvey et al. and leads into their discussion of supported employment.

Second, current service-based gaps and barriers to finding and keeping employment for people with psychosis need to be clearly identified. Based on the full SHIP sample of 1825, of those looking for work, only 30.5% received assistance from the most appropriate type of employment assistance program while 32.1% received assistance from the least appropriate source of assistance – namely, mainstream services for unemployed persons (Waghorn et al., 2012). Further analysis of the SHIP employment data is underway, assessing how people with psychosis access work programs, the type of work they undertake, the level of support they receive, and correlates of their employment outcomes.

Finally, integration of treatments is essential to improving occupational outcomes. Psychotic illness affects many domains of functioning including biological, psychological, neurocognitive and behavioural. Psychopharmacotherapy is important for symptom reduction but needs to be augmented by other evidence-based interventions in order to target this broad range of affected domains. Psychosocial treatments such as cognitive remediation and psychosocial rehabilitation address multiple levels of functioning and play specific roles in reducing disability and improving functioning (Gold, 2004; Wykes et al., 2011). It is of some concern that, while 94.4% of SHIP participants had taken medication in the 12 months prior to interview for their mental health, only 38.6% had received some form of psychosocial intervention.

Employment rates remain poor among people with psychosis. Supported employment and education programs integrated with optimal employment service support and delivery are important as soon as practicable after illness onset and throughout its course to reduce levels of unemployment. However, given the multifaceted nature of deficits and impairments in psychotic illness, these programs need to be underpinned by best-evidence pharmacological and psychosocial interventions within a personalised, collaborative model of care that tailors interventions to individual needs. Such an integrated approach will facilitate better outcomes and improved recovery rates for people with psychosis.

See Viewpoint by Harvey et al., 2013, 47(5): 421–424.