x

Results of a supported employment intervention for people with mood and anxiety (IPS-MA),

and the importance of disclosure

UNIVERSITY OF COPENHAGEN

FACULTY OF HEALTH AND MEDICAL SCIENCES

Lone Hellström, ph.d. cand.scient.san

MENTAL HEALTH CENTRE COPENHAGEN

Agenda

Background

o Development and rationale of the IPS-MA method

Results

o The Randomised Trial

o Trajecories of return to work

Discussion

� The importance of disclosure

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Background

� 15.000 disability pensions granted in Denmark in 2011

� 1:4 due to non-psychotic disorders like mood and anxiety disorders

� Supported employment effective for people with severe mental illness

� Lack of evidence regarding support in return to work or education for people with mood or anxiety

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What we knew before – vocational rehabilitation

Two different approaches to vocational rehabilitation:

� Pre-vocational rehabilitation (train and place). People are trained in company internship programs, sheltered work shops or wage subsidizedjobs before obtaining competitive employment

� Supported employment (place and train). People are supported in a rapid search for competitive employment with on-going support afteremployment

� Individual Placement and Support (IPS) is the most intensively studied

� Good evidence that IPS is effective in supporting people with severemental illness in their return to work, primarily for patients with schizophrenia

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From Sherpa to IPS-MA

SHERPA pilot

Development of the method inspired by pilot, IPS and available literature

Individual placement and support (IPS) -

modified, early intervention for people with mood and anxiety disorder

(IPS-MA)

Effectiveness of IPS-MA in randomised trial with fidelity measurement

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IPS principles Included in IPS-MA

1. Eligibility is based on client choise, no one is excluded (√)

2. Focus is on competitive employment √

3. Rapid job search √

4. Integration of mental health and employment services ÷

5. Attention to client preferences √

6. Employment specialist builds relationship with employers (√)

7. Time-unlimited and individualized support √

8. Personalized benefits counselling (√)6

Organisation of services

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Cooperation between services in the organisation to day

Organisation in the IPS-model in Denmark

Organisation of SHERPA in the IPS-MA trial

IPS-MA

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IPS-MA dual tracked:

� Mentor support in handling everyday life

� Career counselling supporting return to work or education

Interdisciplinary team:

� Mentors are experienced mental health professionals (nurses, occupational therapists, social workers etc)

� Career counsellors have experience from recruitment and human ressources.

� Mentor and career counsellor work closely together throughout the intervention

� Support is timely unlimited

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The randomized trial

Services as usual

Control group, n=164 IPS-MA group, n=162

Services as usual

326 participants with anxiety, depression

or a bipolar disorder

Randomization

1 year follow-up

2 year follow-up

IPS-MA

IPS-MA intervention

Mental health

services

Job center

Sherpa

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Career counselling

Help clarifying private economy Outreach to employers

Coordination of services

Individualisedmentor support

Fidelity assessments

High fidelity at all four assessments!

� The method was well implemented, and support provided in goodcompliance with the IPS-MA principles

Remarks on ‘Outreach to the workplace’ at all four measures:

� not used in practice due to lack of disclosure

� Support only provided ‘behind the scene’

� Limited support in negotiating workplace accommodations and maintaining employment

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RESULTS

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Baseline characterstics

IPS-MA (n=162 ) SAU (n=164 )

Gender, n (%) Female 115 (71) 106 (65)

Age, mean (SD) 34 (10) 36 (11)

Diagnosis, n (%) Depression (F30, F32-39)

Phobic anxiety (F40)

Other anxiety (F41)

Bipolar disorder (F31)

112 (69)

13 (8)

19 (12)

18 (11)

113 (69)

12 (7)

20 (12)

19 (12)

Match group, n (%) Match group 2

Match group 3

106 (65)

56 (35)

108 (66)

56 (34)

Education, n (%) <High school

> High school

63 (39)

99 (61)

49 (30)

115 (79)

Civil status, n (%) Cohabitant

Non-cohabitant

61 (38)

101 (62)

59 (36)

105 (64)

Income support, n (%) Sickness benefit

Education grant (not active)

Social security

Other/none (savings, spouse)

87 (54)

19 (12)

43 (26)

13 (8)

101 (61)

14 (8)

40 (25)

9 (6) 13

Primary outcome – RTW at 24 months

Number returned to employment or education of 326 participants

randomised to control group (n=164) or IPS-MA (162)

N (%) OR (exp(B)) 95% CI p-value

Control group

IPS-MA

62 (37.8 %)

72 (44.2 %)

1

1.34* 0.86-2.10 0.20

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*: adjusted for diagnosis and match group at baseline.

Secondary and exploratory outcomes 12 months 24 months

Employment/education

� Number returned NS

� Assessed ready to work NS NS

Level of Symptoms

� Depresion NS NS

� Anxiety NS NS

Level of function

� GAF-F (interview) NS NS

� PSP (interview) NS NS

� SDS (self-report) NS NS

Quality of life NS

Empowerment Scale NS NS

Readiness to change p=0.03 NS

Satisfaction with treatment p=0.01 p=0.0215

Exploratory - Weeks until return to work

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TRAJECTORIES OF RTW

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Return to work - traditionally

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Baseline 1 year 2 years

Number of weeks in employment in past 6 months

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Trajectories of ‘weeks in employment in past 6 months’

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0,00

5,00

10,00

15,00

20,00

25,00

Baseline ½ year 1 year 1½ year 2 year

we

ek

s in

wo

rk l

ast

6 m

on

ths

Delayed-RTW (19%) Non-RTW (70%) Rapid-RTW (4%)

Rapid-unstable-RTW (7%) Average (one-class)

Discussion

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Challenges related to the IPS-MA method:

� Lack of integration of services

� Ongoing treatment and support

� Lack of disclosure –> insufficient workplace intervention

Disclosure - recommendations

� Disclosure should be:

� Discussed using a systematic approach (for instance CORAL)

� Pros and cons

� Needs (e.g. accommodations, support)

� Values (e.g. role model, challenge attitudes)

� When to disclose

� Who to disclose to

� Discussed repeatedly, also if people say no the first time

� An individual choice

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Thank you very much for your attention!

Lone.Hellstroem@regionh.dk