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. Author manuscript; available in PMC: 2013 Mar 1.
Published in final edited form as: Schizophr Res. 2011 Dec 22;135(1-3):100–104. doi: 10.1016/j.schres.2011.11.036

The Efficacy of Supported Employment for Middle-Aged and Older People with Schizophrenia

Elizabeth W Twamley a,b, Lea Vella c, Cynthia Z Burton c, Deborah R Becker d, Morris D Bell e,f, Dilip V Jeste a
PMCID: PMC3288765  NIHMSID: NIHMS343792  PMID: 22197080

Abstract

Objective

Supported employment is the evidence-based treatment of choice for assisting individuals with severe mental illness to achieve competitive employment, but few supported employment programs specifically target older clients with psychiatric illness. The purpose of this study was to evaluate the efficacy of supported employment for middle-aged or older people with schizophrenia.

Method

Participants included 58 outpatients with schizophrenia or schizoaffective disorder aged 45 or older who were recruited from a community mental health clinic. Participants were randomly assigned to receive Individual Placement and Support (IPS; the manualized version of supported employment) or conventional vocational rehabilitation (CVR) for one year, and completed assessments at baseline, six months, and twelve months.

Results

IPS was superior to CVR on nearly all work outcome measures, including attainment of competitive employment, weeks worked, and wages earned. Fifty-seven percent of IPS participants worked competitively, compared with 29% of CVR participants; 70% of IPS participants obtained any paid work, compared with 36% of CVR participants. Within the IPS group, better baseline functional capacity (as measured by the UCSD Performance Based Skills Assessment) and more recent employment were modestly associated with better work outcomes.

Conclusions

Middle-aged and older adults with schizophrenia are good candidates for supported employment services.

Keywords: psychosis, rehabilitation, geriatric psychiatry

1. Introduction

Unemployment is common in schizophrenia (Marwaha and Johnson, 2004) and contributes most to its economic cost (Wu et al., 2002). However, supported employment (SE) is a widely accepted evidence-based practice focused on competitive work attainment (Dixon et al., 2010). Rates of competitive work in SE are 51–70%, compared with 18–24% in conventional vocational rehabilitation (effect sizes .79–.96; Bond et al., 2008; Campbell et al., 2011; Twamley et al., 2003).

The number of middle-aged and older people with schizophrenia is growing quickly (Palmer et al., 1999), but services have not kept pace. Age does not predict work status in this population or work outcomes in SE programs (Bond and Drake, 2008; Dixon et al., 2010; Bell et al., 2005), but few SE programs specifically target older clients. Many older consumers want to work (Auslander and Jeste, 2002), but the average age of study participants is only 38 (Bond et al., 2008), leaving most service-users under-studied and underserved. Older consumers may have less severe psychiatric symptoms, less substance abuse, and more work experience (Folsom et al., 2009; Jeste et al., 2003; Patterson and Jeste, 1999), but they also face barriers including ageism, longer absences from the workforce, and age-related cognitive decline.

We report the results of the first randomized controlled trial of SE for middle-aged and older people with schizophrenia. Individuals aged 45 or older were included, given the 20% shorter lifespan and earlier onset of “middle-age” in schizophrenia (Kirkpatrick et al., 2008). When compared with conventional vocational rehabilitation (CVR), we hypothesized that Individual Placement and Support (IPS; the manualized version of SE; Becker and Drake, 2003) would produce higher levels of job attainment, weeks worked, dollars earned, and faster job placement.

2. Methods

2.1. Participants

Participants (see Table 1) included fifty-eight outpatients with schizophrenia (n=23) or schizoaffective disorder (n=35) from a community mental health clinic, all aged 45 or older, unemployed, and stating a goal of working. Participants were excluded for substance abuse/dependence within 30 days, history of head injury with loss of consciousness over 30 minutes, mental retardation, or neurological disorders. Most participants were middle-aged (mean=51; oldest=60) and had a “poor vocational outcome” (79% without significant paid work in two years; Bellack et al., 1999), but 86% had once worked at least 12 months continuously. After complete description of the study to the subjects, written informed consent was obtained. The study was approved by the IRB and conducted in accordance with the Declaration of Helsinki. Fifty participants were included in a preliminary report focusing on job acquisition rate (Twamley et al., 2008).

Table 1.

Sample characteristics

CVR (n=30) IPS (n=28)
Mean (SD)/% Mean (SD)/% t* or χ2 df* p
Demographic variables
   Age, years 51.75 (5.08) 50.30 (3.47) −1.26 47.24 .214
   Education, years 12.43 (2.71) 12.43 (2.40) 0.01 54.03 .994
   Gender, % male 53.6 73.3 2.45 1.00 .118
   Ethnicity, % Caucasian 57.1 63.3 0.23 1.00 .630
Illness-related variables
   Diagnosis, % schizoaffective 67.9 53.3 1.28 1.00 .259
   Antipsychotic Type 4.37 3.00 .224
     None 10.7 13.3
     Atypical 78.6 66.7
     Typical 10.7 6.7
     Typical and atypical 0.0 13.3
   Daily antipsychotic dose, CPZE 258.46 (255.49) 390.49 (444.71) 1.34 41.48 .188
   Duration of illness, years 23.43 (11.52) 24.97 (10.05) 0.54 53.75 .591
   PANSS - Positive Total 14.91 (6.24) 15.86 (4.13) 0.62 36.78 .537
   PANSS - Negative Total 17.00 (5.85) 15.21 (5.41) −1.12 45.50 .268
   HAM-D 17 - Total Score 11.27 (7.77) 10.11 (6.52) −0.56 40.92 .575
   Alcohol/substance abuse during study, % 18.2 25.9 0.42 1.00 .518
Work experience variables
   Monthly entitlement income, dollars 828.90 (312.24) 830.91 (285.14) 0.64 53.71 .525
   Time since last job, years 7.67 (6.83) 6.02 (7.29) −0.88 54.90 .381
   Percent of lifetime working 55.25 (27.68) 50.81 (29.22) −0.58 52.83 .565
   UPSA - Total Score 84.12 (9.52) 83.76 (10. 12) −0.13 44.78 .901
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Note.

*

t and df for unequal variances used. CPZE = chlorpromazine equivalent; CVR = Conventional Vocational Rehabilitation; HAM-D = Hamilton Depression Rating Scale; IPS = Individual Placement and Support; IQ = Intelligence Quotient; PANSS = Positive and Negative Syndrome Scale; UPSA = UCSD Performance-Based Skills Assessment

Twelve participants (IPS=7; CVR=5) dropped out (see CONSORT diagram in Supplemental Data; no significant difference between groups, χ2=0.27, p=0.607). Dropouts were less likely than study completers to be taking atypical antipsychotics (41.7% vs. 80.4%; χ2=10.57, p=0.014), more likely to have a diagnosis of schizophrenia (66.7% vs. 33.3%, χ2=4.61, p=0.032), and had a more remote work history (13 vs. 5 years since last job; t=2.44, df=11.89, p=0.032).

2.2. Procedure

Referrals were made by clinicians and diagnoses were confirmed with DSM-IV criteria-based chart reviews. Participants were randomized to IPS (n=30) or CVR (n=28) for one year, with assessments administered at baseline, 6 months, and 12 months, and work outcome data collected weekly.

IPS

IPS participants received manualized SE (Becker and Drake, 2003) from an employment specialist whose maximum caseload was 25. IPS emphasizes competitive work, integrated mental health and SE services, any client can participate, rapid job searching, service-users’ preferences, time-unlimited follow-along support, benefits counseling, and providing services in community settings. IPS fidelity ratings (Bond et al., 1997), by DRB, improved from “fair” to “good” over the study. “High” fidelity could not be achieved due to study design (only schizophrenia/schizoaffective clients included; study duration was one year; only one employment specialist).

CVR

Participants randomized to CVR were referred to the Department of Rehabilitation for orientation, intake, and eligibility determination, then became clients of a brokered program for individuals with mental illness. Vocational counselors carried caseloads of 35 clients; additional staff provided job-readiness and prevocational coaching/classes. To promote engagement and reduce attrition, study staff assisted CVR participants with appointment-setting, reminder calls, and transportation, if needed, to the first three appointments.

2.3. Measures

The UCSD Performance-Based Skills Assessment (UPSA; Patterson et al., 2001) measured functional capacity in five domains (Household Chores, Communication, Finance, Transportation and Planning Recreational Activities). Psychiatric symptom severity measures included the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) and Hamilton Rating Scale for Depression (HAM-D; Hamilton, 1960). Raters were blinded and reliable (ICCs>.80).

Hours worked and wages earned (verified with pay-stubs) were collected weekly via self-report. Competitive work was defined as employment paying at least minimum wage and not reserved for the disabled; other paid employment included set-aside jobs and work paying below minimum wage.

2.4. Analyses

All analyses were intent-to-treat. Dropouts were assumed not to work (Mueser et al., 2004); zeros were imputed for employment data following dropout. Wages earned and weeks worked were not normally distributed due to zero values, necessitating nonparametric tests (Delucchi and Bostrom, 2004).

Demographic characteristics and time to first job were compared between groups using t-tests and χ2 analyses. Work attainment was examined using χ2 analyses, area under the curve (AUC), and number needed to treat (NNT; Kraemer and Kupfer, 2006). Weeks worked and wages earned were examined with Mann-Whitney nonparametric tests. Pearson and Spearman correlations were used to examine relationships between work outcomes and various predictors within each group.

3. Results

The IPS and CVR groups did not differ on any demographic characteristics (all ps>0.12; see Table 1).

IPS was superior to CVR on most outcome measures (see Table 2). Fifty-seven percent of IPS participants worked competitively, compared with 29% of CVR participants; 70% of IPS participants obtained any paid work, compared with 36% of CVR participants. Rates of competitive employment over time are shown in Figure 1. The AUC for competitive work was 0.64, indicating that IPS yielded better work outcomes than did CVR. The NNT for competitive work (3.56) indicated that providing IPS to about three people would result in one more competitive job than would CVR. AUCs and NNTs were similar for any paid work (0.67 and 2.92, respectively). Table 3 shows jobs obtained. The IPS group had greater median values for weeks worked and wages earned. Those receiving IPS obtained their first competitive job non-significantly faster (94 days) than did those receiving CVR (138 days).

Table 2.

Work outcomes in IPS and CVR

IPS (n=30) CVR (n=28)
% % χ2 df p
Obtained competitive work, % 56.7 28.6 4.66 1.00 .031
Obtained any paid work, % 70.0 35.7 6.84 1.00 .009
Median Median MW Z-Score p
Weeks of competitive work 4.50 0.00 −2.34 .019
(mean=10.50, SD=13.50) (mean=3.61, SD=7.80)
Wages from competitive work $644.17 $0.00 −2.21 .027
(mean=$1857, SD=$2969) (mean=$456, SD=$883)
Weeks of any paid work 5.50 0.00 −2.49 .013
(mean=12.07, SD=14.18) (mean=4.92, SD=9.19)
Wages from any paid work $730.00 $0.00 −2.58 .010
(mean=$2047, SD=$3018) (mean=$607, SD=$1174)
Mean (SD) Mean (SD) t df p
Time to competitive work, days 94.06 (87.99) 138.00(108.10) −1.08 11.55 .336
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Note. Means and SDs for weeks worked and wages earned are provided, but medians were used for inferential statistics due to skewed distributions. CVR = Conventional Vocational Rehabilitation; IPS = Individual Placement and Support; MW = Mann-Whitney

Figure 1.

Figure 1

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Percent of CVR and IPS Participants Working Competitively By Month in Study

Table 3.

Types of employment in IPS and CVR

IPS CVR
Competitive Jobs Competitive Jobs
Amusement Park Worker House Repairer
Baler Kitchen Helper
Bell Ringer Maintenance Repairer
Boat Loader Office Furniture Mover
Carpenter Receptionist
Cashier Sandwich-Board Carrier
Certified Nursing Assistant Stock Clerk
Collection Clerk Telephone Solicitor
Dishwasher
Food Service Driver
Landscape Laborer
Mail Handler
Maintenance Repairer
Membership Solicitor
Merchandise Deliverer
Parking Lot Attendant
Personal Attendant
Receptionist
Service Station Attendant
Social Services Aide
Stock Clerk
Telephone Solicitor
Usher
Other Paid Jobs Other Paid Jobs
Advertising Material Distributor Animal Caretaker
Auto Body Repairer Health Companion
Cook Helper House Repairer
Dining Room Attendant Photocopy Machine Operator
Dishwasher Sales Driver Helper
Election Clerk Social Services Aide
Janitor Teacher Aide
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In exploratory analyses, we examined the bivariate relationships between competitive work outcomes and demographic characteristics, illness-related variables, previous work experience, and UPSA performance (see Tables 4 and 5). In IPS, the longer clients had been unemployed, the less likely they were to work, the fewer weeks they worked, and the less money they earned; higher levels of baseline functional capacity were associated with higher rates of competitive work. In CVR, more severe depressive symptoms were associated with worse work outcomes.

Table 4.

Bivariate correlations between predictor variables and competitive work outcomes in the IPS group (n=30)

Attainment of
competitive work		 Weeks of
competitive work		 Wages from
competitive work
n r p n ρ p n ρ p
Demographic variables
   Age, years 30 −.16 .399 30 −.27 .147 30 −.23 .214
   Education, years 30 .07 .694 30 .08 .661 30 .08 .673
   Gender (male/female) 30 −.22 .236 30 −.13 .503 30 −.07 .703
   Ethnicity (Caucasian/minority) 30 −.31 .094 30 −.22 .241 30 −.21 .259
Illness-related variables
   Diagnosis (schizoaffective/schizophrenia) 30 .13 .508 30 .17 .371 30 .14 .471
   Daily antipsychotic dose, CPZE 27 −.04 .861 27 −.33 .095 27 −.31 .115
   Duration of illness, years 30 −.03 .874 30 −.04 .845 30 −.08 .658
   PANSS - Positive Total 28 −.17 .376 28 −.21 .280 28 −.21 .282
   PANSS - Negative Total 28 −.14 .488 28 −.05 .804 28 −.01 .962
   HAM-D 17-Total 28 .01 .946 28 .08 .676 28 .02 .901
   Alcohol/substance abuse during study (yes/no) 27 .19 .345 27 .14 .498 27 .15 .462
Work experience variables
   Monthly entitlement income, dollars 30 −.24 .209 30 −.08 .688 30 −.08 .677
   Time since last job, years 30 −.40 .030 30 −.36 .048 30 −.43 .017
   Percent of adult lifetime working 29 .34 .072 29 .32 .090 29 .32 .088
Cognitive/Functional variables
   Premorbid IQ estimate 28 −.24 .226 28 −.16 .409 28 −.15 .445
   Attention z-score 29 −.12 .535 29 −.10 .597 29 −.06 .771
   Processing Speed z-score 29 .00 .988 29 .03 .881 29 .10 .591
   Working Memory z-score 29 −.11 .570 29 −.22 .251 29 −.18 .344
   Language z-score 29 .04 .839 29 −.13 .507 29 −.04 .831
   Learning z-score 29 .17 .374 29 .12 .532 29 .14 .468
   Memory z-score 29 .20 .295 29 .29 .120 29 .30 .119
   Executive Functioning z-score 29 −.04 .841 29 −.07 .729 29 −.02 .901
   Global Neuropsychological z-score 29 −.02 .913 29 −.06 .767 29 .00 .986
   UPSA - Total Score 25 .41 .041 25 .37 .072 25 .32 .115
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Note. Bold font indicates a statistically significant correlation; CPZE = chlorpromazine equivalent; HAM-D = Hamilton Depression Rating Scale; IPS = Individual Placement and Support; IQ = Intelligence Quotient; PANSS = Positive and Negative Syndrome Scale; UPSA = UCSD Performance-Based Skills Assessment

Table 5.

Bivariate correlations between predictor variables and competitive work outcomes in the CVR group (n=28)

Attainment of
competitive work		 Weeks of
competitive work		 Wages from
competitive work
n r p n ρ p n ρ p
Demographic variables
   Age, years 28 .11 .574 28 .13 .519 28 .16 .416
   Education, years 28 .19 .320 28 .09 .662 28 .09 .654
   Gender (male/female) 28 .27 .162 28 .32 .094 28 .32 .094
   Ethnicity (Caucasian/minority) 28 −.23 .243 28 −.29 .133 28 −.27 .167
Illness-related variables
   Diagnosis (schizoaffective/schizophrenia) 28 −.24 .215 28 −.25 .201 28 −.21 .275
   Daily antipsychotic dose, CPZE 27 .15 .459 27 .16 .412 27 .12 .554
   Duration of illness, years 28 −.01 .960 28 .03 .873 28 .00 1.000
   PANSS - Positive Total 23 −.10 .664 23 −.07 .753 23 −.09 .667
   PANSS - Negative Total 23 −.27 .206 23 −.33 .124 23 −.25 .256
   HAM-D 17-Total 22 −.50 .018 22 −.73 .000 22 −.70 .000
   Alcohol/substance abuse during study (yes/no) 22 .03 .910 22 .05 .823 22 .05 .823
Work Experience variables
   Monthly entitlement income, dollars 26 .21 .297 26 .15 .458 26 .15 .471
   Time since last job, years 27 −.27 .173 27 −.20 .317 27 −.21 .302
   Percent of adult lifetime working 26 .17 .411 26 .08 .689 26 .11 .610
Cognitive/Functional variables
   Premorbid IQ estimate 22 −.13 .576 22 −.01 .972 22 .00 .995
   Attention z-score 24 .03 .892 24 .11 .615 24 .14 .519
   Processing Speed z-score 24 −.04 .856 24 .06 .797 24 .00 .998
   Working Memory z-score 24 .23 .289 24 .17 .418 24 .17 .436
   Language z-score 24 .13 .555 24 .13 .533 24 .11 .620
   Learning z-score 24 −.07 .729 24 −.05 .812 24 .02 .944
   Memory z-score 24 −.05 .819 24 −.03 .895 24 −.02 .937
   Executive Functioning z-score 24 .10 .655 24 .05 .803 24 .04 .855
   Global Neuropsychological z-score 24 .04 .846 24 .06 .795 24 .06 .780
   UPSA - Total Score 22 .10 .665 22 .04 .854 22 .06 .793
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Note. Bold font indicates a statistically significant correlation; CPZE = chlorpromazine equivalent; CVR = Conventional Vocational Rehabilitation; HAM-D = Hamilton Depression Rating Scale; IQ = Intelligence Quotient; PANSS = Positive and Negative Syndrome Scale; UPSA = UCSD Performance-Based Skills Assessment

4. Discussion

Our results suggest that middle-aged and older people with schizophrenia can benefit from SE: 57% of our sample obtained competitive work, and 70% obtained any paid work. The rate of competitive employment in our IPS group was similar to benchmarks from meta-analyses (51–70%; Bond et al., 2008; Campbell et al., 2011; Twamley et al., 2003) and consistent with retrospective analyses demonstrating that older clients can benefit from SE (Bell et al., 2005; Campbell et al., 2011).

Similar to Campbell et al. (2010), we found that people with more recent work histories had better work outcomes, possibly reflecting better work skills and functioning, or better chances of getting hired with more recent job experience. Better baseline functional capacity was also associated with obtaining competitive work, supporting the UPSA as a predictor not only of current functional status (Mausbach et al., 2008), but also of future functioning.

Consistent with previous work (Bond and Drake, 2008), most demographic and illness characteristics did not predict work outcomes. In CVR, depressive symptoms adversely affected work outcomes, perhaps due to lack of integration between CVR and psychiatric treatment. Unlike some previous work (Campbell et al., 2010), we found that entitlement benefits did not affect work outcomes, although we examined benefit amount, not mere presence of benefits.

Our study has several limitations. Our sample size was small and some of our analyses may have been underpowered. IPS was delivered by a single employment specialist. We considered dropouts not to have worked, although some dropouts may have worked on their own. We did not correct for alpha inflation, and our results should be considered preliminary until they are replicated. Longer studies will be needed to examine the long-term outcomes of SE.

We conclude that middle-aged and older patients with schizophrenia can benefit from SE and should be recruited into SE programs. Although recency of past work and functional capacity were associated with SE outcomes in our sample, the associations were moderate, suggesting that even individuals with remote histories of work or poor functional skills can be successful. Augmenting SE with additional psychosocial treatment (Kern et al., 1999) aimed at reducing individual barriers to work (Campbell et al., 2011) may improve work outcomes and functional recovery more broadly.

Supplementary Material

01

Acknowledgments

The authors gratefully acknowledge the contributions of Amanda Lewis, Nicole Loebach, and Jenille Narvaez to this study.

Footnotes

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Conflict of interest

The authors report no financial disclosures or conflicts of interest.

Contributors

Elizabeth W. Twamley and Dilip V. Jeste designed the study. Elizabeth W. Twamley, Lea Vella, and Cynthia Z. Burton conducted the statistical analyses. Elizabeth W. Twamley wrote the first draft of the manuscript and all co-authors edited and revised the manuscript. Morris D. Bell and Deborah R. Becker assisted with interpretation of data analyses. Deborah R. Becker additionally provided guidance on supported employment implementation and fidelity ratings. All authors contributed to and approved the final manuscript.

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