Characteristics Associated with the Pursuit of Work and School Among Participants in a Treatment Program for First Episode of Psychosis

Abstract

Objective

This study examines the pursuit of education and employment among participants in the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program, a first episode of psychosis (FEP) treatment program emphasizing participation in school and work.

Methods

Data were collected from 2011–2013 on all 65 individuals in the RAISE Connection Program. Descriptive statistics, ANOVA, and multinomial logit random-effects models were used to examine rates of work/school participation and predictors of work/school participation.

Results

Most participants who eventually engaged in vocational activities did so within the first year of participation. Many engaged in both school and work. Those working (alone or with school) had better pre-morbid functioning and cognition and less-severe concurrent symptoms.

Conclusions and Implications for Practice

Participants in FEP programs emphasizing school and work can have high rates of vocational participation, engaging early, and often simultaneously in work and school.

Coordinated specialty care (CSC) services provide a wide range of community-based early intervention services for individuals experiencing a first episode of psychosis (FEP) (Heinssen et al, 2014). Key features of CSC include supported education and employment (SEE) services. CSCs typically serve young people (e.g. ages 15–35) who are transitioning to adulthood. The emergence of FEP often presents challenges to pursuing vocational goals as well as staying in school (Heinssen et al, 2014). Pursuing school and work goals is normative at these ages, and is thus a priority in FEP treatment.

A strong evidence base supports the use of Individual Placement and Support (IPS) for supported employment for adults with serious psychiatric disorders (Bond and Drake, 2014). Supported education services have developed more organically. Some programs combine supported employment and education services, while others utilize separate providers (Manthey et al 2012, Killackey, 2015). Combined services let single specialists work with clients as they move between education and employment (Nuechterlein et al, 2008, Smith-Osborne, 2012), while separate services allow providers to specialize in each service (Ellison et al, 2015). The choice to provide combined or separate services is not necessarily related to program size, as part-time workers can be used to fill these roles.

CSCs have demonstrated improvements in vocational activity (Bond et al, 2015, Rosenheck et al. 2016), and vocational recovery has been associated with full functional recovery (Alvarez-Jimenez et al, 2012). This study examines patterns and characteristics of individuals who pursue school, work, or both, during their participation in a CSC, the Recovery After an Initial Schizophrenia Episode Connection (RAISE) Connection Program (CP), which offered combined education and employment services.

Methods

The RAISE Connection Program

RAISE CP served a total of 65 individuals in Maryland and New York from 2011 to 2013. Details of program implementation have been described elsewhere (Dixon et al, 2015, Essock et al., 2015); inclusion criteria and demographic characteristics are available in the online appendix. Participants were ages 15–35 years old and were followed by the research study for up to two years. As previously reported, participants in RAISE CP showed significantly improved occupational functioning over the course of the study (Dixon et al, 2015, Marino et al, 2015). A full-time specialist trained in the IPS supported employment model, and trained in supported education service delivery, was integrated into each treatment team (Dixon et al, 2015). All participants were eligible to receive SEE services, and the SEE specialist attempted to meet with all participants.

Data

Participants were interviewed at the time they entered RAISE CP and every six months thereafter (at six, 12, 18, and 24 months after entry or until the end of the research project, whichever came first) by trained clinical research interviewers.

Measures

Participants reported whether they were employed at any time since the previous interview and whether they were employed or enrolled in school at the time of the interview. These responses were categorized into a measure of school/work status: those reporting participation only in school, only working, both (either simultaneously or consecutively during the reporting period), or neither. Participants reported demographic characteristics and substance abuse in the past 30 days.

Positive, negative, general, and total symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) (Kay et al, 1987). Also administered were cognition tests (NAB Mazes, BACS Symbol Coding, Letter-Number Test Span, Animals Category Fluency, and Managing Emotions), and the Cannon-Spoor general pre-morbid functioning scale (lower score indicates better functioning (Cannon-Spoor et al, 1982)).

Statistical Analysis

Descriptive analyses examine the time to engagement in school or work, and baseline characteristics, by school/work status. ANOVA was used to test the significance of the means of continuous baseline characteristics across the four school/work status groups (work only, school only, both or neither), and Fisher’s Exact test was used for categorical variables. Multinomial logit random-effects models examined the association between concurrent symptoms (at each time point) and work/school status (at each time point) during participation. Analyses were conducted in Stata 13.1. The Institutional Review Boards of New York State Psychiatric Institute and University of Maryland approved study procedures.

Results

Participants who engaged in vocational activity typically did so within months: 28 participants (43%) engaged in work or school at baseline, rising to 44 (68%) ever reporting vocational activity at some time in the first 6 months, and 51 (78%) in the first 12 months; only two additional participants began vocational activity after their first year of participation (Figure 1). No significant differences were observed in time to enter work/school among the four groups. Of the 53 participants who engaged in vocational activity, 33 (62%) were always engaged in vocational activity until their interviews ended, eight (15%) later stopped, three (6%) stopped but later re-engaged in vocational activity, and nine (17%) were not interviewed again after first reporting engagement in vocational activity. Figure 2 shows the number engaged in work and school at each time point.

Figure 1.

Time to Engagement in Work and/or School

Figure 2.

Percent of Participants Working or in School at Each Interview

Note: Enrollment took place July 2011–February 2013. Research assessments ended June, 2013, thus most participants did not complete research interviews for the full 24 months (Marino et al, 2015). 44 respondents participated in the 12 month interview; one respondent did not respond to work and school questions at that interview.

Nineteen individuals (29%) reported being only in school during their participation in the study, 15 (23%) only working, 19 (29%) in both school and work at some point during their participation, and 12 (18%) were never reported in school or work (Table 1). Of the 19 individuals who reported both school and work during the study, 17 (89%) were engaged in both simultaneously at some point during their participation.

Table 1.

Baseline Predictors of School/Work Status During Enrollment

							Pairwise Comparisons (t-test) p-value
Baseline variables	In school but not work	Working but not in school	In school and working	Neither in school nor working	ANOVA F (df)	p- value	School only vs work only	School only vs both	School only vs neither	Work only vs both	Work only vs neither	Both vs neither
Total [N(%)]	19 (29%)	15 (23%)	19 (29%)	12 (18%)	NA	NA	NA	NA	NA	NA	NA	NA
Demographics
Age [Mean (SD)] [range 16–33]	18.6 (2.2)	25.2 (3.8)	23.4 (4.2)	22.3 (2.8)	12.0 (3)	<0.01a	<0.01	<0.01	<0.01	0.20	0.03	0.39
Female [N (%)]	6 (32%)	6 (40%)	7 (37%)	5 (42%)	NA	0.94b	0.64	0.76	0.59	0.86	0.92	0.79
Race (black vs non-black) [N (%)]	10 (53%)	7 (47%)	7 (37%)	4 (33%)	NA	0.69b	0.74	0.34	0.29	0.58	0.48	0.83
Hispanic [N(%)]	4 (21%)	3 (20%)	5 (26%)	4 (33%)	NA	0.89b	0.94	0.73	0.49	0.69	0.87	0.69
Parent employed	14 (74%)	7 (47%)	10 (53%)	6 (50%)	NA	0.38b	0.12	0.19	0.20	0.74	0.88	0.88
Live with parents	15 (79%)	7 (47%)	12 (63%)	8 (67%)	NA	0.28b	0.06	0.29	0.49	0.37	0.32	0.83
Cognition
NAB Mazes [Mean (SD)]c [range 17–62]	31.2 (8.6)	39.5 (13.0)	44.8 (12.4)	38.9 (10.4)	4.7 (3)	<0.01a	0.04	<0.01	0.06	0.24	0.90	0.19
BACS Symbol Coding [Mean (SD)]d [range 3–63]	28.0 (15.8)	32.1 (12.0)	38.4 (11.6)	28.4 (14.7)	2.1 (3)	0.11a	0.40	0.03	0.95	0.14	0.53	0.10
Letter-Number Test Span [Mean (SD)]c [range 8–62]	32.9 (10.3)	41.4 (11.7)	39.9 (11.9)	38.9 (11.4)	1.9 (3)	0.14a	0.03	0.06	0.18	0.72	0.60	0.83
Category Fluency, Animals [Mean (SD)]e [range 26–64]	39.7 (10.3)	41.6 (7.6)	40.7 (7.9)	38.6 (9.0)	0.3 (3)	0.85a	0.55	0.74	0.77	0.74	0.40	0.54
Managing Emotions [Mean (SD)]e [range 14–77]	36.0 (17.1)	39.2 (11.1)	40.6 (14.0)	45.8 (11.4)	1.1 (3)	0.36a	0.52	0.38	0.08	0.75	0.17	0.29
Substance Use
Tobacco [N(%)]	12 (63%)	7 (47%)	14 (74%)	7 (58%)	NA	0.47b	0.37	0.48	0.79	0.12	0.59	0.38
Alcohol [N(%)]	15 (79%)	12 (80%)	18 (95%)	8 (67%)	NA	0.25b	0.94	0.16	0.49	0.22	0.47	0.08
Marijuana [N(%)]	12 (63%)	11 (73%)	14 (74%)	8 (67%)	NA	0.90b	0.55	0.48	0.83	0.95	0.75	0.69
Other Drugs [N(%)]	6 (32%)	6 (40%)	10 (53%)	3 (25%)	NA	0.46b	0.69	0.23	0.65	0.47	0.43	0.12
Pre-Morbid Functioning
Cannon-Spoor General Scoref [range 0.11– 4.2]	2.2 (0.8)	1.5 (0.9)	1.2 (0.8)	2.0 (1.0)	5.1 (3)	<0.01a	0.02	<0.01	0.61	0.43	0.16	0.05

^aSignificance test based on ANOVA;

^bSignificance test based on Fisher’s exact test

^cn=63;

^dn=61;

^en=62;

^fn=60

Participants observed in school only were significantly younger than the other groups (mean age 18.6, p<0.01) (Table 1). Those observed working (only or along with school) had higher NAB Mazes cognition scores (39.5 and 44.8, respectively) while those only in school had the lowest (31.2) (p<0.01), and better scores on the Cannon-Spoor General Pre-Morbid Functioning score (1.5 and 1.2) (p<0.05). No significant differences were seen across the groups by other baseline demographic variables, substance use or other cognitive variables. 62 participants (95%) used the SEE specialist at least once during their participation and 59 (91%) used the SEE specialist at least three times; no significant differences between school/work groups were observed.

Over the duration of program participation (Table 2), higher concurrent PANSS symptoms (negative, general, and total symptoms) were associated with lower likelihood of working (only or with school) (p<0.05). Higher concurrent positive symptoms were associated with lower likelihood of working only (p<0.05).

Table 2.

Symptoms and Work/School Status

	Work/School Status Relative RiskRatio (RRR) [95%CI] (reference group: Neither in school nor working)
	School Only	Work Only	Both Work and School
Symptoms
Positive score	0.92 [0.84–1.01]	0.86 [0.78–0.95]	0.94 [0.85–1.04]
Negative score	1.00 [0.93–1.07]	0.86 [0.78–0.94]	0.82 [ 0.72–0.92]
General score	0.96 [0.90–1.02]	0.87 [0.81–0.93]	0.90 [0.83–0.98]
Total score	0.98 [0.95–1.01]	0.92 [0.89–0.95]	0.94 [0.90–0.98]

Note: Bold indicates significance (95% level).

Discussion

Participants in FEP programs emphasizing school and work can have high rates of vocational participation, engaging early, often simultaneously in work and school. These high rates of participation occurred even while clients were learning to manage a newly emerged illness that can present challenges to pursuing vocational goals. Participants who began school or work tended to do so within the first year. This underscores the desirability of providing rapid access to SEE services, which is a principle of IPS (Swanson and Becker, 2013).

Nearly 30% of participants engaged in both school and work, often at times simultaneously. Thus, participants may need assistance in navigating school and work as well as the transitions in between in order to achieve their long-term goals. This points to the benefits of providing supported education and employment services from a single provider (Manthey et al 2012).

Those who pursued school only tended to be younger than those working. This is not surprising, as most young people age 21 and under are enrolled in school (US Census, 2014). Individuals who were working (only or with school) typically had better pre-morbid functioning and cognition, and lower symptoms than those who were not working. There may be several reasons for this.

Individuals who have stronger cognitive skills and appear less symptomatic may be more appealing to employers. Employers may be less tolerant of poor performance than schools, as employers may incur economic costs when retaining a poor performer. Conversely, public K-12 schools are required to accept anyone who meets eligibility requirements, and may offer greater accommodations for disabilities (US Dept of Ed, 2016) than are offered by many employers. Moreover, performance may be more difficult to monitor in school, as exams and other assessments may occur infrequently, whereas work output may be continually measured.

Study limitations should be noted. RAISE CP had a relatively small sample size (n=65), and the study ended before all had been observed for the maximum two-year period (Marino et al, 2015). Any changes occurring after the end of research interviews would not have been captured, and it is possible that some who never reported vocational participation would have if they had been observed for the full two-year period. As this was a self-reported, observational study with no control group, we cannot determine causality.

Despite the limitations, this study provides insight into the characteristics of individuals with FEP pursing work or school. The study supports the utility of CSC programs offering supported education and employment services from the same staff person rather than separating these functions and in offering these services early in a person’s participation in CSC. Future research should examine participants’ motivations for pursuing vocational activities and whether particular accommodations might make it easier for individuals with greater symptoms to succeed in the labor market.