Abstract
Background
Strong empirical evidence has indicated that the severity of cognitive deficits predicts functional outcome in the early course of schizophrenia, while equally strong evidence has shown that supported employment and supported education can substantially increase the proportion of first-episode psychosis patients who return to school or work. How do these influences on the early course of work/school outcome interface?
Methods
Within a randomized controlled trial of Individual Placement and Support (IPS) and a Workplace Fundamentals Module (IPS-WFM) vs. conventional vocational rehabilitation plus social skills training with 69 individuals with a recent first episode of schizophrenia, we examined both supported employment/education and cognitive deficits in relationship to work/school outcome. A cognitive battery was administered at baseline and after 6 months of randomization to IPS vs. conventional vocational rehabilitation. To examine whether cognitive deficit level at baseline predicted work/school recovery in the context of these treatment conditions, we used as summary scores the first principal component as an overall index of cognitive deficit and the first rotated principal component, a processing-speed/attention factor. We also examined individual cognitive test scores to determine whether IPS-WFM impacted cognitive deficit level.
Results
Within 6 months after randomization, 83% of patients in the IPS-WFM intervention participated in competitive employment or school, compared to 41% in the conventional vocational rehabilitation group (p < .005), indicating a strong impact of supported employment/education. Overall level of baseline cognitive deficit significantly predicted participation in competitive work or school by 6 months in the entire sample (r=0.45, p<.002) as well as separately within the IPS-WFM group (r=0.35, p=.05) and the comparison group (r=0.60, p<.03). Using the Work Personality Profile factors to index work/school performance, we found that the baseline processing-speed/attention factor predicted Task Orientation, Work Motivation, and Social Skills in the full sample (r = 0.47, 0.54, and 0.65, respectively, all p<.01) and in the IPS-WFM group (r=0.39, p<.06; r=0.54, p<.01; r=0.68, p<001, respectively). We found no significant impact of IPS-WFM vs. conventional vocational rehabilitation on cognitive performance from baseline to 6 months.
Discussion
Supported employment/education strikingly improves the odds of returning to work or school after a first psychotic episode. Cognitive deficit levels are not altered, however, and baseline cognitive deficit level continues to play a role in predicting both return to work or school and the quality of work/school performance even in the presence of this enhanced vocational rehabilitation strategy. This pattern of results suggests that supported employment/education is a powerful compensatory intervention that can override in many cases the role of cognitive deficits in limiting return to work or school. Other complementary interventions are likely to be needed to improve the persistent cognitive deficits.