Drake 1996.
| Methods | Allocation: randomised Method: multicentre Duration: 18 months Country: New Hampshire, USA |
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| Participants | N = 143 Diagnosis: a major mental illness with major role dysfunction of at least 2 years and clinical stability (i.e. out of the hospital) for at least 1 month 47% schizophrenia and related psychotic disorders, 43% bipolar and other severe mood disorders Setting: CMH centres Age: 20‐65 years, mean 37.0 years Gender: 48% male Ethnicity: 95% white Substance abuse: 20% alcohol use/dependence, 11% drug abuse/dependence Living situation: 84% independent, 9% community residence Marital status: 50% never married, 38% separated/divorced, 10% married, 2.1% widowed Employment status: unemployment for at least 1 month, 36% currently working in non competitive employment (22% sheltered workshop), 0% in competitive employment Motivation: interest in competitive employment Work history: good employment histories Education: 40% > high school, 34% high school, 26% < high school Disability benefit: not reported Excluded: significant memory impairment, medical illness or substance dependence that would preclude participating in a training programme |
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| Interventions |
IPS (N = 74) IPS used a team approach to integrate mental health and vocational services. Employment specialists were hired by mental health centres and attached directly to clinical teams to ensure coordinated services. Rather than providing pre‐employment assessment and training in job‐related activities, IPS employment specialists began helping clients to find jobs immediately and, after securing employment, provided training and follow‐along supports as needed. Implementation of IPS differed in the two cities. Both IPS programmes assisted some clients in obtaining volunteer work and sheltered jobs. In one site, these jobs were used as a means of transitioning clients to competitive work. In the second site, however, employment specialists placed more emphasis on sheltered jobs and used them for assessment and long‐term placement, contrary to the IPS model. Despite feedback to supervisors from the project director, this pattern persisted throughout the study, and this site was considered to have a weaker implementation of IPS. The research director monitored implementation through visits and reviewed computerised data. Data generally supported fidelity. Group skills training (GST) (N = 69) The programme offered individualised intake, pre‐employment training in a group format, individualised placement and support on the job, liaison with mental health providers, and follow‐along supports. The pre‐employment training was designed to develop awareness and skills in the three areas of choosing, getting, and keeping a job. In addition to discussing and practicing the skills needed for these tasks, clients were encouraged to explore work‐related values and to understand realistically their strengths and weaknesses as workers. Following the initial skills training, clients met with staff in a group twice each week to continue building interview skills and to discuss potential job leads and interviews. Once employed, clients continued to receive individual support services from GST staff. |
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| Outcomes | Percentage of participants who obtained competitive employment Dropouts Mental health (BPRS, no data available) Quality of life (QOLI, no data available) |
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| Notes | Competitive employment was defined as work in the competitive job market at prevailing wages supervised by personnel employed by the business | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Clients were stratified on the extent of previous employment and randomly assigned within site |
| Allocation concealment (selection bias) | Unclear risk | No details |
| Blinding of participants and personnel (performance bias) All outcomes | High risk | Participants and personnel could identify the intervention by contents of the programme |
| Blinding of outcome assessment (detection bias) All outcomes | High risk | Employment was assessed weekly by employment specialists and by direct interviews with clients. No details about blinding, but unlikely |
| Incomplete outcome data (attrition bias) All outcomes | Low risk | Data were obtained for 140 of 143 participants. Two dropped out of the study, and one participant died (IPS lost 2, GST lost 1) |
| Selective reporting (reporting bias) | Low risk | All listed outcomes reported |
| Other bias | Low risk | This work was supported by US Public Health Services Grant MH‐00839 from the National Institute of Mental Health and Grant MH‐47650 from the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration and by the New Hampshire Divisions of Mental Health and Vocational Rehabilitation, the Mental Health Center of Greater Manchester, the Central New Hampshire Community Mental Health Services, and the Employment Connection Specialists. Group equivalence upon study entry was tested for 78 variables. Significant differences were found for two variables. IPS participants were less likely to report that they were not working because of mental disability, and they had more favourable scores on the Rosenberg Self‐Esteem Scale than did GST enrollees |