Person-related predictors of employment outcomes after participation in psychiatric vocational...

Soc Psychiatry Psychiatr Epidemiol (2005) 40 : 408–416 DOI 10.1007/s00127-005-0910-5

■ Abstract Background There is increasing recognitionof the importance of psychiatric vocational rehabilita-tion (PVR) programmes in helping individuals with se-vere mental illnesses to find and secure jobs. However,little is known concerning the factors related to PVRoutcomes. Objective This review identifies those person-related factors which most strongly influence employ-ment outcomes after participation in PVR programmes.Method Medline, Psychinfo, Pubmed and CINAHL weresearched for studies using multivariate analysis of lon-gitudinal data, which analysed employment outcomesafter at least 6 months of programme participation, andwhich analysed at least three predictor domains. ResultsEight studies presented in 16 publications met all thecriteria. Better employment outcomes were moststrongly related to better work performance measuredduring PVR participation and to higher work-relatedself-efficacy. Better social functioning during PVR par-ticipation was also significantly related to positive em-ployment outcomes, but this relationship was generallyweaker than those of the two aforementioned factors. Inmost studies, employment outcomes after PVR were notrelated to past functioning, including work history and

diagnosis. Findings on the severity of psychiatric symp-toms measured during PVR were mixed. In terms ofcontribution to outcome, severity of symptoms usuallyranked below work performance, when measured con-currently. Conclusion Contrary to previous reviews, thisstudy suggests that the influence of past functioning, in-cluding work history, diagnosis and psychiatric history,is outweighed by work performance in PVR. Furtherprospective and controlled studies are needed to reachmore definite conclusions about the individual contri-butions of person-related factors.

■ Key words vocational rehabilitation – severe mentalillness – outcome prediction – review

Introduction

Many individuals with disabilities resulting from severemental illness need training and support to find andmaintain jobs. This need has been addressed by a vari-ety of specialised psychiatric vocational rehabilitation(PVR) programmes. The efficacy of one such pro-gramme, Individual Placement and Support (IPS), issupported by strong evidence [1–7]. Other highly re-garded programmes, like Transitional Employment(TE) [8] and the Choose-Get-Keep approach [9], havenot yet been evaluated as rigorously as IPS. Neverthe-less, these programmes are still in circulation and someof their elements have even been incorporated into IPS[10].

An important question is whether personal aspectssuch as work performance and illness-related factors arein some way related to PVR outcomes [11, 12].While theresults of research into this topic would not be used toscreen out the most disabled candidates, they couldguide attempts to match clients with PVR models and toidentify the most suitable rehabilitation goals.

In our view, a comprehensive theoretical predictionmodel should have five distinct domains (see alsoBolton et al. [13] whose model is incorporated in this

ORIGINAL PAPER

Harry W. C. Michon · Jaap van Weeghel · Hans Kroon · Aart H. Schene

Person-related predictors of employment outcomes afterparticipation in psychiatric vocational rehabilitation programmesA systematic review

Accepted: 21 December 2004

SPPE

910

H. W. C. Michon, M.A. (�) · H. Kroon, Ph.D.Research unit of ReintegrationDept. of Cure, Care and RehabilitationTrimbos Institute (The Netherlands Institute of Mental Health andAddiction)P. O. Box 7253500 AS Utrecht, The NetherlandsTel.: +31-30/297-1100E-Mail: [email protected]

J. van Weeghel, Ph.D.Dept. of Cure, Care and RehabilitationTrimbos InstituteUtrecht, The Netherlands

A. H. Schene, M.D., Ph.D.Program for Mood DisordersDept. of PsychiatryAcademic Medical Center, De MerenAmsterdam, The Netherlands

408_416_Michon_SPPE_910 27.04.2005 10:51 Uhr Seite 408

409

scheme). These are: (a) demographic variables, i. e. fac-tors such as gender and age, representing static charac-teristics; (b) personal history, i. e. factors such as workexperience and pre-morbid social functioning, repre-senting characteristics which, while irreversible, can becompensated for; (c) current personal functioning inPVR programmes, i. e. all aspects of functioning such ascurrent work skills or social skills, representing charac-teristics that can be potentially influenced directly or in-directly by PVR; (d) PVR characteristics, i. e. factors rep-resenting intervention content, such as the nature of thevocational services provided; and (e) contextual vari-ables, i. e. aspects referring to the broader environment,which have their own impact on PVR, such as local andnational legislation and regional socio-geographic as-pects.

The present review focuses on person-related predic-tors (i. e. the first three domains) and on the relative con-tributions of various factors within these domains. Rel-evant sub-domains within ‘personal history’ (b) are:work history, psychiatric history (including diagnosis)and other past functioning (e. g. educational back-ground and social functioning). Sub-domains within‘personal functioning in PVR programmes’ (c) are: cur-rent work performance (e. g. generic work skills in thefirst programme phase), illness-related characteristics(e. g. severity of symptoms) and current functioning inother areas (e. g. social and cognitive functioning duringthe programme). This classification is a response to theview that future vocational or job performance is moststrongly associated with current or past aspects of work,while functioning in other areas might act as a mediat-ing factor.

Various recent reviews have focused (either exclu-sively or partly) on predictors of vocational outcomesfor individuals with psychiatric disabilities [14–19]. Acommon finding of these reviews is that better employ-ment outcomes are strongly associated with better past(social) functioning [14, 16, 18], and most strongly withmore favourable work histories in particular [14–19].There is some evidence that a more extensive psychiatrichistory (e. g. number of hospitalisations) is related topoorer vocational outcomes [14, 16–19]. Another find-ing common to most of these reviews is that individualswith a diagnosis of schizophrenia/psychosis spectrumtend to have less favourable employment outcomes thanthose with other diagnoses [14–18].Also,most recent re-views report a tendency for people with more severe(negative) psychiatric symptoms to have poorer em-ployment outcomes [14–18].

Regarding current functioning, some reviews reportthat better employment outcomes are related to betterwork performance as measured in PVR [16,17,19].Mostreviews concluded that better employment outcomesalso seem to be related to better current social function-ing [15–17] or to social (work) skills [15–17, 19].

However, all previous reviews in this area share cer-tain limitations. Firstly, they fail to clarify their publica-tion inclusion criteria, nor is there any systematic exam-

ination of the studies’ methodological quality. Secondly,while the findings of longitudinal studies are obviouslymore valid than those of cross-sectional studies in termsof prediction, there is no systematic attempt to disen-tangle these two distinct designs. Thirdly, there is no at-tempt to distinguish between different vocational out-come domains. For instance, the results of studies thatdefine outcome as (improvement of) work skills withinsheltered PVR work environments are pooled with theresults of studies that define outcome as obtaining ormaintaining a job outside the programme.

Another feature shared by previous reviews is thatthere is no systematic distinction between the results ofstudies restricted to PVR participants and broader-based studies (e. g. of patients discharged from hospital,including those who did not receive PVR). One excep-tion is a review by McGurk and Mueser [20]. However,their review considers only two specific sub-domainsmentioned here, severity of symptoms and cognitiveabilities.

The results of studies restricted to those participat-ing in vocational rehabilitation programmes should beanalysed separately from those obtained from othersamples. PVR programmes are generally intended forindividuals who aspire to some kind of vocational goal.Thus, some predictors that work reliably for the broadpopulation of individuals with mental illness might beless valid or powerful within the restricted population ofparticipants in vocational rehabilitation programmes[18, 20]. Anthony hypothesised, for example, that the in-fluence of a good work history might diminish once par-ticipants had been offered the chance to gain work ex-perience [19].

Finally, previous reviews do not systematically dis-tinguish studies using bivariate or ‘zero order’ analyses(examining each relationship between predictor vari-able and outcome separately) from those using multi-variate analyses (examining the combined influence ofpredictor variables).

The present review identifies those variables that aremost strongly related to obtaining and maintaining em-ployment, following participation in a psychiatric voca-tional rehabilitation programme. For this purpose, mul-tivariate analyses are more appropriate than bivariateanalyses, because only the former analyses provide as-sessments of the relative contribution of variables toemployment outcome. Accordingly, the focus here is onthe results of studies using multivariate analyses.The re-sults of this review will be compared to the findings ofearlier reviews.

Subjects and methods

■ Search

In the period prior to September 2003, searches were carried out onMedline,Psychinfo,Pubmed and CINAHL (Nursing and Allied Health)for articles on the vocational rehabilitation of individuals with severemental illness. Various key words and phrases relating to vocational


410

rehabilitation were used. Some examples are vocational rehabilita-tion, supported employment, work adjustment training, occupationalrehabilitation, and work therapy. These were combined with keywords for severe mental illness, e. g. chronic mental illness, chronicpsychosis, schizophrenia, severe* mental* ill*, psychiatric* disab*, se-vere mental disorders, serious mental* ill* (further details availablefrom the first author upon request). There was no limitation on theyear of publication. The reference lists of reviews on this topic werealso checked. All preliminary hits were scanned for the following cri-teria: context is PVR for individuals with SMI; all study participantsreceived vocational services; multivariate analysis of longitudinaldata; analysis of employment outcomes at least 6 months after start-ing programme participation; analysis of at least three predictor do-mains of the model featuring in this review; appropriate choice ofanalysis. As the focus of this review is on finding and keeping em-ployment, vocational outcome measurements were excluded wherethese related to aspects of prevocational training such as (improve-ment of) work skills within sheltered PVR work environments or ex-pectations of outcomes during PVR participation.

■ Coding

All articles which initially fulfilled the aforementioned criteria werecoded for specific characteristics, e. g. PVR type and format (first twoauthors). They were also awarded a quality score, using a checklistspecially developed for this purpose. The checklist contained ten di-chotomous items (‘yes’ if a criterion was fulfilled, and ‘no’ if it was notfulfilled or inapplicable, see appendix for details). Scores were as-signed on the basis of consensus (first three authors). An aggregatescore on a scale of 0–10 was worked out for all articles. This was thenused to set a threshold value (articles scoring below 6 were excluded).Scores of 6–7 were labelled ‘medium’, and scores of 8–10 were labelled‘good’.

■ Analysis

The analysis focuses on studies rather than on articles or analyses.Publications whose samples overlapped (either partially or com-pletely) were regarded as belonging to one study.The studies were ini-tially analysed for predictors within specific outcome domains (find-ing competitive employment, finding paid employment, andmaintaining employment). This was followed by an overall analysis,regardless of outcome domain. The findings of a given study countedonly once in each analysis. Whenever a characteristic was signifi-cantly related to outcome in one or more publications deriving from

a given study, the result was counted, even if other publications basedon that study failed to find a significant relationship.

Some studies used a ‘pre-analysis – final analysis’ procedure, as asmall sample size prevented all of the independent variables from be-ing examined at once. This means that a first round of separate pre-analyses was carried out to explore separate sub-sets of independentvariables (e. g. all variables related to illness such as psychiatric his-tory or symptoms) to find out which of these showed the strongest re-lationship with the outcome measure. Those studies subsequentlyperformed a final analysis, which was restricted to these ‘winning’variables. In cases of this kind, we counted only the results of the ‘fi-nal’ analysis model.

Results

Table 1 lists the eight separate studies, represented by 16publications included in the review [7, 21–35]. Of the 77articles containing empirical information on predictorsof PVR outcome, 61 articles were excluded. Of these, 49were excluded because they were not longitudinal andmultivariate studies. Another 12 articles were excludedfor one or more of the following reasons. Firstly, becausethe outcome measurements were restricted to perfor-mance within PVR (e. g. improved performance duringparticipation in PVR, or expected outcome) [36–41].Secondly, because they studied only a single predictordomain [42, 43], or, thirdly, because they did not pass thequality threshold, i. e. more than five ‘no’ answers on thequality checklist [44–46]. One of these 12 articles was ofa high standard, but the canonical correlation analysisused an outcome definition that mixed salary level withlevel of residence. This made it difficult to draw clear in-ferences about predictions of the ‘employment part’ ofthe outcome [47].

The sample sizes used by the studies included hereranged from 60 to 907.The mean age of participants rep-resented in the samples ranged from 28 to 37 (overallmean 33). The percentage of female participants variedfrom 49 to 70. The percentage of individuals with a di-

Appendix Parameters for quality coding

Item Criterion

1. Prediction is the main focus of the article Yes, if the prediction question is a substantial topic in all sections (introduction, method, results and discussion)

2. The PVR programme concerned is well described Yes, if the type of programme studied is clear and if programme components are described in some detail

3. PVR programme fidelity or quality is examined Yes, if the degree to which the intended model is put into practice is examined

4. Multi-site study design Yes, if the study is conducted at two or more different programme sites

5. Outcome measure(s) are clearly defined Yes, if the nature of the work outcome concerned is defined, clarified and specified in terms of the time involved (e. g. obtained X after Y months or maintained X for Y months)

6. Substantial follow-up time Yes, if a follow-up period of at least six months was used

7. Sufficient predictor domains Yes, if at least three different predictor domains (with a multivariate design) were studied

8. Sufficient sample size Yes, if the ratio of sample size to the number of independent variables was at least 10

9. Sufficient information about substantiality Yes, if details of the significance level of each predictor according to the multivariate analysis are providedof prediction results

10. Sufficient information about associations Yes, if at least bivariate (crude; zero-order) relationships between separate predictors and outcome were between predictors and outcome analysed and if levels of association and significance are presented

The responses to all items must be restricted to ‘Yes’ or ‘No’ answers. PVR Psychiatric Vocational Rehabilitation. A value of one was assigned to ‘Yes’ answers. These werethen added up to produce a total score ranging from zero to ten. Articles receiving a score of less than six were excluded


411

agnosis of schizophrenia/psychosis spectrum variedconsiderably (range 28–100).

The quality scores of the studies included here variedfrom 6 to 9 (see Table 1). Three studies in particular ex-amined a very large number of potential predictors inrelation to the size of the random sample [24–29, 31, 32].These were primarily analyses in which maintainingemployment was the outcome measure.Accordingly, theresults in question may have been sample specific. Noneof the studies concerned corrected for this, for instance,by modifying the significance level. This review is re-stricted to results derived from analyses with a suffi-ciently large sample (relative to the number of predic-tors).

All of the studies selected finding employment as theoutcome [seven used competitive employment, two alsoused finding paid employment (i. e. including non-com-petitive gainful employment), and one used startingsalary]. Four studies also included maintaining compet-itive employment as an outcome variable. Given the lim-ited number of studies and the fact that sensitivityanalyses generally produced similar results, the remain-der of the Results section mainly deals with predictorsof ‘employment outcome’ in general. The term ‘employ-ment outcome’ in this section refers to finding competi-tive or paid work after programme participation. Ta-bles 1 and 2 show the specific outcome definitions usedby the various studies.

■ Identified predictors

Table 2 shows the outcomes of the eight studies.

Demographic factors

Demographic factors rarely proved to be significant pre-dictors of finding and keeping employment after pro-gramme participation. None of the six studies involvedshowed gender to have a significant effect. Cook et al.[21–23] found that individuals with better employmentoutcomes tended to be younger and were less likely tobelong to ethnic minorities.

Psychiatric illness factors

Psychiatric history was included in five studies, one ofwhich showed it to be of significance (participants withmore hospitalisations had poorer employment out-comes [31]). Five studies showed that diagnosis was notsignificant (most of the diagnoses in question were ofschizophrenia,as opposed to other conditions) [7,30,31,34, 35].

Measurements of the severity of psychiatric symp-toms during participation in PVR produced mixed find-ings. Nevertheless, three out of five studies found thatparticipants with more severe symptoms did indeedhave poorer employment outcomes [27, 29–31]. Rekerand Eikelmann [32] also found that the more protracteda participant’s period of illness, the poorer the employ-ment outcome. In general, severity of symptoms hadlower significance levels than work skills assessed in anearly programme phase, indicating that variations inemployment outcome could be better explained by workperformance. One study provided evidence that PSRparticipants with less severe symptoms are in a betterposition to maintain competitive jobs [30]; however, an-other study found no such relationship for IPS partici-pants [7, 24, 25].

Table 1 Predictors of employment outcomes following psychiatric vocational rehabilitation; characteristics of included studies

Authors Year of Programme M months of Design M months Outcome No. indep. N: no. Qualitypublication type participation follow-up variables variables rate

Cook et al. [21–23] 94–95 PSR TE 17 Retro/Pros 8 find 16 36 m/g

Drake et al. [7, 24, 25] 96–98 IPS 8 Pros 18 find + keep 19 7 m/g

Hoffmann et al. [26–29] 97–03 PT 9 Pros 6 find + keep 11 7 m/g

Rogers et al. [30] 97 PSR ? Pros 9 find + keep 16 13 m

Reker and Eikelmann [31, 32] 98 PT SE 10 Pros 30 find + keep 19 4 m/g

Regenold et al. [33] 99 SE 7 Pros 7 find 4 15 m

Jones et al. [34] 01 IPS ? Retro 15 find 8 113 g

Henry et al. [35] 01 TE 5 Retro 12 find 11 12 g

? unknown; M mean score; all programmes involved aimed at individuals with ‘severe mental illnesses’ or ‘psychiatric disabilities’Programme types: PSR Psychosocial Rehabilitation; TE Transitional Employment; IPS Individual Placement and Support; PT Prevocational Training; SE Supported Employ-mentMonths of programme participation: for the Drake et al. study, this is an estimate based on mean contact hoursDesign: Pros prospective; Retro retrospectiveOutcome: main outcome domain: find finding paid or competitive employment; keep keeping paid or competitive employmentNo. indep. variables: number of independent variables (predictors)N: no. variables = Ratio of sample size by number of independent variables. Where more than one analysis has been published: highest sample size by total number of dif-ferent independent variables across analysesQuality rate: g good or score range 8–10; m medium, or 6–7


412

Tabl

e2

Pred

icto

rs o

f em

ploy

men

t out

com

es fo

llow

ing

psyc

hiat

ric v

ocat

iona

l reh

abili

tatio

n; sa

mpl

e de

scrip

tion

and

outc

omes

of i

nclu

ded

stud

ies

Auth

ors

Incl

usio

n cr

iteria

Outc

ome

defin

ition

(% p

ositi

ve o

utco

me)

Posit

ive

outc

omes

wer

e as

soci

ated

with

...:

Cook

eta

l.1.

All

p. h

avin

g M

carr

on-D

ial s

core

[21]

1. O

btai

ned

any

gain

ful e

mpl

oym

ent d

urin

g f-u

p 1.

Mor

e ye

ars s

pent

in e

duca

tion;

long

er p

rogr

amm

e te

nure

; [2

1–23

]2.

All

p. re

ceiv

ing

voca

tiona

l ser

vice

s [22

](a

t 6 m

onth

s 40

%; a

t 12

mon

ths 3

6%

) [21

]be

tter

cogn

itive

-voc

atio

nal a

bilit

ies [

21]

3. A

ll p.

who

hel

d an

y ty

pe o

f em

ploy

men

t in

stud

y pe

riod

[23]

2. G

ainf

ully

em

ploy

ed a

t f-u

p m

omen

t (fig

ures

unk

now

n) [2

2]2.

Low

er a

ge; b

ette

r PVR

wor

k pe

rform

ance

; bet

ter G

AS a

t end

3. O

btai

ned

com

petit

ive

job

durin

g f-u

p (2

0%

) [23

]of

pro

gram

me;

cont

inue

d vo

catio

nal s

uppo

rt [2

2]3.

Mor

e (t

ime

in) T

E jo

bs; l

onge

r pro

gram

me

tenu

re; w

hite

neig

hbou

rhoo

d an

d hi

gher

SES

; had

indi

vidu

al T

E; n

on-

min

ority

; bei

ng m

arrie

d; m

ore

year

s spe

nt in

edu

catio

n [2

3]

Drak

e et

al.

1. M

otiv

ated

for f

indi

ng co

mpe

titiv

e jo

b; m

inim

ally

2 y

ears

1. O

btai

ned

com

petit

ive

wor

k du

ring

f-up

(60

%) [

7]1.

Bet

ter w

ork

hist

ory;

rece

ptio

n of

IPS

[7]

[7, 2

4, 2

5]dy

sfun

ctio

n; cl

inic

ally

stab

le; u

nem

ploy

ed [7

]2.

Len

gth

of jo

b te

nure

. Med

ian

first

job

tenu

re 7

0 da

ys [2

4]2.

Bet

ter w

ork

hist

ory;

hig

her j

ob sa

tisfa

ctio

n in

initi

al p

hase

; 2.

All

p. in

sam

ple

1 w

ho o

btai

ned

com

petit

ive

jobs

[24]

3. E

xper

ienc

ed sa

tisfa

ctor

y (4

8%

) firs

t job

term

inat

ion

[25]

less

per

ceiv

ed a

uton

omy

in w

ork

envi

ronm

ent;

mor

e pe

rcei

ved

3. A

ll p.

in sa

mpl

e 1

who

obt

aine

d an

d te

rmin

ated

com

petit

ive

inno

vatio

n in

wor

k en

viro

nmen

t [24

]jo

bs [2

5]3.

Bet

ter w

ork

hist

ory

[25]

Hoffm

ann

etal

.1.

& 2

. All

p. e

nrol

led

so fa

r [26

, 27]

1. L

evel

at f

-up:

pro

gram

me

drop

-out

(68

%),

obta

ined

1.

Les

s neg

ativ

e sy

mpt

oms;

less

conc

eptu

al d

isorg

anisa

tion;

[2

6–29

]3.

& 4

. All

p. o

f sch

izop

hren

ia/p

sych

osis

spec

trum

enr

olle

dco

mpe

titiv

e em

ploy

men

t (6

%),

mai

ntai

ned

com

petit

ive

less

diso

rder

of r

elat

ing

[26]

so fa

r [28

, 29]

empl

oym

ent (

27%

) [26

]2.

Low

er e

xter

nal l

ocus

of c

ontr

ol; h

ighe

r out

com

e 2.

Lev

el a

t f-u

p: p

rogr

amm

e dr

op-o

ut (6

7%

), ob

tain

edex

pect

atio

ns; l

ess p

rono

unce

d ne

gativ

e sy

mpt

oms;

less

co

mpe

titiv

e em

ploy

men

t (11

%),

mai

ntai

ned

com

petit

ive

‘dep

ress

ion-

resig

ned’

copi

ng [2

7]em

ploy

men

t (22

%) [

27]

3. L

ess i

mpa

ired

cogn

ition

; mor

e fa

talis

tic co

ntro

l bel

iefs

[28]

3. L

evel

at f

-up:

une

mpl

oyed

(26

%);

shel

tere

d em

ploy

men

t4.

Bet

ter P

VR w

ork

perfo

rman

ce; l

ess ‘

depr

essio

n-re

signe

d’

(42

%);

com

petit

ive

empl

oym

ent (

32%

) [28

]co

ping

; bet

ter s

ocia

l wor

k pe

rform

ance

; bet

ter s

ocia

l 4.

Lev

el a

t f-u

p: u

nem

ploy

ed (2

7%

); sh

elte

red

empl

oym

ent

func

tioni

ng [2

9](4

5%

); co

mpe

titiv

e em

ploy

men

t (28

%) [

29]

Roge

rs e

tal.

All p

. with

voc

atio

nal g

oal

a. O

btai

ned

com

petit

ive

empl

oym

ent d

urin

g f-u

p (5

3%

)a.

Bet

ter P

VR w

ork

perfo

rman

ce; l

ess s

ever

e sy

mpt

oms (

p 0.

6);

[30]

b. M

aint

aine

d co

mpe

titiv

e em

ploy

men

t ful

l tim

e 12

wee

ks (2

2%)

bein

g m

arrie

d (p

0.6

)b.

less

seve

re sy

mpt

oms;

abse

nce

of cr

imin

al p

ast;

abse

nce

ofps

ychi

atric

med

icat

ion

(p 0

.8)

Reke

r and

Eik

elm

ann

1. A

ll p.

dia

gnos

ed a

s sch

izop

hren

ic [3

1]1a

. Wer

e co

mpe

titiv

ely

empl

oyed

at f

-up

(22

%)

1a. M

ore

year

s spe

nt in

edu

catio

n[3

1, 3

2]2.

All

p. w

ho h

ad fo

und

a jo

b w

ith P

VR h

elp

in 9

1–92

1b. O

btai

ned

com

petit

ive

empl

oym

ent d

urin

g f-u

p (4

0%

) [31

]1b

. Hig

her e

xpec

tatio

ns o

f voc

atio

nal f

utur

e; le

ss ti

me

(56

% o

f tot

al) [

32]

2. W

ere

still

com

petit

ivel

y em

ploy

ed a

t f-u

p (6

2.5

%) [

32]

betw

een

hosp

ital a

nd e

ngag

emen

t in

reha

bilit

atio

n; le

ssho

spita

lisat

ions

; hig

her i

nter

est i

n so

ciet

al d

evel

opm

ents

;hi

gher

scor

es o

n ‘a

ggre

ssiv

e sy

ndro

me’

; mor

e ye

ars s

pent

ined

ucat

ion

[31]

2. B

ette

r PVR

wor

k pe

rform

ance

; bei

ng m

enta

lly il

l for

long

erpe

riod;

rece

ptio

n of

reha

bilit

atio

n su

bsid

ies [

32]

Rege

nold

et a

l. [3

3]Al

l une

mpl

oyed

p. o

r p. w

ho p

refe

rred

oth

er jo

bHa

d pa

id w

ork

at f-

up (1

7%

)Hi

gher

care

er se

lf-ef

ficac

y

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413

Work performance

Of the seven studies which analysed work history, onefound it to be significant. Drake et al. [7, 24, 25] consis-tently found better employment outcomes for individu-als with better employment histories (measured as totalmonths of employment during the 5 years precedingparticipation in PVR). The remaining studies found nosuch relationship, regardless of the way they measuredvocational background.

Better work performance as measured during or atthe start of PVR was significantly related to positive em-ployment outcomes, in all five studies that included thispredictor [21, 23, 29, 30, 32, 35]. Three of these studiesused some measure of generic work skills, such as ‘keep-ing time’or ‘cooperating with others’ [29,30,32].The twoother studies measured PVR work performance as func-tioning in TE (Transitional Employment), either interms of the number of jobs found or their duration [23,35]. Rogers et al. found that, following programme ter-mination, participants with better generic work skillswere more likely to be in competitive employment [30].

Three studies included some measure of work-re-lated self-efficacy, which could be interpreted as a roughor distal measurement of self-perceived work perfor-mance. These studies yielded that participants withhigher outcome expectancies [27, 31] or higher ratingsof ‘career-search self-efficacy’ [33] had better employ-ment outcomes.

A positive work-related self-efficacy and better PVRwork performance generally had higher significancelevels and odds ratios than other significant person-re-lated variables.

Functioning in other areas (i. e. social functioning)

Of the four studies which examined educational back-ground, two found it to be related to employment out-come [21, 23, 31]. The latter studies found a positive re-lationship between better outcomes and the number ofyears spent in education. The two other studies used anordinal or dichotomous measure, e. g. less than highschool – at least high school.

In most cases, current general functioning was notfound to be significant. Three studies that includedbaseline Global Assessment of Functioning (GAF) mea-sures found no relationship between GAF scores andoutcome [22, 23, 31, 32, 34].

Three studies found a significant relationship be-tween positive employment outcomes and better socialfunctioning measured at baseline. Participant successwas associated with being married or having a partner[23, 30], or having better social adjustment skills [31].

One of the two studies of cognitive ability showedbetter cognitive functioning to be positively related tosalary level [21]. In their most conclusive analysis [29],Hoffmann and Kupper found no significant relation-ship, nor one that was close to being significant. This in-validated their previous finding that better cognitive

functioning measured at baseline predicted good em-ployment outcomes after PVR [28].

Current work performance strongest predictor

Four studies each included at least one analysis of thecombined influence of three factors that have domi-nated prediction literature to date. The factors in ques-tion are work history, PVR work performance, andseverity of symptoms (outcome expectancy was countedas PVR work performance here) [29, 30, 32, 33]. None ofthese studies showed work history to have a significantinfluence on employment outcome. In all four, betterPVR work performance was significantly related to apositive employment outcome, outweighing the influ-ence of work history and severity of symptoms. Three ofthese studies found no independent relationship be-tween severity of symptoms and employment outcome[29, 32, 33]. Rogers et al. [30] used two distinct defini-tions of outcome. The first was obtaining competitivework, and the second was maintaining a full-time com-petitive job for more than 12 weeks. Using the first defi-nition, the only significant predictor of outcome wasPVR work performance (symptomatology approachedsignificance).With the second definition, a positive out-come was strongly related to less severe symptoms (withno significant contribution by work performance orwork history) [30].

Conclusion and discussion

This review focused on person-related predictors of theemployment outcomes of psychiatric vocational reha-bilitation programmes (PVR). The selection criteriawere met by 16 publications, representing eight separatestudies. Positive PVR employment outcomes are mostclearly and strongly related to better work performance,as measured at the start of PVR programmes. This wasregardless of programme content or the definition ofoutcome that was used. Though the influence of this fac-tor has already been recognised in most other reviews,the present work focuses more on its relative strength incomparison with other factors. Other strong predictorsrevealed by this review are a higher work-related self-ef-ficacy (i. e. positive outcome expectancy or career-re-lated self-efficacy), social functioning during PVR, anda longer period of education. Previous reviews failed toclearly identify an expectancy of positive outcome andeducation as predictors.

While previous reviews tend to conclude that indi-viduals with less severe psychiatric symptoms have bet-ter employment outcomes, the influence of psychiatricsymptoms on PVR outcomes can be neither ruled outnor definitely confirmed. When measured concurrentlywith PVR performance,severity of symptoms was foundto have less influence.

Diagnosis and psychiatric history were not associ-ated with PVR outcome. This finding differs from the re-


414

sults of the latest reviews, which show that individualswith a diagnosis in the psychosis spectrum and thosewith a more extensive psychiatric history tend to haveless favourable outcomes.

One major finding of this review is that work perfor-mance and social functioning, when measured duringparticipation in PVR, are more predictive of vocationaloutcomes than work history and social functioningmeasured prior to programme commencement. This iscontrary to the results of previous reviews. Past func-tioning might be a valid predictor of future vocationalfunctioning within the broad population of individualswith mental illness, but it seems to be a less powerfulpredictor within the restricted population of partici-pants in vocational rehabilitation programmes.

In view of the small number of studies included here,it is not yet possible to draw far-reaching conclusionsabout the predictive value of work history. In order toprovide direction to subsequent studies, we have formu-lated three alternative explanations for this remarkablefinding.One possible explanation for this finding is that,within a certain subgroup of participants, PVR pro-grammes can compensate for vocational disabilitieswhich have represented barriers in the past. They canalso strengthen existing or unexpected abilities [19, 20].

Another possibility is that these findings reflect theselective nature of traditional prevocational PVR pro-grammes (i. e. using preparatory sheltered work envi-ronments). To some extent, traditional PVR pro-grammes restrict referral to regular jobs to participantswho perform well in the work environments these pro-grammes offer. Unfortunately, most of the articles in-cluded here are rather vague when describing the tran-sition from programme to job. IPS is the onlyprogramme that clearly ‘promises’ to provide each par-ticipant with support in finding and maintaining a job.

A third, quite simple, explanation is that the more re-cently work performance is measured, the more predic-tive it is of good outcome. This could explain why onlyIPS seems to be more effective for individuals with bet-ter work histories. In another IPS trial conducted by thesame research group, not included here, work historyagain was the only variable associated with employmentoutcome [6]. In studies of IPS programmes, the rapidand unconditional job search greatly reduces the timelag between work history and outcome.Accordingly, thisperiod is substantially shorter than in studies of PVRprogrammes which include preparatory phases. There-fore, in the case of IPS, work history may essentially be a‘proxy’ measure of actual work capacities.

Prediction studies are needed to determine which ofthese interpretations (if any) is correct. Studies involv-ing IPS should assess the participants’ work perfor-mance during an initial phase of IPS (e. g. in the firstweeks or months of competitive work).

■ Limitations of this review

Various safeguards have been used to restrict this reviewto results derived from high quality studies. The inclu-sion criteria were that studies must have a longitudinaldesign, must have used (appropriate) multivariateanalyses, and must have received a score of six or aboveon the quality checklist. In spite of these precautions, thestudies used exhibited various methodological limita-tions. Major drawbacks include retrospective designs,small sample sizes, a lack of clarity when describing theinput and coding of variables, or incomplete statistics.

Other limitations are related to the format of this re-view. The use of selection criteria restricted the reviewto journal articles alone. This may have caused somesample bias, as any results presented in conference pa-pers, dissertations and other publications would havegone unnoticed.

Some publications were excluded because the samplewas only partly made up of individuals who had re-ceived vocational rehabilitation services. Macias et al.studied the influence of work interest on the timeneeded to obtain a first job, after participating in PACTor TE (approximately 75 % of the participants receivedvocational services) [8]. A multivariate analysis showedthat an expressed interest in finding paid work and par-ticipation in vocational services were the only signifi-cant predictors (while other factors such as work historyand diagnosis were found to be non-significant). Thelatter study confirms this review’s finding that outcomeexpectancy is an important person-related predictor.

Lehman et al. conducted a randomised controlledtrial to study IPS effectiveness, with PsychoSocial Reha-bilitation (PSR) as comparison intervention (33 % of thePSR participants received vocational services) [3]. Theyfound a significant positive relationship between ob-taining competitive work and lower age, higher educa-tion, and a diagnosis other than psychotic. Accordingly,factors such as age and diagnosis may be more impor-tant than this review suggests. This specifically appliesto broader samples of individuals who have not yet de-cided to make use of vocational rehabilitation services,or who may be experiencing barriers to PVR participa-tion.

This review presents a mixed picture of the relation-ship between psychiatric symptoms and outcome. Oneline of research not included here addresses the influ-ence of psychiatric symptoms on work skills, as mea-sured within sheltered work environments provided byPVR programmes for prevocational training. Other re-cent reviews (which did include such studies) concludedthat psychiatric symptoms, especially negative symp-toms, are significantly related to current work skills[15–17]. These findings have been confirmed by morerecent research [38]. This suggests that symptoms couldhave an important moderating effect on the relationshipbetween work skills and employment outcomes. No rig-orous studies of this possibility have yet been carriedout.


415

Finally, being restricted to longitudinal, multivariate-analysis studies, the review may have missed several po-tentially powerful predictors. For instance, a growingnumber of cross-sectional or prospective bivariate stud-ies [40, 48–54] indicate that individuals with a superiorcognitive ability have better vocational outcomes. Afterreviewing the literature on this subject, McGurk andMueser concluded that superior cognitive ability is in-deed related to better PVR outcomes, although this rela-tionship was much stronger in ‘general psychiatric sam-ples’ [20].

■ Future research

More prospective and rigorously controlled research isobviously needed. Future studies should adhere moreclosely to basic methodological criteria than has usuallybeen the case in the past. In particular,sample sizes mustbe sufficiently large and there should be a clear, com-prehensive presentation of design, procedures, analysis,and findings. Concise descriptions of programmemechanisms should also be made available, includingbuilt-in procedures for making the transition from pro-gramme to competitive employment.

Ideally,future research should take account of the pre-dictor model proposed in this review. Some importantvariables used in the studies included here need furtherrefinement and elaboration. PVR work performance inparticular needs further differentiation,in view of the ev-idence indicating the importance of separate skill di-mensions. Tsang et al. [16] mention social work skills asspecific predictors. Bryson et al. [42] found that specificdimensions of PVR work performance (measured withthe Work Behavior Inventory) were related to differentoutcomes.Work habits were more strongly related to thehours worked after programme participation than toother dimensions of work behaviour. On the other hand,social skills and work quality were the strongest predic-tors of total earnings after PVR.

Some studies included here provide evidence for theinfluence of self-perceived employment opportunities[33]. This suggests that an individual’s self-image as aworker is an important factor in vocational rehabilita-tion. It might also indicate that the average PVR partic-ipant possesses considerable self-knowledge. To date,however, there have been very few empirical studies ofself-image as a worker and related concepts, such as vo-cational readiness [15, 17–19]. One such exception, asmall-scale study by Ferdinandi et al. [55], indicates thatgoal readiness (e. g. commitment to change) is stronglyrelated to vocational outcomes.

Other factors, related to the interaction between in-dividuals and their illness,also need to be studied.Theseinclude the side-effects of medication [56] and illnessself-management strategies, such as coping with psychi-atric symptoms.Another poorly studied aspect, which isoften put forward by individuals with severe mental ill-nesses themselves, is support from others.Alverson et al.

[57] found tentative support for the importance of socialnetwork variables and self-management. This was basedon an ethnographic study among sub-groups of indi-viduals involved in the New Hampshire RCT on IPS [7].

Other outcome measures need to be examined aswell. There is a need for research into different yard-sticks. In particular, it is strongly recommended thatstudies be carried out including the assessment of as-pects of work performance in the favoured work situa-tion, such as generic work functioning, work-cutbackdays and job satisfaction [58].

■ Acknowledgements This study was funded by UWV (Workers In-surance Authority), Trimbos Institute and Altrecht GGZ (DivisionWestelijk Utrecht). We would like to express our special thanks toRobert E. Drake (Dartmouth Medical School, Hanover, NH), whocommented on an earlier version.

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