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Research TeamTom Burns, Ksenija Yeeles, Catriona Anderson

Research shows that people generally enjoy better mental health when they are in paid employment.  The longer individuals are absent or out of work, the more likely they are to experience depression or anxiety (DW&P and DOH, 2009).  However, people with mental health problems are almost three times more unlikely to be employed than any other group of people with disabilities.  Over half a million people of working age with MH problems are ‘economically inactive’ i.e. not seeking work or permanently sick (DOH, 2003), and the UK Government pays out an estimated £8 billion in benefits every year.


While treatments to reduce symptoms are now generally effective, consistent and evidence-based, they seem to do little to improve the social exclusion that often comes with having mental health problems.  Mental health care increasingly aims to improve wider aspects of patients’ lives, but reducing symptoms alone does not seem to solve these other problems.  However, paid employment is correlated with improved personal wellbeing, increased social inclusion and a reduced sense of stigma.  There is also evidence that it reduces the use of health services, and people who are employed have fewer hospital admissions. 


The 1930 Mental Treatment Act stated that hospitals should provide employment and entertainment as well as medical attention, and patients were actively employed in the running of their hospitals right up to the 1960s.  While the transition from inpatient to community care has enabled patients to live more dignified and rewarding lives, they may be left with few activities to fill the days, and need extra support to get back to work.


Types of occupational intervention


Traditional vocational rehabilitation in mental health emphasises detailed assessments of disabilities, and structured programmes to reduce or accommodate them.  While these types of intervention provide meaningful activity, qualifications and sometimes pay, participants are mainly brought into contact with other service users, the programmes cost a lot to run, and there is little opportunity for promotion or pay rise.  While sheltered employment suits some people, many patients express a wish to return to open, competitive employment.  Several forms of supported employment have been devised to help patients make this return.


What is Individual Placement and Support (IPS)?


Individual Placement and Support (IPS) is a type of supported employment that aims to return its’ clients to the workplace quickly, and without any extra training.  Clients are referred by their mental health team to the service, where their suitability for the service is assessed in one session.  If they are taken on by the service, they are assigned an Employment Specialist who then helps to build their CV and search for jobs vacancies.  They may also help the client fill out the application forms and offer advice about interviews.  A key principle of the IPS service is that support is not time limited - the client has access to the service for as long as s/he wants, even if a job is found.


Why should we fund IPS? 


In a meta-analysis of four American randomised controlled trials which compared IPS with other traditional approaches, Campbell et al (2009) found that patients using an IPS service were more likely to find paid employment, and to work for longer, than patients using other types of rehabilitation service.  This was regardless of the patients’ demographics, diagnosis and past employment. 


The first European trial of IPS, EQOLISE, assigned 312 patients with a diagnosis of psychosis, in 6 European countries, to receive IPS or vocational services.  55% of patients in the IPS service worked for at least one day compared with 28% assigned to the other services.  The IPS group were also less likely to drop out of the service, or be readmitted to hospital.  They also kept their jobs for longer and worked more hours.


Refining Individual Placement and Support – IPS-LITE


IPS is recommended as an evidence-based intervention.  It requires little capital investment, but it is expensive in manpower because employment specialists should only have a caseload of 25 clients.  As the support continues for as long as the clients want it, potentially these clients are never discharged.  This limits access to the service to those who are referred first. 


The EQOLISE study found that few patients not employment by 9 months subsequently became employed.  If a client found a job, contact with their employment specialist naturally dropped off after 4 months, without any impact on job retention. 


The main aim of the study is to compare traditional IPS with a simple modification – IPS-LITE.  This would be a time-limited service, in which patients would have 9 months to search for a job, and 4 months work support after starting a job.  Discharging patients from the service would increase access to the service, and return a greater number of people to work.


Research Questions


1) Is IPS-LITE as, or more effective, than standard IPS?

Is there a difference in the proportion of patients who return to open paid employment in the two interventions? 


2) Is IPS-LITE more cost-effective?


In terms of cost-per-case return to work
In terms of cost per quality of life year gained 


3) Are there differences in other outcomes (vocational and health-related) between the two interventions?


4) Are there differences in patient baseline characteristics which influence the response to the two interventions?