Vocational rehabilitation for people with severe mental illness.

BACKGROUND: Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre-vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on-the-job support (Supported Employment). It is unclear which approach is most effective.

OBJECTIVES: To assess the effects of Pre-vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre-vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention.

SEARCH STRATEGY: Searches were undertaken of CINAHL (1982-1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1887-1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies.

SELECTION CRITERIA: Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness.

DATA COLLECTION AND ANALYSIS: Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross-checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta-analysis). A sensitivity analysis was performed, excluding poorer quality trials.

MAIN RESULTS: Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre-vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre-vocational Training. There was no evidence that Pre-vocational Training was more effective in helping clients to obtain competitive employment than standard community care.

REVIEWER'S CONCLUSIONS: Supported employment is more effective than Pre-vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre-vocational Training is effective.