The EQOLISE project: the European experience

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The EQOLISE projectthe European experience

• Durk Wiersma
• University Medical Centre Groningen
• Rob Giel Research centre
• The Netherlands

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• Enhancing the Quality Of Life and Independence of
  persons disabled by severe mental illness through
  Supported Employment
• An RCT in London, Rimini, Ulm, Groningen, Zurich
  and Sophia

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Participants EQOLISE

• Tom Burns (Oxford), Jocelyn Catty (London), Sarah
  White (London), Martin Knapp (London), Robert E.
  Drake (New Hampshire USA)
• Thomas Becker (Ulm), Reinhold Kilian
• Angelo Fioritti (Rimini), Denise Manchisi
• Wulf Rössler (Zurich), Christoph Lauber (Zurich)
• Toma Tomov (Sofia), Dimitar Germanov
• Jooske van Busschbach (Groningen), Durk Wiersma
  (Groningen),

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Two models of vocational rehabilitation

• Traditional structured rehabilitation
• Countering deficits
• Training skills
• Sheltered employment and workshops
• Independent Placement and Support (IPS)
• Patient preference
• No exclusions
• Rapid job search
• Find a job, then support

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US evidence

• 13 studies favour IPS over structured vocational
  rehabilitation (VR)
• 3075 obtain jobs in IPS
• 5 - 30 obtain jobs in VR
• Accepted as US evidence-based standard

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Competitive Employment Rates in 13 Randomized
Controlled Trials
Presentatie IPS
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Why another study?
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Variation in research outcomes

• Effects of complex interventions like ACT or IPS
  may vary markedly internationally
• Opportunity to exploit differences in European
  context to illuminate processes

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Cultural attitudes and Context differences

• Attitudes towards (un)employment and poverty
• Employment legislation practice
• US hire and fire versus European employment
  protection and stability
• Benefit levels
• European benefits generally higher
• Varies considerably across Europe
• Benefit trap

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Benefit trap

• Benefits gt Salaries
• Benefits to make up shortfall in salary
• UK, NET
• Benefits salaries
• Benefits linked to previous income
• GER SWI
• Benefits lt salaries
• BUL IT (like USA)

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Design and Method

• Randomised control trial (RCT) in six European
  countries
• Compares IPS with structured VR
• Psychotic patients with extensive unemployment
• Randomisation at the patient level,
• Stratified using minimisation technique by
• Centre, gender and work history
• N300, 50 from each centre
• Assessments at baseline, 6, 12 and 18 months
• Primary outcome open employment for one day

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Inclusion criteria

• SMI, psychotic illness
• 18 local retirement age (60/65)
• Ill major role dysfunction gt 2 yrs
• Living in community
• Not in competitive employment preceding year
• Wish to enter competitive employment
• Recruitment April 2003 May 2004 312 randomly
  assigned and 252 completed final follow-up

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Study population

• Age 38 years
• Male 60
• Age at first contact
• 90 one or more admissions
• Schizophrenia 80 and Bipolar disorder 17
• 44 worked more than 1 month in last five years
• 90 born in country or residence

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IPS intervention

• One IPS worker per site trained and centrally
  supervised
• IPS Principles
• Goal is competitive employment
• Rapid job search, no lengthy pre-employment
  training
• IPS worker integrated with MH team
• Services based on clients' preferences and
  choices
• Unlimited follow-along support

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VR intervention

• Vocational rehabilitation using structured,
  step-wise approach
• Well established and respected locally
• Requirements
• Assess within a month of referral
• Start rehabilitation within two months of referral

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Three questions

• Is IPS effective in Europe?
• Is its effectiveness influenced by broader social
  factors?
• Does return to work for SMI patients involve
  health risks?

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Question 1 Is IPS effective in Europe?
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Vocational outcomes
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Predictors of Employment

• More likely to obtain employment working longer
  if
• Previous work history
• Fewer met social needs
• Better relationship with vocational worker
• In remission (first 6 months) and swifter service
  uptake associated with working longer
• Greater IPS fidelity associated with greater
  effectiveness

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Question 2 Is IPS affected by local
socio-economic circumstances?
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Worked for at least one day by centre
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IPS effectiveness within centres (proportions
finding a job with 95 CI)
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IPS effectiveness within centres (proportions
finding a job with 95 CI)
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Socio-economic sources of heterogeneity
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Effect of local unemployment rate on IPS
superiority over VR
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Effect of benefit trap on IPS effect size
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Effect of benefit trap on getting a job overall
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Question 3 Does returning to work make you ill?
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Hospitalisation during study
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Impact of SE and Working on clinical and social
functioning

• No difference between SE VS in functioning
  after 18 months
• If worked, better global functioning, fewer
  symptoms, less social disability
• If working, in remission out of hospital for
  previous 6 months
• Conclusion no concern about possible detrimental
  effects of working, on the contrary, working
  beneficial effects on functioning

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Conclusions

• IPS is twice as effective in obtaining employment
  as structured VR
• Matches US levels
• Effect varies and is influenced by
• Local unemployment rates (significant)
• The benefit trap (trend)
• Patients are not made unwell by IPS

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Clinical implication

• IPS should probably be provided for individuals
  with severe mental illness
• However
• Will the benefits be sustained?
• How much is due to enthusiasm?
• Do we know if all the components are necessary?

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Vocational Rehabilitation in Guidelines
Schizophrenia?

• Draft Update September 2008 18 RCT in Cochrane
  review 2001 2 new RCT all but one in USA
• N.B. No mention of Eqolise trial!!!
• Strong evidence that SE is superior to
  pre-vocational training in gaining (and being
  longer in) competitive employment, that
  Pre-vocational training no benefits to standard
  care
• Recommendation SE programmes should be provided
  for people with schizophrenia who wish to return
  to work
• Implementation difficult in UK (135 PVT schemes
  and 77 SE programmes), even in Oxford

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SCION A Study on Cost-effectiveness of IPS
regarding Open employment in the Netherlands

• Trimbos-institute Rob Giel Research centre
• 4 centre prospective randomised controlled trial
  with assessments at 6, 18 30 months follow-up
• In community mental health care, 18-65 yrs, N151
• Male 74, mean age 37 yrs, 82 unmarried, 67
  psychotic Sx at first contact, on average 13 yrs
  in contact with MHC
• After first 6 months (slight) advantage for IPS

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Important factors in implementation IPS (in USA)

• Work on consensus
• Strategy for financing
• Recovery-orientation of MHC
• Inspiring leadership
• Adaptation of structure of organisation
• Continuing education and training in IPS
• Timeline for implementation
• Monitoring porcess of outcome

Presentatie IPS
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When in doubt whether working is good for SMI,
remember the following

• If you think work is bad for people with mental
  illness, try poverty, unemployment, and social
  isolation.
• Marone Golowka (2000) Psychiatric
  Rehabilitation Journal

19-11-2009
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Thank you for your attention
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Publications about Eqolise-project
The effectiveness of supported employmentfor
people with severe mental illness a randomised
controlled trial. Lancet 2007, 370,
1146-52 Predictors of employment for peole with
severe mental illness results of an
international six-centre controlled trial. BJP
192, 224-231 2008 The impact of supported
employment and working on clinical and social
functioning resultes of an international study
of individual placement and support. Schiz
Bulletin april 2008 Experiences of vocational
rehabilitation for psychosis clientsperspectives
on IPS, routine vocational rehabilitation and
working. In submission