Vocational rehabilitation for people with severe mental illness

Ruth Crowther; Max Marshall; Gary R Bond; Peter Huxley

doi:10.1002/14651858.CD003080

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Analysis 1.1

Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 1 Not in competitive employment (at 8 months).

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Analysis 1.2

Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 2 Not in any form of employment (at 8 months).

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Analysis 1.3

Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 3 Not participating in program (excluding employed).

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Analysis 1.4

Comparison 1 PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE, Outcome 4 Not discharged from hospital (at 8 months).

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Analysis 2.1

Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 1 Not in competitive employment.

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Analysis 2.2

Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 2 Not in any form of employment.

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Analysis 2.3

Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 3 Not participating in program (excluding employed).

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Analysis 2.4

Comparison 2 PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE, Outcome 4 Admitted to hospital (by 1 year).

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Analysis 3.1

Comparison 3 SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE, Outcome 1 Not in competitive employment (at 24 months).

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Analysis 3.2

Comparison 3 SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE, Outcome 2 Not in any form of employment.

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Analysis 3.3

Comparison 3 SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE, Outcome 3 Admitted to hospital in first year of study.

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Analysis 4.1

Comparison 4 MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 1 Not in any form of employment (at 6 months).

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Analysis 4.2

Comparison 4 MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 2 Not participating in program.

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Analysis 4.3

Comparison 4 MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 3 Admitted to hospital during first year of study.

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Analysis 5.1

Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 1 Not in competitive employment.

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Analysis 5.2

Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 2 Not in any form of employment.

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Analysis 5.3

Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 3 Not in any form or employment or training or education at end of study.

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Analysis 5.4

Comparison 5 MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE, Outcome 4 Not participating in program.

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Analysis 6.1

Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 1 Not in competitive employment.

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Analysis 6.2

Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 2 Not in any form of employment (at 15 months).

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Analysis 6.3

Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 3 Numbers not participating in program.

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Analysis 6.4

Comparison 6 MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE, Outcome 4 Number readmitted to hospital (at about 15 months).

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Analysis 7.1

Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 1 Not in competitive employment.

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Analysis 7.2

Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 2 Not in any form of employment.

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Analysis 7.3

Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 3 Numbers not participating in program.

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Analysis 7.4

Comparison 7 SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE, Outcome 4 Numbers admitted to hospital during study.

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Analysis 8.1

Comparison 8 SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING, Outcome 1 Not in competitive employment.

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Analysis 8.2

Comparison 8 SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING, Outcome 2 Not in any form of employment.

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Analysis 8.3

Comparison 8 SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING, Outcome 3 Numbers not participating in program.

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Analysis 9.1

Comparison 9 SUB‐ANALYSIS 2: INDIVIDUAL PLACEMENT & SUPPORT (TYPE OF SUPPORTED EMPLOYMENT) versus PRE‐VOCATIONAL TRAINING, Outcome 1 Not in competitive employment.

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Analysis 9.2

Comparison 9 SUB‐ANALYSIS 2: INDIVIDUAL PLACEMENT & SUPPORT (TYPE OF SUPPORTED EMPLOYMENT) versus PRE‐VOCATIONAL TRAINING, Outcome 2 Numbers not participating in program.

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Table 1. Supported Employment versus PVT: Mean hours in competitive employment

Study	Intervention	Mean monthly hrs	t (or F)	p
Drake‐NH	IP	33.7	3.7	<0.001
	PVT	11.4
Drake‐Wash	IP	17.9	4.4	<0.001
	PVT	1.5
Gervey	IP	69	3.7	0.03
	PVT	9.9

Table 1. Supported Employment versus PVT: Mean hours in competitive employment

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Table 2. Supported Employment versus PVT: Mean monthly earnings ($)

Study	Intervention	Mean earnings	t or F	p
Bond‐Indiana	SE	127.1	2.55	<0.05
	PVT	71.7
McFarlane‐New York	SE	41.9	2.35	0.019
	PVT	11.8
Drake‐NH1	SE	188.5	3.34	<0.001
	PVT	59.9
Drake‐Wash	SE	111.1	4.29	NS
	PVT	111.4

Table 2. Supported Employment versus PVT: Mean monthly earnings ($)

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Table 3. Supported Employment versus PVT: Costs of care (mean monthly per patient)

Study	Group	Program costs	Other health costs	Overall costs
Bond‐Indiana	Immediate Placement	$251.6	$263.0	$514.6
	Control	$132.0	$586.5	$718.5
Drake‐NH1	Immediate Placement	$313.1	$801.6	$1114.7
	Control	$307.3	$928.5	$1235.8

Table 3. Supported Employment versus PVT: Costs of care (mean monthly per patient)

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Comparison 1. PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment (at 8 months) Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.63, 1.00]

2 Not in any form of employment (at 8 months) Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.26, 0.68]

3 Not participating in program (excluding employed) Show forest plot	2	78	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.55]

4 Not discharged from hospital (at 8 months) Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.76, 1.19]

Comparison 1. PRE‐VOCATIONAL TRAINING versus STANDARD HOSPITAL CARE

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Comparison 2. PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 at 18 months	1	28	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.87, 1.61]
1.2 at 24 months	1	215	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.77, 1.17]
2 Not in any form of employment Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 at 3 months	1	352	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.89, 1.24]
2.2 at 6 months	1	285	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.81, 1.12]
2.3 at 9 months	1	132	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.76, 1.32]
2.4 at 12 months	1	215	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.77, 1.17]
2.5 at 18 months	1	152	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.57, 1.02]
3 Not participating in program (excluding employed) Show forest plot	2	284	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.52, 1.72]

4 Admitted to hospital (by 1 year) Show forest plot	3	887	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.65, 0.95]

Comparison 2. PRE‐VOCATIONAL TRAINING (ALL APPROACHES) versus STANDARD COMMUNITY CARE

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Comparison 3. SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment (at 24 months) Show forest plot	1	215	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.77, 1.17]

2 Not in any form of employment Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 at 3 months	1	352	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.89, 1.24]
2.2 at 6 months	1	285	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.81, 1.12]
2.3 at 12 months	1	215	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.77, 1.17]
3 Admitted to hospital in first year of study Show forest plot	1	215	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.49, 0.96]

Comparison 3. SUB‐ANALYSIS 1: CLUBHOUSE APPROACH (TYPE OF PVT) versus STANDARD COMMUNITY CARE

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Comparison 4. MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in any form of employment (at 6 months) Show forest plot	1	150	Risk Ratio (M‐H, Fixed, 95% CI)	0.40 [0.28, 0.57]

2 Not participating in program Show forest plot	1	150	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.39, 0.71]

3 Admitted to hospital during first year of study Show forest plot	1	150	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.31, 0.96]

Comparison 4. MODIFICATION 1. PRE‐VOCATIONAL TRAINING + PAYMENT versus PRE‐VOCATIONAL TRAINING ALONE

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Comparison 5. MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment Show forest plot	2	142	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.77, 0.95]

1.1 at 6 months	1	20	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.29, 1.07]
1.2 at 9 months	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.83, 0.99]
2 Not in any form of employment Show forest plot	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.81, 0.97]

3 Not in any form or employment or training or education at end of study Show forest plot	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.52, 0.77]

4 Not participating in program Show forest plot	2	142	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.33, 2.18]

Comparison 5. MODIFICATION 2. PRE‐VOCATIONAL TRAINING + PSYCHOLOGICAL INTERVENTIONS versus PRE‐VOCATIONAL TRAINING ALONE

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Comparison 6. MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 at 9 months	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.90, 1.10]
1.2 at 15 months	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.78, 1.00]
2 Not in any form of employment (at 15 months) Show forest plot	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.69, 1.33]

3 Numbers not participating in program Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 at 4 months	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	1.77 [0.98, 3.21]
3.2 at 9 months	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.74, 1.92]
4 Number readmitted to hospital (at about 15 months) Show forest plot	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.68, 1.62]

Comparison 6. MODIFICATION 3. ACCELERATED ENTRY TO TRANSITIONAL EMPLOYMENT (TE ‐ TYPE OF PVT) versus GRADUAL ENTRY TO TE

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Comparison 7. SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.3 at 12 months	1	256	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.93, 1.09]
1.5 at 24 months	1	256	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.85, 0.99]
1.6 at 36 months	1	256	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.82, 0.96]
2 Not in any form of employment Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3 Numbers not participating in program Show forest plot	1	256	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.55, 1.01]

4 Numbers admitted to hospital during study Show forest plot	1	256	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.63, 1.10]

Comparison 7. SUPPORTED EMPLOYMENT versus STANDARD COMMUNITY CARE

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Comparison 8. SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 at about 4 months	3	364	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.66, 0.81]
1.2 at 6 months	3	364	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.67, 0.82]
1.3 at 9 months	3	364	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.60, 0.76]
1.4 at 12 months	5	484	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.69, 0.84]
1.5 at 15 months	3	364	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.73, 0.91]
1.6 at 18 months	3	364	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.71, 0.87]
1.7 at 24 months	2	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.81, 1.00]
2 Not in any form of employment Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 at 6 months	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.62, 1.78]
2.2 at 9 months	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.61 [0.35, 1.08]
2.3 at 12 months	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.40, 1.12]
2.4 at 15 months	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.53, 1.61]
2.5 at 18 months	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.50, 1.33]
3 Numbers not participating in program Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 at 6 months	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.58, 1.54]
3.2 at 12 months	2	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.48, 0.96]
3.3 at 18 months	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.37 [0.10, 1.32]

Comparison 8. SUPPORTED EMPLOYMENT (ALL APPROACHES) versus PRE‐VOCATIONAL TRAINING

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Comparison 9. SUB‐ANALYSIS 2: INDIVIDUAL PLACEMENT & SUPPORT (TYPE OF SUPPORTED EMPLOYMENT) versus PRE‐VOCATIONAL TRAINING

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Not in competitive employment Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 at 4 months	2	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.62, 0.78]
1.2 at 6 months	2	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.63, 0.80]
1.3 at 9 months	2	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.57, 0.75]
1.4 at 12 months	2	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.70, 0.89]
1.5 at 15 months	2	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.74, 0.93]
1.6 at 18 months	2	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.70, 0.89]
2 Numbers not participating in program Show forest plot	2	295	Risk Ratio (M‐H, Random, 95% CI)	0.52 [0.15, 1.85]

Comparison 9. SUB‐ANALYSIS 2: INDIVIDUAL PLACEMENT & SUPPORT (TYPE OF SUPPORTED EMPLOYMENT) versus PRE‐VOCATIONAL TRAINING

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