IPS Research UpdateIPS Research Update

Bob DrakeBob Drake

Dartmouth Medical SchoolDartmouth Medical School

20112011

Dilemma in 1990Dilemma in 1990

3-5% population disabled by mental illness People with severe mental illness identify work as

their top goal– More than 70% want to work

Less than 10% working No effective interventions

• Bond, 1992

The President’s New Freedom The President’s New Freedom Commission Report (2003)Commission Report (2003)

““The main goal of the mental health system is to help people to The main goal of the mental health system is to help people to live, learn, work, and participate fully in their communities”live, learn, work, and participate fully in their communities”

Mike Hogan (2006): “Work is the most direct step to recovery”Mike Hogan (2006): “Work is the most direct step to recovery”

Current Status of IPSCurrent Status of IPS

IPS model is simple and effectiveIPS model is simple and effective Other benefits accrue with consistent workOther benefits accrue with consistent work Work outcomes improve over timeWork outcomes improve over time IPS is relatively easy to implementIPS is relatively easy to implement

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

96 NH

10 AL

07 IL

04 CT

08 HK

10 CA

08 AUST

06 SC

99 DC

11SWITZ

08 CA

07 EUR

06 QUE

10 HOL

02 MD

11 UK

IPS Control Control 2

Competitive Employment Rates Competitive Employment Rates in 16 Randomized Controlled Trials in 16 Randomized Controlled Trials of Individual Placement and Supportof Individual Placement and Support

Percent Competitively Employed in 24 month period

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Study Time

Percent competitively employed

Standard

IPS

Chrysalis Center

CT Supported Employment StudyCT Supported Employment Study(Mueser, 2004)(Mueser, 2004)

Impact on Impact on Other OutcomesOther Outcomes

Improved self-esteem, symptom control, quality Improved self-esteem, symptom control, quality of lifeof life

Related to sustained competitive employmentRelated to sustained competitive employment No changes with sustained sheltered employmentNo changes with sustained sheltered employment

(Bond, 2001)(Bond, 2001)

Long-Term OutcomesLong-Term Outcomes

4 studies with 10-year follow-ups4 studies with 10-year follow-ups(Test, 1989; Salyers, 2004; Becker, 2006; Bush,2009)(Test, 1989; Salyers, 2004; Becker, 2006; Bush,2009)

Work outcomes improve over timeWork outcomes improve over time Costs decrease dramatically for consistent Costs decrease dramatically for consistent

workers workers (Bush, 2009)(Bush, 2009)

8-12 Year Follow-up: 8-12 Year Follow-up: Day Treatment to IPSDay Treatment to IPS

71% working at follow-up71% working at follow-up85% in competitive jobs85% in competitive jobs71% worked more than 50% of FU71% worked more than 50% of FU90% still receiving benefits90% still receiving benefits

(Becker, 2006)(Becker, 2006)

Cost SavingsCost Savings

Each person with a SMI who becomes employed achieves an average savings in health costs of $5,000 per year (Bush et al. 2009)

Figure 1. Cost Outpatient Services and Institution Days

8000

13000

18000

23000

28000

33000

38000

43000

48000

0 1 2 3 4 5 6 7 8 9 10

Years

Mean Cost

Minimum Work

Steady Work

People with Severe Mental Illness in Treatment

Already Employed

10%

Not Interested in Employment

25%

Evidence-Based

Supported Employement

2%

No Employment

services40%

Ineffective Employment

Services23%

Johnson & Johnson-Johnson & Johnson-Dartmouth ProjectDartmouth Project Mental health-vocational rehabilitation collaboration Mental health-vocational rehabilitation collaboration implement evidence-based SE = IPSimplement evidence-based SE = IPS Local programs selected by statesLocal programs selected by states Dartmouth provides training, consultation, evaluationDartmouth provides training, consultation, evaluation National Learning CollaborativeNational Learning Collaborative States: CT, DC, KS, MD, OR, SC, VT, IL, MN, MO, OH, KY, WIStates: CT, DC, KS, MD, OR, SC, VT, IL, MN, MO, OH, KY, WI Special Projects: NJ, OH, ILSpecial Projects: NJ, OH, IL International CollaborativeInternational Collaborative

• (Becker, 2011)(Becker, 2011)

J&J-Dartmouth Program: Real J&J-Dartmouth Program: Real World AgenciesWorld Agencies

Early InterventionEarly Intervention

First episode psychosis First episode psychosis (Nuechterlein, 2005; Rinaldi, (Nuechterlein, 2005; Rinaldi,

2009; Killackey, 2009)2009; Killackey, 2009)

IPS Supported Employment for Clients with First-episode Schizophrenia

0

20

40

60

80

100

Baseline 6 Months 12 Months 18 Months% of Employment or

school

IPS

SAU

Early Intervention Early Intervention (Nuechterlein, 2005)(Nuechterlein, 2005)

Addressing CognitionAddressing Cognition

Concentration, memory, reaction speed, Concentration, memory, reaction speed, and problem-solvingand problem-solving

Job match Job match Improve cognitive function Improve cognitive function Compensatory strategiesCompensatory strategies

(McGurk, 2008)(McGurk, 2008)

Cognitive TrainingCognitive Training

Practicing cognitive tasks may create Practicing cognitive tasks may create new neuronal connectionsnew neuronal connections

Tasks directly relevant to work tasksTasks directly relevant to work tasksNew capacity may translate to workNew capacity may translate to work

(McGurk, 2005)(McGurk, 2005)

Computer Training and Memory

30

35

40

45

50

Baseline 3 Months

Total Number Correct

Computer Training and Work

0

5

10

15

20

25

30

Baseline 3 MonthsHours worked per Month

Benefits ReformBenefits Reform

People are socialized into disabilityPeople are socialized into disabilityChanging benefits structure essentialChanging benefits structure essential

Policy ChangesPolicy Changes

People with disabilities need cash, health insurance, and a job

They do not need to be assigned to a lifetime of unemployment and poverty in order to get health insurance

Legislative change is critical

Carl Suter, CSAVR (2006)

Federal Funding ReformFederal Funding Reform

We need simple payment systemFederal committeesAdvocacy

ConclusionsConclusions IPS has created hope for for people with IPS has created hope for for people with

psychiatric disabilities, their families, and psychiatric disabilities, their families, and MH/VR practitionersMH/VR practitioners

Outcomes can be enhanced furtherOutcomes can be enhanced further New researchNew research Policy changesPolicy changes

Financial SupportFinancial Support

Grants from NIDA, NIDRR, NIMH, RWJF, SAMHSA

Contracts from Guilford Press, Hazelden Press, MacArthur Foundation, Oxford Press, New York Office of Mental Health, Research Foundation for Mental Health

Gifts from Johnson & Johnson Corporate Contributions, Segal Foundation, Thomson Foundation, Vail Foundation, West Foundation

Many ThanksMany Thanks Deborah Becker Gary Bond Greg McHugo Haiyi Xie Jon Skinner Phil Bush Will Torrey Kim Mueser Rob Whitley Susan McGurk Eric Latimer Elizabeth Carpenter-Song

Matt Merrens Paul Gorman Sarah Swanson David Lynde Howard Goldman Sandy Reese Kikuko Campbell Will Haslett Saira Nawaz Crystal Glover

Information: books, Information: books, videos, research articlesvideos, research articles

Patti O’BrienPatti.O’Brien@Dartmouth.edu603-448-0263http://dms.dartmouth.edu/prc