IPS Research Update

IPS Research UpdateBob DrakeDartmouth Medical School2011

Dilemma in 1990

3-5% population disabled by mental illnessPeople with severe mental illness identify work as their top goalMore than 70% want to workLess than 10% workingNo effective interventionsBond, 1992

The Presidents New Freedom Commission Report (2003)

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

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

Current Status of IPS

IPS model is simple and effectiveOther benefits accrue with consistent workWork outcomes improve over timeIPS is relatively easy to implement

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

CT Supported Employment Study(Mueser, 2004)

Chart1

1.44971.515

8.696193

17194.545

23303

25326

26368

28338

26338

22389

233614

233317

233514

233312

253514

223814

2033.217

173615

143615

193019.7

173321

173620

163018

163317

163918

Standard

IPS

Chrysalis Center

Study Time

Percent employed in any job

Percent Employed in Any Job in 24 month period

Chart2

07.2461.515

018.841.15

2.89918.843.03

7.24630.431.515

7.24631.881.515

8.9634.783.03

5.79733.331.515

5.79733.331.515

4.34837.681.515

5.79736.234.545

4.34833.337.576

2.89934.784.545

2.89933.333.03

7.24634.783.03

5.79737.683.03

5.79731.883.03

7.24634.783.03

7.24634.783.03

10.1428.994.545

8.69631.887.576

8.69634.787.576

8.69628.996.061

7.24631.887.576

7.24636.239.091

Standard

IPS

Chrysalis Center

Study Time

Percent competitively employed

Percent Competitively Employed in 24 month period

Chart9

102.84

367.17

40.56

Mean hours worked (comp)

Mean total hours worked competitively

Chart10

235.42

370.26

143.35

Mean hours worked (any)

Mean total hours worked on any job

Chart11

617.59

2048.23

243.02

Mean wages earned (comp)

Mean total wages earned competitively ($)

Chart12

1124.24

2064.58

731.64

Mean wages earned (any)

Mean total wages earned on any job ($)

Chart13

27.5

73.9

18.2

% employed (comp)

Number of people employed competitively (%)

Chart14

53.6

73.9

34.8

% employed (any)

Number of people employed on any job (%)

Sheet1

Chart 1. Percent Employed in 24 months.SIPSCC

0000ABC

10.010.070.02172

20.090.190.039193

30.170.190.0517195

40.230.300.0323303

50.250.320.0625326

60.260.360.0826368

70.280.330.0828338

80.260.330.0826338

90.220.380.0922389

100.230.360.14233614

110.230.330.17233317

120.230.350.14233514

130.230.330.12233312

140.250.350.14253514

150.220.380.14223814

260.200.330.17203317

170.170.360.15173615

180.140.360.15143615

190.190.300.20193020

200.170.330.21173321

210.170.360.20173620

220.160.300.18163018

230.160.330.17163317

240.160.390.18163918

Chart 2. % Comp. Empl 24 monthsSIPSCC

0000ABC

10.000.070.02072

20.000.190.010191

30.030.190.033193

40.070.300.027302

50.070.320.027322

60.090.350.039353

70.060.330.026332

80.060.330.026332

90.040.380.024382

100.060.360.056365

110.040.330.084338

120.030.350.053355

130.030.330.033333

140.070.350.037353

150.060.380.036383

160.060.320.036323

170.070.350.037353

180.070.350.037353

190.100.290.0510295

200.090.320.089328

210.090.350.089358

220.090.290.069296

230.070.320.087328

240.070.360.097369

StandardIPSPsy Rehab Center

Hours workeded comp.102.84367.1740.56


Hours worked any235.42370.26143.35


Wages earned comp.617.592048.23243.02


Wages earned any1124.242064.58731.64


No. work comp (%)27.573.918.2


No work any (%)53.673.934.8

Sheet2

Sheet3

Impact on Other Outcomes

Improved self-esteem, symptom control, quality of lifeRelated to sustained competitive employmentNo changes with sustained sheltered employment

(Bond, 2001)

Long-Term Outcomes

4 studies with 10-year follow-ups(Test, 1989; Salyers, 2004; Becker, 2006; Bush,2009)Work outcomes improve over timeCosts decrease dramatically for consistent workers (Bush, 2009)

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

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

(Becker, 2006)

Cost 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)

Chart4

37897.7530952.58

31340.9617401.4

35451.7418782.87

39209.2313042.96

37637.6320153.81

31476.1716585.82

32815.8714348.61

23900.8611898.68

26534.7110558.51

24342.399612.65

17948.869731.54

Minimum Work

Steady Work

Years

Mean Cost

Figure 1. Cost Outpatient Services and Institution Days

latgrp-plot

Unconditional model(Log-total Working Hours)

No workLate WorkEarly WorkPredicted (40.5%)Predicted (31.8%)Predicted (27.7%)

00.00800.60321.79140.08670.23201.5896

10.30900.27903.09270.08670.33482.4005

20.14600.51263.46930.08670.47113.2161

30.24241.01594.29150.08670.64673.9449

40.18011.37125.07510.08670.89134.4512average of t3 and time5

50.11781.72645.85860.08671.13594.9575

60.10581.73625.32300.08671.45605.2162

70.08281.76625.27960.08671.82735.3123

80.10352.34935.78090.08672.24765.2480

90.16333.43875.38220.08672.71205.0217

100.25423.54425.10860.08673.21344.6298

Average Working HoursLog working hours (different from Figure 1 generated from latent group analysis)

No workLate WorkEarly WorkNo workLate WorkEarly Work

00.0035.43190.190.000.691.75

119.581.51353.100.330.233.19

22.8135.02397.810.130.513.61

32.8430.43500.500.201.054.45

41.8344.96634.960.131.465.21average of t3 and time5

50.8259.49769.410.061.875.97

62.03115.78744.600.091.835.34

75.7599.12736.190.101.865.25

81.88148.65783.710.152.365.81

95.86209.87629.110.153.595.38

108.51314.58668.200.303.635.12

latgrp-plot

000000

000000

000000

000000

000000

000000

000000

000000

000000

000000

000000

No work

Late Work

Early Work

Predicted (40.5%)

Predicted (31.8%)

Predicted (27.7%)

Years

Mean Hours (Log-Scale)

Figure 1. Group Trajectories for Working Hours in Log-Scale

plot-new

000

000

000

000

000

000

000

000

000

000

000

No work

Late Work

Early Work

Years

Mean Hours

Figure 2. Mean Hours Worked

table1-new

000

000

000

000

000

000

000

000

000

000

000

No work

Late Work

Early Work

Years

Mean Hours

Figure xx. Mean Hours Worked-log scale(for comparison purpose only)

Table2-new

Two Groups

TimeTotal Service HoursLog_Total Serv-HoursTotal costLog total CostHosp & Jail Days (Yes)

Minimum WorkSteady WorkMinimum WorkSteady WorkMinimum WorkSteady WorkMinimum WorkSteady WorkMinimum WorkSteady Work

0156.90178.123.853.9637897.7530952.589.329.270.650.57

1274.71321.524.974.9431340.9617401.49.719.220.50.30

2294.21273.855.074.6635451.7418782.879.728.950.470.25

3292.43160.005.034.3239209.2313042.969.848.530.480.24

4307.07124.354.784.1337637.6320153.819.518.820.420.31

5300.12111.014.653.6631476.1716585.829.37.870.370.29

6267.03102.954.493.5332815.8714348.619.148.070.350.36

7230.3190.334.463.5923900.8611898.689.177.530.310.24

8245.3373.944.313.5326534.7110558.518.987.660.340.19

9255.9962.804.323.2024342.399,612.658.657.330.240.15

10249.9577.784.353.4917948.869,731.548.747.400.250.20

Table2-new

00

00

00

00

00

00

00

00

00

00

00

Minimum Work

Steady Work

Years

Logged Mean Service Hours

Figure 2. Outpatient Service Hours in Log-Scale

table3-new

00

00

00

00

00

00

00

00

00

00

00

Minimum Work

Steady Work

Years

Mean Service Hours

Figure xx. Service Hours

table3-new (2)

00

00

00

00

00

00

00

00

00

00

00

Minimum Work

Steady Work

Years

Proportion with Stays

Figure 3. Stays in Institutions

Sheet3

00

00

00

00

00

00

00

00

00

00

00

Minimum Work

Steady Work

Years

Mean Cost

Figure xx. Cost

00

00

00

00

00

00

00

00

00

00

00

Minimum Work

Steady Work

Years

Logged Mean Cost

Figure 4. Cost of Outpatient Services and Institution Days in Log-Scale

Table 1. Demographic and Clinical Variables at Baseline

VariablesMinimum WorkSteady Work

N = 136N = 51

N%N%Signficance

Sex (Male)97714078ns

Edu (High School or Higher)80594078*

Marital Status (Never Married)56411529ns

Primary Psychiatric Diagnosis (Bipolar)29212039*

Worked past year (any job)45343976**

Hospital & Jail Days past year (Yes)82652957ns

MeanSDMeanSDSignficance

Age33.98.432.26.4ns

AUS3.2 1.03.3 1.0ns

DUS2.4 1.22.2 1.3ns

SATS2.8 1.03.1 1.5ns

BPRS Total47.2 14.441.8 10.3*

*p

Chart3

0.23

0.02

0.25

0.1

0.4

People with Severe Mental Illness in Treatment

Already Employed10%

Not Interested in Employment25%

Evidence-Based Supported Employement2%

No Employment services40%

Ineffective Employment Services23%

Sheet1

23%

2%

25%

10%

40%

Sheet1

People with Severe Mental Illness in Treatment

Ineffective Employment Services23%

No Employment services40%

Evidence-Based Supported Employement2%

Not Interested in Employment25%

Already Employed10%

Sheet2

Sheet3

Johnson & Johnson-Dartmouth Project

Mental health-vocational rehabilitation collaboration implement evidence-based SE = IPSLocal programs selected by statesDartmouth provides training, consultation, evaluationNational Learning CollaborativeStates: CT, DC, KS, MD, OR, SC, VT, IL, MN, MO, OH, KY, WISpecial Projects: NJ, OH, ILInternational Collaborative

(Becker, 2011)

J&J-Dartmouth Program: Real World Agencies

Early Intervention

First episode psychosis (Nuechterlein, 2005; Rinaldi, 2009; Killackey, 2009)

Early Intervention (Nuechterlein, 2005)

Chart3

00

9350

9353

9355

IPS

SAU

% of Employment or school

IPS Supported Employment for Clients with First-episode Schizophrenia

Sheet1

Susan McGurk

Baseline3 Months

CT & SE3744

SE3638

Baseline3 Months

CT & SE327

SE21

Keith Nuechterlein (UCLA)

Baseline6 Months12 Months18 Months

IPS0939393

SAU0505355

Sheet1

CT & SE

SE

Total Number Correct

Computer Training and Memory

Sheet2

CT & SE

SE

Hours worked per Month

Computer Training and Work

Sheet3

IPS

SAU



Addressing Cognition

Concentration, memory, reaction speed, and problem-solvingJob match Improve cognitive function Compensatory strategies

(McGurk, 2008)

Cognitive Training

Practicing cognitive tasks may create new neuronal connectionsTasks directly relevant to work tasksNew capacity may translate to work

(McGurk, 2005)

Chart1

3736

4438

CT & SE

SE



Sheet1

Susan McGurk

Baseline3 Months

CT & SE3744

SE3638

Baseline3 Months

CT & SE327

SE21



IPS0939393

SAU0505355

Sheet1

00

00

CT & SE

SE



Sheet2

00

00

CT & SE

SE



Sheet3

00

00

00

00

IPS

SAU



Chart2

32

271

CT & SE

SE



Sheet1

Susan McGurk

Baseline3 Months

CT & SE3744

SE3638

Baseline3 Months

CT & SE327

SE21



IPS0939393

SAU0505355

Sheet1

CT & SE

SE



Sheet2

CT & SE

SE



Sheet3

IPS

SAU



Benefits Reform

People are socialized into disabilityChanging benefits structure essential

Policy Changes

People with disabilities need cash, health insurance, and a jobThey do not need to be assigned to a lifetime of unemployment and poverty in order to get health insuranceLegislative change is critical

Carl Suter, CSAVR (2006)

Federal Funding ReformWe need simple payment systemFederal committeesAdvocacy

Conclusions

IPS has created hope for for people with psychiatric disabilities, their families, and MH/VR practitionersOutcomes can be enhanced furtherNew researchPolicy changes

Financial SupportGrants from NIDA, NIDRR, NIMH, RWJF, SAMHSAContracts from Guilford Press, Hazelden Press, MacArthur Foundation, Oxford Press, New York Office of Mental Health, Research Foundation for Mental HealthGifts from Johnson & Johnson Corporate Contributions, Segal Foundation, Thomson Foundation, Vail Foundation, West Foundation

Many ThanksDeborah BeckerGary BondGreg McHugoHaiyi XieJon SkinnerPhil BushWill TorreyKim MueserRob WhitleySusan McGurkEric LatimerElizabeth Carpenter-Song

Matt MerrensPaul GormanSarah SwansonDavid LyndeHoward GoldmanSandy ReeseKikuko CampbellWill HaslettSaira NawazCrystal Glover

Information: books, videos, research articles

Patti [email protected]://dms.dartmouth.edu/prc

*Dartmouth Psychiatric Research Center*

Documents

IPS Research Update