resumption of work or studies after firstepisode psychosis...

Original Article

Resumption of work or studies after first-episodepsychosis: the impact of vocational

case managementAmal Abdel-Baki,1,2,3 Geneviève Létourneau,1 Caroline Morin2 and Albert Ng1

1Faculty of Medicine, Department ofPsychiatry, University of Montreal,2Clinique Jeunes Adultes Psychotiques(JAP), Centre hospitalier de l’Université deMontréal (CHUM) – Notre-Dame Hospital,and 3CHUM Research center (CRCHUM),Montreal, Quebec, Canada

Corresponding author: Dr AmalAbdel-Baki, Clinique JAP, CHUM –Notre-Dame Hospital, 1560 SherbrookeStreet East, Louis Charles SimardBuilding, 6th floor, Montreal, QC, CanadaH2L 4M1. Email: [email protected]

Received 7 March 2012; accepted 16September 2012

Abstract

Background: Psychosis compromisesthe educational and professionalprojects of young patients. Vocationalcase management (VCM) offers com-prehensive support for reintegrationinto work or studies within an earlypsychosis intervention programme.

Aims: To evaluate the effectiveness ofVCM in resumption of work or schooland to identify the predictive factorsof occupational outcome.

Methods: This descriptive studyfocused on occupational status of anearly psychosis cohort during the first5 years of VCM.

Results: 56.6% of 97 study subjectshad a diagnosis of schizophrenia, 32%

had type I bipolar disorder with psy-chotic features. 68% held a productiveoccupation the year prior to admis-sion, and 47.4% at admission. Theoccupational rate rose from 57.1% at12 months to over 70% after 48months. 65.6% maintained orimproved their occupational status.Most subjects held competitiveemployment, and the employmentrate was similar to that of the generalpopulation. Prior employment andnon-affective psychosis were associ-ated with better outcome.

Conclusion: The majority of individu-als suffering from early psychosisresume productive activity rapidlywhen offered VCM within an earlyintervention programme during afollow-up period of up to 5 years.

Key words: bipolar disorder, first-episode psychosis, schizophrenia,supported employment, vocational rehabilitation.

INTRODUCTION

Work is a priority for people with mental disorderswhatever the diagnosis or illness severity.1,2 90% ofmental health service users are interested inworking, whereas the remaining 10% have no suchinterest because of their illness, medication, dis-crimination or loss of benefits.2 Despite the desire towork, subjects with psychosis have the lowestemployment rate compared to all other disabilitygroups.3 During the last decade, employment ratesamong people with schizophrenia were between 4%to 27% in different countries2 and between 15% to25% in people with severe mental illness in the USA.Supported employment (SE) and especially indi-vidual placement and support (IPS) are more effec-

tive than other vocational rehabilitation methods inhelping people with severe mental illness obtaincompetitive employment.4 Although the AmericanPsychiatric Association guidelines propose that SEshould be available to schizophrenia patients,5 fewIPS programmes are currently in place in clinicalsettings. One recent randomized controlled trialdetermined that IPS programmes were effectivewhen added to specialized first-episode psychosis(FEP) services,6 compared to referral to specializedexternal placement agencies for mental healthpatients: subjects were more likely to acquire a job, towork more hours per week, to maintain their jobsand to become less dependent on welfare benefits.Other studies have disclosed the importance andfeasibility of extending vocational services to include

Early Intervention in Psychiatry 2013; ••: ••–•• doi:10.1111/eip.12021

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education since, in that age group, schooling is oftena main goal and offers prospects for better jobopportunities.7–9

INTERVENTION PROPOSED

Clinique Jeunes Adultes Psychotiques (JAP), anearly psychosis intervention programme operatingsince 1999 within the Centre hospitalier del’Université de Montréal (CHUM), provides com-prehensive 5-year treatment for young adults (18–30years). Its main goal is to help people return to pro-ductive activities as early as possible. Since we didnot have the resources to hire a vocational specialistto implement IPS and we wanted to integrate voca-tional support within our first-episode programme,we created vocational case management (VCM), amodel of case management ‘adopting’ IPS princi-ples. VCM differs from regular early intervention (EI)case management as its main objective is to assistclients in resuming productive activities within thetreatment of psychosis. For example, work is doneon managing symptoms or on compliance withmedication to help patients reach their goal ofretaining a job. Vocational case managers assistclients through all necessary steps to obtain andmaintain a productive occupation (writing arésumé, negotiating work conditions or studyaccommodations, etc.). All interventions (psychiat-ric follow up, individual VCM, group therapies)gradually target that goal. More than a treatmentobjective, acquiring a job or going back to school isconsidered a treatment modality. Observations inthe group programme and individual follow upallow clinicians and patients to monitor andimprove the ability needed to resume productiveactivities, even during acute episodes, when possi-ble. Clients are offered the group programme for afew weeks (less than 8 weeks on average) right afteradmission to the clinic, even if they are still hospi-talized, and will usually continue until they begin aproductive occupation. The group programme con-tains a psycho-education group, an occupationaltherapy workshop, sports activities, cognitive–behavioural therapy, a motivational group tocombat substance abuse comorbidity and a pre-paratory group for return to work/studies (discuss-ing issues related to getting or keeping a job, rightsand responsibilities, practising job interviews, etc.).Weekly team meetings allow group therapists, psy-chiatrists and case managers to share information,modify goals, if necessary, and always ensure thatadherence to vocational outcomes remains the corepurpose of treatment. All case managers participate

as co-therapists in the group programme and areentirely responsible for their clients’ vocationalsupport. Regular peer group supervision of voca-tional case managers is provided, and senior casemanagers also offer individual assistance to juniorones, if needed on a daily basis. Clients (about 10%of our sample) who do not find work rapidly withVCM assistance (within 3 to 6 months) can bereferred to an external agency worker involved inthe clinic. This worker comes to the clinic at leastonce a month to consult clients and participate inteam meetings.

OBJECTIVES

1. Evaluate the effectiveness of VCM offered withinFEP services to help young people return to workor school.

2. Describe which factors influence occupationalprofile.

METHOD

Participants

This descriptive study included all subjects admit-ted to Clinique JAP between October 2002 and July2006. The catchment area comprises part of down-town Montreal, Canada, with a heterogeneouspopulation that averages 185 000 persons. It coverssome of Montreal’s poorest areas and some middleclass and student areas.

Clinique JAP offers services to all CHUM patientsmeeting the following inclusion criteria: agebetween 18 and 30 years at admission, affectiveor non-affective psychosis (main diagnosis) anduntreated or treated for less than 1 year forpsychosis.

Data collection

Data collected by file review included independentvariables (diagnosis, sex, age at admission, andoccupational status before and at admission) anddependent variables (occupational status at differ-ent time points). Diagnoses were established withfile information by best estimate consensus accord-ing to the Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition, Text Revision byone or two psychiatrist(s) and one resident. Thetreating psychiatrist or case manager was consultedif information was insufficient. To preserve confi-dentiality, no nominal data were used, and no

Vocational intervention for early psychosis

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subject was contacted for the study, which wasapproved by the CHUM research ethics and scien-tific committees.

Definitions

Full-time jobs were defined as working at least 30 hper week. Full-time study was defined as taking fouruniversity courses, obtaining 12 credits per sessionor attending adult high school courses for morethan 4 days per week. Regular work was consideredas competitive employment that paid at leastminimum wages. Non-mental health rehabilitationprogrammes referred to programmes open to allindividuals having difficulties integrating into thework market, whereas mental health rehabilitationprogrammes referred to such programmes that spe-cifically support mentally ill individuals. Shelteredwork corresponded to specific sponsored jobsadapted to integrate people with deficits secondaryto their illness.

Statistical analyses

Statistical analyses were undertaken with the Statis-tical Package for Social Sciences software (version16.0; SPSS Inc., Chicago, IL, USA) under supervisionby a statistician. Descriptive analyses disclosed theevolution of occupational status at various timepoints.

Chi-squared tests assessed the impact of eachpredictive factor (sex, diagnosis, premorbid occupa-tional status) on occupational status at differenttime points and t-tests examined the effect of age atadmission. For analytical purposes (because somegroups were too small), we assembled subjects intotwo diagnostic subgroups: schizophrenia spectrumpsychosis (SSP) and non-schizophrenic affectivepsychosis (NSAP). Those with psychosis not other-wise specified were classified on an individual basisin the most appropriate subgroup.

McNemar tests determined whether the evolu-tion of occupational status between admission andevery time point (between admission and 2 years,between admission and 4 years) was statisticallysignificant. To test if the evolution of occupationalstatus between time points was significant,patients were separated into four evolution pro-files: those who always had an occupation, thosewho deteriorated (lost their occupation), thosewho never had an occupation and those whoimproved (obtained a new occupation duringfollow up). These proportions were compared by c2

tests.

RESULTS

Of the 136 subjects admitted to Clinique JAPbetween October 2002 and July 2006, 114 metthe inclusion criteria. The others were excludedbecause of misdiagnosis or had received more than1 year of previous treatment.

Of these 114 subjects, 97 were included, whereasthe remaining 17 subjects (followed at the clinic forless than 1 year (median of 4.3 months)) wereexcluded since no effect on occupational statuscould be attributed to the VCM programme. These17 excluded subjects did not differ in sociodemo-graphic data or predictive variables from the rest ofthe sample, nor did their occupational statuschange for the duration of their follow up (at 3 and 6months).

Of the 97 subjects included, 13.4% were lost tofollow up at 18 months, 20.6% at 24 months, 25.8% at36 months and 30.9% at 48 months. At the end of thestudy (60 months), 60% of subjects were still followedat the clinic, one patient died, 11% were transferredto other services (mainly because they were stableand functioning well enough to be followed by theirfamily doctor or because they had moved out of theMontreal area), and 27.6% were lost to follow up. 56%of patients were grouped in the SSP group (includingschizophrenia (45%) and schizo-affective disorder(10%)) and 44% in the NSAP group (type I bipolardisorder with psychotic features (32%), psychoticdepression 8%)). Mean age at admission was 23.5years, and 78.3% were male (no statistical differencebetween both diagnostic groups).

82% of subjects had previous work experience.Figure 1 tracks the evolution of occupational statusat different time points. From 68% of subjectshaving a productive occupation (work, studies, stay-at-home mothers), at some point during the yearprior to admission, the occupation level dropped to47% the month before admission and remainedstable until admission. By month 3, the level of pro-ductive occupation returned to the admission level;some subjects never stopped working, but most ofthem resumed work after a short leave. Amongthose returning to productive activity, 76% resumedtheir activity by month 6. Productive occupationincreased gradually to a greater proportion frommonth 6 until the end of the study, reaching thepremorbid level at 2 years post-admission andimproving further with time.

Figure 2 illustrates that the majority of subjectsworked full time except at 3 months when the pro-portion of part time workers was greater. After 36months of follow up, at least half of the sample hada full-time job.

A. Abdel-Baki et al.


Figure 3 summarizes the type of job held by FEPpatients during their follow up. Throughout thestudy, more than 80% of those working hadobtained competitive employment, with very fewneeding specific mental health work rehabilitationprogrammes.

The proportion of subjects studying was low andnever reached the premorbid level (Fig. 4). Most of

them were full-time students and, from year 1,10–18% of the sample was working at the same time(Fig. 1).

Of those still followed at year 4 (n = 66), 34.8% sawtheir occupational status improve, 34.8% were ableto keep their occupation for the entire study period,13.6% remained without a productive occupationsince admission and 16.7% deteriorated. Of thosewho never held a productive occupation duringfollow up, very few wanted one, despite encourage-ment from the treating team, mostly because theyhad no interest or they considered themselvesunable to work (because of residual symptoms,including positive symptoms, cognitive deficits,severe anxiety and low stress resistance). Thefew individuals who did not succeed in work-ing had very severe cognitive deficits, chronictreatment-resistant disorganization, agitation andsignificant positive and negative treatment-resistant symptoms.

PREDICTORS OF OUTCOME

Having had work experience any time beforeadmission was not linked to any outcome measure.However, having had an occupation at admission,as well as over the month and year before, wasstrongly coupled with occupational outcomeduring early follow up (first 12 months). This asso-ciation weakened as follow up progressed and

FIGURE 1. Productive occupation in early psychosis subjects. ( ) No, ( ) Work and studies, ( ) Study, ( ) Work. Compared to admission(McNemar test): *P < 0.0001, **P < 0.05, ***P = 0.058.

FIGURE 2. Employment in first-episode psychosis. ( ) Full time,( ) Part time, ( ) None.



was no longer significant after the first years.For example, working during the previous yearbefore admission was associated with productiveoccupation at 3 months (c2 = 45 382, d.f. = 9,P > 0.0001) until 36 months (c2 = 20 334, d.f. = 9,P = 0.016); working during the month beforeadmission was associated with productive occupa-tion at 3 months (c2 = 52 962, d.f. = 9, P < 0.0001)until 24 months (c2 = 19 889, d.f. = 9, P = 0.019);and working at admission was correlated withoccupation at 3 months (c2 = 51 413, d.f. = 9,P < 0.0001) until 18 months (c2 = 22 848, d.f. = 9,P = 0.007).

Figure 5 reports productive occupation ratesbetween the two diagnostic groups. No statistical

difference was observed in early follow up (before24 months) between the two groups. However,NSAP, compared to SSP, was associated withproductive occupation at 24 months (c2 =8188, d.f. = 3, P = 0.042), at 36 months (c2 = 11 459,d.f. = 3, P = 0.009) and at 60 months (c2 = 14 749,d.f. = 3, P = 0.002). Nevertheless, about 50% ofpatients suffering from schizophrenia also held aproductive occupation throughout follow up (defi-nitely higher than rates reported in the literature).Moreover, the diagnostic group did not predictoccupational status evolution between admissionand 4-year outcome. No other factor (sex, age atadmission or having had previous work experience)predicted occupational outcome.

FIGURE 3. Type of work subjects treated with VCM within an early intervention service. ( ) Regular work, ( ) Non-mental healthrehabilitation program, ( ) Adapted work, ( ) Mental health rehabilitation program, ( ) Motherhood.

FIGURE 4. Studies in first-episode psychosis. ( ) No, ( ) Part time, ( ) Full time.



DISCUSSION

Early detection probably helps prevent the conse-quences of untreated psychosis, such as job loss,since interventions will occur before disabilityreaches its peak or before functional impairmentaffects work performance (justifying being fired) orbefore patients quit their jobs (either for delusionalreasons or because they are unable to fulfil job orstudy requirements). It has already been observedthat FEP patients employment rates at admissionare higher than those in more chronic schizophre-nia populations.10–12 However, these rates declinesignificantly during early follow up (first 1–5 years)when no specific intervention addresses occupa-tional issues. Our results greatly differ as occupa-tional rates improved during follow up and areconcordant with a report that found comparableresults supporting the effectiveness of adding voca-tional interventions to FEP services.13

During follow up, high occupational levels couldbe explained by the many incentives to return towork. 61% of our subjects were living independentlyat admission, whereas the majority of subjects inother FEP samples were residing with their parents(54% to 70%).14–16 We encouraged families to helptheir relatives become financially independent assoon as possible, to motivate them to get a job, andwe avoided signing long-term work disabilitywelfare certificates, unless the disability had beendemonstrated by many failed treatment attempts.Such certificates were determined to be a negativepredictor for obtaining a job17 and they sent the

‘ambiguous’ message that we consider people withpsychosis as being unable to work.

We hypothesize that VCM is the main factorresponsible for the quick return to work and thehigh levels of productive activity since all SE princi-ples are seen in our programme. The integration ofrehabilitation and mental health teams allowspatients to see only one worker/team (with whom atrusting therapeutic relationship develops) whooffers specific, individualized and time-unlimitedsupport for vocational recovery, as well as mentalhealth care. Consequently, there is no delay in initi-ating job searches compared to referrals to an exter-nal service or even to someone else in the sameinstitution. Also, VCM focuses primarily on com-petitive employment, and the type of jobs/studiessearched is rooted in consumer preferences.

Even if psychosis interrupts their vocationaldevelopment for a relatively short time period (a fewmonths), the occupational profiles of young peoplewith psychosis do not differ dramatically from thoseof the general population, in comparison to thosewith chronic illness, and therefore, do not becomesuch a major obstacle in getting a job.

The similarity of our sample’s employment rate(up to 65.1%) to that of Montreal’s general popula-tion16 of the same age (69.5%) seems surprising con-sidering their lower education level, their severemental illnesses and the usual perception aboutpsychotic patients’ capacity to work. Moreover, 50%to 70% of studying patients were also working com-pared to 62% of their age group. However, we couldhypothesize that a proportion of subjects lost to

FIGURE 5. Occupation in schizophrenic psychoses versus non-schizophrenic psychoses. ( ) Schizophrenic psychoses, ( ) Non-schizophrenic psychoses. *P < 0.05, **P < 0.01, ***P = 0.058.



follow up (about 40% at the end of the follow-upperiod) had a poor vocational outcome, possiblybiasing our results positively.

Levels of employment among our sample’sschizophrenia patients, although lower than thoseof the other diagnostic group, are still quite highwhen compared to patients not receiving any spe-cific vocational help.1,2

The proportion of patients studying after admis-sion to our FEP clinic diminished throughout thefollow-up period, possibly reflecting that mostpeople in their twenties will finish or end theirstudies to obtain a remunerative occupation. Still,comparing our patients’ education levels15 withthose of the general Montreal population18 high-lights major differences (e.g. 29% of patients had nodiploma at admission to the clinic, 36% had a highschool certificate, 15% had a college diploma and18% had completed university compared to 18%,31%, 19% and 32%, respectively, in the generalpopulation). Higher education levels are related tobetter employment access, salaries, work condi-tions, quality and type of jobs, and the possibility ofimproving socioeconomically.19

Limitations

Our findings indicate that VCM makes a positive dif-ference in the occupational prognosis of FEPpatients. However, we could not identify ‘active ele-ments’ and, owing to the lack of a control group,VCM’s specific impact could not be distinguishedfrom that of EI. Also, our methodology did not allowus to evaluate job stability, salaries as well as howsubjects pursued their vocational development.Nevertheless, those who eventually found a job atsome time point seemed to stay employed. Finally,monitoring occupational status at distinct timepoints could have made us overestimate the delaysin returning to work or study.

Clinical and research implications

Psychosis arises in young people’s developmentperiod when identity, including vocational choices,consolidates. Therefore, it interferes with normallife experiences that allow patients to learn aboutwork market requirements, and identify job inter-ests and life goals. Some patients may have to grieveover vocational projects and choose new onesadapted to their limitations. Ambivalence, hope-lessness and low self-esteem have to be targetedearly. Positive experiences, including brief-durationpre-vocational activities or work reintegration pro-grammes, might be helpful in attempting new expe-

riences despite their ‘fear of failure’, or in achievingsuccess, since some patients will have faced manyfailed trials due to their illness or unrealistic workmarket expectations.

Further research should be undertaken to repli-cate these results with a more robust study design,such as randomized controlled trials comparingregular EI to VCM. Although some variables linkedto favourable occupational prognosis were identi-fied, further research should also discern factorsassociated with failure of VCM to help some FEPpatients maintain their job or educational projectand lead to the development of interventions forrefractory patients.

CONCLUSION

Although Killackey et al.6 have already shown thatadding IPS to specialized FEP services improvesoccupational prognosis, our study indicates thatVCM could be another model of care to enhancevocational outcomes in FEP.

VCM in FEP clinics certainly helps young peopleto invest themselves in their treatment. Retentionand compliance could probably increase sinceVCM gives very concrete meaning to all these treat-ments, and contributes to the reduction of stigmaby normalizing young people’s daily life and pro-moting recovery in a social role. Not wanting towork or study at such a young age is often linkedwith loss of self-confidence or internalized stigma,and has to be worked on within psychologicalinterventions.

This philosophy of treatment considers theperson as a whole with his/her abilities and difficul-ties (including illness) instead of illness being themain focus of intervention. More than offeringvocational aid to those who want to work, wesuggest that vocational rehabilitation should be partof standard care for FEP patients and offered as sys-tematically as other interventions (e.g. medication);it could give a powerful message of hope andimprove self-confidence as well as self-efficacy.

Unemployment is responsible for more than halfof the total costs of psychotic illness and is associ-ated with poor autonomy in life functioning, poorsocial and economic inclusion, and severe symp-tomatology. The present study supports the Interna-tional First Episode Vocational Recovery Groupconsensus statement emphasizing the rights ofyoung people with psychosis to pursue employ-ment, education and training and the importanceof functional recovery in the treatment of earlypsychosis.20



ACKNOWLEDGEMENTS

The authors thank all Clinique JAP patients andworkers who made this research project possible.

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