Supported Employment Over the Long Term: From Effectiveness to Sustainability

For most of us, work provides not only financial remuneration but also a sense of purpose and connection to society. While a majority of people with mental illness would like to work, many face challenges in finding and maintaining a job, including lack of skills and experience, fear of losing disability benefits, and stigma (1). These barriers may be worsening over time. In the United States, employment rates for individuals treated in community mental health settings declined from 23% in 2003 to 17.8% in 2012 (2). Globally, rates of mental disability are rising, and individuals with mental disorders now constitute one-third of disability claimants in developed countries (3).

In the early years of the community mental health movement, mental health providers rarely included vocational rehabilitation as part of their core services. Beginning in the 1950s, organizations such as Fountain House began to provide employment support services in the community (4). Supported employment built on core principles from these programs, while integrating these vocational services into mental health settings (5). The most fully elaborated and widely researched supported employment model—individual placement and support—is based on eight principles: 1) it focuses on competitive employment at the prevailing wage; 2) it is open to anyone who wants to work, regardless of the nature or severity of their illness; 3) it offers a rapid job search, with limited prevocational training, using a “place and train” rather than a “train and place” approach; 4) specialists work to help clients obtain jobs that match their specific goals and interests; 5) placement and support services do not have a time limit and remain available after a client transitions to work; 6) placement and support services are integrated into the individual’s overall mental health treatment program; 7) personalized counseling on Social Security and other disability benefits allows a smooth transition to the workplace; and 8) employment specialists engage with local employers to develop a network of jobs in the community (6).

Individual placement and support is one of the best-established evidence-based interventions available for the treatment of people with serious mental illness. Recent reviews have synthesized results across more than a dozen randomized trials comparing individual placement and support to traditional vocational rehabilitation or treatment as usual (7–9). Across these studies, supported employment increased employment levels more than threefold and extended the length of employment and job tenure (7). These reviews noted at least two major gaps in the literature warranting further research. First, most programs lasted for no more than 24 months, which raises the issue of the durability of effects over the long term. Second, while studies found clear effects on job-related outcomes, less information was available for other mental health measures, including mental health service use and costs. Both longer-term follow-up and impact on service use are critical for establishing the overall cost-effectiveness of these programs (10, 11).

The article by Hoffmann et al. in this issue (12) provides important new data on the long-term outcomes and costs of supported employment. The authors present 5-year results from a Swiss trial comparing individual placement and support to traditional vocational rehabilitation. The study found that participants in the supported employment group were about twice as likely as those in the comparison group to have obtained competitive work (65% compared with 33%), with slightly lower rates at the 2-year follow up (58% compared with 26%) (13). These differential benefits were sustainable with reduced support from an employment specialist over time (from 67% at 2 years to 38% at 5 years). Furthermore, the proportion of participants in supported employment who had inpatient mental health admissions was less than half the proportion in traditional rehabilitation (21% compared with 47%). Taken together, increased earnings and reduced inpatient costs resulted in a higher social return on investment for supported employment participants than for the comparison group (12).

These findings support the growing consensus among researchers and policy experts that from a societal perspective, supported employment is highly cost-effective and may even be cost saving (10, 11, 14, 15). However, uptake of these programs remains troublingly low. As of 2012, it was estimated that only 1.7% of individuals treated in the U.S. public mental health system had access to a supported employment program (2). Financing remains the single most important barrier to broader use of these services. In the United States, vocational rehabilitation funding is generally limited to 90 days, and local mental health service providers typically are unable to recover the costs associated with hiring, training, and retaining employment specialists (16).

Supported employment challenges us to rethink fundamental concepts about the purpose of, and payment for, our treatments for people with serious mental illness and other disadvantaged populations. Unlike the majority of interventions that target psychiatric symptoms, the primary goal of supported employment is to improve a social outcome—unemployment—in a highly disadvantaged population. This is a worthy goal that is consistent with the values of patient centeredness, recovery, and social inclusion (17). However, medical insurers have historically been reluctant to cover social services that go beyond the scope of “medically necessary” care. The findings from the Hoffmann et al. study make a strong business case for insurers and governments to reimburse supported employment as a mainstream mental health service.

New policies are creating opportunities to improve access to supported employment in both the United States and Europe. In the United States, the Affordable Care Act allows states to amend their Medicaid state plans to provide services not traditionally covered under Medicaid, including supported employment, to people with serious mental illness (18). In Europe, the European Social Fund is funding multiple supported employment projects as part of its mission to promote job growth throughout the European Union (19). We need to seize these opportunities to provide widespread access to high-quality supported employment programs for people with serious mental illness. Doing so will provide benefits for patients, communities, and society as a whole.