Helping Patients With Mental Illness Get Back to Work

The onset of schizophrenia often happens during young adulthood. The illness disrupts the normal developmental goals of young adulthood, including intimacy, friendship, education, and vocation. Patients and their families need guidance on how to adapt to a future that includes having a serious psychiatric illness. One of the central questions for young patients is whether to seek (or return to) a “real” job once a diagnosis of schizophrenia is made.

A landmark study by McGurk and colleagues in this issue of the Journal (1) tackles the broader question of the potential reversibility of ongoing disability by targeting key cognitive barriers to getting and holding a job. The study evaluated the impact of adding a focused cognitive component to current state-of-the-art employment services. In this editorial, I discuss some of the background and context within which the study was conducted, as well as importance of these results to the field at large.

When I was in my residency training in the early 1980s, the prevailing belief was that schizophrenia is progressive. A diagnosis of schizophrenia meant a life of deterioration devoid of further adult development. Therefore, we were taught to discourage schizophrenia patients from going back to work. The belief was that attempts to work were destined to fail, and that they would trigger stress-related symptoms and feelings of defeat. Almost all “rehabilitation” treatments were protected, with little or no expectation of returning to the “real world.” The emphasis was on maintaining stability rather than “pushing” the patient and risking relapse.

Fortunately, a small cadre of rehabilitation specialists did not see it this way. They believed that persons with severe mental illness were not destined to fail. They believed that lack of employment was not the same as lack of capacity for employment (2). They believed that meaningful work is essential for meaning in life, and that schizophrenia patients could return to work given the right circumstances or the right kind of rehabilitation. Their efforts in programmatic development and evidence-based research over the past decades have resulted in the recognition that supported employment programs can often help disabled, persistently ill patients achieve their goal of competitive paid employment. Supported employment is now an accepted evidence-based practice whose aim is to help “people with [psychiatric] disabilities participate as much as possible in the competitive labor market, working in jobs they prefer with the level of professional help they need” (3).

The overall weight of the evidence is such that the most recent Schizophrenia Patient Outcomes Research Team recommendations (PORT 2009) included supported employment as one of only eight psychosocial interventions meeting their strict criteria for inclusion: “Any person with schizophrenia who has the goal of employment should be offered supported employment to assist them in both obtaining and maintaining competitive employment” (4). PORT 2009 also addressed and dismissed the concern that returning to work was too stressful and would worsen symptoms: “There is no evidence that engagement in supported employment leads to … negative clinical outcomes” (4).

No longer can patients with severe mental illness be thought of as “once disabled, always disabled.” The broader implication is that schizophrenia is not a vocational graveyard. However, the fact remains that current supported employment programs have a long way to go. Success in supported employment is generally limited to achieving competitive employment for a set period of time, and only 40%–50% of individuals entering a supported employment program will meet success criteria. Furthermore, getting competitive employment in the short run is not the same as achieving long-term job retention and sustained economic self-sufficiency (5).

Perhaps cognitive impairments associated with schizophrenia explain some of the current limitations of supported employment programs. It is now widely recognized that cognitive impairment is a major cause of long-term functional disabilities associated with schizophrenia, including employment. Cognitive problems can be thought of as a measurable and clinically significant difference between a person’s premorbid cognitive potential relative to measured cognitive functioning with a diagnosis of schizophrenia (6). Therefore, cognitive impairment may still account for the outcome limitations of current supported employment programs. If true, then a natural treatment target is to improve those cognitive impairments that continue to interfere with employability. As reviewed a few years ago in the Journal (7), cognitive remediation therapy can improve cognition on neuropsychiatric testing, and when combined with psychiatric rehabilitation can also generalize to improved functioning. Cognitive remediation therapy is behavior-based training that aims to improve cognitive processes by employing techniques ranging from computer-based exercises to therapist-led problem-solving sessions.

In this issue, McGurk et al. report on a trial evaluating the efficacy of integrating a state-of-the-art cognitive remediation program into a supported employment program. The study was done at two sites that already had established supported employment programs with staff trained in delivery of supported employment services. The study subjects were selected for their relative lack of success in achieving competitive employment, defined as not finding or holding on to a competitive job for at least 3 months despite being engaged in a supported employment program. After screening, consenting subjects were randomly assigned to receive 6 months of a cognitive enhancement program either with or without an additional cognitive remediation program called “Thinking Skills for Work.” From a research perspective, this was an ideal way to do a “proof of concept” in that the cognitive intervention group was compared with others who were also receiving all other aspects of supported employment services.

The Thinking Skills for Work program began with an individualized assessment of cognition, especially those aspects of cognition that pertain to obtaining and keeping a job. Part of the intervention entailed the use of a curriculum of cognitive exercises from COGPACK, which is a software program known to improve scores on neurocognitive tests in patients with schizophrenia. An important point here is that the intervention was not just having patients go to the computer: it also involved one-on-one coaching with a cognitive specialist on a weekly basis. The Thinking Skills for Work cognitive specialist used a range of techniques designed to enhance cognitive performance at work: cognitive exercise practice, strategy coaching, and teaching coping/compensatory strategies. The same cognitive specialist also met with the supported employment team to give and get feedback during their weekly meetings. The intervention was designed for 24 sessions to take place over a 6-month period.

The outcome measures included cognitive performance on a standard neurocognitive battery and work outcomes, including the proportion of each group who obtained competitive employment over the next 18 months. The main finding was that there was an early but sustained response in some of the key employment outcomes, such as achieving competitive employment over each 6-month follow-up interval and mean hours worked in competitive employment per week. The differences in employment outcome did not depend on primary psychiatric diagnosis, but the cognitive gains were somewhat stronger in the schizophrenia and schizoaffective disorder diagnostic groups than in others. The outcome differences could not be explained by overall participation in the ongoing supported employment program, which was fairly good (and not different) across the randomized groups. One example was that 60% of the Thinking Skills for Work group obtained competitive employment, compared with 36% of the comparison group. Overall attendance and participation did not differ between the groups, so the difference was not an artifact of more time spent in the supported employment program.

The results from this study are very encouraging. Cognitive problems are one of many barriers to finding and keeping a job. It is far from obvious that improving cognitive functioning would matter, especially if the relative change in cognition was not contextually relevant for someone stuck in a kind of supported employment “holding pattern.” But the addition of Thinking Skills for Work seemed to partly reverse the previous impasse at achieving competitive employment. The intervention seemed to change the work trajectory well beyond the 6 months of the intervention itself, as shown by a continued positive slope of proportion achieving competitive employment up to a year and a half after the actual cognitive intervention ended. Previous studies of cognitive remediation therapy have shown persistence of improved work outcomes long after the intervention has ended. Thus, once remediation is done and a job is started, staying at work might now replace the cognitive remediation therapy as a source of ongoing cognitive stimulation (7).

The results of the study have an immediate impact on our understanding of the mechanism of why psychiatric disabilities persist over time, and they show that what appears to be a life of permanent unemployment can, for many individuals, be partly reversed with focused and individualized attention to improving cognition. As the authors stated, “This is the first study of cognitive enhancement to focus on individuals who were operationally defined as not having benefited from an evidence-based psychosocial treatment.”

To use a psychopharmacology analogy, patients were selected on the basis of a history of supported-employment “resistance,” in a way that reminds me of how patients were selected for treatment-resistant symptoms for a clinical trial for treatment-resistant schizophrenia. To push the analogy further, I think of how the Clozapine Study 30 in the 1980s (8) demonstrated better efficacy in patients with otherwise medication-resistant illness, and that Study 30 was the harbinger of ending the 25 years of stagnation in the pharmacologic treatment of schizophrenia that came before the clozapine proof of concept.

Just as clozapine is a challenging drug in practice, so is integrating and personalizing cognitive enhancement with supported employment. It is labor intensive and requires considerable skill, training, and supervision on the part of the cognitive specialist. It remains to be seen whether the future of integrating cognitive remediation with functional goals can be done in a way that is less resource intensive. There are other cognitive remediation therapy interventions that are less complicated and not as labor intensive as the Thinking Skills for Work intervention. It will be important to study those as well, which would be an important step for scalability. Likewise, there is a great need to do better research on the interactions between optimizing pharmacologic treatment hand-in-hand with targeted interventions for cognition. In the meantime, the authors are to be commended for their significant contribution to understanding the synergistic effects of cognitive remediation with supported employment, and their demonstration that work disability is at least partly reversible even when the immediate outlook seems gloomy.