Supported Employment Helps Patients, Cuts Costs

Supported employment is associated with significant reductions in mental health service utilization costs by people with serious mental illness.

The finding, reported in APA's journal Psychiatric Services in August, builds on a substantial literature and clinical lore testifying to the dramatic benefits of employment on functioning and outcome for people with serious mental illness. But the Psychiatric Services study is the first to examine long-term economic benefits of employment.

“We have known for a while that once people become steady workers, they do better in other areas of their lives,” coauthor Robert Drake, M.D., told Psychiatric News. “They feel better about themselves and about their relationships, and they may have a little more money so they are more independent. And they control their symptoms better and stay out of the hospital. We have had so many patients over the years say that work is what really helped them recover and get out of the mental health system and have a life of their own.

“But nobody had looked at the long-term economic effects of supported employment programs,” continued Drake, a professor of psychiatry and community and family medicine at Dartmouth Medical School.

In the study, Drake and colleagues calculated annual costs of outpatient services and institutional stays over a 10-year period for 187 subjects in the New Hampshire Dual-Diagnosis Program. Patients who met the following criteria were included: long-term psychotic illness (schizophrenia, schizoaffective disorder, or bipolar disorder), active substance use disorder within the past six months, and absence of mental retardation.

These participants were heavy service users at baseline. They were identified by their interest in co-occurring disorder services rather than in employment services; however, many were exposed to supported employment during the 10 years of follow-up, because New Hampshire implemented this service widely during the 1990s.

Group differences in utilization and cost were examined over the follow-up between two groups: a “steady-work group” (n=51) who averaged 5,060 hours per person over 10 years, and a “minimum-work group” who averaged about 45 hours per person over 10 years.

Drake and colleagues found that use of outpatient services for the steady-work group declined at a significantly greater rate than for the minimum-work group, and that the average cost for outpatient services and institutional stays for the minimum-work group exceeded that of the steady-work group by $166,350 per participant over 10 years.

Statistical controls for group differences did not make the large effects disappear, Drake told Psychiatric News. “We were shocked when we looked at the magnitude of the effect,” he said.

More education, a bipolar disorder diagnosis (versus schizophrenia or schizoaffective disorder), work in the past year, and lower scores on the expanded Brief Psychiatric Rating Scale predicted membership in the steady-work group.

“The most parsimonious explanation for this finding, consistent with many stories of recovery, is that clients who develop independent vocational lives outside of the mental health system decrease their use of the mental health system,” the researchers wrote.

“There are now five long-term follow-up studies showing that over time people who are exposed to supported employment work more hours and stay employed more of the time, over time, and consider their job a career,” Drake told Psychiatric News. “That's interesting by itself because it's so different from everything we have found in mental health services, where treatment effects invariably tend to erode over time or go away completely. That's not so with employment—people get better and better.”

The authors acknowledged in the study that they could not rule out a possibility that their findings resulted from subjects' being less ill, being better motivated, or responding better to treatments than their counterparts. However, the authors deemed these explanations unlikely for several reasons. For example, statistical controls for age, previous work, and illness severity did not strongly affect or eliminate the associations they found in the study.

Drake said that for policymakers and program administrators, the study's message is clear—supported employment works.

“In the U.S. today, we provide supported employment for about 1 percent of people with serious mental illness, and that's because there is no simple way to pay for this service,” he said. “Programs are just struggling to survive financially so they are going to go on providing services paid for by Medicaid that we know are ineffective. Everyone believes we will have this gap between needs and services until we have an obvious and simple payment mechanism.”

Drake added that there is also a positive message for the practicing clinician. “When we do long-term follow-up with people who have done well and become steady workers, one of the things that surprised us is that many people say they went back to work because their psychiatrist told them they could.”

And changing medications or lowering doses to reduce side effects that can interfere with working has also turned out to be important, he said.

He noted that in the past the conventional wisdom was that people with psychotic illness couldn't work because employment would be too stressful.

“It turns out that it's unemployment that is stressful,” Drake said.

“The Long-Term Impact of Employment on Mental Health Service Use and Costs for Persons With Severe Mental Illness” is posted at<http://ps.psychiatryonline.org/cgi/content/full/60/8/1024>.▪