Download - IPS Research Update
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IPS Research UpdateBob DrakeDartmouth Medical School2011
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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
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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
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Current Status of IPS
IPS model is simple and effectiveOther benefits accrue with consistent workWork outcomes improve over timeIPS is relatively easy to implement
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Competitive Employment Rates in 16 Randomized Controlled Trials of Individual Placement and Support
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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
StandardIPSPsy Rehab Center
Hours worked any235.42370.26143.35
StandardIPSPsy Rehab Center
Wages earned comp.617.592048.23243.02
StandardIPSPsy Rehab Center
Wages earned any1124.242064.58731.64
StandardIPSPsy Rehab Center
No. work comp (%)27.573.918.2
StandardIPSPsy Rehab Center
No work any (%)53.673.934.8
Sheet2
Sheet3
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Impact on Other Outcomes
Improved self-esteem, symptom control, quality of lifeRelated to sustained competitive employmentNo changes with sustained sheltered employment
(Bond, 2001)
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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)
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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)
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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
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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
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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)
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J&J-Dartmouth Program: Real World Agencies
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Early Intervention
First episode psychosis (Nuechterlein, 2005; Rinaldi, 2009; Killackey, 2009)
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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
% of Employment or school
IPS Supported Employment for Clients with First-episode Schizophrenia
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Addressing Cognition
Concentration, memory, reaction speed, and problem-solvingJob match Improve cognitive function Compensatory strategies
(McGurk, 2008)
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Cognitive Training
Practicing cognitive tasks may create new neuronal connectionsTasks directly relevant to work tasksNew capacity may translate to work
(McGurk, 2005)
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Chart1
3736
4438
CT & SE
SE
Total Number Correct
Computer Training and Memory
Sheet1
Susan McGurk
Baseline3 Months
CT & SE3744
SE3638
Baseline3 Months
CT & SE327
SE21
Keith Nuechterlein (UCLA)
Baseline6 Months12 Months18 Months
IPS0939393
SAU0505355
Sheet1
00
00
CT & SE
SE
Total Number Correct
Computer Training and Memory
Sheet2
00
00
CT & SE
SE
Hours worked per Month
Computer Training and Work
Sheet3
00
00
00
00
IPS
SAU
% of Employment or school
IPS Supported Employment for Clients with First-episode Schizophrenia
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Chart2
32
271
CT & SE
SE
Hours worked per Month
Computer Training and Work
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
% of Employment or school
IPS Supported Employment for Clients with First-episode Schizophrenia
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Benefits Reform
People are socialized into disabilityChanging benefits structure essential
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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)
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Federal Funding ReformWe need simple payment systemFederal committeesAdvocacy
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Conclusions
IPS has created hope for for people with psychiatric disabilities, their families, and MH/VR practitionersOutcomes can be enhanced furtherNew researchPolicy changes
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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
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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
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Information: books, videos, research articles
Patti [email protected]://dms.dartmouth.edu/prc
*Dartmouth Psychiatric Research Center*