Is employment ?

Employment: a cure for mental illness?Silje Endresen RemePhD and psychologist

Uni Research Health & Oslo University Hospital

1The effect of sick leaveThe longer a person is off on sick leave, the smaller are the chances of that person to ever return to work (Waddell & Burton, 2006)

Sick leave negative health consequences (verland et al 2008; Joner et al 2008; Thomas et al 2005)

Sick leave: prevented later burnout in doctors (Isaksson Ro et al, 2012)

It has been said that sick leave should be considered a treatment with possible effects and side effects. We know, for instance, that the longer a person is off on sick leave, the smaller are the chances of that person ever returning to work, and we know that sick leave and loss of work in and of itself can lead to negative health outcomes and be particularly counterintuitive for people with CMDs. In other words, the side effects might be quite severe. But we also have examples of positive effects of sick leave, for instance in a recent Norwegian study of doctors with burnout. Here, the number of weeks of sickness absence after a counseling intervention for burnout had a positive predictive effect on reduction in emotional exhaustion among doctors at work 3 years later.2The effect of workSystematic review of 18 studies (2012)The social causation hypothesisStrong supporte.g: unemployment alcohol abusee.g: return to work reduced depressive symptomThe social selection hypothesisSome support e.g: good health more attractive at job marketRueda, S. et al. (2012). Association of returning to work with better health in working-aged adults: a systematic review. Am J Public HealthHowever, my focus today is on the effects of work, in which we know much more about, and whether there is any support for the question: could employment be a cure for mental illness?

The social causation hypothesis suggests that employment leads to health benefits, and the social selection hypothesis proposes that health is a necessary condition for employment. Research suggests that the causation effect may be of greater importance than the selection effect, but both mechanisms may interact and reinforce each other.

Of the studies that exclusively found support for the hypothesis that returning to work results in better health, one found that reemployment reversed the negative effect of unemployment on mental health. Another study suggested that the high prevalence of heavy drinking among the unemployed was mostly explained by unemployment preceding heavy drinking rather than alcohol abuse causing unemployment. In a third study, participants who returned to work reported less psychological distress than did those who remained unemployed, and participants who were unable to find employment reported no change in distressover time.

Support for the selection hypothesis: healthy job seekers are more attractive to employers or more likely to survive the challenges of job hunts.

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That is exactly why numerous efforts are set in to help people return to work. And preferably as soon as possible, because, as Waddell and Burton said, the longer a person is off on sick leave, the smaller are the chances of that person ever returning to work. 4Sick leave by diagnosis 2014The long-term sick leave in Norway is dominated by two diagnostic categories; musculoskeletal complaints and mental disorders. The same pattern is seen when it comes to disability pension. However, of note is that disability pension due to mental disorders are given, on average, 9 years earlier than for other diagnoses, and in that way have bigger consequences.

Legemeldte sykefravrsdagsverk etter diagnose, 1 kvartal 20145Vocational Rehabilitation

The trajectory from sick leave to permanent disability almost always involve some sort of vocational rehabilitation. In Norway, this is usually offered when the worker has been sick listed more than a year. 6Perspectives in vocational rehabilitationTrain and placeTraditional approachsheltered training job searchTraineeship in a Sheltered Business

Place and trainInnovative approachordinary employment get training thereSupported Employment (SE) Individual Placement and Support (IPS)

Bond et al. (1999), Corrigan (2001), Drake et al. (2012), Wehman & Moon (1988).Preparation for work before job search7IPS supported employmentEvidence-based supported employmentFor people with severe mental illnessEmployment is a primary goal of most people with serious mental illness8 core principles

65% of people with severe mental illness want to work, but only about 15% are employed.88 core principlesCompetitive employmentClients choiceIntegrated servicesClients preferencesBenefit counselingRapid job searchEmployer relationshipContinuous support

Integration of mental health and employment services

Work incentives planning9

Evidence from 19 randomized controlled trialsBond et al 2012, World Psychiatry The effectiveness of IPS has now been thoroughly documented through 19 randomized controlled trials, all documenting that IPS results in much higher employment rates than the traditional approach involving sheltered work training. About two-thirds of IPS participants succeed in competitive employment, typically working 20 h or more per week, and they sustain employment for years.10Secondary effectsEnhanced:IncomeSelf-esteemQuality of lifeSocial inclusionControl of symptomPersist at 10-year follow-upsBond et al 2001; Burns et al. 2009 ; Mueser et al. 1997; Turner et al. 2012; Becker et al. 2007b; Salyers et al. 2004People who obtain competitive employment through IPS enhance their income, self-esteem, quality of life, social inclusion, and control of symptoms. These enhancements to well-being persist at 10-year follow-ups.But the approach has only been tested for people with severe mental illness.

11At Work and Coping (AWaC)

Until2010, when we started working on a project called AWaC. In this study. IPS was tried out for a different group of people, namely people with common mental disorders. CMDs are far more common and represents a bigger societal burden than severe mental illness, and the idea was, if this works so well for people with severe mental illness, why not for people with CMDs in need of vocational rehab? 12Study population (N=1193)People struggling with work participation due to common mental disorders On sick-leaveAt risk of going on sick-leaveOn long-term benefits

The Norwegian health and welfare authority commissioned the trial and specifically called for an experimental evaluation, which is a first in history within this particular field. The study population was from the outset divided in three.13The AWaC interventionIPS supported employment+Work-focused cognitive behavior therapy

Within the AWaC framework, integration refers to the constant strive to combine therapy and an explicit work focus into one single process, and thus avoiding two parallel lines of action.

The CBT was characterized by cognitive work-coping, focusing on management of mental health problems as they related to work situations. The approach was characterised by directly addressing symptoms and daily functioning, and the clients coping ability related to this. The term work coping points to the importance of using work participation as a tool in the therapeutic process. 14PopulationAWaCTAUWork participationWork participationRandomizationConsentDo not consentExcluded (no data)Design15

Substantial depression:50%# of health complaints: 11Age: 40Women:67%Substantial anxiety:70%

Higher education: 55%Bullied at work:36%Violence victims:36%Sample characteristics:Back painStomach problemsSleep problemsHeadacheLvvik et al, JOR, 2013 16

Results: work participation6.2% diff.%Reme et al submitted17Results: sub-group, long-term benefits12% diff.

Reme et al submittedAt the time of inclusion, 16.2% of the participants were working, 15.7% were working and 50% on sick leave, 39% were fully on sick leave, 25% were on long-term benefits, while 4% were not working or receiving social insurance benefits. N for figuren: 34618Results: long-term follow-upResults: mental health (depression)

Reme et al submittedResults: mental health (anxiety)

Reme et al submittedResults: health-related quality of life

Reme et al submittedLimitationsNo formal IPS fidelity assessmentsInformal assessments indicated gradual implementationConclusionWork-focused CBT and IPS was more effective than usual care in increasing or maintaining work participation for people with common mental disordersThe effects were profound for people on long-term benefitsThe cost-benefit analyses did not show positive economic returns of the program, but for the sub-group on long-term benefits, the stronger effect sizes translated to a large positive economic net return on the investments The research team

Camilla LvvikUni Research HelseSimon verlandFolkehelseinstituttetStein Atle LieUni Research HelseKari LudvigsenUni Research RokkanAstrid GrasdalUniversitetet i BergenYngvil StarheimArbeid og VelferdsdirektoratetEffect Evaluation of Individual Placement and Support (IPS)

In an ongoing project, we evaluate the effectiveness of IPS on the original target group, namely people with severe mental illness. Again, the welfare authorities asked for en effect evaluation26OverviewRandomized controlled multicenter trial6 centers407 participants includedStudy population: People with moderate/severe mental illnessFunder: The Directorates of Health and Labour 3 parts:Effect evaluationProcess evaluationCost/benefit-analysis

The project is requested from the ministries of Health Services, and the ministry of Labour. 27

Supported Employment and preventing Early Disability (SEED)

28OverviewNorwegian Research CouncilIPS vs sheltered employmentYoung work disabled peopleRegardless of diagnoses

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http://SEED-trial.com30SummaryEmployment leads to health benefitsEmployment is better achieved through place & train than train & placeIPS well documented in severe mental illnessThe effectiveness extends to common mental disordersAWaC trial: Integration of work-focused therapy and IPSand beyond?

Work participation used as therapeutic tool

31Is employment a cure for mental illness?Male IPS participant (28):

Being employed and going to work every day has not cured me from my schizophrenia, but it has helped me manage my symptoms better, and it has given me a greater sense of purpose in life

Thank you!

silje.reme@uni.no33