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Updated 7-4-22 by Gary Bond

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Evidence for the Effectiveness of �Individual Placement and Support Model of Supported Employment

Employment is a Social Determinant of Health

“Employment is a critical mental health intervention.”

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Drake and Wallach (2020)

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Why Focus on Work for People with Serious Mental Illness?

• Most people with mental illness want to work!
• Most see work as a key part of recovery
• Being productive = Basic human need
• In most societies, typical adult role
• Working can be a way out of poverty
• Working may prevent entry into disability system
• Working contributes to better health and well-being

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Positive Impact of Competitive Employment �on Mental Health and Well-Being

In general population:

• Work is beneficial for employee well-being, if:
• good-quality supervision
• positive workplace environment
• work is meaningful
• Beneficial even if working as little as 8 hours/week

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(Modini, 2016; Kamerāde, 2019)

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Positive Impact of Competitive Employment �for People with Mental Illness

Benefits of work for people with mental illness similar to those for general population:

increased self-esteem, improved financial security, reduced mental health symptoms, less social isolation, reduced substance use, and reduced health care

(Drake, 2020; Gibbons, 2019; Luciano, 2014;Wallstroem, 2021)

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Negative Impact of Job Loss �and Extended Unemployment

• Job loss leads to demoralization, lowered self-esteem, social isolation, depression, suicide, substance abuse, health issues
• Huge impact on earnings, in both short and long term
• Return to work increasingly difficult as time passes
• Some laid-off workers never return to the labor force

(especially true for women)

(Korpi, 2001; Paul, 2009; Roelen, 2012)

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Unemployment and Disability Benefits

• When people cannot find work, applications for disability benefits surge
• During Great Recession of 2008, one million unemployed workers applied for SSDI and over 400,000 new beneficiaries joined disability roles
• The disability trap (not working to avoid losing benefits) becomes a way of life

(Maestas, 2018)

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Compared to people without disabilities, people with any mental disability are:

• Far less likely to work.
• If not working, more eager to work,
• BUT far less hopeful that they will get a job.

(Ali, 2011)

After Their First Hospitalization, �Few People with Schizophrenia Work

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(Hakulinen et al., 2019)

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Finnish study using high-quality data from national registry

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People who are hospitalized and diagnosed with schizophrenia are mostly unemployed over the next 10 years. Less than 15% are working at any time.

Need for Employment Services

• Over 60% of people with serious mental illness want to work, but less than 20% employed.

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Expressed Interest in Employment

Reported in 11 Surveys

Individual Placement and Support (IPS)

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Evidence-Based Supported Employment Model

Developed by Deborah Becker and Robert Drake

A Working Life (1993)

Four Trends in IPS Research ����

1. Expanding the evidence base
2. Assessing IPS effectiveness in target subgroups of people with mental illness
3. Extending IPS to new populations beyond people with severe mental illness
4. Developing strategies to disseminate, implement, sustain, and expand IPS

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Trend 1: Expanding the Evidence Base�

• Number of studies showing IPS effectiveness continues to grow
• Long-term outcomes are more positive than previously known
• IPS cost studies are exploring its cost-effectiveness

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Day Treatment Conversions to IPS: �Common Study Design in 4 Studies

• Discontinued day treatment
• Reassigned day treatment staff to new positions
• Implemented new IPS program
• Compared to day treatment sites not converting

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Sources: Drake and Becker

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Day Treatment Conversion Studies�Comparing 6 Sites Converting to IPS�to 4 Control Sites That Continued Day Treatment

Bond (2004)

Similar Results in All �Day Treatment Conversions

• Large increase in employment rates
• No negative outcomes (e.g., relapses)
• Clients, families, staff liked change
• Most former day treatment clients spent more time in community, even those not working
• Resulted in cost savings

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Study Characteristics of 28 Randomized Controlled Trials (RCTs) of IPS for People with Serious Mental Illness

Summary Statistics for 28 RCTs of IPS

• 12 US RCTs and 16 RCTs in 12 other countries
• 17/28 studies had at least 18-month follow-up
• Total enrollment = 6,468 participants
• Most studies recruited participants from community mental health agencies
• In most studies, the control group received services as usual (sometimes best practices)

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Competitive Employment Rates�in 12 RCTs of IPS in United States

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Competitive Employment Rates�in 16 RCTs of IPS Outside United States

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Competitive Employment Rates by Continent �in 28 Randomized Controlled Trials of IPS

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Updated from Drake et al. (2019)

Overall Findings for 28 RCTs

Mean Competitive Employment Rates Across RCTs

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• IPS had a significantly higher employment rate in all but one study

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Systematic Reviews of IPS �for People with Serious Mental Illness

• Many systematic reviews of RCTs of IPS literature
• All conclude: IPS effective in improving competitive employment outcomes
• No other employment model has a robust evidence base

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(Bond et al., 2012; Brinchmann et al. 2020; de Winter et al., 2022; Frederick & VanderWeele, 2019; Kinoshita et al., 2013; Marshall et al., 2014; Metcalfe et al., 2018; Modini et al., 2016; Suijkerbuijk et al., 2017; Weld-Blundell et al., 2021)

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IPS Typically Has Better Monthly Employment Rates: Examples from Two RCTs��

Bond et al. (2007)

Mueser et al. (2004)

Compared to usual services, IPS has superior employment outcomes on numerous criteria

• 33% fewer days to first job
• Four times as many weeks worked during follow-up
• Triple the earnings from employment
• Triple the number working 20 hours/week or more
• Greater job satisfaction

(Bond, et al., 2020)

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18-Month Competitive Employment Outcomes �in 4 Controlled Trials of IPS (Bond et al., 2012)

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Mean Job Tenure in Two IPS Studies

Steady Employment Over Long Term for IPS: Combined Data from 3 Studies��

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Follow-up periods: Hoffmann (2014): 5 years;

Salyers (2004): 10 years; Becker (2007): 8-12 years

Long-Term Outcomes Improve Over Time �for Clients with Severe-Moderate Mental Illness��

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Annual earnings (based on employer IRS filings) during 5-year follow-up�IPS > Control, p < .001��Mean annual earnings for IPS grew $950 (40%) over 5 years; controls increased $300 (17%)�

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Employment Outcomes Maintained Over Long Term

in Mental Health Treatment Study (Baller et al., 2020)

IPS Has Been Implemented Widely �in Routine Practice�

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• IPS has been successfully implemented across the U.S. and worldwide
• Program leaders have overcome geographic challenges
• IPS is effective in both urban and rural communities

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Competitive Employment Outcomes in �Routine Practice Across U.S. (N=151 Programs)�

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Benchmark for good outcome: 41%

Barriers to Implementing IPS �in Rural Areas����

• Rural areas require traveling long distances for face-face services
• Many rural regions are poor
• Rural regions have health care professional shortages

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�IPS Implementation Barriers and Strategies�in Rural Communities: Qualitative Study����

• Long distances, lack of public transportation and poor internet connectivity require creative strategies to job development and travel
• Limited jobs and closeness of business ownership affect job development and follow-along supports
• Local culture requires local knowledge and familiarity

Al-Abdulmunem et al. (2021)

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IPS Fidelity and Employment Rates Similar �in Urban and Rural Communities

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Cost-Effectiveness of IPS:�Areas of Impact Compared to Controls���

IPS…

• Had reduced psychiatric hospital use in some studies
• In short term, similar or more outpatient treatment
• In long term, reduced outpatient treatment
• Not yet rigorously studied: IPS impact on general health care, SSI/SSDI, and criminal justice system

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�Annual Per-Client Cost of IPS Services�(in 2022 US dollars)�

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�IPS Studies of Costs and Cost-Effectiveness (adapted from Zheng et al., 2022)�

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Does IPS Directly Impact�Mental Health and Well-Being?

• Most RCTs have not found a direct impact of IPS

on mental health, quality of life, or most other nonvocational outcomes (Frederick & VanderWeele, 2019: Kukla & Bond, 2013)

• A few exceptions: IPS > controls:
• improved interpersonal relationships (Mueller, 2019)
• Improved mental health and well-being (Drake, 2013)

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Trend 2: Assessing IPS Effectiveness in Target Subgroups of People with Mental Illness�

Studies show effectiveness of IPS for:

• People with justice involvement (3 RCTs)
• Disability beneficiaries (4 RCTs)
• People with co-occurring mental illness and substance use (many studies, including RCTs)
• Homeless people with mental illness (4 studies)
• Young adults (7 RCTs and many other studies)

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IPS Is Effective for Many Subgroups of People with Serious Mental Illness (Campbell, 2011)�

• Different diagnostic groups, including schizophrenia
• All age groups and both men and women
• Diverse ethno-racial backgrounds
• Entire range of work history, including little or none
• All levels of educational attainment
• Mild or severe psychiatric symptoms
• Extensive hospitalization history

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Equality of IPS Access and Outcome �for People of Color (Perkins,2021)�

UK Study of 779 IPS clients

• Equality of access (compared to access to community mental health services):
• Asian and White clients had similar access to IPS
• Black access to IPS = 52% greater than White access
• Equality of IPS outcomes (% employed):
• Whites (34%); Asians (38%); Blacks (33%)

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Recent Focus on Employment Services�for Young Adults�

Many different subgroups of young adults:

• High school students with psychiatric symptoms
• Foster care children being emancipated from child and family services
• Young adults with first episode of psychosis
• Young adults seeking treatment at community mental health centers

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International Focus on �Employment and Education for Young Adults

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• Young adults who are not in employment, education, and training (“NEET”) are increasingly entering disability systems in Europe, Australia, and Canada
• Long periods of unemployment in young adulthood associated with poorer lifetime employment (Gregg et al. 2005)

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Employment Rates Decline Over Time After Early Episode of Psychosis (Ajnakina et al., 2021)

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Meta-Analysis of 7 RCTs of IPS for Young Adults (Bond et al., submitted)

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Meta-Analysis: Employment Rates During Follow-up in 7 RCTs of IPS for Young Adults

Bond et al. (submitted)

Mean Employment and Education Rates in Controlled Trials of IPS for Young Adults

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Research on IPS for Young Adults�Summary

• The young adult population is very diverse – IPS is being offered to many different target groups
• Positive employment outcomes for IPS
• Weak findings for education outcomes
• Young adults drop out of IPS at high rates?
• Are modifications of IPS model necessary?

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���Trend 3: Expanding IPS to New Populations Beyond People with Severe Mental Illness��

Research completed or underway for people with:

• Substance use, including opioid addiction
• Autism spectrum disorder
• Intellectual disabilities
• Common mental disorders
• Justice involvement (felony convictions)
• Medical conditions (primary care patients)
• TANF benefits (Temporary Aid to Needy Families)

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Competitive Employment Rates in 13 RCTs of IPS in Other Populations (updated from Bond et al., 2019)

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CMD = common mental disorder; MI = mental illness; PTSD = posttraumatic stress disorder; SUD = substance use disorder

Emerging Research on IPS for People with Substance Use Disorders� ���

• Three multisite RCTs of IPS for people with primary diagnosis of substance use disorder
• IPS-AD – UK study nearing completion (Marsden)
• Norwegian study – (launched in March 2020) (Rognli)
• Project BEES – US study (Baird and Drake)

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Trend 4: Developing Strategies to Disseminate, � Implement, Sustain, and Expand IPS ��

Scaling Up IPS: How do we close the gap between:

• 60% who express a desire to work competitively and
• 2% of clients in public mental health system who have access to IPS (Bruns et al., 2016)
• Even in a state with broad access to IPS, only 5% of Medicaid beneficiaries with SMI receive IPS (Salkever et al., 2017)

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International IPS Learning Community���

• 26 states/regions in the US
• 4 European countries
• Montreal, Canada
• New Zealand

(Drake et al., 2020)

https://ipsworks.org

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U.S. includes 352 IPS programs

U.S. includes 352

local IPS programs

U.S. membership

includes 348

local IPS programs

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IPS Learning Community Growth in

Number of IPS Programs in US (2002-2020)

Mean Annual Growth Rate: 24.5%

2004: 40

2009: 108

2020: 353

2014: 161

In US, More Rapid Growth of IPS Services in Learning Community Than Outside ����

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(Pogue, 2022)

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Employment rate for last quarter of 2021: 46.3%

(exceeds 41% benchmark for good outcome)

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�State Agency Strategies for Promoting IPS����

• Start small
• Secure funding
• Ensure interagency collaboration (MH and VR)
• Build a learning community among stakeholders
• Provide technical assistance
• Monitor fidelity and outcome

(Bond et al., 2021)

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Learning Community States Provide More State Support for IPS Than Do Other States ����

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(Pogue, 2022)

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Learning Community States Access More Funding Sources for IPS Than Do Other States ����

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(Pogue, 2022)

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Most IPS Programs in Learning Community�Meet Fidelity Standards (≥100)

(Bond et al., 2012)

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Within IPS Learning Community, Most IPS Programs Sustain Services for Many Years

(Swain et al., 2010; Bond et al., 2016)

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Quality of Services in IPS Learning Community Improves Over Time

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N=122 IPS programs in 13 states

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(Bond et al., 2016)

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International Spread of IPS…

to 21 other nations, and counting

European IPS Learning Community (Jónasson, 2022)

Over 600 IPS programs outside US (Knutzen, 2020)

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Portugal

Finland

Factors Promoting Spread of IPS Outside US (Drake, 2020)���

• International consensus that IPS is evidence-based
• IPS research studies conducted locally
• Dedicated leaders
• Technical assistance and fidelity monitoring
• National initiatives setting targets for IPS growth
• In some countries, rapid growth of long-term disability rolls

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Factors Associated with Lower Employment Rates for IPS in Europe �

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• Labor laws and unions protect workers from being terminated, but make it harder for unskilled people to gain work (Brinchmann et al., 2020)
• “Disability trap”: Disability policies may discourage return to work

(Burns et al., 2007; Metcalfe et al., 2018)

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Growth in Number of IPS Programs �in the Netherlands, 2014-2018

de Winter et al., 2020

High and Low Fidelity Supported Employment Programs in Japan��

Programs rated on a modified version of IPS-25

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Yamaguchi et al. (2020)

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Growing Recognition:

Vocational rehab experts rate IPS as highly relevant (3^rd) with strong evidence (3^rd)

(Leahy et al., 2018)

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IPS Evidence Base: Current Status��

• IPS improves competitive employment outcomes for people with serious mental illness
• Its applicability to many other groups is promising
• IPS learning community principles appear to facilitate IPS sustainment and expansion
• IPS is by far the most extensively and carefully researched of all vocational models

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�Future Directions for IPS Research��

• Assessing long-term outcomes for IPS clients
• Determining cost-effectiveness of IPS
• Conducting evaluations of IPS for people with other health conditions and determining whether IPS adaptations are needed
• Developing evidence-based strategies for increasing access to IPS

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IPS Research Evidence: Powerpoint, Reference List, and Brief Review Paper�

https://ipsworks.org 🡪 Library🡪 Search for “research”

powerpoint, reference list, and paper

Bond, G. R., Drake, R. E., & Becker, D. R. (2020). An update on Individual Placement and Support. World Psychiatry, 19, 390-391. 

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garybond@westat.com

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