According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) 2017 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services, 2018), an estimated 4.5 percent of all adults age 18 and older have a serious mental illness. Adults with serious mental illness include those people with any mental illness who have “any mental, behavioral, or emotional disorder that substantially interfered with or limited one or more major life activities” (Substance Abuse and Mental Health Services, 2018); this definition is similar to the definition of psychiatric disability according to the Americans with Disabilities Act (ADA National Network, 2018). For the purposes of this priority, the terms “serious mental illness” and “psychiatric disability” are considered synonymous.
People with psychiatric disabilities commonly report having positive goals and expectations related to work; for example, those receiving public income support are more likely to report such positive employment goals and expectations than members of other disability groups receiving such support (Livermore & Baldos, 2017). Furthermore, employment has been demonstrated to yield mental health benefits for individuals with serious mental illness (Modini et al., 2016a; Mueser, Drake, & Bond, 2016). Nevertheless, people with psychiatric disabilities face significant barriers to employment and economic well-being. People with mental illness are far less likely than people without mental illness to be employed, and this gap increases with the severity of mental illness (Luciano & Meara, 2014). One report indicated that more than 80% of people with serious mental illness were not employed (National Alliance on Mental Illness, 2014). Interventions and supports are needed that assist people with achieving their employment goals and expectations. In addition, there is a significant need for further education of the behavioral health workforce, as well as family members and the public, on the benefits of work for those with serious mental illness to address low expectations for clients served in treatment settings and to enhance employment as an expectation of care. More robust availability of and access to quality benefits counselling for people served should be included in workforce development activities.
One of the most promising models for improving employment outcomes for people with psychiatric disabilities is supported employment. Individual Placement and Support (IPS) is an evidence-based supported employment model that has been demonstrated to improve employment outcomes for people with psychiatric disabilities (Cook et al., 2016; Kinoshita et al., 2013; Modini et al., 2016b; Mueser et al., 2016; O’Day et al., 2017). However, there are still challenges to eliminating the disadvantages in employment and earnings experienced by people with psychiatric disabilities. First, the earnings increase resulting from supported employment is typically insufficient to maintain self-sufficiency or to support disenrollment from public income benefits. (Cook et al., 2016; Livermore & Bardos, 2017). Second, there are structural barriers to accessing IPS services that are provided as originally proven to be effective (Drake & Bond, 2014; Metcalfe et al., 2018); furthermore, there is little understanding of the implications for the effectiveness of IPS when it is adapted in real-world service settings (Kim et al., 2015; Waghorn et al., 2018). Third, it is clear that not all people with psychiatric disabilities benefit from IPS; differences may stem from system-level or individual-level characteristics (Corbière et al., 2017; Metcalfe, Drake & Bond, 2018). Therefore, there is a need for a range of complementary or alternative supports that meet their vocational needs (McGurk et al., 2017; O’Day et al., 2017).
ADA National Network (2018). Mental health conditions in the workplace and the ADA. Retrieved from https://adata.org/factsheet/health.
Cook, J. A., Burke-Miller, J. K., & Roessel, E. (2016). Long-term effects of evidence-based supported employment on earnings and on SSI and SSDI participation among individuals with psychiatric disabilities. American Journal of Psychiatry, 173(10), 1007-1014.
Corbière, M., Lecomte, T., Reinharz, D., Kirsh, B., Goering, P., Menear, M., Berbiche, D ., Genest, K., & Goldner, E. M. (2017). Predictors of acquisition of competitive employment for people enrolled in supported employment programs. The Journal of nervous and mental disease, 205(4), 275-282.
Drake, R. E., & Bond, G. R. (2014). Introduction to the special issue on individual placement and support. Psychiatric Rehabilitation Journal, 37(2), 76.
Kim, S. J., Bond, G. R., Becker, D. R., Swanson, S. J., & Langfitt-Reese, S. (2015). Predictive validity of the individual placement and support fidelity scale (IPS-25): a replication study. Journal of Vocational Rehabilitation, 43(3), 209-216.
Kinoshita, Yoshihiro, et al. "Supported employment for adults with severe mental illness." Cochrane Database of Systematic Reviews 9 (2013).
Livermore, G. A., & Bardos, M. (2017). Characteristics of adults with psychiatric disabilities participating in the federal disability programs. Psychiatric rehabilitation journal, 40(2), 153.
Luciano, A., & Meara, E. (2014). The employment status of people with mental illness: National survey data from 2009 and 2010. Psychiatric Services, 65(10), 1201-1209.
McGurk, S. R., Mueser, K. T., Xie, H., Welsh, J., Kaiser, S., Drake, R. E., Becker, D.R., Bailey, E., Fraser, G., Wolfe, R., & McHugo, G. J. (2015). Cognitive enhancement treatment for people with mental illness who do not respond to supported employment: a randomized controlled trial. American Journal of Psychiatry, 172(9), 852-861.
Metcalfe, J.D., Drake, R.E., Bond, G. R., (2018). Economic, labor, and regulatory moderators of the effect of Individual Placement and Support among people with severe mental illness: A systematic review and meta-analysis. Schizophrenia Bulletin, 44, 22-31.
Modini, M., Joyce, S., Mykletun, A., Christensen, H., Bryant, R. A., Mitchell, P. B., & Harvey, S. B. (2016a). The mental health benefits of employment: Results of a systematic meta-review. Australasian Psychiatry, 24(4), 331-336.
Modini, M., Tan, L., Brinchmann, B., Wang, M. J., Killackey, E., Glozier, N., Mykletun, A., & Harvey, S. B. (2016b). Supported employment for people with severe mental illness: systematic review and meta-analysis of the international evidence. The British Journal of Psychiatry, 209(1), 14-22.
Mueser, K. T., Drake, R. E., & Bond, G. R. (2016). Recent advances in supported employment for people with serious mental illness. Current opinion in psychiatry, 29(3), 196-201.
National Alliance on Mental Illness. (2014). Road to recovery: Employment and Mental Illness. Arlington, Virginia, NAMI. Retrieved from https://www.nami.org/work.
O’Day, B., Kleinman, R., Fischer, B., Morris, E., & Blyler, C. (2017). Preventing unemployment and disability benefit receipt among people with mental illness: Evidence review and policy significance. Psychiatric Rehabilitation Journal, 40, 123–152.
Substance Abuse and Mental Health Services Administration (2018). Key substance abuse and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report.
Waghorn, G., van Veggel, R., Chant, D., & Lockett, H. (2018). The utility of item level fidelity scores for developing evidence based practices in supported employment. Journal of Vocational Rehabilitation, 48(3), 387-391.
Priority--RRTC on Improving Employment Outcomes For People with Psychiatric Disabilities
The Administrator of the Administration for Community Living establishes a priority for an RRTC on Improving Employment Outcomes for People with Psychiatric Disabilities. This RRTC will also conduct activities funded by the Center for Mental Health Services, of the Substance Abuse and Mental Health Services Administration. The RRTC must conduct research or evaluative studies designed to improve the employment outcomes of people with psychiatric disabilities. Evaluative studies conducted by this RRTC will focus on assessing the effectiveness of existing programs or services; research studies will generate new knowledge, generalizable to the relevant target populations.
The RRTC must contribute to improving the employment outcomes of individuals with psychiatric disabilities by:
(a) Conducting studies to develop a better understanding of the barriers to and facilitators of improved employment outcomes, or to implement and test models that are designed to improve employment outcomes for people with psychiatric disabilities. In order to maximize the relevance and usability of the new knowledge generated by the RRTC, these studies must involve key stakeholder groups, including people with psychiatric disabilities, in all phases of study activities. These studies will address one or more of the following priority areas, focusing on people with psychiatric disabilities as a group or on people in specific disability or demographic subpopulations of individuals with psychiatric disabilities:
(i) Barriers to and facilitators of providing access to Individual Placement and Support (IPS) services that are provided with fidelity to the evidence-based practice.
(ii) Employment outcomes associated with common provider-generated adaptations to IPS.
(iii) Supports needed to help people with psychiatric disabilities earn a higher income than they do currently with existing employment supports. Research topics in this area may include supports aimed at assisting individuals with navigation of public benefits programs as income increases.
(iv) Supports needed to meet the range of vocational needs of people with psychiatric disabilities. These supports may include but are not limited to IPS services (including IPS services combined with complementary supports) and supported education.
(b) Focusing research on one or more specific stages of research. If the RRTC plans to conduct research that can be categorized under more than one of the research stages, or research that progresses from one stage to another, those stages must be clearly specified. These stages and their definitions are provided in this notice; and
(c) Serving as a national resource center related to improving employment outcomes for people with psychiatric disabilities. Resources should be designed for and disseminated to people with psychiatric disabilities, their families, service and support providers, and other stakeholders. Among other topics, these resources should address low work expectations for clients served in treatment settings and enhance employment as an expectation of care. In addition, the Center must:
(i) Conduct knowledge translation activities that include but are not limited to: Providing information and technical assistance to service providers, people with psychiatric disabilities and their representatives, and other key stakeholders;
(ii) Provide training, including graduate, pre-service, and in-service training, to graduate students and postdoctoral fellows, rehabilitation service providers and other disability service providers, to identify and facilitate more effective delivery of services to individuals with psychiatric disabilities. One goal of this training should be improved availability of and access to quality benefits counseling. This training may be provided through conferences, workshops, public education programs, in-service training programs, and similar activities;
(iii) Disseminate research-based information and materials related to improving employment outcomes for people with psychiatric disabilities to key stakeholders, including individuals with psychiatric disabilities.
General Rehabilitation Research and Training Center Requirements
The effectiveness of any RRTC depends on, among other things, how well the RRTC coordinates its research efforts with the research of other NIDILRR-funded projects, and involves individuals with disabilities in its activities. Accordingly, the RRTC must:
(a) Coordinate on research projects of mutual interest with relevant NIDILRR-funded projects as identified by the NIDILRR Project Officer.
(b) Involve individuals with disabilities, including individuals with disabilities from minority backgrounds, in planning and implementing its research, training, and dissemination activities, and in evaluating the RRTC.
(c) Coordinate with the appropriate NIDILRR-funded Knowledge Translation Centers and professional and consumer organizations to provide scientific results and information to policymakers, service providers, researchers, and others, including employers, vocational rehabilitation providers, and independent living centers.
Definitions - Stages of Research:
(a) Exploration and discovery means the stage of research that generates hypotheses or theories through new and refined analyses of data, producing observational findings and creating other sources of research-based information. This research stage may include identifying or describing the barriers to and facilitators of improved outcomes of individuals with disabilities, as well as identifying or describing existing practices, programs, or policies that are associated with important aspects of the lives of individuals with disabilities. Results achieved under this stage of research may inform the development of interventions or lead to evaluations of interventions or policies. The results of the exploration and discovery stage of research may also be used to inform decisions or priorities.
(b) Intervention development means the stage of research that focuses on generating and testing interventions that have the potential to improve outcomes for individuals with disabilities. Intervention development involves determining the active components of possible interventions, developing measures that would be required to illustrate outcomes, specifying target populations, conducting field tests, and assessing the feasibility of conducting a well-designed intervention study. Results from this stage of research may be used to inform the design of a study to test the efficacy of an intervention.
(c) Intervention efficacy means the stage of research during which a project evaluates and tests whether an intervention is feasible, practical, and has the potential to yield positive outcomes for individuals with disabilities. Efficacy research may assess the strength of the relationships between an intervention and outcomes and may identify factors or individual characteristics that affect the relationship between the intervention and outcomes. Efficacy research can inform decisions about whether there is sufficient evidence to support “scaling-up” an intervention to other sites and contexts. This stage of research can include assessing the training needed for wide-scale implementation of the intervention and approaches to evaluation of the intervention in real-world applications.
(d) Scale-up evaluation means the stage of research during which a project analyzes whether an intervention is effective in producing improved outcomes for individuals with disabilities when implemented in a real-world setting. During this stage of research, a project tests the outcomes of an evidence-based intervention in different settings. It examines the challenges to successful replication of the intervention and the circumstances and activities that contribute to successful adoption of the intervention in real-world settings. This stage of research may also include well-designed studies of an intervention that has been widely adopted in practice, but lacks a sufficient evidence base to demonstrate its effectiveness.