The Importance of Func1onal Recovery in Mental Illness Eóin Killackey
WHO Defini1on of mental health • Mental Health refers to a broad array of ac1vi1es directly or indirectly related to the mental well-‐being component included in the WHO's defini1on of health: "A state of complete physical, mental and social well-‐ being, and not merely the absence of disease". It is related to the promo1on of well-‐being, the preven1on of mental disorders, and the treatment and rehabilita1on of people affected by mental disorders.
Where to start • A lot of effort goes into treatment but despite this people with mental illness are over-‐represented among: • • • • • •
Unemployed Homeless Single Poor physical health Jailed Vic1ms of crime
Homelessness • 20-‐50% of homeless people across Australian, US and UK studies have diagnosable schizophrenia • Studies indicate that MI preceded homelessness
• DOHA, 2005 Homelessness and Mental Health Linkages: Review of Na1onal and Interna1onal Literature
• 10% transi1on to homelessness through inpa1ent stay
Alone • Males more likely to be single than females • People with schizophrenia more likely to be single than controls • Less likely to have children • Hutchinson et al. 1998 European Psychiatry
Poor physical health • A range of factors contribute here • Poor lifestyle choices – worse than SES controlled comparators • More smoking • Symptom factors e.g. poor self care • Medica1on side effects (weight gain etc.) • Connolly & Kelly Advances in Psychiatric Treatment (2005), vol. 11, 125–132
Crime • • • • • •
More likely to have a convic1on than general community Increased rates of convic1on since deins1tu1onalisa1on More substance related offences than general community More likely to be a vic1m of crime than the general community 5% of people with a mental illness imprisoned compared to 1.8% in the general popula1on Cost of imprisonment of young men with mental illness $260M •
Wallace et al., American Journal of Psychiatry 2004; 161:716– 727)
Unemployed • 40-‐50% of people in first-‐episode cohorts • 75-‐95% of people with schizophrenia • Employment is number one goal of people with psycho1c illness • Cost of unemployment is over half of all costs associated with illness • Unemployment exacerbates illness and predisposes to all the other factors men1oned •
Killackey et al, 2006 ANZJP
Why? • We have beher medica1ons and more knowledge about pharmacotherapy than ever before. • More knowledge about psychosocial interven1ons • We don’t use that knowledge
Implementa1on • Rates of implementa1on by clinical staff of guideline recommenda1ons are very low • 0-‐43% in psychosocial interven1ons • 30-‐100% in pharmaceu1cal interven1ons • West et al. Psychiatric Services 2005; 56:283-‐291.
Importance of Employment Protec1on of employment Level of employment Desire to work Costs of unemployment
Why start with employment? • No other technique for the conduct of life attaches the individual so firmly to reality as laying emphasis on work; for his work at least gives him a secure place in a portion of reality, in the human community." • Freud" • Everyone has the right to work" • Article 23, Universal Declaration of Human Rights, United Nations, 1948"
Employment is good in general
Employment • Or meaningful occupa1on is protec1ve against: • • • • •
Unemployment Homelessness Aloneness Poor physical health Criminal involvement – either side of the crime
What is unemployment? • Defini1onal problems – what is employment/ unemployment/underemployment • What does the official unemployment rate mean? • How have studies in people with psycho1c illness defined it?
Unemployment in First Episode Psychosis • Rates vary between studies and cultures with a range of 13-‐65% in 11 studies (Marwaha & Johnson, 2004)
• First Episode Psychosis 40-‐50% (Killackey et al. 2006)
And then what happens? • 75-‐90% unemployment among persons with serious mental illness in the U.S. • 70-‐80% pre 1990 and 77%-‐96% post 1990 in UK (Marwaha & Johnson, 2004) • 70-‐84% unemployment rate for persons with schizophrenia in Australia: SANE (2002)
So is unemployment a problem in psycho1c illness? • Only if people with psycho1c illness want to work, and; • If so, only if they are more unemployed than the general popula1on.
People with psychosis don’t want to work •
“I want a day, where I don't have to go to work” –
The Living End
The literature describes open employment as the most frequently-‐iden1fied long-‐term goal of people with mental illness ( Rogers et al, 1991; Secker et al, 2001) • Employment is the number one goal of first episode psychosis clients (49% nominated employment as a goal 33% nominated health and stability as a goal) (Ramsay et al., 2011) •
•
4 most important areas in SHIP – Finance, Employment, Social Isola1on and Physical Health (Morgan et al., 2011)
Compared to popula1on rates Country / Region
Unemployment rate (%)
Australia Brunei China Gaza Germany Greece Hong Kong Indonesia Ireland Macau Malaysia New Zealand Philippines Russia Singapore Spain UK USA
4.9 3.7 4.1 37.8 5.8 18.4 3.5 6.56 14.5 3.0 3.0 6.6 7.2 7.6 1.9 22.9 8.3 8.6
Costs of people with schizophrenia not working Total cost of Cost associated % of total illness with unemployment Australia (2001)
$1.8 billion
$1.08 billion
60%
USA (2004)
$61 billion
$32 billion
52%
Costs • It has been es1mated that increased par1cipa1on in meaningful ac1vi1es by 10% of unemployed people with a psycho1c disorder would result in poten1al savings of $136 million per year in Australia (Carr, 2002)
Barriers Skills Pensions Self iden1ty Accommoda1ons S1gma Disclosure Overcaring clinicians
Barriers to work 1%
Barriers to work
2% 1% 4%
Lack experience
18%
Other
11%
Qualifica1ons/skills Health/Disability Too many applicants 11%
14%
Transport Lack of desired jobs Unsuitable hours Discrimina1on
12% 14% 12%
Employers think I'm too young Language
Welfare benefits and first episode psychosis N=48 7 on benefits at 1me of admission 30 others ini1ated receipt of benefits with median 1me 7 months from admission • Only 2 stopped receiving benefits over a 5 year follow up • At 5 years 35/48 (73% con1nued to receive benefits) • • •
•
Ho B-‐C, Andreasen N, Flaum M: Dependence on public financial support early in the course of schizophrenia. Psychiatric Services 1997; 48(7):948-‐950
Self Iden1ty
Disclosure • It is not necessary to disclose any condi1on as long as it does not interfere with safety of role
Accommoda1ons
Mismanifested care
• “we must have the opportunity to try and to fail and to try again…Professionals must embrace the concept of the dignity of risk and the right to fail if they are to be suppor1ve of us”
Something old Historical place of work in mental health care
Work and treatment • New York State Asylum at U1ca had work or educa1on for pa1ents “not merely to divert but to benefit the inmates” (AJP Vol. 1. p1-‐8, 1844) • Noted to be different to other states • By 1918 noted to be not as directed towards benefiyng pa1ents • “Considering that our hospitals are necessarily under the direc1on of medical men, it is not surprising that the pedagogic side of the treatment has been neglected.” (Briggs, 1918)
Industrial therapy • “An occupa1on that will divert the mental pa1ent's mind from himself and that at the same 1me will lead to natural refreshing sleep is of value in therapy. The various tasks necessary on a farm afford these two advantages in a marked degree. The author has directed the farm work of 63 demen1a praecox pa1ents and reports improvement in many cases.” •
Iles U.G. (1928). Farm work for mental cases. US Veterans Bureau Medical Bulle1n, 4, 282-‐285
Newer approaches Clubhouses Social Firms Supported Employment
Social firms • Not-‐for-‐profit businesses set up to provide a product or service to the public and in doing so create employment for people who may ordinarily be excluded from the labour market due to illness or disability.
Clubhouses • Consumer driven club that has a hierarchy of interven1ons from the work ordered day through to independent employment. Transi1onal employment is a defini1ve interven1on in club houses.
Supported Employment • Place and train/support • Supported employment • Supported educa1on
Individual Placement and support (IPS) Components Outcomes in schizophrenia
Individual Placement and Support (IPS) 1. It is focussed on compe11ve employment as an outcome; 2. the service is open to any person with mental illness who chooses to look for work and that acceptance into the program is not determined by measures of work-‐ readiness or illness variables; 3. job searching commences directly on entry into the program; 4. the IPS program is integrated with the mental health treatment team; 5. poten1al jobs are chosen based on consumer preference; 6. the support provided in the program is 1me-‐unlimited, con1nuing azer employment is obtained, and is adapted to the needs of the individual; 7. and personalised benefits planning is provided.
Compe99ve Employment Rates in 12 RCTs of IPS 90%
Mean = 65% Chronic, 84% FEP
80%
70%
60%
50% IPS Control
40%
Control 2
30%
20%
10%
0% 96 NH
07 IL
04 CT
08 HK
06 SC
99 DC
08 CA
07 EUR
06 QUE
02 MD
08 A US
08 L A
Something old, somewhere new Why intervene early IPS in First Episode Psychosis
Why early may be a greater opportunity? • • • • • •
Young people are less removed from (and may s1ll be on) their original voca1onal trajectory Physical health is likely to be beher now than later More likely to s1ll have a peer group Less likely to have serious forensic involvement Are in a developmental phase where learning new skills is norma1ve Young people with few skills and lihle work history are easier to find jobs for than older people with the same skills and experience.
Employment interven1ons in First Episode Psychosis • 1 prevoca1onal training study • 1 integrated supported employment study • 3 naturalis1c studies of IPS • 2 RCTs of IPS
The study
(Killackey, Jackson & McGorry, BJP, 193, 114-‐120)
Recruited 41 people with first episode psychosis and randomly allocated to groups Baseline assessment: SCID, CESD, QOL, BPRS, Job history, SANS, SOFAS Treatment as usual (n=21)
Individual placement and support + treatment as usual (n=20)
6 month assessment: SCID, CESD, QOL, BPRS, Job history, SANS, SOFAS, Indiana Job sa1sfac1on scale, work related variables e.g. $ or hours per week etc.
IPS (n=20)
TAU (n=21)
Sig.
Jobs
13
2
P
