1. Employment: a cure for mental illness? Silje Endresen Reme PhD and psychologist Uni Research Health & Oslo University Hospital

2. The effect of sick leave The 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 (Øverland et al 2008; Joner et al 2008; Thomas et al 2005) Sick leave: “prevented” later burnout in doctors (Isaksson Ro et al, 2012)

3. The effect of work Systematic review of 18 studies (2012) The social causation hypothesis Strong support e.g: unemployment alcohol abuse e.g: return to work reduced depressive symptom The social selection hypothesis Some support e.g: good health more attractive at job market Rueda, S. et al. (2012). Association of returning to work with better health in working-aged adults: a systematic review. Am J Public Health

5. Sick leave by diagnosis 2014

6. Vocational Rehabilitation

7. Perspectives in vocational rehabilitation “Train and place” Traditional approach sheltered training  job search Traineeship in a Sheltered Business “Place and train” Innovative approach ordinary employment  get training there Supported Employment (SE) Individual Placement and Support (IPS) Bond et al. (1999), Corrigan (2001), Drake et al. (2012), Wehman & Moon (1988).

8. IPS supported employment Evidence-based supported employment For people with severe mental illness Employment is a primary goal of most people with serious mental illness 8 core principles

9. 1.Competitive employment 2.Client’s choice 3.Integrated services 4.Client’s preferences 5.Benefit counseling 6.Rapid job search 7.Employer relationship 8.Continuous support

10. Evidence from 19 randomized controlled trials Bond et al 2012, World Psychiatry

11. Secondary effects Enhanced: Income Self-esteem Quality of life Social inclusion Control of symptom Persist at 10-year follow-ups Bond et al 2001; Burns et al. 2009 ; Mueser et al. 1997; Turner et al. 2012; Becker et al. 2007b; Salyers et al. 2004

12. At Work and Coping (AWaC)

13. Study population (N=1193) People struggling with work participation due to common mental disorders On sick-leave At risk of going on sick-leave On long-term benefits

14. The AWaC intervention IPS supported employment + Work-focused cognitive behavior therapy

15. Population AWaC TAU Work participation Randomization Consent Do not consent Excluded (no data) Design

16. Substantial depression: 50% Substantial depression: 50% # of health complaints: 11 # of health complaints: 11 Age: 40 Women: 67% Women: 67% Substantial anxiety: 70% Substantial anxiety: 70% Higher education: 55% Bullied at work: 36% Bullied at work: 36% Violence victims: 36% Violence victims: 36% Sample characteristics: Back pain Stomach problems Sleep problems Headache Løvvik et al, JOR, 2013

17. Results: work participation 6.2% diff. % Reme et al submitted

18. Results: sub-group, long-term benefits 12% diff. Reme et al submitted

19. Results: long-term follow-up

20. Results: mental health (depression) Reme et al submitted

21. Results: mental health (anxiety) Reme et al submitted

22. Results: health-related quality of life Reme et al submitted

23. Limitations No formal IPS fidelity assessments Informal assessments indicated gradual implementation

24. Conclusion Work-focused CBT and IPS was more effective than usual care in increasing or maintaining work participation for people with common mental disorders The effects were profound for people on long- term benefits The 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

25. The research team Camilla Løvvik Uni Research Helse Simon Øverland Folkehelseinstituttet Stein Atle Lie Uni Research Helse Kari Ludvigsen Uni Research Rokkan Astrid Grasdal Universitetet i Bergen Yngvil Starheim Arbeid og Velferdsdirektoratet

26. Effect Evaluation of Individual Placement and Support (IPS)

27. Overview Randomized controlled multicenter trial 6 centers 407 participants included Study population: People with moderate/severe mental illness Funder: The Directorates of Health and Labour 3 parts: Effect evaluation Process evaluation Cost/benefit-analysis

28. Supported Employment and preventing Early Disability (SEED)

29. Overview Norwegian Research Council IPS vs sheltered employment Young work disabled people Regardless of diagnoses

30. http://SEED-trial.com

31. Summary Employment leads to health benefits Employment is better achieved through “place & train” than “train & place” IPS well documented in severe mental illness The effectiveness extends to common mental disorders AWaC trial: Integration of work-focused therapy and IPS …and beyond?

32. Is 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”

33. Thank you! silje.reme@uni.no