People with severe mental illness show high rates of unemployment and work disability,
however, they often have a desire to participate in employment. People with severe
mental illness used to be placed in sheltered employment or were enrolled in prevocational
training to facilitate transition to a competitive job. Now, there are also interventions
focusing on rapid search for a competitive job, with ongoing support to keep the job,
known as supported employment. Recently, there has been a growing interest in combining
supported employment with other prevocational or psychiatric interventions. To assess
the comparative effectiveness of various types of vocational rehabilitation interventions
and to rank these interventions according to their effectiveness to facilitate competitive
employment in adults with severe mental illness. In November 2016 we searched CENTRAL,
MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised
controlled trials and systematic reviews. We identified systematic reviews from which
to extract randomised controlled trials. We included randomised controlled trials
and cluster‐randomised controlled trials evaluating the effect of interventions on
obtaining competitive employment for adults with severe mental illness. We included
trials with competitive employment outcomes. The main intervention groups were prevocational
training programmes, transitional employment interventions, supported employment,
supported employment augmented with other specific interventions, and psychiatric
care only. Two authors independently identified trials, performed data extraction,
including adverse events, and assessed trial quality. We performed direct meta‐analyses
and a network meta‐analysis including measurements of the surface under the cumulative
ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within
the network meta‐analysis according to GRADE. We included 48 randomised controlled
trials involving 8743 participants. Of these, 30 studied supported employment, 13
augmented supported employment, 17 prevocational training, and 6 transitional employment.
Psychiatric care only was the control condition in 13 studies. Direct comparison meta‐analysis
of obtaining competitive employment We could include 18 trials with short‐term follow‐up
in a direct meta‐analysis (N = 2291) of the following comparisons. Supported employment
was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and
transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training
was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining
competitive employment. For the long‐term follow‐up direct meta‐analysis, we could
include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49
to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training
(RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented
supported employment was more effective than supported employment (RR 1.94, 95% CI
1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational
training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective
than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training
(RR 2.31, 95% CI 1.85 to 2.89). Network meta‐analysis of obtaining competitive employment
We could include 22 trials with long‐term follow‐up in a network meta‐analysis. Augmented
supported employment was the most effective intervention versus psychiatric care only
in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate‐quality
evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5,
low‐quality evidence). Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA
40.3, very low‐quality evidence) and transitional employment were not considerably
different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low‐quality
evidence) in achieving competitive employment, but prevocational training stood out
in the SUCRA value and rank. Augmented supported employment was slightly better than
supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA
value and mean rank were higher for augmented supported employment. The results of
the network meta‐analysis of the intervention subgroups favoured augmented supported
employment interventions, but also cognitive training. However, supported employment
augmented with symptom‐related skills training showed the best results (RR compared
to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3). We graded the
quality of the evidence of the network ranking as very low because of potential risk
of bias in the included studies, inconsistency and publication bias. Direct meta‐analysis
of maintaining competitive employment Based on the direct meta‐analysis of the short‐term
follow‐up of maintaining employment, supported employment was more effective than:
psychiatric care only, transitional employment, prevocational training, and augmented
supported employment. In the long‐term follow‐up direct meta‐analysis, augmented supported
employment was more effective than prevocational training (MD 22.79 weeks, 95% CI
15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining
competitive employment. Participants receiving supported employment worked more weeks
than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or
prevocational training (MD 11.56, 95% CI 5.99 to 17.13). We did not find differences
between interventions in the risk of dropouts or hospital admissions. Supported employment
and augmented supported employment were the most effective interventions for people
with severe mental illness in terms of obtaining and maintaining employment, based
on both the direct comparison analysis and the network meta‐analysis, without increasing
the risk of adverse events. These results are based on moderate‐ to low‐quality evidence,
meaning that future studies with lower risk of bias could change these results. Augmented
supported employment may be slightly more effective compared to supported employment
alone. However, this difference was small, based on the direct comparison analysis,
and further decreased with the network meta‐analysis meaning that this difference
should be interpreted cautiously. More studies on maintaining competitive employment
are needed to get a better understanding of whether the costs and efforts are worthwhile
in the long term for both the individual and society. What is the aim of this review?
The aim of this review was to find out if it is possible to help adults with severe
mental illness get a job and to keep it. People with severe mental illness, such as
schizophrenia or bipolar disorder, are more often unemployed. However, these people
still often have a desire to work. There are many ways to try and help them obtain
a competitive job. People with severe mental illness used to be placed in sheltered
employment or they were enrolled in prevocational training, before searching for competitive
work. Now there are also interventions focusing directly on finding a job quickly,
with ongoing support to keep the job. This is known as supported employment. Recently,
there has been a growing interest in combining supported employment with other prevocational
or psychiatric interventions. Key messages Supported employment and augmented supported
employment are more effective than the other interventions in obtaining and maintaining
competitive employment for people with severe mental illness without increasing the
risk for hospital admissions. The difference in effectiveness between supported employment
and augmented supported employment is small. Future research should evaluate the cost‐effectiveness
of augmented supported employment compared to supported employment only. What was
studied in the review? We included 48 randomised controlled trials involving 8743
participants. The interventions included prevocational training, transitional employment,
such as sheltered jobs, supported employment, supported employment augmented with
other specific interventions or psychiatric care only. We used the data from these
studies about the number of participants who obtained a competitive job and the number
of weeks they worked. Through a direct comparison meta‐analysis and a network meta‐analysis
we assessed the difference in effectiveness between all interventions, and ranked
these accordingly. What are the results of the review? Supported employment and augmented
supported employment are more effective than prevocational training, transitional
employment or psychiatric care only in obtaining employment in both types of meta‐analysis.
In the direct comparison meta‐analysis prevocational training was also more effective
than psychiatric care only. Augmented supported employment shows slightly better results
than supported employment alone, again in both types of meta‐analysis. However, this
result was less clear in the network meta‐analysis. In the subgroup analysis supported
employment with symptom‐related skills training showed the best results. The results
are based on moderate‐ to very low‐quality evidence, meaning that the results of future
studies could change our conclusions. Augmented supported employment is more effective
than prevocational training and supported employment in maintaining competitive employment
in the direct comparison meta‐analysis. The results favour supported employment compared
to transitional employment in maintaining competitive employment. Overall, we did
not find any differences between interventions in the risk of participants dropping
out or hospital admissions. How up to date is this review? We searched for studies
that had been published up to 11 November 2016.