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| Data analysis of a multi-locality, longitudinal schizophrenia study by faculty from the JHU/UMD Center for Research on Services for Severe Mental Illness reveals the impact of schizophrenia on employment. Background: The low rate of employment among people with schizophrenia is a forceful reminder of the disabling impact of the disease, and the need for improvements in treatment. The vast majority of people with schizophrenia, 73% to 90%, are not employed at any given time, and those who are work part time or are in non-competitive situations such as workshops or enclave jobs. One of the impediments to employment is the presence of symptoms. Previous studies with small samples of clinic patients have suggested that negative symptoms, that is poverty of speech, affective flattening, avolition or attentional impairment, are stronger predictors of employment and social functioning than are positive symptoms (auditory hallucinations, delusions, or incoherence and illogical thought). Other problematic symptoms include depression and extrapyramidal side effects of antipsychotic medications which can affect motor function and physical appearance.
Advance: There has been little quantitative analysis to indicate the extent to which improvements in treatment that ameliorate symptoms would bring about improvements in employment outcomes. This analysis addresses the relationships among treatment, symptoms, and employment outcomes, and seeks to predict changes in rates of different types of employment that might result from reductions in symptom levels. The data come from a sample of 1,643 adults with a schizophrenia diagnosis participating in a longitudinal study of treatment and outcomes (the Schizophrenia Care and Assessment Program, SCAP) in six localities in the US. Three employment measures were used: not employed, employed in a sheltered or supported job, and employed in a non-supported job. The symptom measures, which were obtained by trained clinical assessors, included scores on the Positive and Negative Symptom Scale (PANSS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Simpson-Angus Scale (SA) for extrapyramidal side effects of antipsychotic treatment.
Of the four symptom categories, negative symptoms had the most substantial adverse effect on employment, whether employment opportunities were for sheltered/supported jobs or non-supported jobs. Moreover, the effect of an improvement in symptoms on employment is stronger for non-supported employment than for working in sheltered or supported employment. For example, a 20 percent reduction in negative symptoms from the median would increase the mean rate of unsupported employment by 2 percentage points, to 11.6 percent, compared to an 0.26 percent increase for symptoms of depression, an 0.4 percent increase for positive symptoms, and an 0.27 percent increase in extrapyramidal side effects The impacts on employment of other symptoms are not as large, but significant effects were also found for depression. However, even with improvements in treatment and large (i.e., 40 percent) reductions in all categories of symptoms, these results indicate that the rate of non-supported employment among people with schizophrenia would remain quite low, and only one-third of consumers would work for pay. Significance: Symptoms of the disease alone do not explain the low rate of employment for persons with schizophrenia and results indicate that the disease has a profound negative impact on employment even after symptoms are brought under control. This suggests that improved treatment that results in reduced symptom levels will increase rates of employment among people with schizophrenia, but that large effects on employment probably also require more effective rehabilitative therapies that target improvements in functioning. Greater access to, and improvement in, vocational rehabilitation services, including employment programs, may be effective in facilitating patients' transitions into competitive jobs. Additionally, expansions of supported employment opportunities and removal of work disincentives in public income-support programs are two measures that may also help to increase employment participation. REFERENCES: Slade E and Salkever D. Symptom effects on employment in a structural model of mental illness and treatment: Analysis of patients with schizophrenia, J. of Mental Health Policy and Economics 2001; 4: 25-34. Last Updated November 12, 2002 |
