Occupational and symptom outcomes of combining vocational rehabilitation and cognitive remediation in people with schizophrenia

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Despite improvements in treatments and psychosocial interventions, workforce participation by people with psychotic illness remains low. In Australia, nearly 90% of people with psychotic illnesses receive income through government benefits and less than one third participate in paid employment. Unemployment rates for people with psychotic illness are five times greater than those in the general population. Work is highly valued and has many beneficial effects for people with schizophrenia. Some studies suggest that stability of work may reduce psychiatric hospitalisation. Increased productivity and reduction in hospitalisation has potential to reduce healthcare costs associated with these conditions. Individual Placement and Support programmes have been shown to improve job placement, hours worked and job retention for people with severe mental illnesses, however a significant proportion of those accessing this intervention still do not achieve employment. IPS services were established at various South and North Metropolitan Health sites though partnerships with DES providers since 2013. Cognitive and functional deficits are prevalent among people with psychotic illness such as schizophrenia and robust links between cognitive deficits (CD) and poor community functioning have been consistently demonstrated. Recently, neuroplasticity based cognitive training (CT) has shown promising results in people with schizophrenia. However, the effectiveness of CT to improve employment outcomes among these people has not been well researched. It is unclear whether CT would lead to improved occupational functioning and employment outcomes when offered as adjunctive therapy to IPS participation. We plan to evaluate whether delivering IPS and CT programmes in an integrated manner will further improve cognition, work and other functional outcomes over a one year period in people with schizophrenia. Further, we will ascertain whether these improvements translate into reduced need for psychiatric hospitalisation. We aim to recruit 80 adult patients with schizophrenia who are involved with the IPS programmes at 4 metropolitan sites for the study: Bentley Health Service; Peel and Rockingham Kwinana Mental Health Service; Osborne Community Mental Health Service and Swan Community Mental Health Service. Participants will be randomly allocated to 2 groups; one group will receive IPS service without CT and the second group will receive IPS and 40 hours of computer based CT using BrainHQ software. Socio-demographic data, clinical and work history, symptoms (psychotic, negative, depressive and anxiety), cognition and community functioning will be evaluated at baseline, after CT (or 8-10 weeks for the non-CT group) and 12 months after interventions in both groups. Similarly, occupational outcomes such as number of competitive jobs obtained, days worked and pay rates and healthcare expenses such as number and days of psychiatric hospitalisation in the 12 month period will be assessed in both groups. Between groups differences for continuously distributed variables will be assessed using independent samples t-test or analysis of covariance. Ordinal and nominal data will be treated using non-parametric procedures. The health economist involved with this study will calculate governmental cost savings by calculating expenses and savings through reduced psychiatric hospitalisation and extrapolating these figures to patients with schizophrenia cared for by WA Health. Productivity gains will also be calculated separately. If we find that integrating CT and IPS have promising benefits, we plan to embark on a study with larger sample size and longer follow up periods accessing national funding sources and advocate for the implementation of these programmes into evidence based clinical practice for people with schizophrenia.

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