Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events. It is a dreadful disorder, that can make the sufferer feel guilt at the incident, stop them from sleeping and isolate them from their friends and family. It has the potential to completely take over someone’s life, change their personality and affect them every day through nightmares and flashbacks. Those who suffer need the best help possible to aid them in their recovery.

PTSD impacts a person’s ability to function at work (Erbes et al. 2011; Adler et al. 2011) and negatively affects long-term employment (Amick et al. 2017) and income (Pabayo et al. 2017). Veterans who screen positive for PTSD are more likely to be unemployed than those without PTSD (Sripada et al. 2016). This study examines two different techniques for employment support: vocational rehabilitation for veterans with PTSD, involving a step-by-step transitional work programme in a Veterans Affairs (VA) setting, as opposed to a referral to an Individual Placement and Support (IPS) programme, which has strong evidence of its effectiveness in people living with serious mental illness and other conditions (Drake et al. 2013, Drake et al. 1999, Lehman et al. 2002, Cook et al. 2005, Mueser et al. 2016, Salyers et al. 2004), including 1 small pilot study in veterans with PTSD (Davis et al. 2012). A previous study from 2017 found that veterans are significantly more likely to be employed at discharge from VA supported employment (like IPS) compared with VA transitional work programmes (Abraham et al. 2017). However, a lack of evidence and the inherent cost of IPS has led to the VA reducing the ability of veterans with PTSD to access IPS employment programmes (Abraham et al. 2014).

IPS involves job development to rapidly obtain competitive work in the community that aligns with the participant’s preferences, skills and abilities (Carolan, 2016), whilst Transitional work is a step-by-step vocational intervention within the VA that involves vocational assessments followed by pre-employment, non-competitive, time-limited, minimum wage activity, typically maintenance, housekeeping or laundry services within the VA itself. The transitional work assignments differ from a competitive job: there is no job application, no competitive selection process, the incumbent does not have ownership of the position, it is temporary and there is no scope for advancement.

Methods

The study is a multi-centre, prospective RCT comparing the effectiveness of IPS vs transitional work in unemployed veterans with a diagnosis of PTSD. The investigators theorised that more veterans in the IPS group would become steady workers (primary outcome) and earn more income from competitive jobs (secondary outcome) over the 18-month follow-up compared with the transitional work group. Veterans were recruited between December 2013 and April 2015 from 12 VA medical centres. Veterans with a diagnosis of PTSD who were aged 65 years or younger, currently unemployed, interested in seeking competitive employment, eligible for transitional work and willing to be randomised were included. Veterans with a diagnosis of schizophrenia, schizoaffective disorder, or current suicidal or homicidal ideation were excluded. Participants were randomised to either IPS or transitional work and followed up for 18 months, regardless of their adherence to the intervention.

The investigators stated that the primary outcome was steady work, defined as holding a competitive job for at least 39 weeks out of the 78 week follow-up period. Competitive employment was defined as a non-sheltered job earning a salary, wages, or commission, excluding transient cash-based jobs. The participant did not have to hold the same job during consecutive weeks to be counted towards meeting the threshold of a steady worker.

The power analysis was based on the results of a 12 month PTSD study comparing IPS with transitional work. The planned sample size of 540 was projected to provide 90% power to detect a 12.5% difference in the participants achieving steady worker status.

Results

A total of 588 participants were recruited, randomised to IPS (n=271) and transitional work (n=270), with 437 (80.8%) completing the study and no significant difference in retention between the two groups. Participants were unemployed for a median of 1.4 years, 47% had not held a job in the previous 18 months, and the mean age was 42 years. 99 were women (18.3%), 275 were white (50.6%), 225 were African American (41.6%) and 90 were Hispanic or Latino (16.6%). Half were receiving service income and 55.6% presented with a disability, with PTSD being the most prevalent. A total of 329 participants served in the Army (60.8%), 99 in the Navy (18.3%), 84 in the Marines (15.5%), 47 in the Air Force (8.7%) and 39 in the Coast Guard or National Guard (7.2%). The average length of service was 8.3 years, with 324 serving in Iraq/Afghanistan (59.9%) and 389 serving in a combat zone (71.9%). Participants’ primary trauma resulting in PTSD was identified as nonsexual combat-related (n=319, 59%), 93 due to military sexual assault (17.2%) and 71 due to other military-related events (13.1%). In the cohort, 413 scored above the PCL-5 threshold for current PTSD diagnosis at baseline (76.3%).

Study outcomes

Outcome	Individual Placement and Support (IPS) (n=271)	Transitional Work (n=270)	P Value
Primary outcome Steady worker	105 (38.7%)	63 (23.3%)	<.001
Secondary outcome Mean income from competitive source	$14,462	$10,989	.004
Other employment outcome
Competitive job within 18 months	186 (68.6%)	154 (57.0%)	.005
Competitive job within 12 months	179 (66.1%)	127 (47.0%)	<.001
Competitive job within 6 months	145 (53.5%)	86 (31.9%)	<.001
Mean weeks employed in competitive jobs	17.5	12.1	<.001
Mean days employed in competitive jobs	122.3	84.9	<.001
Mean time to first competitive job (weeks)	18.4	28.2	<.001
Employment outcomes from transitional work assignments
Worked in transitional work assignment	11 (4.1%)	142 (52.6%)	<.001
Mean weeks in transitional work assignment	0.2	6.9	<.001
Mean income from transitional work sources	$205	$2,986
Mental health outcomes
Mean estimated change to PCL-5	-3.66	-0.82	.07

The primary outcome of the study reveals that significantly more participants in the IPS group achieved steady work status when compared with the transitional work group (p=<.001) over the 18 month follow-up. Specifically, 105 of the IPS participants (38.7%) compared with 63 of the transitional work group (23.3%) became steady workers.

The other study outcomes revealed that an IPS participant gained competitive employment far more rapidly than transitional work participants, and compared with those in the transitional work group, IPS participants were significantly more likely to: obtain a competitive job, work competitively at any timepoint in the study, and to work more. It is perhaps unsurprising that transitional work participants were more likely than IPS participants to work in a transitional work assignment (52.6% v 4.1%). In the transitional work cohort, 52% of participants began a transitional work assignment after an average delay of 9.7 weeks.

Finally, a review of job classifications (using the Hollingshead scale) found that the number of participants and competitive jobs in each category was similar between the two groups, except for a significant increase in the number of IPS participants working in semi-skilled jobs.

Conclusions

This study provides evidence for the effectiveness of IPS for veterans living with PTSD and the supremacy of IPS over the VA’s transitional work programme in terms of gaining competitive employment, subsequent earnings and time spent in employment. The IPS intervention resulted in significantly earlier competitive job acquisition and far longer job tenure. Whilst PTSD symptoms improved over the 18-month period to a similar extent in both groups, 38.7% of IPS participants became steady workers compared with 23.3% of those following the transitional work programme. Based on the findings of the study, it can be recommended that the VA should provide greater access to IPS for veterans with PTSD.

Strengths and limitations

The study benefits from the fact that it is an RCT, presenting Phase I evidence. Further, the outcomes of the study are consistent with previous findings, a meta-analysis of 21 RCTs found the primacy of competitive employment in IPS with alternative vocational services (Metcalfe et al. 2017). Whilst the study is correct to claim that the broad inclusion/exclusion criteria do match real-world settings (i.e. varying levels of PTSD and the inclusion of those with active substance use), the exclusion of those with serious mental health conditions, and common mental health conditions for that matter, does reduce the applicability of these findings.

The study does have a number of limitations that should be considered. These include the length of the follow-up being only 18 months, the fact that job satisfaction was not considered within the study and the lack of consideration for mental health conditions other than PTSD. Finally, the study could have also benefitted by considering the wider benefits of open, competitive employment in comparison to transitional work placement in relation to the creation of wider personal relationships and the opinions of employers in relation to the experience gained from the two programmes.

Implications for practice

The study correctly identifies that the VA should provide greater access to IPS for veterans with PTSD, but wider consideration should also be paid to the lessons learned in terms of IPS more generally. PTSD is a terrible condition, which impacts people from all walks of life, including veterans. We owe it to them, and to all people who live with this condition, to do our absolute best to support those suffering and to ensure that they have the best resources at hand to help them through what can be a totally debilitating disorder. With that in mind, Prof Kim Mueser in an outstanding editorial relating to this study, says it best:

The time has come to surmount the barriers to funding IPS-supported employment, and to make this effective vocational program available to all people who are struggling with major mental illness.
– Prof Kim Mueser, 2018.

Conflicts of interest

Harry Palmer is a member of the Centre for Mental Health, a key institution in the expansion of IPS in the UK and the primary performer of UK IPS fidelity reviews.

Links

Primary paper

Davis LL, Kyriakides TC, Suris AM, et al. (2018) Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2018;75(4):316–324. doi:10.1001/jamapsychiatry.2017.4472

Other references

Erbes CR, Kaler ME, Schult T, Polusny MA, Aribisi PA. Mental health diagnosis and occupational functioning in National Guard/Reserve veterans returning from Iraq. J Rehabil Res Dev. 2011;48(10):1159-1170.

Adler DA, Possemato K, Mavandadi S, et al. Psychiatric status and work performance of veterans of Operations Enduring Freedom and Iraqi Freedom. Psychatr Serv. 2011;62(1):39-46.

Amick MM, Meterko M, Fortier CB, Fonda JR, Milberg WP, McGlinchey RE. The deployment trauma phenotype and employment status in veterans of the wards in Iraq and Afghanistan [published online April 18, 2017]. J Head Trauma Rehabil. Doi:10.1097/HTR.0000000000000308.

Pabayo R, Fuller D, Goldstein RB, Kawachi I, Gilman SE. Income inequality among American states and the conditional risk of post-traumatic stress disorder. Soc Psychiatry Psychiatr Epidemiol. 2017;52(9):1195-1204.

Sripada RK, Henry J, Yosef M, et al. Occupational functioning and employment services use among VA primary care patients with posttraumatic stress disorder [published online December 12, 2016]. Psychol Trauma. Do:10.1037/tra0000241.

Drake RE, Frey W, Bond GR, et al. Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work. Am J Psychiatry. 2013;170(12):1433-1441.

Drake RE, McHugo GJ, Bebout RR, et al. A randomised clinical trial of supported employment for inner-city patients with severe mental disorders. Arch Gen Psychiatry. 1999;56(7):627-633.

Lehman AF, Goldberg R, Dixon LB, et al. Improving employment outcomes for persons with severe mental illnesses. Arch Gen Psychiatry. 2002; 59(2):165-172

Cook JA, Leff HS, Blyler CR, et al. Results of a multisite randomised trial of supported employment interventions for individuals with severe mental illness. Arch Gen Psychiatry. 2005;62(5):505-512.

Mueser KT, Drake RE, Bond GR. Recent advances in supported employment for people with serious mental illness. Curr Opin Psychiatry. 2016;29(3):196-201.

Salyers MP, Becker DR, Drake RE, Torrey WC, Wyzik PF. A ten-year follow-up of a supported employment program. Psychiatr Serv. 2004;55(3):302-308.

Davis LL, Leon AC, Toscano R, et al. A randomized controlled trial of supported employment among veterans with posttraumatic stress disorder. Psychiatr Serv. 2012;63(5):464-470.

Abraham KM, Yosef M, Resnick SG, Zivin K. Competitive employment outcomes among veterans in VHA therapeutic and supported employment services programs. Psychiatr Serv. 2017;68(9):938-946.

Abraham KM, Ganoczy D, Yosef M, Resnick SG, Zivin K. Receipt of employment services among Veterans Health Administration users with psychiatric diagnoses. J Rehabil Res Dev. 2014;51(3):404-414.

Carolan S. Employment in mind: The Poppy Factory employability service and veterans with mental health conditions. https://www.centreformentalhealth.org.uk/employment-in-mind-the-poppy-factory-employability-service-and-veterans-with-mental-health-conditions.

Metcalfe JB, Drake RE, Bond GR. Economic, labor, and regulatory moderators of the effects of individual placement and support among people with severe mental illness: a systematic review and meta-analysis [published online September 28, 2017]. Schizophr Bull. doi:10.1093/schbul/sbx132.

Mueser KT. (2018) Supported Employment for Persons with Posttraumatic Stress Disorder. JAMA Psychiatry. doi:10.001/jamapsyhciatry.2017.4471

Photo credits

• Photo by Fancycrave on Unsplash
• Photo by Tim Mossholder on Unsplash
• Photo by Håkon Sataøen on Unsplash
• Photo by Cytonn Photography on Unsplash