Effects of IPS plus cognitive remediation in early psychosis: 18-month functioning outcomes of a randomized controlled trial
Introduction
People who experienced a first episode of psychosis often have poor employment outcomes (Cougnard et al., 2009; Bertelsen et al., 2008). Completing education and having access to employment are critical aspects toward recovery for this group (Rinaldi et al., 2010a). Employment provides structure, purpose, financial independence, inclusion, self-esteem, and social status (Drake et al., 2013). Besides these substantial personal merits, competitive work in people with psychosis is of great value for society: Loss of productivity due to unemployment ($21.6 billion in the US in 2002) is the factor that contributes most to the indirect costs of psychotic illness (Wu et al., 2005).
The Individual Placement and Support (IPS) model of supported employment can help people with severe mental illness to obtain competitive employment, in a job they prefer, with the level of professional help they need (Bond et al., 2001). In people who recently experienced a first psychosis, success rates of IPS vary from 40 to 65% for enrollment in competitive employment and from 20 to 30% in regular education (Killackey et al., 2008; Rinaldi et al., 2010b). Despite the beneficial effects of IPS for people with early psychosis, they encounter many barriers to successful (re-)entry into work and education, such as low self-esteem, stigma, and sedation and weight gain due to medication (Bassett et al., 2001). Another major barrier is the occurrence of cognitive deficits, such as reduced verbal and visual memory, attention, speed of information processing, and executive functioning, which are common in schizophrenia (Bowie and Harvey, 2006) and first episode psychosis (Mesholam-Gately et al., 2009).
Given that cognitive deficits are associated with a reduced response to rehabilitation programs and poor work performance (Tsang et al., 2010; McGurk and Mueser, 2004), several studies have attempted to augment the effect of vocational rehabilitation by improving cognitive functioning through various cognitive remediation techniques (i.e., training focused on improvement of neurocognitive functioning). These techniques have also shown positive results in terms of symptoms (Wykes et al., 2011), and psychological gains such as improved empowerment, self-esteem, motivation and reduced self-stigma (Reeder et al., 2016; Contreras et al., 2016). Most of the studies that have combined vocational rehabilitation with cognitive remediation (CR), focused on people with schizophrenia or other severe mental illnesses (Duin van et al., 2019). Little is known about the effectiveness of such combined intervention in people with early psychosis. Evaluating results in this group is especially important because vocational rehabilitation in early psychosis can not only yield short-term experience regarding work and education, but it may also prevent development of long-term unemployment (Rinaldi et al., 2010a), and is predictive of long-term social and clinical recovery (Alvarez-Jimenez et al., 2012).
The current study evaluated to what extent CR reinforces the effects of IPS in people with early psychosis, in terms of participation in competitive employment or regular education. Our hypotheses were:
- 1)
Employment and education outcomes improve more in the IPS + CR group than in the IPS + control group.
- 2)
Cognitive functioning improves more in the IPS + CR group than in the IPS + control group.
- 3)
Empowerment improves more and self-stigma and psychological distress decrease more in the IPS + CR group than in the IPS + control group.
Section snippets
Method
The study was a multi-centered randomized controlled trial (RCT) that evaluated the effect of IPS plus adjunctive CR, compared to the effect of IPS plus an active control intervention. The study (A2016.366/2014.355/NL50176.029.14) was approved by the Medical Ethics Committee of the “Vrije Universiteit Medisch Centrum.” The study protocol (NL4705/NTR4975) was registered prospectively at the Netherlands National Trial Register (NTR).
Participant flow
Participants who completed baseline assessment (N = 73) were considered in the intention-to-treat analyses (Fig. 1). Fifty-seven participants (78%) completed the 6-month assessment (T1), 56 participants (77%) completed the 18-month follow-up assessment (T2). The number of participants with a monthly assessment of vocational data varied from 57 to 64 assessments, with a mean assessment rate of 85.7% in the treatment period (0-6 months) and 76.5% in the follow-up period (7-18 months).
Baseline characteristics
There were
Discussion
The results of this study suggest that employment outcomes can be improved when IPS is combined with CR in patients with early psychosis, particularly in the longer term. Over the complete study period, the experimental and control group both improved in the number of hours worked in competitive employment. During the follow-up period (months 7-18), however, participants receiving IPS with adjunctive CR worked significantly more hours per month (38.5 h) compared with participants who received
Conclusions
Augmenting IPS with cognitive remediation has a significant impact on competitive employment in people with early psychosis, with beneficial effects mainly seen in the longer term. This phenomenon is important because employment of people with early psychosis has a strong predictive value for future (un)employment and recovery. Future studies with a larger sample size are needed to evaluate the impact of cognitive remediation as an add-on to IPS in patients with early psychosis. Future research
Informed consent
A written informed consent was obtained from all patients participating in the trial. IRB approval was obtained for this trial (2014.355/NL50176.029.14).
Previous presentation
Data concerning this quality-improvement project have not been presented on an international conference.
Role of funder
This work was supported by the Ministry of Social Affairs and Employment Opportunities in The Netherlands (grant number 3165). The funder had no role in the study design, in the analysis and interpretation of data, or in the final report of the findings.
CRediT authorship contribution statement
All authors contributed to the manuscript through writing or edits.
Declaration of competing interest
The authors have declared that there are no conflicts of interest in relation to the subject of this study.
Acknowledgments
We would like to acknowledge all patients and professionals that participated within the study. In addition, we want to acknowledge Jos Twisk for his advice on statistical methods.
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