IPS in E urope

1. IPS in Europe Research, practice and current challenges Tom Burns University of Oxford

2. Principles of IPS • Competitive employment • Open to anyone who wants to work • Rapid job search • Attention to client preferences • Time-unlimited support • Integrated with mental health care • Personalised benefits counselling

3. US evidence • >13 studies (5 RCTs) consistently and overwhelmingly favour IPS over train and place • 20–60% obtain jobs in IPS • 10–20% in train and place • Accepted as the evidence-based standard

4. Why, then, a European study? • Good evidence from Assertive Community Treatment literature that Mental Health Services research into complex interventions may not travel • Opportunity to exploit differences in European context to illuminate processes

5. US and Europe very different • Employment culture • US ‘hire and fire’ versus European employment protection and stability • Welfare state provision • European benefits generally higher • Varies considerably across Europe

6. Benefit trap • Benefits > Salaries • Benefits to make up shortfall in salary; • UK, NT • Benefits ≈ salaries • Benefits linked to previous income; • DE & SW • Benefits < salaries • BG & IT (like USA)

8. Design and Method • Randomised control trial (RCT) in six European countries • Comparing ‘place and train’ (IPS) with ‘train and place’ • Psychotic patients with extensive unemployment • Randomisation at the patient level, • Stratified using minimisation technique by: • Centre, gender and work history • N=300, 50 from each centre • Assessments at baseline, 6, 12 and 18 months • Primary outcome open employment for one day

9. Three questions • Is IPS effective in Europe? • Is its effectiveness influenced by broader social factors? • Does return to work for SMI patients involve health risks?

10. Is IPS effective in Europe?

11. Vocational outcomes

12. Is IPS affected by local socio-economic circumstances?

13. Worked for a day by centre

14. Socio-economic sources of heterogeneity

15. Effect of local unemployment rate on IPS vs outcomes

16. Effect of benefit trap on getting a job overall

17. Effect of benefit trap on IPS effect size

18. Does returning to work make you ill?

19. Hospitalisation during study

20. Conclusions • IPS is twice as effective in obtaining employment in Europe as standard rehab • 54.5% vs 27.6% • Close to US levels • Effect varies and is influenced by • Local unemployment rates • The benefit trap • Patients are not made unwell by IPS

21. Current UK IPS Trials • IPS + CBT module • IPS + motivational interviewing • IPS in first onset psychosis • IPS-LITE

22. IPS-LITE • 9 months, no job – refer back to MH team • ‘perhaps not the right time’ • ‘welcome back if things change’ • 9 months in job • 4 months persisting support with discharge clearly understood • Back to MH team or discharge

23. Hypotheses • Less effective but higher throughput thus more cost beneficial • Lower right hand corner of cost-benefit plane • More effective • Focuses both client and job coach on getting on with it

24. What are the challenges? SWAN Trial

26. What challenges from SWAN? • IPS in high unemployment - recession • Voluntary sector or Health services provision? • Differences between US and UK management cultures for services • Balancing principles • Rapid job search vs client choice • Training or quality control?

27. Thank you for you time Greetings from Oxford