Evidence-based supported employment for people with mental illness recently housed by a housing first project: helping homeless people achieve their goals of employment

People with mental illness, recently housed by a Housing First program, experience rates of unemployment exceeding 95%. A large majority would like to return to employment, but face significant obstacles that result from their experiences of homelessness and mental illness. Some of these obstacles persist after they receive housing support, suggesting that they require assistance attaining their employment goals. Individual placement and support (IPS) is effective at increasing employment rates among stably-housed people with mental illness. Less is known about the impact of IPS on homeless people with mental illness. This mixed methods study was undertaken to evaluate the effect of IPS and Housing First on employment and includes three datasets (two quantitative and one qualitative). It is from these datasets that the content of this thesis is derived: 1) A large dataset of 2148 participants from the At home/ Chez Soi Housing First randomized controlled trial (RCT). 2) A site-specific sample of 90 participants from an RCT testing the effect of IPS. And 3) a sample of 27 participants interviewed as part of the qualitative strand. Dataset 3 was obtained from a subsample of dataset 2, which was a subsample of dataset 1. The randomized control trials of IPS and Housing First suggest that neither alone is sufficient to significantly increase peoples' odds of obtaining employment compared with usual services, but that IPS does increase the odds slightly to a statistically significant extent. With time Housing First does have an impact, but the odds remain lower than those observed in the control group. The effect of IPS may have been diluted by problems related to implementation and homelessness. Qualitative interviews suggest that IPS appears to have beneficial effects on participants' search for employment by facilitating the establishment of trusting working alliances.Les personnes atteintes de maladie mentale, récemment logés par un programme «logement d'abord» (type «Housing First») ont un taux de chômage qui dépasse 95%. Une grande majorité souhaite retourner à l'emploi, mais font face à des obstacles importants qui résultent de leurs expériences d'itinérance et de maladie mentale. Certains de ces obstacles persistent après avoir reçu de l'aide d'un programme «Housing First», ce qui suggère qu'ils ont besoin d'aide additionnelle pour atteindre leurs objectifs d'emploi. Le model Individual Placement and Support (IPS) est efficace et augment le taux d'emploi chez les personnes atteintes de maladie mentale logés de manière stable. Nous connaissons moins à propos de l'impact d'IPS sur les personnes sans-abri atteintes de maladie mentale. Cette étude, de méthodes mixtes, a été menée pour évaluer l'effet d'IPS et du programme «Housing First» sur l'emploi compétitif, et comprend trois bases de données (deux quantitatives et une qualitative). C'est à partir de ces bases de données que le contenu de cette thèse est dérivée: 1) Une grande base de données de 2148 participants de l'étude randomisés At Home/ Chez Soi. 2) Un échantillon spécifique de 90 participants qui participaient à une étude randomisés qui testait l'effet d'IPS. Et 3) un échantillon de 27 participants interrogés dans le cadre du volet qualitatif. Les données 3 ont été obtenue à partir d'un sous-échantillon des données 2, qui étaient un sous-échantillon de données 1. Les études randomisés d'IPS et du «Housing First» suggèrent que ni l'un ni l'autre est suffisante pour augmenter les chances d'obtenir un emploi par rapport aux services habituels, mais que le programme IPS augmente les chances un peux. Cependant, avec le temps «Housing First» a un impact. L'effet d'IPS peut avoir été dilué par des problèmes liés à l'implantation du programme et aux expériences d'itinérance. Les entrevues qualitatives suggèrent que le programme IPS semble avoir des effets positifs sur la recherche d'emploi en facilitant l'établissement d'une relation caractérisé par la confiance qui produit une alliance de travail

Stakeholder perspective on barrier to the implementation of Advance Care Planning in a traditionally paternalistic healthcare system.

BackgroundAdvance psychiatric agreements could guide medical teams in providing care consistent with the incapacitated service user's wishes. However, these types of agreements are rarely completed in Asian settings. What challenges can a traditionally paternalistic healthcare system expect to encounter when attempting to implement psychiatric advance directives?MethodsWe answered this research question by exploring the cultural, administrative and logistical challenges that might impede the implementation of the system supporting the service. We interviewed key stakeholders, 28 service users and 22 service providers, to seek their views and interests in the implementation of directives. We structured our analyses along a literature-review-based framework designed to guide further implementation studies, proposed by Nicaise and colleagues (2013). Accordingly, we divided our inductively generated themes into four longitudinal categories: pre-development stage, development stage, implementation stage, post-implementation stage.ResultsOverall, the findings indicated that many service users and service providers are interested in advance care planning. They believed that foreseeable challenges could be overcome with appropriate measures. However, the multiple challenges of implementation led some service providers to be ambivalent about their implementation and led service users to dismiss them. Specifically, factors related to the local culture in Singapore necessitated adjustments to the content and structure of the directives. These include language barriers in a multicultural society, conflicting wishes in a collectivist society, taboos for speaking about undesirable outcomes in a traditionalist society, and time limitations in a fast-paced society.ConclusionWhile culture-specific changes may be required to enable service users in a small Asian country to employ existing advance psychiatric agreement approaches, service providers and service users see their benefits. However, service providers must be mindful not to assume that service users are willing to defer every decision to their physician

Employment and Income of People Who Experience Mental Illness and Homelessness in a Large Canadian Sample

This is an article published by the Canadian Psychiatric Association in the Canadian Journal of Psychiatry.Objectives: Research suggests that homeless people with mental illness may have difficulty obtaining employment and disability benefits. Our study provides a comprehensive description of sources of income and employment rates in a large Canadian sample. Methods: Participants (n = 2085) from the 5 sites of the At Home/Chez Soi study were asked about their income, employment, and desire for work during the pre-baseline period. The proportion of participants employed, receiving government support, and relying on income from other activities were compared across sites, as were total income and income from different sources. Generalized linear models were used to identify participant characteristics associated with total income. Results: Unemployment ranged from 93% to 98% across 5 sites. The per cent of participants who wanted to work ranged from 61% to 83%. Participants relied predominantly on government assistance, with 29.5% relying exclusively on welfare, and 46.2% receiving disability benefits. Twenty-eight per cent of participants received neither social assistance nor disability income. Among the 2085 participants, 6.8% reported income from panhandling, 2.1% from sex trade, and 1.2% from selling drugs. Regression models showed that income differed significantly among sites and age groups, and was significantly lower for people with psychotic illnesses. Conclusion: These results suggest that homeless people with mental illness are predominantly unemployed, despite expressing a desire to work. In Canada, this group relies predominantly on welfare, but has access to disability benefits and employment insurance. These findings highlight the importance of developing effective interventions to support employment goals and facilitate access to benefits

Healthcare utilization and costs of singaporean youth with symptoms of depression and anxiety: results from a 2022 web panel

Abstract Background There is evidence that the prevalence of depression and anxiety among youth is increasing and that these factors contribute to high healthcare costs and poor school performance. The goal of this study is to provide up-to-date estimates of the prevalence and economic burden of depression and anxiety among youth in Singapore. Methods Using an existing web panel, 991 parents filled out the PHQ-4 screener on behalf of 1,515 youth. 104 of these parents whose children (ages 4 to 21) had symptoms consistent with depression or anxiety filled out a full survey with questions on mental health symptoms, school absences, school performance, and healthcare utilization. The survey was fielded between April and June 2022. Publicly available prices were used to estimate the cost associated with the observed rates of health service use. Findings Based on parental responses, 11.7% (95% CI:10.2 − 13.5%) of youth had symptoms consistent with depression and 12.8% (95% CI:11.2 − 14.6%) had symptoms consistent with anxiety. In total, 16.2% (95% CI:14.5 − 18.3%) were reported to have symptoms consistent with at least one of these conditions. These youths missed an average of 190 (95% CI: 126–254) hours of school per year due to their mental health conditions and parents reported that school and daily activities performance was significantly degraded. Per capita annual healthcare costs averaged S$10,250 (95$1.2 billion (95% CI:S$1.1bn – S$1.4bn). Interpretation Even with significant potential for underreporting, these results reveal concerning rates of Singaporean youth with symptoms consistent with depression or anxiety, many of whom remain untreated. Results also reveal the short-term economic burden caused by these symptoms and hint at longer-term consequences resulting from poor school performance. This study should represent a call to action for Singapore to address poor mental health among youth

Promoting continuity of care for homeless adults with unmet health needs: The role of brief interventions

Promoting timely and continuous care for people experiencing homelessness has been a challenge in many jurisdictions, plagued by access barriers and service fragmentation. As part of a larger programme evaluation, this study used qualitative methods to examine the role of a brief interdisciplinary intervention in supporting continuity of care for this population in a large Canadian urban centre. The intervention provides time-limited case management, primary and psychiatric care, and peer accompaniment to homeless adults with unmet health needs discharged from hospital. Data were collected from 52 study participants between July 2013 and December 2014. Three focus groups were conducted with service providers and people with lived experience of homelessness, and 29 individual, semi-structured interviews were conducted with service users and other key informants. Transcripts were analysed using thematic analysis. Analysis was informed by existing frameworks for continuity of care, while remaining open to additional or unexpected findings. Findings suggest that brief interdisciplinary interventions can promote continuity of care by offering low-barrier access, timely and responsive service provision, including timely connection to long-term services and supports, appropriate individualised services and effective co-ordination of services. Although brief interdisciplinary interventions were perceived to promote access, timeliness and co-ordination of care for this population with complex health and social needs, gaps in the local service delivery context can present persisting barriers to care comprehensiveness and continuity.We appreciate funding support from the Canadian Institutes of Health Research. We thank Adam Whisler and Dr. Agnes Gozdzik for their contributions to data collection and analysis

Perceived Case Management Needs and Service Preferences of Frequent Emergency Department Users: Lessons Learned in a Large Urban Centre

<div><p>Objectives</p><p>This study aimed to explore the service needs and preferences of frequent emergency department users with mental health and addictions concerns who participated in a brief intensive case management intervention.</p><p>Methods</p><p>We conducted semi-structured individual interviews with 20 frequent emergency department users with mental health and addictions challenges, 13 service providers involved in the delivery of a brief case management intervention, and a focus group with intervention case managers. Thematic analysis was used to explore perceived service user profiles, service needs and preferences of care.</p><p>Results</p><p>Service users experienced complex health and social needs and social isolation, while exhibiting resilience and the desire to contribute. They described multiple instances of stigmatization in interactions with healthcare professionals. Components of the brief intensive case management intervention perceived to be helpful included system navigation, advocacy, intermediation, and practical needs assistance. Frequent service users valued relational responsiveness, a non-judgmental stance, and a recovery orientation in case managers.</p><p>Conclusion</p><p>Interventions for frequent service users in mental health may be enhanced by focusing on the engagement of formal and informal social supports, practical needs assistance, system navigation, advocacy and intermediation, and attention to the recovery goals of service users.</p></div

The Impact of Stakeholder Preferences on Service User Adherence to Treatments for Schizophrenia and Metabolic Comorbidities

<div><p>Objective</p><p>To determine how stakeholder opinions of treatments influence service user decisions to adhere to courses of actions necessary to treat metabolic conditions.</p><p>Methods</p><p>Qualitative open-ended interviews were conducted with 20 service providers, 25 service users, and 9 caregivers. Grounded theory was used to generate an understanding that linked preferences of care with adherence to follow-up treatments.</p><p>Results</p><p>Participants spoke about several considerations when discussing adherence: Resource limitations were the predominant consideration. Social considerations such as stigma and support surfaced in caregiver and service-user interviews. The influence of symptoms, especially their absence could reduce adherence, and organizational considerations related to the opinions they had about the qualifications of professionals.</p><p>Discussion</p><p>A rational patient model partially organizes our findings, but emotional components related to stigma and the opinion of service providers do not fit well into such a model. If service providers do not consider components of the decision making process which fall outside of the rational patient model, they may incorrectly be leveraging suboptimal values to bring about adherence to treatment plans. Being sensitive to the values of service users and their caregivers may allow service providers to better act on points that may bring about change in non-compliant service users with schizophrenia and metabolic comorbidities.</p></div