Co-Occurring Disorders

Supported employment interventions, particularly Individual Placement and Support (IPS), have shown strong, consistent evidence for improving employment outcomes in individuals with Severe Mental Illness (SMI). Numerous randomized controlled trials (RCTs) and systematic reviews affirm IPS’s effectiveness in boosting job acquisition and hours worked. However, critical barriers remain — especially for individuals with co-occurring disorders and cognitive impairments. This document summarizes current knowledge and implementation challenges, drawing from leading studies and clinical evaluations.

Key Findings

1. Effectiveness of Supported Employment (IPS)

• IPS and other supported employment models significantly improve employment rates and total hours worked among individuals with SMI.
• Benefits are strongest when the employment intervention is integrated with mental health services and includes ongoing, individualized job support.
• Multiple RCTs and systematic reviews confirm the superiority of IPS over traditional vocational rehabilitation.

2. Impact of Co-Occurring Disorders

• Individuals with co-occurring substance use disorders, physical health problems, or cognitive impairments experience lower employment rates and reduced workplace productivity.
• These comorbidities are associated with:
  • Fewer job offers and slower job acquisition
  • Decreased work performance and shorter job tenure
  • Higher drop-out and relapse rates

3. Challenges in Job Retention

• Even among those who achieve employment, job retention remains low.
• Studies indicate that maintaining employment is more difficult when comorbidities are present, particularly when symptoms interfere with social and cognitive functioning.
• Factors contributing to low retention:
  • Lack of workplace accommodations
  • Fluctuating mental health symptoms
  • Insufficient post-placement support

4. Cognitive Remediation as a Complementary Intervention

• Cognitive remediation — targeted training to improve memory, attention, and executive function — has been linked to better employment outcomes in individuals with cognitive impairments.
• One RCT demonstrated that participants receiving both IPS and cognitive remediation showed greater job acquisition and duration compared to IPS alone.

5. Gaps in Quality of Life & Work Functioning Measures

• Many studies fail to report on quality of life and functional work outcomes, or do so inconsistently.
• Where measured, improvements are often modest and variable, highlighting the need for standardized outcome measures across employment research.

6. Limited Evidence for Specific Subgroups

• Evidence for particular diagnostic subgroups (e.g., dual diagnosis, schizoaffective disorder) is less robust.
• Subgroup analyses are often underpowered or inconsistently reported, making it difficult to draw strong conclusions about efficacy for these populations.

Implications for Practice

• Integrated care is essential: Employment support must be embedded within a comprehensive mental health care plan.
• Tailored support for comorbidities: Clients with co-occurring conditions need additional, often specialized support to succeed.
• Emphasis on retention: Strategies should shift from just getting jobs to helping clients keep them through coaching, employer engagement, and crisis support.
• Expand cognitive interventions: Combining IPS with cognitive training shows promise and should be explored further.

Bottom line: Supported employment works — but to make it sustainable, we must address the cognitive, emotional, and structural barriers that still hold people back.