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A randomized controlled trial of supported employment among veterans with posttraumatic stress disorder (Davis et al. 2012)

Citation

Davis, L., Leon, A., Toscano, R., Drebing, C., Ward, L., Parker, P., ..., & Drake, R. (2012). A randomized controlled trial of supported employment among veterans with posttraumatic stress disorder. Psychiatric Services, 63(5), 464-470.

Highlights

  • The study’s objective was to examine the impact of individual placement and support (IPS) on competitive employment, earnings, and income for U.S. military veterans with posttraumatic stress disorder (PTSD).
  • The study was a randomized controlled trial conducted at the Tuscaloosa Veterans Affairs (VA) Medical Center. Treatment group members received IPS services, whereas the control group received standard Vocational Rehabilitation Program (VRP) services. Data sources included patients’ records from the clinical research coordinator and daily logs completed by participants.
  • The study found that IPS had positive impacts on competitive employment and gross income.
  • The quality of causal evidence presented in this report is high because it is based on a well-implemented randomized controlled trial. This means we are confident that the estimated effects are attributable to IPS, and not other factors.

Intervention Examined

Individual Placement and Support and Vocational Rehabilitation Program

Features of the Intervention

IPS was a type of supported employment intervention that aimed to improve occupational and rehabilitation outcomes for people with severe and persistent mental illness. IPS participants received rapid job search and individualized job placement services from IPS specialists, who provided IPS services exclusively and carried out all phases of vocational services. IPS participants made their job choices based on their preferences and strengths. All IPS clients were encouraged to participate in services with no exclusion criteria. IPS specialists continually helped clients find other jobs when one job ended, spent 70 percent or more of their time in the community supporting participants, and were available for virtually unlimited support and follow-up. IPS specialists maintained a caseload of 25 or fewer clients and were integrated with each client’s clinical medical treatment team.

VRP services, which were the standard care provided at the Tuscaloosa VA Medical Center, were typically less intensive and less specific to the individual. For example, the choice of employment was less related to the preferences and strengths of the client, but instead was driven more by general labor market conditions, such as available short-term transitional work experiences. In contrast to IPS specialists, VRP specialists provided some services in the community, provided limited follow-up and support, and did not have strict caseload size limits. They were not integrated with clients’ clinical medical teams.

Features of the Study

This study used a randomized controlled trail to examine the impact of IPS on veterans’ competitive employment, earnings, and income. To be eligible for the study, veterans at the Tuscaloosa VA Medical Center had to have a PTSD diagnosis, be age 19 to 60, have a medical clearance for work activity, be unemployed but interested in competitive employment, and plan to remain within a 100-mile radius of Tuscaloosa for the 12-month study duration. Eligible veteran volunteers were enrolled in the study from 2006 to 2010 and were randomly assigned into the treatment group, which was eligible to receive IPS services, or the control group, which could receive standard VRP services. There were 85 randomly assigned participants: 42 were assigned to IPS and 43 to VRP. In addition to a diagnosis of PTSD, 89 percent of study participants had major depressive disorder, 42 percent had alcohol dependence, 21 percent abused alcohol, 37 percent were drug dependent, and 18 percent abused drugs.

The authors’ impacts evaluation method varied across outcomes. The authors used a Kaplan-Meier survival analysis with a log-rank test to measure whether IPS affected time until the first week worked in a competitive job. For the other outcomes, including the number of weeks, days, and hours worked in a competitive job and gross wages, they performed t-tests to measure program impacts.

Findings

  • The study found that IPS participants achieved competitive employment more quickly than did VRP participants. This difference in employment times, which was not quantified, was statistically significant.
  • The IPS group was competitively employed 21.6 weeks on average during the 52-week intervention period compared with 6.8 weeks on average for the VRP group. This difference was statistically significant.
  • On average, total gross 12-month income from competitive sources was $9,264 for IPS and $2,601 for VRP, with a statistically significant difference of $6,663. The difference in favor of the IPS group extended to total gross 12-month income from all sources—$9,308 for IPS relative to $3,909 for VRP.

Considerations for Interpreting the Findings

To be eligible for the study, veterans had to have expressed interest in competitive employment. Therefore, the results might not extend to people with PTSD who had not expressed an interest in competitive employment.

Causal Evidence Rating

The quality of causal evidence presented in this report is high because it was based on a well-implemented randomized controlled trial. This means we are confident that the estimated effects are attributable to the IPS program, and not to other factors.

Reviewed by CLEAR

September 2015