Review
Does employment alter the course and outcome of schizophrenia and other severe mental illnesses? A systematic review of longitudinal research

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Abstract

Introduction

This review synthesized prospective evidence to assess whether achieving employment alters the course of schizophrenia-spectrum disorder.

Method

Researchers identified relevant analyses for review via PubMed, expert referral, and reference review and systematically applied two levels of screening to 1484 citations using seven a priori criteria.

Results

A total of 12 analyses representing eight cohorts, or 6844 participants, compared illness course over time by employment status in majority schizophrenia-spectrum samples. Employment was consistently associated with reductions in outpatient psychiatric treatment (2 of 2 studies) as well as improved self-esteem (2 of 2 studies). Employment was inconsistently associated with positive outcomes in several other areas, including symptom severity, psychiatric hospitalization, life satisfaction, and global wellbeing. Employment was consistently unrelated to worsening outcomes.

Discussion

Achieving employment does not cause harm among people with schizophrenia-spectrum disorder and other severe mental illnesses. Further detailed mechanistic analyses of adequately powered long-term follow-up studies using granular descriptions of employment are needed to clarify the nature of associations between employment and hypothesized benefit.

Introduction

Negative outcomes often observed among people with psychiatric illness, including early school or work dropout, stigma, disability enrollment, poverty, and passive time use, lead mental health professionals to identify these persons as vulnerable to the stressors of employment (Hayes and Halford, 1996, Krupa et al., 2003, Eklund et al., 2010). Yet the field awaits a systematic examination of available evidence regarding whether employment has a positive or negative influence on the course and outcome of severe mental illnesses (e.g., schizophrenia, bipolar, and major depressive disorder).

In the general population, joblessness is associated with poor physical health (Studnicka et al., 1991, Martikainen and Valkonen, 1996, Korpi, 1999), anxiety and depressive symptoms (Bromberger and Matthews, 1994, Claussen, 1994, Comino et al., 2000), low self-esteem (Linn et al., 1985, Feather, 2011), and suicide (Eisenberg and Lazarsfeld, 1938, Yur'yev et al., 2012), even among people without previous psychological vulnerability (Montgomery et al., 1999). Conversely, returning to work is associated with improved psychological health (Payne and Jones, 1987, Caplan et al., 1989), financial security (Payne and Jones, 1987), self-esteem (Caplan et al., 1989, Vinokur et al., 1991), quality of life (Caplan et al., 1989, Vinokur et al., 1991), and physical health (Ferrie, 2001). Evidence in populations with disabilities also indicates that employment is more helpful than harmful (Inge et al., 1988, Burkhauser and Daly, 2011, Hall et al., 2013). Previous reviews of the related observational literature in psychiatric populations have documented many plausible associations between employment and other outcomes (Marwaha and Johnson, 2004, Waddell and Burton, 2006, Kukla, 2010, Drake et al., 2012, Schennach et al., 2012), yet none reported conclusive findings. The lack of research consensus may be due to undiscovered research: none of the previous research summaries included a systematic literature search.

We aimed to provide a systematic review to improve understanding of how employment improves or exacerbates the course and outcome of severe mental illness. We focused on observational research because researchers cannot practically or ethically randomize participants to employment versus joblessness. Acknowledging that it is not possible to establish a direct causal link between employment and the course of severe mental illness in the absence of randomization, we relied on the best available evidence of the possible causal relationship between employment and other, non-vocational outcomes—prospective cohort studies.

We considered two a priori hypotheses: 1) Among non-workers with severe mental illness, transitioning to employment is not associated with worsening non-vocational outcomes compared to people who remain jobless; and 2) Among non-workers with severe mental illness, transitioning to employment is associated with improvements in non-vocational outcomes compared to people who remain jobless. These roughly correspond to the following—1) employment is not harmful; and 2) employment is beneficial.

Section snippets

Methods

Our systematic review followed PRISMA (Moher et al., 2009) and MOOSE (Stroup et al., 2000) reporting guidelines.

Study selection

Over the past two decades, 12 analyses representing eight cohorts investigated whether changes in employment status altered the clinical course and other non-vocational outcomes of severe mental illness. For a summary of the retrieval process results, see the PRISMA flowchart (Moher et al., 2009) in Fig. 1.

Study characteristics

Table 1 summarizes the characteristics of the eight cohorts included in the 12 eligible analyses. The median number of participants across the cohorts was 187 (range = 143 to 5431

Summary of findings

Employment has been conceptualized as both a positive health determinant (e.g., by encouraging self-esteem) and an adverse health determinant (e.g., by causing stress and anxiety). Whether these opposing properties create, on balance, a net positive or net negative influence of employment on the course and outcome of severe mental illness has not been systematically reviewed before. Our summary of prospective research found: 1) employment is not risky and 2) employment is rehabilitative. The

Conclusion

Conclusions are drawn from currently available prospective evidence, which is limited to 12 analyses overall and fewer analyses within non-vocational outcome categories. Published prospective research indicates that (1) employment is not detrimental to the health or functioning of people with schizophrenia and other severe mental illnesses; (2) employment is consistently associated with reduced use of psychiatric treatment and increased self-esteem; and (3) employment is inconsistently

Role of funding source

None.

Contributors

Luciano wrote the first draft of the manuscript. All authors contributed to the design, execution, and authorship of the review and approved the final manuscript.

Conflicts of interest

None to disclose.

Acknowledgments

The authors thank Karen Odato, Heather Blunt, and Anne Story for their assistance with the electronic literature search. The authors also thank Gregory McHugo for helpful comments on an earlier draft of this manuscript.

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