Long-term employment among people at ultra-high risk for psychosis

Abstract

Background

Psychotic disorders are associated with high rates of sustained unemployment, however, little is known about the long-term employment outcome of people at ultra-high risk (UHR) of developing psychosis. We sought to investigate the long-term unemployment rate and baseline predictors of employment status at follow-up in a large UHR cohort.

Method

268 UHR patients recruited from the Personal Assessment and Crisis Evaluation clinic in Melbourne, Australia were followed-up over 2–14 years after initial presentation to the service. Individuals in no form of employment or education were classed as unemployed. Logistic regression analyses were used to examine predictors of employment outcome.

Results

A high rate of unemployment was present at follow-up in this UHR sample (23%). At baseline, those who were unemployed at follow-up had a longer duration of untreated illness, more severe negative symptoms, lower IQ, poorer social and occupational functioning and reported more childhood trauma than the employed group. At follow-up, unemployed individuals exhibited significantly more severe symptoms on all measures and were more likely to have been diagnosed with a mood, anxiety, psychotic or substance use disorder. Childhood trauma and the duration of untreated illness at baseline were significant independent predictors of employment status at follow-up in the multivariate analyses.

Conclusions

Nearly a quarter of this UHR sample was unemployed at long-term follow-up. The duration of untreated illness and the effects of childhood trauma are potentially modifiable risk factors for long-term employment outcome in this group. Vocational support may be beneficial for many UHR patients presenting to services.

Introduction

Psychotic disorders such as schizophrenia are associated with high rates of sustained unemployment (Marwaha and Johnson, 2004, Marwaha et al., 2007, Waghorn et al., 2012). In an effort to reduce this, there is a growing international consensus that vocational support should be offered for these patients (Kreyenbuhl et al., 2010, National Institute for Health and Care Excellence, 2014, Galletly et al., 2016). In England, mental health services are now required to assist patients with first-episode psychosis to engage in employment, education or training as part of the new ‘Early Intervention in Psychosis Access and Waiting Time standards’ (NHS England, 2016). As well as reducing the high societal cost of these disorders (Knapp et al., 2004), employment is thought to improve the general wellbeing of people with psychosis and is widely considered to be an important aspect of recovery (Rinaldi et al., 2010, Ramsay et al., 2011).

In contrast, little is known about the long-term employment outcome of young people who are at ultra-high risk (UHR) of developing a psychotic disorder (Yung et al., 1996, Yung et al., 1998, Fusar-Poli et al., 2013a). This is a group for whom similar provision of resources may be important. At presentation to services, UHR patients are significantly more likely to be unemployed compared to their peers (Fusar-Poli et al., 2010), with reports suggesting up to 46% are not in employment, education or training (Fusar-Poli et al., 2013b). However, data on employment outcome in this population is limited to only a few short-term follow-up studies (Velthorst et al., 2011, Salokangas et al., 2013). To our knowledge, no studies have examined the long-term unemployment rate or baseline predictors of employment outcome in the UHR group.

The aims of the current study were;

• To examine the rate of unemployment among a large UHR cohort at long-term follow-up

• To determine which clinical and demographic baseline variables were the strongest predictors of employment status at follow-up