There is strong evidence that patients with severe mental illness can be successfully employed. Is the effect sustainable long-term?

Mental illness is the most common cause of disability in most western countries, and the proportion of people who become disabled with a background in mental illness has increased in recent decades. Only five to ten percent of people diagnosed with schizophrenia in Norway are employed. Participation in working life can increase the quality of life of the individual, as well as reduce the socio-economic burden. There may be a solution to this challenge. Individual job support (IPS) is specially adapted for people with severe mental illness. Over 20 randomized controlled trials (RCTs) from many countries and continents, including Norway, have shown that IPS increases the proportion of people in work, compared with traditional approaches to work-oriented rehabilitation. This literature suggests that there would be great benefits both for society and the individual patient, if IPS could be implemented as a standard practice and replace current practice. Effects observed in experiments such as the 20 RCTs unfortunately often do not produce as promising results when the measures are implemented in ordinary practice. This can have many causes. The purpose of the IPS Bodø project is to follow the implementation of IPS in ordinary practice over several years to investigate whether it is possible to achieve increased employment and reduced social security dependence for the target group in practice. The authorities' expectations of IPS, and the main argument for investing in IPS, is that the measure should be able to reduce welfare dependency for relatively large groups in society. A challenge here is, of course, that the target group for IPS from the IPS practice field's perspective is probably somewhat narrower than the target group from the authority's perspective. We have used register data to investigate whether the IPS implementation in Bodø has actually reduced welfare dependency at the societal level: We defined the target group as AAP recipients between the ages of 18 and 40 in the period 2010-2019. This applies to 2340 people in Bodø municipality. We defined the period 2010-2014 as before IPS implementation, and 2015-2019 as after. A control group of 10 municipalities about the same size as Bodø where IPS has not been implemented was also identified. Approximately 200 people have used IPS services in Bodø during the period, and the majority of these were AAP recipients. Early register analyzes suggest that there is a certain decrease in social security dependence in Bodø compared with the control group. The effect is demonstrably and statistically significant, but somewhat modest, mainly because the target group for IPS is significantly narrower than the relatively larger group of AAP recipients. The effect can nevertheless be socio-economically profitable, as the savings for society can be large by helping people into work and avoiding long-term welfare dependence. This is something we should count on. ? Experiences with IPS implementation in Bodø are also a theme for the project. IPS is challenging to implement because it requires interdisciplinary and interagency collaboration. IPS advisers are usually employed by NAV, and are intended to work in practice in the health sector. This presents challenges in many areas, including access to medical records systems and privacy challenges, challenges of being integrated into clinical teams, cultural differences and challenges with high turnover. The project has documented higher turnover rates among IPS employment specialists than public employees in general. The reason for turnover is partly factors related to employment specialists, and partly with the job situation (Butenko 2022; Butenko 2022).

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The proportion of young people on disability benefits due to mental disorders is increasing. This is unfortunate for society and for the individual patient with severe mental illness. Individual Placement and Support (IPS) is a vocational rehabilitation program that is popular among both patients with severe mental illness and health professionals. However, IPS is still not implemented beyond pilots and projects. We recently published a meta-analysis of 20 RCTs of IPS, concluding in that IPS method is way more effective in increasing employment and reducing welfare dependency, compared to current practice. Full-scale implementation would require a political decision to reform the collaboration between the welfare sector and the health sector. This decision rests on four remaining questions: First, RCT evidence for efficacy does not always translate into effectiveness in the real world. RCTs are well-resourced and patients selected. Does IPS work also in the real world? Second, there are now published trials of IPS with long-term follow-up. Are IPS effects sustainable beyond two years follow-up? Third, IPS is more labor intensive than current practice, but may also be cost-effective for society if successfully reducing welfare-dependency during long-term follow-up. Published health economic evaluations are inconclusive due to uncertainty regarding long-term effects. What are the economic consequences for society of implementing IPS? Fourth, how does IPS feel? Some patients report IPS as a positive, helpful and preferred rehabilitation model. On the contrary, receiving IPS may also involve repeated rejections and experience of failures. User involvement is essential to help improve the delivery of IPS, thus we need to systematically interview users at 3-6 years follow-up. This project aims at closing these four knowledge gaps, which is key for evidence based decisions regarding full-scale implementation of IPS.