P1: GAD

Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004 18:24 Style file version June 22, 2002

Mental Health Services Research, Vol. 6, No. 1, March 2004 (°
C 2004)

Association Between Demographic and Diagnostic Factors
and Employment Outcomes for People With Psychiatric
Disabilities: A Synthesis of Recent Research

Nancy J. Wewiorski1,3 and Ellen S. Fabian2

Employment outcome for individuals with psychiatric disabilities has been a focus of empirical
research over the past decade or so. The purpose of this paper is to review recent literature
on the association between demographic and diagnostic factors and employment outcome,
and to conduct meta analyses of the results of studies that report the association between
these variables. Seventeen studies were included in these meta analyses. Results of the meta
analyses tended to corroborate most of the significant findings found in the literature review.
The authors review some of the issues for the meta-analyst interested in synthesizing research
findings on employment outcome, including the challenges and limitations encountered in the
published research currently available.
KEY WORDS: employment; outcome; factors; psychiatric; disability; meta-analysis.

INTRODUCTION of more useful and sophisticated tools for conducting
meta-analytic research (Cooper & Hedges, 1994).
Research synthesis is an important method A major concern in the field of vocational reha-
that can extend our knowledge base by combining bilitation that lends itself to meta-analysis is the issue
and comparing studies related to a common theme of employment among adults with severe and persis-
(Cooper & Hedges, 1994). It is particularly a useful tent mental illness. This group of about 4–5 million
tool when there is a significant body of empirical data adults, or 2.6% of the total population of persons with
with commonalities regarding populations and vari- mental health disorders, has had persistently low rates
ables. When there are numerous studies around a fun- of labor force participation, with most estimates rang-
damental problem or research question, this method ing from about 10 to 30% (NIDRR, 1992; LaPlante &
can be used in the development of theory or the iden- Carlson, 1996). Individuals with psychiatric disorders
tification of most effective practices (Smith & Glass, comprise the largest single diagnostic group of
1977). In the past decade or so, reports of quantitative Supplemental Security Income (SSI) beneficiaries,
research syntheses, or meta-analyses, have increased accounting for almost 30% of the total (Kochlar &
in the social science literature, in part because of the Scott, 1995). In addition, they are the least likely to
need to integrate findings from growing bodies of re- leave the disability rolls (Muller, 1992). Although in-
search evidence, but also because of the availability dividuals with schizophrenia constitute only about 1%
of the total mental health population, they are over
1Center for Psychiatric Rehabilitation, Boston University, Boston, represented on the SSI rolls, making up about 33% of
Massachusetts. SSI beneficiaries with mental illness. Proposed expla-
2Department of Counseling and Personnel Services, University of
nations for these persistently low rates of labor force
Maryland, College Park, Maryland. participation include the characteristics of the illness
3Correspondence should be directed to Nancy J. Wewiorski, Cen-

ter for Psychiatric Rehabilitation, Boston University, 940 Com-
itself, the lack of success of vocational rehabilitation
monwealth Avenue, West Boston, Massachusetts 02215; e-mail: programs, the work disincentives imbedded in public
wewiorsk@bu.edu. disability policy, and the labor market liabilities of

9
1522-3434/04/0300-0009/0 °
C 2004 Plenum Publishing Corporation

are related to Efforts to understand the entrenched unemploy. Takamaru. Hackett & Byars. For example. Salyers. including competitive employment. 2000. These data are briefly re- crimination (e. 2002 10 Wewiorski and Fabian persons with psychiatric disabilities (Baron & Salzer. T.g. 1984. as well. ment discrimination.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6. disability in. such as prior work history and educational level. 2000). socioeconomic status. We found Predicting employment outcome is difficult in the a sizeable body of literature on individuals with psy- vocational rehabilitation field and empirical evidence chiatric disorders that focuses on vocational issues. on employment outcomes. M. younger age is asso- and/or too infrequently reported with sufficient detail ciated with better employment outcomes. ited their usefulness for meta-analysis. the population of individuals with psychiatric disabil- Tsang. & Kregel.. particularly in terms of job retention (Bond et al. 1996) consistent findings. When compared to other disabil. relate to vocational outcomes. 2001. it has long been demonstrated by dearth of meta-analytic studies that combine results research in the career psychology literature that de- across studies. see Brown. gender. 2002). databases and sources that are reflective of psychi- 2002).. K. P. tween age and employment outcome have had fairly iously measured (Rucker. 2001. there is a ities. ables make to the outcome. subgroups that historically have experienced employ- ies that include demographic and diagnostic variables. Mowbray. medical. 1996 on vocational behavior related The purpose of this paper is to review the existing to gender and race). of both getting and keeping a job.g. 1992. Wehman. these data may tors associated with successful vocational experiences. but not included in sider psychiatric diagnoses. First. Bybee and colleagues (1995) found comprehensive by searching a number of different younger age to be positively related to enrollment . Harris. For example. it can help sort behavior in their effects on work (Bond et al. Ng. 1994. Mueser. & Breier. we attempted to be expectations. the meta analysis. Sociodemographic Variables Predicting employment outcome is further compli- cated because of the unique factors associated with Several studies have examined the extent to psychiatric disability. However. 1995. race. Strauss. and the relationship between medication and tion is useful in a number of ways. age. appropriate and/or effective for various subgroups of Anthony & Jansen. or vocational performance. viewed in the following section. Demographic factors also define literature on employment outcome.. its characteristics. are Studies that have examined the relationship be- not included in our analyses because they are too var. ployment. the variations in its prognosis and and age. work history. and rehabilitative research. and Mueser. Lehman et al. 1987). are cited. There also are a number of stud- variables and employment outcome. employment outcome. in terms for meta-analysis. although some important earlier studies rates in the state–federal vocational rehabilitation sys. to identify stud.. The following ity groups. Second. suggest the type and intensity of intervention most including several literature reviews (Anthony. P. individuals with mental illness historically overview primarily focuses on publications within the have achieved less successful rehabilitation closure last decade. such as the heterogeneity of which demographic variables. and gender) and also con. (2001) found younger age predictive of longer job dura- LITERATURE REVIEW tion. and McCrohan (1995) found younger age predictive of more positive work Although not exhaustive.. notably race. another factor that may relate and then to conduct meta-analyses of those studies to employment outcomes for some individuals with a that report the degree of association between these psychiatric disability. tors in combination with illness factors. R. Lam. out whether illness factors alone. atric. Such studies would be valuable in the mographic factors play a role in shaping individual identification of variables that may be associated with perceptions of career and work (e. Such informa- course. in and of themselves can be factors in employment dis. Bybee. supported em- ployment outcome. as insufficient statistical data lim- such as education. Cook & Razzano. tem (NIDDR. 2004 18:24 Style file version June 22. or whether other fac- Harding. work success for people with psychiatric disabilities. although it sometimes is diffi- ment of individuals with psychiatric disabilities have cult to separate the discrete contribution these vari- resulted in a large number of studies examining fac. For the purposes ies that examine the effect of social background vari- of this paper.. Other important factors. come status. Brooks. Generally. we focus on demographic variables that ables. offers limited guidance about factors related to em. & Leung. 1997) and less success in sup- ported employment programs.. and social competence.

work-related behavior of minority groups has gener- orders (Coursey. effect employment for 3+ months or history of gainful em- for gender (Rogers et al. both evidence that stability of prior work (Goldberg et al. and Cook and Hennessey (1997) found that Caucasian males tended colleagues (2001) found younger age predictive of to have longer job tenure. Stackman. For example. two of the most potent pre- poorest employment tenure. & Farkas. are equivocal. ment outcome for persons with psychiatric disabilities ment tend to be more equivocal. 2000). and there is little reason to believe that it would be vances in neuroleptic treatment and the trend toward different for the population of individuals with psy- reducing hospitalization have had an impact on psy. ment (Drake et al. Rogers and colleagues dictors of vocational performance (Lent. Tsang and colleagues (2000) (Moriarty et al. but his study did not inves- employment success for homeless persons with men. in general. Rogers sequent employment. predicts outcome. 1997.. Jacobs.. 2002 Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables 11 in a vocational placement program. and duration of prior employment (Goldberg patterns of employment. but the reactions and attitudes from work capacity may be improved by more effective others that it evokes. a factor that may be attributed found no significant association between posthospi- to males having an earlier onset of the disorder.. a finding consistent with gen. such as supported employ- (1997) found that women evidenced high work skills. persons. Brown. 2001). 1994). chiatric impairments. a robust predictor of successful outcome. For example. & Davies above treatment effects. Cohen.. 2004 18:24 Style file version June 22. Gen.. 1990. Anthony & Jansen. Cook et al. Research that has examined the chosocial functioning for people with psychiatric dis. Similarly. 1992). Wissusik. al. History of prior employment has been found to be ever. and speculated that it was not work experience per ing to work persistence among SSDI beneficiaries. for example. 2001. 1995. tant. insignificant. & Burkeman. Carpenter & Strauss. that previous job tenure among individuals with psychiatric disor. Fabian (1992) studied (Fabian. race and the sociocultural environment may constrict ket. tigate disability category. It may be. positive experiences improve vocational efficacy and ders and found that African American males had the outcome expectancies. ployment for 2+ years in a Hong Kong sample. 1997) and also ally concluded it is not race or ethnicity per se that may affect their capacity to work. Arns & Linney. but the pattern of prior employment that deter- eral population wage data. Cohen. 1992). The interaction of younger persons who may be entering the labor mar. in a (Anthony. How. thus benefiting portunities (Lent & Brown. but the .. Mueser et al. Certainly. Rogers.S. race is a factor tal illness. 1996). et al. However. are more likely to be in the labor eventually decreasing performance.. Strauss & Carpenter. to explain how previous competitive employment abilities and found that race was not associated with relates to future job expectations are not available employment history. likely to be employed at 12 month follow-up. there is Findings regarding the importance of race. market and probably would have higher expectations Research has tended to find prior employment regarding work than persons who are older. 1996. recent ad. for in the labor force participation rates of men in the individuals with psychiatric disabilities. as well as the relationship of medications that target positive and negative deficits these factors to limiting career and employment op- associated with psychiatric disorders. se that made a difference in work retention. over and cial programs. 2000). Anthony. Tsang et al. studies that would help us patterns of inner-city residents with psychiatric dis. 2001. confounded by other factors. tal employment status and either history of gainful erally. 1974). age may be general population (U. 2001). studies have found a small. mines outcome (Baron. although gender was not a significant predictor of sub. 2000). 1995) predict future work Goldberg and colleagues (2001) studied employment outcome. recent studies also have noted that it ries indicate that women have smaller reported wages may not be simply prior employment that is impor- than men (Scott. However. Department of Labor. For example. Mowbray et al. (2001) found males more 1991. in terms of predicting work status and in examining 2001). it is important to note that. work intervention program for homeless persons with 1984.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6. In order words. to be among the strongest predictors of employ- Findings about the effect of gender on employ. (1997) did not find prior employment history to been reported to have poorer functional outcome be significant. mental illness. Unfortunately. However. & Alford. In terms of labor market attachment. though reports of earnings of disabled SSI beneficia. Males with schizophrenia have et al. & (1997) found race modestly associated with 1 year Hackett. Moreover. Safajan. In a study reporting the factors contribut. Baron (2000) investigated the career vocational outcome for psychosocial rehabilitation patterns of 38 individuals with psychiatric disorders clients. Collier. For example. in a study of participants in three psychoso. younger the individual’s vocational expectations and efficacy.

M. In a report Although the evidence supporting the relationship on work persistence factors for SSDI beneficiaries. Meuser. with poor work functioning (Bell & Lysaker. Mintz. Although. J. cational levels of the sample was not given. Goldberg et al. Mueser Schreiber. For who started work after receiving benefits had at least example. Lenzenweger & Loranger. averaged across studies. For each of these variables. to predict occupational functioning 2 years after first ment of inner-city residents with psychiatric disorders episode (Beng-Choon.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6. Given the cognitive and so- disabilities are the specific issues arising from their ill. Dyer. Tsang et al. Flaum. this brief review of bining information across related but independent studies that have examined symptoms provides a con.. ies that compare vocational outcomes for groups of and then to convert to a common statistic that can be individuals with different psychiatric diagnoses con. 1991). affective disorders. Mintz. (2001) studied long-term unemploy. The general ap- dictor of work attainment and employment tenure proach is to compute an effect size for each study us- has resulted in fairly consistent findings. (2001) found that educational level was related ies on the functional consequences of neurocognitive to job retention in their sample of 313 patients with deficits in schizophrenia. ing extracted data relevant to the variables of interest. 1998). race. but negative symptoms were.. for the META-ANALYSIS methodological reasons discussed below. Meta-analysis is a systematic approach for com- agnosis and vocational outcome. 1998. Gitlin. modestly with occupational functioning among clients abilities. across studies and analyzes the extent to which the 1993) and poorer patterns of job retention (Anthony. Studies of persons with schizophre- Educational background is another factor that nia have found negative symptoms to correlate highly has been studied. 1992). gender. and Rogers. symptoms. 2002 12 Wewiorski and Fabian individual’s perception of the value and meaning of and skills deficits are the most significant determi- these experiences. Cohen. retaining jobs.. nants of outcome. tioning 6 years after an index hospitalization (Brier. Tsuang & Coryell. & Bellack. Nopoulos. Many stud. 1992. S. 1995. 1981. poorer vocational outcomes (Ciardiello. are associated with specific vocational out- et al. and to predict occupational func- to patterns of unemployment. 2004 18:24 Style file version June 22. it would be expected that these individuals would encounter Illness Factors more difficulty in initiating and. Coryell The second part of this review combines results & Tsuang.. & and concluded that educational level was not related Andreasen. & Hwang.. 1985. between symptoms and vocational functioning in Hennessey (1997) did not find educational level to schizophrenia seems clear. Jacobs diagnosis. Green (1996) concluded that schizophrenia. a high school diploma. but are issues associated in gen. Psychiatric diagnosis as a pre. taking into account sample clude that people with schizophrenia do demonstrate size and variability in each individual study. & Davies. comes among persons with severe and persistent men- Recent research on diagnosis suggests that it is tal illness. represented using a common statistic. ployment and higher educational level. Arndt. Massel et al. psychotic symptoms were not associated with occu- (2000) found a positive association between unem. & Alt- chiatric disabilities. cial deficits that are characteristic of schizophrenia- nesses. In a Hong Kong sample. In the work-related studies on psychiatric disabil- ity. factors discussed above. but the range of edu. particularly. studies when results from the primary studies can be text for our analyses. L. our meta- analyses focus only on the association between di. 1990. (1992) found that symptoms were strongly corre- The demographic and social factors reviewed lated with occupational functioning for clients with above probably are not unique to individuals with psy. meta-analyses the symptoms of the illness. but did note that almost 70% of those people with affective disorders are less consistent. 1989). with some inconsistent results. shuler (2000) found that symptoms correlated only eral with work-related decisions of people with dis. Fabian. namely age. spectrum disorders (Blanchard. whereas Hammen. illness factors that have been examined include di- agnosis. that is the most important predictor of outcome. On the with many studies reporting that negative symptoms basis of the literature reviewed above. and skill deficits. 1995). we posited . and these factors are considered below. the published literature from 1989 to 2001. & Pickard. In a review of stud- et al. What distinguish individuals with psychiatric with bipolar disorders. pational functioning. findings from research on be predictive. Arruda. rather than the diagnostic were conducted using available data from reports in label.

major variables examined in most of the published affective disorder. an effect size estimate (r . race. other = 0). variables. meta-analyses. and WebofScience. identified and a meta-analysis was conducted when- analytic techniques. three dichotomized diagnosis vari- nostic variables of interest here would not be the ables were created and coded: (a) schizophrenia vs. included document source. and. were so inconsistently defined across studies and and outcome variables. as well. Thus. two reported attainment of search of 15 journals in the mental health and vo. gender. and (c) affective disorder vs. 2004 18:24 Style file version June 22. outcome variable was not consistent across studies: PsychINFO. and (d) a confidence . and nine reported a vocational outcome by for meta-analysis. between 1989 and 2001. However. subjects received a Our initial plan was to examine education and vocational intervention. list) constituted the sample considered for meta- pirical evidence. (4) the were consistent across studies. Con. included studies regardless by gender. analysis. client. extracted appropriate data variable combination. and then applied meta. F = 0). research design. psychiatric diagnosis.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6. for each set of studies as follows: (a) for each indi- and/or diagnosis were not clear. (b) this statistic was refereed journals that reported on the findings of 18 converted to a common statistic. thus maximizing the study included a measure of vocational outcome. other diagno- studies and. for each study in separate studies. 10 reported a vocational sequently. data collection method. and also reviewed nine reported employment status. We identified potential studies us. As expected. gender. year of publication. 20 papers (noted with an asterisk in the reference analytic techniques to synthesize the available em. or phi) broader populations. (b) schizophrenia vs. 2002 Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables 13 directional hypotheses about persons with severe and that had a matching demographic variable-outcome persistent mental illness. prior employment. we sorted studies into sets for meta-analysis. reported separately for groups in these studies. 2001) could not be included in any of the computed with each effect size weighted by the in- meta-analyses because there were no other studies verse of its estimated variance. Client variables included age. race (Caucasian = 1. the results for individuals with was computed for the relationship between the de- severe and persistent mental illness were not reported mographic or diagnostic variable and the vocational separately. type of intervention (if present). r . and diagnosis. (2) the study reported data and two reported the amount/extent of supported on a sample of persons with severe and persistent employment in the past year. to include such studies in our sis. (c) a weighted average effect size was (Mueser. 17 studies reported in from published reports. these variables Studies were coded on methodological. In eight of these studies. we would have to aggregate the data coding. analyses were not possible. thus. and clarity of complexity to the measure of the dependent variable. Studies were excluded if (1) the ever there were two or more studies with combin- reported vocational variables were not clearly de. data mental illness in the United States. Methodological variables so rarely reported with sufficient detail that meta. A separate meta-analysis was conducted fined. to maximize the number of studies available for the We anticipated that the demographic and diag. studies to avoid introducing increased study sample. analyses to U. and number of studies available for meta-analysis. two reported employment cational area. one study the analysis. Diagnosis was coded according to the Meta-Analytic Methodology diagnostic groups defined in the study and then. independent of how those variables Our search yielded 21 papers published in 10 were treated in the original study. rho. other disorder. seven reported at- reference lists and conducted an exhaustive manual tainment of employment. (2) the value assignments for age. two reported used for selecting studies: (1) results were published employment status 6 months after job placement. race. (5) demographic and vocational outcome data were Sets of studies having comparable variables were presented in a form that allowed for the use of meta. After meta-analyses. When possible. gender (M = 1. able data. and/or diagnosis. competitive employment. we expected most of the extracted data to outcome by age. Among the 17 studies. outcome variable. We also limited our meta. or (3) in studies of vidual study. The following inclusion criteria were status 3 months after job placement. 13 reported a vocational outcome be correlational. Among these 18 studies. nine reported a vocational outcome by of research design if they reported data appropriate race.S. (3) reported data was regrouped within studies to create variables that included age. operational definition of demographic and outcome employment. the vocational ing an extensive computer-based search of Medline. thus.

(1995) 277 0 . compared to a diagnosis of affective disorder. Sibulkin. 2004 18:24 Style file version June 22. Pulice. These analyses found no significant lated and the homogeneity of the overall effect size overall effect of gender on employment status. employment 3 months after details for these procedures can be found in Cooper placement. Also.037. Be.500 Drake.02 .500 Cook & Razzano (1995) 602 . and vocational outcome. and Hedges (1994. 16–19). sult. a significant overall effect and generally no effect was Table 4 presents the results of three meta- seen in any of these studies. Meta-Analytic Results of Age on Vocational Outcome Overall effect Homogeneity of Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size? −.010 . Toole.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6.497 Okpaku. It should be noted that two (1995). there was a significant overall effect size of −.500 Arns & Linney (1995) 138 −. cational outcome. and nine on diagnosis. This procedure yielded 18 meta. but persons cational outcome.547 a Overall effect significant at the level of p < . −. Although race was not found to have a significant overall effect on employment sta- Meta-Analytic Results tus. analyses were based on a fixed effects model using the Table 3 presents the results of three meta- specific meta-analytic techniques detailed by Cooper analyses that consider the relationship between race and Hedges (1994. icantly more likely to attain employment. & Brown (1991) 275 0 . 1995) overall effect sizes were based on a phi coefficient for that showed males as less likely to be employed than all variables except age.869 Employment statusa (−. see chap. four on gender. pp.659 >.20.127) No Fabian (1989) 81 0 .500 Mowbray et al. females (n = 85). which used the Pearson cor. & McCormick (1996) 46 0 .275. Results .164 Shafer & Hsaio-Wen (1995) 107 0 . for attainment of employment was due to one study This suggests that being employed is associated with (Shafer & Hsaio-Wen. 233. age was not found to have studies reported effects in opposite directions. In the five studies that reported of color were more likely to be employed 6 months the relationship between age and employment sta. there was heterogeneity of that even though there was a significant overall effect effect size because three of the five studies reported for employment status 6 months after placement. analyses that consider the relationship between vo- Table 2 presents the results of four meta-analyses cational outcome and a diagnosis of schizophrenia that consider the relationship between gender and vo. 238. studies showed no significant gender difference. McHugo. (1995) 179 −.201 Q = 82. Thus. Caucasians were signif- that consider the relationship between age and vo. For the five studies reporting attainment of finding was based on only two studies and these two employment as an outcome.073) Yes Rogers. or employment 6 months after placement.500 . 237.018 Q = 0. Formulas used and tainment of employment. the remaining six of seven relation coefficient.999 Dewees. it was found to have a significant overall effect on attainment of employment and on employment sta- Table 1 presents the results of two meta-analyses tus 6 months after placement. However. cluding studies with a much larger n than Andia et al. three on race. there was an overall nonsignificant re- meta-analyses on gender.05.516 Attain employment (−. Anderson. there was agnosis were computed on only two studies each. Note that the heterogeneity of effect tus. this no effect. Anthony. at- was evaluated using the Q statistic. in- analyses: two on age. the effect was largely due to one study (Andia et al. Becker. & Clark (1996) 140 . it should be noted relationship was negative. although the overall race in the opposite direction. As can be seen. one on race.040 . after placement. Note that for employment status the heterogeneity of cause all variables except age were dichotomized. 2002 14 Wewiorski and Fabian Table 1. and six on di. . All homogeneity of effect across the studies. Anthony.. & Butler (1997) 152 −. 1995) that showed an effect of being younger. For all remaining vocational outcomes.001 . interval around the weighted mean effect was calcu. 265–268).592 Braitman et al.

758 Cook & Razzano (1995) 602 . 2004 18:24 Style file version June 22.059 . Meta-Analytic Results of Race (Caucasian = 1. 1993 448 .091) Yes Fabian (1989) 81 .105 . (1997) 152 . (1997) 275 0 .829 suggest that persons diagnosed with an affective heterogeneity of effect for amount of employment in disorder are significantly more likely than persons di.110 −. .150 <. . .050 .784 Cook & Razzano (1995) 602 −.192) Yes Fabian (1992) 90 −. It should be noted that the spectrum disorder compared to diagnosis with Table 3. the past year is due to one of the two studies reporting agnosed with schizophrenia to be employed 3 months a non-significant finding.193 Employed @ 3 months (−. (1996) 47 0 . (1997) 152 .099) Yes Fabian (1992) 90 . Table 5 presents the results of three meta- ated with significantly better outcome overall in terms analyses that consider the relationship between vo- of employment status or amount of competitive em. . (1995) 85 −.205 .035 .787 Attain employmenta (. . 2002 Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables 15 Table 2.980 Rogers et al.110 Drake et al.011) No Fabian (1989) 81 .500 Braitman et al.181 Cook & Razzano (1995) 602 . after placement.953 Employment status (−.129) Yes Fabian. Other = 0) on Vocational Outcome Overall effect Homogeneity of Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size? .330 >.342. (1995) 179 .500 Mowbray et al.222 .474 Shafer & Hsaio-Wen (1995) 52 .500 Okpaku et al.029 Cook & Rosenberg (1993) 448 −.665 Attain employment (−.050 .136) No Fabian (1992) 86 . Meta-Analytic Results of Gender (Male = 1.05. −.902 . (1991.007 .023.013. 1997) 275 0 . .999 a Overall effect significant at the level of p < .464 . (1995) 277 0 .094.012 .144.500 Mowbray et al.043 Q = 2. 1992 90 . (1995) 277 0 .500 Rogers et al.042 Q = 20.024 Q = 0.078 .044 Q = 0.045 .P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6.100 .041. cational outcome and diagnosis with a schizophrenia ployment in the past year. However.001 Shafer & Hsaio-Wen (1995) 86 −.087.171) No Fabian (1992) 86 .246 Employed @ 6 monthsa (−.002 Q = 0.099 .622 Andia et al.2584 Employed @ 6 months (−.642 Cook & Rosenberg. Female = 0) on Vocational Outcome Overall effect Homogeneity of Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size? −.500 .080 Q = 12. neither diagnosis is associ.000 Arns & Linney (1995) 138 0 .500 .709 .256 Q = 11.075 .039 .500 Okpaku et al.009 Employment status (−.458 Arns & Linney (1995) 138 0 . .890 Shafer & Hsaio-Wen (1995) 107 0 .

1995 37 .502 a Overall effect significant at the level of p < . (1995) 256 −. Meta-Analytic Results of Diagnosis (Schizophrenia = 1. 2002 16 Wewiorski and Fabian Table 4. or being employed 3 months after placement. (1995) 215 −. (1999) 152 0 .001 .005) Yes Mowbray et al. (1999) 152 0 . Meta-Analytic Results of Diagnosis (Schizophrenia = 1. zero effect because a non-significant finding was re.169 Employment status (−.280. albeit not necessarily sig.038 .113 . Results of the other two geneity of effect for employment status can be ex- meta-analyses showed that persons with a schizophre. The hetero- be due to this one study. (1995) 227 −. Thus. Other Disorder = 0) on Vocational Outcome Overall effect Homogeneity of Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size? −.05.004 Anthony et al.003 Shafer & Hsaio-Wen. (1997) 981 −. It should be noted that analytic results showed that diagnosis with an affec- the heterogeneity of effect for attainment of com. individuals diagnosed with an affective disorder were ported.165 Q = 6.048 Q = 1.129 Q = 9.214 Q = 2. Table 5.300 Russo et al. −.009) Yes Mowbray et al. Although a diagnosis of schizophre.561 −. . two of the three studies did Table 6 presents the results of three meta- show a less favorable outcome for those with a di. (1999) 152 0 .500 a Overall effect significant at the level of p < . on employment status. tion of effect between the two studies included in this nia was not found to have an overall significant effect analysis. cational outcome and diagnosis with an affective nificantly less favorable.500 −. −.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6. plained by two of the four studies: one study had a nia diagnosis were significantly less likely than others nearly zero effect and the second had a zero effect to attain competitive employment or to be employed because it reported a non-significant finding. analyses that consider the relationship between vo- agnosis of schizophrenia.049 −.500 −.466 <. not a difference in direc.013) Yes Fabian (1992) 64 −. (1997) 797 −. another disorder. the overall non-significant finding may significantly more likely to be employed.415.010) No Tsuang & Coryell (1993) 54 −.038 Russo et al.305 .734 Employed @ 3 monthsa (−.292 .061 .117 Drake et al. .106.100.267. 2004 18:24 Style file version June 22. Compared to those with other diagnoses. −.043 Drake et al.001 Drake et al.050 Q = 2.335 .111 .212 Q = 2.036) Yes Fabian (1992) 87 −.05.051) No Jacobs et al. . tive disorder did not have a significant overall effect petitive employment is due to a difference in the on the vocational outcomes of attaining employment magnitude of the effect.026 . Meta- 3 months after placement.697 Amt comp empl past yr (−. The third study showed a disorder. (1992) 84 −.665 Employed @ 3 monthsa (−.035 .002 Shafer & Hsaio-Wen (1995) 44 .056 Attain comp empla (−. .979 Employment status (−. Affective Disorder = 0) on Vocational Outcome Overall effect Homogeneity of Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size? −.387.

that Caucasians are signifi. could alter these find- sons with other diagnoses. many of these analyses were likely to be employed.199 .006 Drake et al.038 . Meta-analytic results conduct such analyses. it also omitted small effect sizes ment.077 Q = 8. It would have been very informative very small effect sizes for age. that could be explored with to persons with other psychiatric diagnoses. and so forth. Where we found heterogeneity of effect across Although the number of studies was very small. race. the availability of more studies also would these findings do suggest that diagnosis may be a allow for moderator analyses that might help expli- predictor of vocational outcome for individuals with cate the findings. to be able to go beyond diagnosis and examine func- nosis as predictors of vocational outcome. Compared ticipants. intervention factors. 2004 18:24 Style file version June 22. In addition. .05. Meta-analytic results showed mix factors. nificantly more likely to be employed than those with ities. Thus. and that persons diagnosed ings relatively easily. Without further investigation. 2002 Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables 17 Table 6. (1997) 981 . . studies. as well. tioning or impairment. Although was that persons of color are significantly more likely this approach allowed for the inclusion of more stud- than Caucasians to be employed 6 months after place.500 . computed on the basis of a very small number of cantly more likely than persons of color to attain em. individuals with affective disorders were sig- tional outcome for persons with psychiatric disabil.005 . In general. ses.055. In demographics and diagnosis as predictors of voca. showed that younger people are significantly more As already noted. However. the inclusion of just a few more stud- ployment. cluded several studies with a zero effect size because tional outcomes than others.088 . However. those with able evidence and provide greater precision and more schizophrenia disorders also were significantly less detail about our accumulated knowledge concerning likely to be employed 3 months after placement.487 Russo et al. there were these analyses did produce results that tend to cor. For example.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6. insufficient studies with comparable independent and roborate some of the findings summarized in our gen.136 Attain comp empl (−. studies. larger. and diag. our analyses in- with affective disorders generally have better voca. some of the included studies.323) Yes Fabian (1992) 87 . and samples.204) Yes Jacobs et al. differences in the differences between various diagnostic subgroups in racial/ethnic composition of the non-Caucasian sub- employment status. When compared These meta-analyses synthesize currently avail. that persons diagnosed with schizophrenia ies.234 . DISCUSSION icantly less likely to attain employment or to be em- ployed 3 months after placement. gender.002 . (1999) 152 0 . differences in the age ranges of study par- employment 3 months after placement. these meta-analytic findings showed other diagnoses. (1997) 152 . dependant variables as well as appropriate data to eral overview of the literature.844 Employment statusa (.027. it is difficult to that may have made a difference in some analy- interpret this result.128) No Arns & Linney (1995) 138 .015 Shafer & Hsaio-Wen (1995) 44 . there may be case- psychiatric disabilities.606 Employed @ 3 months (−. .148 Q = 1.220 . (1992) 84 . those more extensive analysis if the number of studies were with a schizophrenia spectrum diagnosis were signif.474 .035 Okpaku et al. Meta-Analytic Results of Diagnosis (Affective Disorder = 1. attainment of employment. An unexpected finding results were reported as non-significant.005 Mowbray et al.597 a Overall effect significant at the level of p < . (1995) 256 . addition. or even the availability of exact p values from generally have poorer vocational outcomes than per. only to persons with affective disorders. Other = 0) on Vocational Outcome Overall effect Homogeneity of Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size? . . ies in the analyses.075 Q = 2.028.

In addition to the problems dis- possible to perform additional analyses that would ex. has created unevenness ies. others reported it as a baseline measure for ferences we found between subgroups reflect well- a community-based intervention. Common purposes for in. service broadly. employment outcome differently. in the field of psychiatric vocational rehabilitation Beyond these limitations. their relationship to other variables are pation. to ful in strengthening research studies. ment needs. Having such ber of existing studies because of differing outcome data to include in meta-analyses might yield results variables. measure a large number of different employment out- pants measure age and gender. job-related factors race. 92) note. it might be accumulated to date. 2002 18 Wewiorski and Fabian Because of the limited number of studies suit. As Cook and evaluate its representativeness of the relevant popu. that pro- variables that were quite coarse. This suggests ported prevalence in the psychiatric population more that change may be needed in social policies. and Some studies reported employment status at hospital their ability to sustain employment. and hours worked per week. including placement ratios. 2004 18:24 Style file version June 22. and yet others re. Researchers often measure the same analyses do provide some useful findings for the field. For example. Attainment of employment was reported as systems. hourly salary. problem because of our focus on demographic vari. Access to original datasets or meta-analysis and many separate analyses must be agreement in the field about standardized reporting performed. we in. a major constraint confronting the would increase the number of available studies and meta-analyst in the psychiatric rehabilitation field is would give meta-analysts more precise and more com. mote employment opportunities for persons of color. and to determine whether there is covariance and report data on standard labor force indicators that needs to be controlled. With the availability of lated literature on vocational outcome also revealed more studies. we needed to define outcome the unique needs of persons who are older. p. als with affective disorders in terms of their employ- such as hours worked. that could be reported with greater confidence than Second. The intensity or duration of an intervention Although this meta-analytic study did find de- was not considered in any of these analyses. the research literature contains studies that ables. The stud.” When the dependent variable varies across not reported in detail unless a statistically significant studies. known inequities in the larger society. such as employment status. First. and job duration. the meta-analyst also might be able to six general problems and concerns that preclude more consider vocational outcome variables that are more extensive use of this powerful research methodology narrowly defined and specific. variability in the measurement of the de- those provided here. in- bilitation program or other community-based inter. or type of job. terventions may need to occur on many levels. Thus. and re. (wages earned. ous demographic and diagnostic subgroups. it also revealed a number of intervention programs and the types of placements of problems and limitations in using this methodology that were provided. The validity and reliability of these mea. Some of the dif- admission. A sures tends to be assumed. For example. as well. job tenure versal inclusion of these variables in research stud. vention. our effort to synthesize the accumu- plore some of these variations. consensus around reporting outcomes would be help- cluding these variables are to describe the sample. our meta-analyst. we encountered a currently. pendent variable also can present challenges to the Despite the limitations we encountered. wages earned. Despite the almost uni. Razzano (2000. Thus. Virtually all studies involving human partici. “the failure to gather lation. a need for specific policies and services that address able for meta-analysis. Often. stud- Our meta-analytic findings suggest that there may be ies measure employment outcome as a variable that . between individuals with schizophrenia and individu- gardless of the specific characteristics of employment. those studies cannot be combined in one relationship is found. and many measure comes. If there were a larger number to synthesize findings from the large body of evidence of studies appropriate for meta-analysis. program practices. cussed above. their opportunities for employment. and public attitudes that a follow-up measure to an index hospitalization as differentially affect the vocational outcomes of vari- well as an outcome measure of a vocational reha. they generally are not the major variables in a in our knowledge about actual labor force partici- study. cluded all studies that reported employment status and that recognize and address possible differences regardless of when that status was measured. mographic and diagnostic factors that may be impor- ies that measured employment status at 3-month and tant in determining the vocational outcome of persons 6-month follow-up time points also varied in the types with psychiatric disabilities. the inability to synthesize findings across a large num- plete data on demographic variables. hours worked).P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6.

graphic subgroups. Thus. As reviewed earlier. or categorical. Nonethe- Fourth. more conscientious and consistent in defining and se- variate analyses. even when it is. In general. development. and so forth. specific factors and employment outcome eventually tailed statistical results. studies also vary in the amount of detail ultimately limits our capacity to devise effective poli- given about the data and about the results of statistical cies and practices (Fabian. a form appropriate for combining findings across studies. such as socioeconomic status. even when studies have clearly defined less. To make better use rehabilitation field report the results of multivariate of these methodologies. When intervention studies do not in. Although this issue may not seem of major studies use different categories or break points for the concern. termining the employment success of various demo- Sixth. there can be a problem be. orous studies that are designed not only to inform ducted in the psychiatric rehabilitation field tends to various stakeholders. or chiatric disabilities. the intervention often is not clearly de. Published reports often do not provide ef. purposes of meta-analysis is to advance theory. As a final point. such as fact that researchers are not also focusing on theory a dichotomous variable. There is a need to analyses. For example. The field of psychiatric vocational rehabilitation quently small and often drawn from a single program. operate in determining vocational outcome. but also to advance theory. fidelity of implementation the acknowledgment that this process may not be is not measured. people with significant the precision of the data entered into a meta-analysis psychiatric disabilities are marginally represented in and yields meta-analyses with limited power to detect the labor market. survival analysis. 2000). often the problem can. race. different tigations. understand which factors are relevant and how they fect sizes. Meta-analysis and research synthesis techniques tical techniques and procedures. much of the body of psychiatric rehabilita. This very common reporting prac. regression procedures. we emphasize the importance of ing exact values. researchers in this area tion research consists of atheoretical empirical inves. need to focus their studies on the development of . As one of the major meta-analyst can overcome this problem by redefin. Sample sizes are fre. But. This limits abilities. dichotomous. curity Disability Income Support programs. outcomes of the psychiatrically disabled population Third. or age. lecting variables for study.P1: GAD Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6. will enable us to build theoretical models that will cause relationships between the independant and contribute to a body of knowledge concerning what dependant variables of interest are not reported in works and for whom. ferences. To include such studies. but that explore subgroup dif- tors. The outcome variable may be analyzed and reported using comparative parametric statistics. the ing outcome variables into a common variable. it has hindered the development of a uni- same outcome variable. A particular problem are powerful research tools that are underutilized in is that many well-designed studies in the psychiatric the psychiatric rehabilitation field. porting the results. ings as “significant” or “not significant” without giv. assume homogeneity. considering these findings in the context of employ- analyst typically uses the conservative approach of ment outcomes for individuals with psychiatric dis- entering zero effect sizes into an analysis. CONCLUSION repeated measures or time series analysis. be quasi-experimental at best. it is difficult to determine if subgroups within the population of persons with psy- the psychiatric illness accounts for the outcomes. and conduct methodologically rig- Fifth. 2004 18:24 Style file version June 22. process of obtaining and sustaining employment with fined and. much of the intervention research con. for further analysis when analyzing their data and re- analyses. not be resolved and studies must be excluded from to help explain vocational behavior and vocational analysis. investigators must become analyses without also reporting the results of uni. numerous studies report find. This requires studies that do not whether the outcomes are determined by other fac. and overrepresented in Social Se- effects that actually may exist. consider the implications tice precludes the use of these data for future meta. needs to increase its understanding of the complex In addition. research that focuses on the relationship between independent and dependant variables and report de. uniform across various demographic and diagnostic clude statistical controls. or many other statis. the meta. that identify interventions that are effective many intervention studies are of questionable quality with subgroups. Sometimes the fied research agenda in this area. MH/VR service system that may be relevant in de- ing overall treatment effects. and that identify factors outside the for inclusion in meta-analyses concerned with assess. 2002 Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables 19 is continuous. or the application of existing theories.

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