At the Intersection of Health, Health Care and Policy

Cite this article as:
David Mechanic, Scott Bilder and Donna D. McAlpine
Employing Persons With Serious Mental Illness

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team
Health Affairs 21, no.5 (2002):242-253
doi: 10.1377/hlthaff.21.5.242

The online version of this article, along with updated information and
services, is available at:
http://content.healthaffairs.org/content/21/5/242

For Reprints, Links &
Permissions : http://content.healthaffairs.org/1340_reprints.php
Email Alertings : http://content.healthaffairs.org/subscriptions/etoc.dtl

To Subscribe : https://fulfillment.healthaffairs.org

Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown
Road, Suite 600, Bethesda, MD 20814-6133. Copyright ©
by Project HOPE - The People-to-People Health Foundation. As provided by
United States copyright law (Title 17, U.S. Code), no part of
may be reproduced, displayed, or transmitted in any form or by any means,
electronic or mechanical, including photocopying or by information storage or
retrieval systems, without prior written permission from the Publisher. All
rights reserved.

Not for commercial use or unauthorized distribution

A variety of factors reinforce the perception that persons with mental illness are limited in their work participation. 2016 by HW Team profiles similar to those of persons without mental illness. a diagnosis associated with high impairment. and some with even the most serious mental disorders hold jobs requiring high levels of functioning. Most persons with mental illness want to work. Approximately two-thirds are enrolled in federal disability insurance programs. McAlpine ABSTRACT: Data from various national surveys find that approximately half the population with mental disorders is gainfully employed across the entire range of occupations. the stigma David Mechanic directs the Institute for Health. Inc. Scott Bilder is a research analyst there. Scott Bilder. which reinforces the con- cept that this represents the range of work such clients can do. . 242 September/October 2002 ©2002 Project HOPE–The People-to-People Health Foundation. and Aging Research at Rutgers. such persons have an employment rate of about two-thirds that of the general population. many mental health programs that seek to assist persons with mental illness to gain and retain employment focus their efforts on placing clients in unskilled and semiskilled positions. New Jersey. More than a third of persons with serious mental illness also work. few people leave. have occupational Downloaded from http://content. Once enrolled in the Social Security Administration’s Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs. Educational attainment is the strongest predictor of employment in high-ranking occupations among both the general population and per- sons with mental disorders. and Donna D. more complicated picture of the links between mental illness and employment. Such persons constituted approximately 34 percent of working-age enrollees in the SSI program and 27 percent of SSDI beneficiaries in 1999. health services research and policy. by David Mechanic. only slightly more than a fifth are at work. Health Care Policy.D ata Wat c h Employing Persons With Serious Mental Illness Workers with mental illness. Our analyses indicate con- siderable diversity of jobs among persons with various mental disorders. As a re- sult. and many hold high-status po- sitions. at the University of Minnesota School of Public Health. Finally. I t i s w e l l e s ta b l i s h e d t h at m e n ta l i l l n e s s e s such as schizophrenia and major mood disorders cause considerable distress and disability. in New Brunswick. and 12 percent are working full time. even serious disorders. persons with these disorders work less than others in the general popula- tion do and are overrepresented in public and private disability programs.healthaffairs. Among those with schizophrenia.1 Moreover. Donna McAlpine is assistant professor. This paper seeks to go beyond these common observations to offer a richer. the State University.org/ by Health Affairs on July 15.

supplemented by data from other national surveys.7 We focus on this survey because it provides the largest.227 respondents reported on 120. employees often do not reveal their mental health histories or treatment status to employers. also sug- gest that as many as ten million people may have such conditions. television. Identifying factors associated with employ- ment outcomes points to areas that warrant policy attention. 66. this paper seeks to construct a more complete picture of the employment situations of persons with mental ill- ness.S. de- signed to collect data on the prevalence and correlates of disability in the noninstitutionalized U.216 household members ages 18–65. In phase one. The main data reported here come from the 1994/1995 NHIS-D. Conclusions drawn from studies of enrollees with mental illness in employ- ment rehabilitation programs also can be misleading. reinforces the view that per- sons with mental illness are unpredictable and possibly dangerous.2 It is little wonder that many employers are reluctant to place persons known to have a his- tory of mental illness in responsible jobs. Households that completed the core NHIS (94 percent of those sampled) were eligible for the first phase of the NHIS-D. numbers of persons with mental illness accumulate over time and constitute a large proportion of all disability insurance recipients.3 For this reason.5 Unlike persons with serious heart disease or cancer. We also focus on persons with the most serious disorders and show that even among this group. Study Methods nSamples. These programs typically deal with selected samples of persons with extensive disabilities and long histo- ries of repeated episodes of illness and care. and approximately half. many persons manage employment. N u m b e r 5 243 .org/ by Health Affairs on July 15. persons with serious mental illness often be- come symptomatic early in their lives and enter disability status at relatively young ages. Mental Illne ss of mental illness. The number of Downloaded from http://content.healthaffairs. including themselves.6 Generalizations from these selected populations to most people with even serious mental illnesses are invalid. based on images of floridly psychotic persons that are dissemi- nated by movies. Since few persons who achieve SSI/SSDI eligibility leave the disability rolls. national estimates. as much as one-third of the population is reported to have a mental disorder in any year. on which this paper is based. civilian population. at some point in their lives. based on data collected in the early 1990s. and other mass culture. Using data from the National Health Interview Survey on Disability (NHIS-D). and some hold high-status occupational positions.4 Although serious mental illnesses are much less prevalent. most comprehensive data source available linking mental dis- orders and disability to employment. We also report data that we analyzed from three other nationally representative household surveys: the NHIS Mental Health Supple- H E A L T H A F F A I R S ~ Vo l u m e 2 1 . The facts on which these images are based can be misleading. 2016 by HW Team persons with mental illness on SSI/SSDI partly reflects the high prevalence of per- sons with mental illness in the general population. NHIS-D data were collected from 93 percent of eligible households.

1989 (NHIS-MHS-1989). Those working thirty-five hours or more per week were classified as working full time. each assessed by a single item: “a lot of trouble making and keeping friendships”. We divided self-assessments of health into those who reported their health as “excellent” or “good” versus others. Free- dom from problems with activities of daily living (ADLs) and instrumental activi- ties of daily living (IADLs) was based on items asking about difficulties with these functions. and “serious difficulty coping with day-to-day stresses” (Cronbach’s alpha .healthaffairs. “a lot of trouble getting along in social situa- tions”.9. Substance abuse disorders were treated as a separate variable. We also examine persons who reported depressive symptoms for two or more weeks in the past twelve months or who had ICD-9 codes reflect- ing depressive disorders not elsewhere classified or neurotic depression. specific categories: schizophrenia and depressive symptoms.D ata Wat c h ment.327 persons ages 18–65.0–319. Serious mental illness in this study includes schizophrenia. Re- Downloaded from http://content. This condition was mea- sured by the respondent’s report of schizophrenia or conditions with an ICD-9 code of 295.org/ by Health Affairs on July 15. Ninth Revision (ICD-9) categories. 244 September/October 2002 . “a lot of trouble concentrating long enough to complete tasks”.74). and childhood- specific mental disorders were excluded. We use a measure of psychological functioning based on the presence or ab- sence of problems in five areas. Evidence is lacking of a clinical disorder in this category.393 persons ages 18–54.8 n Major measures. Mental retardation. mental illness with organic origin. and the 1997/1998 Healthcare for Communities (HCC) survey of 8. paranoid states.99) were included as mental disorders. “frequent disorientation. confusion. which provides data on 70. the 1990/1992 National Comorbidity Survey (NCS) of 5. This paper focuses on three categories: persons with serious mental illness. or both. and other nonorganic psychoses and psychoses with origins specific to childhood. Those associated with mental illness (codes 290.047 respondents. Persons were identified as being employed in the past two weeks if they had worked or had a job and were not laid off. Diagnostic measures were constructed using either of two criteria. and persons with no known mental illness. We also look at two important. Schizo- phrenia is generally regarded as the most disabling of the more common mental disorders and is a subgroup of serious mental illness.0–295. Disorders often included as serious mental disorders such as panic dis- order and obsessive-compulsive disorders were excluded because it was impossi- ble to distinguish these cases from less serious conditions. 2016 by HW Team spondents also were asked about a variety of medical conditions that were then coded into International Classification of Diseases. and forgetfulness”. mood disor- ders. per- sons with any mental illness. The first involves an affirmative response to one of several questions on a checklist about having specific mental disorders such as schizophrenia or major de- pression or “other mental or emotional disorders” in the past twelve months. but it is well established that subthreshold depressive symptoms are often disabling.

and almost 70 percent of persons with only a physical condition were employed. The disparate work estimates for persons with mental illness among these sur- veys reflect different measures of mental illness. which depends on reported conditions. there is reason to believe that these estimates are overly inclusive.healthaffairs. 2016 by HW Team fects in each survey.9 The NHIS-D includes weights to make estimates representa- tive of the nation’s noninstitutionalized population. Substance abuse conditions were based on checklist responses indicating alcohol or drug abuse problems or for ICD-9 coded conditions for alcohol psychoses. Employment among persons with serious mental illness varied from 32 percent to 61 percent. In these samples 75–83 per- cent reported being employed. The data come from cross-sectional surveys and self-reports of illness and disability. depending on the survey. the measurement approach used by the NCS (and to a lesser extent by the HCC survey). the NHIS. alcohol de- pendence syndrome.11 In contrast. Persons with any mental disorder reported employ- ment rates of 48–73 percent. n Employment rates by diagnostic category. Mental Illne ss Persons who reported conditions other than those classified as mental disor- ders were identified as having a physical condition. is likely to underestimate true psychiatric morbidity because persons often do not know their psychiatric status or are reluc- tant to report it because of stigma. Exhibit 1 presents data on the proportion of persons who reported employment in four nationally representative sample surveys carried out between 1989 and 1997/1998. drug psychoses. persons with mental illness were less likely to be employed.10 Of the four surveys here. In the remainder of this paper we focus on the much more conservative estimates derived from the NHIS data. and causal sequences are difficult to infer from cross-sectional data. drug dependence. N u m b e r 5 245 . based on questions related to the criteria of the psychiatric Diagnostic and Statistical Manual of Mental Disorders (DSM). n Limitations. n Analysis. but sample sizes are not. Such reporting bias need not be at a level of awareness. The percentages reported are weighted. Study Results n Employment rates among the four surveys. and nondependent abuse of drugs (other than tobacco). However. We control for severity of illness and impairment to the extent possible but cannot exclude the possibility that self-report bias may remain. Unemployed persons may report more illness and disability than their objective symptoms warrant as a way of justifying their employ- ment status to themselves and others. While 76 percent of persons without mental illness were employed.org/ by Health Affairs on July 15. varying from more than half of those with a mental illness not classified H E A L T H A F F A I R S ~ Vo l u m e 2 1 . Persons with schizophrenia and related disorders had employment rates of 22–40 percent. Efforts to develop survey esti- mates of various mental illnesses have a long history. but debate continues over their validity. Disablement is a process. is the most carefully developed and most commonly accepted. SUDAAN software was used for all analyses to correct for design ef- Downloaded from http://content.

0 (8–16) Non-SMI mental illness 3. 1994/1995. 1989 1990/1992 1994/1995 1997/1998 Downloaded from http://content.997 76.047 SOURCE: Data come from our analysis of these surveys. b Insufficient cases.healthaffairs.327 5. Supplement. NOTE: Persons ages 18–65 except for the National Comorbidity Survey. The one clear excep- EXHIBIT 2 Employment Among Adults With And Without Mental Illness. Rates of full-time employment were about ten to fifteen percentage points lower for each diagnostic category as well as for persons with no known mental illness. as serious to 22. on Disability.org/ by Health Affairs on July 15.393 120.4 (61–62) SOURCE: National Health Interview Survey on Disability.5 (30–34) Substance abuse 926 54.5 (18–27) 12.216 75. have occupational profiles similar to those of persons without mental illness (Exhibit 3). Major depression is not included as serious mental illness in the other three surveys. NOTES: Persons ages 18–65.445 46. n Employment rates by occupation.5 (69–70) 55. 2016 by HW Team Entire sample 75% 83% 75% 80% No mental illness 76 87 76 84 Any mental illness 51 73 48 66 Serious mental illness 32a 61 37 51 Schizophrenia and related disorders 22 –b 22 40 Unweighted sample size 70.099 48.219 48.1 (35–39) Depressive symptoms 2.7 (32–35) Serious mental illness (SMI) 1. employed persons with men- tal illness. By Diagnostic Category. Comorbidity Interview Survey Healthcare for Mental Health Survey.4 (75–76) 61. 1994/1995 Percent Percent employed Diagnostic category Number employed full time No mental illness 115. a Includes twenty-nine cases of major depression coded under affective psychoses that appear more serious than other coded depressive conditions.907 69. Only 12 percent of persons with schizophrenia worked full time. 1989–1998 National Health National National Health Interview Survey.9 (36–43) Other mental illness 2. 246 September/October 2002 .1 (47–50) 33. Remarkably.1 (50–58) 39.1 (50–54) 37.0 (44–48) 31.0 (46–50) 33.0 (21–27) Schizophrenia 320 22.5 percent among persons classified as schizophrenic (Exhibit 2).4% (62–63) Any mental illness 4. which is persons ages 18–54.114 36.4 (55–56) All persons 120. including those with serious mental illness.8 (33–41) 24.216 8.105 52. 95 percent confidence intervals are in parentheses.4 (31–35) Physical illness 50. Communities.D ata Wat c h EXHIBIT 1 Employment Among Adults With And Without Mental Illness In Four Nationally Representative Surveys.4% (76–77) 62.

9 (1–5) 2. NOTES: Persons ages 18–65.9 (14–18) 15.3 (6. Mental Illne ss EXHIBIT 3 Occupational Categories Among Adults With And Without Mental Illness.1–2. Education is particularly important. since the latter group often have impairments that make it difficult to get and keep jobs. 95 percent confidence intervals are in parentheses.0–6.3 (0–2) 1.) 1. including clerical 14.3) Precision production. 1994/1995.5 (1–2) 1.2 (2.4 (13–16) 10. etc.6 (14. Age.5) Transportation and material moving 2. H E A L T H A F F A I R S ~ Vo l u m e 2 1 . and fishing 1.8–14.7 (6–12) 7.7 (3.9 (1.7 (6–9) 10. but these controls may not completely account for differences in impair- ment.0–11.1–10. In all subsamples.1 (4.5 (10. n Factors associated with employment. 2016 by HW Team Professional specialty 11. We control for disease characteristics and health limitations to the extent possible. It is plausible that persons with mental illness who complete more education are less impaired.healthaffairs. classified.5 (6–13) 6.6–15. Better perceived health.979) (n = 87.0–4. assemblers. Employment for persons with any mental illness and for those with serious mental illness was more likely in the 18–24 age group than the 45–65 age group (Exhibit 4).5 (6–11) 10.6 (0.0% (10–14) 14.0) Service.8) Private household 0. fabricators. administrative.4 (1–2) 2.61) Protective service 1. helpers. with those who finished high school or with college and postcollege education having odds two to five times greater of being employed than those who did not finish high school.7 (2–6) 4. This is in contrast to those without mental illness.6 (1–2) 1.9 (1–3) 1.4 (10.9 (6–8) 6.4) Administrative support.7–2.3) Technicians and related support 3.9) Unknown (includes refused.4 (3–6) 4.org/ by Health Affairs on July 15.6 (2–3) 4.4) Downloaded from http://content.7 (3–5) 3.2 (16–19) 14.2) Sales 8. This is not surprising.3% (8–15) 12. except protective and household 18.4 (0–1) 0. N u m b e r 5 247 . 1994/1995 With serious With any With no mental illness mental illness mental illness Occupational category (n = 398) (n = 1.1% (13. Regression analyses were used to identify factors associated with any employment and location in the employ- ment structure. good psychological functioning. and managerial 11. Education. Being male and having more education increase the odds of employ- ment in all groups (Exhibit 4). and inspectors 9.0 (14.3) Handlers.9–4. who were less likely to be employed at these ages and most likely to be employed at ages 25–44.7) Farming. physical and psychological functioning was associated with employment.6) SOURCE: National Health Interview Survey on Disability.49–0. and lack of reported limitations were associated with higher rates of employment.620) Executive.3 (3–8) 3.7 (0–3) 1.3 (9–12) 11. and repair operators.4–1. and laborers 5.2 (14–22) 14.6 (0–1) 0.2–10.3–14. equipment cleaners. forestry.5 (1. tion is the concentration of persons with mental illness in service occupations (other than protective and household). Those with mood disorders have odds of employment twice as high as those with schizophrenia and related disorders.2 (11.6) Machine operators. and laborers 8.5–3.9 (9–15) 15.1 (3.8 (11–19) 17. craft.

5 times higher than persons ages 45–65. and approximately two-thirds were enrolled in SSI/SSDI.226 0. With repeated episodes of illness and growing impairment.56*** Good health 2. mental health clinicians help persons gain eligi- bility to disability benefits.23*** 2. 1994/1995.11*** –a –a No comorbid physical condition 0. Using Odds Ratios.220 0.15*** 2. persons with schizophrenia were least likely to be employed.92*** 3. As noted earlier.05 ***p < .84 1. In further analyses (not shown). two factors distinguished employed persons from others.66*** 0.126 df 14 12 12 SOURCE: National Health Interview Survey on Disability.09*** Some college or college graduate 2.57*** Model details N for analysis 1.83*** 1.73** 0.97 1.55*** Age 45–65 –b –b –b White 1.82*** 2.19 –a –a Person characteristics Age 18–24 2. **p < .39*** Male –b –b –b Not high school graduate –b –b –b High school graduate 2.80*** Post-college 4.29*** 1. by middle age this population is much less likely to be employed.090 4.37 1.59*** 2.76 0.16*** No comorbid substance abuse 0.01*** 2.86*** No comorbid mental illness 1. ADL is activity of daily living.01 Schizophrenia.118 112. b Denotes reference category.80*** 0.53*** 1.58*** 1.12 1.41** 1. IADL is instrumental activity of daily living.D ata Wat c h EXHIBIT 4 Predicting Employment Among Adults With And Without Mental Illness. NOTES: Persons ages 18–65.81*** Limitations Good psychological functioning 1. 2016 by HW Team Mood disorder 2.68*** Age 25–44 1. In the NHIS-D only sixty-eight persons with this diagnosis were employed.38*** Nonwhite –b –b –b Female 0. Patients with schizophrenia who are employed also have more favorable perceptions of their health status (not shown).42*** 2.healthaffairs.12 Thus.21*** No problems with ADLs/IADLs 3.38*** 2. which may reflect 248 September/October 2002 .org/ by Health Affairs on July 15. Persons ages 18–24 had odds of employment almost 3. Schizophrenia occurs relatively early in life.78*** 4. a Not applicable.577 R-square 0.51** 1.61*** 3. 1994/1995 Person with serious Persons with any Person with no Risk/protective factor mental illness mental illness mental illness Disease characteristics Downloaded from http://content.

and the extent of disability associated with their condition. but each has signif- icantly independent effects on the odds of being employed. level of educational attainment is the most important factor in holding such jobs. This may reflect both the impairments associ- ated with mental illness that handicap even those with high levels of education and the stigma associated with mental illness that may affect employers’ decisions if they know the employee’s mental health history. This reflects in part the waiting pe- riod required to gain eligibility to disability insurance. administrative. Only one-fifth of persons with serious mental illness who had an onset in the interview year receive SSI/SSDI. the increased odds of high-level employment with more ed- ucational preparation were largest for the general population and lowest for per- sons with serious mental illness. There is a lesser advantage in all groups from simply having some college preparation or completing college.3 times more likely to have a higher-level position. and for all subgroups. Persons with mental illness in these occupations have probably completed much of their education prior to their first onset of mental illness. Statistical power for this analysis is limited because of the relatively small size of this subgroup. n Predictors of high-level employment. Persons with serious mental illness who have mood disorders as compared with other serious disorders were 3. Exhibit 5 presents regression analyses that seek to explain what allows persons with mental illness to hold occupational rank in executive. Age and onset are associated. Mental Illne ss where they are in the trajectory of their illness. and having good perceived health. increases the odds of having a high-level job twenty-six times for persons with serious mental illness and forty-three times for persons with any men- tal illness. For exam- ple. or professional specialty occupations. Persons with serious mental illness whose condition began in the past year are almost twice as likely to be em- ployed full time than are those who had an onset more than a year before. being older. managerial. Persons with serious mental illness who have had the onset of their disorder less than five years prior to Downloaded from http://content. these include being female.org/ by Health Affairs on July 15. As Exhibit 5 shows. Support for this interpretation comes from further regression analyses (not shown) examining the relative effects of age versus onset of condition among per- sons with serious mental illness. Other predictors are not statistically significant for this group. but odds of having a high-level job with this level of education are two to nine times greater than among those who have not com- pleted high school. among those without a mental illness. persons without mental illness in these jobs H E A L T H A F F A I R S ~ Vo l u m e 2 1 . their attitudes.13 As with persons with mental illness. the odds of a person with postcollege ed- ucation having such a job is fifty-one times greater than for those who did not gradu- ate from high school. but almost 45 percent of those whose onset occurred more than a year earlier had enrolled in SSI/SSDI. Postcollege education. compared with having less than a high school education. 2016 by HW Team the interview have increased odds of being employed. A number of additional factors predict employment in higher-ranking occupa- tions. These jobs generally require high levels of education. N u m b e r 5 249 .healthaffairs.

a Not applicable. compared with only 25 percent of those without mental illness.57 0.34*** –a –a No comorbid physical condition 0.50 1.21** 42.77 1. **p < . librarians. Or Professional Specialty Occupations Among Adults With And Without Mental Illness.81 –a –a Person characteristics Age 18–24 0.97 1.30*** Good health 0. NOTES: Persons ages 18–65. or counselors or in health assessment and treating occupations. The number of persons with mental illness in this subsample is small.219 0. Using Odds Ratios. they were not very different from those held by persons without mental illness.28*** Male –b –b –b Not high school graduate –b –b –b High school graduate 0.88 0. ADL is activity of daily living.02 1.89 1. 1994/1995.40*** No problems with ADLs/IADLs 2. IADL is instrumental activity of daily living.05 ***p < .46 1. Overall.83*** 8. b Denotes reference category. 1994/1995 Persons with serious Persons with any Persons with no Risk/protective factor mental illness mental illness mental illness Downloaded from http://content.27 1.77 0.52 1.34 6.org/ by Health Affairs on July 15.11*** Some college or college graduate 2. but there were some interesting patterns.32*** Age 25–44 1.222 df 14 12 12 SOURCE: National Health Interview Survey on Disability.87*** Post-college 26.01 are older and more likely to be female and to have favorable perceived health.12 1.D ata Wat c h EXHIBIT 5 Predicting Employment In Executive.82*** Age 45–65 –b –b –b White 0.58** No comorbid mental illness 0. There were no differences between 250 September/October 2002 . 2016 by HW Team Disease characteristics Mood disorder 3.37 0.34*** 0. we examined in more detail the jobs in these occupa- tional categories occupied by persons with serious mental illness.64*** 1.89 Model details N for analysis 382 1.healthaffairs. Using the available data. and thus differ- ences are not statistically significant. Thirty percent of those with serious mental illness were teachers.63*** 50.52 1.97*** Limitations Good psychological functioning 0.66 0.38** 1.95** No comorbid substance abuse 1.228 0.16 0. Administrative.917 84.35*** Nonwhite –b –b –b Female 1.112 R-square 0.92** 2.

in- cluding mental illness. since the demand for such work- ers is high and placement involves few barriers. Traditional pro- grams of this kind. 2016 by HW Team Discussion And Policy Implications In recent years. have not had good success in returning clients to competitive work. and other low-paying service occupa- tions. persons with mental illness often are placed in jobs below their educational background. Clients have been persistently critical of voca- tional rehabilitation services. and job failure. absenteeism. and gradual movement through various steps toward competitive employment. S. training in job skills. most programs and services are oriented to less-educated clients and employment in relatively low status jobs such as janitors. As a result. Inappropriate placement may contribute to boredom. increased efforts have been focused on meeting the employment needs of persons with disabilities. and athletes. with 5 percent occupying such positions compared with 11 percent of others. Persons with mental illness who have achieved higher educational attainment are often frus- trated by the difficulty of identifying programs relevant to their needs and capaci- ties.15 Persons who have a history of severe and persistent mental illness receive some job assistance through mental health rehabilitation programs. Downloaded from http://content. or in manage- ment occupations. dishwashers. and mathematical and computer scientists.18 Despite the evidence that many persons with mental illness with appropriate education hold jobs throughout the occupational structure. entertainers.17 Social Security and other funding agencies must recognize this fact and adapt their policies to support programs that better meet their objectives. 1180. almost two-fifths of both groups were in these occupations. Persons with serious mental illness were less likely to be engineers. but it is not clear to what extent such requirements have contributed to increased employment among persons with mental illness. but programs that place clients into competitive employment with contin- uing mental health services and various supports can lead to improved employ- ment outcomes while being cost-efficient. Other efforts have been made to facilitate trial work without jeopardizing one’s disability sta- tus.healthaffairs. which include prevocational training. work under sheltered conditions. Congress made it possible for persons in the disability pro- gram to keep their federal health benefits when returning to work.R.org/ by Health Affairs on July 15.16 Research indicates that it is difficult to predict success in work. Comparable proportions in both groups were writers. administrators. artists. The 1999 “Ticket to Work” legislation (H. This is often the course of least resistance. in response to disability advocacy groups. H E A L T H A F F A I R S ~ Vo l u m e 2 1 . architects and surveyors. N u m b e r 5 251 .14 The Americans with Disabilities Act also requires that employers make rea- sonable accommodations for persons with disabilities who are appropriately qualified for the position. Mental Illne ss these groups in the proportions who were officials. 331) provides opportunity for clients to gain access to the services they deem use- ful for helping them return to work.

and J. T. It is often diffi- cult to engage patients in treatment and gain their cooperation. The views expressed imply no endorsement by these funders. “Lifetime and Twelve-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey. S.L.” Archives of General Psychiatry 51. 2001). eds.. University of Illinois at Urbana-Champaign.. 1996). Shutt (New York: Elsevier Science. Maintaining educational and job continuity when illness oc- curs in late adolescence and young adulthood is a major challenge. The data show that persons with mental illness who have more educational at- tainment are more likely to be in higher-status occupations. Although we made efforts to control for severity of ill- ness and impairment. NOTES 1. 252 September/October 2002 . McAlpine and L.. “Ritual Conformity to the Americans with Disabilities Act: Coercive and Normative Isomorphism. by National Institute of Mental Health (NIMH) Grant no.D ata Wat c h Many employers are reluctant to hire persons with a history of mental illness because of their concern about unpredictable performance.: Institute for Health.22 This research was funded in part by grants from the Disability Research Institute.P. job coaches increas- ingly are taking on some of these responsibilities. it is possible that more-educated persons are in some way less impaired or have a different illness course. J. 8. Such placement may provide motivation to stay employed and to avoid dependency. 63–64. 1996). Barriers to Employment among Persons with Mental Impairments: A Review of the Lit- erature (New Brunswick.” in Research in Social Problems and Public Policy. and thus cause and effect may be confounded. Reno. 3. and Context (Washington: National Academy of Social Insurance.L. 4. including the inability to work.healthaffairs.P. J. 2–4. Suchman. MH43450.19 One alternative for closing the com- mon communication gap is to ensure that employers get tangible assistance and Downloaded from http://content. 2. and possible disruptions in the workplace. Hartwell and R. 2 (2000): 188–207. no. Mashaw and V. Efforts also should be made to keep clients in competitive employment with appropriate mental health ser- vices and support. Mashaw and V. The Environment of Disability Income Policy: Programs. R.org/ by Health Affairs on July 15. and Aging Research. Bal- ancing Security and Opportunity: The Challenge of Disability Income Policy (Washington: NASI. 1 (1994): 8–19. Phelan et al. People. 2016 by HW Team support in dealing with behavioral problems that might arise.20 It would be useful to help clients to complete their education as part of the larger effort to manage illness so as to prevent sec- ondary impairments.J. Warner. and by a grant from the Robert Wood Johnson Foundation.C.C. ed. Kessler et al. Caution is required in interpreting this finding.L. 2001). N. 47–51. work absenteeism. but there is much evi- dence that secondary disabilities often associated with mental illness can be at- tenuated and even prevented. History. Health Care Policy. Reno.21 Primary prevention of serious disorders remains highly uncertain. Scheid and M. Fear of discrimination often leads to hiding mental health his- tory and forgoing accommodation requests. Aggressive treatment when illness first occurs and good mainte- nance therapy reduce the period of incapacity and are believed by most clinicians to prevent subsequent disability. D.D. Many persons with mental illness are conscientious and reliable employees without special accommodations. JAI Press. vol. but oth- ers require them. “Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to Be Feared?” Journal of Health and Social Behavior 41. no.

8. 3 (2001): 381–400. and counselors... Person and Condition Data (Hyattsville. SUDAAN User’s Manual.” Journal of Behavioral Health Services and Research 25. no. Kessler et al.. J. 11. H E A L T H A F F A I R S ~ Vo l u m e 2 1 . “Benefits and Costs of Supported Em- ployment from Three Perspectives. G. for example. Mechanic... “Implementing Supported Employment as an Evidence-Based Practice. “Helping People with Severe Mental Illness to Obtain Work: Systematic Review.J. teachers. Shah et al.J.” Journal of Vo- cational Rehabilitation 14.” 20. no. Balancing Secu- rity and Opportunity. (Boston: Allyn and Bacon. however.E. 2001). Monahan (Chicago: University of Chicago Press. Work. no. 255–261. ed.A. 6. National Health Interview Survey on Disability: Phase 1. see J. also see Mashaw and Reno..K. 1996 and 1998). “Secondary Prevention of Mental Disorders.M. Bonnie and J. Narrow et al. D. W. no. R. no. Cook et al. 2 (2002): 115–123. thus far. ed. vol. Additional references for other data sources for this survey are available from the authors. “The Design of Healthcare for Communities: A Study of Health Care Delivery for Alco- hol. ed. Mechanic. Department of Human Services. See Weekly Compilation of Presidential Documents.R. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Re- search (Washington: National Academy Press. 22. The Environment of Disability Income Policy.” For a review of the benefit-cost literature on this is- sue. Drug Abuse. and R. 67–68. Manderscheid and M. See.5 (Research Triangle Park. 315–317.” Health Services Re- search 36. Disability. and the Law.A. Thornicroft and G. and McAlpine and Warner. 15.: Research Triangle Institute. 1997).W. the evidence on this point. 4th ed. Mental Health and Social Policy: The Emergence of Managed Care. “Duration of Untreated Psychosis: A Critical Examination of the Concept and Its Importance.R.” British Medical Journal 322. P. 16. Crowther et al..: U. Further analyses find. Kregel et al.” Milbank Quarterly 76. and Mashaw and Reno. “Implementing Supported Employment. no..” in Textbook of Commu- nity Psychiatry. “Revised Prevalence Estimates of Mental Disorder in the United States. 8 (2001): 1075–1080.healthaffairs. G. 1999). 17. Data come from public-use data files provided by the National Center for Health Statistics (NCHS). no. 1997). “Vocational Outcomes among Formerly Homeless Persons with Severe Mental Illness in the ACCESS Program.. Estroff et al. 18. P. 12. and S. engineers.S. no.. 1994). 3 (2000): 153–161. Mental Health. 14..G. Mrazek and R. Release 7.S. is less certain. D. The occupations in which men are more likely to be are less prevalent—for example. Mental Health and Social Policy. Kessler et al. 55–104. Core descriptions of the survey were published in 1996 and 1998. Haggerty. United States.. Malla. Mechanic. 19. and Mental Health Conditions. R. Mashaw and Reno.C. and R. “Serious Mental Illness and Disability in the Adult Household Population: United States. See NCHS. 7. Mental Illne ss 5. no. Mental Health and Social Policy.” in Mental Disorder.. Mashaw and Reno. architects.E.org/ by Health Affairs on July 15. R. 2 (1999): 221–233. Persistent Mental Illness. 106–108. 3 (2001): 313–322. 21. Bond et al. 7280 (2001): 204–208. 1 (1998): 22–34. Downloaded from http://content. Balancing Security and Opportunity. 153–162. Mashaw and Reno.” in Center for Mental Health Services and National Institute of Mental Health. 9.J. 10. no. 2016 by HW Team 1989. The Environment of Disability Income Policy.C. 35 (1999): December 17. Mechanic. Government Printing Office. 1992. There is abundant evidence that treatment reduces periods of incapacity and distress. Bond et al. B. See R. R.” Inquiry 36.” Archives of Gen- eral Psychiatry 59. Although most cli- nicians believe that earlier treatment also reduces later disability. and there is theoretical basis for this view.” Psychological Medicine 31. 94–97. librarians. and Mechanic. McGorry. 6 (2001): 987–1007.” Psychiatric Services 52.” Psychiatric Services 52. Sonnenschein. The advantage of women in holding higher-ranking positions may be puzzling since men are more likely to be employed in all subgroups. 1 (1998): 5–23.E. no. “Cultural and Organizational Aspects of Application of the Americans with Disabilities Act to Persons with Psychiatric Disabilities. 48–55. N u m b e r 5 253 . 131–144. “Lifetime and Twelve-Month Prevalence”. “Cultural and Organizational Aspects. The Environment of Disability Income Policy. (SMA)92-1942 (Washington: U. Barriers to Employment. DHHS Pub.E. that women are vastly overrepresented relative to men in certain occupations that are highly prevalent within these larger occupational catego- ries—for example. Md. N. Szmukler (Oxford: Oxford University Press. “No Other Way to Go: Pathways to Disability Income Application among Persons with Severe. 179–185.. 13. and mathematical and computer scientists. Sturm et al. 101–119. Barker et al. “Supported Employment Benefit-Cost Analysis: Preliminary Findings. and P. 495–508. Clark et al. “The Prevalence and Correlates of Untreated Serious Mental Illness.V. For background. Presidential Remarks and State- ment. eds. 1992). Normand and A.