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Purpose: Positive relationships between employment and clinical status have been found in several studies. However, an unequivocal interpretation of these relationships is difficult on the basis of common statistical methods., Methods: In this analysis, a structural equation model approach for longitudinal data was applied to identify the direction of statistical relationships between hours worked, clinical status and days in psychiatric hospital in 312 persons with schizophrenia who participated in a multi-centre randomised controlled trial comparing the effectiveness of Individual Placement and Support (IPS) with conventional vocational services in six study settings across Europe. Data were analysed by an autoregressive cross-lagged effects model, an autoregressive cross-lagged model with random intercepts and an autoregressive latent trajectory model., Results: Comparison of model fit parameters suggested the autoregressive cross-lagged effects model to be the best approach for the given data structure. All models indicated that patients who received an IPS intervention spent more hours in competitive employment and, due to indirect positive effects of employment on clinical status, spent fewer days in psychiatric hospitals than patients who received conventional vocational training., Conclusions: Results support the hypothesis that the IPS intervention has positive effects not only on vocational but also on clinical outcomes in patients with schizophrenia.

Background: The effectiveness of psychosocial interventions in community mental healthcare has been shown to depend on the setting in which they are implemented. Recently structured patient-clinician communication was found to be effective in a multi-centre trial in six European countries, the DIALOG trial. In the overall study, differences between centres were controlled for, not studied. Here, we test whether the effectiveness of structured patient-clinician communication varies between services in different countries, and explore setting characteristics associated with outcome., Methods: The study is part of the DIALOG trial, which included 507 patients with schizophrenia or related disorder, treated by 134 keyworkers. The keyworkers were allocated to intervention or treatment as usual., Results: Positive effects were found on quality of life (effect size 0.20: 95% CI 0.01-0.39) and treatment satisfaction (0.27: 0.06-0.47) in all centres, but reductions in unmet needs for care were only seen in two centres (-0.83 and -0.60), and in positive, negative and general symptoms in one (-0.87, -0.78, -0.87). The intervention was most effective in settings with patient populations with many unmet needs for care and high symptom levels., Conclusions: Psychosocial interventions in community mental healthcare may not be assumed to have uniform effectiveness across settings. Differences in patient population served and mental healthcare provided, should be studied for their influence on the effectiveness of the intervention. Structured patient-clinician communication has a uniform effect on quality of life and treatment satisfaction, but on unmet needs for care and symptom levels its effect differs between mental healthcare settings.

Objective: To determine the distinctions between the client-keyworker relationship and the client-vocational worker relationship by assessing their impact on clinical outcomes and exploring the associations between the two., Methods: As part of an international randomised controlled trial of supported employment (n = 312), client-keyworker relationship and client-vocational worker relationship were each tested against clinical and social functioning 6 months later. Associations between the two relationships over time were explored., Results: Client-keyworker relationship predicted quality of life, while client-vocational worker relationship, as rated by the client, did not predict any clinical or social functioning outcomes. Vocational worker-rated relationship predicted reduced depression. The client-keyworker and client-vocational worker relationships were correlated, but this did not change over time., Conclusion: The impact of the client-vocational worker is likely to be on the shared task of finding employment, rather than on clinical and social functioning. Good client-vocational worker relationships do not detract from client-keyworker relationships.

Background: Although the effectiveness of individual placement and support (IPS) has been well established, little is known about clients' perceptions of the model compared to usual vocational rehabilitation, nor about their experiences of searching for and returning to work with this kind of support. This qualitative study aimed to explore clients' views of the difficulties of obtaining and maintaining employment, their experiences of the support received from their IPS or Vocational Service workers and the perceived impact of work on clients' lives., Method: Semi-structured interviews were conducted with 48 people with psychotic disorders participating in a six-centre international randomised controlled trial of IPS compared to usual vocational rehabilitation. To assess their experiences of the services and the perceived effects of working, two IPS and two Vocational Service clients at each centre who had found work during the study period were interviewed, along with two IPS and two Vocational Service clients at each centre who had not., Results: IPS clients reported having received more help seeking and maintaining employment, whereas Vocational Service clients reported having received more help in finding sheltered employment or placements. Clients who had worked associated this with financial stability, improved social lives, increased self-esteem, integration into society and amelioration of their symptoms, as well as reduced feelings of boredom and isolation, but also reported increased levels of stress. IPS clients as well as Vocational Service ones reported not receiving enough follow-up support, despite this being proposed as a key feature of the model., Conclusion: Findings from the in-depth interviews reflect differences in service models that have also been tested quantitatively but further work in disaggregating the IPS model and assessing the impact of each component would be valuable.

Background: Mental health interventions should demonstrate an effect on patients' functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment., Methods: Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition., Results: At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect., Conclusions: Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions.