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Original Investigation
April 2018

Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial

Author Affiliations
  • 1Research and Development Service, Tuscaloosa Veterans Affairs (VA) Medical Center, Tuscaloosa, Alabama
  • 2Department of Psychiatry, School of Medicine, University of Alabama, Tuscaloosa
  • 3Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut
  • 4Department of Psychiatry, VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
  • 5Health Services Research and Development, Center of Innovation for Disability and Rehabilitation Research, University of South Florida, Tampa
  • 6Department of Rehabilitation and Mental Health Counseling, University of South Florida, Tampa
  • 7Department of Psychology, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
  • 8Veterans Integrated Service Network (VISN) 1 Mental Illness Research Education and Clinical Center, Bedford, Massachusetts
  • 9Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
  • 10VISN 1 Mental Illness Research Education and Clinical Center, West Haven, Connecticut
  • 11Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, New Mexico Healthcare System, Albuquerque
  • 12Individual Placement and Support Employment Center, Rockville Institute, Westat, Rockville, Maryland
JAMA Psychiatry. 2018;75(4):316-324. doi:10.1001/jamapsychiatry.2017.4472
Key Points

Question  Is individual placement and support–supported employment better than a stepwise vocational rehabilitation program that includes transitional work in helping unemployed veterans with posttraumatic stress disorder become steady workers?

Findings  In this randomized clinical trial of 541 adults with posttraumatic stress disorder, the individual placement and support intervention resulted in 38.7% of participants achieving steady employment compared with 23.3% of participants in the transitional work group—a significant difference. In addition, individual placement and support participants earned significantly more income from competitive jobs compared with transitional work participants.

Meaning  Individual placement and support is more successful than transitional work at helping unemployed veterans with posttraumatic stress disorder obtain and sustain competitive employment.

Abstract

Importance  Posttraumatic stress disorder (PTSD) often interferes with a person’s ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income.

Objective  To determine whether individual placement and support (IPS)–supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment.

Design, Setting, and Participants  The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed.

Interventions  Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community.

Main Outcomes and Measures  A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period.

Results  A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004).

Conclusions and Relevance  This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD.

Trial Registration  clinicaltrials.gov Identifier: NCT01817712

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