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Comment & Response
December 26, 2019

Limited Conclusions Can Be Reached From Danish Randomized Clinical Trial of Supported Employment—Reply

Author Affiliations
  • 1Mental Health Centre Copenhagen, University of Copenhagen, Copenhagen, Denmark
  • 2Research Unit, Mental Health Centre Copenhagen, Copenhagen, Denmark
JAMA Psychiatry. 2020;77(3):327-328. doi:10.1001/jamapsychiatry.2019.4180

In Reply We thank Mueser and McGurk for the interest in this Danish randomized clinical trial investigating the effects of individual placement and support (IPS) and IPS supplemented with cognitive remediation and social skills training among 720 participants with severe mental illness.1

First, the authors state that the rates of competitive employment are low compared with previous IPS trials. This is correct, but the primary aim in our trial was competitive employment and education, which cannot be directly compared with trials exclusively having employment as a primary aim. We consider that 38% in competitive employment is a success because an additional 31% enrolled in education. It is obvious that the employment rates would have been higher if we had excluded all participants who had an aim of education at baseline. Second, the authors raise a critique of the rates of noncompetitive work. In Denmark and other Scandinavian countries, companies usually recruit people who receive social benefits by offering a period of unpaid internship and then afterward competitive employment. This is a culture that has been promoted by the Danish welfare system for decades, and it was not possible to completely avoid. The same tendency was seen in the Swedish IPS trials.2 However, the employment specialists had a very strict focus on minimizing the duration of internships and in accordance with the IPS principles. Third, the average time to first employment in our trial also includes participants who did not obtain employment. They were all rated for 548 days, which was the number of days from baseline to the 18-month follow-up. The average time to competitive employment among participants who obtained at least 1 job was 210 days for the IPS group and 232 days for the group of IPS supplemented with cognitive remediation and social skills training. Fourth, the choice of changing the computer software from COGPACK to Computerized Interactive Remediation of Cognition—a Training for Schizophrenia (CIRCUITS), Danish version, was based on thorough testing. The conclusion of this testing was that CIRCUITS would be more appealing to the young population in our trial. Because CIRCUITS was newly developed, it obviously had less empirical support than COGPACK. Fifth, it is a misunderstanding that 6 of the 12 sessions in the Thinking Skills for Work program were replaced with social skills training. The 6 sessions were a supplement that took place after the participants had finished Thinking Skills for Work.3 Sixth, it is correct that participants had less individual sessions with the cognitive specialist compared with the original Thinking Skills for Work manual, but it was possible for the participants to receive individualized counseling both from the psychologist and the employment specialists who were cotherapists. In addition, we believe that the trial answered several important questions. We demonstrated that IPS can be implemented and be effective in a Scandinavian welfare model and that support for education can be included and work along with the IPS principles. However, we cannot draw firm conclusions on the benefits of augmenting IPS with cognitive remediation. We can conclude that it should not be implemented in the form used in this trial. Effects may be found among participants who are motivated and who do not respond to IPS after 18 months of intervention, as it was demonstrated in the trial by McGurk et al.4

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