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Schizophrenia exacts a heavy toll on a person's capacity to work, and a variety of vocational rehabilitation interventions have been developed over the past few decades to enhance the vocational capacities of persons with this disorder. The research literature on outcomes of vocational rehabilitation during the era of deinstitutionalization for persons with schizophrenia is reviewed. Most vocational rehabilitation programs have a positive influence on work-related activities, but most have failed to show substantial and enduring impacts on independent, competitive employment. Recent advances in supported employment suggest that vocational rehabilitation offers greater promise than do transitional and sheltered employment approaches. Vocational rehabilitation intervention may also exert positive influences on such clinical outcomes as medication compliance, symptom reduction, and relapse. Vocational rehabilitation has assumed increasing importance as part of the array of services available for persons with schizophrenia. Work not only provides financial remuneration but is a normalizing experience, allowing individuals to participate in society, and may promote self-esteem and quality of life. Furthermore, the vast majority of persons with severe mental illnesses identify paid employment as one of their goals (Rogers et al. 1991). Despite this, rates of competitive employment for persons with schizophrenia remain dismally low -- below 25 percent (Anthony et al. 1978). Many different types of vocational rehabilitation programs have been developed and implemented. These are classified as follows (Bond and Boyer 1988): (1) hospital-based programs; (2) sheltered work; (3) assertive case management; (4) psychosocial rehabilitation, including prevocational training, transitional employment, and volunteer placements; (5) supported employment; and (6) counseling and education. The outcomes targeted by vocational rehabilitation interventions are divided into two broad categories. Vocational outcomes include full-time competitive employment, acquisition of job-related skills, acquisition of any job (paid or volunteer), percentage of time in paid employment (full-time or part-time, competitive or sheltered), total job earnings, level of job (unskilled, skilled, etc.), job satisfaction, and job performance. Vocational rehabilitation also may enhance outcomes other than work. These therapeutic outcomes include treatment compliance and symptom reduction, functional status in other areas (activities of daily living, maintenance of living situation, etc.), self-esteem, and subjective quality of life. This review addresses the following questions: 1. Do vocational rehabilitation interventions enhance the vocational outcomes of persons with schizophrenia? 2. Do vocational rehabilitation interventions enhance outcomes other than vocational functioning? 3. Are there differences in the effectiveness of the various types of vocational rehabilitation interventions for persons with schizophrenia? 4. What patient characteristics predict response to vocational rehabilitation? As best as can be determined, all the studies reviewed examine these questions in the context of ongoing clinical treatment. Therefore, these questions are posed with the assumption that patients are receiving adequate clinical care, including antipsychotic medications. Methods This review focuses on the research on vocational rehabilitation interventions in the era of deinstitutionalization; research on vocational rehabilitation for patients who were living in long-term hospitals before deinstitutionalization has questionable relevance to today's community-based care. The computerized bibliographic data bases, PSYCLIT and MEDLINE, were searched for 1966 to 1993. The key words used for these searches were vocational rehabilitation, sheltered workshops, employment or employment supported, and rehabilitation counseling. A total of 497 articles were identified. This search yielded two excellent reviews (Bond 1986, 1992) that met the review criteria of Beaman (1991). However, neither review focused exclusively on studies of persons with schizophrenia. This reflects the fact that in vocational rehabilitation research, psychiatric diagnoses often are not specified, either because they are not available to the researchers or are viewed as irrelevant. These previous reviews cover the broader category of "psychiatrically disabled" or "severe or chronic mentally ill." To deal with this problem, the primary studies covered by the reviews were examined to obtain information about the number and proportion of the subjects in the studies who had a diagnosis of schizophrenia and any information about the relationship of diagnosis to intervention impacts. This allowed an estimation of whether conclusions drawn in the reviews about the more heterogeneous category of persons with psychiatric disabilities need to be modified when restricted only to persons with schizophrenia. Additional primary studies identified through the search were included in this review if they met the following criteria: (1) a design that at a minimum includes some comparison group -- either a control or comparison condition or the same intervention offered to patients with schizophrenia compared with some other diagnostic group; (2) explicit inclusion of patients diagnosed with schizophrenia and at a minimum documentation of the proportion of the study sample that had this diagnosis; (3) evaluation of an explicit vocational rehabilitation intervention; and (4) systematic evaluation of defined and operationalized outcomes. For the review questions posed, this article summarizes the findings from Bond's previous reviews, reexamines the primary studies that he reviewed for findings specific to persons with schizophrenia, and adds results from studies that have been published or are "in the pipeline" since his 1992 review.
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