Advertisement

Working with a Severe Mental Illness: Estimating the Causal Effects of Employment on Mental Health Status and Total Mental Health Costs

Abstract

Employment is an important goal for persons who have a severe mental illness (SMI). The current literature finds some evidence for a positive relationship between employment and measures of mental health (MH) status, however study design issues have prevented a causal interpretation. This study aims to measure the causal effect of employment on MH status and total MH costs for persons with SMI. In a quasi-experimental prospective design, self-reported data measured at baseline, 6-months, and 12-months, on MH status and employment are paired with Public Mental Health System (PMHS) claims data. The study population (N = 5162) is composed of persons with a SMI who received PMHS services for a year or more. Outcome variables are MH status symptom scores from the BASIS-24 instrument and total MH costs. The estimation method is full information maximum likelihood, which allows for tests of employment endogeneity. Outcomes with an insignificant test of endogeneity are estimated using tobit or ordinary least square (OLS). Employment has modest but meaningful effects on MH status (including overall MH status, functioning, and relationships) and reduces total mental health costs on average by $538 in a 6-month period. Tests of endogeneity were largely insignificant, except for the depression score that tested marginally statistically significant. Interaction terms between baseline MH scores and employment indicated larger employment effects for individuals with worse baseline scores. This study demonstrates the non-vocational benefits of employment for individuals with SMI. Results have high generalizability and should be of interest to federal and state governments in setting appropriate disability policy and funding vocational programs. From a methodological perspective, future research should still be concerned with potential endogeneity problems, especially if employment status and MH outcomes are simultaneously measured and/or baseline measures of MH are not adequately controlled for future research should continue to examine the multi-dimensional nature of MH status and costs. Our analyses also demonstrate the practical use of a state-wide outcomes measurement program in assessing the factors that influence the recovery trajectories of individuals with SMI.

This is a preview of subscription content, log in to check access.

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Fig. 1

References

  1. Andrés, A. R. (2004). Determinants of self-reported mental health using the British Household Panel Survey. Journal of Mental Health Policy and Economics, 7(3), 99–106.

  2. Banerjee, S., Chatterji, P., & Lahiri, K. (2017). Effects of psychiatric disorders on labor market outcomes: A latent variable approach using multiple clinical indicators. Health economics, 26(2), 184–205.

  3. Bell, M. D., & Lysaker, P. H. (1997). Clinical benefits of paid work activity in schizophrenia: 1-Year followup. Schizophrenia Bulletin, 23(2), 317–328.

  4. Bell, M. D., Lysaker, P. H., & Milstein, R. M. (1996). Clinical benefits of paid work activity in schizophrenia. Schizophrenia Bulletin, 22(1), 51–67.

  5. Blustein, D. L. (2008). The role of work in psychological health and well-being: A conceptual, historical, and public policy perspective. American Psychologist, 63(4), 228.

  6. Bond, G. R., & Drake, R. E. (2014). Making the case for IPS supported employment. Administration and Policy in Mental Health and Mental Health Services Research, 41(1), 69–73.

  7. Burke-Miller, J. K., Cook, J. A., Grey, D. D., Razzano, L. A., Blyler, C. R., Leff, H. S., et al. (2006). Demographic characteristics and employment among people with severe mental illness in a multisite study. Community Mental Health Journal, 42(2), 143–159.

  8. Burns, T., Catty, J., Becker, T., Drake, R. E., Fioritti, A., Knapp, M., et al. (2007). The effectiveness of supported employment for people with severe mental illness: A randomised controlled trial. The Lancet, 370(9593), 1146–1152.

  9. Burns, T., Catty, J., White, S., Becker, T., Koletsi, M., Fioritti, A., et al. (2008). The impact of supported employment and working on clinical and social functioning: Results of an international study of individual placement and support. Schizophrenia Bulletin, 35(5), 949–958.

  10. Bush, P. W., Drake, R. E., Xie, H., McHugo, G. J., & Haslett, W. R. (2009). The long-term impact of employment on mental health service use and costs for persons with severe mental illness. Psychiatric Services, 60(8), 1024–1031.

  11. Cameron, I. M., Cunningham, L., Crawford, J. R., Eagles, J. M., Eisen, S. V., Lawton, K., et al. (2007). Psychometric properties of the BASIS-24© (Behaviour and Symptom Identification Scale-Revised) mental health outcome measure. International Journal of Psychiatry in Clinical Practice, 11(1), 36–43.

  12. Chatterji, P., Alegria, M., Lu, M., & Takeuchi, D. (2007). Psychiatric disorders and labor market outcomes: Evidence from the National Latino and Asian American Study. Health Economics, 16(10), 1069–1090.

  13. Chatterji, P., Alegria, M., & Takeuchi, D. (2011). Psychiatric disorders and labor market outcomes: Evidence from the National Comorbidity Survey-Replication. Journal of Health Economics, 30(5), 858–868.

  14. Daumit, G. L., Anthony, C. B., Ford, D. E., Fahey, M., Skinner, E. A., Lehman, A. F., et al. (2010). Pattern of mortality in a sample of Maryland residents with severe mental illness. Psychiatry Research, 176(2–3), 242–245.

  15. Diehl, S., Douglas, D., & Honberg, R. (2014). Road to recovery: Employment and mental illness. Arlington, VA. http://www.nami.org/work.

  16. Dixon, L., Goldberg, R., Lehman, A., & McNary, S. (2001). The impact of health status on work, symptoms, and functional outcomes in severe mental illness. The Journal of Nervous and Mental Disease, 189(1), 17–23.

  17. Drake, R. E., Bond, G. R., Goldman, H. H., Hogan, M. F., & Karakus, M. (2016). Individual placement and support services boost employment for people with serious mental illnesses, but funding is lacking. Health Affairs, 35(6), 1098–1105.

  18. Duan, N. (1983). Smearing estimate: A nonparametric retransformation method. Journal of the American Statistical Association, 78(383), 605–610.

  19. Eisen, S. V., Gerena, M., Ranganathan, G., Esch, D., & Idiculla, T. (2006). Reliability and validity of the BASIS-24© mental health survey for whites, African-Americans, and Latinos. The Journal of Behavioral Health Services and Research, 33(3), 304.

  20. Eisen, S. V., Normand, S. L., Belanger, A. J., Spiro, A., & Esch, D. (2004). The revised behavior and symptom identification scale (BASIS-R): Reliability and validity. Medical Care, 42, 1230–1241.

  21. Fisher, W. H., & Rivard, J. C. (2010). The research potential of administrative data from state mental health agencies. Psychiatric Services, 61(6), 546–548.

  22. Gathergood, J. (2013). An instrumental variable approach to unemployment, psychological health and social norm effects. Health Economics, 22(6), 643–654.

  23. Hamilton, V. H., Merrigan, P., & Dufresne, É (1997). Down and out: Estimating the relationship between mental health and unemployment. Health Economics, 6(4), 397–406.

  24. Hogan, M. F. (2003). New Freedom Commission report: The president’s New Freedom Commission: Recommendations to transform mental health care in America. Psychiatric Services, 54(11), 1467–1474.

  25. Jones, D. R., Macias, C., Barreira, P. J., Fisher, W. H., Hargreaves, W. A., & Harding, C. M. (2004). Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatric Services, 55(11), 1250–1257.

  26. Kukla, M., Bond, G. R., & Xie, H. (2012). A prospective investigation of work and nonvocational outcomes in adults with severe mental illness. The Journal of Nervous and Mental Disease, 200(3), 214–222.

  27. Luciano, A., Drake, R. E., Bond, G. R., Becker, D. R., Carpenter-Song, E., Lord, S., et al. (2014). Evidence-based supported employment for people with severe mental illness: Past, current, and future research. Journal of Vocational Rehabilitation, 40(1), 1–13.

  28. Mandal, B., & Roe, B. (2008). Job loss, retirement and the mental health of older Americans. Journal of Mental Health Policy and Economics, 11, 167–176.

  29. Marwaha, S., & Johnson, S. (2004). Schizophrenia and employment. Social Psychiatry and Psychiatric Epidemiology, 39(5), 337–349.

  30. McQuilken, M., Zahniser, J. H., Novak, J., Starks, R. D., Olmos, A., & Bond, G. R. (2003). The work project survey: Consumer perspectives on work. Journal of Vocational Rehabilitation, 18(1), 59–68.

  31. Mueser, K. T., Becker, D. R., Torrey, W. C., Xie, H., Bond, G. R., Drake, R. E., & Dain, B. J. (1997). Work and nonvocational domains of functioning in persons with severe mental illness: A longitudinal analysis. The Journal of Nervous and Mental Disease, 185(7), 419–426.

  32. Mueser, K. T., Yarnold, P. R., Rosenberg, S. D., Swett Jr, C., Miles, K. M., & Hill, D. (2000). Substance use disorder in hospitalized severely mentally ill psychiatric patients: Prevalence, correlates, and subgroups. Schizophrenia Bulletin, 26(1), 179–192.

  33. Ojeda, V. D., Frank, R. G., McGuire, T. G., & Gilmer, T. P. (2010). Mental illness, nativity, gender and labor supply. Health Economics, 19(4), 396–421.

  34. Phelps, C. E. (1997). Health economics (2nd ed., pp. 16–19). Reading, MA: Addison-Wesley.

  35. Provencher, H. L., Gregg, R., Mead, S., & Mueser, K. T. (2002). The role of work in the recovery of persons with psychiatric disabilities. Psychiatric Rehabilitation Journal, 26(2), 132.

  36. Roodman, D. (2011). Fitting fully observed recursive mixed-process models with cmp. The Stata Journal, 11(2), 159–206.

  37. Salkever, D., Abrams, M., Baier, K., & Gibbons, B. (2018). Impacting entry into evidence-based supported employment: A population-based empirical analysis of a statewide public mental health program in Maryland. Administration and Policy in Mental Health and Mental Health Services Research, 45(2), 328–341.

  38. Salkever, D., Gibbons, B., & Ran, X. (2014). Do comprehensive, coordinated, recovery-oriented services alter the pattern of use of treatment services? Mental health treatment study impacts on SSDI beneficiaries’ use of inpatient, emergency, and crisis services. The Journal of Behavioral Health Services and Research, 41(4), 434–446.

  39. Salkever, D. S. (1976). The family provision of children’s health: Comments. In R. Rosett (Ed.), The role of health insurance in the health services sector (pp. 256–259). New York: National Bureau of Economic Research.

  40. Salkever, D. S., Karakus, M. C., Slade, E. P., Harding, C. M., Hough, R. L., Rosenheck, R. A., et al. (2007). Measures and predictors of community-based employment and earnings of persons with schizophrenia in a multisite study. Psychiatric Services, 58(3), 315–324.

  41. Salkever, D. S., Shinogle, J. A., & Goldman, H. (2003a). Return to work and claim duration for workers with long-term mental disabilities: Impacts of mental health coverage, fringe benefits, and disability management. Mental Health Services Research, 5(3), 173–186.

  42. Salkever, D. S., Slade, E. P., & Karakus, M. C. (2003b). Employment retention by persons with schizophrenia employed in non-assisted jobs. Journal of Rehabilitation, 69(4), 19–26.

  43. Sokal, J., Messias, E., Dickerson, F. B., Kreyenbuhl, J., Brown, C. H., Goldberg, R. W., & Dixon, L. B. (2004). Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services. The Journal of Nervous and Mental Disease, 192(6), 421–427.

  44. van der Noordt, M., IJzelenberg, H., Droomers, M., & Proper, K. I. (2014). Health effects of employment: A systematic review of prospective studies. Occupational and Environmental Medicine. https://doi.org/10.1136/oemed-2013-101891.

  45. Warner, R. (2009). Recovery from schizophrenia and the recovery model. Current Opinion in Psychiatry, 22(4), 374–380.

  46. Wooldridge, J. M. (2010). Econometric analysis of cross section and panel data. Cambridge, MA: MIT Press.

Download references

Author information

Correspondence to Brent J. Gibbons.

Ethics declarations

Conflict of interest

This study comes out of work from a Dissertation and no funding was obtained for the research herein. Authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors. This study was reviewed by the University of Maryland, Baltimore County (UMBC) IRB and was considered exempt.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gibbons, B.J., Salkever, D.S. Working with a Severe Mental Illness: Estimating the Causal Effects of Employment on Mental Health Status and Total Mental Health Costs. Adm Policy Ment Health 46, 474–487 (2019). https://doi.org/10.1007/s10488-019-00926-1

Download citation

Keywords

  • Employment
  • Employment mental health
  • Employment health
  • Mental health status
  • Mental health costs
  • Severe mental illness