Introduction

Young adults experiencing mental health problems, in combination with a lack of opportunities to participate in community life as students and employees, are in a position that may include an increased risk for long-term marginalization and a need for continuing care as adults [27, 53]. Mental health problems among young adults have also been reported as one of the most frequently cited reasons for not completing studies [47] and several studies have shown that young people with mental illness are less educated than peers of the same age, which puts them in a more vulnerable position in relation to the increased demands of the labor market [12, 57]. Other studies show that for young adults with mental illness who dropped out of school, more than half wanted to return in order to develop skills and improve their job status, as well as to find opportunities for personal growth [14, 34].

Employment and education are developmentally relevant pursuits for young adults, and the hopefulness that comes with opportunities to work towards a career and life as a participating community member have been described as essential elements of the recovery process [68]. Individual Placement and Support (IPS) is a specific vocational program of supported employment (SE) targeted to individuals with psychiatric disabilities, and has a large body of empirical evidence for its effectiveness [6, 10, 33, 41]. Controlled studies have consistently demonstrated significant gains in employment, when compared with traditional vocational rehabilitation services that emphasize skill training, sometimes referred to as the “train-then-place” model [10, 39].

However, recent research has suggested that the positive outcomes associated with IPS may primarily lead to short term and low status employment and that these individuals must become eligible for higher level positions with the potential for advancement [39, 50]. They suggest that the aims of these interventions shift from low paying and short-term jobs, to ones with higher pay, more security, more mobility and sustainable careers. Many researchers suggest that SE models may be most effective therefore when linked to services that support young adults with educational goals, since educational achievements can contribute to more sustainable and higher status employment [39, 50].

Supported education (SEd) is an intervention that supports functioning, success and satisfaction in academic environments. SEd is defined as the provision of individualized, practical support to assist people with psychiatric impairments to achieve their educational goals and has been used successfully to assist them to complete post-secondary education [61]. Despite these positive indications, SEd does not currently have the evidence base that might lead to more widespread dissemination and replication. The relationship between educational and vocational supports is also one that challenges researchers to develop knowledge of long term supports to a participatory and independent life as an adult.

The aim of this study was to describe the state of current research regarding Supported education services for individuals with mental health problems, with a particular focus on studies that address both educational and vocational goals. The following research questions were explored:

How are Supported education services described and delivered and in what way are they integrated with employment-oriented supports?

What are the specific types of needs young adults experience and what outcomes do the services describe and attempt to measure?

What are the essential components of Supported education that are described in the literature?

Method

This review has been inspired by the methodology of scoping studies [2, 35], and the initial stages were therefore guided by the Joanna Briggs Institute Reviewer’s manual [55] This enabled us to capture a broad picture of the SEd research rather than being guided by a highly focused question or specific research designs which is required when conducting a systematic review (e.g. [21, 54]). However, while scoping reviews are most often limited to collating and summarizing the data collected from included studies [35], this review includes a more comprehensive analysis of the collected data (cf. [21, 54]), a strategy that reflects our ambition to achieve broad as well as in-depth knowledge of the current state of research.

Search Strategies

In line with the ambition of a broad scope, we searched for studies of SEd services designed for individuals with mental health problems; i.e. studies which provided empirical or descriptive presentations of SEd, focused on individuals (age 16 or older) with mental health problems, who studied or had the goal of studying, as well as studies which included outcome variables and experiences related to educational needs and challenges.

We used various terms (MeSH terms when applicable) relating to mental health problems, such as mentally ill persons, mental disorders, severe mental health problems, psychiatric disabilities, serious mental illness, mental health problems. These were combined with terms concerning education, such as education special/education; education, education special/methods, mainstreaming education/special methods, supported education, supportive education.

Additional inclusion criteria were articles written in English and published in peer-reviewed journals within the time frame January 2000–July 2020. Exclusion criteria were formulated as SEd for other target groups, such as people with substance abuse disorder, intellectual disabilities and/or autism.

Databases used were PubMed, Academic Search Elite, Cinahl, PsychInfo, SocINDEX, ERIC, Scopus, and Cochrane library.

Selection of Studies

The selection of studies followed these steps: (1) literature search through databases, (2) removing duplicates (3) initial screening of title and abstracts (4) articles that at least one of the authors considered were relevant based on the abstract reviewed in full-text (5) three of the authors worked independently to determine which full-text articles met inclusion- and exclusion criteria, using a predetermined form for support in assessing relevance. References in the included articles were checked for any additional studies relevant for the review. The authors then compared their inclusion-list of full-text articles and these were discussed in order to develop consensus on final inclusion. Since this was a search for a broad scope of SEd-interventions, including studies with varied designs and research methodologies (many of them not described in detail), a structured assessment of study quality was not performed [54].

A flow diagram is provided in Fig. 1. Included publications are marked with an asterisk (*) in the reference list. A summary table of studied included are presented as an appendix (Table 3).

Fig. 1
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Flow diagram of search and selection process

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Data extraction and analysis

A data extraction form was developed in order to capture detailed information relevant for the purpose of this study. Three of the authors independently read each included article and entered data into an excel file. The data extraction process was aligned with the aim and research questions, and utilized the following categories: descriptive data (author, year of publication, study location, aim of the study, study design, participant population), needs or challenges related to educational support described, outcome measures in terms of education, employment, personal recovery, and experiences from users of SEd, discriptions of SEd-models (adaptations of SEd, and integrated examples of SE and SEd) and discriptions pf essential components of SEd.

Background information including year of publication, study design/research methods, geographical location and professional background of the researchers involved, was examined using a simple descriptive quantitative analysis.

Within each of the categories corresponding to the research questions, a directed content analysis was conducted in order to identify, analyze and interpret patterns of meaning [28]. Data relevant for the content analysis was compiled in separate documents, corresponding to the research questions. This procedure helped to record and summarize the data from all included articles. After having read these documents several times, three of the authors worked independently with the analysis by coding the material. Consensus among the authors, regarding the results to be reported, was progressively reached through discussions utilizing an iterative process. The results are presented as four categories corresponding to the research questions presented in this study.

Results

A total of 56 articles (28 articles 2000–2009 and 28 articles 2010–2020) were identified as relevant (see Table 3). The included studies had varying designs, reporting styles and research methodologies (program evaluations, descriptions of SEd programs, litterature reviews and surveys). The target group in the various studies included individuals with all types of psychiatric disabilities/mental health problems, e.g. anxiety and affective disorders, schizophrenia, bipolar disorders. Most of the studies were completed in the United States (39), the remaining studies in the United Kingdom (2), Australia (6), Israel (3), Canada (2), India (2), Sweden (1) and one collaborative project between the United States and Netherlands. The included articles represented the fields of health care, social care and rehabilitation and the researchers involved in the studies primarily represented psychology, social work, occupational therapy and psychiatry.

The review allowed us to identify some general tendencies in the focus of publications. Many of the articles from the first 10 years (2000–2010) described SEd-models, and evaluations of these services. The following years of the review (2010–2020) consisted of many articles evaluating and/or describing adaptations, the majority of these focused on the integration of SEd into IPS (21/28). However, the tendency to integrate educational goals in vocational models, in order to meet the complex needs of young adults, had already begun during the first period where some researchers had started to question the long-term sustainability of employment achievements [50].

The qualitative analysis of results will be presented in four categories. The first, Needs and challenges in an educational context, describes the individual and contextual aspects of the need for support, including societal opportunities and barriers. The second category, Measuring outcomes in a real-world context, describes the results regarding outcomes that are suggested in the literature. The third category, Evolving models—implementation and adaptation, describes the models represented in the review and the variation in these, as they were implemented for different populations in diverse organizational and community contexts. The final category, Essential educational components in supporting a career-oriented recovery, focuses more specifically on the essential principles and components which were suggested in this review of the literature.

Needs and challenges in an educational context

This category describes the needs and challenges related to studying, which as described in the literature, were often contextual as well as individual. Several of the included articles describe a need for increased knowledge among staff who meet students with mental health problems (e.g. [63]), for example, the specific challenges and difficulties that can arise in a study context. It also appears that student services, while used to working with different forms of disability, often express a lack of knowledge about the challenges, needs, and opportunities for academic adaptations that would benefit this target group [5, 13].

Several of the studies suggested a need to work with attitudes regarding mental health challenges for students, since among educational actors, there is an impression that higher education may not be an achievable goal for some of these individuals (e.g. [5, 36, 39]). Students described a variety of challenges and needs, such as a lack of knowledge about the services available at universities [13], or that they felt insecure in discussing their mental health challenges and seeking available supports (e.g. [13, 19]). Individuals with mental health problems often have previous experiences of failures related to studies, and describe barriers which are sometimes linked to the illness itself, such as symptoms and issues with treatments/medicine (e.g. [19, 30, 34, 44, 63]). Other barriers to studies include; poor academic self-confidence, a lack of academic abilities and challenges in coping with stress [4, 18, 19, 46, 63, 65] a lack of social skills [19, 46, 63, 65, 69], stigma [4, 34], and economic problems [39, 44, 63]. There seems therefore to be a clear necessity for support and guidance from several different stakeholders with varied responsibilities to collaborate in supporting these needs (e.g. [18, 36]). An additional challenge described was that of identifying ongoing funding for services [25, 38].

In addition to the expected psychosocial needs that may be attributed to the individual experience of illness and impairment, stigma, social isolation and the interruption of life cycle appropriate achievements, a surprising number of needs were identified which were related to what might be considered a societal inability to meet the educational needs of individuals experiencing mental health problems (compare [36]). The combination of the individual impairments and the lack of readiness on the part of the community-based educational systems to meet these needs, were in turn often connected to interruptions in establishing a long-term participation in the work market and a risk for marginalization (Table 1).

Table 1 Needs and challenges in a societal context
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Measuring Outcomes in a Real-World Context

This category includes the outcomes described in the reviewed literature and offer a broad perspective on the types of outcomes associated with supported educational services in studies that evaluated these programs. Twenty-three of 56 articles measured outcomes in relation to a specifically defined SEd intervention, 10 studies 2000–2009 and 13 studies 2010–2020.

The identified studies were primarily uncontrolled evaluations. Five studies employed an experimental design [22, 23, 51, 52, 62]. Two of these evaluated what was primarily a six-week occupational therapy-based SEd program which was focused on skills training and providing individual support in preparation for future studies [22, 23] and the results supported the effectiveness of the program. The remaining three studies evaluated adapted models for younger individuals with a recent onset of psychosis. The Nuechterlein et al. [51] study was still on going (initial RCT) at the time of publication, but the authors reported promising results indicating that IPS principles can be successfully extended to integrate SEd and SE within one treatment program. A recently published study by Nuechterlein et al. [52] evaluated a program where IPS was adapted to meet the needs of individuals whose goals might involve either employment or schooling, by adapting SEd to meet the standards of IPS fidelity. The authors found that the combination clearly supported the efficacy of an enhanced intervention focused on recovery of participants in normative work and school settings, in the initial phase of schizophrenia. Rosenheck et al. [62] used data from the RAISE-ETP which compared usual community care to a comprehensive care program (Navigate), that included a supported employment and education component (SEE), based on principles of the IPS-model. Results showed that persons recovering from FEP (First Episode Psychosis) who received comprehensive, coordinated care, received far more SEE services and showed significantly greater increases in work or school participation over two-years compared to those who received usual community care. Over half of RAISE-ETP patients who had 3 or more SEE contacts, first began these contacts 6 months or more after entering the program. This study suggests that many eventual participants in SEE were not initially interested in employment or school, but developed such motivation over 6 months or longer.

Even uncontrolled evaluations showed promising SEd outcomes and suggest that SEd promotes positive possibilities for begining and completing school, for personal development, to achieve academic goals, for seeking paid employment and to promote recovery (e.g. [3, 24, 31, 66, 67, 72]).

There are additionally a number of uncontrolled studies that suggest the potential of integrated models, those that include supports to both school and employment, to produce benefits for young people with early psychosis [17, 29, 30, 32, 58, 60, 63].

Previous reviews have shown the scientific foundation is insufficient to assess the effects of supported education and that further research is recommended (e.g. [11, 49, 59]).

The various outcomes described have been charted and presented in two descriptive categories in the following table in order to illustrate their range and character.

As seen in Table 2, while the literature includes many of the concrete outcomes related to educational and vocational goals, many of the studies describe and discuss longer term outcomes, and reinforce the recovery-focused goals expressed for many of these services.

Table 2 Summary of outcomes
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Evolving models: implementation and adaptation

This category describes the results related to the descriptions of Supported education models as they have developed and been implemented throughout the years included in the review. These suggest a process of adaptation as opposed to fidelity to any one particular model. The literature in fact, describes a wide variation of models, including the Self-contained Classroom model (e.g. [7, 22, 31]), the On-site model (e.g. [47]), Mobile support (e.g. [40]), the Clubhouse model (e.g. [47]), the Free-standing model (e.g. [5, 47, 63]), and these often in combination with each other (e.g. [18, 24, 43]) in the same program. These services were based in a variety of settings (community mental health centers, college/universities, clubhouses), either in coordination with other services or as a free-standing activity.

In addition to these variations, a number of articles described adaptations of the model including: integrating SEd in IPS services in order to facilitate educational and vocational goals (e.g. [17, 29, 30, 32, 39, 49, 51, 57, 63]). SEd programs were also embedded within the research curriculum of a graduate occupational therapy program provided at a college, with master students participating as mentors [66, 67], and offered through ongoing peer support for service users [15, 17, 60].

Based on the variation in models presented in the literature and the manner in which these were described, the results suggest what might be seen as a process of evolving services, which are influenced as much by local conditions as by one particular Supported education model. Many of these adaptations seemed to develop in relation to the local resources, the population funders were prioritizing, needs in the local community, participating stakeholders in the local community and the variety/availability of collaboration partners (e.g. [3, 9, 16, 36, 40, 46, 64]). More recent trends in the literature suggest that while traditional SEd models have naturally included young adults, integrated models which are based on IPS principles, have only recently begun to prioritize this target group. These include those with various types of mental health problems, but especially those with FEP as reflected in a number of recent studies (e.g. [17, 29, 52, 57, 62, 63]).

Essential Educational Components in Supporting a Career-Oriented Recovery

This final category describes the components that emerged in the literature reviewed and presents those that were seen as common for SEd services, regardless of which model or adapted model the particular study investigated/presented.

A Person-Centered Approach

Regardless of the nature of the support, there is a consistent expression that the individual’s wishes, needs, and preferences should be the starting point for the services, i.e. person-centered services. SEd specialists support the individual to set goals based on resources and needs, matching requirements based on individual capacity, following up, encouraging, motivating, informing, orienting and coordinating support from different actors based on emerging needs [18, 25, 45, 50, 67, 70]. Individualized support that follows the student over time is described as a basic component in the services provided (e.g. [8, 18, 25, 36, 39, 42, 51, 60]). The support is most often described as provided by an SEd-specialist, although in some cases the educational focus may be part of a broader responsibility area [17, 39]. The role however, builds on knowledge about the needs of the individual, community resources and expectations as well as factors related to success in educational environments.

Collaborate/Integrate SEd with School, Care and Other Important Actors

In the literature, the SEd specialist role, apart from a relationship-based support, is described as a coordinating function in order to create the conditions for collaboration with other important actors. The literature does not describe as clearly as with IPS, that SEd should be integrated into the psychiatric team, but it is clear that close collaboration with psychiatry is described as a success factor (e.g. [23, 45]). In fact, the studies which occurred in collaboration with the Raise study and focus on FEP, are part of a clinical intervention package that includes medication management, family psychoeducation and Individual resilience training along with SEE [29, 30, 51, 62]. Integration or close collaboration of SEd with educational institutions is also a key ingredient in the service provided to support the individual to achieve his/her goals related to education, and to support the transition from patient to student (e.g. [7, 18, 25, 32, 40, 51, 60, 63, 71]).

The SEd-specialist has the task of building a network around the individual focusing on health and success in the study environment. The composition of the network depends on individual needs, for example, with teachers, psychiatric care, peer support services, student health, or IPS specialists. Here, the SEd service also has a responsibility to convey knowledge about SEd and to educate actors involved to the target group’s needs related to studies [5, 14, 18, 36, 39, 48]. The literature also addresses funding as a major problem, and counseling about the individual’s economic conditions is described as a critical factor (e.g. [14, 18, 36, 39, 50, 64]).

Individual, Social and Academic Adjustments

Although support for people with disabilities is offered by most educational actors, the literature suggests that these services are not always actively utilized by individuals with mental health problems. Barriers described include, a lack of information about what rights they have as students, what services are available, as well as a fear of revealing their difficulties to others. As described in the studies, there is a continuing experience confirming that there is a lack of knowledge as to the particular resources and needs of this target group [4, 13, 26, 32, 34]. Advocating for adaptations in the academic environment, based on the individual’s needs, is described in the literature as an important part of an SEd service (e.g. [18, 34, 39, 60]). This includes informing educational actors about the potential for academic success for the individual, being a support in negotiating with the institution/teacher about what adjustments should be made, as well as training staff at the school on the challenges and needs of people with mental health problems. Accommodations can include access to technical aids, help with notes, extending deadlines for study assignments, and the opportunity to receive support and accommodations when taking exams.

Develop, Support and Use Existing Resources

As mentioned above, the literature describes a wide variety of models often in response to diverse environments. Regardless of where the SEd service is based, the results suggest the importance of the individual receiving support in using the existing resources that the educational institution offers. Examples include the use of the school’s existing teachers in special courses aimed at persons with mental health problems [31], guidance from staff at the institution [26, 39], developing support systems at the university level in cooperation with SEd programs, for example extra support after an illness-related absence [69], and supporting the person to make use of the services available to all students (library services, plug rooms, computer rooms, etc.) [5]. Using the existing resources of the school is also seen as contributing to a recovery perspective, allowing participants to develop and integrate in a natural environment [18, 24, 36].

Develop Individual, Social and Academic Skills

The international literature about SEd often describes preparatory courses as part of the SEd program (e.g. [7, 22, 25, 46]) in order to prepare the participants for regular studies. These can be offered in for example, classrooms at universities, in a clubhouse or in social psychiatric programs, and are often conducted by SEd specialists as well as educators. These courses are often described as recovery-oriented, as the aim is for the individual to have the opportunity to learn more about themselves and their ability, how the education system works (apply, orientation on campus), to start thinking about life and study goals and to develop motivation to continue in regular studies. Examples of content include stress management, coping strategies for dealing with symptoms or other difficulties, e.g. to be in a group or socialize, basic academic skills (e.g. writing, counting, computer use) as well as organization, structure and scheduling in order to study [4, 19, 25, 26, 39, 42, 44, 51]). The support is most often provided to groups, but can continue as an individual support, when beginning with regular studies.

In addition, the literature describes the issue of “disclosure”, which may require i.e. counseling and support to think about and decide on how much and who to tell about their mental health problems [3, 14, 26, 34, 39, 51]. If the individual decides not to disclose, the SEd Specialist can instead be a support in informing and coordinating with other relevant actors in the educational context, and then with a more general aim of increasing knowledge of mental health needs. Consideration of disclosure in relation to social integrity was considered an essential factor in educational supports, as it could lead to individual adaptations essential to academic success [19].

Focus on the Physical and Psychosocial Environment

The issue of life as a student was described as including finding other students to share interests with, working in groups, and daring to make and establish new contacts, all of which can be a daunting challenge [19]. The literature describes the importance of a supportive and positive environment in relation to studies as well [13, 18, 36, 43]. Several articles describe Peer support and mentors as important (e.g. [8, 15, 17, 44]), but also involving family and friends as support during the study period if possible [22, 34]. The importance of attending to sociocultural factors and belief systems as barriers, and the particular importance of family for young adults in many cultures, was emphasized in a study completed in India [4].

Promote career development

Much of the included literature suggests a need to consider work and studies as equally important for young adults. Career development is in this context a term that is often applied [8, 9, 17, 18, 26, 36, 45, 60]. The concept includes practical approaches to planning on a longer term basis and often reflects a recovery-oriented philosophy that focuses on hopefulness towards the future [14, 20, 34, 42, 70]. A career orientation addresses the conditions for the individual as they attempt to identify and explore new and valued roles and to develop a longer term focus on attaining employment when their skills and readiness have developed. The literature suggests that a focus on career development can be strengthened by integrating SEd into an IPS service and thus facilitating the individual´s opportunity to be flexible in exploring and choosing a direction, depending on emerging needs and self-defined goals (e.g. [18, 20, 39, 40, 49,50,51, 57, 60, 63, 67]).

While the specific SEd models that have been presented in the literature offer structures for meeting the needs of individuals experiencing serious mental illness, the variety of individuals requiring and utilizing these services at the present time, and the resources available in differing contexts, suggest the need for programs that develop methods based on the types of generalizable components, as presented in Fig. 2. At the same time, some recent studies suggest a need for more research describing the particular factors and components which comprise SEd in order to develop the evidence base for this intervention [8, 9, 20, 59, 66].

Fig. 2
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Essential components which emerged from the literature

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Figure 2 is presented as a summary of the essential components described above.

Discussion

The aim of this study was to describe the state of current research regarding Supported education services for individuals with mental health problems, with a particular focus on studies that address both educational and vocational goals. The results suggest that the focus in the literature has primarily been on adapting, implementing and, measuring outcomes for integrated models, most often based on IPS principles. While SEd has traditionally and appropriately attempted to serve the needs of young adults, the introduction of this focus in IPS models has contributed to a shift in perspective to long-term needs and goals, one that describes a dynamic career orientation. While promising results have been demonstrated with integrated models, the literature suggests a further need for defining these models and adapting their components in order to reflect the specific and developmental needs that young adults experience as they pursue a career while struggling with mental health problems.

Towards an Integrated Framework

Earlier attempts to implement SEd were based on a number of models, which while exceedingly important in a developmental phase of this intervention, seem to have been replaced by a number of adapted and emerging models. The diversity of models that were reviewed suggest both challenges and opportunities for the future development of Supported education services. They demonstrate broad flexibility and capacity for adaptation, while still considering the basic principles upon which the intervention is based. Recent literature points primarily however to a continued effort to develop integrated services building on IPS principles, and often focused on young adults [11, 29, 51, 57]. The development of more concretely defined, and in some cases manualized models of integrated services, has been studied in response to the needs of those experiencing FEP [30, 52, 62]. This attention to the needs of young adults may be seen as contributing to a more holistic focus on both vocational and educational goals, since there are specific challenges, contacts and context-related supports that may vary from those experienced by traditional IPS services.

The literature suggests that there are a number of environmental and process-based factors that may require further adaptations of the IPS principles [8, 9, 18, 30]. These findings have additional implications for implementing Supported education services in varied social welfare- and health care systems. A lack of clarity in models and appropriate outcomes may lead to a lack of clarity in organizational responsibility [36] and expectations of rapid employment outcomes, as opposed to the longer term outcomes which characterize SEd services that routinely support such natural educational progressions.

Towards a career-oriented recovery

The psychosocial needs and challenges described in the literature are familiar to all working with rehabilitation and recovery models, and the majority of existing educational and vocational models address these in some way (e.g. [18, 43, 44, 63, 71]). However, the societal challenges that were discussed in the literature, are quite specific to the educational life contexts, and therefore worthy of further study [38, 50, 74]. This review suggests that societal challenges influence the individual´s life and career trajectory in a somewhat broader and long-term manner than factors related exclusively to employment. These may contribute to a long-term marginalization that goes well beyond the experience of unemployment as an immediate challenge. The outcomes described support a long-term career-orientation as well, one that might be examined from a life cycle perspective which highlights challenges related to various phases of life [56].

When considering long-term life-cycle related needs, translating and adapting IPS principles to include educational goals is described as a promising path to pursue. Many programs and researchers suggest that supporting the educational goals of SE/IPS participants is a natural outgrowth of providing these services and working from a person-centered perspective [18, 45]. In this manner, educational pursuits are considered a “pathway to work” but the integration of educational and vocational goals is also described as an age-appropriate offering, reflecting the changing priorities of these younger clients as they pursue their goals of establishing themselves as adults.

The term career development, which is often used in these contexts [1, 8, 9, 18, 36], includes concrete and continuous planning strategies which support the individual to find valued roles and a direction in life based on their interests and abilities as these evolve over time. The results suggest that career development goals may be supported by integrating SEd into an IPS service and that the diversity of outcomes that these integrated programs may produce, might be measured in relation to these long-term goals.

Integrating the educational context

The majority of recent studies address both vocational and educational outcomes and describe a number of essential components related to supporting students in specifically educational contexts [3, 8, 9, 16]. Some examples include a focus on establishing connections with available educational actors and resources. Colleges and Universities are a given, but other educational organizations providing e.g. adult education, high school equivalency, vocational training, also appear to be central collaborators. These contacts with key collaborators in educational settings also point to the importance of student health services, school social workers, guidance counselors, and other partners meeting students in vulnerable life transitions. While these additional actors in the educational context have a wealth of knowledge and even access to specific resources, students describe the “pathway” to these types of supports as often challenging, sometimes bureaucratic and often stigmatizing (e.g. [5, 36]). Further research is suggested into developing mental health literacy with existing educational resources who might additionally offer accommodations and supports not just for identified clients but to all students dealing with mental health problems.

Many studies describe the importance of mental health support through contact with traditional mental health services [29, 51] including community mental health centers, clubhouses and other types of rehabilitation-oriented supports that may be or could be actively supporting educational goals (e.g. [25, 40]). Studies additionally point to stress related to the demands of student life, social pressures, difficulties in staying motivated, and the issue of disclosure in seeking services and supports when attempting to establish themselves in the student role (e.g. [34, 39]). Attention to the contextual aspects of the student experience, including physical locations for studying, supports in developing routines and social structures, seems specific to student life, as opposed to worker roles which are often quite structured.

Based on the results discussed here, there are a number of recommendations for research and practice. The continued focus on developing integrated models as they most often address the needs of young adults is undoubtedly positive, but brings with it a number of challenges. These include attempting to clearly define the components and character of the educational supports as they are integrated into IPS services, in order to provide the most relevant supports, but also to allow for outcome studies that can contribute to the evidence base for educational supports [8, 9, 16, 18]. This is especially important since outcomes associated with integrated models seem to present an additional layer of complexity in terms of long-term benefits, in comparison with those of Supported employment models which can demonstrate immediate results. While a career orientation is extremely relevant from a recovery orientation for young adults with mental health problems, it can challenge issues of responsibility in public sector funding which are often short term. The focus on specific factors related to educational supports can also contribute to the relevance of IPS-based integrated models for these young adults. The review therefore suggests a need to look at work and studies as equally important and that knowledge gained from supported education services can contribute to the further development of integrated models for young adults.