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Individual Placement and Support more effective than transitional work for Veterans with PTSD

February 28, 2018

By Tristan Horrom
VA Research Communications

"The IPS Veteran participant is energized and empowered to regain a sense of control and dignity in their life and future."

Individual Placement and Support is more effective than older methods of vocational rehabilitation at helping Veterans with PTSD find sustainable competitive employment, according to a multi-site VA study.

Researchers launched the Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study to measure how well an individualized vocational program could help Veterans with PTSD find jobs. The study ran from 2013 to 2017 and involved 541 Veterans with PTSD at 12 different VA medical centers. Individual Placement and Support (IPS) helped nearly twice as many participants in the study get steady jobs as a program using transitional work.

The results were published in the Feb. 28, 2018, issue of JAMA Psychiatry.

A different approach to vocational rehabilitation

PTSD often interferes with a person's ability to function at work, making it harder to stay employed or earn a higher income. Veterans with PTSD are more likely to be unemployed than those without the disorder. PTSD also often co-occurs with depression, mild traumatic brain injury, and other chronic health conditions, all of which make it harder to find or hold onto a job. The study authors write, "Recovery from PTSD requires a multifaceted treatment approach of which employment should be a central consideration."

IPS was introduced in VA in 2012 for Veterans with PTSD as an alternative to standard step-wise vocational rehabilitation. VA previously promoted IPS for Veterans with serious mental illnesses such as psychosis.

In the older, transitional work program, Veterans work in sheltered, temporary jobs, usually entry-level. The idea is to provide or reinforce basic work skills and habits. This stage is usually followed by a short-term transitional job located within a VA medical center or in the community, but that's typically where the program ends.

IPS is more person-centered, starting with in-depth interviews to explore the Veteran's interests and aspirations. The model relies heavily on individualized job development by employment specialists, who spend most of their time in the community, networking and developing job possibilities geared to Veterans' experiences, interests, and backgrounds. The outreach and support is more intensive in the first few months; it then tapers off as the Veteran gets stabilized in the work setting. Long-term career development continues even once the Veteran is placed.

Rich Toscano of the Tuscaloosa VA Medical Center, one of the study authors, explains that IPS is a model of supported employment designed specifically for people with complex mental health challenges. He states that, beyond just focusing on wages, IPS can "improve self-esteem, increase social and quality of life, heighten awareness about the importance of overall health care, contribute to better control of symptoms, and reduce substance use." Improvement in these different areas leads to wellness and greater productivity, and reduces the use of expensive in-patient services, says Toscano.

The shared decision-making in IPS leads to highly individualized treatment. Job planning grows out of the Veteran's personal dreams and aspirations rather than a one-size-fits all approach, explains Toscano. The employment specialists supplement the job search with support and integration with the PTSD treatment team to help manage the Veteran’s particular symptoms and challenges.

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Dr. Lori L. Davis, also with the Tuscaloosa VA Medical Center and corresponding author on the paper, explains the benefits of a more individual approach: "IPS is very effective for Veterans with PTSD in terms of speed in getting the first competitive job, obtaining jobs over the course of time, and maintaining jobs to achieve steady employment over time. IPS is very individualized and meets the Veteran at their point in the recovery process to help them attain the goals that they personally set in terms of jobs that match with their preferences, skills, and abilities."

Of the 271 Veterans in the IPS group, 39 percent became steady workers over the 18-month study follow-up. By comparison, only 23 percent in the transitional work group became steady workers. Nearly 69 percent of the IPS group found a competitive job, while only 57 percent of the transitional work group found this kind of work. IPS participants also found competitive work faster than the other group. They were more likely to have found full-time work and worked more days during the week and weeks during the month than those in the step-wise program.

The results show that engaging with Veterans individually and early in treatment improves their chances at reintegrating with the working world, say the authors. "The IPS Veteran participant is energized and empowered to regain a sense of control and dignity in their life and future," says Toscano.

Plans for the future

Plans are underway to implement IPS in the VA health care system. The Louis Stokes Cleveland VA Medical Center has already established a designated IPS specialist to serve Veterans with PTSD. The Tuscaloosa VA Medical Center is evaluating the implementation of IPS within the primary care teams. The researchers are also working on a project, funded by VA and private and public partners, to disseminate IPS at VA medical centers in Massachusetts and New York City. The researchers hope to see the approach adopted by more VA sites going forward.

The researchers are preparing to publish results on PTSD symptom improvement and PTSD-related functional outcome improvements related to the IPS intervention. They are also working on a secondary analysis addressing inpatient health care utilization and overall cost-efficacy. Davis says, "We hope that VA leadership will see the value in increasing access to IPS for Veterans with PTSD so that Veterans can have a choice in the type of vocational rehabilitation that they prefer in working towards full recovery from PTSD."

The trial was run by the VA Cooperative Studies Program (CSP), a national clinical research program with over 40 years of experience providing planning and coordination for multisite clinical research projects to improve the health and care of Veterans and the nation. The CSP Coordinating Center in West Haven, Connecticut, provided support and coordination for VIP-STAR. The CSP Clinical Research Pharmacy Coordinating Center in Albuquerque, New Mexico, helped monitor and report on the safety of trial participants.

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