Clinical and non-clinical predictors of vocational recovery for Australians with psychotic disorders - Clinical and Non-clinical Predictors

Journal of Rehabilitation,  Oct-Dec, 2002  by Geoff Waghorn,  David Chant

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The overall burden of disease associated with psychotic disorders is high in spite of the relatively low prevalence of these disorders in the community. In Australia, the prevalence of psychotic disorders was recently estimated at 4.7 per 1000 adult urban residents (Jablensky et al., 1999b). The burden of disease associated with two of the psychotic disorders, schizophrenia and bipolar affective disorder, is particularly high among young Australians. In young Australian males aged 15-24 years, these two disorders accounted for 10.8% of the total disease burden in 1996, representing the third leading cause of disease and injury behind road traffic accidents (13.2%), and alcohol dependence and harmful use (11.3%). Similarly, for Australian females aged 15-24 years, the combined disorders of schizophrenia and bipolar affective disorder were the second leading cause of disease burden (11.7%) behind depression, which accounted for 14.3% of the estimated total burden of disease (Mathers, Vos & Stevenson, 1999).

The high disease burden associated with psychotic disorders may be further compounded by the absence of sufficient assistance and opportunity for vocational recovery. In a recent Australian study (Waghorn, Chant & Whiteford, in press) an unemployment rate of 83.7% was found among persons with schizophrenia, a rate 10.6 times higher than for all Australians in 1997. Similar relatively high unemployment has been found among people with serious mental illness in the USA at 75-90% (Hughes, 1999), and in the UK, at 61-73% (Crowther, Marshall, Bond, & Huxley, 2001). However, unemployment is not a necessary consequence of having a serious mental illness. In a 32 year longitudinal study of people with severe mental illness, Harding, Brooks, Ashikaga, Strauss & Breier (1987) found that for one half to two thirds of participants with a retrospective DSM III diagnosis of schizophrenia, "... long-term outcome was neither downward nor marginal but an evolution into various degrees of productivity, social involvement, wellness, and competent functioning" (p. 730). Although the more detailed prognostic features of psychotic disorders are of ongoing research interest and debate, the heterogeneous pattern of the long-term disease process described by Harding et al. (1987) is widely supported (Carpenter & Strauss, 1991; Harrison, Croudace, Mason, Glazebrook & Medley, 1996; Kruger, 2000; Marengo, 1994; Mason et al., 1995).

The complex heterogeneity of process and outcomes for persons with psychotic disorders supports a continued search for clinical and demographic predictors of vocational recovery. Numerous investigations and several reviews have explored this topic (Anthony & Jansen, 1984; Crowther et al., 2001; Tsang, Lam, Ng & Leung, 2000) with results indicating that few variables confidently predict employment outcomes at the individual level. Tsang, Lam, Ng et al. (2000), reviewed controlled studies between 1985 and 1997, and found that diagnostic category and psychiatric symptoms were inconsistent predictors. Mixed results were obtained for age, sex, ethnicity, marital status, residential area, cognitive functioning, substance abuse, previous hospitalization and pre-morbid occupational performance. Pre-morbid functioning, work history and social skills were the most consistent and powerful predictors. Of the predictors reported by two or more controlled studies, only education consistently had no predictive value. Age at first hospitalization, family psychiatric history, severity of illness, and availability of employment assistance, emerged as having predictive utility in single studies.

Few studies have investigated longitudinal course of illness as a predictor of employment outcomes. Hoffman and Kupper (1996) and Kupper and Hoffman (2000) used repeated formal assessments to derive course of illness type. Although costly, these assessments were able to predict progress in vocational rehabilitation. Harrison et al. (1996) found that a less technical dichotomous classification of two-year course type (recovered versus chronic or relapsing) improved prediction of employment for persons with schizophrenia. Together these findings support the concept that differentiating course patterns of psychotic disorders may predict vocational recovery.

The generalizability of predictors across labor markets has not yet been demonstrated. Much of the research undertaken to date has taken place within the USA labor market, which is fundamentally different in many aspects from other established labor markets (Korpel, 1996; Tsang, Lam, Darasi, Ng & Chan, 2000; Waghorn & King, 1999). A clearer understanding is needed of the predictors of vocational recovery between and within labor markets to help achieve the progress goals of Anthony (1994), who sought to improve program design, encourage tailoring of programs to individual needs, and advance program evaluation by taking into account differences in user-characteristics.

In this study, psychotic disorders included schizophrenia, schizoaffective and schizophreniform disorders, bipolar disorder, depressive psychosis, mania, delusional disorders and other nonaffective psychoses. Psychotic disorders are disorders which "... have their origins in abnormal brain function and are characterized by fundamental distortions of thinking, perception, and emotional response. Clear consciousness and general intellectual capacity are usually maintained, although specific cognitive deficits may evolve in the course of time. Psychotic disorders affect the most basic functions that give a person a feeling of individuality, uniqueness, and self-direction" (Jablensky et al., 1999c, p. 2).