The Impact of Vocational Rehabilitation for Mentally Ill Veterans (VocRehab)

• (1) Compared with standard VRP, veterans in SE will have i) a greater likelihood of attaining and maintaining employment, ii) longer duration of sobriety, and iii) improved psychiatric symptomatology and neurocognitive function.
• (2) Compared with standard VRP, veterans in SE will have improved: i) physical functioning; ii) mental functioning; and iii) overall quality of life.
• (3) Compared with standard VRP, veterans in SE will have improved: i) physical functioning; ii) mental functioning; and iii) overall quality of life.

To study the impact of supported employment (SE) compared to standard vocational rehabilitation program (VRP) for veterans with posttraumatic stress disorder (PTSD).

Hypotheses or Key Questions

I. Primary Hypothesis (obtained + maintained employment): Subjects assigned to IPS will have a higher maintained employed rate for the 12-mo observation period than their standard VRP counterparts.

I.a. First Component Primary Hypothesis (obtained employment): Subjects assigned to IPS will have higher rates of obtained employment for the 12-mo observation period than the VRP subjects.

I.b. Second Component Primary Hypothesis (maintained employment): Among those subjects employed, those assigned to IPS will have worked more weeks for the 12-mo observation period than the VRP subjects.

II. Secondary Hypothesis: Those subjects who obtain competitive employment will have significantly reduced symptoms of PTSD from baseline to endpoint compared to those subjects who do not obtain competitive employment.

III. Confirmatory and Correlational Hypotheses: Compared to VRP subjects, those subjects assigned to IPS will have:

• greater work intensity (# weeks, days, # hours, wages earned)
• higher total earnings
• greater improvement in quality of life outcomes

Supplemental hypothesis (moderator): Because of the superior integration with the mental health (MH) treatment team, social work services, and community resources that the IPS-SE employment specialist provides as part of this model, we hypothesize that the IPS-SE model will have greater success in the maintenance of competitive employment compared to standard VRP for veterans with PTSD challenged in one or more of these psychosocial domains. From a research perspective, a variable that characterizes subjects for whom a particular treatment will be effective is called a moderator of treatment.

The hypothesized moderators of IPS-SE and standard VRP for subjects with PTSD are: 1) Transportation, 2) Housing, 3) Financial Means, and 4) Family Care Burden. We hypothesize that these variables will have moderating effects for each of two outcomes: 1) number of weeks the participant is competitively employed during the 12-month study period and 2) their score on the Sheehan Disability Scale.

Several principles are important in defining a moderator. First, the moderator must precede treatment. In our RCT, these psychosocial domains are baseline characteristics of subjects enrolled in the study. Second, the moderator must be uncorrelated with treatment choice. This will be the case in this RCT due to a 1:1 randomization, which should balance baseline characteristics between the two groups. Third, a moderator of treatment must have a differential effect of treatment for each level of the moderator. The treatment effect (e.g., active vs. comparator) must be shown to be greater for one level of the moderator (i.e. IPS-SE will show a greater effect size than standard VRP in subjects with a moderator present). Also, an index that combines these domains will be explored and formulated to identify subjects that may benefit to greater extent from IPS-SE.

• Behavioral: Standard Vocational Rehabilitation
  Standard Vocational Rehabilitation (VRP) includes 1) the Vocational Assistance Program (includes routine prevocational testing and evaluation for all patients upon referral to VRP), 2) Vocational Rehabilitation Therapy that operates under the Compensated Work Therapy/Veterans Industries (CWT) and provides a work regimen with monetary incentives derived from contracts whereby participants are paid on a piece rate basis related to their production, and 3) Transitional Work Program (TWP) that includes a temporary work experience either within the VAMC or in community settings (called the Transitional Work External or TWE).
  Other Name: VRP
• Behavioral: Supportive Employment
  Supported Employment (SE) involves: a vocational rehabilitation employment specialist who is integrated into the clinical treatment team, carries out all phases of the vocational services, provides predominantly community-based services, provides assertive engagement and outreach, has a case load of ≤ 25 clients; engages in rapid job search, individualized placement in diverse and potentially permanent competitive job(s), ongoing work-based vocational assessment, and assistance in finding subsequent jobs if needed with the view that all jobs are positive learning experiences; continuous time-unlimited follow-along supports to provide vocational services; and weekly group supervision with IPS/VRP team and with IPS supervisor/trainer monthly.
  Other Name: SE

Inclusion

• Signed informed consent
• Diagnosis of PTSD (based on MINI)
• Male or female
• Any race or ethnicity
• Age 19-60
• Currently unemployed
• Interested in competitive employment
• Planning to remain in a 100-mile radius of participating VAMC for the 12- mo duration

Exclusion

• Lifetime history of severe traumatic brain injury that has resulted in severe cognitive disorder
• Diagnosis of schizophrenia, schizoaffective disorder, or bipolar I disorder
• Dementia (a standard exclusion from VRP)
• Immediate need of detoxification from alcohol or drugs (a standard VRP exclusion)
• Pending active legal charges or expected incarceration