Schizophrenia Research

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1 Schizophreni Reserch 146 (2013) Contents lists vilble t SciVerse ScienceDirect Schizophreni Reserch journl homepge: Erly psychosis nd employment Robert E. Drke, Hiyi Xie, Gry R. Bond, Gregory J. McHugo, Crol L.M. Cton Drtmouth Psychitric Reserch Center 85 Mechnic Street, Suite B4-1 Lebnon, NH 03766, United Sttes rticle info bstrct Article history: Received 19 July 2012 Received in revised form 3 Februry 2013 Accepted 6 Februry 2013 Avilble online 13 Mrch 2013 Keywords: Psychosis First episode Employment Bckground: Employment my be n importnt fctor in helping ptients with erly psychosis to recover rpidly nd to void involvement in disbility nd welfre progrms. Methods: This study followed 351 ptients with erly psychoses, either primry psychoses or substnce-induced psychoses, for two yers to exmine their ptterns of competitive employment in reltion to service use, psychosocil outcomes, nd disbility nd welfre pyments. Results: Workers differed from non-workers t bseline nd over two yers. At bseline, they hd better eductionl nd employment histories, were more likely to hve substnce-induced psychoses rther thn primry psychoses, were less likely to hve drug dependence, hd fewer negtive symptoms, nd hd better psychosocil djustment. Over two yers, bseline psychosocil differences persisted, nd the workers used fewer medictions, mentl helth services, nd disbility or welfre pyments. Conclusions: Employment predicts less service use nd fewer disbility clims mong erly psychosis ptients. Thus, greter ttention to supported employment erly in the course of illness my reduce federl insurnce costs nd disbility pyments Elsevier B.V. All rights reserved. 1. Introduction Epidemiologic dt (Kessler nd Frnk, 1997) s well s numerous clinicl studies (Rinldi et l., 2010) show tht employment rtes decline rpidly fter the onset of psychosis. For people with long-term psychotic illnesses, employment rtes re often dismlly low, for exmple, 10 17% (Lindmer et l., 2003; Bertrm nd Howrd, 2006; Rosenheck et l., 2006; Slkever et l., 2007). These studies re, however, often restricted to people with the most serious dignoses, such s schizophreni, nd do not follow people longitudinlly s psychitric disorders evolve. People with less severe disorders my return to the workforce in higher numbers. Severl findings suggest tht employment my hve helthful effect on people with mentl disorders. First, employment provides structure, mening, income, nd positive mentl helth in the generl popultion (Wrr, 1987; Blustein, 2008; Butterworth et l., 2011). Second, mny people who hve been disbled by mentl illness report tht employment ws n essentil feture of their recoveries (Rogers, 1995; Biley, 1998; Steele nd Bermn, 2001; Clevenger, 2008; Strickler et l., 2009). Third, severl studies of supported employment for people with serious mentl illness hve found tht improvements in non-voctionl res, such s self-esteem, friendships, nd symptom control ccrue to those who become workers (Mueser et l., 1997; Bond et l., 2001; Burns et l., 2009). Finlly, studies of erly psychosis ptients hve found tht Supported by the Ntionl Institute on Drug Abuse grnt R01 DA10539 (to Dr. Cton). Corresponding uthor. Tel.: ; fx: E-mil ddress: Robert.E.Drke@Drtmouth.edu (R.E. Drke). erly returns to eduction nd employment my dely or prevent disbility (Cougnrd et l., 2007; Álvrez-Jiménez et l., 2012; Krup et l., 2012). The purpose of this report ws to exmine employment outcomes in lrge nd diverse smple of erly-psychosis ptients who presented to emergency deprtments in upper Mnhttn nd were followed crefully for two yers in the Columbi University Study of Erly Psychosis. Previous reports on this study (Cton et l., 2005, 2006, 2007; Drke et l., 2011) hve not focused on employment. We hypothesized tht the ptients who were employed would fre better on other psychosocil outcomes, would use fewer mentl helth services over time, nd would be less likely to use disbility nd welfre progrms. 2. Methods 2.1. Prticipnts Following previous studies (Bromet et l., 1992), we defined erly psychosis s experiencing psychosis for less thn six months (including hospitliztions or untreted psychotic symptoms) prior to presenttion in emergency deprtments. Reserch interviewers recruited 400 consenting ptients who presented in five psychitric emergency deprtments of upper-mnhttn with initil dignoses of primry psychosis plus substnce use or substnce-induced psychosis between 2000 nd 2002 (Cton et l., 2005). Of these, 15 did not meet study criteri. Interviewers collected dt on 385 t bseline, 319 t one yer, nd 273 t two yers. Of the 351 ptients who were interviewed t bseline nd hd t lest one follow-up interview, 217 (61.8%) hd /$ see front mtter 2013 Elsevier B.V. All rights reserved.

2 112 R.E. Drke et l. / Schizophreni Reserch 146 (2013) reserch dignoses of erly-phse psychosis plus substnce use, 100 (28.5%) hd dignoses of substnce-induced psychoses, nd 34 (9.7%) hd originl dignoses of substnce-induced psychoses but chnged to primry psychoses t the 12-month follow-up interview. No further dignostic chnges occurred in these ctegories between months 12 nd 24. Among the 217 with dignosis of primry psychotic disorder, the dignoses were schizophreni (N=80, 36.9%), psychotic mood disorder (N=73, 33.6%), psychotic disorder not otherwise specified (N=32, 14.7%), schizophreniform disorder (N=18, 8.3%), schizoffective disorder (N=8, 3.9%), nd delusionl disorder (N=6, 2.8%). The most common substnces used by the primry psychotic disorder group were cnnbis (N=120, 55.3%), lcohol (dily or ner dily use for t lest one month) (N=50, 23.0%), cocine (N=35, 16.1%), nd hllucinogens (N=11, 5.1%). Among the 134 ptients initilly dignosed with substnce-induced psychotic disorder, the specific dignoses were psychosis induced by two or more substnces (mostly cnnbis nd one other drug) (N=54, 40.3%), lcohol-induced psychosis (N=25, 18.7%), cocine-induced psychosis (N=24, 17.9%), cnnbis-induced psychosis (N=18, 13.4%), hllucinogen-induced psychosis (N=5, 3.7%), sedtive-induced psychosis (N=3, 2.2%), heroin-induced psychosis (N=2, 1.5%), stimulntinduced psychosis (N=1, 0.7%), nd uncertin (N=2, 1.5%) Mesures Reserch interviewers ssessed current competitive employment every six months (yes/no) using the Qulity of Life Interview (Lehmn, 1988). Competitive employment denotes minstrem jobs, owned by the worker nd pying regulr wges, nd excludes sheltered nd set-side jobs. The number of follow-up ssessments in which the prticipnt ws competitively employed (rnge 0 4) mesured mount of employment. The interviewers estblished dignoses using the Psychitric Reserch Interview for Substnce nd Mentl Disorders (PRISM) (Hsin et l., 1996), n instrument specificlly developed to ssess psychitric nd substnce use comorbidity ccording to DSM-IV criteri (Americn Psychitric Assocition, 1994). According to DSM-IV, psychotic symptom must be persistent or repetitive nd not n isolted experience, nd primry dignosis of psychosis is given only if there is no evidence of hevy substnce use or withdrwl, if the full psychitric syndrome is estblished prior to hevy substnce use, or if the syndrome persists for more thn four weeks fter the cesstion of cute intoxiction or withdrwl. In contrst, substnce-induced psychosis dignosis is given for disorders occurring only during periods of hevy substnce use or soon therefter, provided the substnce ws cpble of cusing the psychotic symptom. During these periods, the psychotic symptoms must exceed the expected effects of intoxiction or withdrwl nd be sufficiently severe to wrrnt independent clinicl ttention. DSM-IV lists the expected intoxiction nd withdrwl symptoms for ech clss of drug. For substnce-induced psychotic disorders, the DSM-IV does not include minimum durtion or symptom requirements s it does for primry psychotic disorder. Dt for the PRISM included ptient self-reports obtined during the interview, observtions nd dignostic ssessments of clinicl stff, hospitl medicl records, fmily/collterl reports of ptterns of substnce use nd onset of psychosis, nd urine toxicology screens conducted routinely on ll emergency deprtment dmissions. Relibility for dignoses relevnt to this report ws good to excellent for current nd lifetime primry nd substnce-induced psychosis nd schizophreni (k= ) nd for current nd lifetime lcohol, cnnbis, cocine nd heroin dependence (k= ) (Hsin et l., 1996). Further detils of PRISM dignostic procedures re described elsewhere (Hsin et l., 1996, 2006b). Interviewers used the Positive nd Negtive Syndrome Scle (PANSS) to ssess psychotic symptoms t ech interview (Ky et l., 1992). The lph coefficients of relibility for the PANSS scle scores were 0.78 for the positive symptom scle nd 0.81 for the negtive symptom scle. Interviewers used the Community Cre Schedule (Cton, 1997)to collect informtion on demogrphics, living rrngements, eduction, employment, nd criminl justice contcts; the Qulity of Life Inventory (Lehmn, 1988) to ssess qulity of life on the overll life stisfction scle (seven points from terrible to delighted t the beginning nd end of interview (rnge=2 14)); nd the World Helth Orgniztion Psychitric Disbility Assessment Schedule (WHO/DAS), which contins rtings on 5-point scle from 1=no disbility to 5=gross disbility, to ssess socil nd fmily problems. WHO collbortors hve reported high levels of inter-rter greement on rtings of mjor socil roles covered in the WHO/DAS: kpps were equl to or greter thn 0.7 in 86% of comprisons, nd equl to or greter thn 0.8 in 60% (World Helth Orgniztion, 1988). Finlly, interviewers ssessed hospitliztions, incrcertions, homelessness, nd tretments, including medictions nd outptient services, t ech interview using time-line follow-bck clendr s prt of the PRISM interview Procedures Following ssessment, tretment, nd stbiliztion in emergency deprtments, interviewers recruited ptients for the study. For bout three-qurters, recruitment occurred fter trnsfer to n inptient service; for the others, recruitment occurred prior to dischrge following tretment in the emergency deprtment for up to 72 h. Interviewers ssessed dignoses, including lcohol nd drug dependence, t bseline, t 12-month follow-up, nd t 24-month follow-up using DSM-IV criteri nd the PRISM interview. Assessments focused on substnce dependence becuse the relibility of buse dignoses hs been generlly lower nd much more vrible thn the excellent relibility of dependence (Hsin et l., 2006). Interviewers dministered the other interviews t bseline nd t 6-, 12-, 18-, nd 24-month follow-ups. The institutionl review bords of the New York Stte Psychitric Institute/Columbi University Medicl Center nd the other prticipting institutions pproved nd monitored the reserch protocol. All prticipnts gve written informed consent Anlyses Becuse mount of employment ws count vrible with lrge vrince (greter thn the men), we ssessed predictors using Poisson regression nd included scle prmeter to djust for over-dispersion. We nlyzed longitudinl correltes of employment sttus using generlized estimting equtions (GEE) (Ling nd Zeger, 1986; Zeger nd Ling, 1986), which ccommodte ttrition, missing dt, nd uto-regression. We used SAS 9.2 (SAS, 2008) for ll nlyses. 3. Results Tble 1 shows demogrphic nd clinicl differences between workers nd non-workers t bseline. The workers t bseline hd more eduction,weremorelikelytobedignosedwithsubstnce-inducedpsychosis (nd not chnging to primry psychosis), were less likely to hve non-lcohol drug dependence, nd hd fewer negtive symptoms. Fig. 1 shows longitudinl employment rtes by dignosis. The substnce-induced psychosis group hd the highest rte of improvement, incresing significntly from 26% t bseline to 44% t 24 months (Z-score=4.05, pb.0001). The primry psychosis group strted t similr level but did not increse significntly over 24 months (24% to 31%). The switch group (substnce-induced psychosis to primry psychosis) begn t very low level nd improved mrginlly (3% to 24%; Z-score=1.75, p=.08) without ctching up with the two other groups. The substnce-induced psychosis group worked in higher proportion of follow-up periods thn the primry psychosis group over time (Z-score=2.41, p=.02).

3 R.E. Drke et l. / Schizophreni Reserch 146 (2013) Tble 1 Bseline chrcteristics of non-workers nd workers. Vribles Non-worker (N=296) Worker (N=89) p-vlue Men/count Std/% Men/count Std/% Gender Femle % % Mle % % Eduction High school or higher % % Less thn high school % % Rce Blck % % Hispnic % % White/others % % Mritl Ever mrried % % Never mrried % % Age Dignosis Primry psychosis % % Substnce induced % % psychosis Switched from substnce % 1 2.9% induced psychosis to primry psychosis Alcohol dependence Yes % % No % % Drug dependence (yes) Yes % % No % % Positive symptoms Negtive symptoms Mritl vrible hs 5 missing. Tble 2 shows prediction eqution for mount of employment during the two-yer follow-up, mesured s the number of follow-up ssessments in which the prticipnt ws working, predicted by bseline chrcteristics. Four vribles significntly predicted mount of employment: greter eduction, younger ge, fewer negtive symptoms, nd better work history. Tble 3 shows correltes of competitive employment, ssessed s time-vrying mesure, over two yers. Compred with non-workers, the workers t bseline hd significntly less drug dependence, homelessness, incrcertion, positive symptoms, negtive symptoms, socil reltionship problems, nd fmily reltionship problems. Most of these vribles, with the exception of incrcertion, improved over time. Alcohol dependence, lthough not different for workers nd non-workers t bseline, lso improved over time for both groups. The bsence of group-by-time interctions indicted persistence of bseline differences between workers nd non-workers. Tble 4 shows mediction use over time. The workers, ssessed gin s time-vrying mesure, were less likely to use ntidepressnts t bseline. Time s showed decresing use of ntipsychotic medictions nd benzodizepines over time. Group-by-time interctions reveled tht the workers were less likely thn the non-workers to use ll medictions over time. Tble 5 shows service utiliztion by working sttus over time. Nonworkers were more likely to see physicins other thn psychitrists nd to be hospitlized t bseline. Over time, use of outptient mentl helth tretment, outptient substnce buse tretment, psychitrists, nd other physicins incresed for both groups. No prticipnts received supported employment services (not shown in the tble). Group-by-time interctions showed tht non-workers significntly incresed their use of outptient mentl helth services nd psychitrists to greter extent over time compred to workers. The most striking group difference ws for hospitliztion, becuse non-workers incurred more hospitliztions over time nd the workers were rrely hospitlized. Tble 6 shows rtes of disbility nd welfre progrm use by working sttus over time. Workers were less likely to use Socil Security Disbility Insurnce, Supplementl Security Income, nd locl welfre progrms t six months. Over two yers, workers continued to use fewer disbility nd welfre progrms. Becuse the primry psychosis nd substnce-induced psychosis groups hd different employment rtes throughout, we repeted ll of the bove nlyses for ech group seprtely nd found essentilly the sme reltionships for ech dignostic group. The dignostic switch group (substnce-induced psychosis to primry psychosis) ws too smll to nlyze seprtely. 4. Discussion In this reltively lrge nd dignosticlly heterogeneous group of erly-psychosis ptients, competitive employment improved grdully over two yers, mostly mong the substnce-induced psychosis prticipnts rther thn mong those with primry psychoses. The mjority of prticipnts in both groups were unemployed t every ssessment, perhps due to their socil disdvntges: poor eductionl bckgrounds, poor work histories, nd lck of ccess to eductionl nd voctionl services. At vrious ssessments, the non-workers were older, hd less eduction, hd more negtive symptoms, nd more drug dependence. They lso hd poorer socil djustment, suggesting tht they differed functionlly from the workers. Previous Fig. 1. Rte of employment cross dignostic groups.

4 114 R.E. Drke et l. / Schizophreni Reserch 146 (2013) Tble 2 Prediction of employment with over-dispersion djusted Poisson regression (N=314). Predictors Estimtes S.E. p-vlue Intercept Dignosis (Substnce induced psychosis vs. primry psychosis) (Switched from substnce induced psychosis vs. primry psychosis) Gender (femle) Eduction (high school or higher vs. less thn high school) Rce (Blck vs. white/others) (Hispnic vs. white/others) Mritl (ever mrried vs. never mrried) Age Alcohol dependence (yes) Drug dependence (yes) Positive symptoms Negtive symptoms Working history (months of working in life time in log scle) Note: Scled Devince=1.08, nd Scled Person Chi-squre=1.00 indicte good model fit. Reported estimtes re chnge in expected counts rther thn log counts. studies of primry psychosis ptients hve found similr risk fctors for poor voctionl functioning (Struss nd Crpenter, 1974, 1977; Rosenheck et l., 2006). Employment improved for the substnce-induced psychosis group becuse mny chieved good remissions of symptoms, especilly if they stopped busing substnces. The lck of deteriortion in work mong the ptients with primry psychoses is somewht surprising, but my be explined by their low level of employment prior to entering the study. Some my hve lost jobs while experiencing psychosis. No prticipnts reported receiving supported employment, which might hve incresed employment outcomes further (Rinldi et l., 2010). Previous work experience is lwys robust predictor of voctionl success, but supported employment often ddresses the vulnerbilities tht these prticipnts showed (Bond nd Drke, 2008; Cmpbell et l., 2010) nd is prticulrly effective for ptients with erly psychoses (Killckey et l., 2008; Nuechterlein, 2010; Bond et l., 2012; Killckey et l., 2012). The service use findings were somewht more surprising. Nerly ll of the prticipnts were prescribed medictions during initil emergency deprtment nd hospitl dmissions, but over time the use of medictions chnged. Non-workers were prticulrly likely to increse their use of medictions nd generlly incresed their use of mentl helth services of severl types over time, while workers were less likely to do so. The simplest explntion of these findings is tht the workers were less severely ill nd therefore needed fewer medictions nd specilty mentl helth services. But both groups improved on symptoms, nd the direction of cuslity is uncertin. Another possibility is tht workers were ble to void involvement in the mentl helth system Tble 3 Outcomes by working sttus over 2 yers. Bseline 6 months 12 months 18 months 24 months Level of significnce N for non-workers Group difference N for workers t bseline Vribles Men±SD/count Men±SD/count Men±SD/count Men±SD/count Men±SD/count Averge time interction Alcohol dependence (yes) b Not working 112 (38%) 46 (24%) 35 (19%) Working 30 (34%) 24 (24%) 11 (12%) Drug dependence (yes) b Not working 139 (47%) 69 (36%) 51 (28%) Working 26 (29%) 20 (20%) 15 (16%) Homelessness (yes) Not working 51 (17%) 35 (17%) 28 (15%) 17 (9%) 14 (8%) Working 4 (4%) 8 (7%) 6 (6%) 2 (2%) 3 (3%) Jil/prison (yes) Not working 31 (10%) 21 (10%) 23 (12%) 19 (10%) 15 (8%) Working 3 (3%) 2 (2%) 4 (4%) 3 (3%) 4 (4%) Positive symptoms b Not working 17.0± ± ± ± ±6.4 Working 15.8± ± ± ± ±3.1 Negtive symptoms b.0001 b Not working 13.7± ± ± ± ±4.9 Working 11.3± ± ± ± ±1.8 Qulity of life Not working 9.1± ± ± ±2.9 Working 10.0± ± ± ±2.2 Socil reltionships b.0001 b Not working 2.7± ± ± ± ±1.4 Working 2.0± ± ± ± ±0.8 Fmily reltionships b.0001 b Not working 3.2± ± ± ± ±1.3 Working 2.0± ± ± ± ±0.8 Totl N vries within ech time period due to missing dt.

5 R.E. Drke et l. / Schizophreni Reserch 146 (2013) Tble 4 Medictions by working sttus over 2 yers. Vribles Bseline 6 months 12 months 18 months 24 months Level of significnce N for non-workers Group difference t N for workers bseline Averge time interction Count Count Count Count Count Antidepression mediction (yes) Not working 94 (32%) 56 (27%) 74 (38%) 72 (38%) 72 (40%) Working 19 (21%) 23 (20%) 15 (15%) 16 (16%) 14 (15%) Antipsychotic mediction (yes) b.0001 b.0001 Not working 206 (70%) 111 (54%) 102 (53%) 100 (53%) 96 (53%) Working 58 (65%) 54 (48%) 24 (24%) 22 (22%) 17 (18%) Euthymic mediction (yes) Not working 65 (22%) 37 (18%) 34 (18%) 41 (22%) 49 (27%) Working 20 (22%) 22 (19%) 11 (11%) 12 (12%) 8 (9%) Benzodizpine b Not working 104 (35%) 26 (13%) 22 (11%) 26 (14%) 20 (11%) Working 30 (34%) 7 (6%) 3 (3%) 3 (3%) 4 (4%) Totl N vries within ech time period due to missing dt. nd use of medictions becuse work provided them with greter sttus, structure, self-esteem, nd options in their lives. Previous studies hve shown tht work cn substitute for mentl helth progrm involvement nd tht workers tend to reduce their use of mentl helth services over time (Jones et l., 2001; Bush et l., 2009; McHugo et l., 2012). Further, mny people prefer to get medicl cre through primry cre physicins rther thn through the mentl helth system (Mechnic, 1997). Mediction use nd service use need to be studied more crefully in rndomized controlled trils nd over longer periods of time. Workers not only used fewer mentl helth services, but lso were less likely to use the disbility nd welfre systems. Similr findings hve been pprent in other nturlistic studies of erly psychosis ptients (Cougnrd et l., 2007; Krup et l., 2012). The literture on erly psychosis nd long-term psychosis ptients demonstrtes tht mny non-workers cn be converted to workers through the use of supported employment (Drke et l., 2012), which could be highly cost-effective if workers erned sufficient income to py txes, to void or decrese involvement in the mentl helth system, nd to void or seprte from disbility nd welfre progrms (Drke et l., 2009; Mnn nd Stpleton, 2011; Slkever, 2011; Krup et l., 2012). A recent lrge experiment hs demonstrted tht enhnced helth nd employment supports for working dults with potentilly disbling conditions of ll kinds cn reduce the likelihood of pplying for federl disbility benefits (Gimm et l., 2011). Limits of the current study include use of self-report on some mesures, lck of detil on the mount of work nd ernings, incomplete dt on service use, nd prticipnts' lck of ccess to supported employment. Nevertheless, the study ddresses the nturlistic course of employment nd service utiliztion experiences over two yers in reltively lrge nd heterogeneous study group of urbn ptients with erly psychoses. 5. Conclusions Erly psychosis ptients who re employed show severl signs of better djustment compred with those who re not employed. Over two yers fter entering tretment, the workers use fewer medictions, helth services, nd disbility or welfre pyments. These findings my generlize to erly psychosis ptients who re helped Tble 5 Service utiliztion by working sttus over 2 yers. Vribles Bseline 6 months 12 months 18 months 24 months Level of significnce N for non-workers Group difference N for workers t bseline Count Count Count Count Count Averge time interction Outptient mentl helth tretment (yes) Not working 21 (7%) 43 (21%) 37 (19%) 39 (21%) 43 (24%) Working 9 (10%) 18 (16%) 13 (13%) 15 (15%) 11 (12%) Outptient substnce buse tretment (yes) Not working 12 (4%) 14 (7%) 14 (7%) 17 (9%) 12 (7%) Working 2 (2%) 6 (5%) 6 (6%) 8 (8%) 5 (5%) Outptient dul disorders tretment (yes) Not working 20 (7%) 30 (15%) 31 (16%) 26 (14%) 33 (18%) Working 6 (7%) 13 (12%) 12 (12%) 9 (9%) 8 (9%) Dys of hospitliztion (yes) Not working 11 (4%) 30 (15%) 18 (9%) 28 (15%) 27 (15%) Working 0 3 (3%) 1 (1%) 1 (1%) 1 (1%) Outptient psychitrist (yes) b.0001 b.0001 Not working 69 (23%) 111 (54%) 108 (56%) 104 (55%) 105 (58%) Working 19 (21%) 57 (50%) 34 (34%) 33 (34%) 31 (33%) Outptient other physicin (yes) Not working 47 (16%) 46 (22%) 44 (23%) 44 (23%) 56 (31%) Working 8 (9%) 11 (10%) 18 (18%) 19 (19%) 16 (17%) Totl N vries within ech time period due to missing dt.

6 116 R.E. Drke et l. / Schizophreni Reserch 146 (2013) Tble 6 SSDI, SSI nd welfre by working sttus over 2 yers. Vribles 6 months 12 months 18 months 24 months Level of significnce N for non-workers Group difference N for workers t 6 months Averge time interction Count Count Count Count SSDI Not working 13 (8%) 15 (10%) 18 (12%) 13 (9%) Working (3%) 2 (3%) SSI Not working 22 (14%) 33 (22%) 35 (23%) 31 (22%) Working 2 (3%) 3 (4%) 2 (3%) 5 (7%) Other welfre Not working 35 (22%) 38 (25%) 28 (19%) 33 (24%) Working 4 (5%) 5 (7%) 8 (11%) 9 (13%) Totl supports b Not working 66 (41%) 78 (51%) 74 (49%) 70 (51%) Working 6 (8%) 8 (11%) 12 (17%) 15 (21%) Totl N vries within ech time period due to missing dt. to return to work through supported employment. The current NIMH Recovery After Initil Schizophreni Episode is testing this hypothesis. Role of funding source None pply. Contributors Drke nd Cton were prt of the tem tht designed nd implemented the study; Xie, Bond, nd McHugo executed the reviews of the literture nd sttisticl nlyses with help from Drke nd Cton; nd ll uthors contributed to the drft nd finl version of the mnuscript. Conflict of interest All uthors declre tht they hve no conflicts of interest. References Álvrez-Jiménez,M.,Gleeson,J.F.,Henry,L.P.,Hrrign,S.M.,Hrris,M.G.,Killckey,E., Bendll, S., Amminger, G.P., Yung, A.R., Herrmn, H., Jckson, H.J., McGorry, P.D., Rod to full recovery: longitudinl reltionship between symptomtic remission nd psychosocil recovery in first episode psychosis over 7.5 yers. Psychol. Med. 42, Americn Psychitric Assocition, Dignostic nd Sttisticl Mnul of Mentl Disorders: DSM-IV, 4th ed. Americn Psychitric Assocition, Wshington, DC. Biley, J., I'm just n ordinry person. Psychitr. Rehbil. J. 22 (1), Bertrm, M., Howrd, L.E., Employment sttus nd occuptionl cre plnning for people using mentl helth services. Psychitr. 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