Relationships between Physical Health and Employment for Adults with SMI

Background/Purpose:  Chronic health condition rates are on the rise in the U.S., and at the same time, Federal and State governments are working to decrease spending, prompting conversations regarding unemployment rates and the number of people receiving unearned income. People with serious mental illness (SMI) experience high rates of chronic physical health conditions and unemployment, even though many report a strong desire to be employed. Health is strongly related to employment, however knowledge about relationships among adults with SMI is incomplete. Employment research that includes people with SMI has primarily focused on mental health symptoms, treatment, and diagnoses, and while clearly important, the roles of physical health are not well-understood. Informed by health economics and public health theories, this study examined direct and indirect relationship between physical health conditions, physical HRQOL, mental HRQOL, and employment.

Methods:  Using data from the Medical Expenditures Panel Survey, collected from three panels of participants between 2012-2015, this study included persons 18-70 years of age who reported an SMI diagnosis (n=648). Physical health conditions (exogenous variable) were measured using 14 priority conditions (e.g., asthma, hypertension, and diabetes), and were included as each a binary variable (i.e., any condition) and summed continuous variable in multivariate analyses. Endogenous variables included physical HRQOL, mental HRQOL, and employment. Physical and mental HRQOL were included as latent variables, measured using the SF-12, and employment was a binary variable (employed/unemployed). Structural equation modeling was performed using Mplus to examine direct and indirect relationships between the variables, controlling for sex, race/ethnicity, age, educational status, health insurance status, healthcare use, and disability income receipt.

Results:  Approximately 70% of the sample was unemployed, 80% had at least one physical health condition, and the sample had an average of 2.7 physical health conditions. Results suggested the hypothesized measurement and conceptual models had good general fit with the data (e.g., RMSEA=.059), and the model explained approximately 55% of the variance in employment status. Physical health conditions were directly related to decreased physical (binary: b= -.746, p<.001; continuous: b= -.444, p<.001)  and mental HRQOL (binary: b= -.570, p<.001; continuous: b= -.302, p<.001); and physical (binary: b= .287, p<.01); continuous: b= -.234, p<.05) and mental (binary: b= .203, p<.005; continuous: b= .210, p<.05) HRQOL were directly related to decreased probability of employment. Further, physical and mental HRQOL mediated relationships between physical health conditions and employment. Importantly, physical HRQOL had a stronger direct and mediating relationship with employment compared to mental HRQOL.

Conclusion/Implications:  This study demonstrates that physical HRQOL is an important component to consider in terms of employment for people with SMI--in fact, more important than simply the presence of diagnosed physical health conditions--and physical HRQOL had a stronger relationship with employment than mental HRQOL.  Implications for social work practice with adults with SMI will be discussed, including the need for employment interventions to comprehensively assess and intervene in regards to physical health.  Implications for health policy will also be discussed, in particular those related to Medicaid demonstration projects that include employment mandates.