Beyond Employment Attainment: Do Vocational Interventions Improve Job Tenure and Quality of Life in Individuals with Serious Mental Illness?

Background and Purpose: Sustaining employment remains a significant challenge for individuals with serious mental illness (SMI) despite its association with quality of life (QoL). Vocational programs such as supported employment (SE), individual placement and support (IPS), social skills training (SST) and cognitive remediation (CR) have demonstrated effectiveness in securing competitive employment in SMI. However, the evidence on helping individuals sustain employment (job tenure) is limited. Job tenure is defined as either the longest-held position or the cumulative duration of employment across all jobs. While prior systematic reviews have primarily focused on employment attainment and related outcomes, considerably less attention has been given to job tenure, an important indicator of recovery and a significant predictor of QoL among individuals with SMI. The purpose of this systematic review is to identify vocational interventions that demonstrate promising effects on job tenure, as well as QoL, among individuals with SMI.

Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically searched PubMed, PsycInfo, SocINDEX, and CINAHL. The search was conducted using keywords serious mental illness combined with supported employment, individual placement and support, job tenure and quality of life. Inclusion criteria included a) RCT, evaluation study or an observational study published between 2014-2024 in English; b) vocational interventions; c) intervention and control/comparison group; d) adults with SMI. Studies that reported QoL without job tenure were excluded. An average between-group effect size was calculated to compare the effect of interventions relative to comparison conditions.

Results: Twenty-three studies met the inclusion criteria. The analysis included (n = 1608) participants in vocational interventions (CM, cognitive behavioral therapy (CBT)+CR, CR, SE+CR, IPS, IPS+CR and IPS+SST) and (n = 1265) participants in control/comparison conditions. On average, vocational interventions had a medium-to-large impact on job tenure relative to the control/comparison conditions (d = 0.55 ranging from 0.005 to 0.82). IPS and IPS+SST had larger effect size on job tenure than control/comparison conditions (k= 5; d = 0.28). CR and vocational interventions augmented with CR had a larger effect size (k=12; d = 0.33) on job tenure than control/comparison conditions. Job tenure was calculated in days, weeks or months with follow-up periods of studies ranging from 6 months to 5 years. Across eight studies examining the impact of vocational interventions on QoL, the average effect size for QoL was (d = 0.57, ranging from 0.1 to 1.90) indicating medium-to-large effect. The analysis included (n = 422) participants in vocational interventions and (n = 491) participants in comparison/control conditions. CM had a larger effect size on job tenure (d = 0.46) and QOL (d = 0.15) than Assertive Community Treatment.

Conclusions and Implications: The findings from this systematic review suggest that CR and IPS may have the greatest impact on job tenure. A consistent definition of job tenure is needed. Further research on vocational interventions is warranted to improve job tenure and QoL in SMI. Future research should examine QoL as a core outcome of vocational interventions, given the limited number of studies reporting QoL.