Unemployment rates among patients with long-term mental health problems: A decade of rising unemployment

AIMS AND METHOD

To examine the vocational status of people with longer-termmental health problems in the inner London Borough of Wandsworth.Data collected over 10 years on 1 April each year as part ofan annual census of adults with longer-term mental health problemsusing community mental health and rehabilitation teams wereanalysed to examine the vocational status of these groups.

RESULTS

Within the borough unemployment rates among people with longer-termmental health problems increased steadily during the 1990s,despite a decreasing rate of general unemployment for the majorityof that period. Unemployment among people with long-term mentalhealth problems increased from 80% in 1990 to 92% in 1999,and the unemployment rates among those with a diagnosis of schizophrenia increased from 88% in 1990 to 96% in 1999.

CLINICAL IMPLICATIONS

Work and employment is important in health as well as socialfunctioning. Greater attention to vocational issues in clinicalteams is required: the challenge for mental health servicesis to make employment interventions of demonstrated effectivenessavailable to all who need them.

Introduction

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Introduction

The importance of work in enhancing the mental health and qualityof life of people who experience mental health problems hasbeen widely documented (Bennett, 1975; Shepherd, 1984; Rowland & Perkins, 1988;Nehring et al, 1993; Warner, 1994). Aswell as an income, employment provides social contacts andsocial support, status and identity, a means of structuringand occupying time and a sense of personal achievement.

Bennett (1975) has characterised work as the performance ofa task within prescribed limits to achieve goals set by others,who judge and reward and thereby link the individual to society.Without work, these links are all too easily lost. The centralityof employment in promoting social inclusion is widely recognisedby government initiatives, including the New Deal for DisabledPeople (Department for Education and Employment, 2001).

For many people who have experienced mental health problems,the main barrier to employment is an unwillingness on the partof employers to consider them because of their psychiatrichistory (Manning & White, 1995; Rinaldi & Hill, 2000). Others have more disabling ongoing problems that can impedework performance. However, research indicates that, with appropriateongoing support, a mean of 58% of people with serious ongoingmental health problems can achieve competitive employment (Bondet al, 1997; Crowther et al, 2001). Although such supportedemployment models were developed in the USA, they are becomingincreasingly available in the UK.

Yet, despite the development of effective models to enable peoplewith mental health problems to gain and sustain employment,and despite the introduction of the Disability DiscriminationAct in 1995, it remains the case that employment opportunitiesfor such people remain scarce. The 1998 Labour Force Surveyshowed that 88% of those with longer-term mental health problems are unemployed (Department for Education and Employment, 1998).

The aim of this paper is to examine trends in the vocationalstatus of people with longer-term mental health problems inthe London Borough of Wandsworth (1998 Index of Local Deprivation,25.05 — rank 30th in the country) during the 1990s, andto compare these with local general employment rates.

Method

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Method

Data concerning the vocational status of people with longer-termmental health problems during the 10 years from 1990 to 1999were collected via an annual census of adults using communitymental health and rehabilitation teams in the south-west LondonBorough of Wandsworth. Basic demographic, psychiatric, serviceusage, accommodation and vocational information was providedby keyworkers for all clients of the services on 1 April eachyear who had experienced their first contact with psychiatricservices at least 2 years previously. Vocational status wasreported in five categories: open employment, sheltered work,voluntary work, education and unemployed. Open employment includedordinary, existing, full-time, part-time or casual work gainedin open competition. It did not include jobs created under special employment schemes for people with mental health problems.

General unemployment rates were obtained from Wandsworth LocalAuthority, based on figures provided by the London ResearchCentre.

Results

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Results

Table 1 shows that there was a mean of about 1015 longer-termservice users in contact with local mental health servicesin the Borough of Wandsworth each year between 1990 and 1999, over half of whom had a diagnosis of schizophrenia.

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Table 1. Characteristics of the population of longer-term service users from the boroughs of Wandsworth and Merton, 1990-1999

Table 2 shows that general employment rates in Wandsworth fellbetween 1990 and 1993 from 94.5% to 86.2%. Employment ratesamong those service users with longer-term mental health problemsalso decreased from 19.7% to 12.3%. However, between 1993 and1999 general employment rates rose again from 86.2% to 95.1%,but employment rates among service users with longer-term mentalhealth problems continued to fall from 12.3% to 8.1%.

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Table 2. Employment rates in Wandsworth, 1990-1999

The situation was even worse among long-term service users witha diagnosis of schizophrenia. Between 1990 and 1993 employmentrates among this group fell from 12.0% to 7.7%, and continuedto fall between 1993 and 1999 to only 4.4%, despite the increasein general employment rates during this period.

Figs 1 and 2 show that as the proportion of longer-term serviceusers engaged in open employment fell, the proportion engagedin voluntary work rose substantially from 0.6% in 1990 to 3.8%in 1999 (from 0.3% to 2.8% among those with a diagnosis ofschizophrenia). Similarly, the proportion engaged in educationcourses rose from 1.4% in 1990 to 5.7% in 1999 (from 0.9% to5.9% for those with a diagnosis of schizophrenia). The proportionengaged in sheltered work rose slightly from 6.9% to 8.5% (from 8.0% to 11.0% for those with a diagnosis of schizophrenia).

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Fig. 1. Percentages of Borough of Wandsworth long-term clients engaged in work or employment.

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Fig. 2. Percentages of Borough of Wandsworth long-term clients with schizophrenia engaged in work or employment.

During the years 1990-1995 there was an expansion of work programmes available to help people with mental health problems in theborough. These included six initiatives providing time-limitedwork preparation and support to obtain open employment, sixservices offering training for work, five sheltered work/workexperience programmes, the introduction into the volunteer bureau of a worker to assist people with mental health problemsin volunteering and links between mental health services andlocal colleges to facilitate access to education.

Discussion

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Discussion

These data clearly show that, during the 1990s, the proportionof people with longer-term mental health problems in employmentdecreased substantially in Wandsworth. This decrease did notreflect general employment rates in the manner that might havebeen expected: employment rates among longer-term mental healthservice users fell when general employment rates were falling, but continued to decrease when general employment rates roseagain. This decrease did not reflect the national data on employmentrates for disabled people more generally either, which remainedconstant at around 40% throughout the 1990s (Burchardt, 2000).It is likely that this difference reflects the greater discriminationexperienced by people with mental health problems.

The decrease in employment rates among longer-term service userswas equally evident for younger ( $<=$ 35 years) and older (>35years) people, but throughout the period the employment rateswere lower for the older group and slower to fall in the firsthalf of the decade for the younger group, although they declinedsubstantially in the second half. The data also indicate thatthe decrease in employment rates was greatest among those witha diagnosis of schizophrenia, in relation to whom employmentdiscrimination is likely to be most acute (Manning & White, 1995).

This decrease in employment occurred despite:

the widely recognised importance of employment for people withmental health problems;
an increasing recognition of theimportance of employment inpromoting social inclusion;
thedevelopment of effective models for supporting people withmental health problems in employment (Bond et al, 1997; Crowtheret al, 2001);
the introduction of national policies such as theDisabilityDiscrimination Act;
policy initiatives such asthe New Deal for Disabled People;
the development of localinitiatives designed to help peoplewith mental health problemsget and keep jobs in open employment.

In place of employment, engagement in voluntary work and educationhave increased. Although these activities may yield benefitsin and of themselves, it is often asserted that engagementin such activities can prepare people for entry/re-entry intoemployment. The continuing downward trend in employment ratesindicates that this has not been the case.

There are a number of possible reasons why those with long-termmental health problems might have failed to benefit from thegeneral decrease in unemployment within the economy.

First, it is possible that the type of jobs lost with the economicdownturn and those created with the economic upturn were ofa different nature. If the jobs lost were primarily entry-levelpositions requiring few educational qualifications, and thosegained were of a more ‘high-tech’ variety, thenit is possible that people whose education was disrupted by mental health problems may not be able to avail themselves ofthe new positions created. Although there are undoubtedly labourshortages at the upper end of the skill range, the EconomicDevelopment Department in the borough indicated that thereare also labour shortages locally in all positions (London Research Centre, 2001).

Second, during this period there has been increasing pressureto reduce bed usage and ensure that as many people as possibleare supported in living outside a hospital setting. This mayresult in mental health workers devoting most of their timeand energy to maintaining people in their accommodation, withrelatively little time devoted to other issues such as employment.It should be noted that if there has been a decrease in attentionto vocational issues then this is likely to jeopardise communitytenure. There is evidence that employment decreases admissionrates: those who have work are likely to stay out of hospitalfor longer periods than those who are out of work (see Nehring et al, 1993).

Third, at the same time as there has been a focus on the roleof employment in promoting social inclusion, there has beenan increasing focus on stress in the workplace and the detrimentalimpact of some employment on mental health. If it is assumedthat work is stressful, and that people who experience seriousmental health problems are not able to cope with stress, thenthere may be a reluctance on the part of clinicians to encourageclients to work, and on the part of clients to undertake anactivity that they believe may worsen their difficulties. However,such arguments do not take into account the stressful effectsof unemployment and the well-documented detrimental impactof unemployment on mental health.

Fourth, the ‘benefits trap’, which makes it difficultfor people with mental health problems to take low paid jobs,especially on a part-time basis, without risking loss of income,is undoubtedly a disincentive to entering employment. The patternof decreasing employment found did not, apparently, changein response to alterations in benefit regulations during theperiod considered. Therefore, the benefit system alone is unlikelyto explain fully the trends found.

Finally, during the 1990s there has been a major increase inthe popular association between violence and mental health:the media are replete with accounts of ‘mad axe-murderers’wandering the streets. It seems unlikely that employers areimmune to such popular representations and they may have becomeincreasingly fearful of employing people who they assume tobe dangerous.

Whatever the explanations for the decreasing employment ratesfound, it is clear that mental health services face a majorchallenge. Unemployment exacerbates the mental health difficultiesof those with serious mental health problems and employmenthas a central role in promoting inclusion: the continuing decreasein employment among this group is therefore a matter of graveconcern. Standard 1 of the National Service Framework for MentalHealth (Department of Health, 1999) requires that we combatdiscrimination against, and promote the social inclusion of,individuals and groups with mental health problems. Standard5 requires that care plans for people with severe mental illnessaddress arrangements for employment, education/training orother occupation. Standard 7 requires that local health andsocial care communities minimise suicides among people withmental health problems, and there is evidence of a link betweenunemployment and increased risk of suicide (Lewis & Sloggett, 1998).

If people with serious long-term mental health problems areto have access to employment, there is an increasing body ofresearch evidence from randomised controlled trials (Drake & Becker, 1996;Bond et al, 1997; Crowther et al, 2001)that indicates the need for:

vocational rehabilitation to be seen as a central and integralcomponent of the work of mental health teams rather than aseparate service — front-line staff must have a vocationalorientation and there must be vocational expertise within teamsif success is to be achieved;
a change in the focus to a supportedemployment model, witha clear goal of open employment in integratedsettings, minimalpre-vocational training, rapid job search,time-unlimited supportand work-place interventions, continuing assessment and adjustmentof support and vocational needs andattention to user preferencesand choices rather than providers'judgements.

The challenge for mental health services is to make employment interventions of demonstrated effectiveness available to allwho need them.

References

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