Employment is an important factor in recovery for individuals with schizophrenia. The illness is, however, associated with consistently high unemployment rates. The high unemployment in this group is found to be associated with a number of both illness-related barriers and system-related barriers to employment.
The main aim of this thesis was to further investigate the barriers to employment in participants with broad schizophrenia spectrum disorders in Norway, a high-income Scandinavian welfare-society, and the societal consequences of a vocational rehabilitation programme augmented with cognitive remediation (CR) or cognitive behaviour therapy (CBT). Results from Paper I revealed a lower than expected prevalence of individuals treated for schizophrenia (0.17%) using comprehensive and mandatory health and welfare registers. Low employment rates and high societal costs were also found. Lost productivity due to unemployment and high costs associated with inpatient care were the main causes of the high societal costs.
Paper II found that at two-year follow-up of the Job Management Programme (JUMP) study, 21% of the participants had obtained competitive employment and 16% had wages as their primary income. An additional 25% had work placements in competitive workplaces where the social services paid their income. We found that high global functioning and self-esteem were strongly associated with competitive employment outcome, and low baseline odds of employment can be compensated for by improvements in global functioning and self-esteem. Competitive employment outcome was also associated with increased global functioning and higher self-esteem.
In Paper III, the cost-effectiveness of the JUMP was examined. We compared health and welfare service costs during the two-year follow-up period with the two-year period prior to inclusion in the programme and found significant reductions in inpatient care. We compared the cost-effectiveness between the JUMP group and a treatment as usual (TAU) group and found that inclusive of the JUMP intervention costs the treatment costs in the JUMP group were € 7 949 lower than in the TAU group, adjusted for baseline differences. In addition the JUMP group had higher effect in terms of quality adjusted life years, making it a costeffective intervention compared to normal care. Finally we found that the CBT group was more cost-effective than the CR group in the JUMP study.
These results confirm that the total burden of schizophrenia is significant, both for the afflicted individuals but also for society at large. We found that Norway has a higher density of inpatient services than most countries within the Organisation for Economic Co-operation and Development (OECD), and consequently a higher expenditure on mental health services. Although Norway is allocating more resources on mental health services than many comparable countries, this does not necessarily generate recovery in patients with schizophrenia, with employment rates as low as 10%. Despite many of the participants having global functioning scores in a range where employment would be expected at baseline, they did not work, indicating that external barriers to employment play an important role. Further investigation are indicated to explore these barriers including how services earmarked for assisting individuals with schizophrenia obtain employment are being integrated. Based on our results, the JUMP was not only effective in helping individuals obtain employment, but it was also an effective treatment approach resulting in larger reductions in treatment costs compared to TAU.