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DataWatch

Employing Persons With Serious Mental Illness

Abstract

 
Data from various national surveys find that approximately half the population with mental disorders is gainfully employed across the entire range of occupations; such persons have an employment rate of about two-thirds that of the general population. More than a third of persons with serious mental illness also work, and many hold high-status positions. Among those with schizophrenia, a diagnosis associated with high impairment, only slightly more than a fifth are at work, and 12 percent are working full time. Approximately two-thirds are enrolled in federal disability insurance programs. Our analyses indicate considerable diversity of jobs among persons with various mental disorders. Most persons with mental illness want to work, and some with even the most serious mental disorders hold jobs requiring high levels of functioning. Educational attainment is the strongest predictor of employment in high-ranking occupations among both the general population and persons with mental disorders.

A variety of factors reinforce the perception that persons with mental illness are limited in their work participation. Such persons constituted approximately 34 percent of working-age enrollees in the SSI program and 27 percent of SSDI beneficiaries in 1999.¹ Moreover, many mental health programs that seek to assist persons with mental illness to gain and retain employment focus their efforts on placing clients in unskilled and semiskilled positions, which reinforces the concept that this represents the range of work such clients can do. Finally, the stigma of mental illness, based on images of floridly psychotic persons that are disseminated by movies, television, and other mass culture, reinforces the view that persons with mental illness are unpredictable and possibly dangerous.² It is little wonder that many employers are reluctant to place persons known to have a history of mental illness in responsible jobs.³ For this reason, employees often do not reveal their mental health histories or treatment status to employers.

The facts on which these images are based can be misleading. The number of persons with mental illness on SSI/SSDI partly reflects the high prevalence of persons with mental illness in the general population; as much as one-third of the population is reported to have a mental disorder in any year, and approximately half, at some point in their lives.⁴ Although serious mental illnesses are much less prevalent, national estimates, based on data collected in the early 1990s, also suggest that as many as ten million people may have such conditions.⁵ Unlike persons with serious heart disease or cancer, persons with serious mental illness often become symptomatic early in their lives and enter disability status at relatively young ages. Since few persons who achieve SSI/SSDI eligibility leave the disability rolls, numbers of persons with mental illness accumulate over time and constitute a large proportion of all disability insurance recipients.

Conclusions drawn from studies of enrollees with mental illness in employment rehabilitation programs also can be misleading. These programs typically deal with selected samples of persons with extensive disabilities and long histories of repeated episodes of illness and care.⁶ Generalizations from these selected populations to most people with even serious mental illnesses are invalid.

Using data from the National Health Interview Survey on Disability (NHIS-D), supplemented by data from other national surveys, this paper seeks to construct a more complete picture of the employment situations of persons with mental illness. We also focus on persons with the most serious disorders and show that even among this group, many persons manage employment, and some hold high-status occupational positions. Identifying factors associated with employment outcomes points to areas that warrant policy attention.

Study Methods

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Samples. The main data reported here come from the 1994/1995 NHIS-D, designed to collect data on the prevalence and correlates of disability in the noninstitutionalized U.S. civilian population.⁷ We focus on this survey because it provides the largest, most comprehensive data source available linking mental disorders and disability to employment. Households that completed the core NHIS (94 percent of those sampled) were eligible for the first phase of the NHIS-D. NHIS-D data were collected from 93 percent of eligible households. In phase one, on which this paper is based, 66,227 respondents reported on 120,216 household members ages 18–65, including themselves. We also report data that we analyzed from three other nationally representative household surveys: the NHIS Mental Health Supplement, 1989 (NHIS-MHS-1989), which provides data on 70,327 persons ages 18–65; the 1990/1992 National Comorbidity Survey (NCS) of 5,393 persons ages 18–54; and the 1997/1998 Healthcare for Communities (HCC) survey of 8,047 respondents.⁸

Major measures. Diagnostic measures were constructed using either of two criteria. The first involves an affirmative response to one of several questions on a checklist about having specific mental disorders such as schizophrenia or major depression or "other mental or emotional disorders" in the past twelve months. Respondents also were asked about a variety of medical conditions that were then coded into International Classification of Diseases, Ninth Revision (ICD-9) categories. Those associated with mental illness (codes 290.0–319.99) were included as mental disorders. Mental retardation, mental illness with organic origin, and childhood-specific mental disorders were excluded. Substance abuse disorders were treated as a separate variable.

This paper focuses on three categories: persons with serious mental illness; persons with any mental illness; and persons with no known mental illness. Serious mental illness in this study includes schizophrenia, paranoid states, mood disorders, and other nonorganic psychoses and psychoses with origins specific to childhood. Disorders often included as serious mental disorders such as panic disorder and obsessive-compulsive disorders were excluded because it was impossible to distinguish these cases from less serious conditions. We also look at two important, specific categories: schizophrenia and depressive symptoms. Schizophrenia is generally regarded as the most disabling of the more common mental disorders and is a subgroup of serious mental illness. This condition was measured by the respondent’s report of schizophrenia or conditions with an ICD-9 code of 295.0–295.9. We also examine persons who reported depressive symptoms for two or more weeks in the past twelve months or who had ICD-9 codes reflecting depressive disorders not elsewhere classified or neurotic depression, or both. Evidence is lacking of a clinical disorder in this category, but it is well established that subthreshold depressive symptoms are often disabling.

Persons were identified as being employed in the past two weeks if they had worked or had a job and were not laid off. Those working thirty-five hours or more per week were classified as working full time.

We use a measure of psychological functioning based on the presence or absence of problems in five areas, each assessed by a single item: "a lot of trouble making and keeping friendships"; "a lot of trouble getting along in social situations"; "a lot of trouble concentrating long enough to complete tasks"; "frequent disorientation, confusion, and forgetfulness"; and "serious difficulty coping with day-to-day stresses" (Cronbach’s alpha .74). We divided self-assessments of health into those who reported their health as "excellent" or "good" versus others. Freedom from problems with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) was based on items asking about difficulties with these functions.

Persons who reported conditions other than those classified as mental disorders were identified as having a physical condition. Substance abuse conditions were based on checklist responses indicating alcohol or drug abuse problems or for ICD-9 coded conditions for alcohol psychoses, drug psychoses, alcohol dependence syndrome, drug dependence, and nondependent abuse of drugs (other than tobacco).

Analysis. SUDAAN software was used for all analyses to correct for design effects in each survey.⁹ The NHIS-D includes weights to make estimates representative of the nation’s noninstitutionalized population. The percentages reported are weighted, but sample sizes are not.

Limitations. The data come from cross-sectional surveys and self-reports of illness and disability. Disablement is a process, and causal sequences are difficult to infer from cross-sectional data. Unemployed persons may report more illness and disability than their objective symptoms warrant as a way of justifying their employment status to themselves and others. Such reporting bias need not be at a level of awareness. We control for severity of illness and impairment to the extent possible but cannot exclude the possibility that self-report bias may remain.

Study Results

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Employment rates among the four surveys. Exhibit 1 presents data on the proportion of persons who reported employment in four nationally representative sample surveys carried out between 1989 and 1997/1998. In these samples 75–83 percent reported being employed. Persons with any mental disorder reported employment rates of 48–73 percent, depending on the survey. Employment among persons with serious mental illness varied from 32 percent to 61 percent. Persons with schizophrenia and related disorders had employment rates of 22–40 percent.

Employment rates by diagnostic category. While 76 percent of persons without mental illness were employed, and almost 70 percent of persons with only a physical condition were employed, persons with mental illness were less likely to be employed, varying from more than half of those with a mental illness not classified as serious to 22.5 percent among persons classified as schizophrenic (Exhibit 2). Rates of full-time employment were about ten to fifteen percentage points lower for each diagnostic category as well as for persons with no known mental illness. Only 12 percent of persons with schizophrenia worked full time.

Schizophrenia. As noted earlier, persons with schizophrenia were least likely to be employed, and approximately two-thirds were enrolled in SSI/SSDI. In the NHIS-D only sixty-eight persons with this diagnosis were employed. In further analyses (not shown), two factors distinguished employed persons from others. Persons ages 18–24 had odds of employment almost 3.5 times higher than persons ages 45–65. Schizophrenia occurs relatively early in life. With repeated episodes of illness and growing impairment, mental health clinicians help persons gain eligibility to disability benefits.¹² Thus, by middle age this population is much less likely to be employed. Patients with schizophrenia who are employed also have more favorable perceptions of their health status (not shown), which may reflect where they are in the trajectory of their illness, their attitudes, and the extent of disability associated with their condition.

Support for this interpretation comes from further regression analyses (not shown) examining the relative effects of age versus onset of condition among persons with serious mental illness. Age and onset are associated, but each has significantly independent effects on the odds of being employed. Persons with serious mental illness who have had the onset of their disorder less than five years prior to the interview have increased odds of being employed. Persons with serious mental illness whose condition began in the past year are almost twice as likely to be employed full time than are those who had an onset more than a year before. Only one-fifth of persons with serious mental illness who had an onset in the interview year receive SSI/SSDI, but almost 45 percent of those whose onset occurred more than a year earlier had enrolled in SSI/SSDI. This reflects in part the waiting period required to gain eligibility to disability insurance.

Predictors of high-level employment. Exhibit 5 presents regression analyses that seek to explain what allows persons with mental illness to hold occupational rank in executive, administrative, managerial, or professional specialty occupations. These jobs generally require high levels of education, and for all subgroups, level of educational attainment is the most important factor in holding such jobs. For example, among those without a mental illness, the odds of a person with postcollege education having such a job is fifty-one times greater than for those who did not graduate from high school. Postcollege education, compared with having less than a high school education, increases the odds of having a high-level job twenty-six times for persons with serious mental illness and forty-three times for persons with any mental illness. There is a lesser advantage in all groups from simply having some college preparation or completing college, but odds of having a high-level job with this level of education are two to nine times greater than among those who have not completed high school. Persons with mental illness in these occupations have probably completed much of their education prior to their first onset of mental illness.

Persons with serious mental illness who have mood disorders as compared with other serious disorders were 3.3 times more likely to have a higher-level position. Other predictors are not statistically significant for this group. Statistical power for this analysis is limited because of the relatively small size of this subgroup.

A number of additional factors predict employment in higher-ranking occupations; these include being female, being older, and having good perceived health.¹³ As with persons with mental illness, persons without mental illness in these jobs are older and more likely to be female and to have favorable perceived health.

Using the available data, we examined in more detail the jobs in these occupational categories occupied by persons with serious mental illness. Overall, they were not very different from those held by persons without mental illness. The number of persons with mental illness in this subsample is small, and thus differences are not statistically significant, but there were some interesting patterns. Thirty percent of those with serious mental illness were teachers, librarians, or counselors or in health assessment and treating occupations, compared with only 25 percent of those without mental illness. There were no differences between these groups in the proportions who were officials, administrators, or in management occupations; almost two-fifths of both groups were in these occupations. Persons with serious mental illness were less likely to be engineers, architects and surveyors, and mathematical and computer scientists, with 5 percent occupying such positions compared with 11 percent of others. Comparable proportions in both groups were writers, artists, entertainers, and athletes.

Discussion And Policy Implications

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In recent years, in response to disability advocacy groups, increased efforts have been focused on meeting the employment needs of persons with disabilities, including mental illness. Congress made it possible for persons in the disability program to keep their federal health benefits when returning to work. Other efforts have been made to facilitate trial work without jeopardizing one’s disability status.¹⁴ The Americans with Disabilities Act also requires that employers make reasonable accommodations for persons with disabilities who are appropriately qualified for the position, but it is not clear to what extent such requirements have contributed to increased employment among persons with mental illness.¹⁵

Persons who have a history of severe and persistent mental illness receive some job assistance through mental health rehabilitation programs. Traditional programs of this kind, which include prevocational training, training in job skills, work under sheltered conditions, and gradual movement through various steps toward competitive employment, have not had good success in returning clients to competitive work.¹⁶ Research indicates that it is difficult to predict success in work, but programs that place clients into competitive employment with continuing mental health services and various supports can lead to improved employment outcomes while being cost-efficient.¹⁷ Social Security and other funding agencies must recognize this fact and adapt their policies to support programs that better meet their objectives. Clients have been persistently critical of vocational rehabilitation services. The 1999 "Ticket to Work" legislation (H.R. 1180, S. 331) provides opportunity for clients to gain access to the services they deem useful for helping them return to work.¹⁸

Despite the evidence that many persons with mental illness with appropriate education hold jobs throughout the occupational structure, most programs and services are oriented to less-educated clients and employment in relatively low status jobs such as janitors, dishwashers, and other low-paying service occupations. This is often the course of least resistance, since the demand for such workers is high and placement involves few barriers. As a result, persons with mental illness often are placed in jobs below their educational background. Persons with mental illness who have achieved higher educational attainment are often frustrated by the difficulty of identifying programs relevant to their needs and capacities. Inappropriate placement may contribute to boredom, absenteeism, and job failure.

Many employers are reluctant to hire persons with a history of mental illness because of their concern about unpredictable performance, work absenteeism, and possible disruptions in the workplace. Many persons with mental illness are conscientious and reliable employees without special accommodations, but others require them. Fear of discrimination often leads to hiding mental health history and forgoing accommodation requests.¹⁹ One alternative for closing the common communication gap is to ensure that employers get tangible assistance and support in dealing with behavioral problems that might arise; job coaches increasingly are taking on some of these responsibilities.

The data show that persons with mental illness who have more educational attainment are more likely to be in higher-status occupations. Such placement may provide motivation to stay employed and to avoid dependency. Caution is required in interpreting this finding. Although we made efforts to control for severity of illness and impairment, it is possible that more-educated persons are in some way less impaired or have a different illness course, and thus cause and effect may be confounded. Aggressive treatment when illness first occurs and good maintenance therapy reduce the period of incapacity and are believed by most clinicians to prevent subsequent disability.²⁰ It would be useful to help clients to complete their education as part of the larger effort to manage illness so as to prevent secondary impairments, including the inability to work. Efforts also should be made to keep clients in competitive employment with appropriate mental health services and support. Maintaining educational and job continuity when illness occurs in late adolescence and young adulthood is a major challenge. It is often difficult to engage patients in treatment and gain their cooperation.²¹ Primary prevention of serious disorders remains highly uncertain, but there is much evidence that secondary disabilities often associated with mental illness can be attenuated and even prevented.²²

Editor's Notes

 
David Mechanic directs the Institute for Health, Health Care Policy, and Aging Research at Rutgers, the State University, in New Brunswick, New Jersey. Scott Bilder is a research analyst there. Donna McAlpine is assistant professor, health services research and policy, at the University of Minnesota School of Public Health.

This research was funded in part by grants from the Disability Research Institute, University of Illinois at Urbana-Champaign; by National Institute of Mental Health (NIMH) Grant no. MH43450; and by a grant from the Robert Wood Johnson Foundation. The views expressed imply no endorsement by these funders.

NOTES

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1. D.D. McAlpine and L. Warner, Barriers to Employment among Persons with Mental Impairments: A Review of the Literature (New Brunswick, N.J.: Institute for Health, Health Care Policy, and Aging Research, 2001), 2–4; J.L. Mashaw and V.P. Reno, eds., The Environment of Disability Income Policy: Programs, People, History, and Context (Washington: National Academy of Social Insurance, 1996), 47–51; and J.L. Mashaw and V.P. Reno, Balancing Security and Opportunity: The Challenge of Disability Income Policy (Washington: NASI, 1996), 63–64.
2. J.C. Phelan et al., "Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to Be Feared?" Journal of Health and Social Behavior 41, no. 2 (2000): 188–207.
3. T.L. Scheid and M. Suchman, "Ritual Conformity to the Americans with Disabilities Act: Coercive and Normative Isomorphism," in Research in Social Problems and Public Policy, vol. 8, ed. S. Hartwell and R. Shutt (New York: Elsevier Science, JAI Press, 2001).
4. R.C. Kessler et al., "Lifetime and Twelve-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey," Archives of General Psychiatry 51, no. 1 (1994): 8–19.[Abstract]
5. R.C. Kessler et al., "The Prevalence and Correlates of Untreated Serious Mental Illness," Health Services Research 36, no. 6 (2001): 987–1007.[Medline]
6. See,, for example, J.A. Cook et al., "Vocational Outcomes among Formerly Homeless Persons with Severe Mental Illness in the ACCESS Program," Psychiatric Services 52, no. 8 (2001): 1075–1080.[Abstract/Free Full Text]
7. Data come from public-use data files provided by the National Center for Health Statistics (NCHS). Core descriptions of the survey were published in 1996 and 1998. See NCHS, National Health Interview Survey on Disability: Phase 1, Person and Condition Data (Hyattsville, Md.: U.S. Department of Human Services, 1996 and 1998). Additional references for other data sources for this survey are available from the authors.
8. P.R. Barker et al., "Serious Mental Illness and Disability in the Adult Household Population: United States, 1989," in Center for Mental Health Services and National Institute of Mental Health, Mental Health, United States, 1992, ed. R.W. Manderscheid and M.A. Sonnenschein, DHHS Pub. no. (SMA)92-1942 (Washington: U.S. Government Printing Office, 1992), 255–261; Kessler et al., "Lifetime and Twelve-Month Prevalence"; and R. Sturm et al., "The Design of Healthcare for Communities: A Study of Health Care Delivery for Alcohol, Drug Abuse, and Mental Health Conditions," Inquiry 36, no. 2 (1999): 221–233.[Medline]
9. B.V. Shah et al., SUDAAN User’s Manual, Release 7.5 (Research Triangle Park, N.C.: Research Triangle Institute, 1997).
10. D. Mechanic, Mental Health and Social Policy: The Emergence of Managed Care, 4th ed. (Boston: Allyn and Bacon, 1999), 48–55.
11. W.E. Narrow et al., "Revised Prevalence Estimates of Mental Disorder in the United States," Archives of General Psychiatry 59, no. 2 (2002): 115–123.[Abstract/Free Full Text]
12. Mashaw and Reno, The Environment of Disability Income Policy, 94–97; Mashaw and Reno, Balancing Security and Opportunity, 67–68; and S.E. Estroff et al., "No Other Way to Go: Pathways to Disability Income Application among Persons with Severe, Persistent Mental Illness," in Mental Disorder, Work, Disability, and the Law, ed. R.J. Bonnie and J. Monahan (Chicago: University of Chicago Press, 1997), 55–104.
13. The advantage of women in holding higher-ranking positions may be puzzling since men are more likely to be employed in all subgroups. Further analyses find, however, that women are vastly overrepresented relative to men in certain occupations that are highly prevalent within these larger occupational categories—for example, teachers, librarians, and counselors. The occupations in which men are more likely to be are less prevalent—for example, engineers, architects, and mathematical and computer scientists.
14. Mashaw and Reno, The Environment of Disability Income Policy, 131–144; and Mashaw and Reno, Balancing Security and Opportunity, 153–162.
15. D. Mechanic, "Cultural and Organizational Aspects of Application of the Americans with Disabilities Act to Persons with Psychiatric Disabilities," Milbank Quarterly 76, no. 1 (1998): 5–23.[Medline]
16. G.R. Bond et al., "Implementing Supported Employment as an Evidence-Based Practice," Psychiatric Services 52, no. 3 (2001): 313–322[Abstract/Free Full Text]; R.E. Crowther et al., "Helping People with Severe Mental Illness to Obtain Work: Systematic Review," British Medical Journal 322, no. 7280 (2001): 204–208[Abstract/Free Full Text]; and McAlpine and Warner, Barriers to Employment.
17. Bond et al., "Implementing Supported Employment." For a review of the benefit-cost literature on this issue, see J. Kregel et al., "Supported Employment Benefit-Cost Analysis: Preliminary Findings," Journal of Vocational Rehabilitation 14, no. 3 (2000): 153–161; and R.E. Clark et al., "Benefits and Costs of Supported Employment from Three Perspectives," Journal of Behavioral Health Services and Research 25, no. 1 (1998): 22–34.
18. See Weekly Compilation of Presidential Documents, vol. 35 (1999): December 17, Presidential Remarks and Statement. For background, also see Mashaw and Reno, The Environment of Disability Income Policy, 101–119.
19. Mechanic, "Cultural and Organizational Aspects."
20. There is abundant evidence that treatment reduces periods of incapacity and distress. Although most clinicians believe that earlier treatment also reduces later disability, and there is theoretical basis for this view, the evidence on this point, thus far, is less certain. See R.M.G. Normand and A.K. Malla, "Duration of Untreated Psychosis: A Critical Examination of the Concept and Its Importance," Psychological Medicine 31, no. 3 (2001): 381–400[Medline]; and P. McGorry, "Secondary Prevention of Mental Disorders," in Textbook of Community Psychiatry, ed. G. Thornicroft and G. Szmukler (Oxford: Oxford University Press, 2001), 495–508.
21. Mechanic, Mental Health and Social Policy, 106–108.
22. P.J. Mrazek and R.J. Haggerty, eds., Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (Washington: National Academy Press, 1994), 315–317; and Mechanic, Mental Health and Social Policy, 179–185.

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