Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial

Abstract

Importance: Posttraumatic stress disorder (PTSD) often interferes with a person's ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income.

Objective: To determine whether individual placement and support (IPS)-supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment.

Design, setting, and participants: The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed.

Interventions: Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community.

Main outcomes and measures: A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period.

Results: A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004).

Conclusions and relevance: This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD.

Trial registration: clinicaltrials.gov Identifier: NCT01817712.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.. Veterans Individual Placement and Support Toward Advancing Recovery (VA CSP #589) Flowchart

IPS indicates individual placement and support; and PTSD, posttraumatic stress disorder.

Figure 2.. Time to First Competitive Job in Veterans With Posttraumatic Stress Disorder Randomized to Individual Placement and Support (IPS) vs Transitional Work

Participants randomized to IPS gain a competitive job more quickly than those randomized to transitional work.

Figure 3.. Percentage of Participants Holding a Competitive Job Over 18 Months Comparing Individual Placement and Support (IPS) With Transitional Work

Participants randomized to IPS are more likely to be competitively employed at any time during the 18-month follow-up compared with those randomized to transitional work.