P1: GAD

Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004 18:24 Style file version June 22, 2002

Mental Health Services Research, Vol. 6, No. 1, March 2004 (

C 2004)

Association Between Demographic and Diagnostic Factors

and Employment Outcomes for People With Psychiatric
Disabilities: A Synthesis of Recent Research

Nancy J. Wewiorski1,3 and Ellen S. Fabian2

Employment outcome for individuals with psychiatric disabilities has been a focus of empirical
research over the past decade or so. The purpose of this paper is to review recent literature
on the association between demographic and diagnostic factors and employment outcome,
and to conduct meta analyses of the results of studies that report the association between
these variables. Seventeen studies were included in these meta analyses. Results of the meta
analyses tended to corroborate most of the significant findings found in the literature review.
The authors review some of the issues for the meta-analyst interested in synthesizing research
findings on employment outcome, including the challenges and limitations encountered in the
published research currently available.
KEY WORDS: employment; outcome; factors; psychiatric; disability; meta-analysis.

INTRODUCTION of more useful and sophisticated tools for conducting

Research synthesis is an important method
that can extend our knowledge base by combining
and comparing studies related to a common theme
(Cooper & Hedges, 1994). It is particularly a useful
tool when there is a significant body of empirical data
with commonalities regarding populations and vari-
ables. When there are numerous studies around a fun-
damental problem or research question, this method
can be used in the development of theory or the iden-
tification of most effective practices (Smith & Glass,
1977). In the past decade or so, reports of quantitative
research syntheses, or meta-analyses, have increased
in the social science literature, in part because of the
need to integrate findings from growing bodies of re-
search evidence, but also because of the availability
1Center for Psychiatric Rehabilitation, Boston University, Boston,
Massachusetts.
2Department of Counseling and Personnel Services, University of
Maryland, College Park, Maryland.
3Correspondence should be directed to Nancy J. Wewiorski, Cen-
meta-analytic research (Cooper & Hedges, 1994).
A major concern in the field of vocational reha-
bilitation that lends itself to meta-analysis is the issue
of employment among adults with severe and persis-
tent mental illness. This group of about 45 million
adults, or 2.6% of the total population of persons with
mental health disorders, has had persistently low rates
of labor force participation, with most estimates rang-
ing from about 10 to 30% (NIDRR, 1992; LaPlante &
Carlson, 1996). Individuals with psychiatric disorders
comprise the largest single diagnostic group of
Supplemental Security Income (SSI) beneficiaries,
accounting for almost 30% of the total (Kochlar &
Scott, 1995). In addition, they are the least likely to
leave the disability rolls (Muller, 1992). Although in-
dividuals with schizophrenia constitute only about 1%
of the total mental health population, they are over
represented on the SSI rolls, making up about 33% of
SSI beneficiaries with mental illness. Proposed expla-
nations for these persistently low rates of labor force
participation include the characteristics of the illness

ter for Psychiatric Rehabilitation, Boston University, 940 Com-

itself, the lack of success of vocational rehabilitation
monwealth Avenue, West Boston, Massachusetts 02215; e-mail: programs, the work disincentives imbedded in public
wewiorsk@bu.edu. disability policy, and the labor market liabilities of

9
1522-3434/04/0300-0009/0
C 2004 Plenum Publishing Corporation
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
10
persons with psychiatric disabilities (Baron & Salzer,
2002).
Predicting employment outcome is difficult in the
vocational rehabilitation field and empirical evidence
offers limited guidance about factors related to em-
ployment outcome. When compared to other disabil-
ity groups, individuals with mental illness historically
have achieved less successful rehabilitation closure
rates in the statefederal vocational rehabilitation sys-
tem (NIDDR, 1992, 1997) and less success in sup-
ported employment programs, particularly in terms of
job retention (Bond et al., 2001; Lehman et al., 2002).
Predicting employment outcome is further compli-
cated because of the unique factors associated with
psychiatric disability, such as the heterogeneity of
its characteristics, the variations in its prognosis and
course, and the relationship between medication and
behavior in their effects on work (Bond et al., 2001;
Harding, Brooks, Takamaru, Strauss, & Breier, 1987).
Efforts to understand the entrenched unemploy-
ment of individuals with psychiatric disabilities have
resulted in a large number of studies examining fac-
tors associated with successful vocational experiences,
including several literature reviews (Anthony, 1994;
Anthony & Jansen, 1984; Cook & Razzano, 2000;
Tsang, Lam, Ng, & Leung, 2000). However, there is a
dearth of meta-analytic studies that combine results
across studies. Such studies would be valuable in the
identification of variables that may be associated with
work success for people with psychiatric disabilities.
The purpose of this paper is to review the existing
literature on employment outcome, to identify stud-
ies that include demographic and diagnostic variables,
and then to conduct meta-analyses of those studies
that report the degree of association between these
variables and employment outcome. For the purposes
of this paper, we focus on demographic variables that
in and of themselves can be factors in employment dis-
crimination (e.g., age, race, and gender) and also con-
sider psychiatric diagnoses. Other important factors,
such as education, socioeconomic status, disability in-
come status, work history, and social competence, are
not included in our analyses because they are too var-
iously measured (Rucker, Wehman, & Kregel, 1996)
and/or too infrequently reported with sufficient detail
for meta-analysis.
LITERATURE REVIEW
Although not exhaustive, we attempted to be
comprehensive by searching a number of different
18:24 Style file version June 22, 2002
Wewiorski and Fabian
databases and sources that are reflective of psychi-
atric, medical, and rehabilitative research. We found
a sizeable body of literature on individuals with psy-
chiatric disorders that focuses on vocational issues,
including competitive employment, supported em-
ployment, or vocational performance. The following
overview primarily focuses on publications within the
last decade, although some important earlier studies
are cited, as well.
Sociodemographic Variables
Several studies have examined the extent to
which demographic variables, notably race, gender,
and age, relate to vocational outcomes. Such informa-
tion is useful in a number of ways. First, it can help sort
out whether illness factors alone, or whether other fac-
tors in combination with illness factors, are related to
employment outcome, although it sometimes is diffi-
cult to separate the discrete contribution these vari-
ables make to the outcome. Second, these data may
suggest the type and intensity of intervention most
appropriate and/or effective for various subgroups of
the population of individuals with psychiatric disabil-
ities. For example, it has long been demonstrated by
research in the career psychology literature that de-
mographic factors play a role in shaping individual
perceptions of career and work (e.g., see Brown, 1995;
Hackett & Byars, 1996 on vocational behavior related
to gender and race). Demographic factors also define
subgroups that historically have experienced employ-
ment discrimination, another factor that may relate
to employment outcomes for some individuals with a
psychiatric disability. There also are a number of stud-
ies that examine the effect of social background vari-
ables, such as prior work history and educational level,
on employment outcomes. These data are briefly re-
viewed in the following section, but not included in
the meta analysis, as insufficient statistical data lim-
ited their usefulness for meta-analysis.
Studies that have examined the relationship be-
tween age and employment outcome have had fairly
consistent findings. Generally, younger age is asso-
ciated with better employment outcomes, in terms
of both getting and keeping a job. For example,
Mueser, K. T., Salyers, M. P., and Mueser, P. R. (2001)
found younger age predictive of longer job dura-
tion, Mowbray, Bybee, Harris, and McCrohan (1995)
found younger age predictive of more positive work
expectations, Bybee and colleagues (1995) found
younger age to be positively related to enrollment
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables
in a vocational placement program, and Cook and
colleagues (2001) found younger age predictive of
employment success for homeless persons with men-
tal illness. However, it is important to note that, for
individuals with psychiatric disabilities, age may be
confounded by other factors. For example, recent ad-
vances in neuroleptic treatment and the trend toward
reducing hospitalization have had an impact on psy-
chosocial functioning for people with psychiatric dis-
orders (Coursey, Safajan, & Alford, 1997) and also
may affect their capacity to work. In order words,
work capacity may be improved by more effective
medications that target positive and negative deficits
associated with psychiatric disorders, thus benefiting
younger persons who may be entering the labor mar-
ket. In terms of labor market attachment, younger
persons, in general, are more likely to be in the labor
market and probably would have higher expectations
regarding work than persons who are older.
Findings about the effect of gender on employ-
ment tend to be more equivocal. For example, in a
work intervention program for homeless persons with
mental illness, Cook et al. (2001) found males more
likely to be employed at 12 month follow-up. How-
ever, in a study of participants in three psychoso-
cial programs, Rogers, Anthony, Cohen, & Davies
(1997) found that women evidenced high work skills,
although gender was not a significant predictor of sub-
sequent employment. Males with schizophrenia have
been reported to have poorer functional outcome
(Moriarty et al., 2001), a factor that may be attributed
to males having an earlier onset of the disorder. Gen-
erally, studies have found a small, insignificant, effect
for gender (Rogers et al., 1997; Tsang et al., 2000), al-
though reports of earnings of disabled SSI beneficia-
ries indicate that women have smaller reported wages
than men (Scott, 1992), a finding consistent with gen-
eral population wage data.
Findings regarding the importance of race, both
in terms of predicting work status and in examining
patterns of employment, are equivocal. For example,
Goldberg and colleagues (2001) studied employment
patterns of inner-city residents with psychiatric dis-
abilities and found that race was not associated with
employment history. However, Fabian (1992) studied
job tenure among individuals with psychiatric disor-
ders and found that African American males had the
poorest employment tenure. Rogers and colleagues
(1997) found race modestly associated with 1 year
vocational outcome for psychosocial rehabilitation
clients. In a study reporting the factors contribut-
ing to work persistence among SSDI beneficiaries,
18:24 Style file version June 22, 2002
11
Hennessey (1997) found that Caucasian males tended
to have longer job tenure, but his study did not inves-
tigate disability category. Certainly, race is a factor
in the labor force participation rates of men in the
general population (U.S. Department of Labor, 2001),
and there is little reason to believe that it would be
different for the population of individuals with psy-
chiatric impairments. Research that has examined the
work-related behavior of minority groups has gener-
ally concluded it is not race or ethnicity per se that
predicts outcome, but the reactions and attitudes from
others that it evokes, as well as the relationship of
these factors to limiting career and employment op-
portunities (Lent & Brown, 1996). The interaction of
race and the sociocultural environment may constrict
the individuals vocational expectations and efficacy,
eventually decreasing performance.
Research has tended to find prior employment
to be among the strongest predictors of employ-
ment outcome for persons with psychiatric disabilities
(Anthony, Cohen, & Farkas, 1990; Anthony & Jansen,
1984; Arns & Linney, 1995; Carpenter & Strauss,
1991; Mueser et al., 2001; Strauss & Carpenter, 1974).
History of prior employment has been found to be
a robust predictor of successful outcome, over and
above treatment effects, such as supported employ-
ment (Drake et al., 1996; Jacobs, Wissusik, Collier,
Stackman, & Burkeman, 1992). However, Rogers
et al. (1997) did not find prior employment history to
be significant. Similarly, Tsang and colleagues (2000)
found no significant association between posthospi-
tal employment status and either history of gainful
employment for 3+ months or history of gainful em-
ployment for 2+ years in a Hong Kong sample.
Moreover, recent studies also have noted that it
may not be simply prior employment that is impor-
tant, but the pattern of prior employment that deter-
mines outcome (Baron, 2000). For example, there is
evidence that stability of prior work (Goldberg et al.,
2001), and duration of prior employment (Goldberg
et al, 2001; Mowbray et al., 1995) predict future work
outcome. Unfortunately, studies that would help us
to explain how previous competitive employment
relates to future job expectations are not available
(Fabian, 2000). It may be, for example, that previous
positive experiences improve vocational efficacy and
outcome expectancies, two of the most potent pre-
dictors of vocational performance (Lent, Brown, &
Hackett, 1994). Baron (2000) investigated the career
patterns of 38 individuals with psychiatric disorders
and speculated that it was not work experience per
se that made a difference in work retention, but the
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
12
individuals perception of the value and meaning of
these experiences.
Educational background is another factor that
has been studied, with some inconsistent results.
Goldberg et al. (2001) studied long-term unemploy-
ment of inner-city residents with psychiatric disorders
and concluded that educational level was not related
to patterns of unemployment, but the range of edu-
cational levels of the sample was not given. Mueser
et al. (2001) found that educational level was related
to job retention in their sample of 313 patients with
schizophrenia. In a Hong Kong sample, Tsang et al.
(2000) found a positive association between unem-
ployment and higher educational level. In a report
on work persistence factors for SSDI beneficiaries,
Hennessey (1997) did not find educational level to
be predictive, but did note that almost 70% of those
who started work after receiving benefits had at least
a high school diploma.
The demographic and social factors reviewed
above probably are not unique to individuals with psy-
chiatric disabilities, but are issues associated in gen-
eral with work-related decisions of people with dis-
abilities. What distinguish individuals with psychiatric
disabilities are the specific issues arising from their ill-
nesses, and these factors are considered below.
Illness Factors
In the work-related studies on psychiatric disabil-
ity, illness factors that have been examined include di-
agnosis, symptoms, and skill deficits. Although, for the
methodological reasons discussed below, our meta-
analyses focus only on the association between di-
agnosis and vocational outcome, this brief review of
studies that have examined symptoms provides a con-
text for our analyses. Psychiatric diagnosis as a pre-
dictor of work attainment and employment tenure
has resulted in fairly consistent findings. Many stud-
ies that compare vocational outcomes for groups of
individuals with different psychiatric diagnoses con-
clude that people with schizophrenia do demonstrate
poorer vocational outcomes (Ciardiello, 1981; Coryell
& Tsuang, 1985; Massel et al., 1990; Tsuang & Coryell,
1993) and poorer patterns of job retention (Anthony,
Rogers, Cohen, & Davies, 1995; Fabian, 1992; Jacobs
et al., 1992).
Recent research on diagnosis suggests that it is
the symptoms of the illness, rather than the diagnostic
label, that is the most important predictor of outcome,
with many studies reporting that negative symptoms
18:24 Style file version June 22, 2002
Wewiorski and Fabian
and skills deficits are the most significant determi-
nants of outcome. Studies of persons with schizophre-
nia have found negative symptoms to correlate highly
with poor work functioning (Bell & Lysaker, 1995),
to predict occupational functioning 2 years after first
episode (Beng-Choon, Nopoulos, Flaum, Arndt, &
Andreasen, 1998), and to predict occupational func-
tioning 6 years after an index hospitalization (Brier,
Schreiber, Dyer, & Pickard, 1991). In a review of stud-
ies on the functional consequences of neurocognitive
deficits in schizophrenia, Green (1996) concluded that
psychotic symptoms were not associated with occu-
pational functioning, but negative symptoms were.
Although the evidence supporting the relationship
between symptoms and vocational functioning in
schizophrenia seems clear, findings from research on
people with affective disorders are less consistent. For
example, Mintz, J., Mintz, L., Arruda, M., & Hwang,
S. (1992) found that symptoms were strongly corre-
lated with occupational functioning for clients with
affective disorders, whereas Hammen, Gitlin, & Alt-
shuler (2000) found that symptoms correlated only
modestly with occupational functioning among clients
with bipolar disorders. Given the cognitive and so-
cial deficits that are characteristic of schizophrenia-
spectrum disorders (Blanchard, Meuser, & Bellack,
1998; Lenzenweger & Loranger, 1989), it would
be expected that these individuals would encounter
more difficulty in initiating and, particularly, retaining
jobs.
META-ANALYSIS
Meta-analysis is a systematic approach for com-
bining information across related but independent
studies when results from the primary studies can be
represented using a common statistic. The general ap-
proach is to compute an effect size for each study us-
ing extracted data relevant to the variables of interest,
and then to convert to a common statistic that can be
averaged across studies, taking into account sample
size and variability in each individual study.
The second part of this review combines results
across studies and analyzes the extent to which the
factors discussed above, namely age, gender, race, and
diagnosis, are associated with specific vocational out-
comes among persons with severe and persistent men-
tal illness. For each of these variables, meta-analyses
were conducted using available data from reports in
the published literature from 1989 to 2001. On the
basis of the literature reviewed above, we posited
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables
directional hypotheses about persons with severe and
persistent mental illness, extracted appropriate data
from published reports, and then applied meta-
analytic techniques to synthesize the available em-
pirical evidence.
Our initial plan was to examine education and
prior employment, as well. However, these variables
were so inconsistently defined across studies and
so rarely reported with sufficient detail that meta-
analyses were not possible. We also limited our meta-
analyses to U.S. studies to avoid introducing increased
complexity to the measure of the dependent variable,
employment.
Meta-Analytic Methodology
We anticipated that the demographic and diag-
nostic variables of interest here would not be the
major variables examined in most of the published
studies and, thus, to include such studies in our
meta-analyses, we would have to aggregate the data
reported separately for groups in these studies. Con-
sequently, we expected most of the extracted data to
be correlational, and, thus, included studies regardless
of research design if they reported data appropriate
for meta-analysis. We identified potential studies us-
ing an extensive computer-based search of Medline,
PsychINFO, and WebofScience, and also reviewed
reference lists and conducted an exhaustive manual
search of 15 journals in the mental health and vo-
cational area. The following inclusion criteria were
used for selecting studies: (1) results were published
between 1989 and 2001; (2) the study reported data
on a sample of persons with severe and persistent
mental illness in the United States; (3) reported data
included age, race, gender, and/or diagnosis; (4) the
study included a measure of vocational outcome; and
(5) demographic and vocational outcome data were
presented in a form that allowed for the use of meta-
analytic techniques. Studies were excluded if (1) the
reported vocational variables were not clearly de-
fined, (2) the value assignments for age, gender, race,
and/or diagnosis were not clear, or (3) in studies of
broader populations, the results for individuals with
severe and persistent mental illness were not reported
separately.
Our search yielded 21 papers published in 10
refereed journals that reported on the findings of 18
separate studies. Among these 18 studies, one study
(Mueser, 2001) could not be included in any of the
meta-analyses because there were no other studies
18:24 Style file version June 22, 2002
13
that had a matching demographic variable-outcome
variable combination. Thus, 17 studies reported in
20 papers (noted with an asterisk in the reference
list) constituted the sample considered for meta-
analysis. In eight of these studies, subjects received a
vocational intervention.
Studies were coded on methodological, client,
and outcome variables. Methodological variables
included document source, year of publication,
research design, type of intervention (if present),
study sample, data collection method, and clarity of
operational definition of demographic and outcome
variables. Client variables included age, gender (M
= 1; F = 0), race (Caucasian = 1; other = 0), and
diagnosis. Diagnosis was coded according to the
diagnostic groups defined in the study and then, to
maximize the number of studies available for the
meta-analyses, three dichotomized diagnosis vari-
ables were created and coded: (a) schizophrenia vs.
affective disorder; (b) schizophrenia vs. other diagno-
sis; and (c) affective disorder vs. other disorder. After
coding, we sorted studies into sets for meta-analysis.
Among the 17 studies, 10 reported a vocational
outcome by age, 13 reported a vocational outcome
by gender, nine reported a vocational outcome by
race, and nine reported a vocational outcome by
psychiatric diagnosis. As expected, the vocational
outcome variable was not consistent across studies:
nine reported employment status, seven reported at-
tainment of employment; two reported attainment of
competitive employment, two reported employment
status 3 months after job placement; two reported
employment status 6 months after job placement;
and two reported the amount/extent of supported
employment in the past year. When possible, data
was regrouped within studies to create variables that
were consistent across studies, thus maximizing the
number of studies available for meta-analysis.
Sets of studies having comparable variables were
identified and a meta-analysis was conducted when-
ever there were two or more studies with combin-
able data. A separate meta-analysis was conducted
for each set of studies as follows: (a) for each indi-
vidual study, an effect size estimate (r , rho, or phi)
was computed for the relationship between the de-
mographic or diagnostic variable and the vocational
outcome variable, independent of how those variables
were treated in the original study; (b) this statistic was
converted to a common statistic, r , for each study in
the analysis; (c) a weighted average effect size was
computed with each effect size weighted by the in-
verse of its estimated variance; and (d) a confidence
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
14
Table 1. Meta-Analytic Results of Age on Vocational Outcome
Outcome variable Sample (n)
Employment statusa
Fabian (1989) 81
Arns & Linney (1995) 138
Braitman et al. (1995) 179
Dewees, Pulice, & McCormick (1996) 46
Mowbray et al. (1995) 277
Attain employment
Rogers, Anthony, Toole, & Brown (1991) 275
Cook & Razzano (1995) 602
Shafer & Hsaio-Wen (1995) 107
Drake, McHugo, Becker, Anthony, & Clark (1996) 140
Okpaku, Anderson, Sibulkin, & Butler (1997) 152
a Overall effect significant at the level of p < .05.
interval around the weighted mean effect was calcu-
lated and the homogeneity of the overall effect size
was evaluated using the Q statistic. Formulas used and
details for these procedures can be found in Cooper
and Hedges (1994, pp. 233, 237, 238, 265268). Be-
cause all variables except age were dichotomized, the
overall effect sizes were based on a phi coefficient for
all variables except age, which used the Pearson cor-
relation coefficient. This procedure yielded 18 meta-
analyses: two on age, four on gender; three on race;
and nine on diagnosis. It should be noted that two
meta-analyses on gender, one on race, and six on di-
agnosis were computed on only two studies each. All
analyses were based on a fixed effects model using the
specific meta-analytic techniques detailed by Cooper
and Hedges (1994, see chap. 1619).
Meta-Analytic Results
Table 1 presents the results of two meta-analyses
that consider the relationship between age and vo-
cational outcome. In the five studies that reported
the relationship between age and employment sta-
tus, there was a significant overall effect size of .20.
This suggests that being employed is associated with
being younger. As can be seen, although the overall
relationship was negative, there was heterogeneity of
effect size because three of the five studies reported
no effect. For the five studies reporting attainment of
employment as an outcome, age was not found to have
a significant overall effect and generally no effect was
seen in any of these studies.
Table 2 presents the results of four meta-analyses
that consider the relationship between gender and vo-
18:24 Style file version June 22, 2002
Wewiorski and Fabian
Overall effect Homogeneity of
Effect (r ) Significance ( p) (95% CI) effect size?
.201 Q = 82.869
(.275, .127) No
0 .500
.02 .592
.659 >.999
0 .500
0 .500
.018 Q = 0.516
(.037, .073) Yes
0 .500
.040 .164
0 .500
.001 .497
.010 .547
cational outcome. These analyses found no significant
overall effect of gender on employment status, at-
tainment of employment, employment 3 months after
placement, or employment 6 months after placement.
Note that for employment status the heterogeneity of
effect was largely due to one study (Andia et al., 1995)
that showed males as less likely to be employed than
females (n = 85). However, the remaining six of seven
studies showed no significant gender difference, in-
cluding studies with a much larger n than Andia et al.
(1995). Thus, there was an overall nonsignificant re-
sult. For all remaining vocational outcomes, there was
homogeneity of effect across the studies.
Table 3 presents the results of three meta-
analyses that consider the relationship between race
and vocational outcome. Although race was not found
to have a significant overall effect on employment sta-
tus, it was found to have a significant overall effect on
attainment of employment and on employment sta-
tus 6 months after placement. Caucasians were signif-
icantly more likely to attain employment, but persons
of color were more likely to be employed 6 months
after placement. Note that the heterogeneity of effect
for attainment of employment was due to one study
(Shafer & Hsaio-Wen, 1995) that showed an effect of
race in the opposite direction. Also, it should be noted
that even though there was a significant overall effect
for employment status 6 months after placement, this
finding was based on only two studies and these two
studies reported effects in opposite directions.
Table 4 presents the results of three meta-
analyses that consider the relationship between vo-
cational outcome and a diagnosis of schizophrenia
compared to a diagnosis of affective disorder. Results
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004 18:24 Style file version June 22, 2002

Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables 15

Table 2. Meta-Analytic Results of Gender (Male = 1, Female = 0) on Vocational Outcome

Overall effect Homogeneity of
Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size?
.042 Q = 20.953
Employment status (.094, .011) No
Fabian (1989) 81 .035 .622
Andia et al. (1995) 85 .464 .000
Arns & Linney (1995) 138 0 .500
Braitman et al. (1995) 179 .059 .784
Cook & Razzano (1995) 602 .050 .110
Drake et al. (1996) 47 0 .500
Mowbray et al. (1995) 277 0 .500
.043 Q = 2.665
Attain employment (.013, .099) Yes
Fabian (1992) 90 .075 .758
Cook & Razzano (1995) 602 .050 .890
Shafer & Hsaio-Wen (1995) 107 0 .500
Rogers et al. (1991, 1997) 275 0 .500
Okpaku et al. (1997) 152 .105 .902
.024 Q = 0.193
Employed @ 3 months (.144, .192) Yes
Fabian (1992) 90 .007 .474
Shafer & Hsaio-Wen (1995) 52 .078 .709
.044 Q = 0.2584
Employed @ 6 months (.041, .129) Yes
Fabian, 1992 90 .039 .642
Cook & Rosenberg, 1993 448 .045 .829

suggest that persons diagnosed with an affective
disorder are significantly more likely than persons di-
agnosed with schizophrenia to be employed 3 months
after placement. However, neither diagnosis is associ-
ated with significantly better outcome overall in terms
of employment status or amount of competitive em-
ployment in the past year. It should be noted that the
heterogeneity of effect for amount of employment in
the past year is due to one of the two studies reporting
a non-significant finding.
Table 5 presents the results of three meta-
analyses that consider the relationship between vo-
cational outcome and diagnosis with a schizophrenia
spectrum disorder compared to diagnosis with

Table 3. Meta-Analytic Results of Race (Caucasian = 1, Other = 0) on Vocational Outcome

Overall effect Homogeneity of
Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size?
.002 Q = 0.009
Employment status (.087, .091) Yes
Fabian (1989) 81 .012 .458
Arns & Linney (1995) 138 0 .500
Mowbray et al. (1995) 277 0 .500
.080 Q = 12.787
Attain employmenta (.023, .136) No
Fabian (1992) 86 .099 .181
Cook & Razzano (1995) 602 .150 <.001
Shafer & Hsaio-Wen (1995) 86 .222 .980
Rogers et al. (1997) 275 0 .500
Okpaku et al. (1997) 152 .100 .110
.256 Q = 11.246
Employed @ 6 monthsa (.342, .171) No
Fabian (1992) 86 .205 .029
Cook & Rosenberg (1993) 448 .330 >.999
a Overall effect significant at the level of p < .05.
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004 18:24 Style file version June 22, 2002

16 Wewiorski and Fabian

Table 4. Meta-Analytic Results of Diagnosis (Schizophrenia = 1, Affective Disorder = 0) on Vocational Outcome

Overall effect Homogeneity of
Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size?
.048 Q = 1.169
Employment status (.106, .009) Yes
Mowbray et al. (1995) 227 .035 .300
Russo et al. (1997) 797 .061 .043
Drake et al. (1999) 152 0 .500
.214 Q = 2.665
Employed @ 3 monthsa (.415, .013) Yes
Fabian (1992) 64 .335 .003
Shafer & Hsaio-Wen, 1995 37 .026 .561
.129 Q = 9.697
Amt comp empl past yr (.267, .010) No
Tsuang & Coryell (1993) 54 .466 <.001
Drake et al. (1999) 152 0 .500
a Overall effect significant at the level of p < .05.

another disorder. Although a diagnosis of schizophre-
nia was not found to have an overall significant effect
on employment status, two of the three studies did
show a less favorable outcome for those with a di-
agnosis of schizophrenia, albeit not necessarily sig-
nificantly less favorable. The third study showed a
zero effect because a non-significant finding was re-
ported. Thus, the overall non-significant finding may
be due to this one study. Results of the other two
meta-analyses showed that persons with a schizophre-
nia diagnosis were significantly less likely than others
to attain competitive employment or to be employed
3 months after placement. It should be noted that
the heterogeneity of effect for attainment of com-
petitive employment is due to a difference in the
magnitude of the effect, not a difference in direc-
tion of effect between the two studies included in this
analysis.
Table 6 presents the results of three meta-
analyses that consider the relationship between vo-
cational outcome and diagnosis with an affective
disorder. Compared to those with other diagnoses,
individuals diagnosed with an affective disorder were
significantly more likely to be employed. The hetero-
geneity of effect for employment status can be ex-
plained by two of the four studies: one study had a
nearly zero effect and the second had a zero effect
because it reported a non-significant finding. Meta-
analytic results showed that diagnosis with an affec-
tive disorder did not have a significant overall effect
on the vocational outcomes of attaining employment
or being employed 3 months after placement.

Table 5. Meta-Analytic Results of Diagnosis (Schizophrenia = 1, Other Disorder = 0) on Vocational Outcome

Overall effect Homogeneity of
Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size?
.050 Q = 2.979
Employment status (.100, .005) Yes
Mowbray et al. (1995) 256 .111 .038
Russo et al. (1997) 981 .038 .117
Drake et al. (1999) 152 0 .500
.165 Q = 6.056
Attain comp empla (.280, .051) No
Jacobs et al. (1992) 84 .292 .004
Anthony et al. (1995) 215 .113 .049
.212 Q = 2.734
Employed @ 3 monthsa (.387, .036) Yes
Fabian (1992) 87 .305 .002
Shafer & Hsaio-Wen (1995) 44 .001 .502
a Overall effect significant at the level of p < .05.
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004 18:24 Style file version June 22, 2002

Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables 17

Table 6. Meta-Analytic Results of Diagnosis (Affective Disorder = 1, Other = 0) on Vocational Outcome

Overall effect Homogeneity of
Outcome variable Sample (n) Effect (r ) Significance ( p) (95% CI) effect size?
.077 Q = 8.844
Employment statusa (.027, .128) No
Arns & Linney (1995) 138 .220 .005
Mowbray et al. (1995) 256 .002 .487
Russo et al. (1997) 981 .088 .006
Drake et al. (1999) 152 0 .500
.075 Q = 2.136
Attain comp empl (.055, .204) Yes
Jacobs et al. (1992) 84 .199 .035
Okpaku et al. (1997) 152 .005 .474
.148 Q = 1.606
Employed @ 3 months (.028, .323) Yes
Fabian (1992) 87 .234 .015
Shafer & Hsaio-Wen (1995) 44 .038 .597
a Overall effect significant at the level of p < .05.

DISCUSSION icantly less likely to attain employment or to be em-

These meta-analyses synthesize currently avail-
able evidence and provide greater precision and more
detail about our accumulated knowledge concerning
demographics and diagnosis as predictors of voca-
tional outcome for persons with psychiatric disabil-
ities. In general, these meta-analytic findings showed
very small effect sizes for age, gender, race, and diag-
nosis as predictors of vocational outcome. However,
these analyses did produce results that tend to cor-
roborate some of the findings summarized in our gen-
eral overview of the literature. Meta-analytic results
showed that younger people are significantly more
likely to be employed, that Caucasians are signifi-
cantly more likely than persons of color to attain em-
ployment, that persons diagnosed with schizophrenia
generally have poorer vocational outcomes than per-
sons with other diagnoses, and that persons diagnosed
with affective disorders generally have better voca-
tional outcomes than others. An unexpected finding
was that persons of color are significantly more likely
than Caucasians to be employed 6 months after place-
ment. Without further investigation, it is difficult to
interpret this result.
Although the number of studies was very small,
these findings do suggest that diagnosis may be a
predictor of vocational outcome for individuals with
psychiatric disabilities. Meta-analytic results showed
differences between various diagnostic subgroups in
employment status, attainment of employment, and
employment 3 months after placement. Compared
to persons with other psychiatric diagnoses, those
with a schizophrenia spectrum diagnosis were signif-
ployed 3 months after placement. When compared
only to persons with affective disorders, those with
schizophrenia disorders also were significantly less
likely to be employed 3 months after placement. In
addition, individuals with affective disorders were sig-
nificantly more likely to be employed than those with
other diagnoses. It would have been very informative
to be able to go beyond diagnosis and examine func-
tioning or impairment, as well. However, there were
insufficient studies with comparable independent and
dependant variables as well as appropriate data to
conduct such analyses.
As already noted, many of these analyses were
computed on the basis of a very small number of
studies. Thus, the inclusion of just a few more stud-
ies, or even the availability of exact p values from
some of the included studies, could alter these find-
ings relatively easily. In addition, our analyses in-
cluded several studies with a zero effect size because
results were reported as non-significant. Although
this approach allowed for the inclusion of more stud-
ies in the analyses, it also omitted small effect sizes
that may have made a difference in some analy-
ses. Where we found heterogeneity of effect across
studies, the availability of more studies also would
allow for moderator analyses that might help expli-
cate the findings. For example, there may be case-
mix factors, intervention factors, differences in the
racial/ethnic composition of the non-Caucasian sub-
samples, differences in the age ranges of study par-
ticipants, and so forth, that could be explored with
more extensive analysis if the number of studies were
larger.
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
18
Because of the limited number of studies suit-
able for meta-analysis, we needed to define outcome
variables that were quite coarse. For example, we in-
cluded all studies that reported employment status
regardless of when that status was measured, and re-
gardless of the specific characteristics of employment,
such as hours worked, wages earned, or type of job.
Some studies reported employment status at hospital
admission, others reported it as a baseline measure for
a community-based intervention, and yet others re-
ported prevalence in the psychiatric population more
broadly. Attainment of employment was reported as
a follow-up measure to an index hospitalization as
well as an outcome measure of a vocational reha-
bilitation program or other community-based inter-
vention. The intensity or duration of an intervention
was not considered in any of these analyses. The stud-
ies that measured employment status at 3-month and
6-month follow-up time points also varied in the types
of intervention programs and the types of placements
that were provided. If there were a larger number
of studies appropriate for meta-analysis, it might be
possible to perform additional analyses that would ex-
plore some of these variations. With the availability of
more studies, the meta-analyst also might be able to
consider vocational outcome variables that are more
narrowly defined and specific.
Beyond these limitations, we encountered a
problem because of our focus on demographic vari-
ables. Virtually all studies involving human partici-
pants measure age and gender, and many measure
race, as well. The validity and reliability of these mea-
sures tends to be assumed. Common purposes for in-
cluding these variables are to describe the sample, to
evaluate its representativeness of the relevant popu-
lation, and to determine whether there is covariance
that needs to be controlled. Despite the almost uni-
versal inclusion of these variables in research stud-
ies, they generally are not the major variables in a
study. Often, their relationship to other variables are
not reported in detail unless a statistically significant
relationship is found. Access to original datasets or
agreement in the field about standardized reporting
would increase the number of available studies and
would give meta-analysts more precise and more com-
plete data on demographic variables. Having such
data to include in meta-analyses might yield results
that could be reported with greater confidence than
those provided here.
Despite the limitations we encountered, our
analyses do provide some useful findings for the field.
Our meta-analytic findings suggest that there may be
18:24 Style file version June 22, 2002
Wewiorski and Fabian
a need for specific policies and services that address
the unique needs of persons who are older, that pro-
mote employment opportunities for persons of color,
and that recognize and address possible differences
between individuals with schizophrenia and individu-
als with affective disorders in terms of their employ-
ment needs, their opportunities for employment, and
their ability to sustain employment. Some of the dif-
ferences we found between subgroups reflect well-
known inequities in the larger society. This suggests
that change may be needed in social policies, service
systems, program practices, and public attitudes that
differentially affect the vocational outcomes of vari-
ous demographic and diagnostic subgroups. Thus, in-
terventions may need to occur on many levels.
Although this meta-analytic study did find de-
mographic and diagnostic factors that may be impor-
tant in determining the vocational outcome of persons
with psychiatric disabilities, it also revealed a number
of problems and limitations in using this methodology
to synthesize findings from the large body of evidence
accumulated to date. In addition to the problems dis-
cussed above, our effort to synthesize the accumu-
lated literature on vocational outcome also revealed
six general problems and concerns that preclude more
extensive use of this powerful research methodology
in the field of psychiatric vocational rehabilitation
currently.
First, the research literature contains studies that
measure a large number of different employment out-
comes, including placement ratios, job-related factors
(wages earned, hours worked), and job duration. A
consensus around reporting outcomes would be help-
ful in strengthening research studies. As Cook and
Razzano (2000, p. 92) note, the failure to gather
and report data on standard labor force indicators
such as employment status, hourly salary, job tenure
and hours worked per week, has created unevenness
in our knowledge about actual labor force partici-
pation. When the dependent variable varies across
studies, those studies cannot be combined in one
meta-analysis and many separate analyses must be
performed. Thus, a major constraint confronting the
meta-analyst in the psychiatric rehabilitation field is
the inability to synthesize findings across a large num-
ber of existing studies because of differing outcome
variables.
Second, variability in the measurement of the de-
pendent variable also can present challenges to the
meta-analyst. Researchers often measure the same
employment outcome differently. For example, stud-
ies measure employment outcome as a variable that
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables
is continuous, dichotomous, or categorical, different
studies use different categories or break points for the
same outcome variable, and so forth. Sometimes the
meta-analyst can overcome this problem by redefin-
ing outcome variables into a common variable, such as
a dichotomous variable. But, often the problem can-
not be resolved and studies must be excluded from
analysis.
Third, studies also vary in the amount of detail
given about the data and about the results of statistical
analyses. Published reports often do not provide ef-
fect sizes. For example, numerous studies report find-
ings as significant or not significant without giv-
ing exact values. To include such studies, the meta-
analyst typically uses the conservative approach of
entering zero effect sizes into an analysis. This limits
the precision of the data entered into a meta-analysis
and yields meta-analyses with limited power to detect
effects that actually may exist.
Fourth, even when studies have clearly defined
independent and dependant variables and report de-
tailed statistical results, there can be a problem be-
cause relationships between the independant and
dependant variables of interest are not reported in
a form appropriate for combining findings across
studies. The outcome variable may be analyzed
and reported using comparative parametric statistics,
repeated measures or time series analysis, survival
analysis, regression procedures, or many other statis-
tical techniques and procedures. A particular problem
is that many well-designed studies in the psychiatric
rehabilitation field report the results of multivariate
analyses without also reporting the results of uni-
variate analyses. This very common reporting prac-
tice precludes the use of these data for future meta-
analyses.
Fifth, much of the intervention research con-
ducted in the psychiatric rehabilitation field tends to
be quasi-experimental at best. Sample sizes are fre-
quently small and often drawn from a single program.
In addition, the intervention often is not clearly de-
fined and, even when it is, fidelity of implementation
is not measured. When intervention studies do not in-
clude statistical controls, it is difficult to determine if
the psychiatric illness accounts for the outcomes, or
whether the outcomes are determined by other fac-
tors, such as socioeconomic status, race, or age. Thus,
many intervention studies are of questionable quality
for inclusion in meta-analyses concerned with assess-
ing overall treatment effects.
Sixth, much of the body of psychiatric rehabilita-
tion research consists of atheoretical empirical inves-
18:24 Style file version June 22, 2002
19
tigations. Although this issue may not seem of major
concern, it has hindered the development of a uni-
fied research agenda in this area. As one of the major
purposes of meta-analysis is to advance theory, the
fact that researchers are not also focusing on theory
development, or the application of existing theories,
to help explain vocational behavior and vocational
outcomes of the psychiatrically disabled population
ultimately limits our capacity to devise effective poli-
cies and practices (Fabian, 2000). There is a need to
understand which factors are relevant and how they
operate in determining vocational outcome.
As a final point, we emphasize the importance of
considering these findings in the context of employ-
ment outcomes for individuals with psychiatric dis-
abilities. As reviewed earlier, people with significant
psychiatric disabilities are marginally represented in
the labor market, and overrepresented in Social Se-
curity Disability Income Support programs. Nonethe-
less, research that focuses on the relationship between
specific factors and employment outcome eventually
will enable us to build theoretical models that will
contribute to a body of knowledge concerning what
works and for whom.
CONCLUSION
Meta-analysis and research synthesis techniques
are powerful research tools that are underutilized in
the psychiatric rehabilitation field. To make better use
of these methodologies, investigators must become
more conscientious and consistent in defining and se-
lecting variables for study, consider the implications
for further analysis when analyzing their data and re-
porting the results, and conduct methodologically rig-
orous studies that are designed not only to inform
various stakeholders, but also to advance theory.
The field of psychiatric vocational rehabilitation
needs to increase its understanding of the complex
process of obtaining and sustaining employment with
the acknowledgment that this process may not be
uniform across various demographic and diagnostic
subgroups within the population of persons with psy-
chiatric disabilities. This requires studies that do not
assume homogeneity, but that explore subgroup dif-
ferences, that identify interventions that are effective
with subgroups, and that identify factors outside the
MH/VR service system that may be relevant in de-
termining the employment success of various demo-
graphic subgroups. In general, researchers in this area
need to focus their studies on the development of
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
20
theories that help solve the puzzle about who achieves
employment success and how that success is achieved.
This calls for a research agenda that employs a variety
of methods to explore all possible explanatory theo-
ries, included theories that consider age, gender, race,
and diagnosis as possible determinants of vocational
outcome.
ACKNOWLEDGMENTS
This study was supported by the National Insti-
tute on Disability and Rehabilitation Research within
the Department of Education, and the Center for
Mental Health Services (CMHS), a division of the
Substance Abuse and Mental Health Services Admin-
istration (Grant # H133B40024). The findings and in-
terpretation of the data expressed in this paper do
not necessarily represent the views of NIDRR or
the CMHS, but are the sole responsibility of the au-
thors. The authors also acknowledge the contribution
of Joseph Massaro in reviewing and interpreting the
meta-analytic results.
REFERENCES
References marked with an asterisk indicate studies included in the
meta-analyses.
Andia, A. M., Zisook, S., Heaton, R., Hesselink, J., Jernigan, T.,
Kuck, J., et al. (1995). Gender differences in schizophrenia.
The Journal of Nervous and Mental Disease, 183(8), 522528.
Anthony, W. A. (1994). Characteristics of people with psychiatric
disabilities that are predictive of entry into the rehabilitation
process and successful employment. Psychosocial Rehabilita-
tion Journal, 17, 313.
Anthony, W. A., Cohen, M. R., & Farkas, M. D. (1990). Psychiatric
rehabilitation. Boston, MA: Boston University Center for Psy-
chiatric Rehabilitation.
Anthony, W. A., & Jansen, M. A. (1984). Predicting the vocational
capacity of the chronically mentally ill: Research and policy
implications. American Psychologist, 39, 537544.
Anthony, W. A., Rogers, E. S., Cohen, M., & Davies, R. R.
(1995). Relationships between psychiatric symptomatology,
work skills and future vocational performance. Psychiatric
Services, 46, 353358.
Arns, P., & Linney, J. A. (1995). Relating functional skills of
severely mentally ill clients to subjective and societal benefits.
Psychiatric Services, 46, 260265.
Baron, R. C. (2000). The past and future career patterns of peo-
ple with serious mental illness: A qualitative inquiry. Mono-
graph of the National Institute of Disability and Rehabilitation
Research (H133F980011).
Baron, R., & Salzer, M. S. (2002). Accounting for unemployment
among people with mental illness. Behavioral Science Law, 20,
585599.
Becker, D. R., Drake, R. E., Bond, G. R., Xie, H., Dain, B. J.,
& Harrison, K. (1998). Job terminations among persons with
severe mental illness participating in supported employment.
Community Mental Health Journal, 34(1), 7182.
18:24 Style file version June 22, 2002
Wewiorski and Fabian
Bell, M., & Lysaker, P. H. (1995). Psychiatric symptoms and work
performance among persons with severe mental illness. Psy-
chiatric Services, 46, 508510.
Beng-Choon, H., Nopoulos, P., Flaum, M., Arndt, S., & Andreasen,
N. C. (1998). Two-year outcome in first-episode schizophre-
nia: Predictive value of symptoms for quality of life. American
Journal of Psychiatry, 155, 11961201.
Blanchard, J. J., Meuser, K. T., & Bellack, A. S. (1998). Anhe-
donia, positive and negative affect, and social functioning in
schizophrenia. Schizophrenia Bulletin, 24, 413424.
Bond, G. R., Becker, D. R., Drake, R. E., Rapp, C. A., Meisler, N.,
Lehman, A. F., et al. (2001). Implementing supported employ-
ment as an evidence-based practice. Psychiatric Services, 52,
313323.
Braitman, A., Counts, P., Davenport, R., Zurlinden, B., Rogers,
M., Clauss, J., et al. (1995). Comparison of barriers to employ-
ment for unemployed and employed clients in a case manage-
ment program: An exploratory study Psychiatric Rehabilita-
tion Journal, 19(1), 38.
Breier, A., Schreiber, J. L., Dyer, J., & Pickard, D. (1991). Na-
tional Institute of Mental Health longitudinal study of chronic
schizophrenia. Archives of General Psychiatry, 48, 239246.
Brown, M. T. (1995). The career development of African Ameri-
cans: Theoretical and empirical issues. In F.T. Leong (Ed.), Ca-
reer development and vocational behavior of racial and ethnic
minorities (pp. 536). Mahwah, NJ: Erlbaum.
Bybee, D., Mowbray, C. T., & McCrohan, N. M. (1995). Towards
zero exclusion in vocational services for persons with psychi-
atric disabilities: Prediction of service receipt in a hybrid vo-
cational/case management service program. Psychosocial Re-
habilitation Journal, 18, 7393.
Carpenter, W. T., & Strauss, J. S. (1991). The prediction of outcome
in schizophrenia IV: Eleven year follow-up of the Washington
IPSS cohort. Journal of Nervous and Mental Disease, 179, 517
525.
Ciardiello, J. (1981). Job placement success of schizophrenic clients
in sheltered workshop programs. Vocational Evaluation and
Work Adjustment Bulletin, 14, 125129.
Cook, J. A., Pickett-Schenk, S. A., Grey, D., Banhart, M., Rosen-
heck, R. A., & Randolph, F. (2001). Vocational outcomes
among formerly homeless persons with severe mental illness
in the ACCESS Program. Psychiatric Services, 52, 10751080.
Cook, J. A., & Razzano, L. (1995). Discriminant function analysis
of competitive employment outcomes in a transitional employ-
ment program for persons with severe mental illness Journal
of Vocational Rehabilitation, 5, 127139.
Cook, J. A., & Razzano, L. (2000). Vocational rehabilitation for
persons with schizophrenia: Recent research and implications
for practice. Schizophrenia Bulletin, 26(1), 87103.
Cook, J. A., & Rosenberg, H. (1993). Predicting community em-
ployment among persons with psychiatric disability: A logistic
regression analysis Journal of Rehabilitation Administration,
18(1), 625.
Cooper, H., & Hedges, L. (Eds.). (1994). The handbook of research
synthesis. New York, NY: Russell Sage.
Coryell, W., & Tsuang, M. T. (1985). Major depression with mood
congruent or mood incongruent psychotic features: Outcome
after 40 years. American Journal of Psychiatry, 142, 479482.
Coursey, R. D., Safajan, B., & Alford, J. (1997). Significant advances
in understanding and treatment serious mental illness. Profes-
sional Psychology: Research and Practice, 28, 205216.
Daradkey, T. K., & Karim, L. (1994). Predictors of employment
status of treated patients with DSM IIIR diagnosis. Can logis-
tic regression find a solution? International Journal of Social
Psychiatry, 40, 141149.
Dewees, M., Pulice, R. T., & McCormick, L. L. (1996). Commu-
nity integration of former state hospital patients: Outcomes
of a policy shift in Vermont Psychiatric Services, 47(10), 1088
1092.
P1: GAD
Mental Health Services Research (MHSR) pp1093-mhsr-479624 January 6, 2004
Demographic and Diagnostic Factors and Employment Outcomes for Psychiatric Disables
*Drake, R. E., McHugo, G. J., Becker, D. R., Anthony, W. A., &
Clark, R. E. (1996). The New Hampshire study of supported
employment for people with severe mental illness. Archives of
General Psychiatry, 56, 627633.
Drake, R. E., McHugo, G. J., Bebout, R. R., Becker, D. R., Harris,
M., Bond, G. R., et al. (1999). A randomized clinical trial of sup-
ported employment for inner-city patients with severe mental
disorders. Journal of Consulting and Clinical Psychology, 64,
391399.
Fabian, E. S. (1989). Work and the quality of life. Psychosocial
Rehabilitation Journal, 12(4), 3949.
Fabian, E. (1992). Longitudinal outcomes in supported employ-
ment: A survival analysis. Rehabilitation Psychology, 37(1),
2335.
Fabian, E. (2000). Applying social cognitive career theory to in-
dividuals with psychiatric disorders. Psychiatric Rehabilitation
Journal, 23, 262269.
Goldberg, R. W., Lucksted, A., McNary, S., Gold, J. M., Dixon,
L., & Lehman, A. (2001). Correlates of long-term unemploy-
ment among inner-city adults with serious and persistent men-
tal illness. Psychiatric Services, 52, 101103.
Green, M. F. (1996). What are the functional consequences of
neurocognitive deficits in schizophrenia? American Journal of
Psychiatry, 153, 321330.
Hackett, N., & Byars, A. (1996). Social cognitive theory and the
career development of African American women. The Career
Development Quarterly, 44, 310321.
Hammen, C., Gitlin, M., & Altshuler, L. (2000). Predictors of work
adjustment in Bipolar I patients: A naturalistic longitudinal
follow-up. Journal of Consulting and Clinical Psychology, 68,
220225.
Harding, C. M., Brooks, G. W., Takamaru, A., Strauss, J. S., & Breier,
A. (1987). The Vermont longitudinal study of persons with
severe mental illness: II. Long-term outcomes of participants
who retrospectively met DSM III criteria for schizophrenia.
American Journal of Psychiatry, 144, 727735.
Hennessey, J. C. (1997). Factors affecting the work efforts of
disabled-worker beneficiaries. Social Security Bulletin, 60, 3
19.
Jacobs, H. E., Wissusik, D., Collier, R., Stackman, D., & Burkeman,
D. (1992). Correlations between psychiatric disabilities and
vocational outcome. Hospital and Community Psychiatry, 43,
365369.
Kochlar, S., & Scott, C. G. (1995). Disability patterns among SSI
recipients. Social Security Bulletin, 58, 314.
LaPlante, M., & Carlson, D. (1996). Disability in the United
States: Prevalence and causes. (Disability Statistics Report 7).
Washington, DC: U.S. Department of Education, National In-
stitute on Disability and Rehabilitation Research.
Lehman, A. F., Goldberg, R., Dixon, L. S., McNary, S., Postrado, L.,
Hackman, A., et al. (2002). Improving employment outcomes
for persons with severe mental illness. Archives of General
Psychiatry, 59, 165172.
Lent, R., & Brown, S. (1996). Social cognitive approach to career
development: An overview. Career Development Quarterly,
44, 310321.
Lent, R., Brown, S., & Hackett, G. (1994). Toward a unifying social
cognitive theory of career and academic interest, choice and
performance [Monograph]. Journal of Vocational Behavior,
45, 79122.
Lenzenweger, M. F., & Loranger, A. W. (1989). Psychosis proneness
and clinical psychopathology: Examination of the correlates of
schizotypy. Journal of Abnormal Psychology, 98(1), 38.
Massel, H., Liberman, R., Mintz, J., Jacobs, H., Rush, T., Gianni, C.,
et al. (1990). Evaluating the capacity to work in the mentally
ill. Psychiatry, 53, 3143.
Mintz, J., Mintz, L., Arruda, M., & Hwang, S. (1992). Treatments
of depression and the functional capacity to work. Archives of
General Psychiatry, 49, 761768.
Moriarty, P. J., Lieber, D., Bennett, A., White, L., Parrella, M.,
18:24 Style file version June 22, 2002
21
Harvey, P. D., et al. (2001). Gender differences in poor out-
come patients with lifelong schizophrenia. Schizophrenia Bul-
letin, 27, 103113.
Mowbray, C. T., Bybee, D., Harris, S. N., & McCrohan, N. (1995).
Predictors of work status and future work orientation in people
with a psychiatric disability. Psychiatric Rehabilitation Journal,
53, 3142.
Mueser, K. T., Salyers, M. P., & Mueser, P. R. (2001). A prospective
analysis of work in schizophrenia. Schizophrenia Bulletin, 27,
281296.
Muller, L. S. (1992). Disability beneficiaries who work and their
experience under program work incentives. Social Security
Bulletin, 55, 219.
National Institute on Disability and Rehabilitation Research.
(1992). Strategies to secure and maintain employment for
people with long-term mental illness. Washington, DC: Na-
tional Institute on Disability, and Rehabilitation Research,
Rehabilitation Services Administration, U.S. Department of
Education.
National Institute on Disability and Rehabilitation Research.
(1997). Trends in labor force participation among persons with
disabilities, 19831994. (Report 10), Washington, DC: U.S.
Department of Education, Office of Special Education and
Rehabilitation Services.
Okpaku, S. O., Anderson, K. H., Sibulkin, A. E., & Butler, J. S.
(1997). The effectiveness of a multidisciplinary case manage-
ment intervention on the employment of SSDI applicants and
beneficiaries. Psychiatric Rehabilitation Journal, 20(3), 3441.
Rogers, E. S., Anthony, W. A., Cohen, M., & Davies, R. R. (1997).
Prediction of vocational outcome based on clinical and demo-
graphic indicators among vocationally ready clients. Commu-
nity Mental Health Journal, 33, 99112.
Rogers, E. S., Anthony, W. A., Toole, J., & Brown, M. A. (1991).
Vocational outcomes following psychosocial rehabilitation: A
longitudinal study of three programs. Journal of Vocational
Rehabilitation, 1(3), 2129.
Rucker, K. S., Wehman, P., & Kregel, J. (1996). Analysis of func-
tional assessment instruments for disability/rehabilitation pro-
grams (Report on findings and recommendation for future di-
rections). Baltimore, MD: Social Security Administration.
Russo, J., Roy-Byrne, P., Reeder, D., Alexander, M., Dwyer-
OConnor, E., Dagadakis, C., et al. (1997). Longitudinal as-
sessment of quality of life in acute psychiatric inpatients: Reli-
ability and validity. The Journal of Nervous and Mental Disease,
185(3), 166175.
Scott, C. G. (1992). Disabled SSI recipients who work. Social Secu-
rity Bulletin, 55, 2636.
Shafer, M. S., & Hsaio-Wen, H. (1995). The utilization of survival
analyses to evaluate supported employment services. Journal
of Vocational Rehabilitation, 5, 103113.
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy
outcome studies. American Psychologist, 32, 752760.
Strauss, J., & Carpenter, W. (1972). The prediction of outcome in
schizophrenia. Archives of General Psychiatry, 27, 739746.
Tsang, H., Bacon, N., Chiu, I. Y., & Mann, S. (2000). Predictors
of posthospital employment status for psychiatric patients in
Hong Kong: From perceptions of rehabilitation professionals
to empirical evidence. International Journal of Social Psychia-
try, 46, 306312.
Tsang, H., Lam, P., Ng., B., & Leung, O. (2000). Predictors of em-
ployment outcome for people with psychiatric disabilities: A
review of the literature since the mid-80s. Journal of Rehabil-
itation, 66, 1931.
Tsuang, D., & Coryell, W. (1993). An 8-year follow-up of patients
with DSM-III-R psychotic depression, schizoaffective disor-
der, and schizophrenia. American Journal of Psychiatry, 150,
11821188.
United States Department of Labor. (2001). Report on the Amer-
ican workforce. Washington, DC: Author. http://www.bls.
gov/opub