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Schizophrenia at School and Work

People living with schizophrenia often suffer from systematic underemployment. The stigma around mental health can cause many employers and governing bodies to misunderstand the condition and their suitability for employment. We include some key suggestions for employers, families, HCPs and institutions to improve the disparity in employment for people with schizophrenia.

People with long-term mental health conditions, including schizophrenia, experience barriers to work, due to stigma, prejudice, and discrimination.1 Despite the fact that the public is becoming more educated in general about mental health, stigma still exists when it comes to schizophrenia. Some believe that people living with schizophrenia are likely to be violent, that they cannot hold steady employment and/or that their behaviour could change suddenly and unexpectedly.2

Schizophrenia usually appears between ages 18 and 35, just when most individuals are in college or laying the foundations of their careers.3 Receiving a diagnosis of schizophrenia seems daunting and might hinder someone’s plans, as they may never receive the education or training needed for success. Schizophrenia is therefore seen as having a crucial impact on their educational and employment opportunities. For those who are in work, symptoms of the illness, side effects of the treatment and relapse may affect their ability to remain employed.4

Several studies illustrated that schizophrenic patients in paid employment are over five times more likely to achieve functional remission than those who are unemployed or in unpaid employment. 5,6 Despite repeatedly expressing the need for job training, placement and support services, this group encounters one of the highest unemployment rates among all vocationally disadvantaged groups.7 Competitive employment rates in schizophrenia are low compared with the general population, with most estimates in the United States and Europe indicating fewer than 20% of people with schizophrenia are working.8 Surveys of consumers with schizophrenia indicate dissatisfaction with the low employment rates, with 55%−70%, indicating an interest in work.9

The costs of unemployment are high in this population, not only in financial means, but also in terms of not getting a socially valuable role and the deprivation of clinical benefits, such as better self-esteem and self-efficacy.10 Furthermore, the promise of work holds the potential for reducing or eliminating disability income payments to at least some individuals in the community.11


Several factors have the potential to affect the employment of people with schizophrenia and response to vocational rehabilitation.12

Cognitive impairment: Cognitive impairment is often present in schizophrenia and presents not only clinical, but also functional significance, evident in a broad range of domains such as attention, memory, executive functioning, and information processing speed.12 It has been recognized as the most problematic factor in terms of work, highlighting difficulties with interpersonal relationships, difficulties with executive function or cognitive impairments, particularly processing and learning new tasks.13

Substance-Induced Disorders: Substance abuse and dependence are highly prevalent in schizophrenia and have been associated with a worse course of severe mental illness, including more relapses and hospitalizations, poorer psychosocial functioning, and more issues related to legislation, health, and housing.14

Physical illness: People living with schizophrenia are more vulnerable to physical illnesses, such as metabolic effects as an adverse outcome of antipsychotic medicines or the adaption of an unhealthy lifestyle, as reflected by behaviors such as high rates of smoking, inactivity, and poor diet.15

For those, who are able to work, there are several benefits of employment, such as financial independence, social contact and improved self-esteem.16 Work is one of the main ways in which people interact with the society they live in and it provides social contact and the opportunity to make new friends. In addition, by being given responsibility in a job, patients will feel more valued and that they have a purpose in life. People suffering with psychosis score very poorly in studies designed to assess their purpose-in-life, which might drive them to substance abuse and/or suicide attempts. 17

Because employment rates among people with schizophrenia are significantly low, efforts tend to focus on getting those who are unemployed into work, rather than supporting those already in education or employment.7 With more timely interventions, it should be possible for those young people with schizophrenia still in education to manage the transition to the world of work and for those people who receive a diagnosis while in a job to stand a better chance of retaining it.5,18

Moreover, many people with schizophrenia are very motivated to work, but expectations about employment among stakeholders vary significantly and many people have low expectations about how well an individual with schizophrenia would be able to adapt to long-term, competitive employment, and often it is not seen as an achievable outcome. Stigma by others often leads to self-stigma, impacting on their initial motivation. 6

Despite the considerable barriers to employment faced by many people with a diagnosis of schizophrenia, the pathways to employment, recovery and inclusion are clear. The solutions lie in the hands of many stakeholders and efforts should be made by several sectors, such as:

Employers: They should ensure that they are sufficiently well-informed and prepared to respond if an employee discloses that they have schizophrenia or another serious mental health condition. In addition, they should enhance disclosure in the organization’s culture and make adjustments to accommodate the needs of people with schizophrenia.

Family and carers: An individual’s support network can make a crucial difference to outcomes for people with mental health conditions such as schizophrenia. Their task should be to support patients’ aspirations and goals and get access to services that offer support to people with schizophrenia and their families, such as those organized by patient advocacy organisations, charities and employment support bodies.

Healthcare professionals: They should ask patients about their work history and career aspirations at the earliest opportunity and provide peer-support service. Employment should be taken into consideration when making decisions about treatment. They should advise career specialists on pathways back to employment and reinforce clinical interventions. They should also support self-management and return to work, as well as providing opportunities for empowerment of people with mental health conditions, though using their experience to help others.

Government: Policy-makers should develop a regional, national or wider-applicable plan to increase employment rates of people with severe mental health conditions. It is essential that each national Government establishes a task force of multi-disciplinary experts, from both the Department of Health and the Department of Work and Pensions, aiming to increase employment rates to 25% within a decade.19

Overall, schizophrenia affects every individual differently. Illness-related factors, such as the onset and type of symptoms, the timing of the diagnosis, and co-morbidities, social factors and available support networks, all vary by each case. Because no individual with schizophrenia is the same, it is challenging to develop an employment support service strategy that would work for everyone.4

An inclusive labour market populated with inclusive workplaces is needed, supported by a healthcare and welfare system which prioritises good quality work as a clinical outcome.

References

  1. Boardman et al. Br J Psychiatry. 2003; 182:467-8.
  2. Farkas. World Psychiatry. 2007;6:4–10.
  3. Cheng et al. Psychological Medicine. 2011;41:949–958.
  4. https://councilfordisabledchildren.org.uk/sites/default/files/uploads/documents/import/working_with_schizophrenia.pdf
  5. Mueser et al. Schizophr Bull. 2001;27:281–296.
  6. Marwaha and Johnson. Soc Psychiatry Psychiatr Epidemiol. 2004; 39(5):337-49.
  7. Rosenheck et al. Am J Psychiatry. 2006;163:411–417.
  8. Salkever et al. Psychiatr Serv. 2007;58:315–324.
  9. Holley et al. Psychiatr Serv. 1998; 49:513–517.
  10. Bond et al. J Consult Clin Psychol. 2001;69:489–501.
  11. Bell et al. Schizophr Bull. 1996;22:51–67. 
  12. Mc Gurk et al. Schizophr Bull. 2009; 35(2): 319–335.
  13. https://councilfordisabledchildren.org.uk/sites/default/files/uploads/documents/import/working_with_schizophrenia.pdf
  14. Drake and Brunette. Recent Dev Alcohol. 1998; 14():285-99.
  15. Meyer et al. Schizophr Res. 2008 Apr; 101(1-3):273-86.
  16. Pharoah et al. Cochrane Database Syst Rev. 2010; (12): CD000088.
  17. Warner R,. The Env of Schizophr, 2000 ; P71.
  18. Schulze et al. Social Science & Medicine. 2003; 56(2): 299-312.
  19. Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, & Turning Point. 2012.
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