Employment rates for patients with psychosis are low, but vary partly depending on illness phase. European studies have reported employment rates between 13 and 65 % for patients with first-episode psychosis (FEP) and 10-20 % for patients with chronic schizophrenia. The first aim of the thesis was to identify the number of patients with psychosis who were working or studying. The thesis included two different FEP samples from the Early Treatment and Identification of Psychosis (TIPS) project and the Thematically Organized Psychosis (TOP) project, and a sample of patients with a longer duration of illness from the TOP project.
Patients from the TIPS project were followed over a two year period, while data from the TOP project were assessed cross-sectionally. We found 41 % of the FEP patients from the TIPS study to be working, while 49 % of the FEP patients from the TOP study were working, including students. For patients with a longer duration of illness, 13 % reported to be working or studying.
Research has reported a strong relationship between neurocognition, negative symptoms and occupational functioning. The association between neurocognition and occupational functioning has, however, mainly been found in more chronic patient groups. Fewer corresponding studies have been conducted on patients with FEP, and these have reported more ambiguous results. Hence, the second aim of the thesis was to investigate the association between neurocognition, symptoms and employment status in patients with psychosis both cross-sectionally and longitudinally. We found no relationship between neurocognition, symptoms and employment status measured cross-sectionally for patients in different illness phases. Investigating the relationship in a longitudinal design for FEP patients revealed that sustained attention predicted employment at two year follow-up.
There is no clear consensus in the literature on how to define employment. Most often a dichotomous division of employment and unemployment has been used that may fail to reflect differences in level of functioning within the groups. Thus, the third aim of the thesis was to elaborate the division of employment and unemployment by investigating the level of functioning first, in a group of students and second, in patients receiving disability benefits. We found that the students and employed patients performed better than unemployed patients on measures of clinical, global and social functioning, while there were no differences between the students and employed patients. For patients receiving disability benefits, the group was divided based on social functioning. The subgroup of patients with higher social functioning was more similar to employed patients than those on disability benefits with lower social functioning. Patients on disability benefits with higher social functioning were characterized by fewer negative symptoms and better executive functioning.
These findings suggest first, that employment rates for patients in different illness phases of psychosis are low, but higher for patients with FEP relative to patients with a longer duration of illness. Second, that the association between neurococognition and employment status may not be as strong as previously reported, at least not when measured cross-sectionally. Alternatively, there may be other internal and/ or external factors influencing this relationship. Third, the results pose an argument for investigating subgroups of employment. For those receiving disability benefits, there may be a subgroup with higher social functioning that has some work capacity.
The current findings underline the need for future studies that investigate internal and external rate-liming factors for employment both cross-sectionally and longitudinally for patients with psychosis. Further, the results underline the importance of investigating subgroups of employment and also evaluating potential work capacity within these groups.