In today’s fast-paced world, the relationship between employment and mental health has never been more crucial. Not only does employment provide financial stability, but also a sense of purpose, social connection, and routine. Consequently, those who are unemployed are more likely to experience chronic mental health difficulties (Zuelke et al., 2018). This blog explores the importance of employment support alongside psychological therapy to reduce severe anxiety and depression in populations receiving welfare benefits.

Generally, evidence-based psychological therapies have been shown to be an effective treatment for anxiety and depression, with over 50% of people being categorised as in ‘clinical recovery’ following a course of treatment (Oparina et al., 2024). However, the same cannot be said for unemployed populations. In fact, evidence has shown that treatments in NHS Talking Therapies (NHSTT; previously known as Improving Access to Psychological Therapies or IAPT) services have been less effective for unemployed adults aged 40+ who are receiving welfare benefits, have high depression and anxiety scores, and are taking prescribed medication (referred to in Thew et al.’s paper as ‘latent profile 7’ [LP7]; Saunders et al., 2016; 2020). This clinical population have been shown to have a 15-18% rate of recovery, compared to recovery rates as high as 73% in other clinical populations.

Whilst previous research has explored the benefits of employment support or Individual Placement and Support (IPS) for those with more severe mental health conditions such as psychosis and bipolar (read John Baker’s blog on individual placement and support for mental health vocational rehabilitation and Andy Bell’s blog on interventions to improve social circumstances among people with mental health conditions to learn more) there is limited research investigating the effect of employment support on clinical outcomes alongside psychological therapy for anxiety and depression in primary care settings.

Methods

Thew et al. (2024) used a case control design to observe the differences in post-therapy clinical scores (GAD-7 for anxiety and PHQ-9 for depression) between those who received employment support alongside their therapy (n = 66), and those who declined the offer for additional employment support (n = 236).

All participants were identified through the NHSTT database for Berkshire, Buckinghamshire, and Oxfordshire, and were included if they attended two or more psychological therapy sessions and met the characteristics of the well-defined target population (LP7; from Saunders’s et al. (2020)). Participants were categorised as receiving employment support if they attended at least one employment support session; on average, these participants completed 3.08 employment sessions.

Participants were deemed to be in clinical recovery if they fell below NHSTT’s standardised clinical threshold (<8 on the GAD-7; Spitzer et al., 2006) or depression (<10 on the PHQ-9; Kroenke et al., 2001), following treatment. Data was then analysed using a 2-step logistic regression to:

1. See if employment support was significantly related to recovery outcome.
2. Account for possible confounds (having a long-term health condition, length of treatment, demographics, baseline clinical scores, and presenting difficulty) in recovery rates.

Results

A total of 302 participants were recruited for the current study, with an average age of 41.98 years (SD = 11.26) and the majority identifying as White (n = 220) and female (n = 202).

31% (95/302) of the overall LP7 sample met NHSTT’s definition of recovery; 47%  (31/66) of those receiving employment support were in clinical recovery, while only 27% (64/236) of those who declined employment support were in clinical recovery.

Results from the logistic regression found that receiving employment support alongside psychological therapy was significantly associated with recovery in the sample (OR = 2.82, 95% CI [1.56 to 5.08], p < .001). This significant association remained after controlling for possible confounding variables (OR = 2.54, 95% CI [1.32 to 4.89], p = .005):

Conclusions

Overall, the results from Thew et al. (2024) suggest that receiving employment support alongside psychological therapy may help the LP7 population – who are typically vulnerable to poor treatment outcomes – beat the odds of recovery from depression and anxiety.

Strengths and limitations

This was a good quality case control study using a pre-validated algorithm to identify a well-defined target population who are typically vulnerable to poor treatment outcomes. The study uses standardised, valid and reliable measures to show the benefits of employment support alongside psychological therapy, increasing the trustworthiness of the findings. The findings also have practical relevance, highlighting easily accessible avenues for improving treatment outcomes for this vulnerable population.

However, a main limitation of this study is that participants were not randomly allocated to receiving employment support; instead, they opted into receiving employment support, which means they were aware of which treatment they were receiving. This could lead to self-selection and ascertainment bias. Whilst the authors took the necessary steps in data analysis to account for possible confounds in the results, some were missed – including the possibility that those who opted into receiving employment support may have been more engaged with the service, and potentially more likely to benefit from the treatment. To better determine whether the addition of employment support leads to improved chances of recovery, a randomised controlled trial is warranted.

Similarly, therapist effects (of the employment workers and therapists) were not measured during this study, despite the relationship between therapist and client being a major contributor to a client’s engagement (Hubbert et al., 2001; Keijsers et al., 2000). Such performance bias may have confounded the results and seems to be an oversight. Whilst some explanation around what employment support entails is offered in the referenced paper (Department of Work and Pensions, 2019), there appears to be wide variation in how this is delivered by employment advisors to the brevity on employment advice guidance. This again calls into question the validity of the current findings and may be problematic for others attempting to replicate the study or intervention itself.

An important extension of this study would be to explore the generalisability of these findings in other geographical areas. The current study only includes a small geographical area of the South-East UK, which is reported to have the highest employment rates in the UK (Office of National statistics, 2024). It would be interesting to see if these results could be replicated in other counties with lower employment rates, for example the East Midlands.

Finally, the study found wide confidence intervals (e.g., 1.56 to 5.08), which indicate instability and reduce how conclusive we can be regarding the treatment effect. This means that the title of the paper, “The addition of employment support alongside psychological therapy enhances the chance of recovery for clients most at risk of poor clinical outcomes”, is an overstatement, and more research is needed to support the reliability of the findings.

Implications for practice

The current research highlights the potential importance of NHSTT services identifying LP7 populations within their service, and prompting their clinicians to offer employment support alongside psychological therapy in a way which clearly highlights the benefits.

It should be noted that introducing a policy whereby NHSTT must identify all LP7 populations may be time and resource consuming. It may be more efficient to introduce a policy whereby any clients who disclose employment difficulties, or receipt of welfare benefits, are given information about the benefits of employment support alongside psychological therapy and given the option to enrol. Further research would be needed to identify how to integrate this.

This paper is particularly relevant to practice, as NHS England are currently in the process of rolling out employment pathways for all NHSTT services nationally. It will be interesting to see how this impacts mental health recovery rates across the nation. In fact, my own service, Staffordshire Talking Therapies, recently implemented their own employment service last year. Not only have we seen extremely promising improvements in our own recovery rates, but service users have reported that the employment service has helped grow their self-confidence, prevented their mental health from spiralling further downwards, and helped them break cycles of unemployment.

However, there is still a long way to go in understanding how employment support might be beneficial within NHSTT services. The current research highlights the need for further qualitative and longitudinal studies on the effects of employment support alongside therapy, as many questions remain, such as:

• How is employment support improving recovery rates?
• Is this only effective if the end result leads to the client finding work?
• Does this reduce the number of future episodes of care?
• What are the perceived barriers to engaging with employment support?

Statement of interests

I declare that the blog was written in absence of any commercial or financial conflicts of interest.

Links

Primary paper

Thew, G. R., Popa, A., Allsop, C., Crozier, E., Landsberg, J., & Sadler, S. (2024). The addition of employment support alongside psychological therapy enhances the chance of recovery for clients most at risk of poor clinical outcomes. Behavioural and Cognitive Psychotherapy, 52(1), 93-99.

Other references

Baker, J. (2015). Individual placement and support for mental health vocational rehabilitation. The Mental Elf.

Bell, A. (2023). Interventions to improve social circumstances among people with mental health conditions. The Mental Elf.

Department for Work and Pensions. (2019). Employment Advisers in Improving Access to Psychological Theraphies: Process Evaluation Report. Employment Advisers in Improving Access to Psychological Therapies: process evaluation report (allcatsrgrey.org.uk)

Huppert, J. D., Bufka, L. F., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2001). Therapists, therapist variables, and cognitive-behavioral therapy outcome in a multicenter trial for panic disorder. Journal of Consulting and Clinical Psychology, 69(5), 747–755.

Keijsers, G. P. J., Schaap, C. P. D. R., & Hoogduin, C. A. L. (2000). The impact of interpersonal patient and therapist behavior on outcome in cognitive-behavior therapy: A review of empirical studies. Behavior Modification, 24(2), 264-297.

Office for National Statistics (2024). Labour market in the regions of the UK: February 2024. Office for National Statistics. Last accessed: 23 May 2024.

Oparina, E., Krekel, C., & Srisuma, S. (2024). Talking Therapy: Impacts of a Nationwide Mental Health Service in England.

Saunders, R., Buckman, J. E., & Pilling, S. (2020). Latent variable mixture modelling and individual treatment prediction. Behaviour Research and Therapy, 124, 103505.

Saunders, R., Cape, J., Fearon, P., & Pilling, S. (2016). Predicting treatment outcome in psychological treatment services by identifying latent profiles of patients. Journal of Affective Disorders, 197, 107-115.

Zuelke, A. E., Luck, T., Schroeter, M. L., Witte, A. V., Hinz, A., Engel, C., … & Riedel-Heller, S. G. (2018). The association between unemployment and depression–Results from the population-based LIFE-adult-study. Journal of Affective Disorders, 235, 399-406.

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