Cogentin

Over the past half-century, many different vocational rehabilitation strategies have been used to help mental health consumers (that is, people with schizophrenia and other severe psychiatric disorders who experience significant difficulty in role functioning) obtain employment. For the most part, these efforts have been disappointing. The base rate for competitive employment for mental health consumers is less than 15% (Anthony & Blanch, 1987); long-term employment rates are not much increased by most psychiatric rehabilitation approaches (Bond, Drake, Becker, & Mueser, in press). By contrast, recent findings suggest that over half of mental health consumers enrolled in supported employment programs obtain competitive employment (Bond, Drake, Mueser, & Becker, 1997). Even with these encouraging results, the reality is that mental health consumers, especially those with schizophrenia, have much less favorable outcomes than other disability groups (Marshak, Bostick, & Turton, 1990).

The central premise of this article is that successful vocational rehabilitation programs for people with schizophrenia require careful attention to the management of psychiatric symptoms. Indirect support for this premise is found in studies showing that employment programs are more successful if they work closely with mental health treatment teams, including psychiatrists and case managers (Drake et al., 1999; Drake, McHugo, Becket, Anthony, & Clark, 1996). One important piece of this equation concerns the role of psychotropic medications. Although practitioners intuitively know that medications are inextricably involved in the rehabilitation process, the research literature has been woefully inadequate for answering the basic questions in this area.

Given the lack of pertinent research, it is not surprising to find that reviews of treatment for schizophrenia rarely integrate findings for medication and psychosocial interventions (Ballus, 1997; Johnson, 1977; Torrey, 1986; Vaccaro, Young, & Glynn, 1993). Reviews present drug and psychosocial treatments as separate domains, typically with an edict that both are necessary for the best treatment outcomes, but without articulating the interaction between the two. An even more striking omission is the lack of reviews discussing the role of medications in vocational rehabilitation.

The development of new medications for schizophrenia has resulted in renewed interest in the role of medications in work, particularly because they may play a more positive role than previously-used medications. The evidence for effectiveness of both the traditional and newer medications for schizophrenia will be reviewed in this article, as these findings have implications for rehabilitation counselors, employment specialists, and others involved in the rehabilitation process. To place this review in context, it begins with a brief description of the symptoms of schizophrenia and how they relate to vocational outcomes. The medications used to treat the symptoms and the side effects of schizophrenia will then be discussed, followed by a comment on how each affects vocational outcomes. Lastly, suggestions for rehabilitation professionals will be given.

Symptoms

People with schizophrenia experience two broad types of psychiatric symptoms, labeled as positive and negative. Positive symptoms are behaviors that are notably odd and socially deviant, such as hallucinations (sensory experiences in the absence of any environmental stimuli) and delusions (false beliefs, often bizarre and firmly held, even in the face of disconfirming evidence). The negative symptoms consist of patterns of nonresponsivity: passivity, a lack of spontaneity, flat affect (a lack of emotional responsivity), the inability to initiate goal-directed activity, social withdrawal, a lack of motivation, and anhedonia (an inability to experience pleasure) (Crow, 1980). Recently, cognitive deficits have received increasing attention (Green, 1996). Cognitive deficits include problems with memory, attention span and concentration, and executive functioning (judgment and decisionmaking).

Intuitively, one would think that positive symptoms would represent a major barrier to employment. Certainly, the stigma attached to schizophrenia among the general public (Link, Cullen, Frank, & Wozniak, 1987) and among rehabilitation counselors as well (Goodyear, 1983) derives largely from the stereotype of people with schizophrenia as having bizarre ideas and behaving unpredictably and possibly violently. Mental health consumers report that they have often been turned down for jobs for which they were qualified on the basis of their psychiatric illness (Wahl, 1997). Somewhat surprisingly, however, the positive symptoms of schizophrenia have not been strongly or consistently associated with poor vocational outcomes (Anthony & Jansen, 1984). Anecdotally, it is known that many people with florid positive symptoms of schizophrenia are able to work, perhaps because they are able to shut out positive symptoms while on the job. The homespun advice - "Don't talk about your delusions on the job" (Dunham, 1982, p. 41) - may in fact have some utility.

On the other hand, research suggests that negative symptoms can be a formidable barrier to successful employment. People with schizophrenia often do poorly in traditional vocational rehabilitation approaches requiring participants to look for jobs on their own. Thus, job clubs, which are used successfully by many rehabilitation clients, are largely ineffective for people with schizophrenia, who often drop out early in the process (Corrigan, Reedy, Thadani, & Ganet, 1995; Jacobs, Wissusik, Collier, Stackman, & Burkeman, 1992). A plausible explanation for the failure of this format for people with schizophrenia is that negative symptoms interfere with completing assignments within a job club program, such as initiating contacts with employers, initiating conversations, and responding appropriately during interviews. Negative symptoms also appear to interfere with performance on the job (including speed and quality of work and interpersonal relationships) (Bell & Lysaker, 1995; Hoffmann & Kupper, 1997; Lysaker & Bell, 1995).

Negative symptoms may affect vocational functioning in other ways. Hayes and Halford (1996) compared unemployed men with schizophrenia to employed men with schizophrenia and unemployed men with no psychiatric diagnosis. They found that the unemployed men with schizophrenia were socially withdrawn and slept more than 1.5 hours more per day, on average, than did men in the other two groups. An interpretation of this study is that unemployment exacerbates negative symptoms, leading to a cycle in which it becomes increasingly harder to become motivated to seek work.

Some preliminary research suggests that cognitive deficits in schizophrenia interfere with vocational functioning (Collaborative Working Group on Clinical Trial Evaluations, 1998; Green, 1996; Jaeger & Douglas, 1992; Lysaker, Bell, & Beam-Goulet, 1995; Meltzer & McGurk, 1999). In theory, the key cognitive deficits seen in schizophrenia (i.e., attention, memory, and executive function) should negatively impact social and vocational functioning. For example, persons with working memory deficits may have trouble remembering phone numbers, what happened a few minutes ago, or what they read at the beginning of a paragraph by the time they get to the end of it.

Traditional Antipsychotics

Although many different medications are used in the treatment of schizophrenia, this discussion will be limited primarily to antipsychotics, which are a group of medications used to treat symptoms of schizophrenia. With the emergence of new medications for schizophrenia starting in the 1980s, antipsychotics are now divided into traditional and atypical antipsychotics.

Effectiveness of traditional antipsychotics. The first widely used antipsychotic, chlorpromazine (Thorazine), was introduced into psychiatric hospitals in the United States in the 1950s. This led to a revolution in the treatment of schizophrenia, with a dramatic reduction over the next three decades in the number of psychiatric inpatients (Marder, Wirshing, & Ames, 1997). Among the most widely used antipsychotics have been thioridazine (Mellaril), fluphenazine (Prolixin), and haloperidol (Haldol). Although all antipsychotics are available in oral form, fluphenazine and haloperidol can also be taken in a long-acting injection form referred to as depot. A large body of research shows that people with schizophrenia receiving antipsychotics show substantial improvement over those receiving a placebo (Davis, 1980). Traditional antipsychotics reduce positive symptoms (Hirsch & Barnes, 1995), but their long-term effect on negative symptoms is minimal (Kane & Mayerhoff, 1989).

Side effects of traditional antipsychotics. Traditional antipsychotics have a variety of troublesome side effects. Among the most serious are extrapyramidal side effects (EPS), which include dystonic reactions, akathisia, and parkinsonism. Dystonic reactions are acute muscular spasms that occur mainly in the head and neck. Akathisia, the most common side effect of antipsychotics, is an inner restlessness that is manifested as an inability to sit still. Parkinsonism involves rigidity of joints, tremors, and a slowing of movements (Marder & May, 1986). About 60% of consumers who receive appropriate dosages of traditional antipsychotics develop EPS (Dawkins, Lieberman, Lebowitz, & Hsiao, 1999).

To combat these effects, patients often are given anticholinergic medication such as benztropine (Cogentin) or diphenhydramine (Benadryl). Parkinsonism can be treated with benztropine and trihexyphenidyl (Artane); however, akathisia usually does not respond to these medications (Janicak, Davis, Preskorn, & Ayd, 1997; Nurnberg & Levine, 1986; Sajatovic & Schulz, 1997). Unfortunately, anticholinergic medications have their own side effects, such as impairment in cognitive functioning, sedation, blurred vision, and dry mouth (Spohn & Strauss, 1989).

The most serious side effect of antipsychotics is tardive dyskinesia, a movement disorder involving involuntary movements such as lip-smacking and facial grimaces. The rate of tardive dyskinesia among patients treated with traditional antipsychotics for more than one year is at least 10% (Kane, Woerner, & Borenstein, 1986), and the cumulative risk is estimated to increase 5% each year the medication is taken (Dawkins et al., 1999). The main strategies to avoid this condition are to discontinue medications, reduce dosage levels, or change to one of the atypical antipsychotics (Bernstein, 1995).

Side effects present significant barriers to employment in two ways. First, they make it harder to perform tasks in the workplace. Akathisia, blurred vision, and sedation are obvious examples. Second, side effects make medication noncompliance more likely, setting off a cycle of relapse. Forty percent or more of people with schizophrenia do not take medications as prescribed (Cramer & Rosenheck, 1998; Streicker, Amdur, & Dincin, 1986), and those who do not take their medication as prescribed are more likely to relapse (Marder et al., 1997). The other significant point to be made about antipsychotics is that, even under the best of circumstances - excellent psychiatric management, cooperative consumers, and supportive family environment - they do not work for everyone. Approximately 30% do not respond to traditional antipsychotics (Dixon, Lehman, & Levine, 1995). Problems with relapse and rehospitalizations have obvious implications for the capacity to hold a job.

Historically, one indicator of "vocational readiness" has been medication compliance (Marrone, Horgan, Scripture, & Grossman, 1984). Medication compliance is influenced by many factors, including the desire for consumers to feel normal, and taking medications may serve as a reminder that they are not. Experiencing side effects is another major reason consumers give for noncompliance (Streicker et al., 1986). Interviews with consumers about their ways of coping with employment suggest that consumers are often ambivalent about medication. Although they acknowledge the role of medications in controlling symptoms and enabling them to function appropriately in the workplace, consumers also view the side effects that accompany medications as interfering with their ability to work (Kirsh, 1996). Thus, consumers admit that they often adjust the amount and frequency of medication they take, depending on the circumstances of the job and their judgment about the level of compliance needed to control symptoms (Alverson, Becker, & Drake, 1995). The other side of the coin is that employment may also be a positive motivator for consumers to take their medications if they believe that doing so is critical to holding their job.

Traditional antipsychotics and vocational outcomes. Since the introduction of antipsychotics, clinicians have looked toward medications as an avenue for improving vocational functioning. However, few studies have actually examined this issue. There were mixed results from some early, methodologically unsophisticated studies addressing the worry that the side effects of medications - especially sedation - would negatively impact work capacity. Mintz, Mintz, Hwang, and Uijtdehaage (1997) reviewed the relationship between antipsychotic medications and vocational functioning in five randomized double-blind clinical drug trials, concluding that traditional antipsychotics do not negatively impact vocational functioning.

A landmark study by Hogarty and Goldberg (1973) examined the interaction between medications and psychosocial interventions. The study was designed to experimentally test the independent effects of antipsychotic drugs and of a psychosocial intervention they called "sociotherapy," as well as the interaction between the two. Thus, the design involved random assignment to four groups: placebo alone, placebo and sociotherapy, drug alone, and drug and sociotherapy. Sociotherapy involved a combination of psychosocial interventions, including supportive therapy, social casework, and rehabilitation counseling. As expected, the group receiving drugs did significantly better in avoiding relapse than those receiving the placebo. The most important finding, however, was that the group receiving both antipsychotic medications and sociotherapy had the best long-term outcomes, including better instrumental role functioning (that is, working in competitive jobs and in homemaker roles). Those receiving sociotherapy and the placebo actually fared worse than those receiving the placebo alone. Remarkably, this single study is one of the few large-scale studies examining the additive effects of medications and psychosocial interventions on role functioning for people with schizophrenia. Despite the lack of direct evidence, the consensus in the psychiatric field is that effective treatment for schizophrenia includes a combination of both psychiatric rehabilitation and antipsychotics (Lehman et al., 1998a).

A number of studies have experimentally examined the impact of traditional antipsychotic dosage level on client functioning. Hogarty et al. (1988) compared a flexible, low dosage regimen to standard dosage. Their results suggested that a low dosage regimen could control symptoms as well as the standard regimen, with much reduced side effects and improvement in instrumental and interpersonal role performance. Other studies have failed to replicate these findings, however. The general consensus is that, while consumers report feeling more comfortable on low dosages of medication, as compared to standard dosages, there is little evidence that consumers actually improve in vocational functioning while on lower dosages (Mintz et al., 1997).

Atypical Antipsychotics

The atypical antipsychotics were developed with the goal of increasing the efficacy in the treatment of both positive and negative symptoms, while decreasing side effects, particularly tardive dyskinesia and EPS (Tamminga, 19971). Clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) are examples of these new antipsychotics, each with its own unique pharmacological impact on the brain. Although we discuss atypicals as a group, their effectiveness and side effects vary. Clozapine, introduced in the United States in 1989, is reserved mostly for "treatment resistant" patients, that is, those who do not respond to traditional antipsychotics (Meltzer, 1995). Because of the risk of agranulocytosis (dangerously low white blood count), clozapine must be monitored closely. Risperidone was introduced to the United States market in 1994, followed by olanzapine in 1996 and quetiapine in 1997. Increasingly, olanzapine and risperidone are being used as "first line" medications for schizophrenia, that is, they are prescribed when schizophrenia is first diagnosed (Chiles et al., 1999). One disadvantage of atypicals is that none is yet available in depot form (Dawkins et al., 1999).

Effectiveness of atypicals. Clozapine is dramatically more effective than traditional antipsychotics in controlling positive symptoms in treatment-resistant patients (Marder, 1996). Aside from clozapine, atypicals are at least as effective as traditional antipsychotics in reducing positive symptoms and may be somewhat more effective than traditional medications in treating negative symptoms, although the efficacy in treating negative symptoms has not been clearly demonstrated (Dawkins et al., 1999; Moiler, Muller, Borison, Schooler, & Chouinard, 1995; Tamminga, 1997; Tollefson & Sanger, 1997). A review of 17 randomized controlled trials comparing atypicals with traditional antipsychotics found a small, but significant, effect on negative symptoms favoring atypicals (Grilli Tissot & Elkis, 1999).

Research on the effects of atypicals on cognitive functioning in schizophrenia is just beginning to appear in the literature. These cognitive improvements from the use of atypicals may be the indirect result of a decrease in EPS and decrease in the use of antiparkinsonian medication (which has been linked to cognitive impairments) (Green & Nuechterlein, 1999; Spohn & Strauss, 1989; Stip & Lussier, 1996). A review by Meltzer and McGurk (1999) concluded that atypicals clearly help cognitive functioning, but that the specific cognitive effects for each atypical appear to be somewhat different. They concluded that (1) there is strong evidence that clozapine improves attention and verbal fluency, and moderate evidence that clozapine improves some types of executive functioning; (2) risperidone has a relatively consistent positive effect on working memory, executive functioning, and attention; (3) preliminary evidence suggests that olanzapine improves verbal learning and memory, verbal fluency, and executive functioning. Based on a meta-analysis of 15 studies, Keefe, Silva, Perkins, and Lieberman (1999) also concluded that consumers using atypicals had significantly better cognitive functioning than those on traditional antipsychotics. Overall, atypicals may have a more positive effect than traditional antipsychotics on cognitive functioning, not only because traditional antipsychotics may interfere with cognitive functioning, but also because atypicals may improve cognitive functioning.

Side effects of atypicals. Compared to traditional antipsychotics, atypicals have fewer EPS side effects (Lieberman, 1996), although weight gain has been reported with some atypicals (Casey, 1996). It has been speculated that the generally reduced side effect profiles for atypicals may lead to greater satisfaction with medications (Zygmunt, Emmanuel, Weiden, & Nathan, 1997) and therefore greater medication compliance. Consistent with this view, some of the original clinical trials suggested higher rates of continued use of atypicals compared to traditional medications (Song, 1997; Tollefson & Sanger, 1997). However, a naturalistic study of risperidone use among patients discharged from a psychiatric hospital found that only 29% remained on the drug after 2 years (Binder, NcNiel, & Sandberg, 1998), reminding us that medication noncompliance and discontinuation is a problem for the atypicals as well.

Atypical antipsychotics and vocational outcomes. If atypicals do prove to be more effective than traditional antipsychotics in the areas of negative symptoms, cognitive functioning, and side effects, then it is reasonable to expect an improvement in vocational functioning with their use. Consequently, it has been speculated that atypicals will allow more people with schizophrenia to benefit from rehabilitation programs than was true in the past (Weiden, Aquila, & Standard, 1996). To date, only a few studies have examined the direct impact of medication type on vocational functioning. Unfortunately, vocational functioning has usually been measured as part of a general quality of life measure. These studies generally have not reported detailed information on work outcomes (Franz, Lis, Pluddemann, & Gallhofer, 1997; Meltzer, Burnett, Bastani, & Ramirez, 1990; Meltzer, Cola, & Way, 1993; Rosenheck et al., 1998; Tran et al., 1997).

Lindstrom and Lundberg (1997) followed 122 consumers on clozapine for a mean of 5.2 years. None of them were working initially, but 40% were working in full- or part-time employment after a minimum of 2 years' treatment. Another uncontrolled follow-up study also found encouraging employment outcomes for consumers on clozapine (Littrell, 1995).

Noordsy and O'Keefe (in press) examined work outcomes for 67 consumers, 6 months after switching from a traditional antipsychotic to olanzapine. Pre-post ratings by case managers showed significant improvement in symptoms and in psychosocial functioning, including vocational functioning. The authors speculate that improvements in cognitive functioning may have led to "synergistic interactions contributing to functional outcomes." As a part of a multi-site randomized clinical trial, Hamilton, Genduso, and Revicki (1998, as described in Glazer, 1998) examined one-year outcomes for consumers receiving olanzapine or haloperidol. At baseline, the two groups had similar employment rates (11% and 9%, respectively). By one-year follow-up, 19% of the olanzapine group were competitively employed, compared to 8% of the haloperidol group, a significant difference, although the employment rate was small even for the olanzapine group. In a cross-sectional study of 82 consumers attending a psychiatric rehabilitation program, Bond et al. (1998) found no differences in employment outcomes between consumers receiving atypicals and those receiving traditional medications. However, the investigators found a significant increase in the annual number of weeks worked in paid employment from 12.7 weeks prior to the switch to an atypical, to 28.3 weeks after switching.

Two weaknesses in this group of studies are that none has used a rigorous research design, nor has any studied atypical in conjunction with a well-implemented supported employment program, that is, the vocational approach which has the strongest evidence for effectiveness. The hope is that if both state-of-the-art medications and best practices vocational services are offered, consumers will show substantial gains in employment.

Implications for Practitioners

This review has several implications for rehabilitation practitioners involved in the vocational rehabilitation of people with schizophrenia and other severe psychiatric disabilities. The first suggestion is, quite simply, for rehabilitation professionals to become educated about the nature of psychiatric disorders, through a thorough acquaintance with the Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994), as a precondition for understanding medications. An understanding of the positive and negative symptoms of schizophrenia is essential to avoid misattributing characteristics of the illness to "laziness" or "lack of motivation" (Braitman et al., 1995). Information on psychiatric diagnosis is widely available in many sources, ranging from technical manuals (American Psychiatric Association, 1994) to abnormal psychology textbooks and guides for the general public (Mueser & Gingerich, 1994; Torrey, 1995). It is equally important to realize that symptoms are an uncertain predictor of capacity to work (Anthony & Jansen, 1984) and should not be used to screen consumers out from receiving rehabilitation services.

Rehabilitation professionals also should acquire a rudimentary knowledge of psychotropic medications, especially in light of the recent revolution in the development not only of the atypical antipsychotics, but other medications as well. Rehabilitation professionals should have access to such resources as practical guides to psychopharmacology (e.g., Gorman, 1998; Gitlin, 1996; Kaplan & Sadock, 1996; Preston, O'Neal, Talaga, 1998) and videotapes made for this purpose (e.g., Center for Mental Health, 1996). In this rapidly changing field, it should be remembered that such sources quickly become outdated. Because of this, continuing education also is essential for rehabilitation professionals to stay current.

Another principle is to select and tailor jobs that take into consideration each consumer's specific symptoms, medication use, and side effects. Successful rehabilitation programs help consumers find jobs that truly are compatible with their preferences, strengths, weaknesses (Becker & Drake, 1994), and, we would add, their medications. For rehabilitation counselors to be successful in this regard, they must listen carefully to consumers. Medications are an element in the day-to-day reality for consumers: to treat medications as a "medical issue" and of no relevance to vocational rehabilitation is a misguided policy.

Job matching includes selecting work environments that are tolerant of consumers' behaviors and symptoms. For example, a consumer who becomes paranoid in groups may be more successful working alone in the evenings (Torrey et al., 1998). When consumers choose to disclose their disability to employers, rehabilitation professionals also may enlist employers in providing accommodations for symptoms and medications. Examples include: (1) allowing workers with dry mouth to drink water at their work space, (2) giving workers with motor side effects more time to perform tasks, (3) giving workers with memory or concentration problems concrete written instructions, and (4) giving workers who are restless more breaks or permission to walk around. In addition, workers on medication may need flexibility in their work schedule to keep psychiatrist appointments (Mancuso, 1990).

A further principle is that rehabilitation professionals should work closely with the consumer's treatment team (Becker & Drake, 1994). Lehman et al. (1998b) found that less than 50% of mental health consumers in mental health treatment were actually receiving psychotropic medications consistent with best practice recommendations, so that employment specialists first should make sure that consumers are receiving basic, proper psychiatric attention. The employment specialist often has critical information that may be of help to the psychiatrist in titrating medications; conversely, the psychiatrist has expertise on features of the medications that may affect work. Rehabilitation professionals should be allies with the treatment team, reinforcing messages about the importance of medications for getting and keeping jobs. Increased contact with others in the work place may help motivate consumers to take medications as prescribed (Draine & Solomon, 1994). Conversely, starting a new job may require adjustments in medication dosage or type, or scheduled times for taking medication. For example, if a medication has sedating effects, then it may be advisable to take it before bedtime and not before work (Torrey et al., 1998). Similarly, medication changes initiated by the treatment team should be closely coordinated with the vocational team. For example, if a consumer is beginning a new medication, it might be wise to postpone starting a new job until the effects of the medication change are clear (Torrey et al., 1998). The important principle here is active communication between rehabilitation and treatment staff, as has been carefully articulated in current supported employment models (Becket & Drake, 1994).

Conclusions

Research over the past four decades on the role of traditional antipsychotics in vocational rehabilitation has not yielded dramatic findings. One reason may be that these drugs mainly reduce positive symptoms, which do not appear to be that closely linked to vocational functioning. The development of new medications for schizophrenia has led to renewed attention to the interrelationship between medications and rehabilitation. The hope is that these new medications may have an impact on areas of functioning directly relevant to successful employment. However, research on the impact of atypicals on role functioning is still very primitive. Moreover, a healthy skepticism should be exercised in assessing the findings from studies funded by pharmaceutical companies. When a new treatment is discovered, it is often accompanied by unbridled enthusiasm, followed later by a more sober assessment. Nonetheless, early studies on atypicals are encouraging for their impact on rehabilitation.

The focus on the role of medications in the vocational process should not obscure the fact that medications alone are not sufficient to improve employment outcomes. Well-implemented vocational programs following validated program models appear to be a necessary ingredient to achieve this goal. The best outcomes are likely when both medications and employment services are considered together. To date, no research has examined the effects of the atypicals in combination with supported employment, which growing evidence suggests improves employment outcomes for people with severe mental illness (Bond et al., 1997).

Future research should examine the impact of side effects on vocational functioning, as well as how side effects serve as a barrier to successful employment. In addition, very little is known about how medications improve vocational functioning and in what areas the improvement actually takes place, such as social relationships on the job, social skills in general, job retention, motivation, and general health. Lastly, there is a lack of literature exploring how employment may facilitate appropriate use of medications. Answers to these questions would help to improve vocational outcomes for persons with schizophrenia.

Work on this paper was partly supported by National Institute of Mental Health Grant 00842 to the first author. We thank Lisa Evans, Hea-Won Kim, Sandy Resnick, and Angie Rollins for their helpful comments on earlier drafts.

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Piper S. Meyer

Indiana University-Purdue University Indianapolis

Gary R. Bond, Department of Psychology - LD 124, IUPUI, 402 North Blackford Street, Indianapolis, IN 46202-3275. Email: gbond@iupui.edu.

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