Abstract
Working holds an important role in society and is the considered normal thing to do. While the majority of people with schizophrenia would like to work, employment rates remain consistently low. This discrepancy indicates the need for improved vocational services for this group. Low employment rates may be due to illness-related or societal factors. Societal and structural factors such as low expectations, stigma and discrimination, and limited access to services contribute to low employment rates. Negative symptoms in general and apathy in particular, have been identified as important predictors of impaired vocational functioning.
The main aim of this thesis was to examine the impact of apathy on vocational functioning in the context of the Job Management Program (JUMP). The JUMP study is a vocational rehabilitation program including close collaboration between health and vocational services, providing participants with ongoing support, psychoeducation and either cognitive remediation or cognitive behavior therapy applied in the work setting. In order to assess work performance, we validated the Work Behavior Inventory (WBI), an on-site assessment of work behavior developed specifically for people with severe mental illness.
Paper I examined the psychometric properties of a Norwegian version of the WBI. The original scale has five subscales. We found that a three-factor model best represented the data, resulting in three subscales: social skills, work quality and complying with work norms. The model had acceptable psychometric properties, indicating that the WBI has good crosscultural properties, and may be used to assess work behavior for people with schizophrenia in Norway.
In Paper II we examined whether baseline apathy predicted vocational outcome defined as the average number of hours worked per week during the study, work behavior and employment status (working or not working) at post treatment (including competitive employment, work placement and sheltered work). We found that apathy predicted the number of hours worked during the study, with participants with higher levels of apathy working fewer hours a week. However, apathy did not predict employment status or work behavior at post treatment.
In Paper III we examined the development in apathy from baseline to post treatment, and whether baseline apathy or change in apathy predicted employment status at follow-up. There was a small but statistically significant improvement in apathy from baseline to post treatment. Baseline apathy did not predict employment status or work behavior, but predicted social functioning at follow-up. Change in apathy did not predict vocational or social functioning at follow-up.
The association between apathy and vocational functioning was not as strong as expected, and many participants were able to work in spite high levels of apathy.
These findings indicate that the impact of apathy on vocational functioning may be attenuated by the JUMP interventions. The JUMP study provided a complex intervention enabling people with schizophrenia to work irrespective of the level of apathy. However, we found some association, as level of apathy predicted hours worked per week.
Our findings underline the need for future studies to investigate the relative importance of various aspects of vocational rehabilitation interventions, so we can best tailor our services to enable people with schizophrenia to work.