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High Unemployment and Disability for People with Serious Mental Illness

The Commission finds that undetected, untreated, and poorly treated mental disorders interrupt careers, leading many into lives of disability, poverty, and long-term dependence. Our review finds a shocking 90 percent unemployment rate among adults with serious mental illness—the worst level of employment of any group of people with disabilities. Strikingly, surveys show that many of them want to work and report that they could work with modest assistance (Drake et al., 1999). Instead, our Nation's largest "program" for people with mental illness is disability payments. The cost of disability is unacceptable in both human and economic terms. The situation is similar in many ways to the old welfare system. Our mental health, rehabilitation, and disability programs unintentionally trap millions of individuals—who want to work—into expensive, long-term dependency.

"… I cannot emphasize enough how important the ability to work in a real job has been to [my daughter's] self-esteem and therefore to her continued stability."
   —Mother of a woman with bipolar disorder

Model Program

There is new evidence that serious mental illness need not lead to "disability dependency." Thirty states and several foreign countries are implementing an innovative supported employment program called IPS, or Individual Placement and Support. Pioneered by researchers in New Hampshire, the program is designed to obtain jobs quickly and efficiently for people with serious mental illness (Box 7). The program has achieved an employment rate of 60-80 percent (Drake et al., 1999). Productive careers and economic independence are replacing "disability welfare" for many people recovering from serious mental illness. IPS starts with the individual's career priorities and, through personal support, helps people recovering from mental illness to choose, get, and keep a paying job.

Many nationwide barriers keep other people with mental illness from achieving these positive employment successes. The Vocational Rehabilitation (VR) system often fails people with a mental illness. They are one of the largest disability groups referred to VR, but they achieve the worst employment outcomes relative to other disability groups. Medicaid is the largest public payer for mental health care, but it does not reimburse for vocational training and support for individuals with a mental illness, although many individuals with developmental disabilities receive such services under Home and Community Based Services programs.

The success of the research-based IPS program highlights another problem: Federal agencies have not proven adept at helping communities implement effective programs on a large scale. The National Institute on Mental Health and the Substance Abuse and Mental Health Services Administration helped research the supported employment model and demonstrate its effectiveness. However, there are not yet tested models to help communities adopt such "evidence-based" services, and to develop service models that are feasible for communities to implement. The Commission will study and make recommendations to improve this "Science to Services" cycle, to make the benefits of research real.

Nationally, our failure to help people with mental illness achieve productive work is not only a personal tragedy, but staggeringly costly. People with mental illness are both the largest and fastest growing group of people with disabilities receiving Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) disability payments. The numbers are immense. An estimated $25 billion is spent annually for these disability payments (SSA, 2001). Despite the high total cost, the benefits paid to individuals are not adequate to ensure safe housing. Instability in housing contributes to cycles of relapse and poor job success.

Another problem is the link between disability payments under SSI and SSDI and eligibility for health care coverage under Medicaid. Many people with a mental illness find that they cannot afford to go back to work because they would lose their Medicaid coverage. The high costs of health care and the unavailability of employer-based health care for people with a "preexisting condition" means that thousands of people with a mental illness make a conscious choice to stay on disability assistance because it provides Medicaid coverage for their expensive medication and treatment needs. Although reforms have been initiated, such as the option for states to extend Medicaid to working disabled individuals, the current economic downturn means that many states cannot afford to implement this option. People with mental illness live in a kind of "disability welfare system" that badly needs reform. The Commission will study this problem and make recommendations for change.

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