At the Intersection of Health, Health Care and Policy

Cite this article as:

David Mechanic, Scott Bilder and Donna D. McAlpine
Employing Persons With Serious Mental Illness

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

Health Affairs 21, no.5 (2002):242-253
doi: 10.1377/hlthaff.21.5.242

The online version of this article, along with updated information and
services, is available at:
http://content.healthaffairs.org/content/21/5/242

For Reprints, Links &

Permissions : http://content.healthaffairs.org/1340_reprints.php
Email Alertings : http://content.healthaffairs.org/subscriptions/etoc.dtl

To Subscribe : https://fulfillment.healthaffairs.org

Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown

Road, Suite 600, Bethesda, MD 20814-6133. Copyright
by Project HOPE - The People-to-People Health Foundation. As provided by
United States copyright law (Title 17, U.S. Code), no part of
may be reproduced, displayed, or transmitted in any form or by any means,
electronic or mechanical, including photocopying or by information storage or
retrieval systems, without prior written permission from the Publisher. All
rights reserved.

Not for commercial use or unauthorized distribution

D ata Wat c h

Employing Persons With

Serious Mental Illness
Workers with mental illness, even serious disorders, have occupational

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

profiles similar to those of persons without mental illness.
by David Mechanic, Scott Bilder, and Donna D. McAlpine

ABSTRACT: Data from various national surveys find that approximately half the population
with mental disorders is gainfully employed across the entire range of occupations; such
persons have an employment rate of about two-thirds that of the general population. More
than a third of persons with serious mental illness also work, and many hold high-status po-
sitions. Among those with schizophrenia, a diagnosis associated with high impairment, only
slightly more than a fifth are at work, and 12 percent are working full time. Approximately
two-thirds are enrolled in federal disability insurance programs. Our analyses indicate con-
siderable diversity of jobs among persons with various mental disorders. Most persons with
mental illness want to work, and some with even the most serious mental disorders hold
jobs requiring high levels of functioning. Educational attainment is the strongest predictor
of employment in high-ranking occupations among both the general population and per-
sons with mental disorders.

I
t i s w e l l e s ta b l i s h e d t h at m e n ta l i l l n e s s e s such as schizophrenia
and major mood disorders cause considerable distress and disability. As a re-
sult, persons with these disorders work less than others in the general popula-
tion do and are overrepresented in public and private disability programs. Once
enrolled in the Social Security Administrations Supplemental Security Income
(SSI) and Social Security Disability Insurance (SSDI) programs, few people leave.
This paper seeks to go beyond these common observations to offer a richer, more
complicated picture of the links between mental illness and employment.
A variety of factors reinforce the perception that persons with mental illness
are limited in their work participation. Such persons constituted approximately
34 percent of working-age enrollees in the SSI program and 27 percent of SSDI
beneficiaries in 1999.1 Moreover, many mental health programs that seek to assist
persons with mental illness to gain and retain employment focus their efforts on
placing clients in unskilled and semiskilled positions, which reinforces the con-
cept that this represents the range of work such clients can do. Finally, the stigma

David Mechanic directs the Institute for Health, Health Care Policy, and Aging Research at Rutgers, the State
University, in New Brunswick, New Jersey. Scott Bilder is a research analyst there. Donna McAlpine is assistant
professor, health services research and policy, at the University of Minnesota School of Public Health.

242 September/October 2002

2002 Project HOPEThe People-to-People Health Foundation, Inc.
 Mental Illne ss

of mental illness, based on images of floridly psychotic persons that are dissemi-
nated by movies, television, and other mass culture, reinforces the view that per-
sons with mental illness are unpredictable and possibly dangerous.2 It is little
wonder that many employers are reluctant to place persons known to have a his-
tory of mental illness in responsible jobs.3 For this reason, employees often do not
reveal their mental health histories or treatment status to employers.
The facts on which these images are based can be misleading. The number of

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

persons with mental illness on SSI/SSDI partly reflects the high prevalence of per-
sons with mental illness in the general population; as much as one-third of the
population is reported to have a mental disorder in any year, and approximately
half, at some point in their lives.4 Although serious mental illnesses are much less
prevalent, national estimates, based on data collected in the early 1990s, also sug-
gest that as many as ten million people may have such conditions.5 Unlike persons
with serious heart disease or cancer, persons with serious mental illness often be-
come symptomatic early in their lives and enter disability status at relatively
young ages. Since few persons who achieve SSI/SSDI eligibility leave the disability
rolls, numbers of persons with mental illness accumulate over time and constitute
a large proportion of all disability insurance recipients.
Conclusions drawn from studies of enrollees with mental illness in employ-
ment rehabilitation programs also can be misleading. These programs typically
deal with selected samples of persons with extensive disabilities and long histo-
ries of repeated episodes of illness and care.6 Generalizations from these selected
populations to most people with even serious mental illnesses are invalid.
Using data from the National Health Interview Survey on Disability (NHIS-D),
supplemented by data from other national surveys, this paper seeks to construct a
more complete picture of the employment situations of persons with mental ill-
ness. We also focus on persons with the most serious disorders and show that
even among this group, many persons manage employment, and some hold
high-status occupational positions. Identifying factors associated with employ-
ment outcomes points to areas that warrant policy attention.

Study Methods
nSamples. The main data reported here come from the 1994/1995 NHIS-D, de-
signed to collect data on the prevalence and correlates of disability in the
noninstitutionalized U.S. civilian population.7 We focus on this survey because it
provides the largest, most comprehensive data source available linking mental dis-
orders and disability to employment. Households that completed the core NHIS (94
percent of those sampled) were eligible for the first phase of the NHIS-D. NHIS-D
data were collected from 93 percent of eligible households. In phase one, on which
this paper is based, 66,227 respondents reported on 120,216 household members
ages 1865, including themselves. We also report data that we analyzed from three
other nationally representative household surveys: the NHIS Mental Health Supple-

H E A L T H A F F A I R S ~ Vo l u m e 2 1 , N u m b e r 5 243
D ata Wat c h

ment, 1989 (NHIS-MHS-1989), which provides data on 70,327 persons ages 1865;
the 1990/1992 National Comorbidity Survey (NCS) of 5,393 persons ages 1854; and
the 1997/1998 Healthcare for Communities (HCC) survey of 8,047 respondents.8
n Major measures. Diagnostic measures were constructed using either of two
criteria. The first involves an affirmative response to one of several questions on a
checklist about having specific mental disorders such as schizophrenia or major de-
pression or other mental or emotional disorders in the past twelve months. Re-

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

spondents also were asked about a variety of medical conditions that were then
coded into International Classification of Diseases, Ninth Revision (ICD-9) categories.
Those associated with mental illness (codes 290.0319.99) were included as mental
disorders. Mental retardation, mental illness with organic origin, and childhood-
specific mental disorders were excluded. Substance abuse disorders were treated as
a separate variable.
This paper focuses on three categories: persons with serious mental illness; per-
sons with any mental illness; and persons with no known mental illness. Serious
mental illness in this study includes schizophrenia, paranoid states, mood disor-
ders, and other nonorganic psychoses and psychoses with origins specific to
childhood. Disorders often included as serious mental disorders such as panic dis-
order and obsessive-compulsive disorders were excluded because it was impossi-
ble to distinguish these cases from less serious conditions. We also look at two
important, specific categories: schizophrenia and depressive symptoms. Schizo-
phrenia is generally regarded as the most disabling of the more common mental
disorders and is a subgroup of serious mental illness. This condition was mea-
sured by the respondents report of schizophrenia or conditions with an ICD-9
code of 295.0295.9. We also examine persons who reported depressive symptoms
for two or more weeks in the past twelve months or who had ICD-9 codes reflect-
ing depressive disorders not elsewhere classified or neurotic depression, or both.
Evidence is lacking of a clinical disorder in this category, but it is well established
that subthreshold depressive symptoms are often disabling.
Persons were identified as being employed in the past two weeks if they had
worked or had a job and were not laid off. Those working thirty-five hours or more
per week were classified as working full time.
We use a measure of psychological functioning based on the presence or ab-
sence of problems in five areas, each assessed by a single item: a lot of trouble
making and keeping friendships; a lot of trouble getting along in social situa-
tions; a lot of trouble concentrating long enough to complete tasks; frequent
disorientation, confusion, and forgetfulness; and serious difficulty coping with
day-to-day stresses (Cronbachs alpha .74). We divided self-assessments of health
into those who reported their health as excellent or good versus others. Free-
dom from problems with activities of daily living (ADLs) and instrumental activi-
ties of daily living (IADLs) was based on items asking about difficulties with these
functions.

244 September/October 2002

 Mental Illne ss

Persons who reported conditions other than those classified as mental disor-
ders were identified as having a physical condition. Substance abuse conditions
were based on checklist responses indicating alcohol or drug abuse problems or
for ICD-9 coded conditions for alcohol psychoses, drug psychoses, alcohol de-
pendence syndrome, drug dependence, and nondependent abuse of drugs (other
than tobacco).
n Analysis. SUDAAN software was used for all analyses to correct for design ef-

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

fects in each survey.9 The NHIS-D includes weights to make estimates representa-
tive of the nations noninstitutionalized population. The percentages reported are
weighted, but sample sizes are not.
n Limitations. The data come from cross-sectional surveys and self-reports of
illness and disability. Disablement is a process, and causal sequences are difficult to
infer from cross-sectional data. Unemployed persons may report more illness and
disability than their objective symptoms warrant as a way of justifying their employ-
ment status to themselves and others. Such reporting bias need not be at a level of
awareness. We control for severity of illness and impairment to the extent possible
but cannot exclude the possibility that self-report bias may remain.

Study Results
n Employment rates among the four surveys. Exhibit 1 presents data on the
proportion of persons who reported employment in four nationally representative
sample surveys carried out between 1989 and 1997/1998. In these samples 7583 per-
cent reported being employed. Persons with any mental disorder reported employ-
ment rates of 4873 percent, depending on the survey. Employment among persons
with serious mental illness varied from 32 percent to 61 percent. Persons with
schizophrenia and related disorders had employment rates of 2240 percent.
The disparate work estimates for persons with mental illness among these sur-
veys reflect different measures of mental illness. Efforts to develop survey esti-
mates of various mental illnesses have a long history, but debate continues over
their validity.10 Of the four surveys here, the measurement approach used by the
NCS (and to a lesser extent by the HCC survey), based on questions related to the
criteria of the psychiatric Diagnostic and Statistical Manual of Mental Disorders (DSM),
is the most carefully developed and most commonly accepted. However, there is
reason to believe that these estimates are overly inclusive.11 In contrast, the NHIS,
which depends on reported conditions, is likely to underestimate true psychiatric
morbidity because persons often do not know their psychiatric status or are reluc-
tant to report it because of stigma. In the remainder of this paper we focus on the
much more conservative estimates derived from the NHIS data.
n Employment rates by diagnostic category. While 76 percent of persons
without mental illness were employed, and almost 70 percent of persons with only a
physical condition were employed, persons with mental illness were less likely to be
employed, varying from more than half of those with a mental illness not classified

H E A L T H A F F A I R S ~ Vo l u m e 2 1 , N u m b e r 5 245
D ata Wat c h

EXHIBIT 1
Employment Among Adults With And Without Mental Illness In Four Nationally
Representative Surveys, 19891998

National Health National National Health

Interview Survey, Comorbidity Interview Survey Healthcare for
Mental Health Survey, on Disability, Communities,
Supplement, 1989 1990/1992 1994/1995 1997/1998

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

Entire sample 75% 83% 75% 80%
No mental illness 76 87 76 84
Any mental illness 51 73 48 66
Serious mental illness 32a 61 37 51
Schizophrenia and
related disorders 22 b 22 40
Unweighted sample size 70,327 5,393 120,216 8,047
SOURCE: Data come from our analysis of these surveys.
NOTE: Persons ages 1865 except for the National Comorbidity Survey, which is persons ages 1854.
a
Includes twenty-nine cases of major depression coded under affective psychoses that appear more serious than other coded
depressive conditions. Major depression is not included as serious mental illness in the other three surveys.
b
Insufficient cases.

as serious to 22.5 percent among persons classified as schizophrenic (Exhibit 2).

Rates of full-time employment were about ten to fifteen percentage points lower for
each diagnostic category as well as for persons with no known mental illness. Only
12 percent of persons with schizophrenia worked full time.
n Employment rates by occupation. Remarkably, employed persons with men-
tal illness, including those with serious mental illness, have occupational profiles
similar to those of persons without mental illness (Exhibit 3). The one clear excep-

EXHIBIT 2
Employment Among Adults With And Without Mental Illness, By Diagnostic Category,
1994/1995

Percent Percent employed

Diagnostic category Number employed full time
No mental illness 115,997 76.4% (7677) 62.4% (6263)
Any mental illness 4,219 48.1 (4750) 33.7 (3235)
Serious mental illness (SMI) 1,114 36.8 (3341) 24.0 (2127)
Schizophrenia 320 22.5 (1827) 12.0 (816)
Non-SMI mental illness 3,105 52.1 (5054) 37.1 (3539)
Depressive symptoms 2,445 46.0 (4448) 31.5 (3034)
Substance abuse 926 54.1 (5058) 39.9 (3643)
Other mental illness 2,099 48.0 (4650) 33.4 (3135)
Physical illness 50,907 69.5 (6970) 55.4 (5556)
All persons 120,216 75.4 (7576) 61.4 (6162)
SOURCE: National Health Interview Survey on Disability, 1994/1995.
NOTES: Persons ages 1865. 95 percent confidence intervals are in parentheses.

246 September/October 2002

 Mental Illne ss

EXHIBIT 3
Occupational Categories Among Adults With And Without Mental Illness, 1994/1995

With serious With any With no

mental illness mental illness mental illness
Occupational category (n = 398) (n = 1,979) (n = 87,620)
Executive, administrative, and managerial 11.3% (815) 12.0% (1014) 14.1% (13.814.4)

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

Professional specialty 11.9 (915) 15.9 (1418) 15.0 (14.615.3)
Technicians and related support 3.7 (26) 4.4 (36) 4.1 (3.94.2)
Sales 8.5 (611) 10.3 (912) 11.2 (11.011.4)
Administrative support, including clerical 14.8 (1119) 17.2 (1619) 14.6 (14.314.8)
Private household 0.4 (01) 0.6 (01) 0.6 (0.490.61)
Protective service 1.7 (03) 1.6 (12) 1.9 (1.72.0)
Service, except protective and household 18.2 (1422) 14.4 (1316) 10.5 (10.210.7)
Farming, forestry, and fishing 1.3 (02) 1.4 (12) 2.2 (2.12.3)
Precision production, craft, and repair operators,
fabricators, and laborers 8.7 (612) 7.7 (69) 10.4 (10.110.6)
Machine operators, assemblers, and inspectors 9.5 (613) 6.9 (68) 6.3 (6.06.5)
Transportation and material moving 2.9 (15) 2.6 (23) 4.1 (4.04.3)
Handlers, equipment cleaners, helpers,
and laborers 5.3 (38) 3.7 (35) 3.7 (3.53.9)
Unknown (includes refused, classified, etc.) 1.9 (13) 1.5 (12) 1.5 (1.41.6)
SOURCE: National Health Interview Survey on Disability, 1994/1995.
NOTES: Persons ages 1865. 95 percent confidence intervals are in parentheses.

tion is the concentration of persons with mental illness in service occupations

(other than protective and household).
n Factors associated with employment. Education. Regression analyses were
used to identify factors associated with any employment and location in the employ-
ment structure. Being male and having more education increase the odds of employ-
ment in all groups (Exhibit 4). Education is particularly important, with those who
finished high school or with college and postcollege education having odds two to
five times greater of being employed than those who did not finish high school. It is
plausible that persons with mental illness who complete more education are less
impaired. We control for disease characteristics and health limitations to the extent
possible, but these controls may not completely account for differences in impair-
ment. Those with mood disorders have odds of employment twice as high as those
with schizophrenia and related disorders. This is not surprising, since the latter
group often have impairments that make it difficult to get and keep jobs.
Age. Employment for persons with any mental illness and for those with serious
mental illness was more likely in the 1824 age group than the 4565 age group
(Exhibit 4). This is in contrast to those without mental illness, who were less
likely to be employed at these ages and most likely to be employed at ages 2544.
In all subsamples, physical and psychological functioning was associated with
employment. Better perceived health, good psychological functioning, and lack of
reported limitations were associated with higher rates of employment.

H E A L T H A F F A I R S ~ Vo l u m e 2 1 , N u m b e r 5 247
D ata Wat c h

EXHIBIT 4
Predicting Employment Among Adults With And Without Mental Illness, Using Odds
Ratios, 1994/1995

Person with serious Persons with any Person with no

Risk/protective factor mental illness mental illness mental illness
Disease characteristics

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

Mood disorder 2.11*** a a
No comorbid physical condition 0.76 0.97 1.16***
No comorbid substance abuse 0.84 1.12 1.86***
No comorbid mental illness 1.19 a a
Person characteristics
Age 1824 2.29*** 1.66*** 0.68***
Age 2544 1.41** 1.53*** 1.55***
Age 4565 b b b
White 1.37 1.58*** 1.38***
Nonwhite b b b
Female 0.73** 0.80*** 0.39***
Male b b b
Not high school graduate b b b
High school graduate 2.15*** 2.01*** 2.09***
Some college or college graduate 2.59*** 2.82*** 2.80***
Post-college 4.78*** 4.92*** 3.81***
Limitations
Good psychological functioning 1.51** 1.83*** 1.56***
Good health 2.23*** 2.42*** 2.21***
No problems with ADLs/IADLs 3.38*** 2.61*** 3.57***
Model details
N for analysis 1,090 4,118 112,577
R-square 0.220 0.226 0.126
df 14 12 12
SOURCE: National Health Interview Survey on Disability, 1994/1995.
NOTES: Persons ages 1865. ADL is activity of daily living. IADL is instrumental activity of daily living.
a
Not applicable.
b
Denotes reference category.
**p < .05 ***p < .01

Schizophrenia. As noted earlier, persons with schizophrenia were least likely to

be employed, and approximately two-thirds were enrolled in SSI/SSDI. In the
NHIS-D only sixty-eight persons with this diagnosis were employed. In further
analyses (not shown), two factors distinguished employed persons from others.
Persons ages 1824 had odds of employment almost 3.5 times higher than persons
ages 4565. Schizophrenia occurs relatively early in life. With repeated episodes of
illness and growing impairment, mental health clinicians help persons gain eligi-
bility to disability benefits.12 Thus, by middle age this population is much less
likely to be employed. Patients with schizophrenia who are employed also have
more favorable perceptions of their health status (not shown), which may reflect

248 September/October 2002

 Mental Illne ss

where they are in the trajectory of their illness, their attitudes, and the extent of
disability associated with their condition.
Support for this interpretation comes from further regression analyses (not
shown) examining the relative effects of age versus onset of condition among per-
sons with serious mental illness. Age and onset are associated, but each has signif-
icantly independent effects on the odds of being employed. Persons with serious
mental illness who have had the onset of their disorder less than five years prior to

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

the interview have increased odds of being employed. Persons with serious mental
illness whose condition began in the past year are almost twice as likely to be em-
ployed full time than are those who had an onset more than a year before. Only
one-fifth of persons with serious mental illness who had an onset in the interview
year receive SSI/SSDI, but almost 45 percent of those whose onset occurred more
than a year earlier had enrolled in SSI/SSDI. This reflects in part the waiting pe-
riod required to gain eligibility to disability insurance.
n Predictors of high-level employment. Exhibit 5 presents regression analyses
that seek to explain what allows persons with mental illness to hold occupational
rank in executive, administrative, managerial, or professional specialty occupations.
These jobs generally require high levels of education, and for all subgroups, level of
educational attainment is the most important factor in holding such jobs. For exam-
ple, among those without a mental illness, the odds of a person with postcollege ed-
ucation having such a job is fifty-one times greater than for those who did not gradu-
ate from high school. Postcollege education, compared with having less than a high
school education, increases the odds of having a high-level job twenty-six times for
persons with serious mental illness and forty-three times for persons with any men-
tal illness. There is a lesser advantage in all groups from simply having some college
preparation or completing college, but odds of having a high-level job with this level
of education are two to nine times greater than among those who have not com-
pleted high school. Persons with mental illness in these occupations have probably
completed much of their education prior to their first onset of mental illness.
As Exhibit 5 shows, the increased odds of high-level employment with more ed-
ucational preparation were largest for the general population and lowest for per-
sons with serious mental illness. This may reflect both the impairments associ-
ated with mental illness that handicap even those with high levels of education
and the stigma associated with mental illness that may affect employers decisions
if they know the employees mental health history.
Persons with serious mental illness who have mood disorders as compared with
other serious disorders were 3.3 times more likely to have a higher-level position.
Other predictors are not statistically significant for this group. Statistical power
for this analysis is limited because of the relatively small size of this subgroup.
A number of additional factors predict employment in higher-ranking occupa-
tions; these include being female, being older, and having good perceived health.13
As with persons with mental illness, persons without mental illness in these jobs

H E A L T H A F F A I R S ~ Vo l u m e 2 1 , N u m b e r 5 249
D ata Wat c h

EXHIBIT 5
Predicting Employment In Executive, Administrative, Or Professional Specialty
Occupations Among Adults With And Without Mental Illness, Using Odds Ratios,
1994/1995

Persons with serious Persons with any Persons with no

Risk/protective factor mental illness mental illness mental illness

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

Disease characteristics
Mood disorder 3.34*** a a
No comorbid physical condition 0.57 0.77 0.95**
No comorbid substance abuse 1.50 1.46 1.58**
No comorbid mental illness 0.81 a a
Person characteristics
Age 1824 0.66 0.34*** 0.32***
Age 2544 1.37 0.88 0.82***
Age 4565 b b b
White 0.77 1.02 1.35***
Nonwhite b b b
Female 1.27 1.38** 1.28***
Male b b b
Not high school graduate b b b
High school graduate 0.52 1.92** 2.11***
Some college or college graduate 2.34 6.83*** 8.87***
Post-college 26.21** 42.63*** 50.97***
Limitations
Good psychological functioning 0.97 1.12 1.30***
Good health 0.89 1.64*** 1.40***
No problems with ADLs/IADLs 2.52 1.16 0.89
Model details
N for analysis 382 1,917 84,112
R-square 0.228 0.219 0.222
df 14 12 12
SOURCE: National Health Interview Survey on Disability, 1994/1995.
NOTES: Persons ages 1865. ADL is activity of daily living. IADL is instrumental activity of daily living.
a
Not applicable.
b
Denotes reference category.
**p < .05 ***p < .01

are older and more likely to be female and to have favorable perceived health.
Using the available data, we examined in more detail the jobs in these occupa-
tional categories occupied by persons with serious mental illness. Overall, they
were not very different from those held by persons without mental illness. The
number of persons with mental illness in this subsample is small, and thus differ-
ences are not statistically significant, but there were some interesting patterns.
Thirty percent of those with serious mental illness were teachers, librarians, or
counselors or in health assessment and treating occupations, compared with only
25 percent of those without mental illness. There were no differences between

250 September/October 2002

 Mental Illne ss

these groups in the proportions who were officials, administrators, or in manage-

ment occupations; almost two-fifths of both groups were in these occupations.
Persons with serious mental illness were less likely to be engineers, architects and
surveyors, and mathematical and computer scientists, with 5 percent occupying
such positions compared with 11 percent of others. Comparable proportions in
both groups were writers, artists, entertainers, and athletes.

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

Discussion And Policy Implications
In recent years, in response to disability advocacy groups, increased efforts have
been focused on meeting the employment needs of persons with disabilities, in-
cluding mental illness. Congress made it possible for persons in the disability pro-
gram to keep their federal health benefits when returning to work. Other efforts
have been made to facilitate trial work without jeopardizing ones disability sta-
tus.14 The Americans with Disabilities Act also requires that employers make rea-
sonable accommodations for persons with disabilities who are appropriately
qualified for the position, but it is not clear to what extent such requirements have
contributed to increased employment among persons with mental illness.15
Persons who have a history of severe and persistent mental illness receive some
job assistance through mental health rehabilitation programs. Traditional pro-
grams of this kind, which include prevocational training, training in job skills,
work under sheltered conditions, and gradual movement through various steps
toward competitive employment, have not had good success in returning clients
to competitive work.16 Research indicates that it is difficult to predict success in
work, but programs that place clients into competitive employment with contin-
uing mental health services and various supports can lead to improved employ-
ment outcomes while being cost-efficient.17 Social Security and other funding
agencies must recognize this fact and adapt their policies to support programs
that better meet their objectives. Clients have been persistently critical of voca-
tional rehabilitation services. The 1999 Ticket to Work legislation (H.R. 1180, S.
331) provides opportunity for clients to gain access to the services they deem use-
ful for helping them return to work.18
Despite the evidence that many persons with mental illness with appropriate
education hold jobs throughout the occupational structure, most programs and
services are oriented to less-educated clients and employment in relatively low
status jobs such as janitors, dishwashers, and other low-paying service occupa-
tions. This is often the course of least resistance, since the demand for such work-
ers is high and placement involves few barriers. As a result, persons with mental
illness often are placed in jobs below their educational background. Persons with
mental illness who have achieved higher educational attainment are often frus-
trated by the difficulty of identifying programs relevant to their needs and capaci-
ties. Inappropriate placement may contribute to boredom, absenteeism, and job
failure.

H E A L T H A F F A I R S ~ Vo l u m e 2 1 , N u m b e r 5 251
D ata Wat c h

Many employers are reluctant to hire persons with a history of mental illness
because of their concern about unpredictable performance, work absenteeism,
and possible disruptions in the workplace. Many persons with mental illness are
conscientious and reliable employees without special accommodations, but oth-
ers require them. Fear of discrimination often leads to hiding mental health his-
tory and forgoing accommodation requests.19 One alternative for closing the com-
mon communication gap is to ensure that employers get tangible assistance and

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

support in dealing with behavioral problems that might arise; job coaches increas-
ingly are taking on some of these responsibilities.
The data show that persons with mental illness who have more educational at-
tainment are more likely to be in higher-status occupations. Such placement may
provide motivation to stay employed and to avoid dependency. Caution is required
in interpreting this finding. Although we made efforts to control for severity of ill-
ness and impairment, it is possible that more-educated persons are in some way
less impaired or have a different illness course, and thus cause and effect may be
confounded. Aggressive treatment when illness first occurs and good mainte-
nance therapy reduce the period of incapacity and are believed by most clinicians
to prevent subsequent disability.20 It would be useful to help clients to complete
their education as part of the larger effort to manage illness so as to prevent sec-
ondary impairments, including the inability to work. Efforts also should be made
to keep clients in competitive employment with appropriate mental health ser-
vices and support. Maintaining educational and job continuity when illness oc-
curs in late adolescence and young adulthood is a major challenge. It is often diffi-
cult to engage patients in treatment and gain their cooperation.21 Primary
prevention of serious disorders remains highly uncertain, but there is much evi-
dence that secondary disabilities often associated with mental illness can be at-
tenuated and even prevented.22

This research was funded in part by grants from the Disability Research Institute, University of Illinois at
Urbana-Champaign; by National Institute of Mental Health (NIMH) Grant no. MH43450; and by a grant from
the Robert Wood Johnson Foundation. The views expressed imply no endorsement by these funders.

NOTES
1. D.D. McAlpine and L. Warner, Barriers to Employment among Persons with Mental Impairments: A Review of the Lit-
erature (New Brunswick, N.J.: Institute for Health, Health Care Policy, and Aging Research, 2001), 24; J.L.
Mashaw and V.P. Reno, eds., The Environment of Disability Income Policy: Programs, People, History, and Context
(Washington: National Academy of Social Insurance, 1996), 4751; and J.L. Mashaw and V.P. Reno, Bal-
ancing Security and Opportunity: The Challenge of Disability Income Policy (Washington: NASI, 1996), 6364.
2. J.C. Phelan et al., Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It
to Be Feared? Journal of Health and Social Behavior 41, no. 2 (2000): 188207.
3. T.L. Scheid and M. Suchman, Ritual Conformity to the Americans with Disabilities Act: Coercive and
Normative Isomorphism, in Research in Social Problems and Public Policy, vol. 8, ed. S. Hartwell and R. Shutt
(New York: Elsevier Science, JAI Press, 2001).
4. R.C. Kessler et al., Lifetime and Twelve-Month Prevalence of DSM-III-R Psychiatric Disorders in the
United States: Results from the National Comorbidity Survey, Archives of General Psychiatry 51, no. 1 (1994):
819.

252 September/October 2002

 Mental Illne ss

5. R.C. Kessler et al., The Prevalence and Correlates of Untreated Serious Mental Illness, Health Services Re-
search 36, no. 6 (2001): 9871007.
6. See, for example, J.A. Cook et al., Vocational Outcomes among Formerly Homeless Persons with Severe
Mental Illness in the ACCESS Program, Psychiatric Services 52, no. 8 (2001): 10751080.
7. Data come from public-use data files provided by the National Center for Health Statistics (NCHS). Core
descriptions of the survey were published in 1996 and 1998. See NCHS, National Health Interview Survey on
Disability: Phase 1, Person and Condition Data (Hyattsville, Md.: U.S. Department of Human Services, 1996 and
1998). Additional references for other data sources for this survey are available from the authors.
8. P.R. Barker et al., Serious Mental Illness and Disability in the Adult Household Population: United States,

Downloaded from http://content.healthaffairs.org/ by Health Affairs on July 15, 2016 by HW Team

1989, in Center for Mental Health Services and National Institute of Mental Health, Mental Health, United
States, 1992, ed. R.W. Manderscheid and M.A. Sonnenschein, DHHS Pub. no. (SMA)92-1942 (Washington:
U.S. Government Printing Office, 1992), 255261; Kessler et al., Lifetime and Twelve-Month Prevalence;
and R. Sturm et al., The Design of Healthcare for Communities: A Study of Health Care Delivery for Alco-
hol, Drug Abuse, and Mental Health Conditions, Inquiry 36, no. 2 (1999): 221233.
9. B.V. Shah et al., SUDAAN Users Manual, Release 7.5 (Research Triangle Park, N.C.: Research Triangle Institute,
1997).
10. D. Mechanic, Mental Health and Social Policy: The Emergence of Managed Care, 4th ed. (Boston: Allyn and Bacon,
1999), 4855.
11. W.E. Narrow et al., Revised Prevalence Estimates of Mental Disorder in the United States, Archives of Gen-
eral Psychiatry 59, no. 2 (2002): 115123.
12. Mashaw and Reno, The Environment of Disability Income Policy, 9497; Mashaw and Reno, Balancing Security and
Opportunity, 6768; and S.E. Estroff et al., No Other Way to Go: Pathways to Disability Income Application
among Persons with Severe, Persistent Mental Illness, in Mental Disorder, Work, Disability, and the Law, ed. R.J.
Bonnie and J. Monahan (Chicago: University of Chicago Press, 1997), 55104.
13. The advantage of women in holding higher-ranking positions may be puzzling since men are more likely
to be employed in all subgroups. Further analyses find, however, that women are vastly overrepresented
relative to men in certain occupations that are highly prevalent within these larger occupational catego-
riesfor example, teachers, librarians, and counselors. The occupations in which men are more likely to
be are less prevalentfor example, engineers, architects, and mathematical and computer scientists.
14. Mashaw and Reno, The Environment of Disability Income Policy, 131144; and Mashaw and Reno, Balancing Secu-
rity and Opportunity, 153162.
15. D. Mechanic, Cultural and Organizational Aspects of Application of the Americans with Disabilities Act
to Persons with Psychiatric Disabilities, Milbank Quarterly 76, no. 1 (1998): 523.
16. G.R. Bond et al., Implementing Supported Employment as an Evidence-Based Practice, Psychiatric Services
52, no. 3 (2001): 313322; R.E. Crowther et al., Helping People with Severe Mental Illness to Obtain
Work: Systematic Review, British Medical Journal 322, no. 7280 (2001): 204208; and McAlpine and
Warner, Barriers to Employment.
17. Bond et al., Implementing Supported Employment. For a review of the benefit-cost literature on this is-
sue, see J. Kregel et al., Supported Employment Benefit-Cost Analysis: Preliminary Findings, Journal of Vo-
cational Rehabilitation 14, no. 3 (2000): 153161; and R.E. Clark et al., Benefits and Costs of Supported Em-
ployment from Three Perspectives, Journal of Behavioral Health Services and Research 25, no. 1 (1998): 2234.
18. See Weekly Compilation of Presidential Documents, vol. 35 (1999): December 17, Presidential Remarks and State-
ment. For background, also see Mashaw and Reno, The Environment of Disability Income Policy, 101119.
19. Mechanic, Cultural and Organizational Aspects.
20. There is abundant evidence that treatment reduces periods of incapacity and distress. Although most cli-
nicians believe that earlier treatment also reduces later disability, and there is theoretical basis for this
view, the evidence on this point, thus far, is less certain. See R.M.G. Normand and A.K. Malla, Duration of
Untreated Psychosis: A Critical Examination of the Concept and Its Importance, Psychological Medicine 31,
no. 3 (2001): 381400; and P. McGorry, Secondary Prevention of Mental Disorders, in Textbook of Commu-
nity Psychiatry, ed. G. Thornicroft and G. Szmukler (Oxford: Oxford University Press, 2001), 495508.
21. Mechanic, Mental Health and Social Policy, 106108.
22. P.J. Mrazek and R.J. Haggerty, eds., Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Re-
search (Washington: National Academy Press, 1994), 315317; and Mechanic, Mental Health and Social Policy,
179185.

H E A L T H A F F A I R S ~ Vo l u m e 2 1 , N u m b e r 5 253