...competitive employment among individuals with schizophrenia range from 10-20% (Cook et al., 2005; Mueser, Salyers, & Mueser, 2001). Although supported employment has been successful in helping up to 40% of individuals with schizophrenia obtain competitive employment (Cook & Razzano, 2000; Lehman et al., 2002), half of them experience job terminations within the first six months of employment (McHugo, Drake, & Becker, 1998). Because the problem of early job termination is better described than understood, a priority for research in vocational rehabilitation of persons with schizophrenia is to identify the factors that impede job maintenance. Knowledge of those factors that are obstacles to employment is critical to designing improved methods of vocational rehabilitation for persons with schizophrenia.

In general, barriers to sustained success at work are inherent in the mismatch between an individual's attributes, deficits, skills and interests on the one hand, and the properties, expectancies and requirements of the job on the other. One characteristic of individuals with schizophrenia that is relevant to successful person-job fit is deficiencies in cognitive capacities (Gold et al., 2002; McGurk & Mueser, 2003). Impaired cognition causes difficulties for persons with schizophrenia in performing many tasks that are found in the workplace. Moreover, well-replicated research has revealed a strong association between cognitive functions and success of schizophrenia patients on a wide variety of instrumental role activities including employment, social skills and social functioning (Green, Kern, Braff, & Mintz, 2000).

The purpose of this study was to determine if the individuals' vocational success might be a function of the cognitive "demands" imposed by typical entry-level job tasks. Three such tasks were used in this study. One involved learning how to select and serially insert parts into a computer motherboard, which emphasizes visual-spatial memory skills; another involved sorting written material alphabetically and categorically, which makes a strong demand on verbal working memory; and the third involved learning the basic procedures of word processing using a personal computer, which taps verbal learning ability (Kern et al., 2002; Zarate, Liberman, Mintz, & Massel, 1998). The hypotheses were that clients would perform better on tasks that required less demands on verbal learning and memory, and that participants who received occupational therapy would do more poorly on the tasks than their counterparts who received specialized training for the tasks.

Methods

Design

The three disparate entry-level work tasks were designed to be representative of entry-level jobs available in the community (Zarate, Liberman, Mintz, & Massel, 1998). Occupational Therapy (OT) was chosen as a comparative method because it was conducted in a manner to give structured opportunities for participants to improve their task-oriented attention, concentration and learning capacities and to give occupational therapists the occasion to prompt and reinforce participants for improved cognitive functioning and task productivity. In addition, OT was designed to serve as a control for the amount of interpersonal contact between participants and therapists. The same certified occupational therapists conducted both Work Training (WT) and OT in groups of 4-6 individuals.

All participants performed each task, and they were evaluated on accuracy and productivity at baseline, immediately before training commenced 4 weeks later (week 4), and at weeks 12 and 24. Participants were randomly assigned to WT that consisted of training on each task over a two-week period or to OT that focused on crafts and other creative activities for the same time as participants in the WT condition. As a fidelity check on the training intervention, that is, to assure that the training designed to improve the targeted skills did in fact do so, participants assigned to WT were assessed for task performance immediately after their two-week training period.

Participants were also randomly assigned to two medication conditions--equipotent risperidone or olanzapine--to determine whether there were any differences between these antipsychotic drugs on the participants' performance on the work tasks. The results of the pharmacological arm of the study on drug-task interactions will be reported in a subsequent publication. For purposes of this study, the participants in both medication conditions were combined for analyses.

Participants

The study group consisted of 120 participants with the clinical diagnosis made by the participants' attending psychiatrist of DSM-IV-TR schizophrenia or schizoaffective disorder. The diagnosis was confirmed using the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996) by an interviewer trained to a high level of reliability (.90) at the UCLA Clinical Research Center for Schizophrenia. The 24-item, expanded version of the Brief Psychiatric Rating Scale (Ventura, Green, Shaner, & Liberman, 1993) was administered at the baseline assessment for evaluating participants' psychopathology during the 2 weeks prior to study entry. The Schedule for the Deficit Syndrome (Kirkpatrick, Buchanan, McKenney, Alphs, & Carpenter, 1989) and the Clinical Global Impression scale (Guy, 1976) were also administered at baseline.

Participants were receiving outpatient treatment at a community mental health center in north Los Angeles County. Participants met the following criteria: (a) DSM-IV-TR diagnosis of either schizophrenia or schizoaffective disorder, (b) not meeting criteria for the deficit syndrome, (c) no alcohol or substance abuse or dependence within past three months, (d) no psychiatric inpatient treatment within the past six months, (e) a resident of Los Angeles County for at least the previous six months, (f) between 18 and 64 years of age, and (g) no history of neurological disorder apart from schizophrenia. These criteria were designed to select participants who needed maintenance antipsychotic medications but who were clinically stable. Stability was...

NOTE: All illustrations and photos have been removed from this article.



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