Cognitive functioning, symptoms, and work in supported employment: a review and heuristic model

Objective: Supported employment has been shown to improve the employment outcomes of clients with severe mental illness (SMI), but many clients who receive this service still fail to achieve their vocational goals. There is a need to better understand how illness-related impairments interfere with work, and how supported employment services deal with those impairments in order to improve the employment outcomes of clients with SMI. Method: We conducted a review of research on the relationship between cognitive functioning, symptoms, and competitive employment in clients with SMI. Based on this review, we developed a heuristic model of supported employment that proposes specific interactions between cognitive factors, symptoms, vocational services, and employment outcomes. Results: The review indicated that cognitive functioning and symptoms were strongly related to work in studies of general psychiatric samples. In studies of clients participating in vocational rehabilitation programs, associations between cognitive functioning, symptoms, and work were also present, but were attenuated, suggesting that vocational rehabilitation compensates for the effects of some cognitive impairments and symptoms on work. We describe a heuristic model of supported employment that posits specific and testable effects of cognitive domains and symptoms on vocational services and employment outcomes. Conclusions: Supported employment appears to work by compensating for the effects of cognitive impairment and symptoms on work. The model may serve as a guide for research aimed at understanding how supported employment works, and for developing supplementary strategies designed to improve the effectiveness and cost-effectiveness of supported employment services.     

A meta-analysis of cognitive remediation in schizophrenia

OBJECTIVE: This study evaluated the effects of cognitive remediation for improving cognitive performance, symptoms, and psychosocial functioning in schizophrenia. METHOD: A meta-analysis was conducted of 26 randomized, controlled trials of cognitive remediation in schizophrenia including 1,151 patients. RESULTS: Cognitive remediation was associated with significant improvements across all three outcomes, with a medium effect size for cognitive performance (0.41), a slightly lower effect size for psychosocial functioning (0.36), and a small effect size for symptoms (0.28). The effects of cognitive remediation on psychosocial functioning were significantly stronger in studies that provided adjunctive psychiatric rehabilitation than in those that provided cognitive remediation alone. CONCLUSIONS: Cognitive remediation produces moderate improvements in cognitive performance and, when combined with psychiatric rehabilitation, also improves functional outcomes.     

Predicting vocational functioning and outcome in schizophrenia outpatients attending a vocational rehabilitation program

BACKGROUND: Vocational rehabilitation is a central issue in the rehabilitation of patients with chronic schizophrenia. However, even with the help of comprehensive integration programs, achieving this objective remains a very ambitious and difficult undertaking. Therefore, a profound and up-to-date knowledge of vocational functioning and outcome predictors in patients who have the goal to return into competitive employment is imperative. The objective of the present study was to test the predictors summarized in the recent review of Cook and Razzano, as well as to test those predictors specified in the nine hypotheses put forward by Anthony and Jansen in schizophrenia patients enrolled in a vocational rehabilitation program. METHODS: The predictive value of ten hypotheses centering on vocational functioning and outcome were consecutively tested in a sample of 53 schizophrenia patients. Those predictors identified as significant were then taken into a 'winner take all' regression in order to determine which of them were the best. RESULTS: The overall work performance observed in a workshop proved to be the best predictor of vocational functioning. Contrary to the pivotal claim in Anthony and Jansen's review, in our sample, negative symptoms indeed influenced vocational functioning, outcome and functional skills. Cognitive impairments, social competence and fatalistic control beliefs also had predictive value for vocational functioning and outcome. CONCLUSIONS: These results reflect the accumulated findings of the past decade as summarized by Cook and Razzano. Moreover, they serve to substantiate the necessity of promoting the concept of cognitive remediation and associated programs designed to transform fatalistic beliefs into feelings of hopefulness, thereby enhancing the readiness of schizophrenia patients to enroll in rehabilitation programs.     

Cognitive remediation. A new chance in rehabilitation of schizophrenic disorders?

A critical review of current approaches and principles of cognitive remediation strategies in rehabilitation of schizophrenia is given. Selection of cognitive functions targeted in compensatory training programs could be based on results of neuropsychological predictor research on social and vocational functioning in community and neuropsychological rate limiting factors in rehabilitation. Methodological flaws in data base, missing of task analysis of more complex skills like social perception, social skills and interpersonal problem solving and the lack of evaluation of training generalization on work performance are discussed. Finally the cognitive remediation program developed in the Department of General Psychiatry and Psychotherapy/University of Freiburg, Germany is proposed. The components focused on training in attention, memory, and executive function (decision making, planning). Compensatory strategy building, and computer-mediated automatization are integrated in a group setting.     

What perspectives for cognitive remediation in schizophrenia?

Cognitive deficits are routinely evident in schizophrenia, and are of sufficient magnitude to influence functional outcomes in work, social functioning and illness management. Cognitive remediation is an evidenced-based non-pharmacological treatment for the neurocognitive deficits seen in schizophrenia. Narrowly defined, cognitive remediation is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning, but from the vantage of the psychiatric rehabilitation field, cognitive remediation is a therapy which engages the patient in learning activities that enhance the neurocognitive skills relevant to their chosen recovery goals. Cognitive remediation programs vary in the extent to which they reflect these narrow or broader perspectives but a metaanalytic study reports moderate range effect sizes on cognitive test performance, and daily functioning. Reciprocal interactions between baseline ability level, the type of instructional techniques used, and motivation provide some explanatory power for the heterogeneity in patient response to cognitive remediation. Recent studies indicate that intrinsic motivation mediates the relationship between neurocognition and functional outcomes. Results of these studies suggest that intrinsic motivation should be a viable treatment target in cognitive remediation intervention. In this perspective, NEAR (Neuropsychological Educational Approach to Remediation) program was created to enhance intrinsic motivation by employing more engaging and interesting software packages for cognitive practice, involving consumers in choosing the focus of training and having the NEAR leader serve as a coach to engage the consumers in active guidance of their own treatment program.     

Support of working life of persons with schizophrenia]

The aim of this study was to review the theories and methodologies for helping persons with schizophrenia to gain employment because working is one of the important factors for normalizing lives. The rate of employment among schizophrenics is determined by several factors including the unemployment rate of the nation, the date, sampling method and so on. However, persons with schizophrenia generally have had a lower employment rate around 20%, calculated as the rate of competitive employment compared to other psychiatric disorders both in the U.S. and Japan. Because traditional vocational rehabilitation did not lead to a good vocational outcome, supported employment has been developed over the last 20 years. Many studies clarified that supported employment led to a better outcome in the competitive employment, especially "Individual Placement and Support (IPS)". The systematic review of the Cochrane database, the Treatment Guideline of Schizophrenia of APA, and the PORT Treatment Guideline of Schizophrenia recommended the use of supported employment. Supplementary programs such as cognitive rehabilitation have been recently developed because psychiatric symptoms and social functioning were not improved and income and tenure of employment were not sufficient, even with supported employment. Cognitive functioning, attention, learning, memory, and executive functioning were verified to have influences on vocational functioning in many studies, and cognitive rehabilitation with supported employment was verified to improve vocational outcome. Six evidence based technologies of vocational rehabilitation were discussed. Vocational rehabilitation centers, day treatment centers aiming at competitive employment, and NPOs for employment of disabled persons are recommended as good clinical models of evidence based vocational rehabilitation. Professionals of the same agency in these models help people concerning both working and independent living, which is one of the important principles of IPS. Finally, we discussed several issues about methodologies and social framework which need further research and social agreement.     

Vocational,Social, and Cognitive Rehabilitation for Individuals Diagnosed With Schizophrenia: A Review of Recent Research and Trends

A growing body of evidence suggests that social and vocational interventions effectively enhance social and vocational functioning for individuals with schizophrenia. In this review, we first consider recent advances in vocational and social rehabilitation, then examine current findings on neurocognition, social cognition, and motivation with regard to the impact these elements have on rehabilitation interventions and outcomes. A critical evaluation of recent studies examining standalone treatment approaches and hybrid approaches that integrate components such as cognitive remediation and skills training reveals several ongoing challenges within the field. Greater understanding of the differential impact of various approaches, methods that may increase the magnitude of treatment effects, and the generalization of treatment effects to community functioning are among crucial areas for future research. Overall, these treatments hold promise in improving psychosocial functioning and helping individuals with schizophrenia acquire important life skills.     

Improved cognitive function in schizophrenia after one year of cognitive training and vocational services

A year-long program of Neurocognitive Enhancement Therapy (NET) was used to remediate cognitive deficits in people with schizophrenia who were participating in a vocational program. Seventy-two stable outpatients with schizophrenia or schizoaffective disorder, recruited from an urban community mental health center were randomly assigned to a twelve-month vocational program (VOC) or NET+VOC. The vocational program had characteristics of individual placement and support (IPS) programs but also included transitional funding. NET included computer-based cognitive training exercises, a social information processing group and a work feedback group. Sixty-two participants completed a neuropsychological test battery before and after treatment. After one year of treatment, participants receiving NET+VOC had significantly greater improvements on measures of executive function and working memory than did participants in the VOC only condition. Augmenting vocational services with a multifaceted cognitive remediation program may improve cognition in participants with schizophrenia or schizoaffective disorder.     

Social-cognitive remediation in schizophrenia: generalization of effects of the Training of Affect Recognition (TAR)

In the last decade, several social cognitive remediation programs have been developed for use in schizophrenia. Though existing evidence indicates that such programs can improve social cognition, which is essential for successful social functioning, it remains unclear whether the improvements generalize to social cognitive domains not primarily addressed by the intervention and whether the improved test performance transfers into everyday social functioning. The present study investigated whether, beyond its known effects on facial affect recognition, the Training of Affect Recognition (TAR) has effects on prosodic affect recognition, theory of mind (ToM) performance, social competence in a role-play task, and more general social and occupational functioning. Thirty-eight inpatients with a diagnosis of schizophrenia or schizoaffective disorder were randomly assigned to 6 weeks of treatment with the TAR--primarily targeted at facial affect recognition-or Cognitive Remediation Training (CRT)--primarily targeted at neurocognition. Intention-to-treat analyses found significantly larger pre-post improvements with TAR than with CRT in prosodic affect recognition, ToM, and social competence and a trend effect in global social functioning. However, the effects on ToM and social competence were no longer significant in the smaller group of patients who completed treatment according to protocol. Results suggest that TAR effects generalize to other social cognitive domains not primarily addressed. TAR may also enhance social skills and social functioning, although this has to be confirmed. Results are discussed with regard to the need to improve functional outcome in schizophrenia against the background of current evidence from other social cognitive remediation approaches.     

Neurocognitive rehabilitation for schizophrenia

A critical review of randomized, controlled trials of extended programs of neurocognitive rehabilitation for the cognitive deficits characteristic of schizophrenia conducted between the years 2000 to 2002 was completed. Over the past several years, two models of cognitive rehabilitation have emerged. In one model, labeled “cognitive remediation,” cognitive deficits are treated directly through repeated practice and acquisition of compensatory strategies on cognitive exercises designed to engage underfunctioning brain systems. In a second model, labeled “cognitive adaptation,” neurocognitive deficits are addressed through modification of the patients’ environment to allow patients to bypass their deficits. Results revealed that a range of cognitive remediation strategies varying widely along dimensions of duration, intensity, method, target of behavioral intervention, and clinical status of participants produced improvements on measures of working memory, emotion perception, and executive function distinct from those trained during remediation. No effects were evident in secondary verbal or nonverbal memory. Results of two pilot studies using functional magnetic resonance imaging to assess changes in task-evoked brain activation have revealed that these interventions may produce changes in several functionally relevant neural systems in a subset of patients. Results from studies of standardized cognitive adaptation interventions have indicated that these treatments can produce improvements in symptoms, psychosocial status, and relapse rates. A variety of approaches for future research are also discussed.     

Impacts de la combinaison de programmes de soutien à l’emploi et de remédiation cognitive sur le maintien en emploi de personnes souffrant de schizophrénie : une méta-analyse

ObjectivesAbout 80% of people suffering from schizophrenia are not working despite their desire to obtain a job. The rate of employment and job tenure remain below the average of the non-clinical population even though supported employment programs (SE) were implemented. Cognitive deficits, among other factors, could influence the occupational functioning of people suffering from schizophrenia. Given that these deficits are highly prevalent in people who have experienced multiple episodes of psychosis, numerous studies have evaluated the efficacy of integrating cognitive remediation to SE programs. Our objective was to conduct a meta-analysis to evaluate the efficacy of these combined programs (SE+) in terms of job tenure.Material and methodsWe searched the literature in several databases (Medline, Embase, Pubmed, PsycInfo, et Cochrane Library) using different keywords (“schiz*”AND “vocation*” AND “rehabilitation or recovery” AND “cogniti*” AND “random* control*”). The selection of studies was limited to those written in French or English, using a randomized-controlled trial or prospective design, including participants with a schizophrenia-spectrum diagnosis, including and presenting work outcomes (e.g., work duration, job acquisition) of a program combining SE and cognitive remediation programs. Following data extraction, we calculated the Hedges’ g effect size for each study that reported job tenure outcomes. We used a random-effects model and evaluated heterogeneity with the Cochran's Q-statistic and the I2 index. Publication bias was estimated through the use of a funnel plot, the Rosenthal's fail-safe N and Egger's asymmetry test.ResultsWe identified 12 studies that presented different SE+ programs comprising 334 and 322 persons suffering from schizophrenia assigned to treatment and control conditions, respectively. Our quantitative results suggest that combining cognitive remediation and SE programs do not significantly impact job tenure. Although our analyses suggest the presence of heterogeneity and publication bias, it is still advisable to conduct a meta-analysis because it allows circumventing the biases introduced when using the vote counting technique (i.e., simply comparing the number of positive and negative studies). Our results should thus be considered as exploratory and future meta-analyses are encouraged when a significantly larger number of studies on the subject will be published.ConclusionsVarious improvements to the reviewed programs could be implemented in order to enhance job tenure, notably by integrating other components such as social skills training or by focusing the remediation on cognitive functions more closely related to job tenure.     

Cognitive remediation and vocational rehabilitation for schizophrenia

Cognitive deficits are a central and debilitating aspect of schizophrenia and other major mental illnesses. Although they are largely refractory to pharmacotherapy, multiple studies have now shown that large and lasting improvements in cognition can result from behavioral interventions. We will review our work over the past 10 years demonstrating that cognitive remediation treatment together with work therapy or supported employment can lead to large, lasting, and clinically relevant improvements in cognition and work functioning. While we will make some references to the work of others in these same areas, this is not a general review of these areas of research. Instead, the goal is to provide the rationale for the progression of our studies, describe the methods, and summarize the results, so that readers may understand, critique, and improve upon what we have done.     

The effects of neurocognitive remediation on executive processing in patients with schizophrenia.

Approaches to cognitive remediation have differed across studies. Most of the larger studies have concentrated on group treatments designed without the benefit of recent laboratory-based studies. The current study describes a randomized trial of an intensive cognitive remediation program involving individual daily sessions of 1 hour for up to 3 months. It targets executive functioning deficits (cognitive flexibility, working memory, and planning) that are known to be problematic in people with schizophrenia. Procedural learning, as well as the principles of errorless learning, targeted reinforcement, and massed practice, was the basis of the intervention. The program was compared with an alternative therapy (intensive occupational therapy) to control for some of the effects of therapeutic contact. Some improvements in cognition followed both therapies. A differential effect in favor of cognitive remediation therapy was found for tests in the cognitive flexibility and the memory subgroups. There was a trend for those receiving atypical antipsychotic medication to benefit more from cognitive remediation for tests of cognitive flexibility. Although there were no consistent changes in symptoms or social functioning between groups, if improvement in cognitive flexibility tasks reached a threshold then there is some evidence that social functioning improved, even over the short duration of the trial. In addition, cognitive remediation differentially improved self-esteem. This study supports the view that cognitive remediation can reduce cognitive deficits and that this reduction may affect social outcome, at least in the short term.     

Is it possible to improve social functioning of schizophrenia with cognitive rehabilitation?]

Social dysfunction of schizophrenia is observed in many domains including social skills, ability to conduct tasks, attention/durability, volition/motivation, stability of social life, and insight of dysfunction. These dysfunctions have been found to relate to non-social cognitive functioning to some extent. Social skills may have a strong relationship with social cognition. The intervention technique of cognitive functioning of schizophrenia, known as cognitive rehabilitation or cognitive remediation, has its main target as non-social cognition. Cognitive behavior therapy focuses on the contents of the cognitive process, while cognitive rehabilitation focuses on the cognitive process (information process) or thinking skills. Which cognitive functioning should be targeted was revealed as were theoretical models of cognitive rehabilitation, and various intervention techniques and their usefulness. It has been found that some elements of cognitive functioning, such as executive functioning, could be improved in experimental settings in efficacy studies. However, comprehensive rehabilitation including cognitive rehabilitation should be used in order to relieve social dysfunctioning or psychiatric symptoms. Some experts insisted that an individualized program with several steps, along with cognitive abilities, is required to enhance usefulness and effectiveness. Other experts said more complex cognitive functioning profoundly associated with social life should be targeted, rather than elementary cognitive functioning. The conclusions of meta-analyses of randomized controlled trails were not consistent until now, because inclusion criteria of meta-analysis was different. Finally, it was discussed how the theory and techniques of cognitive rehabilitation should be implemented in traditional rehabilitation.     

A longitudinal study of learning potential and rehabilitation outcome in schizophrenia

OBJECTIVE: The study examined whether a measure of learning potential is prospectively related to the success of a vocational rehabilitation program for patients with severe mental illness in Germany. METHODS: At rehabilitation intake (November 2002 to January 2004), 41 persons with schizophrenia or schizoaffective disorders completed a test-train-test version of the Wisconsin Card Sorting Test as a measure of learning potential. Research participants were classified as high scorers, learners, or nonlearners. Rehabilitation outcome was assessed with measures of work capability during the rehabilitation program, level of functioning during rehabilitation and at three-month follow-up, and level of vocational integration at three-month follow-up. RESULTS: Individual learning potential was associated with the improvement of work-related learning ability during rehabilitation and with the level of functioning and the level of vocational integration at three-month follow-up (about 15 months after the initial testing). Generally, high scorers had better rehabilitation outcome at all assessment points regarding all outcome measures. Even though learners and nonlearners started at comparable levels at the beginning of the rehabilitation, learners benefited more from the program, whereas nonlearners showed a rather unfavorable rehabilitation outcome. CONCLUSIONS: Findings supported the assumption that learning potential is an informative predictor of rehabilitation outcome and may add information beyond static cognitive measures. Learning potential should be considered in the further development of vocational rehabilitation programs.     

Employment outcome and predictors of competitive employment at 2-year follow-up of a vocational rehabilitation programme for individuals with schizophrenia in a high-income welfare society

Background: Employment is an important part of recovery for individuals with schizophrenia. The employment rate for this group is as low as 10% in Norway, and major system related barriers to employment are evident.

Aims: This study reports the competitive employment outcome at 2-year follow-up of a vocational rehabilitation study augmented with cognitive remediation (CR) or elements from cognitive behaviour therapy (CBT) for individuals with schizophrenia spectrum disorders. It also investigates if global functioning, self-esteem, and depression at baseline predicts employment outcome, and if change in these variables during the intervention period is associated with employment outcome.

Method: One hundred and forty-eight participants with schizophrenia spectrum disorders in six Norwegian counties received 10 months vocational rehabilitation augmented with either CBT (n?=?84) or CR (n?=?64). Both competitive and sheltered workplaces were used. Participants were assessed at baseline, at the end of the intervention period, and at 2-year follow-up.

Results: At 2-year follow-up, 21.2% had obtained competitive employment. A further 25.3% had work placements in competitive workplaces. Significant improvements were found in global functioning, self-esteem, and depression during the intervention period, but no significant differences between the two intervention groups. High baseline global functioning and self-esteem, as well as positive change in these variables during the intervention period, were significantly associated with higher competitive employment outcome at 2-year follow-up.

Conclusion: The results add to existing evidence that competitive employment is attainable for individuals with schizophrenia. High global functioning and self-esteem were strongly associated with competitive employment outcome.     

Cognitive and symptom predictors of work outcomes for clients with schizophrenia in supported employment

OBJECTIVES: This study examined the relationships of measures of cognitive functioning and psychiatric symptoms with work outcomes and use of vocational services for clients with schizophrenia in a supported employment program. METHODS: Thirty clients who were newly enrolled in a supported employment program were evaluated with cognitive and symptom measures at program entry and two years later. The clients' amounts of competitive work, wages earned, on-job support, and contact with employment specialists during the two-year follow-up period were documented. RESULTS: Predictors of clients' work outcomes included previous work history, amount of government entitlement income received, severity of negative symptoms, involvement in sheltered work activity at baseline, and level of cognitive functioning, including scores on measures of executive functioning and verbal learning and memory. The amounts of on-job support and contact with employment specialists were predicted by the cognitive domains of executive functioning, verbal learning, attention, and psychomotor speed as well as by the severity of psychotic symptoms. CONCLUSIONS: Clients with schizophrenia who have higher levels of cognitive impairment may require greater amounts of vocational support than those with lower levels of impairment. A variety of rehabilitation strategies may be required to improve vocational outcomes and reduce the amount of supported employment services needed by clients with schizophrenia.     

Clinical neuropsychology in rehabilitation

Abstract

Despite a growing awareness of the critical role that cognitive factors may play in the rehabilitation process, rehabilitation programs continue to concentrate heavily, if not exclusively, on improving physical disability. In the rehabilitation setting, considerable research has indicated that cognitive variables are not only related to, but are also of significant value in predicting physical rehabilitation outcome. In cases where deficits in cognition constitute not only debilitating but enduring aspects of brain injury, remedial input has been recently shown to improve level of functioning. In this report, we focus broadly and generally on the relationship between cognitive factors and rehabilitation, the emerging field of cognitive remediation, and the critical role clinical neuropsychology has to play in its further development. Several issues of both theoretical and potentially applied importance are highlighted, and some suggestions for future research are offered.     

Assessment of a six-week computer-based remediation program for social cognition in chronic schizophrenia

Background

Programs to remediate cognitive deficits have shown promising results in schizophrenia, but remediation of social cognition deficits is less well understood. Social cognitive deficits may cause more disability than the widely recognized neurocognitive deficits, suggesting that this is an area worthy of further investigation.

Aim

Implement and evaluate a brief computerized cognitive remediation program designed to improve memory, attention, and facial affect recognition (FAR) in outpatients with chronic schizophrenia.

Methods

Baseline assessments of FAR and of clinical, cognitive, and psychosocial functioning were completed on 20 males with schizophrenia enrolled in an outpatient rehabilitation program at the Shanghai Mental Health Center (the intervention group) and on 20 males with schizophrenia recruited from among regular outpatients at the Center (the control group). Both groups received treatment as usual, but the intervention group also completed an average of 12.7 sessions of a computer-based remediation program for neurocognitive, social, and FAR functioning over a 6-week period. The baseline measures were repeated in both groups at the end of the 6-week trial.

Results

There were no statistically significant differences in the changes in clinical symptoms (assessed by the Positive and Negative Syndrome Scale, PANSS) or cognitive measures (assessed using the Hong Kong List Learning Test and the Letter-Number Sequencing Task) between the intervention and control groups over the 6-week trial, but there were modest improvements on the PANSS for the intervention group between baseline and after the intervention. There was a significantly greater improvement in the social functioning measure (the Personal and Social Performance scale, PSP) in the intervention group than in the control group. The pre-post change in the total facial recognition score in the intervention group was statistically significant (paired t-test=-2.60, p=0.018), and there was a statistical trend of a greater improvement in facial recognition in the intervention group than in the control group (F_(1,37)=2.93; p=0.092).

Conclusion

Integration of FAR training with a short, computer-administrated cognitive remediation program may improve recognition of facial emotions by individuals with schizophrenia, and, thus, improve their social functioning. But more work on developing the FAR training modules and on testing them in larger, more diverse samples will be needed before this can be recommended as a standard part of cognitive remediation programs.     

Can computer-assisted cognitive remediation improve employment and productivity outcomes of patients with severe mental illness? A meta-analysis of prospective controlled trials

BackgroundComputer-assisted cognitive remediation (CACR) has been demonstrated to enhance cognition of patients with severe mental illness (SMI). Patients with improved cognitive skills may find it easier to be employed, and the ability to maintain employment is an important sign of recovery.AimTo assess whether CACR is an effective method to enhance work-related outcomes in patients with SMI.MethodProspective controlled trials evaluating CACR on productivity outcomes were systematically identified from the OVID databases. Employment rates, total days of work in a year, and total annual earnings were defined as the productivity outcomes.ResultsNine trials were published between 2005 and 2014 and were conducted in the United States, Germany, Italy, Singapore and Japan. A total of 740 patients with mean age of 36.4 years were included. The duration of CACR ranged from 2 months to 2 years, and the patients were followed-up from 1 year to 3 years. Patients receiving CACR showed 20% higher employment rate (95% CI = 5%–35%), worked 19.5 days longer in a year (95% CI = 2.5–36.6 days), and earned US$959 more in total annual earnings (95% CI = US$285 to US$1634) than those not receiving CACR.ConclusionCACR can enhance productivity outcomes for patients with SMI, including higher employment rate, longer duration of work and higher income. The economic benefit of CACR can enhance the quality of life for patients with SMI, and may reduce financial burden on the health and welfare system. Therefore, CACR can be recommended and incorporated into regular vocational rehabilitation programs.