Employment in people with severe mental illnesses receiving public sector psychiatric services in India

Highlights

• Forty percent of participants were employed.

• Earning money was the most commonly cited motivation to work.

• Among unemployed participants, over 90% wanted to work and identified psychological, mental illness related and work related barriers to employment.

• Most participants interested in working desired help with job search.

• High work interest, identification of numerous obstacles to work and job supports desired by the participants point to the need for vocational rehabilitation for people with severe mental illnesses in India.

Abstract

The limited literature on employment in people with severe mental illnesses (SMI) in developing countries suggests higher rates than in developed countries. The present study explored rates and associated characteristics of work in people receiving public psychiatric services. Semi-structured interviews were conducted with 150 individuals with SMI (90% schizophrenia-spectrum) receiving public outpatient psychiatric services in an urban district in western India to evaluate employment. Forty percent of participants were employed, most for independent employers (86.7%), and were working an average of 53 hours/week. Earning money was reported as the primary motivation to work. A high proportion (92.2%) of unemployed participants wanted to work. Common barriers to work for unemployed participants who were interested in working were psychological (e.g., stress), mental illness (e.g., symptoms), and work-related factors (e.g., difficulty finding a job). Help finding a job and managing mental illness were the primary desired supports. Rates of employment in people with SMI living in urban areas in India are higher than in developed countries, but much lower than the general population. The high interest in work coupled with specific barriers and desired supports point to the need for vocational rehabilitation for improving the employment functioning of people with SMI in India.

Introduction

Severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have a profound impact on occupational functioning, with rates of employment generally below 25% for people living in developed countries (Jonsdottir and Waghorn, 2015; Marwaha et al., 2009). In contrast, research suggests higher rates of employment for people with SMI who are living in developing countries. For example, studies report work rates between 40% and 76% for persons with SMI living in India (e.g., Srinivasan and Tirupati, 2005; Srivastava et al., 2009; Thara, 2004), and between 52% and 77% for people with SMI in China (Ran et al., 2011; Xiao et al., 2015; Yang et al., 2013).

Despite the evidence suggesting higher rates of work for people with SMI in developing countries, many studies have significant methodological limitations. For example, almost all studies lack important information about work, including types of jobs, employers, hours worked, and income earned, and none have examined the perceived benefits of work or problems related to work. Some studies had small samples and excluded women (Prasad and Acharya, 2014; Srinivasan and Thara, 1997). Additionally, few studies from developing countries have evaluated interest in work among unemployed persons (Nagaswami et al., 1985). As vocational rehabilitation is generally not available in developing countries, such information is critical to the development of vocational services for people with SMI in these countries.

In order to better understand work functioning in people with SMI in developing countries we conducted a two-site study of employment in 550 people who were receiving private psychiatric outpatient treatment and were living in urban or rural areas in India. The findings indicated that 60.9% of participants were working, with higher employment rates in rural than urban areas, largely due to working in family owned farms (Khare et al., 2020). A high proportion of unemployed people were interested in work (77.4%), similar to studies in developed countries (Frounfelker et al., 2011; McQuilken et al., 2003; Mueser et al., 2001; Westcott et al., 2015). Further, most participants wanted assistance with work, such as help finding a job or coping with mental illness. The findings suggest that many unemployed individuals are interested in work and could benefit from vocational services tailored to their unique cultural context.

The participants in Khare et al. (2020) were receiving outpatient services at private hospitals, which are common treatment providers in India and other developing countries (Indian Ministry of Statistics and Programme Implementation, 2019; Mackintosh et al., 2016). While both public and private treatment providers charge for services in India and some other developing countries (Dixon et al., 2006; Rajkumar, 2015), public sector services are provided at no cost to families who cannot afford them (Aljunid, 1995). The likely differences in economic standing between people receiving public vs. private sector psychiatric services suggests that employment rates might be higher in the former group due to their greater incentive to work. Indeed, Khare et al. (2020) reported that employment rates among participants receiving private psychiatric services were higher in those who had lower family income. On the other hand, family economic resources other than income could also be important, such as whether the family owns a business that could employ the relative with SMI. The current study addressed these questions by examining employment in people with SMI who are receiving outpatient services at a public hospital in India.

Other under-studied topics include interest in working among unemployed people receiving public sector psychiatric services in India, and motivation for work among those who are employed. Studies from developed countries suggest that although money is an important motivator for work, other benefits of work are frequently reported, such as help coping with psychiatric symptoms, improved self-esteem, and making social connections (Arns and Linney, 1993; Dunn et al., 2010, 2008; Marwaha and Johnson, 2005; Netto et al., 2016). From a broader perspective on motivation, these reasons for working align with Maslow's (1954) hierarchy of needs theory, which posits that lower level needs (physiological, safety, belongingness) must be fulfilled before attending to higher level needs such as self-esteem and self-actualization. Developing countries are characterized by poorer economies than developed countries, and usually do not provide disability payments for SMI, which may contribute to the need to work to earn a living. Unemployed people receiving public sector services may have a particularly strong motivation to work to improve the economic conditions of their family.

Lastly, there is limited information about what hinders work among unemployed people with SMI in developing countries. Qualitative studies from China, India, and South Africa indicate that the stigma of mental illness is a barrier to work (Loganathan and Murthy, 2011; van Niekerk, 2009; Zou et al., 2014), although it was not identified as a major obstacle in Khare et al. (2020). Studies from India and Nigeria suggest that a range of other factors may interfere with employment in people with SMI, including symptoms, medication side-effects, physical health problems, inadequate skills or education, and lack of family or social support (Eaton, 2008; Thomas et al., 2019), consistent with studies from developed countries (Henry and Lucca, 2004; Honey, 2004; Marwaha and Johnson, 2005). A study with integrated quantitative and qualitative methods evaluating barriers to work could improve the understanding of factors impeding employment, similar to studies conducted in developed countries (e.g., Kukla et al., 2015).

To address these questions, this study examined work functioning in people with SMI receiving psychiatric outpatient treatment from a public hospital in India using the same methods as Khare et al's (2020) study of people receiving private treatment. In addition to the evaluation of specific types of work and other characteristics of employment (e.g., employer, hours worked), the perceived benefits and problems related to work were examined. Furthermore, interest in work, barriers to employment, and desired job supports were ascertained among the unemployed participants.