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Principal Investigator: Marina Kukla
Organization: RLR VA MEDICAL CENTER
Fiscal Year: 2024
Funding agency: Veterans Affairs
Project background: Work is a major social determinant of health. In people with serious mental illness
(SMI), work is associated with better wellbeing, physical and mental health, quality of life, and may
prevent the onset of disability. Among Veterans with SMI, work is a protective factor against suicide.
Most veterans with SMI are unemployed and suffer substantially worse health and recovery
across key domains. Despite quality VHA vocational services, such as supported employment (SE),
two-thirds or more of veterans who receive these services experience work dysfunction. A probable
explanation lies in unsolved cognitive and behavioral barriers, such as low work-related self-efficacy,
ineffective coping skills, little hope that work is attainable, poor work motivation and sense of self.
The Cognitive Behavioral Therapy for Work Success (CBTw) intervention was designed to
target these problems and augment VHA SE services to synergistically improve work, as well as health
and recovery, in Veterans with SMI. In an open trial pilot, CBTw was associated with significant
increases in hours worked and wages earned and the majority of CBTw participants became steady
workers. Veterans also experienced improvements in symptoms, recovery, and quality of life.
Project goals: Using Hybrid 1 RCT design, this project will test the effects of CBTw on competitive work
and health and recovery outcomes over a 9-month study period at 3 VA SE programs. Informed by the
RE-AIM framework, an implementation evaluation will examine the success of using SE staff to deliver
CBTw, barriers and facilitators to implementation, and strategies utilized.
Relevance to priorities: This project has high implementation potential and is responsive to the VHA
priority regarding Health Equity, as it will address work functioning, an under studied social determinant
of health. WORKWELL also holds promise to improve health and recovery outcomes among Veterans
with SMI, another HSR&D area of emphasis. Lastly, this study is consistent with the goal of finding
novel strategies toward suicide prevention among vulnerable Veteran groups, including those with SMI.
Objectives: Aim 1: Test the effects of CBTw + SE compared to a control of psychoeducation + SE on
work. Hypotheses: Participants in the CBTw+ SE arm will work significantly more total weeks in
competitive jobs (primary study outcome) and will be more likely to become steady workers.
Aim 2: Test the effects of CBTw + SE on health and recovery. Hypotheses: Participants in the CBTw +
SE arm will have greater improvements on subjective recovery and health-related quality of life, and
decreases in symptoms, suicidal ideation, and inpatient service utilization.
Aim 3: Guided by the RE-AIM implementation science framework, conduct an evaluation of the
implementation of CBTw, including examination of the feasibility of using SE staff to deliver CBTw, and
related barriers and facilitators. The objective is to spur future wide scale CBTw implementation.
Project Methods: WORKWELL is a pragmatic, Hybrid 1 design RCT. CBTw will be tested at 3 SE
sites—Roudebush VA Medical Center, the Edward J. Hines VA Medical Center, and the VA St. Louis
Health Care System. 276 unemployed Veterans with SMI will be randomly assigned to receive CBTw
plus SE or a control of psychoeducation plus SE. Outcomes including total weeks worked in
competitive jobs (primary), achievement of steady work, symptoms, recovery, health related quality
of life, suicidal ideation, and service utilization will be assessed at posttreatment (12 weeks), 6 months
(primary endpoint), and 9 months (to examine sustained effects). CBTw implementation planning,
training, and consultation will be provided. CBTw implementation (fidelity), barriers and facilitators to
implementation, and other RE-AIM elements will be examined using mixed methods.
Terms: <21+ years old><Achievement><Achievement Attainment><Active Follow-up><Address><Adoption><Adult><Adult Human><After Care><After-Treatment><Aftercare><Area><Assess implementation><Behavioral><Cognition Therapy><Cognitive><Cognitive Psychotherapy><Cognitive Therapy><Cognitive treatment><Consultations><Coping Skills><Counselor><Data><Deterioration><Disability prevention><Dysfunction><Economics><Elements><Emergency medical service><Evaluation><Feedback><Feeling suicidal><Functional disorder><Future><Goals><Health><Health Care Systems><Healthcare Systems><Hospital Admission><Hospitalization><Hospitals><Hour><Hybrids><Implementation assessment><Intervention><Intervention Strategies><Interview><Jobs><Link><Maintenance><Medical center><Mental Depression><Mental Health><Mental Health Services><Mental Hygiene><Mental Hygiene Services><Methods><Modeling><Motivation><Occupations><Outcome><Outcome Study><Participant><Personal Satisfaction><Persons><Physiopathology><Pilot Projects><Preventing disabilities><Probability><Professional Positions><Professional counselor><Psychological Health><QOL><Quality of life><RE-AIM><Randomized><Randomized, Controlled Trials><Reach, Effectiveness, Adoption, Implementation, and Maintenance><Recovery><Reporting><Risk Factors><Risk Reduction><Salaries><Self Efficacy><Series><Services><Site><Site Visit><Suicidal thoughts><Suicide><Suicide precaution><Suicide prevention><Supported Employment><Symptoms><Testing><Therapeutic><Therapeutic Intervention><Thinking><Time><Training><Unemployment><Veterans><Vocation><Vocational rehabilitation><Wages><Work><active control><active followup><adulthood><arm><assess effectiveness><chronic mental illness><cognitive assessment><cognitive behavior intervention><cognitive behavior modification><cognitive behavior therapy><cognitive behavioral intervention><cognitive behavioral modification><cognitive behavioral therapy><cognitive behavioral treatment><cognitive enhancement><cognitive testing><compare to control><comparison control><consultation><coping strategy><cost><depression><design><designing><determine effectiveness><disability><disparity gap><disparity in health><economic><effectiveness assessment><effectiveness evaluation><emergency service><equity gap><evaluate effectiveness><evaluate implementation><evaluation of implementation><examine effectiveness><experience><facilitators to implementation><fatal attempt><fatal suicide><follow up><follow-up><followed up><followup><gap in equity><gap in inequality><gap in inequity><health determinants><health disparity><health equity><health related quality of life><health service use><health service utilization><implementation evaluation><implementation facilitators><implementation fidelity><implementation framework><implementation research framework><implementation science framework><implementation strategy><improved><inequality gap><inequitable gap><inequity gap><inpatient care><inpatient service><intent to die><intervention therapy><interventional strategy><jobless><joblessness><meeting><meetings><mental health care><mental healthcare><new approaches><novel approaches><novel strategies><novel strategy><out of work><pathophysiology><persistent mental illness><physical conditioning><physical health><pilot study><pilot trial><post treatment><pragmatic effectiveness trial><pragmatic trial><prevent><prevent suicidality><prevent suicide><preventing><primary end point><primary endpoint><primary outcome><programs><protective factors><psychoeducation><randomisation><randomization><randomized control trial><randomly assigned><reach, efficacy, adoption, implementation, and maintenance><reduce risk><reduce risks><reduce that risk><reduce the risk><reduce these risks><reduces risk><reduces the risk><reducing risk><reducing the risk><risk-reducing><serious mental disorder><serious mental illness><service utilization><severe mental disorder><severe mental illness><social health determinants><strategies for implementation><success><suicidal><suicidal ideation><suicidal risk><suicidal thinking><suicidality><suicidality prevention><suicide ideation><suicide intervention><suicide risk><suicides><supportive employment><thoughts><thoughts about suicide><unemployed><uptake><well-being><wellbeing>