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Although indirect support can be found for the clinical benefits of work, it has not been studied in randomized designs, nor have critical variables been manipulated. One such variable is pay incentive. The authors present a study of 150 subjects with schizophrenia or schizoaffective disorder who were randomized into Pay ($3.40/hour) and No-Pay conditions and offered 6-month work placements within a Department of Veterans Affairs medical center. Subjects participated in a work-related support group and were evaluated weekly on symptom measures. Results indicated that Pay subjects worked more hours and earned more money than No-Pay subjects. Pay subjects showed more total symptom improvement at followup, and more improvement, particularly on positive and emotional discomfort symptoms. They also had a significant lower rate of rehospitalization than No-Pay subjects. Participation in work activity was closely associated with symptom improvement. Participators showed more total symptom improvement at followup than partial participators or nonparticipators, and more improvement, particularly on positive, hostility, and emotional discomfort symptoms. We concluded that pay increased participation and that, in this study, participation in work activity was primarily responsible for symptom reduction.

A 2-year experimental cost study of 10 Intensive Psychiatric Community Care (IPCC) programs was conducted at Department of Veterans Affairs (VA) medical centers in the Northeast. High hospital users were randomly assigned to either IPCC (n = 454) or standard VA care (n = 419) at four neuropsychiatric (NP) and six general medical and surgical (GMS) hospitals. National computerized data were used to track all VA health care service usage and costs for 2 years following program entry. At 9 of the 10 sites, IPCC treatment resulted in reduced inpatient service usage. Overall, for IPCC patients compared with control patients, average inpatient usage was 89 days (33%) less while average cost per patient (for IPCC inpatient, and outpatient services) was $15,556 (20%) less. Additionally, costs for IPCC patients compared with control patients were $33,295 (29%) less at NP sites but were $6,273 (15%) greater at GMS sites. At both NP and GMS sites, costs were lower for IPCC patients in two subgroups: veterans over age 45 and veterans with high levels of inpatient service use before program entry. No interaction was noted between the impact of IPCC on costs and other clinical or sociodemographic characteristics. Similarly, no linear relationship was observed between the intensity of IPCC services and the impact of IPCC on VA costs, although the two sites that did not fully implement the IPCC program had the poorest results. With these sites excluded, the total cost of care for IPCC patients at GMS sites was $579 (3%) more per year than that for the control patients.