Unpacking Social Disadvantage In Not-In-Education-Employment-or-Training (NEET) Status Among Young Adults with Early Psychosis: A Scoping Review

Background: Young adults with early psychosis who are “not in employment, education, or training” (NEET) are at high risk of prolonged disability and long-term poverty. While research has previously identified illness-related reasons for prolonged unemployment, little is known about how social disadvantages (e.g., low socioeconomic status, poverty, educational attainment, and/or being a racial/ethnic minority) impact young adults’ employment or education (EE) trajectories. This paper aimed to explore how existing social disadvantages at the time of entry to early psychosis programs impacts employment or education (EE) outcomes at program completion.

Methods: This scoping review followed PRISMA guidelines, searching PubMed and Scopus databases. The inclusion criteria were: 1) early, first-episode psychosis, or schizophrenia population; 2) mean age < 27; 3) baseline, independent variable, or qualitative factor that included a social disadvantage; and 4) EE, vocational, or functional recovery outcome. Exclusion criteria included: 1) wrong population (e.g., higher mean age, not focused on young adults, or majority non-psychosis diagnosis; 2) wrong comparator (e.g., no social disadvantage variable); or 3) wrong outcome (e.g., not examining EE outcome). Social disadvantage variables were identified via an iterative process with two reviewers and included: “socioeconomic status”, “structural barriers”, “social disadvantage”, “poverty”, “race”, “racial/ethnic minority”, “oppression”, “discrimination”, “family income”, “parent educational level”, “parent occupational status”, “parent disability”, “disability benefits”, “welfare”, “education level”, “years of education”, and “homelessness”. The same two reviewers utilized Covidence software to rate articles for inclusion/exclusion criteria. Following the removal of duplicate articles, 177 articles were reduced to 28 after an abstract and full-text review. We completed our analysis using the following research questions: 1) Which social disadvantages present at baseline were associated with employment/education status program outcomes and 2) what were these associations?

Results:

A review of 28 articles indicated that the most frequently-reported social disadvantage areas influencing EE outcomes at completion of FEP programs are: 1) low educational attainment, 3) being a member of a resident racial/ethnic minority group rather than a recent migrant group, 4) other marker of low SES such as low-income family, social deprivation, recipient of welfare benefits, and 5) substance use during the program, the latter of which was an emerging finding. These social disadvantage areas had adverse effects on EE outcomes and often led to prolonged NEET status at program completion even when controlling for symptom/illness severity, or tested interventions.

Discussion: Reducing prolonged NEET status in early psychosis programs requires a thorough understanding and assessment of social disadvantages that create barriers for young adults’ vocational pathways. In particular, young adults with low educational attainment, low-income families, and/or racial/ethnic minority status require additional engagement and support to make vocational gains. Additionally, substance use complicates pathways to employment and education both during and at program completion, indicating that services should address substance use in the context of providing vocational support. Further research is needed to better understand the unmet needs of this population.