Importance Posttraumatic stress disorder (PTSD) often interferes with a person’s ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income.

Objective To determine whether individual placement and support (IPS)–supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment.

Design, Setting, and Participants The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed.

Interventions Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community.

Main Outcomes and Measures A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period.

Results A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004).

Conclusions and Relevance This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD.

Trial Registration clinicaltrials.gov Identifier: NCT01817712

重要性 创伤后应激障碍（PTSD）通常会干扰一个人获得或维持就业的能力，从而导致劳动力过早退出并减少收入。

目的 确定个体安置和支持（IPS）支持的就业是否比逐步职业康复（包括过渡性工作分配）在帮助PTSD的退伍军人获得稳定，竞争性就业方面更有效。

设计，设置和参与者 退伍军人个人安置和支持康复计划（VIP-STAR）是一项前瞻性，多地点，随机临床试验，包括12个退伍军人事务医疗中心的541名PTSD待业退伍军人。收集了2013年12月23日至2017年5月3日的数据。进行了意向性治疗分析。

干预措施 个人安置和支持是一种受支持的就业干预措施，可以使残疾人迅速参与社区工作的发展，从而根据其个人的工作偏好获得工作。过渡性工作是一种逐步的职业康复干预措施，可将人们暂时分配给非竞争性工作，以为社区中的竞争性就业做准备。

主要结果和测度 一项先验假设是，与过渡工作相比，IPS组中更多的参与者将成为稳定的工人（主要），并在18个月内从竞争性工作中获得更多收入（中等）。稳定工人的定义是在18个月的随访期内至少从事50％的竞争性工作。

结果 共有541名参与者（n = 271 IPS； n = 270项过渡工作）被随机分组​​。平均（SD）年龄为42.2（11）岁；女性为99（18.3％），白人为274（50.6％），非洲裔美国人为225（41.6％），西班牙裔，西班牙裔或拉丁美洲裔为90（16.6％）。与过渡工作组相比，IPS组的稳定就业人数更多（105 [38.7％] vs 63 [23.3％]；优势比为2.14； 95％CI为1.46-3.14）。参加过任何竞争性工作的IPS参与者比例更高（186 [68.6％]比154 [57.0％]；P  = .005），并且来自竞争性工作的累积收入更高（IPS中位数[四分位数范围] $ 7290 [$ 23 174]） $ 1886 [$ 17 167]进行过渡工作；P  = .004）。

结论与相关性 这项多地点试验显示，对于患有慢性PTSD的退伍军人，由IPS支持的就业方式比逐步过渡工作职业康复的有效性要高得多。该结果提供了支持性证据，表明患有PTSD的退伍军人增加了获得IPS的机会。

试验注册 临床试验.gov标识符：NCT01817712