In Reply We thank Mueser and McGurk for the interest in this Danish randomized clinical trial investigating the effects of individual placement and support (IPS) and IPS supplemented with cognitive remediation and social skills training among 720 participants with severe mental illness.¹

First, the authors state that the rates of competitive employment are low compared with previous IPS trials. This is correct, but the primary aim in our trial was competitive employment and education, which cannot be directly compared with trials exclusively having employment as a primary aim. We consider that 38% in competitive employment is a success because an additional 31% enrolled in education. It is obvious that the employment rates would have been higher if we had excluded all participants who had an aim of education at baseline. Second, the authors raise a critique of the rates of noncompetitive work. In Denmark and other Scandinavian countries, companies usually recruit people who receive social benefits by offering a period of unpaid internship and then afterward competitive employment. This is a culture that has been promoted by the Danish welfare system for decades, and it was not possible to completely avoid. The same tendency was seen in the Swedish IPS trials.² However, the employment specialists had a very strict focus on minimizing the duration of internships and in accordance with the IPS principles. Third, the average time to first employment in our trial also includes participants who did not obtain employment. They were all rated for 548 days, which was the number of days from baseline to the 18-month follow-up. The average time to competitive employment among participants who obtained at least 1 job was 210 days for the IPS group and 232 days for the group of IPS supplemented with cognitive remediation and social skills training. Fourth, the choice of changing the computer software from COGPACK to Computerized Interactive Remediation of Cognition—a Training for Schizophrenia (CIRCUITS), Danish version, was based on thorough testing. The conclusion of this testing was that CIRCUITS would be more appealing to the young population in our trial. Because CIRCUITS was newly developed, it obviously had less empirical support than COGPACK. Fifth, it is a misunderstanding that 6 of the 12 sessions in the Thinking Skills for Work program were replaced with social skills training. The 6 sessions were a supplement that took place after the participants had finished Thinking Skills for Work.³ Sixth, it is correct that participants had less individual sessions with the cognitive specialist compared with the original Thinking Skills for Work manual, but it was possible for the participants to receive individualized counseling both from the psychologist and the employment specialists who were cotherapists. In addition, we believe that the trial answered several important questions. We demonstrated that IPS can be implemented and be effective in a Scandinavian welfare model and that support for education can be included and work along with the IPS principles. However, we cannot draw firm conclusions on the benefits of augmenting IPS with cognitive remediation. We can conclude that it should not be implemented in the form used in this trial. Effects may be found among participants who are motivated and who do not respond to IPS after 18 months of intervention, as it was demonstrated in the trial by McGurk et al.⁴

在答复中，我们感谢Mueser和McGurk对丹麦这项随机临床试验的兴趣，该试验研究了720名严重精神疾病患者的个体安置和支持（IPS）以及IPS以及认知矫治和社交技能培训的效果。^1个

首先，作者指出，与以前的IPS试验相比，竞争性就业率较低。这是正确的，但我们试验的主要目的是竞争性就业和教育，不能与仅以就业为主要目的的试验直接比较。我们认为38％的竞争性就业是成功的，因为另外31％的人接受了教育。显然，如果我们排除了所有以接受教育为目标的参与者，那么就业率将会更高。其次，作者对非竞争性工作的比率提出了批评。在丹麦和其他斯堪的纳维亚国家，公司通常通过提供一段时间的无薪实习机会，然后提供有竞争性的就业机会，来招募获得社会福利的人员。这是丹麦福利制度几十年来提倡的一种文化，不可能完全避免这种文化。在瑞典的IPS试验中也看到了相同的趋势。^2个但是，根据IPS原则，就业专家非常注重减少实习时间。第三，在我们的试验中，首次就业的平均时间也包括未获得就业的参与者。他们都被评估为548天，这是从基线到18个月随访的天数。至少获得一份工作的参与者中，获得竞争性就业的平均时间在IPS组中为210天，在IPS组中进行认知矫正和社交技能培训的时间为232天。第四，选择将计算机软件从COGPACK更改为计算机化的交互式认知补救—丹麦语版本的精神分裂症培训（CIRCUITS），是基于全面的测试。该测试的结论是，在我们的试验中，电路将对年轻人口更具吸引力。由于CIRCUITS是新开发的，因此与COGPACK相比，它显然缺乏经验支持。第五，误解是工作思维能力计划的12堂课中有6堂被社交技能培训所取代。这6堂课是对参与者完成工作思维技能后的补充。³第六，与原始的《工作中的思考技能》手册相比，参加者与认知专家进行的个人课程较少，这是正确的，但是参加者有可能接受来自心理医生和共同治疗师的雇佣专家的个性化咨询。此外，我们认为该审判回答了几个重要问题。我们证明了IPS可以在斯堪的纳维亚的福利模型中实施并有效，并且可以包括教育支持并与IPS原则一起工作。但是，我们无法就通过认知矫治增强IPS的益处得出明确的结论。我们可以得出结论，不应以该试用版中使用的形式来实施它。⁴