OCCUPATIONAL THERAPY AND MENTAL HEALTH 1

Occupational Therapy and Mental Health: A Research Critique

Student’s Name

Institutional Affiliation
OCCUPATIONAL THERAPY AND MENTAL HEALTH 2

Occupational Therapy

Purpose

In this paper, the researcher will search for and critique original research studies related

to the impact and effectiveness of occupational therapy on mental health. The results are

expected to provide a broader context into advances in the field and how they can be

implemented to improve individual and community wellness.

Research Context

Occupational therapy is based on humanist principles that emphasize reintegration of people with

mental and physical health challenges into mainstream life through participation in daily

activities. However, over time, practitioner and research interest has gravitated towards physical

problems leading to a decline of focus on mental health (Creek & Cook, 2017). The decline of

OT’s role in mental health rehabilitation can be traced to the Community Mental Health Act of

1963 which requires that treatment of people with mental health conditions be conducted in the

least restrictive setting especially community settings (Longden et al., 2016). However,

deinstitutionalization and the transition to community-based settings led to a decline of OT as

legislators and insurers had limited understanding of its role in teaching and maintaining

medication management, social and work skills. Furthermore, the low number of trained

researchers has also hampered the scholarly documentation of occupational therapy interventions

on mental health (Arbesman et al., 2013). Consequently, there is a need for practitioners to

demonstrate that their interventions and skills are based on theoretically-robust principles as

articulated in the profession’s practice models and evidence-based research (Ikiugu & Smallfield,

2015). Consequently, due to the limited scholarly research on the impact of occupational therapy
OCCUPATIONAL THERAPY AND MENTAL HEALTH 3

on mental health, there is no consensus on the effectiveness of interventions in improving the

lives of clients.

Methodology

In sourcing the research papers for critique, the researcher consulted MEDLINE for relevant

studies on occupational therapy and associated benefits for mental health patients. He also

conducted supplementary searches in multiple catalogs for grey literature such as

ClinicalTrials.gov, the Cochrane Library, in addition to checking the reference lists of included

studies and previous systematic reviews.

Inclusion Criteria

Studies were eligible for inclusion into the literature review if they met the following

criteria:

 They included a method for randomization of participant selection

 The study population was adults diagnosed with mental health conditions

 The chosen intervention involved occupational therapy

The researcher only included randomized control trials and experimental studies

published in English. Furthermore, the studies had to evaluate the participant’s degree of

integration into society before and after the intervention which had to last for more than two

weeks. In searching MEDLINE, the researcher used the following keywords in combination with

Medical Subject Heading (MeSH) terms, including "occupational therapy" OR "occupational"

AND "therapy" OR "occupational therapy" AND "mental health" OR "mental" AND "health"

OR "mental health."
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The researcher also manually evaluated the bibliography of articles to identify eligible

studies. Furthermore, the researcher applied the PRISMA Protocol as developed by Moher et al.

(2009) to evaluate the risk of bias in the studies included in the literature review. The protocol

requires the evaluation of each study to determine whether its meets the following criteria, no

early termination of trials, concealment of randomization, and blinding of research participants,

data collectors, and researchers with studies that meet multiple criteria considered to have less

bias.

Critique

Classen et al. (2014)

Methodology

The researchers used a pre/post test experimental design that included baseline testing involving

clinical test and simulated drive, three OT-DI sessions of 1 hour each, and a posttest similar to

baseline testing in the mobile simulator. The participants drove two 5-minute acclimation

scenarios followed by two main drives. The acclimation drives were used to mitigate sickness

and allow participants to feel comfortable in the simulator. This methodology was suitable for the

research purpose as it helped in identifying the effectiveness of OT interventions on the

participants’ driving skills in a safe and controlled environment (Krass, 2016).

Sample

The participants were returning combat veterans recruited from VA facilities in North Florida and

South Georgia. Eligibility was participation in Operation Enduring Freedom (OEF) and

Operation Iraqi Freedom, a diagnoss of mTBI, orthopedic injury, or PTSD, driving history prior
OCCUPATIONAL THERAPY AND MENTAL HEALTH 5

to the diagnosis, and the potential for following community integration strategies (Mini-Mental

State Examination State of at least 24/30).

Data Collection

Data collection was conducted using standardized data collection sheets adapted from Classen et

al. (2011) to acquire demographic data such as gender, age, race, education, living status, blast

exposure, and marital status. The researchers also sourced data from caregivers, the number of

crashes and citations over the past three years. The visual, sensory, motor, and cognitive function

tests were collected through three OT-DRSs.

Analysis

The researchers used SPSS version 21 to analyze the data determining descriptive statistics

(frequencies, percentages, means, and standard deviations) in addition to a Shapiro-Wilks test to

determine whether the data was normally distributed. Considering the sample size, the Shapiro-

Wilks test was appropriate as it is suited for small sample sizes (Miot, 2017). The normality

results led to the conduction of a nonparametric Wilcoxon signed-rank test to evaluate whether

the difference of means between the baseline and posttest results was statistically significant.

Results

The mean age of participants was 39.83 ranging from 30 to 55 and a standard deviation of 7.80

years. A Spearman-correlation test, used for both baseline and posttest conditions, indicated that

no significant correlations existed between total driving errors and total simulator sickness scores

post-acclimation (r = –0.18, p = 0.68) or post-drive (r = 0.04, p = 0.93). The Shapiro-Wilks test

indicated that almost all of the variables examined were statistically significant (p < 0.05), and as

such, the data were not normally distributed. No statistically significant difference existed among
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simulator sickness scores during baseline testing or during posttesting. However, we did observe

a statistically significant decrease in lane main

Generalizability

Since the study sample was sourced from combat veterans who participated in OIF and OEF, the

results are only applicable to other veterans and not to the general population. Furthermore, all of

the participants were male which limits the generalizability to women combat veterans.

Rigor

The paper was supported by a research ethics organization, the effectiveness and accuracy

worked as a strength of the research. Hence, the paper was accurate and reviewed through an

honest review body. Furthermore, there was no randomization in the selection of participants

which may have introduced bias in the participant experiences.

Foruzandeh & Parvin, (2013)

Purpose

People with Schizophrenia usually have challenges in social and cognitive functions, residual

negative symptoms, self-care, social exclusion, and high rates of unemployment. Therefore, the

researchers aimed to evaluate the impact of occupational therapy on symptoms of patients with

Schizophrenia.

Methodology

The researchers conducted a randomized controlled trial study using an experimental research

design where positive and negative symptoms among patients diagnosed with schizophrenia

were evaluated on a scale.

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Sample

The sample population 76 patients was sourced from Sina Hospital, Shahrekord, Iran identified

as having chronic Schizophrenia through their medical records and structured clinical interviews.

The researchers assigned participants randomly into intervention and usual treatment groups with

30 patients to each group. 16 of the patients initially selected had functional disability leading to

their exclusion from the study. The sample population was suitable for the research purposes as it

provided an efficient way of identifying patients suffering from chronic Schizophrenia (Valerio

et al., 2016). Furthermore, the random assignment of participants into either the control or

intervention groups helped in minimizing researcher bias in addition to determining whether

statistically significant differences existed among the two groups after the intervention (Burgess

et al., 2016).

Data Collection

Data was collected at baseline and after six month which provided a reasonable time period to

determine whether the OT intervention had an impact on the patient’s negative or positive

symptoms. The symptoms were evaluated using ABurgess, S., Davies, N. M., & Thompson, S.

G. (2016). Bias due to participant overlap in two‐sample Mendelian randomization. Genetic

epidemiology, 40(7), 597-608.

ndreasen’s scale for assessment of positive symptoms (SAPS); and Andreasen’s scale for

assessment of negative symptoms (SANS) which are particularly suited for this purpose, and

have been extensively used in research settings which has established their validity and

reliability (Kumari et al., 2017). SANS has 24 items while SAPS has 35 items with both scales

rated from 0-5. Reliability was enhanced by calculating dual ratings on a subset of patients with
OCCUPATIONAL THERAPY AND MENTAL HEALTH 8

the aid of a psychiatrist. When used in combination, these two scales provided the researcher

with a comprehensive assessment of Schizophrenia symptoms.

Analysis

The researchers used SPSS version 11 to determine the normality of collected data. Since it was

normally distributed with no interaction between the two groups, the comparison between

baseline and control patients was done through the independent samples Student’s t-test which

was suited to the task (Kim, 2015). The Paired Samples Student’s t-test was employed to

evaluate for variances between the baseline and follow-up assessments. Social demographic data

was analyzed using the independent samples Student’s t-test and the chi-squared test with all

tests performed at the 0.05, two-tailed significance level.

Results

The researchers found that the mean scores of positive and negative symptoms in the OT group

were, respectively, 96.93 ± 31.78 and 69 ± 21.74, and in the treatment as usual group

97.51 ± 35.42 and 71.23 ± 19.4; therefore, the positive symptoms score of patients with

schizophrenia was higher than negative symptoms at baseline. The findings also indicated that

occupational therapy was effective in reducing negative symptoms in domains such as attention,

anhedonia, apathy, avolition, and thought. After six months, the control group’s scores in SANS

and SAPS had worsened with student’s t-test revealing significant differences between both

groups.

Generalizability

The results are generalize to the larger patient population diagnosed with schizophrenia. Since

the eligibility criteria involved chronic schizophrenic symptoms, the results can be applied to
OCCUPATIONAL THERAPY AND MENTAL HEALTH 9

similar patient populations in other facilities with a reasonable expectation of similar effects.

However, it is uncertain whether the intervention can be applied successfully for other mental

health patients.

Rigor

The researchers received ethical approval from the Shahrekord Medical University of Sciences

Research Ethics Committee which confirms the rigor of methodology, results, and conclusions.

Edel et al. (2017)

Purpose

The authors aimed to evaluate the antidepressive effects of adjuvant occupational therapy for

patients with major depression in a 6 week inpatient setting for both males and females.

Methodology

The study was conducted as a pilot randomized control trial with block randomization. However,

the block size could not be assigned randomly with the trialists selecting blocks of three, four,

and five participants to each group alternately. Board game activities were used as the

experiment control with the slight resemblance to OT increasing acceptability of the control

intervention. Professional occupational therapists conducted interventions 2 hours daily 5 days a

week in groups of 6-8 patients.

Sample

The sample was composed of 131 inpatients who had experienced moderate or severe major

depressive episodes as defined by the DSM-IV criteria sourced from three inpatient units of two

German psychiatric clinics. Of the 131 identified patients, three declined to participate while 14

failed the inclusion criteria. The remaining 114 patients were randomly assigned to either the
OCCUPATIONAL THERAPY AND MENTAL HEALTH 10

experimental or the active comparison group. However, during the first three weeks, 11

participants dropped out of the OT group and 21 from the BG group due to lack of motivation.

The sample size was adequate for the research purpose although the selection of potential

participants from only two localized clinics might have limited the generalizability of conclusion

to a larger population (Garattini et al., 2016). However, the random assignment of participants to

either the experimental or control groups helped in eliminating bias in the research process and

improving the validity of results. Garattini, S., Jakobsen, J. C., Wetterslev, J., Bertele, V., Banzi,

R., Rath, A., ... & Eikermann, M. (2016). Evidence-based clinical practice: overview of threats to

the validity of evidence and how to minimise them. European Journal of Internal Medicine, 32,

13-21.

Data Collection

The main outcome measure was a decrease in depressivity as measured by the Hamilton

Depression Rating Scale, HAMD-21 which has undergone extensive testing proving its fit for

purpose (Bobo, 2017). Furthermore, the researchers employed the Beck Depression Inventory

(BDI) as a secondary outcome measure whose validity was proven by Knaster et al. (2016). State

Anxiety was measured using the Hamilton Anxiety Rating Scale (HAMA) derived from

Thompson (2015) while the Personal and Social Performance Scale (PSP) assessed elements of

social functioning (personal and social relationships, socially useful activities, self care, and

disturbing and aggressive behavior) (Chiu & Hsieh, 2017).

Analysis
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Analysis was done using SPSS version 20. The one-sample Kolmogorov-Smirnov test confirmed

the normality of all interval-scaled variables which is essential in determining whether to

conduct parametric or non-parametric tests. T-tests and Pearson Chi-square tests were used to

compare group means in regards to gender, age, comorbidity, education, depressive

symptomatology, and medication (Sharpe, 2015). Generalized linear models were used to

compare possible treatment effects with repeated measures analyses of variance. Finally, Cohen’s

measure of sample effect size was used to compare the pre and post means thereby determining

the effectiveness of OT in reducing depressive symptoms. All of these statistical analysis

techniques were suited to the data collected and in answering the research question.

Results

The researchers found no significant difference in group means in regards to antidepressive

response or remission after three and six weeks. GLM analysis did not indicate significant time-

by-group interaction effects concerning the primary outcome measure HAMD total score (after 3

weeks: F = 0.141, p = 0.709; after 6 weeks: F = 0.177, p = 0.828) which means that neither group

reached antidepressive superiority. A significant time-by-group interaction effect regarding

the HAMA total score in males after three weeks was observed which suggests superiority of the

OT intervention over the Board game control intervention with the effect being more significant

among males compared to females. While these results are statistically significant, the small

sample size and limited population means they are not clinically significant and cannot be used

as evidence to justify the effectiveness of OT over conventional therapies in treating depressive

symptoms.

Generalizability
OCCUPATIONAL THERAPY AND MENTAL HEALTH 12

The research methodology and sample selection make the results highly generalizable to other

populations. However, the sample size can be increased through inclusion of multiple locations

and/or countries in addition to conducting trials over a longer time frame to increase the clinical

validity of results.

Rigor

All participants gave written informed consent, and the Ethics Committee of the Medical Faculty

of the Ruhr University Bochum approved the study which increases the validity of results.

Strauss et al. (2016)

Methodology

The authors employed a quantiative study design with an experimental approach to evaluate the

impact of music tempo on activity participation of agitated patients with acute psychosis. The

chosen study design was appropriate as it allowed them to analyze the effects of slow vs fast

tempo music on different categories of MHCUs diagnosed with psychosis. As soon as the

researchers identified eight MHCUs who fit the inclusion criteria, they allocated them to two

experimental groups according to a randomization protocol provided by the Department of

Biostatistics of the University of the Free State (UFS).

Sample

The study population was made up of 160 MCHUs admitted to the acute psychiatric wards in a

mental health institution over a year. A licensed occupational therapist screened all newly
OCCUPATIONAL THERAPY AND MENTAL HEALTH 13

admitted patients using an inclusion criteria checklist. The population excluded patients with an

axis II diagnosis or hearing problems in addition to patients readmitted during the study period to

prevent double exposure. The choice to use a mental health hospital was suited to the study’s

purpose due to the vulnerable nature of patients.

Data Collection

The researcher employed a customized data collection instrument for the pre and post tests due

to the lack of standardized tools measuring specific elements for activity participation. The

instrument assessed four dimensions on a scale of 1-5 with each level describing the participant’s

actions and functioning. The four dimensions evaluated were: attention and focus, following of

instructions, directedness towards activity, and willingness to participate. The researchers also

ensured the validity and reliability of the measurement by blinding the assessors about which

group was exposed to a particular type of music, playing a ‘memory game’ before the pre-test to

limit the Hawthorne effect, an inclusion criteria checklist to improve relevance of results, and a

pilot study on two groups (Chen et al., 2015).

Analysis

Analysis was done by the Department of Biostatistics, UFS. Variances between pre and post tests

were compared for the two groups using 95% confidentiality intervals for percentages, averages,

and medians. The analysis also compared percentages through chi-square tests and averaged

through paired t-tests (within groups) and unpaired t-tests within groups. For this study,

improvements of 50% or more were considered as improvements in the subjects. If the scope of

percentages in the 95% CI also exceeded 50%, then the results were considered clinically

significant.
OCCUPATIONAL THERAPY AND MENTAL HEALTH 14

Results

All four groups had improvements in attention after music exposure although a clinically

significant improvement was seen only in the inhibited group that listened to fast tempo music. A

possible reason for this could be that the fast tempo music stimulated movement in the inhibited

MHCUs, facilitating attention (Koelsh, 2009). Both the inhibited and agitated groups also had

clinically significant improvements in the following of instructions. These results could be

explained by Stein and Cutler’s (2002) explanation that slow music inhibits motor activity in the

agitated group while fast tempo music stimulates the inhibited group thereby improving their

ability to follow instructions.

Generalizability

The results are generalizable to the larger population of patients diagnosed with acute psychosis.

However, the intervention has not been proven effecBurgess, S., Davies, N. M., & Thompson, S.

G. (2016). Bias due to participant overlap in two‐sample Mendelian randomization. Genetic

epidemiology, 40(7), 597-608.

tive with large randomized clinical trials which would help to establish its clinical significance

and incorporate it into the current body of knowledge (Rosengarten, & Savransky, 2019).

Rigor

Since this is a vulnerable population, the researchers first obtained authorization for the research

from the research committee of the Free State Psychiatric Complex in addition to ethical

approval from the Ethics Committee of the Faculty of Health Science.

OCCUPATIONAL THERAPY AND MENTAL HEALTH 15

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