Occupational_therapy_critiques.docx

OCCUPATIONAL THERAPY AND MENTAL HEALTH

Occupational Therapy and Mental Health: A Research Critique Student’s Name Institutional Affiliation

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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

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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

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The study population was adults diagnosed with mental health conditions

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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

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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 ShapiroWilks 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

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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

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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

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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 timeby-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

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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

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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.

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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.

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References Arbesman, M., Bazyk, S., & Nochajski, S. M. (2013). Systematic review of occupational therapy and mental health promotion, prevention, and intervention for children and youth. American Journal of Occupational Therapy, 67(6), e120-e130. Bobo, W. V., Angleró, G. C., Jenkins, G., Hall‐Flavin, D. K., Weinshilboum, R., & Biernacka, J. M. (2016). Validation of the 17‐item Hamilton Depression Rating Scale definition of response for adults with major depressive disorder using equipercentile linking to Clinical Global Impression scale ratings: analysis of Pharmacogenomic Research Network Antidepressant Medication Pharmacogenomic Study (PGRN‐AMPS) data. Human Psychopharmacology: Clinical and Experimental, 31(3), 185-192. Burgess, S., Davies, N. M., & Thompson, S. G. (2016). Bias due to participant overlap in two‐sample Mendelian randomization. Genetic epidemiology, 40(7), 597-608. Chen, L. F., Vander Weg, M. W., Hofmann, D. A., & Reisinger, H. S. (2015). The Hawthorne effect in infection prevention and epidemiology. infection control & hospital epidemiology, 36(12), 1444-1450. Chiu, E. C., & Hsieh, C. L. (2017). Internal and external responsiveness of the personal and social performance scale in patients with schizophrenia. European Psychiatry, 41, S189. Classen, S., Levy, C., Meyer, D. L., Bewernitz, M., Lanford, D. N., & Mann, W. C. (2011). Simulated driving performance of combat veterans with mild traumatic brain injury and posttraumatic stress disorder: A pilot study. American journal of occupational therapy, 65(4), 419-427.

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Classen, S., Cormack, N. L., Winter, S. M., Monahan, M., Yarney, A., Lutz, A. L., & Platek, K. (2014). Efficacy of an occupational therapy driving intervention for returning combat veterans. OTJR: occupation, participation and health, 34(4), 176-182. Creek, J., & Cook, S. (2017). Learning from the margins: Enabling effective occupational therapy. British Journal of Occupational Therapy, 80(7), 423-431. Edel, M. A., Blackwell, B., Schaub, M., Emons, B., Fox, T., Tornau, F., ... & Juckel, G. (2017). Antidepressive response of inpatients with major depression to adjuvant occupational therapy: a case–control study. Annals of general psychiatry, 16(1), 1. 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. Ikiugu, M. N., & Smallfield, S. (2015). Instructing occupational therapy students in use of theory to guide practice. Occupational therapy in health care, 29(2), 165-177. Kim, T. K. (2015). T test as a parametric statistic. Korean journal of anesthesiology, 68(6), 540. Knaster, P., Estlander, A. M., Karlsson, H., Kaprio, J., & Kalso, E. (2016). Diagnosing depression in chronic pain patients: DSM-IV major depressive disorder vs. Beck Depression Inventory (BDI). PloS one, 11(3), e0151982. Koelsch, S. (2009). A neuroscientific perspective on music therapy. Annals of the New York Academy of Sciences, 1169(1), 374-384. Krass, I. (2016). Quasi experimental designs in pharmacist intervention research. International journal of clinical pharmacy, 38(3), 647-654.

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Kumari, S., Malik, M., Florival, C., Manalai, P., & Sonje, S. (2017). An assessment of five (PANSS, SAPS, SANS, NSA-16, CGI-SCH) commonly used symptoms rating scales in schizophrenia and comparison to newer scales (CAINS, BNSS). Journal of addiction research & therapy, 8(3). Longden, E., Read, J., & Dillon, J. (2016). Improving community mental health services: The need for a paradigm shift. Isr J Psychiatry Relat Sci, 53, 22-32. Miot, H. A. (2017). Assessing normality of data in clinical and experimental trials. Jornal Vascular Brasileiro, 16(2), 88-91. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Prisma Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine, 6(7), e1000097. Rosengarten, M., & Savransky, M. (2019). A careful biomedicine? Generalization and abstraction in RCTs. Critical Public Health, 29(2), 181-191. Sharpe, D. (2015). Your chi-square test is statistically significant: Now what?. Practical Assessment, Research & Evaluation, 20. Stein F, Cutler SK. Psychosocial Occupational Therapy - a Holistic Approach. 2 nd edn. Canada: Delmar, 2002. Strauss, M., Van Heerden, S. M., & Joubert, G. (2016). Occupational therapy and the use of music tempo in the treatment of the mental health care user with psychosis. South African Journal of Occupational Therapy, 46(1), 21-26. Thompson, E. (2015). Hamilton rating scale for anxiety (HAM-A). Occupational Medicine, 65(7), 601.

OCCUPATIONAL THERAPY AND MENTAL HEALTH Valerio, M. A., Rodriguez, N., Winkler, P., Lopez, J., Dennison, M., Liang, Y., & Turner, B. J. (2016). Comparing two sampling methods to engage hard-to-reach communities in research priority setting. BMC medical research methodology, 16(1), 146.

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