Mental Health & Mental Illness in Occupational Therapy Practice: A Review of the Literature

1. Mental Health & Mental Illness in Occupational Therapy Practice: A Review of the Literature Kathlyn L. Reed PhD, OTR, FAOTA, MLIS Associate Professor, Emeritus Texas Woman’s University klreed3@juno.com

2. Background of the Project • Problem Statement: Occupational therapy practitioners are not recognized as qualified mental health professionals, therapists or providers in the Texas Administrative Code (TAC) • Purpose of Study: To develop “talking points” about occupational therapy in mental health/mental illness practice to convince Texas legislators to add occupational therapists to the list of “qualified mental health providers” so we can participate (and be reimbursed for services) in any legislative approved program that cites “qualified mental health providers” in the provider section of a law. • Due date: Now: so we can start writing results and preparing presentations to key legislators prior to next legislative session in 2015.

3. Texas Administrative Code • Mental health professional. An individual licensed by the state as a • physician, • professional counselor (LPC), • chemical dependency counselor (LCDC), • psychologist, • marriage and family therapist (LMFT), • master social worker (LMSW). • Mental health professional also includes a master’s prepared nurse with national certification in addictions or psychiatric nursing. • (40 TAC Sec. 151.11 Definitions)

4. 28 TAC Sec. 19.1703 (Insurance) • Mental health therapist: a person licensed by or as a: • TSBME (physician) • Psychologist • Psychological associate • Specialist in school psychology • Marriage and family therapist • Professional counselor • Chemical dependency counselor • Advanced clinical practitioner • Master social worker • Social worker • Physician assistant • Registered professional nurse • Vocational nurse • Any person licensed or certified… to diagnose evaluate, or threat any mental or emotional condition or disorder

5. 25 TAC Sec. 419.373 • Qualified mental health professional – A person acting with the scope of his or her training and licensure or certification who is a: • Licensed social worker • Licensed professional counselor • Physician • Licensed nurse • Psychologist

6. Focus of Study • Literature on mental health/mental illness related to occupational therapy throughout the world • Occupational therapy author • Content about occupational therapy practice • Time period: 2000-present • Published studies and literature in English or with English abstract • Available through databases or Interlibrary Loan • Examine all ideas advanced by occupational therapy practitioners, not just those in Texas or the USA

7. Main Questions • Can occupational therapy personnel and service programs promote return to work? • Are occupational therapy services cost effective (cost benefit ratio)? • Can occupational therapy services reduce symptoms of mental illness, disease or disorder? • Can occupational therapy services reduce the amount of treatmenttime while being effective using what medium or method?

8. Additional Questions • Is occupational therapy being implemented by qualified occupational therapy personnel or by other professionals? • Is the indexing in databases accurately identifying occupational therapy content? • What theories, frames or reference or models of practice were being used in practice? • What assessment instruments were used to evaluate clients for inclusion in the study and for results (outcome) of intervention? • Who is doing research in occupational therapy practice and in what countries? • What levels of evidence does the research include?

9. Limitations/Restrictions of Study • Primarily concerned with adults • Less focus on children’s mental health issues • Primary focus on efficacy of client centered programs and interventions • Less focus on analysis of state or country policies toward mental illness: except Texas • Primary focus on major psychiatric disorders • Less focus on behavioral problems associated with aging brain (dementia), traumatic brain injuries or secondary issues to physical disorders (depression following a stroke)

10. Terminology Found in Study • Diagnoses: Most controlled by International Classification of Disease (ICD-9, ICD-10) • Mental illness/mental health definitions seem to be fairly consistent throughout English speaking countries • Services are affected by national health systems in most of the non-USA studies • Supported housing: probably translates as group homes in USA • Specialized mental health programs quickly become international and vice versa

11. Brief History of OT in MH & MI • Moral treatment (Humane treatment): three roots of influence on occupational therapy • England: William Tuke (York Retreat, 1796): anti government, based on self control, moral reason, and Quaker belief that God was in every person • France: Philippe Pinel: became government policy, described by Michel Foucault, philosopher • Germany: Hermann Simon: patients became institutional workers at state facilities

12. Brief History: Progress Era (1890-1915) • Labor Museum: Hull House, Jane Addams, 1901 • Neurestheniaand the Work Cure: H.J. Hall, 1905-1910 • Mental hygiene movement: Dorothea Dix, Clifford Beers (A mind that found itself, 1910) • Illinois Mental Hygiene Society: E.C. Slagle, 1914 • Disorganized habits (habit training): Adolf Meyer • Term “occupational therapy” G.E. Barton, 1914 • Maryland Psychiatric Quarterly (1911-1923): Wm R. Dunton, editor “Occupations & Amusements” column • National Society for the Promotion of OT: March, 1917

13. Names of OT Researchers/Scholars • GinetteAubin – Canada • Ulrika Bejerholm – Sweden • Catherine Briand - Canada • Catana Brown – USA • Tina Champaign - USA • Christine Craik – UK • Mona Eklund – Sweden • Ellie Fossey - Australia • Gordon Giles – USA • Lena Haglund – Sweden • Danielle Hitch - Australia • Hiroyuki Inadomi – Japan • Ann-Britt Ivarsson - Sweden • Bonnie Kirsch – Canada • Terry Krupa– Canada • Nadine Larivière - Canada • ChristelLeufstadius – Sweden • Chris Lloyd – Australia • Karen Rebiero (Gruhl)– Canada • Victoria Schindler - USA • Margaret (Peggy) Swarbrick – USA • Goro Tanaka - Japan • Samson Tse – New Zealand & Hong Kong • Hector W Tsang – Hong Kong

14. Using Author Names in Searches Advantages Disadvantage Not all article subjects may be useful to topic of interest Watch for same names: different people Watch for changes of name. Authors do not always use the same name format in all publications. • Author is already known to be an occupational therapist even if the credentials or occupational therapy workplace title is missing • Get an idea of what journals may publish on topic of interest

15. Databases Searched • PubMedand MEDLINE full text • Psychiatry and Behavioral Sciences • PsychArticles • PsychINFO • Academic Search Complete • CINAHL • Health Source - Nursing • OT Search (bibliographic only) no full text • Nursing and Allied Health Source (Proquest) • OT Seeker (bibliographic) • Google • Health and Wellness • Women’s Studies International • Ovid Journals • Business Source Complete

16. Search Terms • occupational therap* (wild card or truncation for therapy, therapies, therapist, therapists) • “occupational therapy” (bind term on Google, Proquest Nursing and Allied Health Source or TWU “universal” search) • occupational therapy (limit to MeSH term on PubMed) • otr OR mscot OR boccthy OR bsot OR “otreg” (credentials)

17. Search Terms General terms Specific disorders Depress* Schizophreni* Bipolar* Stress Addict* Panic Substance abuse PTSD Eating disorder • Mental health • Mental* ill* • Mental disorder* • Mental disease* • Psychiatr* • Psychiatric disabilit* • Psychiatric rehabilitation • Psychotic • Psychosis or psychoses

18. Search Terms (Non-OT Assessments) • Brief Psychiatric Rating Scale (BPRS) • Positive and Negative Symptoms Scale (PANSS) • Scale for Assessment of Negative Symptoms (SANS) • Scale for Assessment of Positive Symptoms (SAPS)

19. Search Cautions Include Exclude Article indexed under term “occupational therapy” but no mention of occupational therapy in article. Instead terms such as work therapy or activities of daily living appear Occupational therapy is used as the control group. Article is about another topic Occupational therapy appears in the name of a journal in the references but not in text of article • One or more authors is an occupational therapist or assistant. Check credentials, department or school • Content of article specifically mentions occupational therapy or occupational therapist(s) in Methodology or Results sections of research article • Methodology section names an assessment developed by an occupational therapist(s)

20. OT Journals/Serials • Occupational Therapy in Mental Health • Mental Health Special Interest Section Quarterly • Scandinavian Journal of Occupational Therapy • Australian Occupational Therapy Journal • British Journal of Occupational Therapy • Canadian Journal of Occupational Therapy • Occupational Therapy International • Work • American Journal of Occupational Therapy • Occupational Therapy in Health Care • New Zealand Journal of Occupational Therapy • South African Journal of Occupational Therapy • Mental Health Occupational Therapy (UK) (no full text) • OT Practice, Occupational Therapy Now, Occupational Therapy News

21. Non-OT Journals • Aging & Mental Health • Clinical Rehabilitation • Community Mental Health Journal • Disability and Rehabilitation • International Journal of Therapy and Rehabilitation • Journal of Mental Health • Journal of Vocational Rehabilitation • Psychiatry and Clinical Neurosciences • Psychiatric Rehabilitation Journal • Psychiatric Services • Psychiatry Research • Schizophrenia Research • Social and Psychiatric Epidemiology

22. Countries Where Research is Done • Sweden • Australia • Canada • UK (England, Scotland, Northern Ireland) • USA • Japan • Hong Kong • Taiwan • Israel • South Africa • Singapore • Iran • New Zealand

23. Levels of Evidence • Level I: randomized controlled trial (subjects assigned randomly to experimental group(s) and control group • Level II: non-randomized experimental group(s) and control group • Level III: Pre-post test (1 group) • Level IV: Single subject, single series (ABA or ABAB) • Level V (or Not Rated): case study, case history, case report, survey, questionnaire, interview, chart review, data mining, assessment validation, literature review • Lieberman & Sheerer, AJOT, 2007

24. Broad Topics • Work as an occupation and its effect on mental health/illness • Work related programs and mental illness • Program descriptions and model development • Symptom reduction (positive and negative) • Management of negative symptoms • Daily living activities and life style issues • Grocery shopping, meal preparation & cooking • Assessment and measurement • Treatment effectiveness and related costs • Schizophrenia and severe/chronic mental illness

25. Topics/Subjects • Return to Work (RTW) • Supported Employment (SE): • Individual Placement and Support (IPS) • Clubhouse: Transitional Employment (TE) • Quality of Life and Life Satisfaction • Wellness and Well being • Supported Education: healthy living • Sensory Rooms • Social inclusion • Stigma • Hope

26. Topics/Subjects • Occupational performance & participation • Occupational balance/imbalance • Time use • Life style: obesity, housing • Day Care programs • Assertive Community Treatment • Behavioral management programs • Community Mental Health programs • Self help/self management programs • Illness management and recovery • Assessment instrument development and validation

27. Occupational Therapy Assessments • Allen Cognitive Level Screen (ACLS) • Assessment of Motor and Process Skills (AMPS) • Canadian Occupational Performance Measure (COPM) • Executive Function Performance Test (EFPT) • Goal Attainment Scaling (GAS) • Interview Schedule for Social Interaction (ISSI) • Kitchen Task Assessment (KTA) • Kohlman Evaluation of Living Skills (KELS) • Late-Life Function and Disability Instrument • Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) • Occupational Performance History Interview (OPHI) • Occupational Therapy Task Observation Scale (OTTOS) • Perceive, Recall, Plan, and Perform (PRPP)

28. Assessments Continued • Practical Skills Test • Profile of Occupational Engagement in persons with Schizophrenia (POES) • Quality of Life Measure for Persons with Schizophrenia • Residential Environment Impact Survey-Short Form • Role Checklist • Self-Administered Checklist • Social Profile • Test of Grocery Shopping Skills (TGSS) • Worker Role Inventory • Work Environment Impact Scale • Workshop Behavior checklist • Search Hint: Use “Instrument” field in CINAHL

29. Criteria for Outcome Measures • Be standardized (proven reliability and validity) • Be evidence based (backed by research and used by others) • Be sensitive (to changes in client performance) • Fit in (with service program aims and needs) • Be flexible (generic and profession-specific, relevant to different groups) • Be user friendly (quick and engaging) • Be relevant (to both client and service program) • Hitch, D. (2007). Outcome measures in assertive outreach. Mental Health Practice, 10(7), 28-31.

30. Return to Work • Addition of occupational therapy to treatment as usual (TAU) • Resulted in a reduction in work-loss days during the first 18 months • Had a 75.5% probability of being more cost-effective than TAU • Did not increase work stress • But did not improve depression outcomes • Schene, Koeter, Kikkert, Swinkels & McCrone, 2007. Adjuvant occupational therapy for work-related major depression works. Psychological Medicine, 37(3), 351-362.

31. Work-Related Programs • Findings: Over the 18-month study period, compared with participants in the conventional vocational rehabilitation program, those in the supported employment group were more likely to work competitively (70% versus 29%; odds ratio-5.63, 95% confidence internal-2.28-13.84), held a greater number of competitive jobs, earned more income, worked more days, and sustained longer job tenures. • Wong, K.K., Chiu, R., Tang, B., Mak, D., Liu, J. & Chiu, S. N. (2008). A randomized controlled trial of a supported employment program for persons with long-term mental illness in Hong Kong. Psychiatric Services, 59(1), 84-90. (Level I)

32. Cost-Effectiveness • Findings: Significantly more pairs in the treatment group “improved” compared with the usual care group (37% with treatment group vs 2% with usual care/control group). Lead author is an occupational therapist • Graff, M.J., Adang, E.M. Vernooij-Dassen, M.J., Dekker, J., Jönsson, L., Thijssen, M., Hoefnegels, W.H.L., & OldeRikkert, G.M. (2008). Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study (UK). BMJ, 336, 134-138. (Level 1)

33. Cost-Effectiveness • Finding: If the maximum willingness to pay per additional quality adjusted life years is 30 thousand pounds, then there is a 86% chance that a lifestyle intervention may be considered to be value-for-money over 10 months (length of study). Lead author is an occupational therapist. Credential of other two authors not stated. • Lambert, R.A., Lorgelly, P., Harvey, I., Poland, F. (2010). Cost-effectiveness analysis of an occupational therapy-led lifestyle approach and routine general practitioner’s care for panic disorder (UK). Social Psychiatry and Epidemiology, 45, 741-750. (Level 1)

34. Cost-Effectiveness • Participants were 163 culturally diverse volunteers aged 60 and older. Costs for 9-month OT program averaged $548 per subject. Post-intervention healthcare costs were lower for the OT group ($967) than for active control group ($1,726), and passive control group ($3,334) or a combination of the control groups ($2,593). Quality of life index showered a 4.5% QALY differential (OT vs combined control), p < 0.001. Cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747-$25,430). For the passive and active control groups the corresponding costs per QALY were $13,784 and $7,820 respectively. Preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures. • Hay, J., LaBree, L., Luo, R., Clark, F., Carlson, M., Mandel, D., Zemke, R., Jackson J., & Azen, S.P. (2002). Cost-effectiveness of preventive occupational therapy for independent-living older adults. Journal of the American Geriatrics Society, 40(8), 1381-1388. (Level I)

35. Readmission • Participants in the TRIP (Transforming Relapse and Instilling Prosperity) program had significantly fewer re-admissions in the 12-month follow-up period than those who attended the (traditional) ward occupational therapy program. • Program was effective in improving insight and awareness of health as opposed to traditional ward program • Chan, Lee, & Chan (2007). TRIP: A psycho-educational programme in Hong Kong for people with schizophrenia. Occupational Therapy International, 14(2), 86-98.

36. Symptom Reduction • Seventeen clients identified life skill deficits in self-care activities, accessing leisure facilities, household management, employment prospects and communication skills. • Outcome measures were the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein & Opler, 1987) and the Social Functioning Scale (SFS; Birchwood, Smith, Cochrane, Wetton & Copestake, 1990). • On the PANSS, reduction in total symptoms and negative symptoms was significant (p = 0.018 and p = 0.059) but not for positive symptoms or general psychopathology • Mairs, H. & Bradshow, T. (2004). Life skills training in schizophrenia. British Journal of Occupational Therapy, 67(5), 217-224. (Level III)

37. Warning on Interpretation • Statistical significance does not equal clinical significance • Statistical significance based on mathematical formula of probability • Clinical significance is based on observed and measured (documented) change in function, behavior, or performance (What can person do now, he/she could not do before or what was person doing before (negative symptom) that he/she is not doing now?) • Remember: observable-measurable change in function, behavior or performance (occupational performance, social participation, independent living, quality of life)

38. Negative Symptoms • Findings: After 12 months the occupational therapy group showed clinically significant improvements that were not apparent in the control group. • Improvements were in four subscales of the Social Functioning Scale: relationships, independence performance, independence competence and recreation. • Out of 30 people receiving occupational therapy those with a clinical level of negative symptoms receded from 18 (64%) to 13 (46%, p=0.055) on the Scale for the Assessment of Negative Symptoms (SANS) • Authors are from Sheffield, UK. • Cook, S., Chambers, E., & Coleman, J.H. (2009). Occupational therapy for people with psychotic conditions in community settings: a pilot randomized controlled trial Clinical Rehabilitation, 23(1), 40-52.(Level 1)

39. Treatment Effectiveness • In clients with treatment-resistant schizophrenia the combination of OT and clozapine was showed to be more effective that the use of clozapine alone • Using repeated measures of analyses of variance and evaluation of standardized effect sizes • Buchain, P.kVizzotto, A., Neto, J., & Elkis, H. (2003). Randomized controlled trial of occupational therapy in patients with treatment-resistant schizophrenia. RevistaBrasilera de Psiquiatria, 25(1), 26-30.

40. Effectiveness of IPS • Findings: Study investigated the effectiveness of Individual Placement and Support ((PS) to transitional vocational program. • Measurements included the Empowerment Scale, the Worker Role Interview, the Profile of Occupational Engagement and the Manchester Short Assessment of Quality of Life administered to 120 clients at baseline, six, and 18 months. • IPS participants showered higher scores in quality of life (p = 0.002), empowerment (p = 0.047), and work motivation (p = 0.002) at 18 months. Within the IPS group a significant change in QOL was shown at six (p =0.2) and 18 months (p= 0.000) and in occupational engagement (p = 0.003; p = 0.012). • IPS may increase individual life satisfaction and time spent in daily occupations and community life. Study was conducted in Sweden. • Areberg, C., & Bejerhom, U. (2013). The effect of IPS on participants’ engagement, quality of life, empowerment , and motivation: a randomized controlled trial. Scandinavian Journal of Occupational Therapy. Feb 7 [PMIS: 23387398] (Level 1)

41. Effectiveness of Life Skills Program • Findings: Forty-four clients were match on cognitive level. • Cooking was assessed using the Kitchen Task Assessment –Modified (original by Baum & Edwards, 1993). • Each group received three training session in cooking skills Participants in both groups scored significantly higher on the KTA-M after cooking lessons reflecting learning of cooking skills (clinic p < 0.001 and home p < 0.002). • Learning new skills in the home was not better than learning in the clinic for people with schizophrenia in this study. • Duncombe, L.W. (2004). Comparing learning of cooking in home and clinic for people with schizophrenia. American Journal of Occupational Therapy, 58(3), 272-278. (Level 1)

42. Cognitive Skills • Clients with schizophrenia received an Instrumental Enrichment program versus “traditional” occupational therapy program • There was significant differences between the two groups for both memory and thought process suggesting cognitive dysfunction in schizophrenia can be improved • There was no significant difference in IADL questionnaire or self-concept scale • Hadas-Lidor, Katz, Tyano, & Weizman (2001). Effectiveness of dynamic cognitive intervention in rehabilitation of clients with shcizophrenia. Clinical Rehabilitation, 15(4), 349-359.

43. Quality of Life • One hundred three participants. • Work status and activity in terms of actual doing were of some, but minor, importance to subjective quality of life, whereas • Satisfying and valuable activities were consistently associated with more quality of life domains. • Eklund, M. (2009). Work status, daily activities and quality of life among people with severe mental illness. Quality of Life Research, 18, 163-170. (Level V, interview questionnaire).

44. Wellness and Work • Work was seen as a(n) • validation of wellness and self worth • means of managing identity • means of integration through interaction and contribution • means of establishing and maintaining a worker identity • opportunity to develop a worker identity • accommodating shifts in worker identity • opportunity to start over again Van Nickerk, L. (2009) Participation in work: A source of wellness for people with psychiatric disability. Work, 32, 415-465.

45. ADL/IADL Skill Difficulty • Easy to Hard Tasks • Telephone Use • Personal Care/Basic ADLs • Travel/Transport • Washing/Laundry • Shopping • Cooking • Housework • Money management • Medication management • Scanlan, J.N. & Still, M. (2013). Functional profile of mental health consumers assessed by occupational therapists. Psychiatry Research, 208, 29-32. (Level V, assessment)

46. Intervention: Daily Living Food management Others Money management Self-care Room or home cleaning Room/home organization Safe community participation Travel/transportation Shopping (general, clothes) Washing clothes/laundry • Nutrition • Food safety • Budgeting • Microwave cooking • Stove cooking • Obtaining food • Grocery shopping • Meal planning • Meal preparation • Clean-up

47. Intervention: Lifestyle • Physical fitness • Exercise • Health promotion • Dieting • Weight loss • Oral health • Housing • Violence & aggression (threatening behaviors) • Interests & community resources • Education • GED, college, technical • Continuing (for fun) • Employment choices • Relationships • Quality of life • Problem solving • Lifestyle review • Goal setting • Financial management

48. Other Questions • Qualified personnel. In some studies occupational therapy aides (on the job trained) appeared to have been used. Difficult to verify. Program administered by MD/Psych • Indexing: Indexing in MEDLINE is uneven. Work therapy may be indexed under occupational therapy when no therapist was involved • Theories/frames of reference/models of practice. Not fully analyzed. Mostly occupation based.

49. Problems: Salaries • Average salaries are from 2010. • Occupational therapist: $72,320 • Social worker: $42,480 (Clinical social worker, Master’s degree entry) • Recreational therapist: $42,280 Bachelor’s degree (includes music therapist) • Mental health counselor: $39,710 Master’s degree • Rehabilitation counselor: $32,350 Master’s degree • School and career counselor: $53,380 Master’s degree • Bottom line: occupational therapists are expensive • U.S. Bureau of Labor Statistics, 2010 Median Salaries, Occupational Outlook Handbook www.bls.gov/ooh

50. Problems: Education for MH/MI • How many credit hours of abnormal (deviant) psychology do you have? • How many credit hours of psychiatric conditions (disorders) do you have? • How many credit hours of psychiatric or mental health occupational therapy theory do you have? • How many credit hours of psychiatric or mental health fieldwork do you have? • Are occupational therapy students being prepared to hold positions in mental health? • Can you assess work-related, life skills, and life-style problems and plan programs using occupational therapy knowledge and skill to address those problems?