The effectiveness of occupational therapy for mental health disorders in primary care: A systematic review

Abstract

Introduction

Occupational therapy (OT) has a rich history of integrating physical and mental health care services, however, there is a limited evidence base regarding the effectiveness of OT interventions for mental health disorders in primary care.

Methods

A comprehensive systematic review was conducted from database inception through 31 January 2021. Eligible studies had to include: (1) an intervention that involved an occupational therapist in design and/or implementation; (2) a quantitative outcome assessing symptoms related to a mental health disorder; (3) a comparison group; and (4) primary care or community dwelling patients and/or primary care clinical settings.

Results

The researchers identified five studies and there was heterogeneity in the OT interventions. There were no significant differences between intervention and control groups in depression symptoms at different time intervals. Several trials employed interventions that involved interprofessional team members, including OTs, to provide training in specific strategies that promoted functioning. Other studies utilized only OTs within the intervention arm. OT interventions demonstrated no significant difference in anxiety in one study, however, another indicated a reduction in symptoms. The overall risk of bias was considered low in three studies and unclear in two studies.

Conclusion

There is limited evidence demonstrating the impact of OT interventions in primary care settings on quantitative outcomes measuring symptoms related to a mental health disorder. Given the heterogeneity of interventions and variation in reported findings, there is need for further pragmatic trials in this area.

Keywords

Occupational therapy primary care mental health systematic review

Introduction and literature review

Occupational therapy (OT) and primary care share a holistic, contextual worldview of the patient and their larger environment (Bolt et al., 2019b; Donnelly et al., 2014; Martin et al., 2004). Occupational therapists are skilled in assessing the impact of physical, mental, and developmental factors that contribute to an individual’s ability to participate in activities that are important to them, and in developing and implementing interventions that promote these activities (American Occupational Therapy Association, 2017; Bolt et al., 2019a; Christiansen et al., 2015). These skills are particularly applicable for addressing the needs of individuals with chronic medical conditions who have a co-morbid behavioral or mental health condition since they are more likely to have high health care needs and poorer health outcomes (Bolt et al., 2019a; Hayes et al., 2016; Roehrig, 2016). In addition, many of these individuals face significant barriers in accessing care that addresses both their physical and mental comorbidities (Cooper et al., 2003; Dwight-Johnson et al., 2000).

The provision of occupational therapy services in primary care has been evolving over a long period of time and has potential to further expand the treatment of individuals with co-morbid physical and mental health conditions (Donnelly et al., 2016; Rexe et al., 2013; Tyrrell and Burn, 1996). In the US, there is momentum for situating occupational therapy in primary care settings in ways that would promote population health and enhance value-based care (Halle et al., 2018). Occupational therapy’s holistic and functional approach in these settings can lead to the facilitation of increased independence and decreased hospitalization (Donnelly et al., 2016; Rexe et al., 2013; Tyrrell and Burn, 1996). Unfortunately, empiric work of OT in primary care has been underdeveloped, as demonstrated by scoping review of occupational therapy interventions in primary care in Europe, which reported a range of interventions and heterogeneity in the evidence base (Bolt et al., 2019a). Some qualitative studies have explored the value added of OT services in primary care, which point to decreased disability and improved independence for patients (Donnelly et al., 2016; Tyrrell and Burn, 1996). The OT scope of practice may include health promotion interventions, such as targeted home safety assessments or fall prevention strategies (Donnelly et al., 2016; Rexe et al., 2013).

Interprofessional and team-based care has been identified as a strategy for integrating occupational therapy and primary care (Halle et al., 2018). Integrated behavioral health is a team-based model that incorporates primary care and behavioral health clinicians in ways such as treatment for mood and substance use disorders, facilitating chronic disease self-management and treatment adherence, and the promotion of global functioning (Peek CJ and the National Integration Academy Council, 2013). Although behavioral and mental health care in this model is generally provided by social workers, nurses, and/or psychologists, occupational therapists have been minimally utilized, despite a longstanding tradition of providing these services (Aldrich et al., 2017; Ikiugu et al., 2017).

Occupational therapy services have potential to positively impact health outcomes in primary health settings, however, the evidence base that has examined quantifiable mental health outcomes, such as mood symptoms, has been minimally reported (Ikiugu et al., 2017), which may be a barrier to the interprofessional team’s understanding of the role and value of OT (Donnelly et al., 2016). To promote the value occupational therapy services in primary care settings, it is important to identify empiric studies that examine and report mental health outcomes that translate to an interprofessional team (Donnelly et al., 2016). The researchers therefore conducted a systematic review to examine, synthesize, and report the current evidence base on the effectiveness of OT on quantifiable mental health outcomes in primary care patients and settings.

Method

Search strategy

A trained health sciences librarian (STW) conducted an electronic database search of research articles from database inception through 31 January 2021 using Pubmed, PsycINFO on EBSCO, Embase.com, Cochrane Central Register of Controlled Trials, OT Seeker, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO. The librarian was responsible for identifying the following search term concepts with appropriate subject headings added from each database: (primary health care OR primary healthcare OR primary care) AND (occupational therapy OR occupational therap*) AND (outcome* OR Patient Outcome Assessment OR Patient Reported Outcome Measures OR impact* OR intervention*).

The search was not restricted by language and the search yielded 9027 results. Results were downloaded to EndNote and duplicates were removed. All references were uploaded to Covidence Systematic Review software (https://www.covidence.org), a web-based tool designed to facilitate and track each step of the abstraction and review process. The protocol was developed prior to conducting the research. Figure 1 depicts the flow diagram of the review process. Since this was a systematic review, the study was not reviewed by an institutional review board.

Figure 1.

Systematic research review of the effectiveness of occupational therapy for mental health disorders in primary care. Source: reproduced with permission from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group, 2009. For more information, visit www.prisma-statement.org.

Inclusion and exclusion criteria

Two review authors (CED and TPD) independently screened the titles and/or abstracts of articles from the identified studies. To be eligible for inclusion, studies had to include: (1) an intervention that involved an occupational therapist in design and/or implementation; (2) a quantitative outcome assessing symptoms related to a mental health disorders; (3) a comparison group, using either a pre-post design intervention or control group, and; (4) primary care and/or community dwelling patients and/or primary care clinical settings.

Data extraction and bias assessment

The reviewers evaluated all articles for screening selection and abstraction. Disagreements were resolved by discussion. We used a piloted form to extract data that included the following elements: study population and setting; study design; description of intervention; outcome measures; results of intervention effectiveness, and assessment of potential bias. The Cochrane Collaboration tool was used to determine the risk of bias (Higgins and Altman, 2011). Since complete blinding of those providing and receiving mental or behavioral interventions is rarely feasible, we did not include the blinding item in assessing the overall risk of bias (Linde et al., 2015). However, incomplete outcome data, selective outcome reporting, generation of the allocation sequence, attrition, and concealment of allocation were rated as having low, unclear, or high risk of bias (Higgins and Altman, 2011).

Results

The systematic search resulted in 9027 unique references that were imported for screening; 4734 duplicates were removed. A total of 4682 studies were excluded after title and/or abstract screening (Figure 1). The remaining 52 articles were reviewed in full text and of these, eight articles met the inclusion criteria (Table 1). The reasons for study exclusion are noted in the PRISMA Flow Diagram (Figure 1). Selected studies were conducted in Sweden, (Bejerholm et al., 2017) the United Kingdom (Lambert et al., 2007), United States (Fritz et al., 2020), and Ireland (Garvey et al., 2015). The study population included adult patients with mood disorders (Bejerholm et al., 2017) including generalized anxiety and panic disorders; (Lambert et al., 2007), frail older adults (Fritz et al., 2020), and individuals with multimorbidity (Garvey et al., 2015). Study designs were randomized controlled trials, including parallel, (Bejerholm et al., 2017) pragmatic (Garvey et al., 2015; Lambert et al., 2007), and pilot (Fritz et al., 2020) (Danielsson et al., 2020) designs.

Table 1.

Summary of studies assessing the effectiveness of occupational therapy on mental health outcomes in primary care.

First author (Year)	Study design	Setting and population	Intervention	Mental health outcome measure(s)	Results of intervention effectiveness	Risk of bias assessment^a
Danielsson et al. (2020)	Pilot, RCT	42 community dwelling adults in Sweden Working adults 18–65 with clinical depression and/or anxiety disorder 21 to intervention 21 to control	Intervention Work-Directed Rehabilitation -Formulation of work related treatment goals and coping strategies directed by occupational therapist and physiotherapist -Content included: 1) activity analysis, 2) life balance, 3) mindfulness activities, 4) guided exercise Control Physiotherapist counseling on evidence-based physical activity when depressed or anxious	Montgomery-Asberg Depression Self Rating Scale Beck Anxiety Inventory	No significant difference at 24 weeks follow-up in depression score (p = 0.58) and anxiety score (p = 0.26)	(LLHLL)
Bejerholm et al. (2017)	Parallel, RCT	Four community outpatient settings in Sweden Adult patients with depressive disorder, recurrent depression, or bipolar disorder who have not been employed in prior year 33 to intervention 28 to control	Intervention Individual Enabling and Support (IES) -Counseling delivered by employment specialist who received training from psychologist, motivational interviewer, and occupational therapist in “time-for-work” strategies -Content included: 1) enabling mobilization of strategies, 2) completion of career profile and plan, 3) job seeking, 4) support employment phase Control Traditional vocational rehabilitation	Montgomery-Asberg Depression Self Rating Scale	No significant difference at 6-month follow-up (n = 60, Z = −1.83, p = 0.067) but reduced depression severity at 12 months (n = 56, Z = −2.14, p = 0.03)	(LLLLL)
Fritz et al. (2020)	Pilot, RCT	Single site geriatric primary care clinic 30 to intervention 30 to control	Intervention Frailty prevention program provided by trained occupational therapist. -4 monthly face-to-face visits, biweekly check in calls, and tailored text messages. -First session: comprehensive evaluation to assess function, safety, needs, and environment. -Subsequent sessions: physical activity, diet recommendations; goal setting and maintenance plans.	4 mental health items from NIH PROMISE Global Health	Positive trend in mental health (d = 0.26) at 4 months compared to controls.	(LLLLH)
Garvey et al. (2015)	Pragmatic, RCT	3 community care areas in Ireland 50 adult participants with 2 or more chronic conditions and minimum of 4 chronic medications	Intervention OPTIMAL - Weekly group meetings for 6 weeks led by OTs - OT-based interventions to support patient self-management - Peer support - Goal setting and prioritization based on patient preference Control Remain on waitlist for program and receive usual care	Hospital Anxiety and Depression Scale (HADS)	No significant difference in anxiety and depression (p = 0.49) at 2 weeks post intervention.	(LLLLL)
Lambert et al. (2007)	Pragmatic, RCT	15 general practices in the UK Adults with panic disorder on a stable medication dosage for 4 weeks prior to enrollment 31 intervention, 36 control	Intervention 10 occupational therapy-led lifestyle approach interventions over 16 weeks - Lifestyle review using self-report and lifestyle diaries - Education to increase awareness of negative health effects and behaviors - Specific lifestyle changes - Monitoring and review of lifestyle changes Control Routine GP care	Beck Anxiety Inventory (BAI) Panic Attack Frequency, severity, and symptomatology (ADIS-IV)	Intervention group with decreased BAI score (−9.8: −15.0 to −4.6) at 20 weeks but no difference at 10 months. No significant difference between groups in ADIS-IV	(LLULL)

^aRisk of bias: L = low, U = unclear, H = high. Letters in parentheses sequentially indicate risk for following (sequence generation, concealment of allocation, attrition, incomplete outcome data, and selective reporting).

There was heterogeneity in occupational therapy (OT) interventions and the selected studies varied in their intervention strategies, as well as in the level of occupational therapist engagement with the intervention (Table 1). Several trials employed interventions that involved interprofessional team members, including OTs, to provide training in specific strategies that promoted functioning (Bejerholm et al., 2017; Garvey et al., 2015). Other studies utilized only OTs within the intervention arm (Lambert et al., 2007). Additionally, one study followed a group-based approach (Garvey et al., 2015), whereas others were provided interventions at the individual level (Bejerholm et al., 2017; Danielsson et al., 2020; Fritz et al., 2020; Lambert et al., 2007). Only one study (Fritz et al., 2020) utilized the Occupational Therapy Practice Framework of evaluation, intervention to achieve, targeted outcomes, and the purview of the occupational therapy domain (American Occupational Therapy Association, 2020).

Selected studies varied in their quantitative measures of mood symptoms (Table 1). Primary and secondary measures included depression, (Bejerholm et al., 2017; Danielsson et al., 2020; Garvey et al., 2015) and anxiety, (Danielsson et al., 2020; Garvey et al., 2015; Lambert et al., 2007). There were no significant differences between intervention and control groups in depression at 2 weeks, (Garvey et al., 2015) 6 months, (Bejerholm et al., 2017) however, the severity of depressive symptoms was reduced in one study at 12-month (Bejerholm et al., 2017). Within the group intervention led by OTs, there was no significant difference in anxiety at 2 weeks post intervention, (Garvey et al., 2015) however, another study showed a reduction in symptoms at 20 weeks, but no difference at 10 months (Lambert et al., 2007). One study demonstrated a positive mental health outcome trend at 4 months compared to controls yet did not utilize an outcome measure focusing on specific symptoms related to mental health outcomes (Fritz et al., 2020). The overall risk of bias was considered low in three studies, (Bejerholm et al., 2017; Fritz et al., 2020; Garvey et al., 2015) and unclear in two studies (Lambert et al., 2007) (Danielsson et al., 2020).

Discussion and implication

To the researchers’ knowledge, this study is the first systematic review to examine effectiveness of occupational therapy (OT) interventions on quantifiable mental health outcomes in primary care. There was limited and inconsistent evidence demonstrating the effectiveness of OT interventions in primary care settings in a review that was not restricted to OT interventions specifically designed for people diagnosed with a mental health disorder. The utilization of occupational therapists in primary care to address co-morbid physical and mental health conditions is an emerging area. This review found several studies that examined the impact of occupational therapy interventions in primary care settings and included quantitative mental health outcomes, however, these studies did not meet the eligibility criteria of including a comparison group (Cook and Howe, 2003; Guidetti et al., 2020; Stein and Miclescu, 2013; Tran et al., 2020). For example, one study described the impact of an OT-led mindfulness-based stress reduction program in a primary care setting and outlined a future randomized controlled trial (Tran et al., 2020). The future findings that will report on anxiety and depression outcomes will contribute to the evidence base in this field.

A second reason for a sparse evidence base may be associated with the limited use of quantifiable mental health outcomes that are commonly used in medical and primary care settings. The researchers identified several trials with OT interventions that did not include screening and/or symptom measures of mood disorders, such as anxiety and depression, or serious mental illness, such as acute psychosis and schizophrenia (Brandt et al., 2016; Dopp et al., 2015; Egan et al., 2007; Graff et al., 2006; Martensson et al., 1999; Mirza et al., 2020; Richardson et al., 2010; ). In addition, a subset of excluded studies involved non-primary care populations and settings, including individuals with dementia (Dopp et al., 2015; Graff et al., 2006), and those with a recent cerebrovascular accident (Egan et al., 2007), chronic pain (Martensson et al., 1999), and cancer (Brandt et al., 2016).

Another reason for the limited evidence base may be due to the effectiveness of the implementation strategy, findings which were minimally described in this review. The challenge of implementing interventions in different contexts is the tension between maintaining fidelity to the core elements of the intervention while adapting and modifying the intervention to local circumstances (Carroll et al., 2007). This may be demonstrated in an earlier systematic review that evaluated the effectiveness of OT interventions that focused on improving and maintaining participation and performance (i.e., supported employment) in paid and unpaid employment for adults with severe mental illness (Arbesman and Logsdon, 2011). The authors noted evidence of work programs that provided supported employment (SE) and vocational rehabilitation, as well as SE education programs at the post-secondary level, however, the effect size of these program-level interventions was not reported (Arbesman and Logsdon, 2011). In addition, programs that promoted parenting, homemaking, and environmental supports had limited effectiveness with no effect size reported (Arbesman and Logsdon, 2011). The authors reported the strongest evidence for individual-level OT interventions in cognitive and social skills training (Arbesman and Logsdon, 2011). A major limitation to this review was the absence of behavioral and mental health outcomes that were relevant and translatable to primary care, such as depressive symptoms, as well as the lack of clarity regarding the primary care context of the interventions (Arbesman and Logsdon, 2011).

Although the researchers found limited and inconsistent evidence, several studies demonstrate the potential effectiveness of OT in primary care on important mental health outcomes, as well as future directions of integrating OT services in emerging interdisciplinary teams. The pragmatic trial by Garvey and colleagues of an OT-led self-management program in primary care patients with multiple chronic conditions demonstrated significant improvements in activity participation, self-efficacy, and independence of daily activities (Garvey et al., 2015). Although there was no significant difference in anxiety and depressive symptoms, this may reflect the short measurement interval (i.e., 2 weeks) rather than the lack of effectiveness (Garvey et al., 2015).

In addition, the pilot RCT conducted by Danielsson and colleagues demonstrated comparable reductions in anxiety and depressive symptoms for both the physical activity control group and the work-directed rehabilitation intervention group. This finding may reflect the positive, larger effects that physical activity has on mood disorders (Zschucke et al., 2013) and an underpowered sample size. The pragmatic trial by Lambert, Harvey, and Poland in general practices (GP), which employed OT-led behavioral and lifestyle interventions (e.g., lifestyle review and associated changes, health behavioral education), was comparable to routine GP care in ameliorating anxiety symptoms (Lambert et al., 2007).

Limitations

This study had several limitations. First, the number of trials and the number of patients in treatment and control groups was small. The conditions under treatment (e.g., anxiety, depression, and memory disorders) varied widely as did the inclusion criteria across studies. There was also wide variation in the OT interventions that were described, and in the reported intensity and fidelity of the interventions. Although the risk of bias was low in three studies, it was unclear in the other two studies. The review did not include non-English papers which may have resulted in a selection bias. Finally, there was minimal reporting of the acceptability of the interventions and no reporting regarding the feasibility of implementation.

Conclusion

In summary, the researchers found limited and inconsistent data demonstrating the effectiveness of occupational therapy interventions in primary care related to mental health outcomes. This finding may relate to occupational therapy’s primary use of functional-based outcomes, such as performance skills or occupational participation, which are reported in these trials, rather than more widely recognized behavioral or mental health outcomes. At a time of integrating behavioral health and primary care, larger pragmatic trials that provide consistency in OT interventions, and compare intermediate and long-term mental health, physical health, and occupational performance outcomes, are needed to advance the field.

Key findings

• There were no consistent differences between intervention and control groups in mental health outcomes for primary care patients.

• The limited evidence base points to the lack of consistency in OT-based interventions and variability in reported mental health outcomes.

What the study has added

A systematic review to examine the effectiveness of OT interventions on mental health outcomes in primary care found limited data, heterogeneity in the described interventions, and no consistent differences between intervention and control groups.

Footnotes

Statement of Contributorship

CED and TPD conceived the study, developed the study protocol, analyzed the data, and wrote the first draft of the manuscript. STW conducted the literature search. All authors reviewed and edited the manuscript and approved the final version.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Timothy P Daaleman

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