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Applied occupational therapy for major depressive disorder: clinical case report

This clinical report describes a comprehensive occupational therapy evaluation for a 25 year old female with major depression and suicide attempt in an inpatient psychiatric hospital. A thorough evaluation process was conducted by an interdisciplinary team including an occupational therapist. The role of occupational therapy is emphasized in terms of functional assessment and evidence-based occupational therapy interventions for patients with depression. Occupational therapy complements psychotherapy and other medical treatments and is effective in managing symptoms and enhancing cognitive functioning, social interaction skills, and ADLs functional performance for persons with depression.


Introduction
Major depressive disorder (MDD) is a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities. MDD is a disabling condition that adversely affects a person's family, work or school life, sleeping and eating habits, and general health. Depressed people may be preoccupied with thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness, and self-hatred. In the United States, around 3.4% of people with major depression commit suicide, and up to 60% of people who commit suicide had depression or another mood disorder. 1 Depression is also associated with a variety of pathological neuro-physical complications. In severe cases, problems with the limbic system, basal ganglia and hypothalamus may lead to dysregulation in the functional performance of neuro-hormonal activities and play a role in the development of the positive (i.e., delusions, hallucinations, disorganized speech, etc.) and negative symptoms (i.e., restricted emotions, a volition, anhedonia, attention impairment, etc.) of depression disorders. 2 Depression is one of the most common psychiatric disorders. It is a major public health problem and has a negative impact on the quality of life, increases the number of visits to different medical services, and carries a high risk of suicide. 3 There are a variety of evidence-based interventions for depression. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRI) are generally considered as the first line of treatment of depression. 4 Other treatments include psychotherapy, occupational therapy, tai chi, exercise, collaborative comprehensive care, problemsolving therapy, and other medical treatments. These interventions have complementary relationship and have proved to be useful and effective in treating depression. 5 Occupational therapy (OT) is a client-centered health profession concerned with promoting health and well-being through occupation. 6 In its simplest terms, occupational therapists enable people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations). Occupations are organized activities of everyday life that give value and meaning to individuals and cultures. 7 OT has been used along with other medical treatments in treating patients with psychiatric and cognitive disorders and proven to be useful and effective in managing symptom and enhancing and/or maintaining functional performance for persons with mental health problems. 8,9 Intensive psychotherapy and OT therapeutic approaches (i.e., cognitive behavioral therapy (CBT), interpersonal therapy (IPT) in addition to medication has helped more than medication alone or therapy alone. 10 British occupational therapists Cook, Chambers & Coleman 11 provided strong evidence that OT interventions over 12 months significantly reduced negative psychotic symptoms, yielded significant improvements in relationships, performance, competence, and recreation. When working with a person with a mental health condition, occupational therapists apply a variety of evidence-based assessments and interventions. 12 Once a thorough assessment has been conducted and adequate information has been obtained, the therapist creates a personalized occupational profile. This profile is used for goal-setting, treatment planning, and implementation of treatment. 13,14 This article reports a comprehensive occupational therapy evaluation for a clinical case with major depression and suicidal attempt in an inpatient psychiatric setting with an emphasis on the occupational therapy functional assessments and the positive significant impact of the occupational therapy role in managing symptoms of depression.

Case report
Miss XX is a 24-year-old female with a diagnosis of major depression with suicide attempt by overdose of Acetametaphine with codeine. She was sent to the hospital emergency room from college health services, where her roommate had taken her when she started talking about killing herself. She had stopped eating and was having difficulty concentrating on her studies as well. Miss XX is in her last year of biological sciences school. She had been doing well until her younger sister died of breast cancer 6 months ago. They had no other siblings and they were very close to each other. XX used to talk to her deceased sister daily on the phone and always considered her younger sister as her daughter. Being diagnosed with a late-stage breast cancer was shocking to the family especially to XX. Ever since, XX has been having recurrent episodes of depressed mood and lack of interest and pleasure. XX grew up in a large city as the eldest of two children. Her mother died from breast cancer when she was 15, and her father remarried 2 years later. XX did not get along with her stepmother and was thrilled to go as far away from her family as she could for college. Her father supports her during college, and she gets summer jobs to pay for books, clothes, and entertainment. Prior to her hospitalization, XX had been living in an apartment with her roommate of 2 years. They share all the cooking and other domestic duties of the apartment and each has a separate bedroom. She works hard at school and maintains a B average. She is looking forward to finishing and working in biological and laboratory analysis labs. XX is a hardworking driven person. She feels that she has to prove to her father that she is a capable person in her own right and that he does not have to protect her. She was very close to her late mother and younger sister, and their death was very difficult to her. She is on the locked unit on suicide precautions. She is being seen by an interdisciplinary team consists of a social worker, psychiatric nurse, psychiatrist, as well as an occupational therapist.

Occupational therapy evaluation
XX is interviewed and evaluated by OT the morning after she was admitted from the emergency room. She appears disheveled; her hair is uncombed and her clothes are unkempt. Her affect is flat and she makes little eye contact. She speaks softly and looks down when she talks. XX does not note many interests on the interest checklist, but when reviewed with her on a one-on-one basis, she is able to identify past interests in reading, watching TV, and gardening. She has difficulty thinking of interests because everything that she thinks about are things that she and her late sister did together, and she starts to cry. She scored a 5.2 on the Allen's Cognitive Level (ACL) and 22 on the Mini-Mental State Examination (MMSE). She mentions that they camped together and liked the outdoors, movies, and reading. She cannot think of things she did by herself. She speaks about wanting to join her mother, now she has lost everything worthwhile in her life. She is on suicide precautions, with checks every 30 minutes. Her expected length of stay is 2 weeks, with discharge expected back to her own apartment. While pessimistic about her ability to do so, XX is motivated by a desire to get out of the hospital in time and her goal is to return to school to finish her last year with her class. Finals for the first semester are in 1 month, and her goal is to be able to take these with her classmates.

Discussion
The occupational therapy evaluation yielded important information about the strengths, weaknesses and needs, priorities, and personal goals for miss XX. A score of less than 5.8 on the ACL screen indicates that you will likely need or benefit from some type of assistance in daily living tasks. In Allen's cognitive levels, it is in level 5 "Learning New Activity" which indicates that although there may be some mild cognitive impairment, you are often capable of learning new things and functioning quite well. 15 Her MMSE score of 22 indicates a mild cognitive impairment. 16 Per the occupational therapy thorough assessment and the expected short stay of XX, an individualized treatment plan with realistic and achievable goals was implemented ( Table 1) as part of the whole interdisciplinary treatment plan that included tailored services from other healthcare providers (social worker, psychiatric nurse, and psychiatrist). • XX will be able to recognize and mention 5 of her strengths and positive potentials independently after 5 sessions.
• XX will be able to finish a 15-minute cheerful activity and praise herself independently within 5 sessions.
• XX will be able to perform a previously enjoyed interest and develop a new one with minimal visual self-exploration cues after 1 week.
2. XX will demonstrate adequate self-care skills independently within 2 weeks.
• XX will be able to identify at least 5 positive effects of proper personal care on her mental and physical health independently after 3 consecutive sessions.
• XX will be able to iron her clothes and dress up safely with minimal physical assistance after 6 sessions.
3. XX will be able to communicate with others adequately within 2 weeks.
• XX will be able to demonstrate proper eye contact with the therapist while communicating with minimal verbal cues after 4 sessions.
• XX will be able to speak slowly and clearly with other patients while socializing using proper tone of voice within 1 week.
• XX will be able to complete a 20-minute group activity and follow instructions attentively after 1 week.
For 2 weeks, each discipline introduced different interventions during miss XX stay at the hospital and has proved to be effective and helpful in mitigating symptoms of depression. Ongoing support, working with her family and roommate, collaborative and comprehensive care, setting realistic goals, and participation in meaningful and purposeful activities are all important aspects that were taken into consideration while treating miss XX. Per symptoms and problems that miss XX had, the occupational therapist provided both individual and group therapeutic sessions in order to enhance miss XX functional performance and cognitive ability. Occupational therapist use functional activities of daily living (ADLs) that are meaningful and purposeful and apply them in therapeutic ways to enhance and promote functional performance as much as possible in terms of independence, safety, and quality. These selected activities are based on evidence-based therapeutic approaches and techniques that have been used in research and clinical settings and proved to be useful and effective (D'Amico, Jaffe, & Gardner, 2018) ( Table 2). After 2 weeks of treatment with a total of 10 OT sessions (45 minutes/session), and in addition to other medical and social services, miss XX successfully completed 80% of her long and short-term goals as part of her treatment plan. Per treatment plan reevaluation and progress report results, she showed significant improvements in her social skills, cognitive abilities, and ADLs functional performance. She was able to smile again and was motivated to go back to her apartment and to finish school. Furthermore, she could add, in collaboration with her roommate and father, some really good ideas and suggestions about community-based activities to participate in after discharge. A home program and a follow-up plan were discussed and provided to help XX achieve her goals. The results of this clinical case report support the use of evidence-based occupational therapy interventions. Research has shown that effective occupational therapy interventions help people with psychiatric disorders and mental health illnesses to engage in everyday living activities, leisure, social participation, and healthy daily routines. 17 The inclusion of occupational therapy practitioners as mental health service providers in the interdisciplinary healthcare team has a positive significant impact on both physical and mental health and helps provide holistic and integrated intervention planning. 18 This was a single clinical case report, and a future series of a variety of clinical case reports for evidence-based treatments with a focus on applied occupational therapy interventions is needed and recommended to further highlight the vital role of occupational therapy in managing symptoms and enhancing functional performance for individuals with depression and other psychiatric conditions. 19,20 Conclusion Occupational therapy has a complementary relationship with psychotherapy and other medical treatments and is useful and effective in managing symptoms and enhancing cognitive abilities, social skills, and ADLs functional performance in terms of independence, safety, and quality for persons with depression.