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Table of Contents
Year : 2021  |  Volume : 53  |  Issue : 1  |  Page : 23-30

Effect of occupational therapy on cognitive functions and occupational performances in hospitalized patients with mental-health disorder: A single-arm interventional study

Psychosocial Occupational Therapist, Anmol Child Development Clinic, Kandivali (W), Mumbai, Maharashtra, India

Date of Submission17-Jan-2021
Date of Acceptance06-May-2021
Date of Web Publication22-Jun-2021

Correspondence Address:
Pooja Pankaj Mehta
202, Punit Ganga, Gokhale Road, Dahanukar Wadi, Kandivali (W), Mumbai - 400 067, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijoth.ijoth_6_21

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Background: Cognitive dysfunction, a distressing outcome of mental-health disorders (MHDs), hinders an individual's occupational performance (OP). OP is the outcome of dynamic interaction between a person, their unique environment and occupation. With only pharmacological treatment, symptom reduction was not in pace with the recovery rate of cognitive and OP dysfunction resulting persistence of these dysfunctions even post-hospital discharge. Hence, occupational therapy (OT) intervention before discharge would be required, for patient's functioning at premorbid level postdischarge. However, till date, very few Indian studies on the effect of OT on cognition and OP in individuals with MHDs are done with under-representation of the client population. Objectives: To study the effect of OT on cognitive functions and OP in hospitalized patients with MHDs. Study Design: A single-arm interventional study was conducted. Methods: Based on the selection criteria, 88 patients who were (aged 18–55 years) diagnosed with MHDs and were admitted in the hospital were enrolled after screening during their first visit to OT department using the purposive sampling method. Participants recruited were categorized into diagnostic groups: schizophrenia, neurotic disorders, mood disorders, and alcohol-substance use disorders for data analysis. Patients were assessed on Mini-Mental State Examination (MMSE) and comprehensive OT evaluation (COTE) scale pre- and post-therapy after 3 weeks, i.e. after 6 sessions. Cognitive-OP focused-OT intervention was given twice a week. Results: The descriptive data analysis showed an increase in performance posttherapy for all subtests (except Language-praxis subtest in Group-Neurotic Disorders) and overall scores of both assessments in all the groups. Total MMSE performance both pre- and post-therapy was better than total COTE performance in all the groups. Posttherapy, maximum improvement was observed in Recall among MMSE subtests and in Task-behavior among COTE subtests across all groups. Inferential data analysis showed highly significant improvement posttherapy for total MMSE and total COTE scores (P < 0.01, 95% confidence interval: Groups: schizophrenia [(−3.218, −2.302) and (15.991, 18.329)], neurotic disorders [(−3.169, −1.631) and (13.230, 18.970)], mood disorders [(−3.100, −1.650) and (15.095, 19.155)] and Group: alcohol and substance-use disorders [(−4.210, −1.456) and (17.855, 22.47)] respectively). Conclusion: OT intervention is effective in improving cognitive and OP in hospitalized patients with MHDs.

Keywords: Cognition, Mental Health, Neuroplasticity, Occupational Therapy, Task Performance

How to cite this article:
Mehta PP. Effect of occupational therapy on cognitive functions and occupational performances in hospitalized patients with mental-health disorder: A single-arm interventional study. Indian J Occup Ther 2021;53:23-30

How to cite this URL:
Mehta PP. Effect of occupational therapy on cognitive functions and occupational performances in hospitalized patients with mental-health disorder: A single-arm interventional study. Indian J Occup Ther [serial online] 2021 [cited 2023 Jun 7];53:23-30. Available from: http://www.ijotonweb.org/text.asp?2021/53/1/23/318988

  Introduction Top

The most distressing outcome for any mental health disorder (MHD) is cognitive dysfunction and poor occupational performance (OP)[1],[2],[3] which hinders the daily functioning of the individual and escalates the condition further. OP is the outcome of the dynamic interaction between person, his/her unique environment and occupation.[2],[3],[4] This meaningful engagement in activity and environmental interaction is facilitated through cognition and measured through observed behaviors general, interpersonal, and task behaviors (TB).[2],[3] However, with only pharmacological treatment, studies show persistence of cognitive[5] and OP dysfunctions[6] even after hospital-discharge and psychiatric symptoms recovery; affecting return to work, engagement in daily occupations and functional recovery.[5],[6] Hence, occupational therapy (OT) intervention to remediate these dysfunctions before hospital discharge is required, as patients are expected to function at premorbid level postdischarge.[5]

A recent United States study (2017) showed that theory-based OT intervention has a medium effect on improving OP and well-being.[7] However, in India, articles on effect of OT on MHDs patients are scarce,[8],[9] while none found on effect of OT on cognitive functioning and OP among hospitalized patients with MHDs; possibly due to the dearth of OT practice in mental health in India. This dearth has been documented due to use of biomedical model of health care with importance to symptom reduction than functional recovery, absence of emphasis on use of OT as treatment modality by psychiatrists, and eventual limited OT workforce working in mental-health care,[9] in spite the field of OT having emerged as the treatment modality of mental-health in the 18th century across globe and Father of OT being William Rush Dunton Jr., a psychiatrist. Hence, this study aimed at finding the effect of OT intervention on cognitive and OP among hospitalized patients with various MHDs.

  Methods Top

Prospective, single-arm interventional study design with purposive sampling method was selected. Written informed consent from caregivers and verbal assent from patients participating in the study were obtained. The study was conducted adhering to the principles of the “Declaration of Helsinki.”

Study Participants

A single arm of 88 hospitalized patients (54 males and 34 females) satisfying the following selection criteria were enrolled: both male and female patients, aged between 18 and 55 years with diagnoses of MHDs, admitted in wards of the tertiary-care hospital (hospitalized patients) were recruited for the study. Whereas, patients with Mini-Mental State Examination (MMSE) scores <18 (indicating severe cognitive impairment),[10] patients with a history of associated medical conditions (hypothyroidism and seizure disorder); organic brain disease (Dementia, Alzheimer's, etc.); physical disability; severe head injury (unconscious for >2 h); which could compound or cause psychiatric conditions were excluded.

Study Procedure

Over 200 hospitalized patients diagnosed with MHDs were screened for selection criteria during their first visit to OT department over 6 months (from May 2018 to November 2018), of which 116 hospitalized patients satisfied selection criteria. Of these, 12 patient caregivers' agreed but the patients' were not willing to attend the sessions and 16 patients dropped off the study due to missing data due to early discharge or patients absconded, resulting in incomplete study protocol. Thus, a sample of n = 88 hospitalized patients was analyzed for the statistical significance. These patients were assessed on Comprehensive OT Evaluation (COTE) in the OT department while they participated in the activities during their first session. Thereafter, OT intervention as described below was given twice weekly for 3 weeks, i.e. 6 sessions. OT intervention was structured for 3 weeks as most of the patients were admitted for a maximum of 4 weeks; as the directives of the Mental Health-care Act 2017 gazette limited admissions of persons with MHDs with support-needs up to 30 days.[11] MMSE and COTE were re-administered after the 6th session to obtain posttherapy scores. For the statistical analysis, patients were divided into four groups as per their diagnosis:

  1. Group: Schizophrenia: Schizophrenia of all subtypes
  2. Group: Neurotic disorders: Obsessive compulsive disorder (OCD) and conversion disorder
  3. Group: Mood disorders: Bipolar mood disorders (BMDs) in mania and major depressive disorder (MDD).
  4. Group: Alcohol and substance use disorders: Alcohol and/or substance-use disorder.

Assessment Tools

Case-record form recorded demographics, psychiatric history, hobbies/interests, COTE, and MMSE scores. COTE and MMSE were used as assessment and outcome tools. Both these tools are feasible, well-defined, quick to administer (10 min) without taxing the patient, and provide quantitative data on OP and cognitive function, respectively.

COTE[2] is an assessment tool to measure OP in adult mental-health facilities on a regular basis in OT sessions. It has definitions for rating each of the 25 behaviors on a 5-point Likert scale of 0 (normal) to 4 (greatest impairment), thus, quantifying them; avoids subjectivity in scoring of the observed behaviors. It serves as an initial evaluation and as progress record to assist with treatment and discharge planning.[2] These behaviors are divided into: General Behavior (GB), interpersonal behaviors (IPBs) and TB. It has good (0.95) inter-rater reliability and adequate validity.[2] It takes 2 min to score.

MMSE[10] developed by Folstein et al. (1975) is a quick, bed-side, standardized assessment to measure cognitive performance. It has 11 questions and is scored as orientation (10), registration (3), attention and calculation (5), recall (3) and language – Praxis (9) i.e. total 30 points. It takes 5–10 min to administer. It has content and concurrent validity with high test-retest reliability (r = 0.887) and inter-rater reliability (r = 0.827). Norms study for education showed the median MMSE score for 9 years of schooling as 29, for 5–8 years of schooling as 26 and <4 years of schooling as 22.[12] Hence, for this study, MMSE score of 26 was taken as a cutoff for cognitive impairment, considering the education of the patients; and reassessment was done to note change in cognitive performance post-therapy. The severity of cognitive impairment rating 26–30: No cognitive impairment, 18–25: Mild cognitive impairment and 0–17: Severe cognitive impairment.

Occupational Therapy Intervention

OT intervention was client-centered and task-oriented according to the patient's occupation, education, interests, roles-values, baseline (pretherapy) cognitive, and OP. As OT intervention was structured to address cognitive and OP behaviors; it was referred as “Cognitive-OP focused-OT” (COPe-OT). These COPe-OT sessions were conducted in the OT department twice weekly, 30–45 min each, for 3 weeks; with emphasis on patient's volition, active participation in meaningful and purposeful cognitive-perceptual activities; along with appropriate TB (e.g. following directions, attention to task, activity neatness, engagement in activity, etc.); IPB (e.g. co-operation, sociability, accepting “No,” appropriate assertiveness, etc.) and GB (e.g. appearance, responsibility, etc.); collaborating principles of Model of Human Occupation (MOHO);[4] Person-Environment Occupational-Performance Frame of Reference (FOR)[4] and Theory of Object-Relationships and Dyadic Relationships.[13]

Activities were structured from simple to complex; easy to difficult; single-step to multi-step, etc., as per cognitive difficulties and from short duration activity to long duration to account for frustration tolerance. First session included projective activity (A blank page with pencil and colors-crayons/paints given to patient to write/draw anything of his/her choice and interests). Initial 3 sessions were one-to-one sessions; 4th–5th sessions had parallel group, where materials and space were shared by two patients; and 6th session had a project group (limited to 4 patients as per the patient's cognitive and performance level), where short-term projects were done together (e.g. envelope making). The progression of groups was guided by principles of Mosey's Developmental groups for social skills[1],[3],[13] and sessions were structured to improve cognitive and OP abilities.

Each COPe-OT session consisted of:

  1. Initial 5–10 min movement games such as hopscotch, obstacle course, etc., and games with ball/balloon: ball-catching/kicking, ball-hitting with bat, throwing ball in target, bowling pins, balloon-tap, etc., (initial sessions were one-to-one and then in small groups)
  2. Cognitive-perceptual (table-top) activities: for attention (vowel/shape cancellation bead stringing designs, peg designs); for visual-perception (Koh's blocks, 3D construction blocks, lego designs, link designs, tangram, and jigsaw puzzles); for problem-solving (sudoku, word search); for auditory attention (word-antakshari) and for recall (search 3-5 items in the picture (e.g. i-Spy)/in wordsearch/cupboard, etc.)

  3. Activities' number of steps and difficulty level are increased as the patient achieves success at prior simple levels. Verbal cues provided to overcome challenges faced during activities for successful completion of activity. These activities were also selected to help with the emotional needs of patients (dependency needs, need to control, need to express aggression constructively, need to excel, etc.); via emotional gratification and expression of emotional needs as per psychoanalytic FOR.[3],[13]

  4. Last 10 min involved use of therapeutic communication to facilitate correction of erroneous thought processes and cognitive bias as well as use of creative occupations (drawing, writing, etc.,) to nonverbally express themselves, facilitate emotional sublimation and provide ego support.[13]

Data Analysis

Data analysis was done using IBM SPSS (Statistical Package for the Social Sciences), Statistics for Windows, version 23, 2015, IBM Corp., Armonk, NY, USA.

Descriptive statistics of pre- and post-therapy MMSE and COTE scores: mean, percentage (%), standard deviation, and 95% confidence interval were calculated. For COTE-the scoring is reverse than MMSE, i.e. in COTE: higher the score, poorer the performance, whereas in MMSE, higher the score, better the performance. Therefore, for graphic comparative analysis of two assessments' scores within the group, COTE score percentages obtained were reversed (i. e. 100 minus score percentage). So that, both the assessment scores could be interpreted in tandem, i.e. higher the percentage, better the performance.

Inferential data analysis using nonparametric test: Wilcoxon signed-rank test (level of two-tailed significance) with level of significance set at P < 0.05; was done to find the significance of the effect of OT intervention on MMSE and COTE scores within each group.

  Results Top

Demographic profiling showed the mean age of inpatients: 30.8 years (±8.8 years) and following patient and gender distribution in each diagnostic group: Group schizophrenia – 50 (32 males and 18 females), Mood disorders – 16: BMD-8 (5 males and 3 females), MDD-8 (3 males and 5 females), Alcohol and substance use disorder – 12: Alcohol use disorder-8 (all males), Polysubstance use disorder-4 (all males) and Neurotic disorders-10: OCD-6 (1 male and 5 females), and Conversion Disorder-4 (1 male and 3 females).

The descriptive data analysis showed an increase in performance posttherapy for all subtests (except Language-praxis subtest in Group: Neurotic Disorders) and overall scores of both assessments in all the groups. Total MMSE performance both pre- and posttherapy was better than total COTE performance in all the groups. Posttherapy, maximum improvement was observed in Recall among MMSE subtests and in TB among COTE subtests across all groups [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: The Performance Percentage of MMSE and COTE Scores Pre and post-therapy of Psychotic Disorders Group.

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Figure 2: The Performance Percentage of MMSE and COTE Scores Pre and Post-Therapy of Neurotic Disorders Group.

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Figure 3: The Performance Percentage of MMSE and COTE Scores Pre and Post-Therapy of Mood Disorders Group.

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Figure 4: The Performance Percentage of MMSE and COTE Scores Pre and Post-Therapy of Alcohol and Substance Use Disorders Group.

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Inferential data analysis showed highly significant improvement posttherapy for total MMSE and total COTE scores as well for all subtests of both assessments among all groups, except for Language-Praxis subtests: significant improvement was found in only Group: Schizophrenia [Table 1] and [Table 2].
Table 1: Effect of Occupational Therapy Program on Mini.mental State Examination of All Four Groups

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Table 2: Effect of Occupational Therapy Program on Comprehensive Occupational Therapy Evaluation of All Four Groups

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  Discussion Top

The study enrolled 88 MHD inpatients (56.18% schizophrenia, 18.18% mood disorders, 13.63% alcohol and substance use disorders, and 11.36% neurotic disorders) with male hospitalized patients more than females. This diagnostic prevalence and gender distribution concurs with the prevalence of hospitalized patients in tertiary care hospitals in India.[14]

Cognitive Deficits in Mental-Health Disorders

The hospitalized patients' mean MMSE score ranged 23–25, i.e. mild cognitive impairment pretherapy across the groups [Table 1]. Cognitive deficits were more among group-schizophrenia (23.48) than other groups (24.50–25.38), similar to Trivedi[15] findings. Post-therapy, patients across all the groups showed >26 MMSE score, i.e. normal cognitive performance.[12] Posttherapy, MMSE subtests scores across groups showed performance of ≥90% [Figure 1], [Figure 2], [Figure 3], [Figure 4] except Attention-calculation (40.8%–65%). This could imply that for achieving attention-calculation skills performance of ≥90% would require >3 weeks therapy duration. Severe impairments in attention-calculation and recall were found across all the groups [Figure 1], [Figure 2], [Figure 3], [Figure 4], similar to other studies that showed cognitive disruption in attention, memory, and problem-solving among patients with MHDs.[6],[15],[16] Posttherapy, maximum percent improvement was found for recall across all the groups (27.34%–36.7%), followed by attention-calculation (12.8%–21.2%); however, total MMSE scores showed 8%–9.5% improvement [Figure 1], [Figure 2], [Figure 3], [Figure 4]. As there is interdependence of attention and memory, attention provides a bridge to memory, and hence, explicit memory would be impaired when attention gets divided.[17] Thus, the recall subtest which utilizes explicit memory, could be affected due to impaired attention. Furthermore, both subtests (attention-calculation and recall) require working-memory (WM); as per definition, WM is “the ability to retain task-relevant information in accessible state over-time.”[18] It is found to be principally affected in MHDs and it limits adequate functioning of other cognitive areas.[19]

Deficits in Occupational Performance in Mental-Health Disorders

The hospitalized patients showed a mean total COTE range: 52.29%–57.5% pretherapy across the groups [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Groups-Neurotic and Alcohol-substance use disorders showed the same mean total COTE: 57.5% which is better than other groups. Group-Schizophrenia showed the least scores for overall OP and cognitive-performance among all the groups [Figure 1], [Figure 2], [Figure 3], [Figure 4]. This finding is supported by the theory that cognitive deficits significantly impact on OP[1],[2],[3] and especially task performance.[1] This could possibly be explained by MOHO[4] and clinical observations during assessment: avolition (affecting oral or performance subtests of MMSE and COTE); disrupted thought process (affecting language, praxis, attention-calculation and recall subtests and COTE subtests), disorientation to time (affecting orientation subtest of MMSE); impulsivity or slow psychomotor activity (affecting attention-calculation, recall and COTE performance); and social withdrawal and flat affect (affecting COTE performance), similar to observations stated by Trivedi.[15]

Group Schizophrenia showed the lowest Attention-Calculation as well as TB and GB scores, probably as registration was also affected amongst Group-Schizophrenia but not so, in other groups [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Task performance depends on WM and attention and their interaction; and visuospatial attention acts as gateway for WM.[18] Hence, the affected registration could have hindered OP further. Thus, OT intervention utilized this relationship of attention, memory, and TB to improve OP. Furthermore, cognitive performance was better than OP both pre- and post-therapy [Pretherapy: (78.26%–84.6% vs. 52.29%–57.5%) and Posttherapy: (87.46%–92.5% vs. 70.08%–77.67%)] [Figure 1], [Figure 2], [Figure 3], [Figure 4]; findings similar to Hammar and Ardal (2009)[5] and could be explained by Li et al. study that OP is closely related to psychiatric symptoms and to lesser extent with cognitive functioning.[20]

IPB score was most affected for Groups-Neurotic and Mood disorders and could be explained by clinical observations of psychiatric symptoms: withdrawal or expansiveness, aloofness or exaggerated/impulsive or inappropriate interactions, low mood to excitable mood/irritability, decreased or increased talkativeness, decreased self-confidence, mistrust, loss of motivation, etc.

Effect of Occupational Therapy on Cognitive Performance in Mental-Health Disorders

The posttherapy results showed significant improvement in overall cognitive functions and individual subtests: orientation, attention-calculation and recall across all the groups. This suggests OT intervention is effective in remediating cognitive deficits among hospitalized patients with MHDs.

Neuroscience studies have shown that new learning, experiences and physical movements facilitate hippocampal neurogenesis in the human brain.[21],[22] Hippocampus is an area important for encoding information into memory[21] and its efficient functioning is essential for optimal cognitive functioning.[22] Pathophysiological studies show that the hippocampus is vulnerable to atrophy in MHDs like schizophrenia, MDD and BMD due to increased glucocorticoids and decreased neurogenesis.[5] Thus, COPe-OT intervention which started with physical movement during ball/balloon games and obstacle course followed by pursposeful table-top activities provided experiential learning; which should facilitate increase in hippocampal in MHDs. Also, these movement games were backed by Lorna Jean King's Sensory-Integration principles of movement therapy[3],[4],[13] i.e. they were subcortical, pleasurable, leading to feelings of mastery and achievement, geared towards altering postures and increasing movements. These activities provide vestibular and proprioceptive stimulation; thus helps integrate sensory information, which facilitates learning and helps achieve higher cognitive processes.[2],[3]

The Hebbian learning model of neuroplasticity concept is that synaptic plasticity is facilitated by feedback (reafference) of information from the environment and resultant adaptive response.[23] Spatio-temporal adaptation opportunities during movement games lead to dyadic interaction (manipulation/exploration) of a person with the environment, followed by assimilation, multisensory integration (haptic, vestibular, visual, auditory and tactile) and accommodation of information with prior experience to elicit an adaptive response.[1],[2],[3] While, cognitive-perceptual activities aimed to stimulate cognitive areas by active engagement, gradual increase in difficulty level with “just-right challenge” for successful completion of activity. Thus, consistent and repeated stimulation in OT intervention facilitates synaptic plasticity resulting improvement in the cognitive areas targeted during activities; as per the Hebbian neuroplasticity principles.[23]

Spatio-temporal activities also helped patients develop a cognitive map of spatial environment, social proximity/personal space, etc., increasing their spatial orientation.[24] The principle of “neurons that fire together, wire together”[23] was utilized in “hands-on” task performance by providing multi-sensory perceptual activities with cognitive tasks especially attention and memory. Thus, more interconnected the information processed, higher is the probability that it will be recalled when required via cognitive maps formed.[24] and better the probability of successful task performance. Also, brain areas modulating learning and memory i.e. hippocampus, stratum and prefrontal cortex are strongly innervated by serotonergic and dopaminergic afferents.[25] Proactive and consistent engagement in OT activities could result in repeated and consistent firing of the neurons to release these neuro-transmitters causing synaptic plasticity/stimulation in these brain areas; thus improving cognitive performance over the time. These neuroscience theories provide parallel support as well explain the effect of OT intervention on significant improvement in overall cognitive-performance and individual areas: attention-calculation and recall.

Effect of Occupational Therapy on Occupational Performance in Mental-Health Disorders

The posttherapy results showed significant improvement in overall OP and all subtests of COTE across all the groups. This suggests OT intervention helps in improving OP among MHD inpatients. The COPe-OT intervention was client-centered, task-oriented and incorporated the core-concept of OT-”active engagement in highly personalized, meaningful and purposeful activities”[2],[3] and provided opportunities for decision-making (for activity or in activity) to empower the patient. Occupational-performance FOR emphasized on the interaction of the patient with his/her environment and occupation across time and space helps the patient adapt to an ever-changing environment.[4] Along with stimulating cognitive abilities to perform task, effective enablers for OP i.e. appropriate TB, IPB and GB were acquired through social-learning during the session. Using Cognitive Social Learning theory, efficacy-expectation (conviction about one's abilities to execute an expected behavior successfully to get desired outcome) plays an important role in repetition of behavior i.e. probability that a particular behavior occurs.[2],[3] Hence, successful outcome of expected OP behaviors during session help in social-skill acquisition by patients and thus help develop efficacy-expectations for future reference. This helps individual modify/adapt the existing schema to fit reality or replacing existing schema based on new successful experiences in the OT session.[3] Psychodynamically, adaptive responses (successful expected outcomes) to environmental demands help patients with self-concept and identity; probe reality testing, develop constructive coping strategies, sense of control and satisfies the need to excel/achieve as well provide a nonverbal expression medium.[13]

Fidler's Theory of Object Relations and Dyadic relationships[13] and Mosey's developmental groups for social-skill development[3] supported the progression of COPe-OT sessions, where initial sessions were one-to-one, followed by parallel group and then short-term project group. This gradual progression helped in learning required social-skills improving IPB and GB scores.

This integration of the above discussed OT conceptual models and practice frameworks were done to best meet patient's needs and explains the effectiveness of OT in improving cognitive and OP in individuals with MHDs. These findings are supported by recent studies that showed a medium effect of OT into improving OP and wellness[7] and strong evidence for effectiveness of cognitive-based interventions, occupation-based interventions (based on individualized, client-centered goals)[26] and cognitive remediation for people with MHDs.[27]

Implications of the Study

Since 2016, Guidelines for Clinical Practices (GCPs) for treatment of MHDs in India and globally have started emphasizing on psychosocial treatments, cognitive remediation and/rehabilitation as an integral part of mental-health care.[28],[29] Global GCP even suggests to start rehabilitation during the first episode of MHDs to have the best functional recovery, economic independence and social inclusion.[29] However, none of these GCPs in India and across the globe mention “OT” as a treatment modality or its recommendation in mental health care protocol.[28],[29] This study showed effectiveness of OT intervention on cognitive and OP dysfunctions among hospitalized patients with MHDs; making contribution of OT in mental health care.

Furthermore, it highlights the need to add guidelines for rehabilitation of MHDs in all areas of care, including in-patient/acute care and as early intervention from the first episode itself for cognitive remediation and OP training to yield the best rehabilitation outcomes-return to work, bolster employment maintenance, economic independence, decrease caregiver burden/stress, decrease relapse rate,[5] thus improving quality of life and reintegrate in the social settings-work and family life. This implication is supported by global GCP[29] and Tsang et al. review study on rehabilitation outcomes.[30]

Limitations and Suggestions for Future Studies

The study employed a purposive sampling method and had small sample size for neurotic, mood disorders and alcohol substance use disorders groups as against psychotic disorders; hence, generalization of the results with caution is advised. Furthermore, there was difficulty in controlling extraneous variables: pharmacological treatments, investigations, and in-rounds counseling by psychiatrists.

For further research, a long-term study with follow-up even posthospital discharge should be done to understand the effect of OT on ability to maintain employment, relapse-rate, QOL, caregiver burden, etc., Furthermore, randomized controlled trials with case-matching for those individuals who refuse OT intervention vs. those who enroll in OT intervention could be done. Qualitative research to understand patients' and caregivers' perspective on the effect of OT intervention is also suggested.

  Conclusion Top

The COPe-OT intervention (based on core concepts of OT models of practice and frameworks along with neuroplasticity principles) showed statistically significant improvement in cognitive and OP posttherapy among inpatients with MHDs of various diagnostic groups-psychotic, neurotic, mood, alcohol, and substance-use disorders. Thus, it provides evidence to justify recommending OT intervention as part of routine clinical-care, including early intervention during in-hospital stage for individuals with varied MHDs.


Sincere gratitude and thanks to Dean, Dr. Ramesh Bharmal and Dr. (Mrs.) Pratibha Vaidya; I/C and Associate Professor, OT School and Center, Topiwala Nair Medical College and B.Y.L. Nair Charitable Hospital, Mumbai; for permission to conduct the study and her support through the study. I would also like to sincerely thank Dr. Heena N. Patel, MSc (OT) Neurology for her guidance, encouragement, shared experience and knowledge to see me through the study. Also, thanks to all my colleagues (both academic and clinical staff members), all unfailingly gave support, guidance and help whenever asked for. Special thanks to patients and their relatives for utmost co-operation through the study. Last, but not the least, special thanks to God, my dear parents and my friends for constant unconditional support throughout the study.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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