Occupational performance problems in people with depression and anxiety

Abstract

Background

Depression and anxiety often reduce people’s ability to cope with everyday occupations. There is a lack of knowledge about such problems in people of working age with depression and anxiety.

Aim

To describe which problems people with depression or anxiety disorders experience when performing everyday occupations and which occupations are affected.

Materials and methods

Data based on the Canadian Occupational Performance Measure was used in this cross-sectional study. A total of 118 participants aged 18–65 years, with depression or anxiety, were recruited from primary healthcare and general mental healthcare services. The data were analysed with descriptive statistics and directed content analysis.

Results

The participants rated a low level of occupational performance, and their satisfaction with performance even lower. They described a great number of problems with their everyday occupations. The most frequent problem areas concerned household management, socialization and personal care. Detailed descriptions of which type of problem they experienced during everyday occupations are included.

Conclusions

This study provides knowledge of which problems people with depression and anxiety disorders experience in everyday occupations within self-care, productivity, as well as leisure. Furthermore, they rate performance and satisfaction with performance of the five occupations they find the most important to change in everyday life.

Keywords:

• Activities in daily life
• adult
• cross-sectional design
• mental health
• occupational therapy

Introduction

Depression is one of the most common psychiatric diagnoses and the single biggest cause of loss of function with reduced health within all diagnoses [1,2]. The symptoms of depression include low mood, a feeling of hopelessness, and experiences of reduced pleasure and engagement in everyday occupations [3]. Anxiety disorders are also common and can entail a recurring fear of and/or difficulty in managing situations in their everyday life, feelings of nervousness and hopelessness, and exaggerated concerns [3]. When suffering from depression, symptoms of anxiety are quite common and vice versa [4].

Depression and anxiety disorders often lead to a reduction of a person’s ability to cope with everyday occupations [5–7]. These are defined in this study, in accordance with the Canadian Model of Occupational Performance and Engagement (CMOP-E) [8], as everything people do to occupy themselves, including self-care, unpaid/paid productive activities and leisure/socialization. The CMOP-E focuses on occupational performance and engagement in occupations, which are the results of dynamic interactions between the person, the occupation and the environment [8]. There is, however, a lack of knowledge about which specific types of occupational problems people with depression and anxiety experience in their everyday life. This knowledge may be valuable when planning for rehabilitation, which concurs with Griffo [9] who emphasized that the individual’s preferences concerning how to act and live everyday life in interaction with the environment should be emphasized rather than symptoms and shortages. Many people suffer from permanent problems with a reduced engagement in the performance of occupations as well as in relationships in their everyday life despite medical and psychological treatment [7,10]. The severity of depression and anxiety disorders might vary, but also people with less severe symptoms can experience impaired quality of life and problems in coping with everyday occupations including working life [7], which also has consequences related to employment and social issues [11].

Engagement and participation in everyday occupations are of relevance for people’s mental health [8,12], and quality of life [13] and increased knowledge about problems with occupational performance is thus of great relevance. The same concerns knowledge about which type of occupations are affected and whether they are related to self-care, productivity and/or leisure.

In summary, there is a lack of knowledge concerning which type of problems with performance of everyday occupations that adults suffering from depression or anxiety disorders experience. Increased knowledge could be useful for professionals within the healthcare services, especially occupational therapists, in enabling the assessment of the client’s occupational performance [14], and having greater awareness of how symptoms of depression and anxiety may influence an individual’s everyday life. This knowledge can constitute support for intervention planning. The aims of this study are thus to describe which problems people with depression or anxiety disorders experience when performing everyday occupations and which specific occupations are affected.

Material and methods

This study was descriptive and cross-sectional [15], and the data was collected from a sample of the participants in the research project ‘the Treatment of depression and/or anxiety – a randomized controlled trial of the Tree Theme Method (TTM) as intervention’ [16] (Clinical Trials.gov: NCT01980381). The project was approved by the Regional Ethical Review Board in Linköping, Sweden (Dnr 2012/232-31, 2015/12-32). The ethical principles of the Declaration of Helsinki [17] were adhered to, i.e. all participants received both verbal and written information about the project. They were informed that participation was voluntary and about the confidentiality of their personal information. All participants gave their written informed consent. There was a minimal risk that answering questions concerning having problems with everyday occupations would entail increased concern for the participant. The project assistants were trained occupational therapists, responsive and familiar with the target group. The participants were given the opportunity to contact the project assistant or their regular occupational therapist if needed.

Participants, recruitment and data collection

The participants were consecutively recruited from primary healthcare and psychiatric outpatient care systems in three counties in the south of Sweden. The inclusion criteria were: 18 − 65 years of age, diagnosed by a physician as having a primary diagnosis of depression or anxiety disorder and having problems with everyday occupations. The exclusion criteria were psychotic disorders, serious somatic disorders, and/or difficulties in understanding and completing the self-assessment questionnaires.

Recruitment was conducted in several steps. First, physicians meeting a client that matched the inclusion criteria asked whether the client would like to meet an occupational therapist. Second, those clients who accepted and were considered to benefit from occupational therapy, i.e. having problems with everyday occupations due to symptoms of depression and anxiety, were informed about the study and asked about participation by their occupational therapist.

The data were collected by project assistants from January 2013 to June 2016 and the data used in this study were collected prior to the commencement of their allocated treatment [16]. Socio-demographic data concerning: sex, age, living status, having children or not, educational level, main support, diagnosis, and medication, were collected first. Then the semi-structured interview based on the Canadian Occupational Performance Measure (COPM) [18] took place, and each interview lasted approximately 30 min. The project assistants were trained in the COPM to ensure that the data collection was performed in the same way for each participant. This procedure included a validation process whereby data was collected for a test person, who did not participate in the study, and afterwards the first author performed the same data collection. Finally, a short interview was held with the test person with the aim of the data collection to be as similar as possible.

Instrument

The Canadian Occupational Performance Measure (COPM) [18] is based on the CMOP-E [8]. The semi-structured interview concerns problems in occupational performance that the participant may encounter within the main areas of self-care, productivity, and leisure. These main areas are then divided into subareas. Self-care consists of ‘personal care’, ‘functional mobility’, and ‘community management’; productivity consists of ‘paid/unpaid work’, ‘household management’, and ‘play/school’, and leisure consists of ‘quiet recreation’, ‘active recreation’, and ‘socialization’.

In the first step, the participant describes the problems he/she experiences when performing everyday occupations in a dialogue with the project assistant. In the next step, the project assistant summarizes and notes the participant’s experienced problems in relation to the predefined areas of the COPM, in a few sentences. These notes clarified which type of specific activities each participant experienced problems with, but did not include anything concerning how these problems were perceived by the participant. The participant then rates the importance of each occupation on a Likert-scale ranging from 1 to 10 (1 = ‘not important at all’ and 10 = ‘very important’). After prioritizing up to five of his/her most important occupations, which he/she wants to change in everyday life, the participant rates his/her ability to perform each of these occupations on another scale from 1 to 10 (1 = ‘not at all able’ and 10 = ‘able to perform extremely well’). In the final step, the participant rates his/her satisfaction with performance of these occupations on a scale from 1 to 10 (1 = ‘not satisfied’ and 10 = ‘very satisfied’).

The COPM has shown satisfactory internal consistency, and moderate [19] to good [20] test-retest reliability for performance and satisfaction scores. The discriminant validity has been confirmed [20,21], and the COPM has been shown to have satisfactory content validity [22,23], criterion validity [24], construct validity [22,24], concurrent validity [25,26], convergent validity [21], and responsiveness to change [27]. The Swedish version of the COPM [28], used in this study, has shown high responsiveness to change [29] and satisfactory clinical utility [30,31].

Data analysis

Descriptive statistics were used to analyse socio-demographic data, as well as data concerning the number of perceived problems in total and then divided into the three main areas and nine subareas as defined in the COPM. The sample’s prioritized problems, rated on occupational performance, as well as satisfaction with performance were calculated with means and standard deviations. The IBM SPSS Statistics 25 was used.

The notes, collected during the semi-structured interviews, regarding identified problems were analysed by directed content analysis [32], using a deductive approach and the existing theory from CMOP-E [8] and the predefined main areas and subareas from the COPM [18]. This was performed in order to gain knowledge of which problems, in a specific area, participants with depression or anxiety disorders experience in their everyday occupations. First, all the participants' occupational problems within an occupational area were compiled in a document. All data in an occupational area were then read through to gain a sense of the whole. In the next step, data in each occupational area were coded and grouped based on the nature of the problem. The first and second authors started the data analyses, and then the preliminary findings were discussed by all of the authors until all agreed. The analysis of the notes with the summarized descriptions of the participants’ experienced problems with everyday occupations revealed only a few cases that needed to be discussed between the authors before agreement was reached as to which group each one belonged.

Results

A total of 118 participants were included. The majority were women and most participants medicated regularly due to symptoms of insomnia, depression and/or anxiety. The socio-demographic data are presented in Table 1.

Table 1. Sociodemographic and clinical characteristics of the participants with depression and/or anxiety disorders (N = 118).

Characteristics	n (%)
Sex
Men	20 (16.9)
Women	98 (83.1)
Age (years), Mean (SD)	42 (11.8)
Min-Max (Range)	19–64 (45)
Living with someone	75 (63.5)
Have children ≤ 18 years	41 (34.7)
Educational level:
University	35 (29.7)
Secondary school	58 (49.2)
Compulsory school	22 (18.6)
No compulsory school	3 (2.5)
Main occupation:
Employed/Student	39 (29.7)
Unemployed	10 (8.5)
Other (parental leave, retired)	2 (1.6)
Sick leave (including 3 who were in work training)	67 (56.8)
Problem:
Diagnosis depressive	80 (67.8)
disorders (F31–38)
Self-rated depression*
No depression (0–7)	18 (22.5)
Doubtful cases (8–10)	22 (27.5)
Definite cases (11–21)	40 (50.0)
Diagnosis anxiety disorders (F40–49)	38 (32.2)
Self-rated anxiety*
No anxiety (0–7)	2 (5.3)
Doubtful cases (8–10)	6 (15.8)
Definite cases (11–21)	30 (78.9)
Medication for:
Insomnia	54 (46.2)
Depressive symptoms	84 (72.4)
Anxiety symptoms	1 (35.6)

*Self-rated symptoms of depression and anxiety, measured by the Hospital Anxiety and Depression Scale (HADS) according to Zigmond and Snaith [33].

The participants reported a total of 762 problems in their everyday occupations in relation to all the main and subareas, ranging from being mentioned twice to almost one hundred times. Each participant rated on average 6.5 problems. The problems were relatively equally related between the areas of self-care, productivity and leisure. The most frequently experienced problems were related to the main area of personal care, and within the subareas of household management and socialization (Table 2).

Table 2. Occupational performance problems per area and sub area.

Area n problems (%)	Sub area n problems (%)	Occupational performance problems	N
Self-care 212 (28)	Personal care 100 (13)	Taking care of the body	75
		Getting started with daily occupations	16
		Winding down during the day and night	9
	Functional mobility 20 (3)	Moving the body	15
		Standing still	5
	Community management 92 (12)	Occupational performance in a social context	54
		Managing the household economy and administration	22
		Leaving home	9
		Driving a car
Productivity 263 (34)	Paid/unpaid work 92 (12)	Working in the present job situation	50
		Seeking a job or another job	42
	Household management 151 (20)	Take care of the home and belongings	95
		Cooking meals	40
		Doing what is desired with/for the children	12
		Daily routines within household management	4
	Play/school 20 (3)	Studying	11
		Engaging in pleasurable occupations	5
		Starting an education
Leisure 287 (38)	Quiet recreation 88 (12)	Performing quiet recreation	80
		Not having a meaningful quiet recreation	6
		Doing too much quiet recreation	2
	Active recreation 93 (12)	Performing physical recreation	40
		Engaging in active recreation in general	24
		Going on trips	18
		Taking care of pets	7
		Participating in courses and cultural activities	4
	Socialization 106 (14)	Participating in a social context	83
		Maintaining contact with family/friends	20
		Maintaining a balance between being in a social context and being alone	3

A total of 553 occupational problems were prioritized and rated as important to change and the performance and satisfaction of performance were rated. The results showed that the participants consequently rated the satisfaction with occupational performance lower than their performance of these occupations (Table 3).

Table 3. The ratings of performance of everyday occupations and satisfaction with the occupational performance.

Areas	Number of prioritized problems	Number of participants rating	Performance Mean (SD)	Satisfaction with performance Mean (SD)
In total	553	118	3.8 (2.3)	2.9 (2.4)
Self-care
Personal care	68	55	4.8 (2.4)	3.4 (2.9)
Functional mobility	10	9	2.9 (1.7)	1.9 (1.1)
Community management	68	56	3.9 (2.2)	3.0 (2.5)
Productivity
Paid/unpaid work	74	67	3.2 (2.6)	2.4 (2.2)
Household management	97	76	4.0 (2.2)	3.4 (2.5)
Play/school	15	13	3.3 (1.8)	2.0 (1.1)
Leisure
Quiet recreation	51	47	3.4 (2.3)	3.1 (2.4)
Active recreation	77	72	3.6 (2.3)	2.7 (2.2)
Socialization	93	88	3.8 (1.8)	2.8 (2.0)

Self-care

Personal care

The participants reported problems in taking care of their body and looking after their health, such as personal hygiene (e.g. makeup and hair). Some did not shower while others showered irregularly, less or longer than desired. Forgetting to brush their teeth every day or not listening to their body signals in relation to rest and hunger were also mentioned. They also experienced problems with taking care of their appearance, such as getting dressed, choosing clothes, and changing into clean clothes. Further, the participants had problems with buying the clothes they wanted and in being interested in clothes.

Moreover, they reported problems initiating occupations, such as getting up in the morning. They also experienced problems with having daily routines, winding down during the day and night, being able to relax, to deal with stress and to be spontaneous. Finally, problems with sleep; both falling asleep and sleeping long enough were reported.

Functional mobility

Some participants had walking problems, and problems standing still or lying down for a long time as well as standing up and sitting down.

Community management

Problems with performance in a social context were described. These included visiting and performing occupations in places where there were many people, e.g. at stores and shopping centres. Participating in meetings such as parent meetings at pre-school and travelling by public transport were also experienced as being difficult as well as contacting public agencies and housing authorities.

Moreover, the participants described problems with short-term and long-term planning, such as opening their post regularly and in managing their household economy and administration. Problems having sufficient money due to delayed payments from the national social insurance agency were also described. Another problem was taking the initiative to leave home and some of those who drove a car reported the volume of traffic, long distances, and the planning for the drive as difficult.

Productivity

Paid and unpaid work

The participants described problems related to their current work situation, such as managing the job due to difficulties in memory and concentration, initiative, planning or finishing work tasks. Some also reported problems with stress, requirements both from their work and from themselves, with the need to receive praise, and with worrying about not being able to manage their assignments. Furthermore, the participants described feelings of alienation because of only having a part-time job, lack of information, and insufficient contact with colleagues. Problems with their current work situation were also experienced due to a lack of energy, pain and fatigue, which made it difficult to manage the work. This subarea also included problems such as a noisy working environment, not understanding colleagues and managers, and experiencing chaos at work. Finally, they experienced problems related to the work activity itself, such as having monotonous tasks.

Moreover, problems finding a job or seeking another job when having problems with their current one were described. The participants also experienced problems with not having the ability to work at present in their current work situation and thus feeling afraid of seeking another job. Some had problems with not having the ability to work at all currently and therefore not being able to look for a job.

Household management

The participants reported problems with taking care of their homes and belongings, such as tidying up, washing up, and doing their laundry. On the other hand, there were also difficulties in terms of doing too much cleaning and problems of not being satisfied with the results of these efforts. Some experienced problems in creating a daily routine and in following weekly schedules. Difficulties when cooking meals were also reported, these included planning for the meals and for food purchases, while some experienced problems going to the grocery store to do the shopping.

The participants experienced difficulties in doing what they wanted to do with or for their children due to lack of energy, such as playing with them, taking care of them, helping with homework and with driving them to their various occupations.

Play and school

The participants described problems with studying, including reading, concentrating, and remembering what they had read as well as with doing their homework. Some experienced problems with not having any pleasurable activities available to them, as well as with prioritizing leisure activities. There could also have difficulties with starting to study, getting an education, or with the completion of secondary school.

Leisure

Quiet recreation

The participants expressed problems with both concentrating on and allowing themselves to engage in quiet recreational occupations, such as reading books, blogging, photography, writing, making art, and playing a musical instrument as well as listening to the radio and watching television. Some of the participants reported having too little quiet recreation e.g. not having any hobbies, or not knowing which occupations might be fun to do. On the other hand, some reported doing too much quiet recreation such as playing too many computer games and watching too much TV.

Active recreation

Many participants experienced problems when performing physical activities, such as taking walks, going alone to the gym, playing tennis etc. For some participants, there could also be a problem with getting too much exercise, and some had too little active recreation in their everyday life. Too much planning and too many demands on oneself led to not engaging in any active recreation.

Participants also experienced problems with going on day trips, such as to the beach or the forest as well as problems with travelling for longer periods. Problems with taking care of pets were reported and included difficulties going out with the dog due to worries about meeting other people, and problems with different views about how to take care of pets. Furthermore, difficulties in participating in courses and cultural activities were described and this included going to the cinema and participating in occupations as a member of a club or social organization.

Socialization

The participants reported problems with participating in a social context, including meeting people in a social context and in participating in social activities. Some experienced problems when meeting friends, visiting family and relatives and did not prioritize this activity or planned their participation too much that led them to not taking part in a social context at all. Being spontaneous and being in a social context during mealtimes were also found to be difficult situations to cope with.

The participants also experienced problems with maintaining contact with family and friends, such as calling just to talk or to invite family and friends over, or sending emails. The participants also described problems with maintaining balance between being in a social context and being alone.

Discussion

The present study aimed to describe which problems people with depression or anxiety disorders experience when performing everyday occupations and which specific occupations that are affected. The results showed that they rated a low level of occupational performance, and their satisfaction with performance was even lower. The results also demonstrated that this group identified a large number of occupational problems, related to several areas within self-care, productivity and leisure, but more importantly they also revealed detailed descriptions of which occupational problems the participants experienced within these areas.

The participants rated their satisfaction with their occupational performance lower than their occupational performance, in total as well as within all nine subareas. One possible reason can be that suffering from depression and anxiety disorders leads to fatigue and a loss of pleasure when performing everyday occupations [3], which in turn could influence the experience of satisfaction. Furthermore, the lower ratings of satisfaction are similar to those found in other groups of clients of working age, e.g. those with obesity, who also reported symptoms of depression and anxiety [34]. The lower ratings of satisfaction thus highlights the difficulties the target group has in terms of satisfaction with everyday occupations, and indicate the importance of considering the subjective experience, when setting rehabilitation goals within a client-centred occupational therapy context [8].

The results from the present study also revealed detailed descriptions of which occupational problems the participants experienced within the areas self-care, productivity and leisure, and their problems were relatively equally related to the various areas. The most frequently experienced problems described by the participants in the present study were within the subareas of personal care, household management and socialization, and the latter two were the most prioritized occupations, mentioned almost hundred times each. To our knowledge there are no studies with participants with depression and anxiety concerning problems with everyday occupations. However, the results of one study [35], with a focus on depressive symptoms, showed that the participants generally described problems with completing everyday occupations and with interaction with others. On the other hand, these results differ from those in a study focussing on obesity [34], where 33% of the participants also experienced symptoms of depression and anxiety. The participants in the latter study rated community management as the most important, and only mentioned social interaction a few times.

The large number of experienced performance problems confirm that everyday occupations can be a challenge for people who experience mental illness [36], related to work [2,7] but also within self-care, which in the present study mostly included problems with taking care of their bodies and getting started with daily routines. This corresponds to the findings in previous research about elderly people where depression was shown to be significantly correlated with personal care [37,38]. The second most common problem in the present study in self-care was within the subarea community management, in which the participants in the present study described performance problems in a social context ‘due to too many people’ in e.g. a store. This could be related to depression and anxiety often entailing difficulties in dealing with social situations [5,39] and that a stressful environment can impair a person’s social capacity [40].

Limitations in functional mobility were mentioned fewer times by a small number of the participants, e.g. problems with standing still or lying down for a long time, which can be interpreted as being linked to symptoms of anxiety [3]. The results concur with those in a study [41] with participants with fibromyalgia, who only mentioned functional mobility a few times. On the other hand, the results in the present study, not unexpectedly, contrast to those in another study [42] on elderly people with somatic disorders such as fractures, dizziness or orthopaedic disorders, who more frequently mentioned mobility limitations when going for a walk or climbing stairs.

The participants in the present study described having problems with performing work, which corresponds with the Swedish National Guidelines, which state that this target group experiences problems with working life [7], however, the present study adds detailed descriptions about the type of problems this concerns. The participants in the present study spoke of barriers within themselves that involved cognitive components, e.g. problems with concentrating, taking initiatives, finishing tasks and remembering. This is similar to the difficulties described in previous research, such as concentrating and remembering [39,43]. Furthermore, the participants talked of barriers within the environment; such as noisy working environments, lack of information about work and having insufficient contact with colleagues. Problems similar to these were demonstrated in another study [44], in which people with mental disorders experienced work instability including problems of creating distance from others both inside and outside their jobs, which in turn had led to feelings of social isolation [44]. When an occupation, usually employment, was felt to be beyond an individual’s capabilities, it could be detrimental to his/her quality of life [45]. The participants in the present study, of whom 70% did not work at the time of the data collection, rated low satisfaction with their occupational performance in relation to work indicating that productivity and employment may be an issue in people with depression and anxiety disorders [11]. This is in line with the results in studies showing that people with depression have difficulties coping with employment [39], and have more unemployment, sick leave and work performance deficits compared to those without depression [46]. This is further corroborated in the national statistics from the Swedish Social Insurance Agency, where depression, together with anxiety and stress-related disorders accounted for 44% of sick leave in 2016, with the longest periods of sick leave and the lowest rate of return to work [47]. Similar levels of sick leave are also found in the rest of Western Europe [48]. Helping people with depression and anxiety disorders to return to work or maintain their jobs is of importance. By using the COPM as an assessment tool, occupational therapists can avoid missing important information about a client’s total situation in terms of self-care, productivity and leisure, when all of these areas impact on an individual’s working life. With this knowledge, occupational therapists can better plan for rehabilitation, as well as for supporting a client when meeting expectations and requirements from the social insurance office and the employment services. Furthermore, the results concerning having problems getting started in the mornings or leaving home, managing daily routines within the household, or not having a meaningful leisure time, may also impact on an individual’s work ability. This provides additional relevant knowledge in relation to the statements, in the Swedish National Guidelines [7] and by Evans-Lacko and Knapp [2], that people with depression and anxiety have difficulties in relation to their working life and social functioning. The present study indicates the need for a detailed description of limitations and abilities in a client’s performance of and satisfaction with everyday occupations, when setting rehabilitation goals [8], in order to constitute client-centred occupational therapy.

Moreover, taking care of the home and one’s belongings was another frequently experienced performance problem within the main area of productivity. This included difficulties such as cleaning the house and washing up, both doing too little or too much, which may indicate an occupational imbalance [49]. Having problems with household management is also in line with the outcomes from previous research on people over 65 years with depression and anxiety disorders [50].

Problems with performing quiet recreation, in the area of leisure, were reported and this concerned not having the drive to engage in activities, such as reading books or performing creative activities, or watching television. This corresponds to the fact that, when suffering from depression, it is common to have a loss of interest or pleasure in performing activities that had previously generated satisfaction [5]. On the other hand, these results contrast those from other groups reporting symptoms of depression and anxiety, e.g. those with obesity [34] and fibromyalgia [41], who do not report problems with quiet recreation.

Problems with participating in a social context were the most common problem related to leisure. This included meeting family and friends, which is similar to the findings in previous research [10,44], which showed that people with work instability could have more problems due to distancing themselves from other people both inside and outside the workplace, which in turn leads to isolation.

In summary, the results from the present study confirmed that clients with depression and anxiety disorders have problems with their everyday occupations. Our results emphasize the importance of taking the performance of and satisfaction with the performance of everyday occupations into consideration, when meeting people suffering from depression and anxiety disorders in the healthcare services. The COPM was found to be useful for identifying the everyday occupations that the participants with depression and anxiety disorders prioritized to change, and which type of occupational problems they experienced. Further research is warranted, but the COPM appears to be a possible assessment tool thus concurring with Hitch et al. [14], who emphasized the need for occupational therapists to be familiar with instruments such as the COPM for assessing clients with depression prior to rehabilitation. However, due to a lack of research based on occupational therapy interventions for people with depression and anxiety disorders [51], it is reasonable to assume that clients from this target group are not always referred to occupational therapists, in spite of the potential benefit from this [52].

Methodological considerations

The trustworthiness of the present study needs to be taken into consideration [32]. Credibility [53] was strengthened as the COPM [18] was a well-suited measurement for answering the aims of the study. The COPM is client-centred, taking the problems of everyday occupations into account and focussing on what is of importance for the individual.

Moreover, the COPM has been shown to be an adaptable tool for highlighting problem areas in mental health [54] and has been found to have satisfactory validity [20–22,24–26,55] and reliability [19,20], thus enhancing the probability of satisfactory credibility in the present study.

This credibility [53] was further strengthened because of the use of both quantitative and qualitative data in the COPM measurement, resulting in a greater understanding of the experienced problems in everyday occupations. Even though the summarized sentences in the COPM measurement identified which specific everyday occupations the participants perceived, future research using interviews based on a qualitative design would be valuable in order to gain a greater understanding of the target group’s experiences of their performance of and satisfaction with everyday occupations.

The dependability [53] was strengthened as the project assistants were trained in the COPM in order to perform the data collection in as similar a way to each other as possible.

There is a limitation using just a single group of participants with depression and anxiety disorders. It would have been of interest to divide the participants into groups of mild, moderate and severe levels of symptoms, as it is known that symptom severity can impact on a client’s functional ability [2,3] and on their performance of and satisfaction with everyday occupations. The sample in the present study was, however, too small for performing a study focussing on groups with differing symptom levels. The latter would be a relevant focus for future research with larger samples.

A further limitation was that the only research that the results in the present study could be compared with were mainly those focussing on the elderly and people with somatic illnesses. This highlights a knowledge gap and indicates the need for further research targeting the performance of and satisfaction with performance of everyday occupations for people suffering from depression and anxiety disorders. Furthermore, a limiting factor was that only 17% of the participants were male and the results can thus not be transferred [53] to men. On the other hand, this also reflects the fact that fewer men suffer from depression than women (36% of Swedish women and 23% of Swedish men) and similarly for anxiety disorders (where the prevalence among men is two to three times less than among women) [3,7].

Conclusion and significance

The present study showed that people with depression or anxiety disorders experience a wide variety of problems with their everyday occupations, within the areas of self-care, productivity, leisure and their subareas. Their occupational performance was rated at a low level, and their satisfaction with occupational performance was lower. The results show the importance of taking the individual’s problems with everyday occupations into consideration, and occupational therapists can support their clients to talk about the everyday occupations they want to do, need to do, or are expected to do, aiming to highlight what is not functioning in their everyday life. When the problems have been identified and assessed, the occupational therapist and the client can in a dialogue decide which type of intervention she/he needs in order to enhance the performance of and satisfaction with everyday occupations.

Disclosure statement

The authors report that they have nothing to declare.

Additional information

Funding

The present study received financial support from the Kronoberg County Health Authority, Southern Health-Care Region, and the Medical Research Council of Southeast Sweden.