Occupational performance issues in a longitudinal perspective in people with depression and/or anxiety on sick leave, returning to work or working

Abstract

Background

People with depression and anxiety disorder may experience occupational performance issues (OPIs). Further knowledge about these issues longitudinally and about potential differences between people is valuable.

Aim

To explore experienced OPIs longitudinally in a sample living with depression and/or anxiety disorder participating in occupational therapy and varying in terms of their work situation.

Material and methods

The Canadian occupational performance measure (COPM) was completed by 54 participants with depression and/or anxiety at four measure-points from baseline to one-year after participation in occupational therapy. The participants constituted three groups: continuously on sick leave (SL), returned to work within a year and continuing working. Descriptive and non-parametric analysis was used.

Results

Participants in all groups identified OPIs in all occupational areas in the COPM. All groups increased their occupational performance and satisfaction with their occupational performance in the area socialisation. Each group also made improvements in relation to other occupational areas, varying between the groups.

Conclusions

OPIs and improvements were identified among the participants regardless of them being on SL, returning to work or working.

Significance

The diverse nature of OPIs and improvements in the clients indicate the relevance of occupational therapy.

Keywords:

• Canadian occupational performance measurement
• COPM
• everyday occupation
• occupational areas
• return to work
• sick leave

Introduction

Occupation is a fundamental feature of everyday life and it has been stated that people ‘are most true to their humanity when engaged in occupation’ [1,p.7]. However, not everyone has the possibility to perform the occupations, which they want and need to do and may therefore experience occupational performance issues (OPIs) [2]. These issues are a relevant focus for occupational therapists ‘when solutions to choosing, organizing, or performing an occupation become a challenge’ (p.380). One group facing OPI are people living with depression and/or anxiety disorder [3–6], who also constitute a large group in society [4,7] and have high numbers of sick leave (SL) [8]. The occupational areas where OPI are experienced in this group have been investigated [6], which is useful for occupational therapists working with these clients. However, exploring potential variations between people with depression and/or anxiety disorders varying in terms of being on SL, returning to work or working could also provide knowledge about how they manage their everyday life and its occupations. Such knowledge would be significantly useful for occupational therapists working with these clients as their focus is on the clients’ whole everyday lives, regardless of their paid working situation. However, as far as we have ascertained, no study has been identified investigating this issue, which is thus the rationale for the present study.

The client-centered instrument Canadian Occupational Performance Measure (COPM) [9] has been shown to be suitable for evaluating self-identified OPI in different occupational areas in various client groups [6,10–14]. The COPM [9], based on the CMOP-E [2], is completed in a semi-structured interview. It provides considerable information about the clients’ experiences of these difficult occupations, the importance of managing to perform each occupation and the clients’ self-ratings of their occupational performance and satisfaction with their occupational performance. A few studies [6,12,15] have been identified where the COPM has been used in samples with depression or anxiety and has described the participants’ OPI in relation to the specified occupational areas. However, no study has been identified reporting both the OPI in relation to specific occupations combined with the longitudinal ratings of the COPM in relation to each occupational area. The results from a cross-sectional study [6], showed a variety of OPI, and that each main occupational area was prioritized for change to a similar extent. The lowest ratings in both occupational performance and satisfaction with the occupational performance in relation to various occupational areas were identified in the subarea functional mobility. The highest ratings of occupational performance were found for the occupational area personal care and the highest ratings of satisfaction with occupational performance were found in the subareas personal care and household management. Furthermore, a study with adults [15], where a majority had depression or anxiety, showed that the participants’ occupational performance and satisfaction with their occupational performance had improved after participating in occupational therapy. However, the authors did not relate the results to any specific occupational areas [12]. However, no study has been identified reporting both the OPI in relation to specific occupations combined with the longitudinal ratings of the COPM in relation to each occupational area.

The present study uses data from a randomized controlled trial where the Tree Theme Method^® (TTM) was applied as an intervention and compared to occupational therapy treatment as usual [16], the follow up which occurred directly after occupational therapy [17] and at 3 and 12 months afterwards [18], have shown improvements in the participants’ summarized scores of their self-rated occupational performance and satisfaction with the occupational performance, but the outcomes were not related to any specific occupational areas. It was also noted in the trial that there was a difference in terms of to what extent the participants were on SL, returned to work (RTW) or worked (W) during the project period. This was the rationale for the present study as it would be valuable for occupational therapists to gain knowledge about potential variation in people on SL, returning to work or working regarding their experienced OPI and their ratings of their occupational performance and satisfaction with their occupational performance. Such knowledge may result in different approaches towards clients differing in relation to paid work or in other adaptations to better meet the various needs of the clients.

The aim of the present study was thus to explore OPIs prior to occupational therapy and up to a year afterwards in a sample of people with depression and/or anxiety disorders constituting three groups: on continuous SL, returning to work or continuing working. The research questions were:

1. Which types of perceived OPIs do these groups of participants identify prior to occupational therapy, i.e. at baseline, and to which occupational areas do these belong?

2. How do participants in the respective group longitudinally rate their occupational performance and satisfaction with their occupational performance in relation to each occupational area?

3. Do the longitudinal ratings of occupational performance and satisfaction with the occupational performance differ between participants in the three groups?

Method

The present study used data from the randomized controlled trial of TTM and occupational therapy treatment as usual. The trial was conducted in primary health care and mental health outpatient clinics in southern Sweden (Clinical Trials.gov: NCT01980381) [16]. The intervention group received five sessions of the TTM [19] and the control group received five sessions of standard occupational therapy, as defined and performed by occupational therapists. The participants in the intervention and control group did not differ significantly in outcomes after received occupational therapy [17,18], and were thus treated as one group in the present study irrespective of which treatment they were allocated to and received in the trial.

Data were collected on four occasions: prior to and directly after occupational therapy as well as 3 and 12 months afterwards. The data were collected by project assistants, all of whom were occupational therapists, but not involved in the treatment or previously known to the participants. The project assistants were trained by the project leader prior to the commencement of the project to make sure that they were familiar with the instruments used. They were also validated, through the project assistant and the project leader collecting the same data from a voluntary (non-participating) person, who thereafter gave feedback about the process and similarity in data collection.

The inclusion criteria in the trial were a diagnosis of depression and/or anxiety disorder and aged 18–65 years. The exclusion criteria were psychotic or serious somatic disorder, and/or difficulties in understanding or completing interviews based on questionnaires in Swedish. A total of 118 participated in the baseline data collection and 84 in the data collection 12 months after the performed occupational therapy intervention. Those participants, who were included in the present study, were those who met the further inclusion criteria of having participated in all four data collections and either: been on SL on all occasions; been on SL at baseline but RTW to some extent during the period; remained working to some extent during the whole period. Fifty-four participants met all the criteria and were included in the present study [17,18].

Data collection

Each presumptive participant meeting the inclusion criteria of the randomized controlled trial was informed by their occupational therapist. If they declared an interest in participating, they met a project assistant and received further information prior to giving their written informed consent. The participants then answered questions concerning demographic characteristics such as sex, age, education, living and working situation and whether they had young children or not. A number of questionnaires concerning everyday occupations and health related aspects were also completed in each data collection period. Only demographic data and the Swedish version of the COPM [20] have been used in the present study.

Participants

The 54 participants were divided into three groups based on their paid work status: 24 participants had been on SL throughout the period (SL group); 13 participants had RTW (group) to some extent during the period; and 17 participants had remained working (W group). The characteristics of the participants are described in Table 1.

Table 1. Demographic characteristics of the participants at baseline (N = 54).

	SL (n = 24)	Return to work (n = 13)^a	Working (n = 17)
Sex
Women, n (%)	22 (92)	11 (85)	14 (82)
Age
Years median (range)	51 (21–60)	42 (19–60)	39 (20–57)
Education
University, n (%)	6 (25)	3 (23)	6 (35)
Mandatory or high school, n (%)	18 (75)	10 (77)	11 (65)
Living situation
Alone, n (%)	12 (50)	4 (31)	7 (41)
Cohabiting, n (%)	10 (42)	7 (54)	9 (53)
With parents, n (%)	2 (8)	2 (15)	1 (6)
Children <18
Yes, n (%)	6 (25)	3 (23)	3 (18)
Main diagnosis
Depression, n (%)	20 (83)	12 (92)	7 (41)
Anxiety, n (%)	4 (17)	1 (8)	10 (59)
Treatment
TTM, n (%)	9 (38)	7 (54)	9 (53)
OT as usual, n (%)	15 (62)	6 (46)	8 (47)

^aIn the return-to-work group, one participant worked 50% at the data collection directly after treatment, eight participants worked after 3 months (25%–100%, mean 60%) and all had RTW at 12 months after (25%–100%, mean 72%).

OT as usual: occupational therapy as usual; TTM: tree theme method.

Instrument

The COPM [20] includes a semi-structured interview, in which the participant identifies and describes OPI in his/her everyday life related to three predefined main occupational areas. Each area includes three subareas: self-care (personal care, functional mobility and community management); productivity (paid/unpaid work, household management and play/school); and leisure (quiet recreation, active recreation and socialisation). The project assistants conducted the interviews, made short notes in the COPM questionnaire about the OPI described by the participant and the occupational areas where these were experienced. The participants also assessed the importance of performing each occupation (not included in the present study). The participant then considered which occupations he/she prioritized to change in everyday life (a maximum of five of their described OPI). The participant also rated his/her occupational performance and satisfaction with the occupational performance. Each of these aspects can be rated from 1 to 10 and the higher the ratings the better the occupational performance and satisfaction with the occupational performance. The Swedish version has shown good internal consistency [17] and responsiveness to change [21].

Data analysis

Descriptive statistics were used to describe the characteristics of the participants. The baseline numbers and percentage of participants reporting OPI, the numbers and descriptions of OPI were presented in relation to each occupational area. The participants’ self-ratings of their occupational performance and satisfaction with the occupational performance were described. Medians were described and non-parametric statistics were used for investigating potential differences between the groups (Kruskal Wallis) and within respective group over time (Wilcoxon and Friedman) in relation to each of the occupational areas. The analyses of each occupational area were corrected using Bonferroni adjustment [22] due to the large number of analyses performed. p-Values < 0.05 were considered significant. The SPSS version 25 was used.

Ethical considerations

The participants were informed about the aim of the project, the voluntary nature of their participation, confidentiality and possibility to withdraw. They also had the opportunity to ask questions prior to signing the informed consent. The project was approved by the Regional Ethical Review Board in Linköping, Sweden (2012/232-31 and 2015/12-32) and this study followed the ethical principles of Declaration of Helsinki [23].

Results

Identified OPI at baseline

The participants in all groups identified OPI in all occupational areas. The largest proportion of participants in the SL group reported issues in socialisation, followed by household management. The largest proportion of participants in the RTW group reported issues in socialisation, followed by paid/unpaid work. The largest proportion of participants in the W group reported issues in active recreation followed by socialisation (Table 2). The specific occupations and the type of issues described by the participants varied between the groups (Table 3).

Table 2. Number of participants reporting OPIs, number of occupations reported and percentage of prioritized occupations among these in the COPM* areas at baseline (N = 54).

Occupational area	SL^a (n = 24)	RTW^b (n = 13)	W^c (n = 17)
Self-care
Personal care
Participants reporting, n (%)	16 (67)	5 (39)	10 (59)
Occupations, n	20	5	11
Prioritized occupations (%)	85	100	82
Functional mobility
Participants reporting, n (%)	5 (21)	3 (23)	7 (41)
Occupations, n	5	3	7
Prioritized occupations (%)	80	0	29
Community management
Participants reporting, n (%)	14 (58)	8 (62)	7 (41)
Occupations, n	18	8	8
Prioritized occupations (%)	61	75	50
Productivity
Paid/unpaid work
Participants reporting, n (%)	18 (75)	11 (85)	7 (41)
Occupations, n	22	13	8
Prioritized occupations (%)	77	100	50
Household management
Participants reporting, n (%)	21 (88)	9 (69)	14 (82)
Occupations, n	28	11	20
Prioritized occupations (%)	64	55	80
Play/school
Participants reporting, n (%)	2 (8)	2 (15)	2 (12)
Occupations, n	2	2	3
Prioritized occupations (%)	100	100	50
Leisure
Quiet recreation
Participants reporting, n (%)	12 (50)	10 (77)	9 (53)
Occupations, n	14	13	14
Prioritized occupations (%)	64	62	50
Active recreation
Participants reporting, n (%)	16 (67)	9 (69)	16 (94)
Occupations, n	16	11	19
Prioritized occupations (%)	88	82	90
Socialisation
Participants reporting, n (%)	22 (92)	12 (92)	15 (88)
Occupations, n	25	12	16
Prioritized occupations (%)	88	92	94

COPM, Canadian occupational performance measure.

^aSL group.

^bReturn to work group.

^cWorking group.

Table 3. Prioritized OPIs reported in the occupational areas and the kind of problems related to them as mentioned by one or several participants in the different groups at baseline (N = 54).

Occupational area		Occupations	SL^a	RTW^b	W^c	Occupational area		Problems related to the occupations	SL	RTW	W
Self-care	Personal care	Dressing	X		X	Self-care	Personal care	Lack of energy	X	X
		Food		X	X			Lack of motivation	X
		Getting started in the morning	X		X			Performance (too little or not as wished)	X	X	X
		Hygiene	X	X	X			Physical limitations	X
								Stress			X
	Functional mobility	Walk	X				Functional mobility	Lack of energy		X	X
								Performance (too little or not as wished)	X	X	X
								Physical limitations	X
	Community management	Shopping	X	X			Community management	Economy	X		X
		Transportation	X	X				Initiate		X	X
								Performance (too little or not as wished)	X	X	X
								Stress	X		X
								Worries			X
Productivity	Paid/unpaid work					Productivity	Paid/unpaid work	Lack of energy		X
								Own requirements	X
								Performance (too little or not as wished)	X	X	X
								Tired due to work			X
								Transport to work	X
								Work related demands/stress	X	X	X
								Worries		X
	Household	Baking		X	X		Household	Economy			X
		Cleaning	X	X	X			Lack of energy	X	X	X
		Cooking	X	X	X			Low expectations from others	X
		Homework with child		X				Own requirements		X
		Renovation			X			Performance (too little or not as wished)	X	X	X
		Wash up the dishes	X					Problems concentrating	X
		Washing			X
	Play/school	Fun activities		X			Play/school	Initiate			X
								Lack of energy	X
								Own requirements	X
								Performance (too little or not as wished)		X
Leisure	Quiet recreation	Computer	X	X	X	Leisure	Quiet recreation	Economy	X		X
		Football		X				Lack of energy	X		X
		Needle work	X	X	X			Own requirements			X
		Radio/Television	X		X			Performance (too little or not as wished)	X	X
		Reading	X	X	X			Problems concentrating	X	X
								Problems with memory		X
								Worries			X
	Active recreation	Associations	X				Active recreation	Economy			X
		Dance			X			Initiate	X		X
		Exercise	X	X	X			Lack of energy	X	X	X
		Tennis		X				Lack of motivation			X
		Travel/trips	X	X	X			Own requirements		X
		Walks	X	X	X			Performance (too little or not as wished)	X	X	X
	Socialisation						Socialisation	Lack of energy	X	X	X
								Limited contacts	X	X	X
								Own requirements		X
								Performance (too little or not as wished)	X	X	X
								Time	X		X
								Want/need to restrict contacts	X		X

^aSL group.

^bReturn to work group.

^cWorking group.

Changes in occupational performance and satisfaction with the occupational performance between the groups over time

Statistical analyses of the participants’ ratings of their occupational performance and satisfaction with the occupational performance in the occupational areas revealed few significant differences between the groups (Table 4). OPI related to functional mobility and play/school were described and rated by a too small number of participants for statistical analyses to be carried out. In terms of occupational performance, paid/unpaid work differed significantly between the groups on all occasions. For satisfaction with occupational performance, paid/unpaid work did not differ significantly between the groups directly after occupational therapy but on the other occasions.

Table 4. Performance of prioritized occupations in the occupational areas (COPM-P^V) and satisfaction with the occupational performance (COPM-S^VV) before and after occupational therapy treatment as well as 3 and 12 months afterwards.

Group	COPM-P baseline median	COPM-P after median	COPM-P 3 months median	COPM-P 12 months median	p Value within s amples^a	COPM-S baseline median	COPM-S after median	COPM-S 3 months median	COPM-S 12 months median	p Value within samples^a
	Personal care	Personal care	Personal care	Personal care		Personal care	Personal care	Personal care	Personal care
SL^b (n = 16)	5	5	6	6	1.00	2	4	5	4	1.00
RTW^c (n = 5)	4	6	8	6	1.00	1	5	8	4	0.20
W^d (n = 10)	4	6	7	7	0.02	2	7	8	8	1.00
P value between samples^e	1.00	1.00	1.00	1.00		1.00	1.00	0.68	0.60
	Functional mobility	Functional mobility	Functional mobility	Functional mobility		Functional mobility	Functional mobility	Functional mobility	Functional mobility
SL^b (n = 4)	4	4	3	3	–	3	4	6	4	–
RTW^c (n = 3)	–	–	–	–	–	–	–	–	–	–
W^d (n = 4)	4	9	10	10	–	5	8	10	10	–
	Community management	Community management	Community management	Community management		Community management	Community management	Community management	Community management
SL^b (n = 11)	3	3	4	4	0.28	2	4	3	3	1.00
RTW^c (n = 6)	3	7	7	7	0.05	6	7	8	9	0.81
W^d (n = 4)	5	5	4	7	1.00	3	2	4	7	1.00
P value between samples^e	1.00	0.47	0.32	0.98		0.52	0.18	0.26	0.49
	Paid/unpaid work	Paid/unpaid work	Paid/unpaid work	Paid/unpaid work		Paid/unpaid work	Paid/unpaid work	Paid/unpaid work	Paid/unpaid work
SL^b (n = 17)	1	1	1	3*	0.02	1	1	1	2	0.08
RTW^c (n = 11)	2	2	6	8	<0.01	2	1	4	7	<0.01
W^d (n = 4)	7	8	9	9	0.91	3	8	9	8	0.23
P value between samples^e	0.02	<0.01	<0.01	<0.01		0.04	0.21	0.01	<0.01
	Household	Household	Household	Household		Household	Household	Household	Household
SL^b (n = 18)	3	4	4	5	0.10	2	4	5	5	1.00
RTW^c (n = 6)	4	8	8	9	0.82	3	8	8	9	0.23
W^d (n = 14)	4	7	7	8*	<0.01	4	7	7	8	<0.01
P value between samples^e	1.00	0.67	0.95	0.17		1.00	0.19	1.00	0.34
	Play/school	Play/school	Play/school	Play/school		Play/school	Play/school	Play/school	Play/school
SL^b (n = 2)	3	4	4	3	–	4	4	4	3	–
RTW^c (n = 2)	7	7	8	8	–	4	5	9	8	–
W^d (n = 1)	4	6	6	5	–	4	6	7	5	–
	Quiet recreation	Quiet recreation	Quiet recreation	Quiet recreation		Quiet recreation	Quiet recreation	Quiet recreation	Quiet recreation
SL^b (n = 9)	4	4	4	3	1.00	3	3	3	2	1.00
RTW^c (n = 8)	5	7	7	7	0.62	3	6	7	7	0.41
W^d (n = 7)	3	6	6	6	0.93	4	5*	5	6	0.61
P value between samples^e	1.00	1.00	1.00	1.00		1.00	1.00	1.00	0.90
	Active recreation	Active recreation	Active recreation	Active recreation		Active recreation	Active recreation	Active recreation	Active recreation
SL^b (n = 14)	5	4	4	5	1.00	3	4	4	4	0.42
RTW^c (n = 9)	3	7	7	8	0.09	1	7	7	8	<0.01
W^d (n = 16)	2	5*	5	7	<0.01	2	6*	6	6	0.12
P value between samples^e	1.00	0.28	0.46	0.33		1.00	0.37	1.00	1.00
	Socialisation	Socialisation	Socialisation	Socialisation		Socialisation	Socialisation	Socialisation	Socialisation
SL^b (n = 21)	2	5*	4	6	<0.01	2	4*	3	5	<0.01
RTW^c (n = 12)	4	5	6	7	<0.01	2	4*	5	6	<0.01
W^d (n = 15)	5	6*	7	8	<0.01	4	6	7	8	<0.01
P value between samples^e	0.22	1.00	0.07	0.20		0.17	1.00	0.06	0.28

^aFriedman.

^bSL group.

^cReturn to work group.

^dWorking group.

^eKruskal Wallis.

Bold = Significant changes.

*Sign (0.05) within group (Wilcoxon) in relation to previous measurement. Bonferroni corrections have been conducted in relation to each occupational area.

^VCOPM-P: Canadian occupational performance measure-performance.

^VVCOPM-S: Canadian occupational performance measure-satisfaction with performance.

Changes in occupational performance and satisfaction with occupational performance over time within the respective groups

The SL group significantly increased their occupational performance in the areas of paid/unpaid work. Their satisfaction with their occupational performance increased significantly in socialisation. The RTW group significantly increased their occupational performance in paid/unpaid work and socialisation. Their satisfaction with their occupational performance increased significantly in paid/unpaid work, active recreation and socialisation. The W group significantly increased their occupational performance in the areas of personal care, household, active recreation and socialisation while their satisfaction with their occupational performance increased significantly in household and socialisation.

Discussion

The present study aimed at exploring self-reported OPI and the occupational areas in which they occurred for people living with depression and/or anxiety. Further, the aim was to investigate the participant’s self-rated occupational performance and satisfaction with their occupational performance over time, as well as to investigate potential differences between participants in the three groups (SL/RTW/W). The discussion will follow this order.

Firstly, the participants with depression and/or anxiety disorder in the present study reported issues related to all occupational areas. This result is similar to the findings in our previous study [6], where only the baseline data from all participants in the project were used, as well as to those in studies using the COPM in other populations [10–13]. However, the additional knowledge gained in the present study is the finding that issues were reported in relation to all occupational areas regardless of whether the participant was working or on SL at baseline. The results of the present study also show that a specific OPI could be reported by participants in one or several of the groups. It can be speculated that some of the OPI described can be a cause or a consequence of the current situation. For example, the lack of energy described by participants in all groups may mean something different in relation to active recreation for the participants in each group, respectively, reflecting their different circumstances. A lack of energy may, however, also be caused by depression [24]. Moreover, as the participants in all groups in the present study mentioned issues related to work, they may be suffering from work instability. Work instability is a potentially reversible ‘state in which the consequences of a mismatch between an individual's functional abilities and the demands of his or her job can threaten continuing employment if not resolved’ [25,p.350]. Experiences of work instability in people with depression or anxiety disorder who had worked or had a shorter period of SL have previously been described [26].

Secondly, improved occupational performance and satisfaction with the occupational performance over time were seen in all groups in relation to some occupational areas. There were also similarities and differences between the groups in terms of which occupational areas that had improved. Socialisation was the subarea mentioned as problematic by the largest/second largest proportion of participants in the respective groups. Participants in all groups also increased their ratings for occupational performance in socialisation. The improvement in the socialisation area is seen as an important result in the present study, given that managing social occupations have previously been described as challenging [24]. Some group/groups increased their ratings over time in relation to other areas, while others did not. The RTW group increased both their occupational performance and their satisfaction with the occupational performance in terms of work, which may probably mirror their increased work ability. On the other hand, there is no information about the rationale behind their return to work and whether this coincided with regained work ability, or with other factors such as denied benefits of continued SL [27]. Furthermore, there is no knowledge concerning their perception of their home-related demands in relation to their return to work, something that also can vary between genders [28].

The SL group also increased their ratings of occupational performance for work but from very low levels and the ratings was still low at the end of the study. We have, however, no knowledge about the causes of this improvement, but a study with a qualitative design could well shed some light upon this result. Having an even longer follow-up period than the current 12 months may also have been valuable in this respect. Furthermore, there is little research with this approach of focussing COPM ratings in each occupational area over time. The only identified study [14] concerns young people with physical disabilities participating in a one-year rehabilitation programme, where the population was different but the longitudinal nature of the study was similar to the one in the present study. The participants in that study significantly increased their ratings of occupational performance and satisfaction with the occupational performance in relation to work but not in relation to any other occupational areas [14]. Another finding in the present study was that occupational performance and satisfaction with the occupational performance can increase over time in people living with depression and anxiety disorder regardless of whether they are on SL, returning to work or working. However, the participants in W group increased their ratings significantly in more areas in occupational performance compared to the other groups, four areas (personal care, household, active recreation and socialisation) versus two areas in the RTW and SL groups (work and socialisation). Moreover, the RTW group increased their ratings of their satisfaction with the occupational performance significantly in three occupational areas (work, active recreation and socialisation), the W group in two areas (household and socialisation) while the participants in the SL group only increased in socialisation.

The results also indicate the relevance of occupational therapy, as the higher levels of ratings occurred after occupational therapy treatment, thus supporting the emerging evidence of the benefit of occupational therapy for this group [29,30]. Moreover, the results highlight the value of occupational therapists gaining information about all occupational areas in their clients’ everyday life, regardless of whether they are on SL, returning to work or working. The COPM seems to be a suitable tool for enabling engagement in everyday life [2]. The usefulness of the COPM here also concurs with the results from the previous studies using this instrument [6,10–13], but also from studies of its clinical utility [15,31]. The benefits of a more routine use of the instrument have been emphasized but also that training for this might be needed [31].

Thirdly, the results revealed a few group differences in the ratings of occupational performance and satisfaction with the occupational performance. The W group rated a significantly higher level of occupational performance for work on all four occasions and greater satisfaction with the occupational performance on all occasions except directly after the intervention. The W group’s high ratings at baseline may be the reason why there were no significant increases in this area. The very low number of participants reporting OPI in relation to work in the W group should also be noted. The differences in ratings between the RTW and the W groups related to the occupational area, work was greater at baseline and after treatment than at 3 and 12 months, which coincides with the fact that more and more of the RTW participants had RTW on these latter occasions. The SL group, however, also significantly increased their occupational performance in relation to work but their ratings were consistently much lower than the ratings for the other groups. This finding of the SL group’s consistently lower ratings in relation to most occupational areas (although not always significant) may be an indication of the differences between the groups that can affect their work ability, further studies are thus needed to gain more in-depth knowledge about this.

Methodological considerations

The present study has strengths as well as limitations that need to be taken into consideration. The strengths include the study’s occupational focus and longitudinal design, both of which are relevant considering its aim. Using the COPM [9] was also appropriate as the instrument provides information about OPI, as experienced by participants living with depression or anxiety, in relation to the occupational areas and this strengthens the internal validity of the study. The instrument has also been found to be responsive to change [21], and the fact that all the project assistants were trained and validated is a further strength of the study. The study’s occupational focus, however, also entails a limitation, as ratings of medical circumstances such as medications, somatic disorder, as well as the level of severity of depression and anxiety were not followed longitudinally. Neither was information about the length of their diagnoses collected, which is a limitation. Moreover, combining the COPM with measures of well-being might also have provided a broader picture of the participants’ situation, and further studies related to this are warranted. Furthermore, it should be considered as a limitation that the sample was small and that no power calculation was conducted for these participants. However, several medians of the occupational areas changed two or more steps in the COPM during the year, indicating clinical relevance [20] and further studies in larger samples would be valuable.

It should also be recognized that the descriptions of OPI gathered via the COPM are very limited in comparison to the results that could be gained by the use of a qualitative interview study focussing on this. Finally, more in-depth information about events of importance in the participants’ everyday lives over time, such as why the participants in the RTW group RTW when they did as well as length of the participants’ SL would have been valuable. This type of data was, however, not collected.

Conclusion

The participants in all groups reported OPIs related to all occupational areas in the COPM prior to occupational therapy. Socialisation was a highly affected area in all groups but was also the occupational area where all groups significantly improved their occupational performance and satisfaction with their occupational performance. All groups also improved in some other occupational area. Further studies with larger samples are needed but this study indicates that people living with depression and anxiety may need and benefit from occupational therapy regardless of whether they were on SL, returning to work or working.

Ethical approval

The project has received approval from the Regional Ethical Review Board in Linköping, Sweden (Reg. Nos. 2012/232-31 and 2015/12-32).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The present study received funding from the AFA Insurance. The main project received financial support from the Kronoberg County Health Authority, Southern HealthCare Region and the Medical Research Council of Southeast Sweden.