HEALTH POLICY
The Role of Occupational Therapy in the
Management of Depression
This document was prepared at the
request of the Depression Panel of
the Office of the Forum for Quality
and Effectiveness in Health Care
within the Agency for Health Care
Policy and Research, an agency of
the us. Public Health Seroice. The
panel was charged to develop clini-
cal practice gUidelines for the
management of depression to be
used by general medical and fam-
ily medicine pl'actitioners in pri-
mary care settings. The form of the
panel's questions shaped the intro-
ductory portion of the document.
After receiving the questions posed
by the panel (which are stated lat-
er in this document), it was neces-
sary to define the context of the use
of occupation and occupational
therapy to broaden the panel's un-
derstanding of these terms.
A
though in the United States, oc-
cupational therapy had its roots
in psychiatry, beginning with the
Moral Treatment era of the early 1800s
(Hopkins, 1988), a cluster of outcome
studies relating to the effect of occupa-
tional therapy on the treatment of de-
pression has been reported in the litera-
ture just within the past 10 years (see
Table 1).
Reference to occupation in the title
is in the context of goal-directed use of
time, energy, interest, and attention
(American Occupational Therapy Associ-
ation [AOTA], 1972) to foster adapta-
tion and productivity, to minimize pa-
thology, and to promote the
maintenance of health:
Occupational therapists work in a
broad range of practice areas and set-
tings. Within the scope of general psy-
chiatry, services are provided to chil-
dren, adolescents, adults and elderly of
The American Journal oj Occupational Therapy
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Elizabeth Devereaux,
Michael Carlson
Elizabeth Devereaux, M5W. ACS'J//L OTR/L,
FAOTA, is Associate Professor, Depart-
ment of Psychiatly, Marshall University
School of Medicine, 1801 Sixtb Avenue,
Huntington, West Virginia 25755-9460
Michael Carlson, PhD, is Research Assis-
tant Professor, Department of Occupa-
tional Tberapy, University of Soutbern
California, Los Angeles, California.
This article was accepted for publication
September 15, 1991
all functional levels and diagnostic cate-
gories, in institutional, communiry-
based, partial hospitalization, residen-
tial treatment and forensic programs.
These programs are offered in general
and psychiatric hospitals, nursing
homes, psychosocial and physical reha-
bilitation centers, sheltered workshops,
clinics, public and private schools,
group homes, correctional institutions,
home health agencies, community
mental health centers, day care cemers,
private practice, physician's [sic I of-
fices, as well as industry and business.
(Fine, 1983, p. 1)
Depression does take its toll on oc-
cupation - in fact, the condition is char-
acterized by changes in capacities to en-
gage in goal-directed use of time,
energy, interest, and attention. Addi-
tionally, occupation, in its broadest con-
text, is precisely that: the goal-directed
use of time, energy, interest, and atten-
tion. However, occupation that is rel-
evant and appropriate to a given per-
son's capacities and needs may also
serve to alter his or her mood by cap-
turing interest, focusing attention, creat-
ing a meaningful time structure, dim in-
ishi.1g helplessness, establishing a sense
of effectiveness and personal control,
and meeting a range of cultural and
social-interpersonal needs. Similarly, ac-
tivities and environmental contexts that
are unduly stressful can diminish cogni-
tive and social-interpersonal capacities,
diminish personal effectiveness and
control, and provoke or exacerbate de-
pression. Work may meaningfully har-
ness the energies of a person despairing
over a broken marriage, while it may in-
undate another person confronting the
long-term prospects of a chronic illness.
Occupation needs to be understood in
the broader context of life roles and ac-
tivities. Employment is but one of a
range of such activities that characterize
and define human existence. Leisure
time; parenting; home management;
self-care; and educational, volunteer,
and social activities all playa potentially
important role in defining the quality,
pattern, and substance of a person's
inner and public lives. These activities
require and contribute to the goal-
directed use of time, energy, interest,
and attention (S. B. Fine, personal com-
munication, December 11, 1990).
For example, a person whose life
roles include those of wife, mother,
daughter, and chemical engineer might
have performance deficits different than
those of a person whose life roles en-
compass those of wife, student, and
part-time phlebotomist, though both
are experiencing severe depression. The
overall treatment goals would be similar
for both (namely, to overcome those
performance deficits, perhaps through
adaptation or through learning new
skills), but the treatment plans would
be individualized in ways meaningful to
each person. The focus of treatment for
the first person, for example, might be
time management; for the second per-
son, skill development.
175
 Table 1
Summary of Research Studies Relevant to the Treatment of Depression Symptomatology in Occupational Therapy
Author Study Population Type of Design Treatment Group" Outcome Variable Findings (Effect Size)h
Dc Carlo & Mann Psychiatric day treat- Pretest-posllest con- Activi~y group Interpersonal com- Activity treatment
(1985) mem cemer c1iems, trol group experi- (n=7): munication skills produced signifi-
including persons mental design Engagement in (based on the Inter- cantly higher in-
with schizophrenia meaningful group personal Communi- creases in skills
and depression activities. cation Inventory) than did the verbal
(ages 26-64 years) Verbal group (n = 6): treatment (+ 1.3).
Engagement in Activity treatment
group discussions. produced nonsigni-
Control group ficantly higher in-
(n =6): crements in skills
Participation in the than did the control
clinics normal mi- condition (+ 0.8).
lieu therapy.

Fine (1988) Adult psychiatric in- Experimental two- Life skills cumcu- Problem-solving Preliminary results
patients, short-lerm group design lum: Educational skills; communica- suggest sustained
acute care selling, social-learning ap- tion skills; commu- improvement in
with bipolar or ma- proach to skill ac- nityadjustment problem-solving
jor depressive affec- quisition designed and communication
tive disorders (ages to enhance commu- skills at conclusion
18-55 years) nity adjustment of treatment. Func-
Standard occupa- tional gains general-
lional therapy ly sustained in spite
of significant in-
crease in depressive
symptoms at 6-
week follow-up. All
results based on
small initial sample
(n=5).

Gangl (1987) Chemically depend- Single-group pretest- Open occupational General, interperson- Over time, improve-
ent and emotionally posllest design therapy treatment al, and work behav- ment was noted in
disturbed adoles- centering on work iors (based on the general behavior
cents at a residen- skills and/or rela- Jamestown Occupa- ( + 0.5), interper-
tial treatment cen- tionship skillS tional Therapy sonal behavior
ter (ages 13-14 (n = 33) Assessment) ( + 0.8), and work
years) behavior (+ 0.6).
(Effect size esti-
mates are based on
mean change scores
divided by change
score standard
deviations.)

Good-Ellis, Fine, Recently admilled in- Single-group pretest- Occupational ther- Role performance Unipolar and bipolar
Haas, Spencer, & patients with major posllest design apy services, based (based on the Role groups demonstrat-
Glick (1986) affective disorders, on the occupational Activity Perform- ed different pat-
including unipolar behavior model, ance Scale) terns of recovery.
and bipolar disor- featuring emphasis Trajectory of im-
ders (ages 15-45 on activities of daily provement during
years) living, goal selling, 6-18 month period
future planning, showed social and
recreation, and pre- leisure role im-
vocational services provement preced-
(in conjunction with ing work, school,
standard hospital and other primary
treatment with em- roles.
phasis on family in- At both 6 months
tervention) (n = 50) and 18 months
follow-up, more
subjects improved
than worsened in
their role activity
performance (re-
spective effect size
estimates = + 0.1
and +0.4).

176 February 1992. Volume 46, Numher 2

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 Table 1
(Continued)
Author Study Porulation Type of Design Treatment Grour" Outcome Variable findings (Effect Size)o

Kielhofner & Brin- Hospitalized psychi- Randomized posttesl- Treatment [?I"Qup Recidivism; the KatZ Suhjects in the ex-
son (1989) atric ratients with only experimental (n=20): Adjustment Scales; perimental group
at least 6 months of design Small group ses- The Occurational were nonsignificant-
rsychiatric history sions with struc- Questionnaire (a Iy less likely to
and 2 or more hos- tured objectives and daily activity experience rehospi-
pitalizations (ages activitic, related to assessment) talization following
25-40 years) skills, roles, leisure discharge (+ 0.5).
Control group Katz scores were
(n = 14) nonsignificantly dif-
ferent between
groups ( + 0.0).
On the Occupational
Questionnaire. ex-
perimental subjeers
had a nonsignifi-
cantil' higher mean
for the amount of
work than did con-
trol subjects
( +06)

Kremer, Nelson, & Chronic rsychiatric Randomized posuest- Cookinft (n = 9): Rated evaluation, Participation in cook-
Duncombe (19H4) patients (mainly only experimental Engagement in power. and action ing produced high-
schil.Ophrenics) design cookie making with of the activitv er evaluation ratings
rarticipating in a group (based on Osgood's than either craft or
day treatment pro- Crali (n=H) Semantic Differen- ~cnsory awareness
gram (average age Participation in col- tial Scale) following (+ 1.7) activities
49.6 years) lage making participation in the Engagement in cook-
Sensol)' awareness activjt~' ing led to nonsigni-
(n = S): ficantl)' lower ra!-
Participation in ings of power than
group senson' exer- did craft or sensory
cises and awareness (-0.5).
movements Action rallngs did
not meaningfully
differ among the
three activities.

Stein & Smith (19H9) Acutely depressed Single-group pretest- Occupational/hera- S-Anxiety Scale of the Subjects were signifi-
rsychiatric inpa- posw:st design p)'-hased stress State-Trait Anxietv cantly less anxious
tients (ages 20-45 marzaRement train- InventorY al the conclusiun of
years) ing. including the program than
group discussion. they were prior to
biofeedhack, relax- its initiation (+ 0.8).
'Hion training, be-
havioral rehearsal,
and attention to
evel)/cby Stressors
and activities useful
in controlling stress
en =7)
"The occupational therapy groups are underlined within each studv. °Positive effcet sil.e estimates reOeet a heneficial treatment effect, where relevant.
Effcct size estimat<:~ arc ha~ed on the d statistic and arc corrected for sample size bias (Glass. ;VkGaw. & Smith. 1981).

In their study of depressed women,
Weissman and Paykel (1974) found that
despite the social impairments and ac-
companying discomforts of acutely de-
pressed patients, a reasonable number
of these women continued to work dur-
ing the acute episode. Within this group
of subjects, women who worked outside
the home showed less impairment than
housewives. The authors noted that
though these differences could be relat-
ed to the tendency of the most im-
paired patients to give ur work, the
findings suggested that a job outside
the home has a rrmective effect.
Of particular importance for occu-
pational therapy intervention is the find-
ing that many depressed patients have
persistent symproms and psychosocial
and occupational impairment even after
recovery from an acutc episode (Dever-
eaux, 1986; Keller et aI., 1982). Follow-
ing the remission of depressive symp-
toms, the person may experience up ro
a 6-month time lag in returning to a pri-
m level of social functioning (Dever-
eaux, 1986). Several studies have shown
that rharmacotherary is effecrive in
controlling many of thc symptoms of
derression but has little or no influence
on the adaptive skills required fm living
in the community (Blackburn, 1983;
Murphy, Simons, Wetzel, & Lustman,
[984; Rush, Beck, Kovacs, Weissen-
burger, & Hollon, 1982). A study hy
Neville-Jan (1987) revealed the presence

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 of high correlations between adaptive
occupational behavior (as is promoted
by occupational therapy) and important
volitional variables (internal locus of
control, experiencing pleasure in daily
activities, and planning and organizing
future events) among persons with
moderate and severe levels of depres-
sion. Further investigation is warranted
related to the effect of occupational
therapy treatment in addressing these
concerns, which may lead to or main-
tain paid employment.
Method for Obtaining Studies
The primary purpose of this report was
to review research related to the effect
of occupational therapy in the treat-
ment of depression. The first screen of
the literature search focused on re-
search related to occupational therapy,
affective disorders, and efficacy and out-
come studies. The second screen
changed affective disorders to depres-
sion and was limited to those research
articles published within the past 10
years.
The following resources were used
in conducting the literature search:
• The Wilma L. West Library, spon-
sored by the American Occupa-
tional Therapy Foundation
(AOTF) and AOTA, has a com-
puterized database and compre-
hensive collection of occupation-
al therapy literature, known as
OT BibSys, which currently con-
tains approximately 15,000
records.
• Medline, the computerized listing
from the Index Medicus at the
National Library of Medicine.
• Selected lists of research grants
awarded by AOTF in the field of
menta] health between 1979 and
1988.
• A set of articles collected by
AOTA staff as well as by experts
in the field of occupational
therapy.
• The Psychological Abstracts Infor-
mation Service of the American
Psychological Association.
• A collection of 162 abstracts pub-
lished in Occupational Therapy
and Mental Health (Ostrow &
Kaplan, 1987).
• Nursing and allied health biblio-
178
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graphic databases covering the
past 10 years.
The first author retrieved and re-
viewed 53 articles and 3 graduate theses
from the 88 citations that were
screened, recommendations of experts
in the field, and the 162 abstracts re-
viewed. Of these, 7 studies were select-
ed for analysis (see Table 1). Due to the
contamination of some subject groups
with diagnoses other than depression
(e.g., schizophrenia) and the paucity of
occupational therapy outcome studies
reported in the literature, some of the
research studies selected for analysis in-
cluded subjects with conditions other
than depression.
Assessment of Evidence
Table 1 provides a summary of research
studies that assess the effect of occupa-
tional therapy on the functioning of per-
sons with affective or emotional disor-
ders. Within this set of studies, the
quality of research design varies greatly,
ranging from relatively weak single-
group designs (Campbell & Stanley,
1966) to a randomized experiment fea-
turing pretesting, posttesting, and a
control group. Table 1 includes a wide
array of treatment methods and out-
come assessments. The outcome mea-
sures, which reflect constructs such as
anxiety (Stein & Smith, 1989), activity
evaluations (Kremer, Nelson, & Dun-
combe, 1984), interpersonal skills (De-
Carlo & Mann, 1985; Fine, 1988; Gangl,
1987), and role performance (Good-
Ellis, Fine, Haas, Spencer, & Glick,
1986), in each case playa potentially
important role in the facilitation of life
adjustment.
The last column of Table 1 lists the
major relevant findings within each
study along with associated effect sizes,
when relevant, that correspond to the
magnitude of the treatment effect. In
most instances, the data reveal a posi-
tive outcome associated with occupa-
tional therapy, with the central tenden-
cy for effect size (M = t.58, medium =
0.6) falling within the range of what Co-
hen (1977) described as an average de-
gree of effect. The tendency toward
positive effect sizes is fairly consistent,
despite obvious fluctuations in the types
of subjects studied, the characteristics
of the underlying treatment programs,
design features, and outcome assess-
ments. When a single mean effect size is
calculated for each study, the combined
positive outcome is highly significant
(Stauffer Z = 3.37, P < .001). Due to
the inclusion of unpublished studies as
well as published studies that featured a
nonsignificant result, it is unlikely that
publication bias can account for the
overall result. Additionally, the calculat-
ed fail-safe N(23) , which represents the
number of unreported studies with ef-
fect sizes of a that would need to exist
in order to overturn the overall positive
result of Table 1, seems acceptably high,
given the paucity of research on the
topic. Thus, these data tentatively sug-
gest that occupational therapy is associ-
ated with life, functional performance,
and work-relevant skills and behaviors
among psychiatric patients, including
patients with depression. Interpretive
caution is warranted, however, due to
the incomparability of the studies, the
weakness of many of the underlying de-
signs, the nonstandard nature of several
of the derived effect-size estimates, and
the inclusion of nondepressed patients
in some of the samples (see Table 1).
Questions Posed by the Agency
for Health Care Policy and
Research Depression Panel
The first question posed was, "What is
the evidence that depression takes its
toll on occupation, or what kind of toll?"
The diagnostic criteria that indicate
difficulties in doing one's customary oc-
cupations are selected from the Diag-
nostic and Statistical Manual of Men-
tal Disorders (3rd ed., rev.) (American
Psychiatric Association, 1987). Symp-
toms that are expressed while a person
is performing an activity are the factors
that are apt to take a toll on occupations.
Major depressive episode is charac-
terized by the following symptoms
(Note. Symptom No.3 was excluded
from this list):
1. Depressed mood.
2. Markedly diminished interest or
pleasure in all, or almost all, ac-
tivities most of the day, nearly
every day.
4. Hypersomnia nearly every day.
5. Psychomotor agitation or retar-
dation nearly every day.
6. Fatigue or loss of energy nearly
every day.
February 1992, Volume 46, Number 2
 7. Feelings of worthlessness or ex-
cessive or inappropriate guilt.
8. Diminished ability to think or
concentrate or indecisiveness.
DysthymiC disorder is character-
ized by the following symptoms:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty
making decisions.
6. Feelings of hopelessness.
Melancholia is characterized by
the follOWing symptoms:
1. Loss of interest or pleasure in
all, or almost all, actiVities.
2. Lack of reactivity to usually
pleasurable stimuli.
3. Depression regularly worse in
the morning.
4. Early morning awakening.
'5. Psychomotor retardation or agi-
tation. (c. K. Allen, personal
communication, December 13,
1990)
The second question posed was,
"Given an unemployed patient, what is
the evidence that getting a depressed
person employment (even in a shel-
tered workshop) does anything good
for depression, in the shon or long
run?"
If this question is asked within the
context of the medical model, there is
little to no evidence that work by itself
will have much effect on the diagnostic
criteria cited above. In this paper, we
do not claim that the value of occupa-
tion is curative in the medical model
view of treatment effectiveness. The val-
ue of occupations vary according to the
changing medical condition of the de-
pression. During an acute episode, oc-
cupations can be used to measure a re-
duction in those symptoms expressed
while a person is doing an activity. The
reduction in symptoms is associated
with psychopharmacological effects but
is not necessarily causal. Ideally, all
symptoms of depression would he re-
lieved by medical treatment.
When residual symptoms remain, a
totally different view of change is re-
qUired and was best expressed by the
World Health Organization in the Inter-
national Class~fication of Impairments,
Disabilities and Handicaps (ICIDH)
The American .Journal of Occupational Therapv
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(World Health Organization, 1980).
ICIDH is driven by the consequences of
health problems that are shared by
many different diagnostic categories
(eg., being in a wheelchair). ICIDH is
helpful in determining the rehabilitation
and social welfare needs of persons who
have residual limitations. Within the
ICIDH model, occupations elicit the
person's remaining abilities within the
least restrictive environment.
Guidelines for the skilled use of oc-
cupations in the treatment of the con-
tinuum of depression are suggested as
those used by Blue Cross of California.
Although use of this classification sys-
tem is not mandatory, its use will assist
the proVider through the provision of a
recognized nomenclature to describe
the need for skilled therapy services
(c. K. Allen, personal communication,
December 13, 1990).
Research Issues
Although occupational therapy services
are Widely recognized under federal and
state statutes as an appropriate and ef-
fective component in the treatment of
psychiatric disorders in both institution-
al and community-based settings, there
exists no broad base of research attest-
ing to its efficacy with this population. A
major reason for this situation lies in
the historical absence of federal suppon
for basic research initiatives in this area,
specifically through the program of
mental health research grants autho-
rized by Title III of the Public Health
Service Act and administered by the Na-
tional Institute of Mental Health. In light
of the critical need for additional effica-
cy data relative to occupational therapy,
the research grant program of the Na-
tional Institute of Mental Health should
be modified to facilitate increased sup-
pon for focused research on selected
occupational therapy interventions with
psychiatric patients (F. Somers, person-
al communication, November 23, 1990).
Of the seven studies reponed in Table
1, three were rotally or partially funded
by AOTA and AOTF; these three studies
combined cost less than $1 '5,000. Clear-
ly, much larger funding amounts are
necessary in order to conduct sufficient-
ly rigorous outcome studies, which we
believe are sorely needed.
Collaborative multidiSCiplinary stud-
ies are indicated. These studies should
incorporate various occupational ther-
apy protocols with various psychothera-
py protocols, with and without pharma-
cotherapy for all subjects, depending on
the level of severity of depression in the
subjeCts involved, to determine what
combinations of treatments produce the
best outcome.
Additional areas for research would
include, but are certainly not limited to,
the following:
• The concept of rehabilitation po-
tential for persons with intracta-
ble depression.
• Supportive employment.
• Episodic and interepisodic longi-
tudinal studies of patterns of
function. Did the strengthening
of skills insulate depressed per-
sons from the symptoms of
depression?
• Randomized, controlled trials
that screen for likeness, are of
sufficient size, and use assess-
ment instruments Widely accept-
ed among depression research-
ers (e.g., the Hamilton
Depression Rating Scale, the Re-
search Diagnostic Criteria, the
Zung Self-rating Depression
Scale, the Beck Depression In-
ventOlY) enhance the usefulness
of the research being reported
(Devereaux, 1986). A good de-
sign would include appropriate
protocols and training for their
use as well as interrater
reliability.
Summary
In summary. a good deal of theoretical
and empirical work supportS the notion
that occupational engagement is associ-
ated with a reduction in depressive
symptoms. Because of its explicit focus
on roles, behaViors, and adaptive skills,
occupational therapy can playa key role
in the treatment of depression. Out-
come studies are needed that indicate
when, during the depressive episode, or
interepisode, occupational therapy in-
tervention is most effective, along with
the study of variables, such as types of
interventions and with what age groups.
Occupational therapists are moving
funher toward practice policy and are
drafting gUidelines toward this effon.
These are done by therapists who cre-
179
 ate, develop, test, and implement clini-
cal guidelines .•
Acknowledgments
We thank the following persons for reviewing
this report: Claudia Allen, MA. OTR. rAoTA;
Belle Bonder, PhD. OTI\II.. FAOTA; Virginia
Dickie, MS. OTR; Susan B Fine, MA. OTR. FAOT,\;
Mary Foto, OTI{. FAOTA; Nelha Gillcue, MEJ,
om. f,\OT,\; Sarah Henfelder. MEd. MOT OTR;
Stephanie Hoover, EdD. OTR, r,\OT,\; Ann
Neville-Jan, PhD. 01R FAOTA; Kathy Kannen-
berg, ~u\, OTR; Kathy L Kaplan, MA, OTR; Fran-
ccs Palmer, MS. om; and Fred Somers.
References
American Occupational Therapy Associ-
ation. Council on Standards and Executive
Board. (1972). Occupational therapy: Its defi-
nitions and functions. American jounwl o(
Occupational Tbempy, 26. 204-205
American Psychiatric A>sociation. (1987).
Diagnostic and statistical manual of men-
tal disorders (3rd ed., rev.) Washington. DC:
Blackburn, l. (1983). Changes in cogni-
tion with pharmacotherapy and cognitive
therapy. En'tisb jow'nal of Psycbiatry. 143.
609-617.
Campbell. D. T, & Stanley, J C: (1966).
E\perimental and quasi-experimental de-
signs(or researcb. Chicago: Rand McNally.
Cohen,j. (1977). Statistical power anal-
ysis(or the bebavioral sciences (rev. ed.).
New York: Academic Press.
DeCarlo. J J. & Mann, W C: (1985).
The effectiveness of verbal versus activity
groups in improving self-perceptions of inter-
personal communication skills. American
Journal of Occupational Tberapy, 39, 20-
27
Devereaux, E. (1986). Current issues in
the assessment and treatment of depression.
In Depression assessment and treatment up-
date. proceedings (pp. 2-13). Rockville. MD:
American Occupational Therapy Association.
Fine, S. 13. (1983) Occupational ther-
180
Downloaded From: http://ajot.aota.org/ on 03/22/2017 Terms of Use: http://AOTA.org/terms
apl': The role o( rehabilitation and pUipose-
Jid activily in mental beallb practice.
American Occupational Therapy Association
White Paper. 1-11 [Official document1,
Fine, S. B. (1988). Eualuating tbe im-
pact of occupational therapy with affective
disorders Paper presented at the 68th Annu-
al Conference of the American Occupational
Therapy Association. PhoenLx.
Gangl, M. L. (1987). The effectiveness of
an occupational therapy program fOl' chemi-
cally dependent adolescents. Occupational
Therapy in Mental Healtb, 7, 67-B8.
Glass. G. V. McGaw, B, & Smith, M. L
(1981). Meta-analysis in social research.
Beverly Hills, CA: Sage.
Good-Ellis, M., Fine, S. B.. Haas, G L,
Spencer, J H, & Glick, I. D. (1986). Quanti-
tative role and performance assessment: Im-
plications and application to treatment of
major affective disorders. In Depression as-
sessment and treatment update, proceed-
ings (pp. 26-48). Rockville, MD: American
Occupational Therapy Association
Hopkins, H. L. (1988). An historical per-
spective on occupational therapy. In H, L
Hopkins & H. D Smith (Eds.), Willard and
Spackman's occupational therapy Oth ed"
pp. 16-37) Philadelphia: Lippincott.
Keller, M. 13., Klerman, G. L, Lavori, P w.,
Fawcett, J, Coryell, W., & Endicott, J (191:)2)
Treatment received by depressed patients.
]oumal o( the American Medical Associ-
ation, 248. 1848-IH55.
Kielhofner, G., & Brinson. M. (1989).
Dcvelopment and evaluation of an aftercare
program for young chronic psychiatrically
disabled adults. Occupational Therapy in
:vlental Heallb, 9. 1-25.
Kreme'-, E. R H, Nelson. D. L, & Dun-
combe. L. W (1984). Effects of selected ac-
tivities on affective meaning in psychiatric pa-
tients. American journal of Occupational
Therapy, 38, 522-528.
Murphy, G. E., Simons, A D., Wetzel,
RD., & Lustman, P. .J. (1984). Cognitivc ther-
apy and pharmacotherapy: Singly and togeth-
er in the treatment of depression. Archives
of Geneml Psycbial1y, 4/, 33-41.
Neville-Jan, A. M, (1987). Tbe relation-
shljJ of locus of control, future time perspec-
live and interest 10 productiuity among in-
diuiduals witb llmying degrees of
depression. Unpublished doctoral dissena-
tion, New York University, New Yurk.
Ostrow, P C, & Kaplan, K. L (Eds.).
(1987). Occupational thempy in mental
beallb. A guide to outcomes researcb. Rock-
ville, MD: American Occupational Thecapy
Association.
Rush, A J, Beck, A. T, Kovacs, M., Weis-
senburger, J. & Hollon, S. D. (1982). Com-
parison of the effects of cognitive therapy
and pharmacotherapy in hopelessness and
self-concept. American journal of Psychia-
l1y. /39. 862-866.
Stein, F., & Smith,]. (1989). Short-term
stress management programme with acutely
depressed in-patients. Canadianjounwl of
Occupational Therapy, 56, 185-191.
Weissman, lvI., & Paykel, E. (1974). The
depressed woman: A study 0/ social rela-
tions. Chicago: Univcrsity of Chicago Press.
world Health Organization. (1980). /n-
ternational classijication of impairment,~
disabilities and bandicaps: A manualo(
classi(ications relating /0 tbe consequences
q( disease. Geneva: Author.
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Pebruary /992. Volume 46, Numher 2