Depression screening by physical therapists: Practices,beliefs,barriers

Abstract

BACKGROUND:

Depression, a common comorbidity encountered in physical therapy (PT) practice, negatively impacts outcomes. There is limited knowledge of PT practice patterns relative to screening for depression.

OBJECTIVE:

Objectives were to describe beliefs regarding depression, and identify practice patterns and perceived barriers regarding screening for depression among APTA Board Certified Orthopedic Clinical Specialist (OCS) PTs.

METHODS:

Surveys were distributed to all PT OCSs in the US; 416 responses were analyzed. Descriptive, univariate and multiple regression analyses were performed.

RESULTS:

Ninety-five percent of respondents believed that depression has a moderate to high influence on PT outcomes, whereas 68% believed a pre-existing diagnosis of depression influences the plan of care. Most believed that 20% or more of their current patients presented with symptoms of depression. Nevertheless, only 18% formally screen for depression during the initial evaluation. Those with formal depression screening education were 2.3 times more likely to screen at initial examination. Common barriers to screening included lack of department policy, limited knowledge and lack of follow-up resources.

CONCLUSIONS:

Formal screening did not occur as frequently as expected, given the belief regarding depression’s impact on plan of care and outcomes. Addressing barriers may assist in greater compliance with recommended screening guidelines.

Keywords

Physical therapy physical therapists depression screening beliefs barriers

1. Introduction

Major Depressive Disorder (MDD), characterized by a decreased interest in activities, sadness, and anxiety lasting more than 2 weeks, is one of the most prevalent mental disorders in the United States [1]. Depression affects people of all ages, genders, races, socioeconomic classes, and medical diagnoses [1]. It is costly, chronic, and undiagnosed 35–50% of the time [2, 3]. Without appropriate screening and treatment, depression is expected to become the second leading cause of disability worldwide by 2020 [2, 3].

MDD is associated with increased morbidity [4] and mortality, decreased quality of life, increased health care utilization [4, 5] and poorer treatment outcomes [4, 5, 6]. It is also associated with increased pain intensity, physical and psychosocial disability, medication use and likelihood of unemployment [7]. Depression often presents with other illnesses that may precede, cause, or occur as a consequence of it [8]. The concomitant presentation of depression and other medical disorders result in the amplification of somatic symptomatology [9].

With the advent of direct access, physical therapists (PTs) often become the primary care practitioner for patients with neuromusculoskeletal conditions, and are therefore responsible for the identification of comorbidities, including MDD, that may have an impact on a patient’s plan of care, prognosis and/or treatment outcomes. The prevalence of depression in the general outpatient physical therapy population was estimated to be between 25 and 50% of patients referred to physical therapy for musculoskeletal conditions [10, 11]. It has been estimated that 40% of patients with low back pain [10], 40–80% of those with fibromyalgia [12] and 33% of those with chronic pain [13] have depression. MDD is also a prevalent co-morbidity in conditions that are not musculoskeletal in nature, but are often seen in the outpatient setting. These include stroke (30–55%) [14], cancer (50%) [15], HIV (22%) [16], traumatic brain injury (46%) [17], chronic migraines (17.6%) [18] and multiple sclerosis (19–54%) [19].

Across physical therapy settings, depressive symptoms have been associated with pain intensity [20], functional limitations [21, 22], disability [20, 5, 21, 23], and negative rehabilitation outcomes [21, 22, 23, 24]. In addition, the reduction of depressive symptoms has been strongly associated with decreased pain intensity [23]. The early recognition and alleviation of depression has been shown to improve self-reported functional status and physical therapy outcomes [23], as well as the outcome of the concurrent illness [9].

Several organizations have provided recommendations related to screening for depression. For example, the United Kingdom’s National Institute for Care and Excellence Guidelines (NICE) [25] recommend that practitioners be alert for signs of depression in persons with a past history of depression or a chronic physical problem with associated physical impairment. In addition, the United States Preventive Services Task Force (USPSTF) [26] recommends screening all adults and adolescents (ages 12–18) for depression regardless of the presence of risk factors. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. In relation to physical therapists screening for depression in persons with low back pain, the Low Back Pain Clinical Practice Guideline specifically identifies screening for depression by physical therapists as a key component to the overall evaluation and plan of care [27].

Contrary to conventional wisdom, simple observation of patient behavior is an inaccurate way to detect depression [28]. Even when faced with severe cases of depression, physical therapists were not able to identify depressed patients as accurately as a 2-item test which asked “During the past month have you been bothered by feeling down, depressed or hopeless?” and “During the past month have you been bothered by little interest or pleasure in doing things?” [10]. Numerous authors have therefore advocated for this short, user-friendly validated instrument [29] for PTs to screen patients for depression [10, 30, 5, 6, 20].

These findings suggest a need to investigate and identify current clinical practices related to screening for depression by PTs. The aim of this study was therefore to benchmark the role of American Board of Physical Therapy Specialists Orthopedic Clinical Specialists (OCSs) in screening patients for depression: specifically, to describe their 1) demographic characteristics in relation to their practice of screening for depression; 2) methods and practice patterns of those who screen for depression; 3) beliefs regarding depression and its’ influence on patient outcomes; 4) characteristics that predict the likelihood of screening for depression; and 5) perceived barriers to screening for depression.

2. Methods

A survey was developed to collect data on respondents’ demographic characteristics, and beliefs and practice patterns related to the screening and management of depression. The demographic component of the survey was based in part on the American Physical Therapy Association’s (APTA’s) Employment Survey [31]. Survey questions were reviewed by three Rutgers University Rehabilitation and Movements Sciences faculty members who were familiar with orthopedic physical therapy practice. Modifications were made based on their feedback. The final survey contained between 16 and 29 questions. Subjects were directed to different sets of questions, based on their response to prior questions; thus the total number of questions administered to respondents varied. Some questions contained options for open-ended answers. When feasible, these open-ended answers were incorporated into closed-ended responses or evaluated as separate categories. For example, if a respondent commented that s/he used the Beck Depression Inventory to screen for depression during the initial examination, but did not check off that box in the closed-ended response section, that respondent was categorized as using this tool to screen for depression at initial examination.

Because of their advanced training and knowledge and the required demonstration of continued clinical competency, we surveyed APTA’s Board Certified OCS PTs. We thereby restricted our sample to subjects who were likely to utilize examination and intervention strategies consistent with good clinical practice.

This study was approved by the Rutgers University School of Biomedical Health Sciences Institutional Review Board. Completion and return of the survey constituted informed consent. Surveys were sent via SurveyMonkey between December 4, 2013 and February 3, 2014 to all 2248 physical therapists listed as having Orthopedic Clinical Specialty certification with the APTA as of August 2013. Three reminders to complete the survey were sent. Responses returned by February 10, 2014 were retained for analyses.

Survey results were entered into a database and analyzed using SAS 9.3. Descriptive statistics were reported by means and percentages, whereas inferential statistics were calculated using ANOVA and Chi Square analyses.

Table 1
Demographic characteristics

Variable ( $n$ )	Mean or percent
	(95% CI)
Demographics
Age (413)	44.0 years
	(43.0, 44.9)
Gender (406)
Male	56.6% (51.8, 61.5)
Race/ethnic origin (410)
White/Caucasian (not Hispanic)	91.2% (88.5, 94.0)
Hispanic/Latino	1.9% (0.6, 3.3)
Asian	3.9% (2.0, 5.8)
African American or Black	0.5% (0.0, 1.2)
American Indian or Alaskan Native	0.7% (0.0, 1.6)
Other	1.7% (0.4, 3.0)
Professional characteristics
APTA member (410)	87.6% (84.4, 90.8)
ABPTS certification $>$ 1 area (416)	7.2% (4.7, 9.7)
Non PT similar level or
higher level degree (411)	64.2% (59.6, 68.9)
Years practicing as a PT (411)	18.5% (17.5, 19.5)
Practice area (408)
Academic medical center	10.5% (7.5, 13.5)
Acute care hospital	4.2% (2.2, 6.1)
Acute inpatient rehabilitation	0.2% (0.0, 0.7)
Sub-acute inpatient rehabilitation	0.0%
Physical therapist owned practice	46.1% (41.2, 50.9)
Corporate owned practice	14.5% (11.0, 17.9)
Physician owned practice	3.7% (1.8, 5.5)
Chiropractic owned practice	0.0%
Skilled nursing facility	0.5% (0.0, 1.2)
Home care	2.4% (0.93, 3.9)
School system	0.0%
Post-secondary education facility	3.4% (1.7, 5.2)
Health and wellness facility	1.7% (0.5, 3.0)
Research center	0.0%
Other	15.2% (11.7, 18.7)
Type of entry level degree (412)
Baccalaureate	34.0% (11.7, 18.7)
Certificate	3.6% (1.8, 5.5)
Masters	38.3% (33.6, 43.1)
DPT	23.8% (19.7, 27.9)
Employment
$>$ 30 hours/week (409)	88.7% (85.4, 91.3)
$\geqslant$ 50% time spent in orthopedics or
sports (408)	82.2% (78.5, 86.0)

3. Results

Of the 2248 surveys sent via email to potential respondents, 126 were returned as undeliverable and 38 opted out of the process. Thirteen surveys were incomplete and were not included in the data analyses. A total of 416 completed surveys were returned, resulting in a response rate of 19.1%. To determine if the response rate was representative of the geographical distribution of OCSs within the United States, we calculated the response rate by geographical region. The $p$ -values for the probability that the response rate by geographic area differs from the percentage of OCSs in that geographical area ranges from 0.18 to 0.78.

3.1 Demographic characteristics of subjects

A majority of the respondents were male (56.6%), Caucasian (91.2%), and APTA members (87.6%). The mean age was 44 years with a mean of 18.5 years in clinical practice. The most frequent entry-level physical therapy degree reported was a Masters in PT (38.3%). Of those subjects who obtained additional degrees beyond their entry level PT degree, a majority, 56.9%, reported completion of a transitional DPT degree. The most frequently reported practice setting was private practice (44.9%). ‘Physical therapist educational program’ was the most frequent response to a question regarding how therapists learned to screen for depression (39.4%), followed by self-taught (37.2%) and continuing education program (28.7%) (Table 1). Twenty percent of respondents reported that they did not learn how to screen for depression.

3.2 Practice patterns of OCSs who screen for depression

Subjects were asked to identify reasons for screening for depression at any time during an episode of care. The most common reasons cited included personal routine practice (63.9%), comfort level in relation to asking about the topic (33.3%), lack of progress (27.1%), practice setting policy (20.1%) and diagnosis (19.8%). Specific diagnoses that triggered a screen for depression included chronic pain (73.3%), low back pain (63.5%), cancer (54.6%), headache (52.2%) and multiple trauma (51.2%). A clear majority of respondents (88.7%) reported screening either formally or informally at some point during the episode of care. Of those that reported screening for depression at any time during an episode of care, 66.1% reported screening at the initial examination; followed by when they identified a problem (45.7%) and if there was a lack of progress (18.7%). During an episode of care, therapists relied most heavily on observation of behavior (70.9%) or informal questioning (73.3%) to determine the presence of depressive symptoms. A small percentage (11.3%) reported never screening at any time within the episode of care.

The use of a formal screening tool was reported by 31.2% and 27.7% of therapists who screen at any time during the episode of care, and all respondents respectively. Slightly more than 18% (18.3%) of all respondents used a formal screening tool during the initial examination. The General Health Screening Questionnaire (29.2%) and the Beck Depression Inventory (20.0%) were the most commonly utilized formal screening tools.

The most common follow up actions reported if the PT OCS suspected that a patient is depressed were refer to primary care practitioner (74.8%), document in the record (66.3%), refer to a mental health practitioner (38.9%) and refer to community resources (27.6%).

3.3 Beliefs regarding depression and its influence on patient outcomes

Most respondents (94.6%) believed that depression had a moderate to high influence on physical therapy outcomes. Furthermore, 67.9% believed that a pre-existing diagnosis of depression influenced their plan of care. A majority (57.3%) of all respondents reported that 20% or more of the patients on their current caseload demonstrated symptoms of depression; whereas more than 40% of respondents reported that less than 20% of their caseload exhibited symptoms of depression. Of those therapists who screen for depression during the initial examination, 65.2% believed that at least 20% of their patients demonstrated symptoms of depression, whereas among those who did not screen at the initial examination, 48.3% reported this belief ( $p<$ 0.01). Nevertheless, only 18% formally screened for depression during the initial examination.

Table 2
Association between predictor variables and screening behavior ${}^{*}$

Variable	Screening question
	When do you either formally or informally screen for depression? $n=$ 416 $p$ -valueMean or percent of all screeners at any time during the episode of care (88.7%) Mean or percent of all non-screeners during the episode of care (11.3%)	Is some form of screening for depression a part of the initial evaluation for all patients? $n=$ 403 $p$ -value Mean or percent of all screeners at initial examination (56.8%) Mean or percent of all non-screeners at initial examination (43.2%)
Age 43 or older	$p=$ 0.55	$p=$ 0.66
(43 is the median	50.4%	51.1%
cut point)	48.9%	48.8%
Male sex	$p=$ 0.54	$p=$ 0.30
	56.1%	59.3%
	60.9%	54.1%
Race
White	$p=$ 0.60	$p=$ 0.45
	89.4%	89.1%
	93.6%	91.4%
Hispanic	$p=$ 0.61	$p=$ 0.01
or Latino	2.2%	3.5%
	0.0%	0.0%
Asian	$p=$ 0.70	$p=$ 0.13
	3.8%	2.6%
	4.3%	5.8%
African	$p=$ 0.21	$p=$ 1.0
American	0.3%	0.4%
or Black	2.1%	0.6%
American	$p=$ 1.00	$p=$ 0.26
Indian or	0.8%	1.3%
Alaskan Native	0.0%	0.0%
Geographical location
New England	$p=$ 1.00	$p=$ 0.38
	5.1%	4.4%
	4.3%	6.3%
Mid Atlantic	$p=$ 0.51	$p=$ 0.20
	17.3%	15.3%
	21.3%	20.1%
South	$p=$ 0.18	$p=$ 0.94
	21.1%	22.7%
	29.8%	22.4%
Midwest	$p=$ 0.37	$p=$ 0.65
	22.8%	23.1%
	17.0%	21.3%
Southwest	$p=$ 0.10	$p=$ 0.69
	9.5%	9.2%
	2.1%	8.0%
West	$p=$ 0.70	$p=$ 0.61
	23.0	24.0%
	25.5	21.8%

${}^{*}$ Determined by Chi Square (Fishers Exact Test when any cell count was $<$ 5).

Table 2, continued
Variable	Screening question
APTA member	$p=$ 0.14	$p=$ 0.01
	88.4%	91.6%
	80.8%	82.7%
ABPTS certification	$p=$ 0.56	$p=$ 0.26
in more than 1 area	7.6%	8.7%
	4.3%	5.7%
Possesses a non-physical	$p=$ 0.30	$p=$ 0.07
therapist similar or	65.1%	67.8%
higher degree	57.4%	59.0%
Has been a practicing physical	$p=$ 0.77	$p=$ 0.44
therapist for 16 years or more	50.9%	53.3%
(16 is the median cut point)	53.2%	49.4%
Percent in different primary practice areas
Academic medical	$p=$ 0.45	$p<$ 0.01
center	10.8%	14.8%
	6.4%	5.2%
Community based acute	$p=$ 0.71	$p=$ 0.41
care hospital	4.3%	3.5%
	2.1%	5.2%
Acute in-patient	$p=$ 0.11	$p=$ 0.43
rehabilitation	0.0%	0.0%
	2.1%	0.6%
Physical therapist-	$p=$ 0.94	$p=$ 0.82
owned practice	45.3%	45.4%
	44.7%	46.6%
Corporate-owned	$p=$ 0.14	$p=$ 0.06
practice	13.3%	11.8%
	21.3%	18.4%
Physician-owned	$p=$ 0.68	$p=$ 0.18
practice	3.5%	2.6%
	4.3%	5.2%
Skilled nursing	$p=$ 1.00	$p=$ 1.00
facility	0.5%	0.4%
	0.0%	0.2%
Home care	$p=$ 0.61	$p=$ 0.05
	2.7%	3.9%
	0.0%	0.6%
Post-secondary education	$p=$ 1.00	$p=$ 0.83
facility	3.5%	3.1%
	2.1%	3.4%
Health and wellness	$p=$ 0.03	$p=$ 0.05
facility	1.1%	0.4%
	6.4%	3.4%
(No respondents stated that they were employed in a sub-acute in-patient rehabilitation facility, research facility or school system)
Employed 51% or more in	$p=$ 0.84	$p=$ 0.96
orthopedics or sports	86.1%	86.0%
	87.2%	86.2%
Employed 31 hours or	$p=$ 0.83	$p=$ 0.57
more per week	9.7%	8.7%
	10.6%	10.4%
How learned to screen for depression
PT education program	$p<$ 0.01	$p=$ 0.01
	40.9%	44.1%
	14.9%	31.6%

Table 2, continued
Variable	Screening question
Non-PT education program	$p=$ 0.50	$p=$ 0.79
	6.2%	5.7%
	2.1%	6.3%
Continuing education	$p<$ 0.01	$p<$ 0.01
	30.9%	34.1%
	2.1%	21.3%
Department in-service	$p=$ 0.04	$p=$ 0.02
	8.1%	10.0%
	0.0%	4.0%
Residency or fellowship	$p=$ 0.24	$p=$ 0.03
	4.6%	6.1%
	0.0%	1.7%
Self taught	$p<$ 0.01	$p=$ 0.69
	38.5%	37.5%
	14.9%	35.6%
Did not learn	$p<$ 0.01	$p<$ 0.01
	13.0%	10.0
	70.2%	32.8
Belief that 20% or more of their	$p=$ 0.22	$p\leqslant$ 0.01
patients have depression	48.9%	65.2%
	58.4%	48.3%

3.4 Characteristics that predict the likelihood of screening for depression

APTA membership ( $p=$ 0.01), and practicing in an academic medical center ( $p<$ 0.01) or home care environment ( $p=$ 0.05), where depression screening is often required, were associated with a greater likelihood of screening at initial examination. Respondents who identified themselves as “Hispanic” or employed in “health and wellness facility” were also more likely to screen at initial examination ( $p=$ 0.01) however, there were not enough respondents in those specific categories to draw any associative conclusions.

Therapists that learned to screen as part of a formal educational process, such as through a physical therapy educational program ( $p=$ 0.01), continuing education course ( $p<$ 0.01), department in-service ( $p=$ 0.02) or residency program/fellowship ( $p=$ 0.03) were more likely to screen for depression at initial examination than those that were not taught in the context of these educational venues. These therapists were 2.3 times more likely to screen at initial examination than those that reported that they did not learn to screen ( $p<$ 0.001). There were no statistically significant associations between screening behavior and numerous other predictor variables, including age, sex, geographical location, number of years in clinical practice and number of hours employed per week (Table 2).

Figure 1.

Perceived barriers to screening for depression at initial examination $n=$ 174.

3.5 Perceived barriers to screening for depression

Among therapists that did not routinely screen all patients for depression at the initial examination, the most common reasons cited were: not department policy (33.9%), limited knowledge (31.6%) and lack of follow-up resources (27.0%). Additional barriers to screening were identified as: other health care providers’ responsibility (13.8%), not relevant for my practice setting (9.8%) unfamiliarity with screening tool (9.4%), and uncomfortable asking about topic (8%) (Fig. 1).

4. Discussion

Current evidence demonstrates that depression is prevalent and often undiagnosed in patients receiving physical therapy for musculoskeletal conditions, and that this co-morbidity negatively influences physical therapy outcomes. Although PTs are not formally trained to treat depression, knowledge of the condition as a co-morbid condition may also inform the physical therapy plan of care.

At present, effective psychotherapeutic treatments for MDD include antidepressant medication and psychotherapy [32]. Other evidence-based treatment options include Cognitive Behavioral Therapy (CBT), relaxation training, and physical activity [2]. Many of the strategies employed by physical therapists, including components of CBT, such as activity pacing and goal setting, and typically prescribed exercise overlap with these intervention strategies. Furthermore, physical exercise, an important tool already widely used by physical therapists, has been shown to be an effective treatment alternative to achieve a reduction of depressive symptoms [33, 34, 35].

Several investigators have voiced support for screening for depression by physical therapists [10, 31, 5, 20, 6]. Furthermore, multiple authors [10, 5, 23] support the use of a formal screen for depression over the use of informal screening methods, as they are quick and easy to administer and more accurately identify depressive symptomatology.

Despite these conclusions, our survey results suggest that OCSs, clinicians recognized as having advanced clinical knowledge, experience and skills in orthopedic physical therapy [36] often fail to formally screen for depression, despite being aware of the implications of this co-morbidity on patient care. Moreover, formal screening did not occur as frequently as could be expected given the percentage of therapists that believe depression has a significant impact on outcomes and the percentage that believe their patients have symptoms of depression.

An additional concern is the discrepancy between the perceived prevalence of depression among the caseload of respondents and the prevalence of depression reported in the literature for the outpatient setting. Our survey results suggest that PTs are underestimating the presence of depressive symptoms among their patients. This finding suggests the need for increased clinician awareness of the prevalence of depressive symptoms among patients being seen for musculoskeletal conditions and knowledge of established best practice recommendations.

Finally, the percentage of respondents who report using only informal methods to screen for depression suggests an over-reliance on inaccurate methods to screen for depression among those who do screen. This inaccuracy is likely to result in the lack of identification of patients with depressive symptoms who should be referred as well as the potential overutilization of services for those patients that are incorrectly identified as demonstrating depressive symptoms.

A number of factors that influence the practice of screening for depression were identified by this study. APTA membership, practicing in an academic medical center or home care environment, and obtaining information relevant to depression through a formal educational process were associated with higher rates of screening at initial examination. While the cross-sectional design of this study precludes making determinations regarding the causal nature of the association between APTA membership and clinical setting, and formal depression screening; the educational process is likely a determinant of whether a clinician routinely performs this screen. Educational programs can be modified to incorporate information regarding depression relevant to physical therapy practice.

Barriers to screening for depression identified in this study include a lack of department policy, limited knowledge, a lack of follow-up resources, a belief that screening for depression was another health care providers’ responsibility, a belief that screening for depression was not relevant to their practice setting, unfamiliarity with screening tools, and discomfort asking their patients about their depressive symptoms. These barriers mirror provider-based barriers reported by multiple authors across various health care disciplines [37, 38, 39, 40, 41, 42, 43, 44]. Each of the reasons cited for not screening for depression are modifiable, either through clinician education, department institutional policy and/or implementing a more inclusive referral practice pattern. Increasing the prevalence of depression screening by minimizing these identified barriers is therefore an attainable objective.

5. Strengths and limitations

To our knowledge, this was the first study to survey practicing physical therapists regarding their depression screening beliefs and practices. The electronically distributed survey allowed for tracking of responses, timed reminders, and increased speed and cost effectiveness as compared with paper surveys. The sample size was large enough to generate precise statistical estimates of most variables of interest. The geographical distribution of respondents was representative of the geographical location of OCSs throughout the United States, thereby enhancing generalizability of study results to the broader OCS population. Limitations of this study include the recall bias and social desirability bias inherent in the cross – sectional nature of the study design. These biases likely inflated our results regarding the prevalence of screening for depression in the clinical setting. In addition, the sample was largely homogeneous: Caucasian, male, APTA members, and almost exclusively currently OCS certified; thereby limiting the generalizability to the broader PT community.

The survey response rate was roughly 20% of OCSs located in the United States. Sheehan [45] reported an overall trend toward declining response rates from email surveys. Of 31 studies assessed by Sheehan, the response rate averaged 31%, with a high of 42.15% in 1995 and a low of 24% for the most recent data from 2000 [45]. Our response rate was therefore not atypical. Nevertheless, the low response rate likely affects the validity of our findings. We hypothesize that respondents were more likely to believe that depression is an important issue for physical therapists to address than non-respondents. If so, study results would likely be inflated regarding the prevalence of depression screening; similar to the expected effects of recall and social desirability bias. Our belief that respondents were more likely to screen for depression than non-respondents is supported by two prior studies in which the investigators concluded that screening for depression by physical therapists is not common during routine clinical practice [40, 41]. In one of these studies, of 37,754 patients with low back pain, only 2% provided depression data at intake [40].

6. Future research and unanswered questions

In this study, practicing OCSs were surveyed. Future studies should include a broader sample of physical therapy clinicians. Other areas for research include the identification of content currently taught in physical therapy academic programs and continuing education programs, related to depression. Exploration of the interconnectedness of somatic symptoms and depression is also a key area for further education and study. Additionally, intervention studies identifying the relative effectiveness of various physical therapy interventions in the management of depression would provide valuable information to inform clinical practice.

7. Implications for practice

The results of this study are beginning steps in evaluating the need to advance clinical practice related to screening for depression of patients with musculoskeletal conditions by physical therapists in the clinical setting.

Conflict of interest

None to report.

Footnotes

Acknowledgments

The authors wish to acknowledge the Department of Rehabilitation and Movement Sciences, Doctoral Programs in Physical Therapy at Rutgers University, Newark, New Jersey for the support of this project.

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Depression screening by physical therapists: Practices,beliefs,barriers

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Methods

Table 1 Demographic characteristics

3.1 Demographic characteristics of subjects

3.2 Practice patterns of OCSs who screen for depression

3.3 Beliefs regarding depression and its influence on patient outcomes

Table 2 Association between predictor variables and screening behavior *

4. Discussion

5. Strengths and limitations

6. Future research and unanswered questions

7. Implications for practice

Conflict of interest

Footnotes

Acknowledgments

References

Table 1
Demographic characteristics

Table 2
Association between predictor variables and screening behavior ${}^{*}$