Screening and Referral Practices for Symptoms of Anxiety and Depression in Private Physiotherapy Practices for Chronic Musculoskeletal Pain: A Qualitative Study.

Chronic musculoskeletal pain often comes bundled with anxiety or depressive symptoms, and how physiotherapists in everyday private practice notice and respond to this is not well understood. This qualitative study interviewed 18 Belgian physiotherapists about how they recognise, screen for, manage, and refer patients with these co-occurring psychological symptoms, then analysed the interviews thematically. The physiotherapists described leaning on informal observation and clinical intuition rather than standardized screening questionnaires. They named real obstacles, such as limited training, uncertainty about where physiotherapy's role ends, time pressure, and patchy referral systems, while also pointing to things that helped, like motivation toward whole-person care and trusting therapeutic relationships.

Many also spoke of feeling emotionally burdened doing this work without adequate backup. Because this is a qualitative study of a specific group of clinicians, the findings describe experiences and barriers rather than proving any screening approach improves outcomes, and may not generalise beyond this sample and setting.

If you've been treated for ongoing musculoskeletal pain, you may have noticed your physiotherapist asking about your mood or stress, even informally. This study looked at how physiotherapists in private practice in Belgium actually approach noticing and responding to anxiety or depression symptoms in patients with chronic pain, based on interviews with 18 of them. What they described was mostly gut feeling and conversation rather than formal questionnaires.

They talked about wanting to treat the whole person, but also about not having enough training, not being sure where their job ends and a mental health professional's begins, running out of time in appointments, and difficulty finding clear pathways to refer patients onward. Several also said this part of the job weighs on them emotionally.

Because this is based on interviews with a specific group of clinicians rather than a trial testing a treatment, it tells us about real-world experiences and challenges rather than proving any particular approach works better for patients.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

This study speaks to the practical question of how screening and referral for anxiety and depressive symptoms actually happens, or doesn't, in private musculoskeletal physiotherapy practice, rather than testing whether a screening protocol changes outcomes. Through semi-structured interviews with 18 Belgian physiotherapists analysed using framework analysis, ten interrelated themes emerged describing how clinicians recognise, manage, and refer patients with these symptoms. The analysis suggests that informal, intuitive assessment currently substitutes for validated screening tools in many practices, and that this is shaped by a mix of personal factors (training gaps, role uncertainty, emotional burden of managing symptoms without support) and systemic ones (time constraints, inconsistent referral pathways).

Facilitators identified included intrinsic motivation toward biopsychosocial care and strong therapeutic alliances, alongside clinical intuition, though these were described as helpful rather than shown to improve patient outcomes. As a qualitative study of a specific national sample in private practice, the findings illuminate barriers and experiences relevant to implementing mental health screening in this context, but they do not establish the prevalence of these symptoms, the effectiveness of any screening tool, or whether findings generalise to other settings or healthcare systems.