Mental health is a growing issue across the country—and it’s one that’s affecting healthcare providers of all stripes. According to a study conducted in 2022 by the Kaiser Family Foundation and CNN, nine out of 10 Americans feel that there is a mental health crisis in the country. This is a significant, rapid acceleration of a long-extant problem, considering this study from Mental Health America that showed just over 20% of Americans were suffering from mental illness in 2019-20—to say nothing of the 970 million people worldwide. Given the vast number of people affected, it’s unavoidable that PTs are treating patients who are also dealing with mental health challenges. But how much are those issues affecting the outcome of the work that PTs are doing? And how can patients struggling with their mental health be identified and provided the help they need? It’s a difficult topic to navigate, but one PTs must consider in our current climate.

Patients’ mental health is impacting physical therapy.

Physical, behavioral, and mental health all play an integral and interconnected role in the overall ability of a patient to engage with and adhere to physical therapy treatment. With every clinician understanding how a patient’s mindset can impact the course of PT care and eventual outcomes,  the American Physical Therapy Association House of Delegates published a position statement, #P06-20-40-10 in 2020 stating that “(i)t is within the professional scope of physical therapist practice to screen for and address behavioral and mental health conditions in patients, clients, and populations.”

This position is in alignment with a growing breadth of research pointing to the overwhelming impact mental health can have on physical well-being. According to the National Alliance on Mental Illness (NAMI), people suffering from mental illness have a 40% higher risk of developing cardiovascular or metabolic diseases—and people with serious mental illness are twice as likely to develop those diseases. Thus, physical therapists can and must play a vital role in considering the whole person—not just the physical aspects—in order to optimize outcomes and, ultimately, to have the best interests of the patient at heart.

Many therapists have seen it firsthand, for example, say you have a patient who suffered a relatively simple ankle sprain three months ago but continues to report ongoing severe pain and disability. Simple biomechanical and biological explanations can’t account for those ongoing symptoms; however, by taking into consideration other aspects of the patient’s well-being, including mental health, you can get a clearer picture of the underlying issues.

Granted, most PTs might feel out of their depth trying to counsel patients. But we must recognize that PTs are uniquely positioned to be front-line operators in addressing patients’ mental health.

Physical therapists can play a part in mental health.

Recognizing and dealing with patients’ mental health struggles can be difficult for PTs; for all of our training, we’re not fully equipped to help with the emotional constraints that patients may be dealing with. And we’re certainly not paid for those services, despite the ability to screen for and identify challenges. But better mental health plays a huge role in improved outcomes—which means having solutions to address patients’ mental health needs is critical.

For a start, we’re already helping just by the nature of our treatment, as there is a well-established connection between exercise and alleviating depression and anxiety symptoms. But as PTs, we’re usually at a loss when it comes to what to do beyond that for those suffering from mental health issues. That doesn’t mean we’re powerless, though. Here are a few things you can do to ensure your patients are getting the holistic care they deserve.

Screen patients for potential yellow flags.

Although we might not be fully equipped for all the mental health challenges a patient is dealing with, we should nevertheless be looking to spot them in our interactions with every patient. There are a few obvious things to look out for with your patients:

• Rating their pain as a 10 out of 10 on an intake form;
• Frequent cancellations;
• Expressive signs of distress during appointments; and
• PMH including counseling or antidepressants.

These potential yellow flags warrant a process to make sure you’re not letting potential mental health issues go unaddressed. If a patient is rating their pain at a 10 on intake, never disregard their answer as false; instead, have a conversation with the patient about their mood during their initial eval. When frequent cancellations occur, have a policy to trigger a call from your front-office staff to check on the patient’s well-being as well as notify the referring physician as to non-compliance.

If patients are canceling due to pain or other factors related to their rehab care, reaching out to them to address these issues can open the door to a conversation regarding their physical and mental health. Use that opportunity to talk to the patient and get them back in for more immediate treatment.

Your intake forms can be your initial screening process.

In addition to gauging a patient’s pain level, intake forms can be used to spot potential yellow flags for mental health issues.  If your forms don’t already have a question addressing past medical history or mood, look to add one. And if yellow flags appear, using a more objective screening tool like the patient health questionnaire (PHQ)-9 form can be helpful. It features a series of questions to screen for depression and anxiety helping to provide more insight into potential issues.

Within this form, suicidal ideation is listed, and—although rare—therapists must be ready to act if they suspect any intent of physical self-harm. This, of course, is a red flag and an immediate assessment like the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) should be conducted. A call to the referring physician should also be completed as well as documentation outlining the steps and conversations had with the patient.

Of course, those intake forms are just the screening process, and any potential concerns should be addressed further during the subjective portion of the initial examination. Other symptoms or verbal descriptions to look out for include:

• unrealistic beliefs about pain or the nature of the pain,
• impaired pain behaviors (e.g., fear-avoidant behavior or kinesiophobia), or
• an overreliance on passive treatments like chiropractic adjustments or massage.

Some of these behaviors have long been associated with workman’s compensation patients, who may be dealing with mental health issues related to their job and workplace satisfaction or their worker’s comp case—which are out of our control as health care providers. However, as health care professionals, it’s imperative to be mindful of the mind-body connection in the healing process as we push toward positive outcomes.

Educate patients on mental health’s connection to their physical well-being.

Patient education is already a main ingredient of every plan of care and every treatment session from tissue healing principles and posture to assistive device and home exercise instruction. For patients with identified mental health struggles, adding a deeper explanation of how physical activity and specific movement changes can help alleviate their pain can motivate them to push beyond their perceived boundaries. Taking the time to understand what motivates them as individuals will also help with adherence to visits and their home exercise programs (HEP).

Dealing with depression, anxiety, and other difficult emotions isn’t as simple as just giving patients the facts, though. Finding ways to equip them with the tools to help deal with those feelings constructively should be part of the plan of care. Why not make mental health interventions part of your treatment plan?

Granted, offering services like cognitive behavioral therapy or stress-management techniques might fall outside your staff’s expertise and require additional training (and compliance considerations) before you could provide and bill for them. That’s why you should look into adding a mental health specialist to your clinical team as someone to address the mental side of recovery. Having a mental health professional could serve as a differentiator for your practice as well as an additional revenue stream. Combining a more intentional focus on the behavioral and mental health components along with the physical could improve patient satisfaction as well as your tracked clinical outcomes and should be a no-brainer.

Weave mental wellness interventions into PT plans of care.

Screening and education have played a large role—and for some therapists, the only role—in the intersection between mental health and physical therapy for some time now, but more direct interventions can be applied to a multitude of patients. Using treatment approaches like cognitive behavioral therapy (with its many nuances), mindfulness-and-acceptance-based intervention, and pain neuroscience education, physical therapists can be better equipped to accept their role as primary care providers in musculoskeletal (MSK) dysfunction and treat the whole patient.

Create relationships with mental health providers.

Given that mental and physical health are so clearly linked, it only makes sense to expand your professional relationship network to include mental health professionals. PTs have long had referral relationships with other healthcare providers to ensure a holistic, patient-centered approach to treatment. And it’s always nice when the stars align and the right thing to do for a patient also makes good business sense. Having a mental health professional who you can trust with your patients and that can reciprocate with referrals to you from their book of business is a win for everyone.

Take care of your own mental well-being.

Providers aren’t immune to the current mental health crisis themselves. In fact, the stress of the COVID-19 pandemic saw rates of depression, anxiety, and burnout among healthcare workers rise higher than those of the general population. And we’ve felt this problem acutely in rehab therapy; in WebPT’s State of Rehab Therapy report for 2022, 35% of respondents said that they were burned out, with many seeking an exit from clinical care.

To take the best care of their patients, PTs must ensure they’re first taking care of themselves. Admittedly, taking time for yourself can be difficult when patient volumes remain high for most practices out of necessity. It takes a committed effort on the part of clinic leaders and clinicians themselves to make provider mental health a priority. With that in mind, here are a few things you can implement in your practice to help improve your staff’s mental well-being.

Look at flexible or hybrid schedules.

Your staff may be looking for more time away from the clinic in order to stay grounded and feel energized. Working with your providers to understand the clinic’s peak operating hours and having scheduling options such as working three full days and two half days or four-day work weeks can help you offer more flexibility while still meeting your practice’s (and your patients’) needs. And with reimbursement for remote therapeutic monitoring still available for PTs, rolling out the option for hybrid workdays can also provide flexibility in schedule management.

Consider alternative performance and payment models.

The pandemic also caused many people to reconsider their priorities and determine that they were willing to trade a bit of income for more free time. That’s particularly true in rehab therapy, where increasing patient loads haven’t led to an increase in pay that would justify the added hours. Rather than only focusing on productivity numbers as a reward for increased compensation, think about assessing top performers on patient satisfaction scores, patient-reported outcomes, referral relationship management, and professional growth metrics. You can also consider offering a revenue-sharing model or a fixed-pay/performance-based bonus hybrid; it gives your staff more control and flexibility over their own income, which in turn can lead to greater job satisfaction.

Take care of your body and mind.

Taking advantage of your paid time off (PTO) benefits should not be frowned upon—especially when you’re using that time to de-stress. You’ve probably heard most of the tips for dealing with stress ad nauseum, like:

• Exercise;
• Eat healthy, nutritious meals;
• Get enough sleep; and
• Take time for hobbies and the things and people you love.

There’s a reason that they’re repeated so often: they work! And yet too many people aren’t acting on those things in their own lives, instead allowing stress to build up to an unhealthy level.

As the workforce has changed, so has the work culture. As a Gen-Xer, I believe in work-life balance—but I was also raised by immigrant parents with undaunting work ethics, so I have some perspective on both ends of the spectrum. Millennials and Gen-Z, who are even more adamant about work-life balance, now make up 46% of the US workforce. That’s why it’s critical to build relationships with your team to understand their needs—and ultimately improve your employee retention.  The APTA has recognized the need for more resources around PTs maintaining their wellbeing and created its Fit for Practice series. These blogs, videos, and more offer providers the tools and materials they need to better cope with the stress and challenges that are still present in our profession post-pandemic.

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Mental health can be tough to talk about, and even tougher to address. While there’s been significant progress in recent years, the lingering stigma around mental health makes it hard for patients and providers to have an open and honest dialogue—especially if that provider isn’t a mental health professional. However, PTs are uniquely positioned to be key advocates for their patients to help ensure effective treatment and the best clinical outcomes.