Screening for depression misses people with suicidal ideation in patients with persistent musculoskeletal pain attending private physiotherapy

This is the authors' abstract. We don't add key points for this paper.

Background Patients with persistent musculoskeletal pain face an increased risk of suicidal ideation, yet suicide risk is not routinely assessed in physiotherapy. Many primary care professionals use a two-stage screening approach, assessing depression first and only asking about suicide if depressive symptoms are present.Objective This study examines the appropriateness of this approach in private musculoskeletal physiotherapy practicein Belgium and whether physiotherapists’ observations of patients’ distress align with patient self-reports.Methods Four-hundred fifty patients completed thePatient Health Questionnaire-9 (PHQ-9), which includes the PHQ-2 and a suicide ideation item, while 84 physiotherapists completed an observer-report PHQ-2. Cross-tabulation and logistic regression compared observer ratings with patient-reported distress.Results Mean scores on the observer-report and self-report PHQ-2 were similar (1.6 ± 1.6 vs. 1.6 ± 1.5, p = .79)and moderately correlated (r = 0.50, p < .001). Among patients reporting suicidal ideation (16.4%; n = 74), 41.9% (n = 31) scored below the PHQ-2 cutoff of 3, and 52.7% (n = 31) scored below on the observer-report version. A self-report PHQ-2 score of 3 or above was more strongly associated with suicidal ideation (odds ratio[OR] = 6.76; 95%CI = 3.96–11.53) than an observer-report PHQ-2 score of 3 or above (OR = 3.72; 95%CI = 2.21–6.28), though the latter had higher classification accuracy (83.6% vs. 76.2%). Physiotherapists were more likely to recommend professional support for patients with suicidal ideation (50.0% vs. 34.6%, p = .012), but coping advice did not differ by suicide risk.Conclusion Many patients with suicidal ideation did not meet the PHQ-2 depression threshold, highlighting the limitations of a two-stage screening approach in physiotherapy. Based on these findings, this approach is not recommended.