Screening for depression, anxiety, and psychological distress associated with low back pain by musculoskeletal and spinal clinicians. A scoping review

Purpose: A biopsychosocial assessment of a person with low back pain (LBP) should include the detection of psychological risk factors. Pragmatically, clinicians often use their clinical impression rather than questionnaires to screen for psychological risk factors. This scoping review explores how accurately depression, anxiety, and psychological distress can be identified by musculoskeletal (MSK) or spinal clinicians using clinical impression alone. Methods: The study protocol was pre-registered on Open Science Framework (OSF) https://osf.io/pt3a6/. A comprehensive search strategy using five databases (MEDLINE, CINAHL, Academic Search Complete, APA PsycInfo, APA PsycArticles) was conducted by two independent reviewers, with additional searching of references. Studies must have included adults with LBP, who were assessed by MSK or spinal clinician for depression, anxiety or psychological distress using their clinical impression as well as a reference standard questionnaire. Data were synthesised descriptively and thematically for each psychological factor separately. Results: Eight studies involving MSK clinicians (n = 4) and spinal clinicians (n = 4) were eligible. Four different reference standard questionnaires were used. Overall MSK and spinal clinicians were not accurate at identifying depression, anxiety or psychological distress in adults with LBP using only clinical impression. Mean sensitivity for accurate identification of high reference standard questionnaire scores for depression, anxiety, and psychological distress ranged between 12.0% and 40.0%. Mean sensitivity was marginally higher when the threshold was reduced to analyse clinician ability to accurately capture any abnormal psychological state (34.0% to 54.1%). Mean specificity values across higher thresholds ranged from 88.7% to 93.6%. Conclusion: Overall, clinician impression alone is insufficient for MSK and spinal clinicians to accurately identify depression, anxiety and psychological distress in adults with LBP. The general tendency of the clinicians was to underestimate their presence. Without formal assessment of the psychological status of patients with LBP, clinicians will have an incomplete understanding of concordant psychological factors, and may fail to notice the requirement to refer on for appropriate psychological management.