Introduction

According to the World Health Organization (WHO),1 mental disorders are characterized by clinically significant disturbances in an individual’s cognition, emotional regulation, or behavior. There are many different types of mental disorders, such as schizophrenia spectrum disorders, major depression, and bipolar disorder.1 All of these are categorized as severe and persistent mental illnesses (SPMI), which are associated with high levels of disability that affect personal, social, and occupational functioning.1 Lower socio-economic status and unhealthy lifestyles also contribute to poor physical health.2 According to WHO,1 in 2019, one in every eight people worldwide was living with a mental disorder, anxiety, or depression; in 2020, because of the COVID-19 pandemic there has been a 26% and 28% increase respectively for anxiety and major depressive disorders.1 Likewise, the prevalence of mental disorders in Saudi Arabia increased throughout different phases of the pandemic.3

People who experience severe and persistent psychological problems, such as schizophrenia, bipolar disorder, and major depressive disorder, report having poor physical health and a high prevalence of coexisting medical conditions (respiratory and cardiovascular diseases, diabetes mellitus, and obesity, among others).4 Additionally, these patients also have a higher likelihood of engaging in unhealthy behaviors like smoking, abusing drugs, poor physical activity, and maintaining a sedentary lifestyle.4 Studies showed that patients with chronic pain report a wide range of experiences, indicating that pain is only one aspect of their suffering and that patients are more impacted by the psychological discomfort that results from having chronic pain, such as anxiety, loneliness, and agony.5,6

Craft & Perna7 revealed the relationship between exercise and depression, through physiological and psychological mechanisms, including the endorphin and monoamine theories. Exercise, according to the endorphin theory, reduces depression by increasing the release of endorphins afterward which are associated with a good mood and an improved overall sense of well-being.7 According to the monoamine hypothesis, physical activity increases the availability of brain neurotransmitters like serotonin, dopamine, and norepinephrine, which are reduced during depressive episodes.7 Exercise may also exert its antidepressant benefits through improving self-efficacy.7 Self-efficacy refers to the confidence an individual has in their ability to possess the essential skills required to accomplish a task and the assurance that the task can be successfully completed with the intended results achieved.7

Individuals experiencing mental health disorders may enhance their quality of life through physical therapy, which can boost their physical health, reduce psychosocial challenges, and complement primary treatments for their mental condition.4 Evidence suggests that gains in muscle balance and flexibility are linked to improved safety and self-worth, and better posture can lessen physical pain while enhancing mood, self-esteem, and body image.4 Strong evidence also supports the idea that patients with mental illnesses like depression and anxiety benefit from a regular physical exercise program.4 McGrath et al8 reported the physiotherapists’ frequency of contact with clients perceived to be experiencing psychological distress, and clients contemplating or engaging in non-suicidal self-harm and suicidal behaviors. However, due to a lack of mental health training, physiotherapists feel unprepared to treat patients who are experiencing poor mental health.8,9 Moreover, physiotherapists are hesitant to address mental health issues like suicide due to fears of inadvertently triggering unmanageable situations.8,9 This hesitation stems from concerns about the potential escalation of difficulties beyond their capacity to effectively handle, leading to further complexities in their professional practice.8,9 In a recent scoping review by Heywood et al,10 it was noted that physical therapists’ interactions with patients having mental health conditions showed significant diversity. Notably, a disparity exists in the levels of confidence between specialized physical therapists in mental health settings and those who identify knowledge deficiencies.10

As per Almirón et al,4 a reported 75.94% of physical therapists indicated their awareness of the therapeutic applications of physiotherapy in addressing specific mental disorders, serving as a complement to both pharmacological and psychological interventions.4 Lee et al11 found that the factors preventing people with mental disorders from accessing physical therapy services include the lack of knowledge among mental health practitioners and individuals with severe and chronic mental illness regarding physiotherapy and its connection to physical health in mental healthcare. Additionally, extended waiting times; lack of integration between services; diagnostic overshadowing, where the physical complaint is assumed to be the result of mental health; and a perceived lack of patient motivation or adherence leading to early discharge from physiotherapy have all been identified as major barriers to accessing physical healthcare for those with mental disorders.12 Furthermore, the stigma around mental health impedes access to healthcare services.13 Hemmings and Soundy12 conducted a study to gain insight into how people with mental health issues experienced physical therapy care. They found that patients frequently reported feeling unheard and misunderstood, and physiotherapists partaking in focus groups felt that a lack of education and experience in mental health specialties was partly to blame for the lack of consideration of psychosocial components of care.12

Determining the knowledge of physiotherapists about their role in treating patients with mental health issues can help provide evidence about the importance of training physiotherapists in performing this critical role. This aligns with the WHO’s “Comprehensive Mental Health Action Plan 2013–2030”, which aims to strengthen efficient leadership and governance; provide comprehensive, integrated, and responsive community-based care; put promotion and prevention strategies into place; and strengthen information systems, evidence, and research.1 Also, the vision statement of the physical therapy profession, as articulated by the American Physical Therapy Association (APTA) “transforming society by optimizing movement to improve the human experience” emphasizes that the healthcare system needs to evolve from a medical to a biopsychosocial model.14 Recently, Furness et al15 reiterated the emphasis on educational requirements for Australian physiotherapists, underscoring a strong demand for curriculum involving mental health conditions, the scope of physiotherapy practice, and treatment approaches for individuals with mental health concerns.15 Given the lack of studies investigating Saudi physiotherapists’ knowledge of their role in dealing with patients with mental illness, this study aims to determine the self-reported knowledge of physiotherapists regarding this role. It is hypothesized that physical therapists have poor knowledge and negative attitudes regarding treating patients with mental disorders.

Materials and Methods Study Design

This study is a descriptive, cross-sectional, and prospective observational survey design. The Local Committee of Scientific Research Ethics at Princess Nourah bint Abdulrahman University (PNU) granted ethical approval for this study (IRB: HAP-01-R-059). The survey was adapted from Andrew et al.2 The original authors authorized the adaptation of the instrument. The survey’s content validity was verified by experts to ensure it fits with the culture of our sample, and its face validity was verified by physiotherapy students at PNU to ensure clarity. Additionally, reliability was assessed using Cronbach’s alpha test.

Sampling

This study used convenient sampling methods to recruit practicing physical therapists of different ages and from different regions of Saudi Arabia. The estimated population of physical therapists was obtained from the Saudi Commission for Health Specialties. The sample size of 326 was estimated based on a population of 6000 physical therapists practicing in KSA, with a 95% confidence interval and a margin of error of 5%. Sampling calculations were obtained from Open-Source Statistics for Public Health. The inclusion criteria included being licensed in physiotherapy, practicing physiotherapy in Saudi Arabia, and holding a bachelor’s degree or higher degrees. The exclusion criteria included being a physiotherapy assistant or practicing without a license.

Procedure

After the participants confirmed their informed consent, they completed the five-part survey (Appendix 1). Part one included questions about participants’ demographic information, such as age, gender, education, residential place of practice, years of experience, employment status, practice setting, prior job experience in a mental health context, caseload of individuals with mental illness, kind of referral, and psychology training were among the demographic variables. Part two included questions about the participants’ knowledge of mental illness. There are four questions in the knowledge portion. Each respondent’s total knowledge scores (ranging from 0 to 4) were computed; a right response netted one point, while an incorrect response netted none. Based on Bloom’s cutoff,16 the overall knowledge scores were divided into three levels: high, moderate, and poor. Part three included questions about participants’ attitudes toward patients with mental illness. The attitude section consisted of three questions. The total attitude scores were calculated for each respondent and categorized into three levels based on Bloom’s cutoff: a positive attitude (ranges 7–9), a neutral attitude (ranges 5–6), and a negative attitude (ranges >5). Lastly, part four contained questions about their perception of the gaps in their knowledge about patients with mental illness.

Data Collection and Analysis

The data were collected through an online survey between March 2023 and October 2023. The survey has been spread through Google Forms and distributed through emails, social media applications, and physical distribution. All participants were informed about the study’s purposes and provided informed consent at the beginning of the online survey. Data was kept confidential and used for study purposes only. The data obtained from the online survey was only accessed by the researchers through their secure access.

Statistical analysis was carried out using JMP. Descriptive statistics were used to analyze all the variables that were undertaken from the survey, in addition to the chi-square and ANOVA test used for the comparative questions. The results of these analyses were presented using frequencies and percentages for categorical variables and mean and standard deviations for continuous variables. All tests of associations were carried out at a significance level of 0.05 and 95% confidence interval. Sample size calculations were obtained from an online sample size calculator assuming 95% confidence interval and 5% margin of error.

Results

Two hundred and eight physiotherapists completed the survey, this sample acquired indicated an 85% of confidence interval with a 5% margin of error. Of these, 61% were female (127 participants), and 39% were male (81 participants), with a mean age of 31.5 years and a standard deviation of ±7.32 years. The majority of the responses were from physiotherapists who had more than ten years of experience as a physical therapist 29%, had a bachelor’s degree 49%, worked in the central region 64%, and worked mostly in a public hospital 40%. Their primary area of professional practice was musculoskeletal physiotherapy 47%, and 74% worked in an outpatient setting. Other sociodemographic data are shown in Table 1. Of the 208 participants, only 22% obtained a high knowledge score, while the majority 50% had poor knowledge regarding mental health. The majority of the participants 48%had a positive attitude score, with 40% having a neutral attitude and 12% having a negative attitude toward treating patients with mental health issues (Table 2).

Table 1 Demographic Data

Table 2 Bloom’s Knowledge and Attitude Scores

PT Knowledge of People with Mental Disorders

Differences in knowledge scores among different demographic characteristics were assessed using the Chi-square test and ANOVA (Table 3). The results showed that the knowledge scores were high among middle-aged therapists (30.5±7.54), and physiotherapists with less than two years of experience showed a high knowledge score in 43% of cases, while those with over ten years demonstrated a low score in 39% of instances (p-value = 0.001*). Furthermore, 30% physiotherapists who lived in the central region showed a moderate knowledge score, while 46% displayed a low score (p-value = 0.0309*). Among physiotherapists who underwent psychological course training, 28% achieved a high knowledge score, whereas 47% scored lower (p-value= 0.0017*).

Table 3 The Impact of Demographic Data on the Knowledge and Attitude Score

Although they were insignificant, the results showed that the knowledge scores of females and more experienced therapists with a bachelor’s degree (p-value = 0.2568) and musculoskeletal subspecialty who worked in an outpatient department (OPD) of a public hospital (p-value = 0.5913) were higher than the scores of other therapists.

PT Attitudes Toward People with Mental Disorders

The Chi-square analysis did not reveal any significant differences (p>0.05) in relation to the demographic data except, physiotherapists with less than a quarter proportion of their caseload inclusive of people with mental illness, 53% displayed a positive attitude, 30% were neutral, and 11% showed a negative attitude (p-value=0.0143) (Table 3).

PTs’ Perceived Knowledge Gap Regarding Their Role in Mental Health

Part four of the study contained two questions aimed at determining whether physiotherapists needed more education or knowledge, and which types of information might be helpful for physiotherapists in managing the physical health needs of people with mental illness. The vast majority of respondents 86% agreed that they needed more training or information, and when they were asked what kind of information they would like to receive, most of them identified general mental health illnesses, physical health issues frequently linked to mental illness, and management of physical health issues in patients with mental illness. Most respondents, in general, agreed that they needed more education and practice on a wide range of information. At the end of the survey, an open-ended question was asked to determine whether the participants had any opinion about physiotherapists’ involvement in managing mental illness. Most of the answers (45.9%) followed two themes: (1) the need for more training and courses regarding mental disorders and physical therapy and (2) the need for collaboration between the physical therapist and psychologist/psychiatrist.

Discussion

Despite the lack of research on physiotherapists’ knowledge about their role in treating patients with mental illness in Saudi Arabia, determining their knowledge can assist in providing evidence of the necessity of training physiotherapists to perform this crucial role. This study aimed to investigate physiotherapists’ knowledge of their role in treating mental illnesses and their attitudes toward patients with mental disorders.

PT Knowledge About Their Role in Mental Health

Our findings in this study imply that participants’ knowledge about mental health and their role in people with mental disorders was inadequate; only 22% of the participants had higher knowledge scores, which is consistent with findings of Hooblau et al,17 as participants in a focus group stated that they did not feel equipped to handle people living with a mental illness due to the insufficient knowledge they had gained at an undergraduate level. Similarly, Almirón et al4 reported that 61.50% of physiotherapists showed a lack of knowledge about the physical conditions affecting patients with mental disorders and that 55.61% requested more information and training on the subject. Furthermore, in a systematic review by Vancampfort et al,18 which found that in current Sub-Saharan African mental health policies, only 2 out of 22 screened plans made reference to the importance of considering physiotherapy within multidisciplinary treatment, indicating that mental health care providers have limited knowledge of the advantages of physiotherapy in mental health treatment. Vancampfort et al18 attributed this neglect to policymakers, training institutes, and other mental health care professionals’ lack of knowledge about the benefits of physiotherapy in mental health care.

This lack of awareness among physiotherapists might be related to the misconception of mental health spectrum which extends beyond just the realm of mental disorders, as highlighted in the exchange between McGrath et al19 and Heywood et al.20 Where McGrath et al, sheds light on the intersection between physical therapy and mental well-being, emphasizing that mental health encompasses a broader spectrum of factors beyond diagnosable mental disorders, including emotional well-being, resilience, and overall psychological functioning. Dillon et al21 revealed the multifaceted nature of mental health and the influence of psychosocial factors, such as distress and coping mechanisms, on individuals’ experiences of chronic pain.

McGrath et al22 advocate for integrating mental health screening and interventions into physiotherapy practice to provide comprehensive care to patients with both physical and psychological needs. Tatta23 suggests that physiotherapists can play a more active role in addressing mental health concerns, not only managing physical symptoms but also providing support and interventions to improve mental well-being. This highlights the importance of recognizing the broader concept of mental health and the role of physiotherapists, in addressing the interconnectedness of physical and mental well-being. This also aligns with results of this current study regarding physiotherapists’ need for more education about mental health and their role in addressing psychological well-being alongside physical symptoms in healthcare settings.

PT Attitudes About Their Role in Mental Health

The study findings reveal that most of the participants held neutral to negative attitudes 52% toward treating patients with mental illnesses. Driver et al24 conducted a systematic review of 15 studies focusing on the knowledge, behaviors, attitudes, and beliefs of physiotherapists toward applying psychosocial interventions in practice; they concluded that physiotherapists’ attitudes and beliefs were mainly positive.

As found in the results, female physiotherapists working in the central region predominantly exhibited positive attitudes. This might be attributed to the high percentage of population living in the central region compared to other regions, leading to more exposure to patients with mental health, which might be identified as a factor that could enhance healthcare providers’ attitudes toward them. This agrees with findings of Prasanna et al25 where physiotherapists’ attitudes toward patients with mental disorders were neutral and explained that their attitudes may be influenced by the low exposure to such cases in their practice. These findings align with those of Lennon et al,26 who discovered that physiotherapists in Ireland were generally supportive of patients with comorbid psychological issues and acknowledged the need to address such concerns. Similarly, the results of Hooblau et al’s17 study mirror our findings, demonstrating that public sector physiotherapists in KwaZulu-Natal exhibited good attitudes towards managing people living with mental illness and mental health. Moreover, and aligning with our findings, Lucas and Parker’s27 results showed that in outpatient and community rehabilitation settings, physiotherapists dealt with anxiety in patients with multiple sclerosis and believed they could help when it manifested.

This study showed that positive attitudes were seen among physiotherapists with less than two years of experience. This aligns with a study conducted by Ghuloum et al28 revealed that recent graduates who were in contact with patients with mental illness tended to have a more positive attitude towards them. Additionally, the study suggests that attitudes of healthcare providers may evolve with experience and education.

One of the key findings of our survey was that most physiotherapists felt a need for more education and training to manage the physical health problems of people with mental illness. This finding suggests that there is a gap in the education and training of physiotherapists in Saudi Arabia that needs to be addressed to provide high-quality care to patients with mental illness. Several previous studies have emphasized the importance of healthcare professionals having adequate education, training, and support to manage the physical health problems of patients with mental illness. Dandridge et al29 conducted a survey of physiotherapy students’ experiences and attitudes toward treating individuals with mental illness and found that students felt that they needed more education and training in this area. Similarly, Lucas and Parker27 conducted a mixed-methods study on the perceived role of physiotherapists in managing anxiety in patients with relapsing-remitting multiple sclerosis and found that physiotherapists’ perceived role in managing anxiety was limited due to a lack of training and experience. The findings of the current study are consistent with those of these previous studies and highlight the need for more emphasis on the education and training of healthcare professionals, including physiotherapists, in managing the physical health problems of patients with mental illness.

Implications to PT Practice

The findings of this study emphasize the need for healthcare professionals to have adequate education and training (both in undergraduate and graduate studies and at the professional level) to manage the physical health problems of patients with mental illness, the prevalence of which has greatly increased following the COVID-19 epidemic.3 The study encourages academia to incorporate more courses and training related to mental illness and connect them to clinical practice. The courses need to address mental illnesses and the role of physiotherapists in treating them, including how to effectively manage the physical health problems of patients with mental illness. Furthermore, the study emphasizes the need for the government to promote mental wellness and psychological interventions nationwide to minimize the impact of the stigma associated with mental illness in Saudi Arabia, which makes it more difficult for patients to access appropriate care.13,30

Limitations

Some limitations of the study should be noted. The first limitation is the small sample size, as only two-thirds of the calculated sample was obtained. This can be explained by the sample selection method, which was a convenience sample. For the same reason, another limitation is the over-representation of the central region. It was challenging to obtain more responses from the other regions, given that the study was conducted in the central region.

Conclusion

There is a lack of knowledge and a positive attitude toward treating patients with mental disorders, which highlights the need for more training to fill the gap in knowledge and guide and build upon the positive attitude of physiotherapists toward treating patients with mental disorders. Further research is needed to identify the specific areas where physiotherapists require more education and training and to develop effective training programs that can improve their knowledge and skills in managing the physical health problems of patients with mental illness.

Acknowledgments

The authors acknowledge the support provided through the Princess Nourah Bint Abdulrahman University Researchers Supporting Project (No.PNURSP2024R535), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Disclosure

The authors report no conflicts of interest in this work.

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