How Physical Therapy Can Benefit Patients With Depression And Mental Health Conditions With Tony Varela, PT, PhD

Welcome back to the Healing Pain Podcast with Tony Varela, PT, PhD

It is great to be here with you again. In each episode, we generally discuss the impact of physical therapy treatments on the management of chronic pain and other chronic diseases. From there, we have explored other overlapping problems and conditions, such as things like opioids, the over-prescribing of opioids or addiction, and the movement to choose physical therapy as an alternative to opioid medication.

A clear movement also exists for a physical therapist to play a more pivotal role in treating and managing non-communicable diseases such as diabetes, metabolic syndrome, hypertension, and cardiovascular disease. This should not be too much of a leap because, as physical therapists, we have had a specialty in cardiopulmonary physical therapy for many decades. Something happened during the COVID-19 pandemic which changed our profession as well as changed our personal lives.

America’s mental health declined, with anywhere between 28% to 40% of adults struggling with depression during the height of the pandemic. Many of those numbers have stayed consistent. More people have been prescribed antidepressant medications and the mental health care shortage intensified with many providers in clinics having waitlists of 4 months to 1 year, which left many people without essential healthcare or mental health care services. As licensed doctoral trained healthcare professionals, we, physical therapists, whether realize it or not, see people with mental health concerns daily in almost every practice setting.

Our profession, like many others, has begun to advocate for ways to improve mental health and mental well-being. We now know that the epidemic of depression requires a supporting role by physical therapists. The reason is that the influence of physical therapy extends way beyond the physical benefit. It improves mental health and promotes mental well-being. Screening and addressing behavioral and mental health concerns are within the scope of physical therapy practice guidelines.

The American Physical Therapy Association published these guidelines in 2020 in the House of Delegates’ position statement. This position is generally in line with the best evidence and the growing trend in psychological uniform physical therapy, which incorporates bio-psycho-social treatments for chronic pain and other health conditions.

A few decades before the American Physical Therapy Association published these guidelines, there was the International Association for Physical Therapy and Mental Health, which is a sub-chapter of the World Confederation of Physical Therapy, which described the need and scope of physical therapy and mental health, behavioral health, and psychiatry.

What we are seeing is the construct of psychologically informed physical therapy is the same, similar to, or compliments mental health physical therapy, which is used to facilitate body awareness, problem-solving skills, cognitive restructuring, and ways to cope, which reinforce self-efficacy and improve quality of life in the face of poor mental health.

It would then appear inherent that a physical therapist can use biomedical treatments as well as psychosocial treatments based on their key role in reducing disability and fostering positive human growth. Occasionally, as physical therapists, we sell ourselves short and fail to understand the depth and the breadth of the impact we can have on someone’s quality of life. What I am referring to is the emotional and psychological benefits that can increase the value of care that we provide as individuals and as a profession.

Now more than ever, it is important that we understand and explain the breadth of the therapeutic benefits that we provide because studies demonstrate that approximately a quarter of all Americans may have a mental health condition. 25% to 50% of patients in a general outpatient physical therapy clinic have a mental health condition and upwards of 70% of patients with low back pain that report to physical therapy have some level of depression. We are already seeing this in practice.

There is a place for us to be primary care and entry point providers into the mental health care system. However, that does not mean that we simply “refer out.” It means that. As professionals, we stay engaged in patient care, and we continue to play a role independently or in the code management of the mild, moderate, and severe depression or other mental health conditions that exist in the populations of patients that we treat.

In fact, there is some literature that mild to moderate depression improves over the course of physical therapy, regardless of whether or not a mental health provider is engaged in the plan of care. How can that be or why is that? It is because movement, body awareness, physical activity, exercise, and many other interventions that we use as professionals are a catalyst for positive mental health and improved psychological well-being. When you combine physical activity with cognitive reappraisal, there is generally a greater impact on outcomes and the quality of life of the patients that you care for.

Joining us to discuss the role of the physical therapist in treating depression is Dr. Tony Varela. He is a physical therapist who brings many years of experience in musculoskeletal health, including pain management. His professional principles were paved through residency and fellowship, grounded and rich patient experiences, and reinforced by serving those surviving chronic pain, cancer, as well as trauma, and PTSD from war.

He believes there is a better version of ourselves ready to push through and he is an Assistant Professor at Arkansas College of Health Education. Tony authored a paper in the February 2022 edition of Physiotherapy Theory and Practice called The Theatre of Depression: A Role for Physical Therapy, which we will discuss in this episode. Without further ado, let’s begin. Let’s meet Tony and discuss the role of physical therapy in the treatment of depression.

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How Physical Therapy Can Benefit Patients With Depression And Mental Health Conditions With Tony Varela, PT, PhD

Tony, thanks for joining me.

Thank you. It is great to be here.

I am excited to speak with you. I know you published an article perspective paper called The Theatre of Depression: A Role for Physical Therapy. It is in the 2022 journal of Physiotherapy Theory and Practice. It is a great paper that you wrote. The title as our researching through the lecture popped off the page to me. We do not often hear of there being a role for physical therapists in treating mental health, specifically, the condition or diagnosis of depression.

It is becoming talked about more and more in professional circles, literature, DPT education, continuing education, and public venues like this. There are both people with chronic health conditions as well as professionals that are interacting, collaborating, and listening in a community environment. I know you teach and do research. Where did the idea for this manuscript originate from?

The title for the papers was something that came to me as a title that would encompass the spectrum of depression and mental health that physical therapy could be involved with and to a much greater degree. I think we have to accept that there is a role, and the mental health community also has to bring us into that theater or that realm of mental health. That is one of the reasons why I wrote it, but it has been an evolution in my career and in my understanding of what the psychologically informed physical therapist is and should be.

Now I have landed on the idea that mental health is a part of physical health. If we are going to promote mind, body connection, and awareness, we have to embrace the mental health portion of it. I do think there is a spectrum of mental health issues that physical therapy could be involved with and needs to be involved with not only from our side as we move into that world, but from the mental health world, willing to open up and utilize us to a much better degree. I hope that answers the question, which talks to the idea that it has been an evolution for me. Now I am trying to promote the idea that it is an evolution for and mental health.

It addresses that question as we begin. Even in what you said right there, there is a lot to unpack and we will unpack that as we go through this episode. Let’s talk about a couple of things there. You mentioned that there is a role for physical therapy in different types of mental health conditions. You are saying things like depression, which is in the paper, anxiety, PTSD, and maybe other types of psychopathology. Within those conditions, there is also the severity. For example, there is mild, moderate, and severe depression. Is there a role for PT at all three of those levels for mild, moderate, and severe conditions or severe disease?

I do think there is a role for all three. Where we can open the door and drive an impact that shows the mental health community that we should be an integral part of that community would be on the mild and moderate levels of depression and then utilized accordingly or appropriately once things stabilized with the more severe cases, particularly in isolated to depression, but that certainly would not include issues of PTSD and some of the other mental health concerns.

In that case, we are talking to the physical therapist and helping them identify that they have a role in mild, moderate, and potentially even severe depression. You brought in the idea that you would like to have mental health professionals bring our profession under the umbrella of mental health treatment.

I have spoken to many mental health providers on this show and support the work they do, but I have many licensed psychologists and mental health providers on this show say things like this, “Once the patient’s pain decreases, then I can refer them to physical therapy or once their depression gets better, then I can refer them to physical therapy.”

As I listened to them, and because I am on a show, I do not necessarily want to disparage too strongly what they are saying or maybe even some of their research, but I think there is this idea of, “If the pain goes away, then I can exercise. If depression decreases, then I can engage in a physical activity program,” where we have to educate the public that these two things can exist at the same time.

The paper speaks to the idea that, in general, exercise delivered by the physical therapist is considered ancillary or alternative medicine.

The word ancillary drives me up a wall. We are talking peer-to-peer. The word ancillary to me sounds like we do not need it, but we will allow it to happen basically.

It is time to include it as colleagues that can contribute to not only the full diagnosis of depression because there are physical impairments and levels of disability that directly relate to the levels of depression, so why not get involved from the very beginning? The idea of eliminating fit a movement and physical awareness from the rehab process of mental health may be doing them a disservice. I have with the paper to suggest that, clearly, whatever has been going on now has not been working. It requires, at the very least, rethinking the patterns that have got us to this point and how they can change.

Because we are talking about depression, the guidelines for depression are CBT or antidepressant medication as the first line of treatment works sometimes.

As I said in the paper, even pharmacology or pharmacotherapies, for all intents and purpose, is a blunt instrument that helps a few individuals.

For example, as first-line therapy, you are potentially suggesting that physical therapy could be added to the first-line treatment of something like depression that takes some exercise. I want to place that there lightly because there is a lot more we do as professionals than just therapeutic exercise. We know that the research on exercise for depression is quite strong. If you combine exercise with cognitive-behavioral techniques, the impact is probably greater.

The reappraisal of the sensations, movement patterns, and self-awareness combining the cognitive-behavioral therapies and the therapeutic exercises enhances whatever other psychotherapies they have been receiving and going through as well as the application or efficacy of the medications.

If our treatment can enhance the outcome, then it should not be looked upon as ancillary.

HPP 279 | PT For Mental Health
If we are going to promote mind-body connection and awareness, we have to embrace the mental health portion of it.


I have a hard time wrapping my mind around the idea that that word is still being used with physical therapy or occupational therapy.

As you were starting to put together this manuscript, you were outlining it and doing the research. Was there a concern about how the manuscript would be received by our peers within the PT profession or by other colleagues outside of the physical therapy profession about a physical therapist talking about the treatment of depression? Maybe this guy is a little bit outside or he is outside his scope.

Writing did not come with a certain level of anxiety on my part because I am putting myself out there and going against what seems to be the status quo here in the United States. I did have apprehension about suggesting the challenges with our state of affairs in mental health. I did not want it to come across as disrespectful in any way because I think the intentions are genuine. The purposes that drive the other disciplines are genuine.

What I am concerned with is why aren’t we willing to discuss the challenges that they face, and why aren’t we invited into that conversation? In the end, I landed on the idea to not publishing it or not making the suggestion was probably more of a disservice than holding back those thoughts. It does come from a place of respect for all disciplines. We all have something to contribute. Now it is time for physical therapy to offer the opportunity to contribute to a greater degree than we have.

You mentioned the potential perspective of a growing trend now called Mental Health Physical Therapy or Mental Health Physiotherapy, which probably started somewhere in the Northern European countries. I had come across some of the alerts here when I wrote my paper on mindfulness, which is in PTJ.

I know you have come across it in this manuscript that you completed is now published in physiotherapy theory and practice. What are the differences or some of the eye-opening moments that you saw when you were writing this manuscript, and what are physiotherapists potentially doing in those Northern countries from their perspective versus what we are doing here in the United States?

It was an eye-opening endeavor for me to get the nuances. That has been part of my evolution to understand the psychologically informed physical therapists. With that being said, we are looking at how mental health or depression specifically is being diagnosed. It is through psychiatry and psychology but more importantly, it is being diagnosed in primary care. They are the gateway to mental health.

The idea is that many times, the expressions of depression are unique to the individual that there are probably a lot of cases that are overlooked as a mental health issue because the expression seems to exaggerate pain or disability as opposed to despondence, despair, and sheer negativity on life. That carries over into physical therapy, where we will see somebody exaggerate their pain levels and focus on levels of disability and poor movement strategies as the issue.

There is an underlying cause that is directly related to their mental health, and that is established in the paper. We need to open up our eyes to understand the correlation between those mental aspects and physical impairments to a much better degree. To reiterate, the idea is we are probably already more involved than we give ourselves credit for. There is an aspect that is being overlooked by the mental health community that should be an eye-opening moment for them to invite us into the conversation. That was probably the most enlightening aspect of the paper.

Let’s talk about that a little bit because I know what you are saying because I have read some of the research on that. There have been some studies where they have looked at outpatient physical therapy clinics and also surveyed physical therapists about what percent of patients they see on a daily basis potentially present with a mental health challenge. The numbers are somewhere between 40% and upwards of 70%, depending on the practice. We see that in practice, and you are saying the gateway for that is through primary care or even orthopedic care because that is oftentimes how people find us.

The majority of those cases go into mental health, if they go into it, which is a whole other discussion to the primary care.

That talks to the idea. It is not whether we can see patients with mental health needs or not. We are already seeing those patients in our clinic. Some of them may not necessarily be identified through the depression and stress scale, for example.

The challenge goes a little bit farther for us because I know a lot of clinics do screen for depression, particularly if they are outpatient clinics associated with the hospital, but then they never do anything with that information.

The piece that I want to backtrack a little bit is what you said in primary care that many physical complaints may be disguised as “mental health conditions.” I wonder if we reframe that more as there are bi-directional associations between mental and physical health if that is more helpful for those who are suffering from these types of conditions. If we say to people, “You went to your primary care doctor for chronic low back pain and you were sent to the physical therapist, but it was discovered that you have, let’s say, primary depression.”

There isn’t a role than physical medicine in that person’s care where if we talk about these conditions as having bi-directional mechanisms between the physical and the emotional or the physical and psychological, then it helps people to potentially embrace the idea that, “I am a whole person. As part of my whole health, I have to care for my mental health as well as my physical health. When I do that, both of them have a positive impact on my well-being and resilience.”

I did not mean to imply that it was not. What I was expressing is directly related to the way that the patients are going to express it. I do 100% agree with you. It is bi-directional. The overlap between them is incredible and nuanced. We have to respect the expressions that are important to the person that we serve and the context in which they are expressing them. They might focus on the physical impairments sitting in front of a physical therapist. The levels of disability associated with that individual and with a mental health need to be addressed as we would normally address them, but now bring in the cognitive portions and the cognitive functional therapies that are consistent with that.

There are a lot of physical therapists reading this episode right now. Many of them are interested in mental well-being and mental resilience approaches. Some of this is new for them. If they had been following some of my work, it is probably not new, but there are people reading this for the first time because they said, “This is an interesting topic. I want to know what Tony and Joe were talking about with regard to mental health physiotherapy.” Let’s play devil’s advocate. I want to ask you a couple of questions. Some of these will be yes and no. Some of these will need a little more to unwind from what we have here. First one, does a physical therapist have a role in mental health?


Can a physical therapist treat depression as a primary diagnosis?

HPP 279 | PT For Mental Health
There are physical impairments and levels of disability that directly relate to the levels of depression, so why not get involved from the very beginning?


If physical therapists can treat depression as a primary diagnosis, I am very cautious about saying that the diagnosis of that should come from other professionals. A level of collaboration is required to understand these specific mental health diagnoses that would be provided by a counselor, a psychiatrist, or somebody of that nature.

Can physical therapists screen for psychological and emotional components of health and well-being?

Absolutely. I have alluded to that. We are already doing that to some degree. The challenge is we screen for it and overlook it for the most part.

If physical therapists have been identified as primary care providers and entry point providers, can we then evaluate/screen and diagnose primary depression?

Therein lies the rub. We want to have direct access. We want to be primary care practitioners. With that comes the responsibility of taking on mental health. I do think that we should take that responsibility.

I appreciate you making the distinction between direct access and primary care because direct access means that I can see a physical therapist without a physician’s referral, where primary care physical therapy means that I, as a licensed doctoral trained health professional, can embrace a full systems view of the body, know-how to evaluate and screen for things, and then triage the patient appropriately.

Also, it reflects on my own personal scope of practice and knows that if I have taken ten different courses in Mental Health Physiotherapy, it may be well within my scope of practice to screen or diagnose and treat this patient and/or refer and collaborate if needed or I may be, in a primary care setting where I screen for depression identify it and then refer on to the appropriate mental health provider or a licensed health provider to treat them. There are lots of different professionals who fall into different areas, and as their profession advances or as they advance their scope of practice and their education, their approach may change as well.

I would go one step farther and suggest that if we are going to take on that role or any individual in the physical therapy discipline takes on that role, they need to also embrace this component of it. As I have suggested, the mental health gateway is through primary care. Recognizing that puts a much greater onus of responsibility on us to help contribute and manage the challenges that the primary care physicians are going through.

I have heard psychologists say that primary care providers are not very good at evaluating and diagnosing mental health conditions. A lot of people fall through the cracks there.

The paper speaks to that as well. The middle part is a 50% diagnostic accuracy, and most of the time, it is done on a clinical determination without full screening or anything else. It speaks to the potential door that is open for physical therapy to come in and help primary care in general. They are busy and get schedules that are full moments. They have their algorithms. They go through those algorithms and anything out of that algorithm gets potentially overlooked. Physical therapists can help with that.

A colleague in front of mine, Jeremy Fletcher, who teaches a Trauma-Informed Pain course here at the Integrative Pain Science Institute oftentimes says that in some parts of the country, in some clinical contexts, physical therapists are becoming the de facto mental health providers in their area, either because they are not enough mental health providers or they are coming through gateways like primary care where there may be improperly diagnosed or misdiagnosed, or we have a role to fill. If our peers recognize that, and your research is supporting it in some ways, we are becoming de facto mental health providers for certain mental and physical health conditions. Why are some of our peers potentially hesitant to take on this responsibility of mental health physical therapy or mental health physiotherapy?

I completely agree with the comment that Jeremy Fletcher stated. Asa good example of that, I believe in collaboration with the other disciplines, which includes occupational therapy. With that being said, I have tried to refer some of my patients to counseling and psychotherapist. I get a response. I can get them on my schedule four months from now. By default, I have to take on the part of that responsibility.

The challenge of other therapists taking it on is the educational process has not completely embraced it. It might be psychosocial, bio-psycho-social, embodiment theories, and social cognitive theories sprinkled throughout the curriculum. It has never been fully embraced, even though some universities now have a Bio-Psycho-Social course and may involve some psychologists as part of that.

The psychosocial components were threaded through all of the books that we are teaching from, whether it is ortho, neuro, pediatric, geriatric, or whatever. That is a part of it. The other challenge is still this abrasiveness between some of the disciplines that consider us ancillary, alternative medicines, the last resort, and the Allied health components. It put us in a corner where we are hesitant to fight our way out because of whatever reasons, like stepping on toes or respect for the community. I am not sure where that goes.

The combination of those three things is the challenge that we face and have to overcome, education, taking on the responsibility, and then having the patient speak for us. I know when I have embraced it and have taken that on with my patients and those that I serve, they are grateful. They end up spreading the word. Some of those primary care practitioners ended up referring back to me because I was willing to take it on.

Part of that conversation goes is that, on some level, we compete as professionals. I have a colleague who works in a multi-disciplinary pain program with an inpatient and outpatient component. They frame it as a psychology-led program. I have always found that interesting. I am nothing against psychology. I love psychology, but I am like, “Psychologists can’t perform a physical evaluation. How would they be able to differentially diagnose, let’s say, chronic low back pain from a tumor in someone?” These are things that circle through my mind.

I know in a university setting and university hospital settings, collaboration is a lot easier. In our capitalistic US healthcare system, we compete for patients. We compete for insurance coverage. For example, there are many insurances that will not cover two different types of therapies at the same time.

There are systemic reasons why this does occur to some extent where the onus may be on the insurance company to provide more coverage or maybe laws in certain states that would open up more avenues for us to function in our fullest capacity as primary care physical therapists and to facilitate this type of conversation that you are opening. If you are talking to your colleagues in mental health, how would you like them to start to approach physical therapists and have this conversation with them about depression since that is the theme of your paper?

You touched on a few things that are also important, going back to the previous question. The issue of the system itself is a barrier that we have to overcome as well. The insurance companies in the way that they see us, and part of that is it is a very tough idea of the nuances that are associated with mental health and the balance between the mind and the body. It does require a special kind of person, something to the effect of like pediatrics. I am not the person for the pediatric patient, but I think I am the person for mental health. With that being said, that is where I land with this last question. I would want someone who is interested in physical therapy to embrace the idea that it does take you slowing down a little bit.

HPP 279 | PT For Mental Health
The mental health gateway is through primary care. Recognizing that puts a much greater onus of responsibility on physical therapists to help contribute and manage the primary care physicians’ challenges.


It takes an open mind and a willingness to understand an individual from the way that they see life and the issues that have got them to that point, both mental and physical. At the same time, if we are going to embrace the idea of the bio-psycho-social components, we do it with a genuine reverence for the human condition and the spectrum and nuances associated with that. If we all liked the sports therapists, we would jump on Sports Psychology, which might not be any different than the individual who is struggling with a fear of falling or who is dealing with chronic pain in overlapping depression, distress, and anxiety. It is nuanced. It requires a special ability to negotiate that emotional and physical traffic between you and the individual that you are serving.

How is your research on this work impacted your personal life?

All I know is a lot of people say I am a great listener. I have learned to slow down and hear what people are saying. That is the way that it is impacted me. I do some mindfulness work with my patients. I believe in reappraising the perceptions and the cognitions around them. Our behaviors and efficiency of our movement reinforce anything internal, which are our sensations, perceptions, and cognitions. I try to be that within myself, be more aware of it within myself, and truly walk the walk when it comes down to it.

With that in mind, I have also been branching out because I think the common threads with mental health and chronic pain also carry over to substance abuse. Those common threads are self-efficacy and emotion regulation. Those are aspects that come through with mind and body connections, therapeutic exercise, functional exercise, as well as mindfulness training. I would also tell my colleagues that they need to embrace the idea of mindfulness training as a portion of that. We are talking across the spectrum, whether it is spinal cord injury, Parkinson’s, chronic pain, and possibly even pediatrics.

What you are saying is, as a profession, we are latching on to the idea of psychologically informed care for people with pain. We have checked off that box, we get that, and professionals have embraced that unless you are saying chronic pain is only a small part of what we do as PTs. There is a whole other realm of different practice settings where we are functioning, most of them you mentioned, where these skills can be used as well.

I do think that we have gotten to the point where it is a disservice if we are isolating ourselves from the chronic pain patient. There are a lot of people struggling out there. We can tie it all together with the mental health, the substance abuse, the chronic pain, and then the day-to-day struggles of anxiety, distress, and the associated comorbidities with that. We have a lot of work to do as to what it comes down to. We should be a much bigger part of the mental health component across the spectrum of the diagnoses that we would see in physical therapy.

The American Physical Therapy Association released a position statement in 2020 on the role of the physical therapist and behavioral and mental health, which is great. House of Delegates’ position statement or perspective, we hope, gets adopted by state practice associations. Sometimes it does in a direct way. Other times it is a little bit of an indirect way. What would you like to see our professional association, state and national levels, do with regard to moving forward the idea that physical therapists have a role in treating depression?

We need to lobby to a much greater degree to be involved as a mental health team. That is where I land on that. What is interesting is there is not a mental health physical therapy SIG. Maybe that is where we start, then start a lobby to a much greater degree to have us included or become inclusive to the mental health community. We should be colleagues with counselors, social workers, psychiatrists, and primary care physicians that are all taking care of mental health.

To piggyback on that, there is also the International Association of Mental Health Physiotherapy, which I believe is a group under the World Confederation of PT. The US is not a member country of that.

It is interesting because I did email and communicate with them to try to make that, and they referred me to you. They said, “You need to collaborate with Joe and get this going.”

The International Association is a wonderful association. They have some great guidelines. A lot of them we have spoken about, in some way, in this episode. We have specific practices and systemic guidelines that exist within the insurance and state laws that are both implicit and explicit that slow down this conversation at a time when this conversation should be rapidly evolving, especially in the United States of America in a post-COVID era. I have multiple friends in the mental health profession. I spoke to them, and they said, “I think it is 2 or 3-month waiting list.” I do not say anything because I am not advocating for them at that moment.

They are my friends, not colleagues, but in the back of my mind, I am like, “What are these people with mild to moderate depression doing as they are sitting around waiting for a mental health service to open up?” We know that might not open up the way things are going. To speak about that on a more significant and serious level, we know that when people have a condition and do not have access to care, their symptoms may get worse. We know when people have chronic pain and comorbid mental health challenges that go and addressed, it leads them potentially more towards suicidality.

This is why I appreciate your paper and this conversation because as a profession, we need to be a lot more aggressive in what we are saying in our literature, teaching in school, and in the professional conversations, we are having online and offline with colleagues, universities, and medical centers and say, “Mental health is clogged up. I am not saying I can treat schizophrenia necessarily but you can send me your patients with mild to moderate anxiety and depression. Exercise and physical activity, along with some cognitive skills that we use naturally as PTs and coaching skills, can positively impact that person’s health and mental well-being and resiliency as they are waiting to get in to see a mental health provider who can go deeper on the topics that they need to go on.”

As the commercial says, “If you are not getting help here, please get help somewhere.” We are already doing it to a certain degree. Now it is time to up our game with it so that we are more involved. Clearly, the situation has become one where there is a huge fallout and unintended consequences of the comorbidities associated with depression, disability, the behavioral challenges with our mortality, and the progression of the disease process, including mental health diseases that are going to make it even more challenging in the future if we do not address and jump in now. Those are the cases that we know. There are probably a lot of other cases that we are unaware of or we overlook because of some of the physicality that is associated with them.

This came up early in the evolution of this show as I was speaking with Beth Darnall, who is a pain psychologist. She does amazing work on studying and investigating tapering. Her work shows that when you use some basic cognitive skills to help people taper, it not only helps with their pain but it helps them taper off opioids in a way that is healthier. My question is, “If we took the millions of people that were on opioids who potentially chose because people choose to taper. Typically, it is more successful, but there are not enough mental health providers to help those people taper.”

“The next best person for that is a physical therapist. We have meta-analyses and systematic reviews that demonstrate we can use cognitive behavioral skills, traditional CBT, and whole protocols of traditional CBT to treat pain. Why can’t we now expand that to treat pain and help someone taper at the same time and know the limits of our scope of practice when that taper is not going well, and then refer someone back to whatever primary care or addiction medicine?”

We probably have a couple of million people who want to taper and do not have the resources to do that or the professional to help them do that. When I read your paper, there were overlaps with depression, anxiety, pain, and physical health, and then you mentioned addiction and things like tapering.

That parallels with primary care who were prescribing the opioids and then, in many cases, stopped because of the bylaws, the mandates, and other things of that nature. Now, they have left a group of people abandoned. If we are going to accept that primary care role and that responsibility, those are people that we did not have to abandon. I love Beth Darnall’s work. I follow her as well.

It has been a great time with you about the role of physical therapy in the treatment of depression and other mental health conditions. If people want to learn more about you and your work besides this paper, how can they follow you?

HPP 279 | PT For Mental Health
It takes an open mind and a willingness to understand an individual from how they see life and the issues that got them to that point, both mental and physical.


At the very least, I hope that that paper is inspiring to a group of physical therapists and occupational therapists. Thank you for having me. I do not do a whole lot of social media. I am trying to change that. I do have an Instagram, Facebook, and a webpage, The handles are @Physical.Intel. People can also reach me. The easiest way to do it would be to email if they wanted to communicate. I would hope that we can do some work together or get the word out there to start a SIG or become a part of some of those other organizations that you have mentioned.

If you are reading this episode and you are on your smartphone or cell phone, take a picture of the episode, and you can tag Tony on Instagram and me @DrJoeTatta. We will be sure to get some more of our colleagues interested in this conversation and start to open up a broader conversation, not only in the PT world but in the mental health profession as well. It has been great to spend this time with all of you and we will see you in the next episode.

Thank you very much.


Important Links


About Tony Varela

Dr. Varela brings 20 yrs of experience in musculoskeletal health including pain management. His professional principles were paved through residency and fellowship, grounded in rich patient experiences, and reinforced by serving those surviving chronic pain, cancer, and war. Dr. Varela believes there is a better version of ourselves ready to push through.

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