Binit J. Shah, MDDecember 8, 2011

Psychiatric and Psychiatric and Psychological Psychological Consideration for SCSConsideration for SCS

Psych vs. Psych

Psychological Trying to understand the patients current

mental state The ability to follow through on instructions Realistic expectation of results, coping skills

Psychiatric Capacity to give consent for the procedure Substance abuse Underlying Axis I or II pathology that needs

to be treated before they can undergo a trial or would preclude them from trial/implant for the foreseeable future

History of Psych eval in SCS

C. Norman Shealy recognized the importance of psychological screening for SCS: Absence of elevations on the MMPI

(except depressive scale) Emotional stability Involvement in a rehabilitation program

Current state of psych eval

Centers for Medicare and Medicaid Services (CMS) “Patients must undergo a careful

screening, evaluation and diagnosis, by a multidisciplinary team prior to implantation. (Such screening must include psychological as well as physical evaluation)”

What is a psychological evaluation? American Psychological Association

“Psychologists provide opinions of the psychological characteristics of individuals only after they have conducted an examination of the individual adequate to support their statement or conclusions.”

“When interpreting assessment results, including automated interpretations, psychologists take into account the purpose of the assessment and various factors, test-taking abilities, and other characteristics of the person being assessed such as situational, personal, linguistic, and cultural differences that might affect the psychologists' judgment or reduce the accuracy of their interpretation.”

Who should I refer to?

Someone good Someone who is timely and

responsive to you Someone who understands pain, the

patient’s diagnosis Someone who understands what SCS

really involves Someone who doesn’t approve all of

your patients

Assessment begins in your office You will (should) know the patient

better than the person you are referring to

Give information that is relevant Pt overly sedated in the office Pt told by workman’s comp this is the next

step of treatment 52 yo surgeon who wants to avoid all

meds and stay functional Give your impression of whether they

are suitable

Don’t underestimate the reports of office staff Patient calls multiple times a day to

complain of pain Patient repeatedly calls for refills

early or after hours Staff notice the patient walking

vigorously in the hallway or outside the office

Other people are calling on behalf of the patient

What (should) happens during psych evaluation? Review of medical records Psychological testing/screening forms

Beck Depression Inventory, Hamilton Depression Rating Scale, Beck Anxiety Inventory, McGill Pain Questionnaire

Clinical interview → This is really what the patient is being

sent for Assessment of risk factors/predictors of

trial success

Psychological Tests

MMPI Symptom Checklist 90-R Derogatis Affects Balance Scale Chronic Illness Problem Inventory Spielberger State-Trait Anxiety Inventory (STAI)

Scale and State-Trait Anger Scale Absorption Scale Locus of Control Scale Sickness Impact Profile Oswestry Disability Index Roland Morris Questionnaire Fear-Avoidance Beliefs Questionnaire

Clinical Interview

Risk Factors – patient beliefs

Pain is purely physical Psychological/social factors aren’t

important Pain can only be relieved if the

medical cause is eliminated Medical technology holds the key to

treatment

Risk Factors – physician beliefs Failure of intervention is the patient’s

fault Trial outcome is the only predictor of

success Because a procedure is reversible or

non-destructive, patient selection can be less stringent

Relief of pain will automatically lead to improvements in all other areas (psychological well being, increased function)

Price D, Finniss DG, Benedetti F: A comprehensive review of the placebo effect: recent advances and current thought, Annu Rev Psychol 59:565-590, 2008.

Expectation

Can contribute significantly to patient outcome

Overall, placebo effect is 2 on NRS of 0-10

When patients are given the expectation of benefit, the can have as much as a 5-point reduction in pain.

Clinical Summary

At this time, there are no contra-indications to the use of spinal cord stimulation in this patient. There is no evidence of severe untreated Axis I disorder, no evidence of somatoform disorder, no severe Axis II pathology that needs to first be addressed. Patient has a logical thought process free of psychotic influences and is able to understand the risks, benefits and alternatives of the procedure as well as what is expected from a patient perspective. Has a realistic goal regarding pain improvement, and understands limitations such as subsequent MRI and is able to verbalize understanding of wound care instructions during the trial and post-op period.

Be specific in your request

Psychological/psychiatric evaluation for appropriateness for SCS trial/implant Evaluate for severe or untreated Axis I

diagnoses and somatoform disorders Evaluate for Axis II diagnoses Evaluate capacity to give consent for the

procedure

North R, Shipley J: Practice parameters for the use of spinal cord stimulation in the treatment of chronic neuropathic pain, Pain Med 8(suppl 4): S200-S275, 2007.

What is the value of psych eval? “We lack sufficient information to predict

SCS outcome from the result of a pretreatment psychological evaluation, but SCS, as is the case for every interventional pain treatment, is reserved for patients with no evident unresolved major psychiatric co-morbidity.”

“…provides patient selection information by identifying the small percentage of patients who might benefit from psychological treatment before undergoing SCS therapy or in whom SCS therapy might be complicated by psychological factors.”

Long DM et al: Electrical stimulation of the spinal cord and peripheral nerves for pain control: a 10-year experience, Appl Neurophysiol 44(4):207–217, 1981.

What is the value of psych eval? 70% success rate in those who had a

psych eval vs. 33% in those who did not