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Pearls


Pre-surgical psychiatric evaluation: 6 considerations

A patient with an inadequately treated psychiatric disorder and/or poor social support is not a good candidate for surgery

Vol. 9, No. 10 / October 2010

Insurance companies and surgical teams usually require patients to undergo a psychiatric evaluation before major surgeries such as organ transplants,1 amputations, or bariatric procedures because these surgeries are expensive, require patients to change their lifestyle, and use limited resources. Psychiatrists perform pre-surgical evaluations by diagnostic interview, observation, and obtaining collateral information. Your evaluation should address key elements and give the surgical team input about a patient’s suitability for surgery. You also can comment on treatments that would make the patient a better candidate for surgery and plan for post-surgery psychiatric morbidities.

Key elements

Major mental illness. Without adequate treatment, major mood disorders can make a patient unable to undergo surgery. In addition, these types of surgeries are substantial life events that can trigger mood episodes. Educate patients about early signs of relapse and suggest a plan of action for treatment. A patient with an uncontrolled psychotic disorder and poor social support and/or case management is not a good candidate for surgery.

Substance use. Patients with active substance dependence are poor candidates for major surgeries unless they receive substance abuse treatment. During evaluation, motivational interviewing can help guide a patient toward treatment. Ensure that patients whose substance dependence is in remission have adequate support and treatment plans to prevent relapse.

Capacity to make decisions is based on the nature of the procedure and the patient’s ability to understand the process and risk vs benefits. The threshold for capacity can vary based on the procedure and the risks.2

Treatment adherence requires compliance with close medical follow-up, complicated medications, or lifestyle changes. A history of compliance with medical directives, medications, and appointments is important. Collateral information from the surgical team or caregivers can be helpful.

Coping style and strategies. Quiz the patient about internal and external resources they have used to cope with stress. A pattern of decompensation to using primitive defense mechanisms to handle stress suggests that the patient may have a personality disorder and might be a poor surgical candidate. Ability to use relatively mature defense strategies in stressful times suggests a good candidate.

Safety. Active suicidal or homicidal ideation is problematic in patients seeking major surgical interventions. Ensure that the stress of the surgery will not trigger dangerous behaviors. A history of frequent self-harm or impulsive suicidality suggests the that patient may have an unstable axis I or II disorder and might be a poor candidate for major surgery without further treatment.

References

1. DiMartini AF, Dew MA, Trzepacz PT. Organ transplantation. In: Levenson JL, ed. The American Psychiatric Publishing textbook of psychosomatic medicine. Washington DC: American Psychiatric Publishing, Inc.; 2005:675–700.

2. Magid M, Dodd ML, Bostwick JM, et al. Is your patient making the “wrong” treatment choice? Current Psychiatry. 2006;5(3):14-20.

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