I recently had an incident involving a long-time patient. This particular encounter proved to be challenging. The patient had chronic pain for years and had already exhausted all conventional treatment options. Ironically, he was otherwise healthy and fit. His recalcitrant condition made him a prime candidate to be treated with a spinal sord stimulator (SCS).
An SCS is an implantable device with two electrode leads connected to a battery-powered pulse generator. The electrodes are inserted into the epidural space and positioned alongside the ascending pain fibers at the level of the nerve causing symptoms. The generator sends pulses to stimulate the nerve and block pain signals from reaching the brain. SCSs are ideal for treating neuropathic pain, Complex regional pain syndrome, and failed back surgery syndrome. SCSs are an excellent treatment option, particularly in cases where other approaches have proven unsuccessful. However, the treatment is not without risks and associated costs.
There was just one problem. The standard requirement is to complete a psychiatric evaluation to get approval for the surgery. Furthermore, as it turned out, doing so was against this patient’s religious beliefs.
My patient was a member of one of several religious organizations that consider the entire practice of psychiatry forbidden. In some cases, such patients believe that interacting with the mental health system in any way will jeopardize their spiritual or physical well-being by showing a lack of faith in their God. He apologetically informed me that if taking a psychiatric evaluation was the only way for him to get a spinal cord stimulator, he’d have to do without one.
Although somewhat taken aback by his treatment refusal, I could empathize with his dilemma. This also made me reflect on the purpose of these psychiatric evaluations. Since mental illnesses often manifest as physical pain, the spinal stimulator screening protocol addressed potential psychiatric causes of pain before considering a potentially dangerous and costly surgery.
However, if this is true, why were psychiatric evaluations not required for other medical interventions routinely used to treat chronic pain in patients? What was unique about this particular procedure? Since psychiatric comorbidities can worsen almost every known medical symptom, shouldn’t we have been screening patients for psychiatric issues before any non-emergency surgery if our concern was ensuring patients received the least invasive treatments possible?
The implications were troubling. Was the requirement for the psychiatric evaluation related to the still-widespread perception that many chronic pain sufferers are “crazy” or “faking”? I thought back to a documentary I’d recently watched. Take Care of Maya is a documentary about a young girl suffering from complex regional pain syndrome who was accused by medical staff of faking her pain. Those who took an oath to treat her pain dismissed her as hysterical even as they billed her insurance for the same diagnosis they told her she concocted in her head.
Too many medical providers still believe that chronic pain with no apparent mechanical source cannot be genuine. Was this why we were compelled to check our patients for psychiatric diagnoses before performing this surgery?
Another possible reason for this screening requirement lies in the for-profit insurance industry. It is widely known that insurers often invest considerable effort to identify reasons to deny coverage for treatments. Psychiatric evaluations provide a convenient tool for this. Insurance companies have implemented psychiatric evaluation requirements for numerous surgeries, including organ transplants, bariatric surgery, in vitro fertilization, and cosmetic surgery.
In some cases, the rationale was that behavioral changes are needed after surgery to ensure good outcomes. Some have argued that patients seeking cosmetic and other elective surgeries should undergo a mental health exam before going under the knife, as they need to be “protected from” their own choices. Others have argued that, since donor organs should go to patients with the best chance of surviving transplantation, evaluating a patient’s psychiatric prognosis before giving an organ to them instead of another patient is warranted.
I agree that psychiatric assessments are warranted under certain conditions and can play a role in preventing unnecessary risk-prone procedures. Nevertheless, the extent of implementation with such a broad spectrum of applications begins to sound overly Draconian. Eligibility for appropriate and best medical care should not depend on subjective assessments that may be biased toward denying care for non-medical reasons. A key question is: What standards are used to judge the correlation between psychiatric distress and surgical outcomes?
A literature review titled “Psychiatric Screening for Spinal Cord Stimulation for Complex Regional Pain Syndrome” documents 15 psychological screening tools studied. This review showed inconclusive evidence linking screening test scores with predicting SCS outcomes. This means there is no apparent benefit to requiring a psychiatric evaluation to qualify for this procedure in practice.
Psychiatric evaluations could be a legitimate and valuable tool for treating the whole patient. That becomes especially true with a robust, evidence-based system for providing psychiatrically distressed patients with mental health treatment and community support. Unfortunately, that is not in place in the United States today. So, we must be exceedingly careful in deciding who determines who is “eligible” for treatment and what criteria we use to make that decision.
I advocate for further clarity and standards on who decides whether a patient must undergo a psychiatric evaluation. These fundamental decisions for critical health care should be detached from any conflict of interest that may arise from financial considerations.
What if research reveals that these evaluations are causing harm by denying treatment to patients who would still benefit from the surgery despite their psychological difficulties? What do we do with cases like my patient, who refuses to receive a psychiatric evaluation due to religious convictions before the procedure?
At the very least, we should demand scientifically sound evidence that denying patients treatment due to their mental state is in the best interest of the patient. We must be mindful of who decides who receives treatment and who doesn’t. We must be careful not to do harm because of the stigma around mental health.
Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness.
Christian Youssef is a medical student.