What’s Important: A Call for a Preoperative Psychiatric Risk-Assessment Metric for Orthopaedic Surgery

While having only recently started my residency training, I have become acutely aware of the profound impact of psychiatric conditions on patient outcomes following various orthopaedic procedures. An abundance of literature outlines poor improvement in self-reported pain scores postoperatively among patients with psychosomatic conditions or mood disorders, such as major depressive disorder (MDD)1-3. What’s more, a mounting body of evidence appears to suggest that patients with psychiatric conditions will not only have poor subjective outcomes but will have a more complicated perioperative course from an objective standpoint. Indeed, length of stay, rates of common postoperative complications, and total systemic costs after surgery all have been reported to be higher in patient populations with psychiatric comorbidities4-6. The literature is robust, but as someone working on refining my ability to identify a patient for whom operative intervention will be successful, I find few resources at my disposal for assessing the likelihood of surgical success from a psychiatric perspective. Few tools exist for preoperative risk-benefit analysis by which a patient’s current and past psychiatric history is considered and symptom severity is factored in. The development of preoperative psychiatric risk-assessment protocols could prove extremely valuable, especially for use by trainees in the field of orthopaedic surgery. For example, I believe that a preoperative psychiatric risk-assessment metric could be developed for orthopaedic surgery using the existing literature and cross-collaboration with our colleagues in psychiatry. In the same way that indices like the ASA (American Society of Anesthesiologists) score can quantify the risk of administering anesthesia7, and cardiac risk calculators can provide an indication of the likelihood of an adverse cardiac event8, such an index could provide a surgeon with a valuable piece of information to aid in the risk-benefit analysis that is inherent to any surgical decision-making. This metric would not serve as a definitive cutoff for surgery, but rather would help a provider gain a more complete understanding of a patient’s health. Bariatric surgery has long used such an approach. Protocols exist for the psychiatric assessment of candidates for bariatric surgery who may risk death if adherence to strict postoperative instructions is not maintained9. Understandably, these metrics focus on alcohol and drug use (following bariatric surgery, patients can become intoxicated at very low levels of consumption) and behavioral risk assessments. Therefore, a patient who has had a long history of alcohol abuse may represent a poor surgical candidate, and preoperative psychiatric assessment may preclude such a patient from bariatric surgery. In the same way, a patient with an unaddressed psychosomatic condition may not be an ideal candidate for an elective spinal procedure, especially in the setting of borderline pathology on advanced imaging. A psychiatric risk-assessment tool could further delineate these surgical contraindications and provide a means of quantification for future research. One obvious difficulty with a preoperative psychiatric risk assessment is that many psychiatric symptoms are reported subjectively (e.g., feelings of mood depression in patients with MDD) rather than objectively (e.g., ejection fraction percentage for cardiac risk). This makes the generalizability of a protocol difficult. That said, psychiatric conditions often exist on a gradient, and in the psychiatric literature, a number of metrics and scales exist for the quantification of degree of disease morbidity for common psychiatric conditions. For example, the Patient Health Questionnaire (PHQ)-9 can be used to assign a score from 0 to 27 to quantify the severity of MDD that is experienced by a patient10. Through careful evaluation of both the orthopaedic and psychiatric literature, a scoring system could be generated for specific surgeries (e.g., total hip arthroplasty) that could then be validated clinically. I recognize that a psychiatric risk score might be of more utility to an orthopaedic surgeon who is still developing his or her pattern-recognition skills with regard to patients with psychiatric conditions who are unlikely to have a good operative outcome. Perhaps a senior surgeon with years of experience is able to perform risk assessments based on a review of the chart and his or her own clinical acumen regarding the patient’s potential for pain catastrophizing. This ability would mirror that of an anesthesiologist who can simply “eyeball” a patient and make an assumption regarding perioperative risk. For those of us who are just beginning our careers, however, such a tool could be especially valuable. Even for experienced surgeons, the contribution of psychiatric diagnoses to poor operative outcomes is important to recognize. There are times when operative intervention remains the only step forward in a patient’s care, regardless of baseline psychiatric history. In these cases, the risk score could be used to allocate finite resources toward perioperative psychiatric care in order to improve the outcome as well as serve the patient more holistically. Furthermore, for patients who desire a procedure that may not be indicated, this metric could serve as a discussion point for why surgical intervention may not be beneficial. Even more importantly, I fear the possibility of capitalizing off of a patient’s condition that may have complex contributing factors that are better served with a multidisciplinary approach. Injecting an expensive biologic agent into the knee of a patient with osteoarthritic pain whose symptoms are, in fact, more consistent with fibromyalgia is unethical. Plastic surgeons face a similar dilemma when offering cosmetic surgery to a patient with body dysmorphic disorder11. In both of these cases, the true underlying pathology requires psychiatric consultation and careful consideration of first-line treatments for these conditions prior to (or in lieu of) surgical intervention. When presented with such complex cases, a psychiatric risk-assessment score may help less-experienced surgeons avoid, at best, an unnecessary cost to the health-care system and, at worst, the risk of an adverse outcome from a nonindicated procedure. I hope that the creation of a cross-disciplinary psychiatric risk-assessment score for orthopaedic surgery would encourage collaboration between 2 disciplines that often are considered very far removed from each other. In my very limited experience, I have found there to be considerable overlap, with many of the patients I encounter experiencing concomitant psychiatric illness. I often have been impressed with several of my senior attending surgeons’ careful attention to a patient’s mental and cognitive status. I believe a psychiatric risk-assessment tool would help accelerate a trainee’s recognition of the complex interplay between pain conditions, psychiatric disease, and many of the pathologies that we treat as orthopaedic surgeons.