Psychological assessment for implantable therapies Dr Pete Murphy Consultant Clinical Psychologist Dept. of Pain Management Walton Centre

Is psychological assessment necessary for SCS patients? YES - 1998 Consensus statement Task Force of the European Federation of IASP Chapters (EFIC) - Gybels et al. (1998)‏ YES – 2004 Pain Society Guidelines “ data from the literature shows that a careful psychological screening leads to a significantly better outcome for SCS procedures”

YES - 1998 Consensus statement Task Force of the European Federation of IASP Chapters (EFIC) - Gybels et al. (1998)‏

YES – 2004 Pain Society Guidelines

“ data from the literature shows that a careful psychological screening leads to a significantly better outcome for SCS procedures”

Psychological Assessment of Candidates for Spinal Cord Stimulation for Chronic Pain Management. Expert Panel Report 2004 ( Beltrutti … North, Turk, Melzack & others) Pain Practice vol. 4 Sept. 2004 ) Found Personality per se is not predictive of outcome evidence supports psychological assessment, but it’s based on single centre studies, with different methodologies and small numbers therefore meta-analyses difficult recommend a brief battery with clinical interview

Found

Personality per se is not predictive of outcome

evidence supports psychological assessment, but it’s based on single centre studies, with different methodologies and small numbers therefore meta-analyses difficult

recommend a brief battery with clinical interview

Why Assess ? Mental health problems common in Chronic Pain Chronic Pain and anxiety 15% to 50% (McCracken et al. 1999) Chronic Pain & depression 30% to 100% (Fishbain et al. 1997)‏ Chronic Pain and somatoform disorder ? (Bankier et al. 2000)‏

Chronic Pain and anxiety 15% to 50% (McCracken et al. 1999)

Chronic Pain & depression 30% to 100% (Fishbain et al. 1997)‏

Chronic Pain and somatoform disorder ?

(Bankier et al. 2000)‏

Psychological factors are associated with poor outcome Depression Catastrophising Anxiety are strongest predictors of disability at 2 yr follow-up Significantly better than pain or current level of disability (Sullivan 2001)‏

Depression

Catastrophising

Anxiety

are strongest predictors of disability at 2 yr follow-up

Significantly better than pain or current level of disability (Sullivan 2001)‏

psychological factors contd... active psychosis somatisation disorder severe sleep disturbances serious drug or alcohol addiction lack of social support major cognitive deficits unresolved compensation unrealistic outcome expectations (Gureje et al. 1998; Macfarlane et al. 1999)‏

active psychosis

somatisation disorder

severe sleep disturbances

serious drug or alcohol addiction

lack of social support

major cognitive deficits

unresolved compensation

unrealistic outcome expectations

(Gureje et al. 1998; Macfarlane et al. 1999)‏

Current UK practice Survey by ACKROYD et al. 2003 69 Consultants involved in SCS implants contacted - 44 responded 41 respondents work in MDT setting 38 had a Clinical Psychologist in the team 24 worked with developed guidelines

69 Consultants involved in SCS implants contacted -

44 responded

41 respondents work in MDT setting

38 had a Clinical Psychologist in the team

24 worked with developed guidelines

So for the MDT… The question is not just are they suitable but also are they ready?

The question is not just are they suitable but also are they ready?

Psychologist can be involved at: Assessment & preparation During the procedure (trial & implant)‏ Post trial Post implant

Assessment & preparation

During the procedure (trial & implant)‏

Post trial

Post implant

Initial clinical interview Psychosocial setting ( maintaining factors)‏ Family background, current stressors Significant others Beliefs Check for understanding & possible misunderstandings Expectations Do they have a plan B if SCS doesn’t work?

Psychosocial setting ( maintaining factors)‏

Family background, current stressors

Significant others

Beliefs

Check for understanding & possible misunderstandings

Expectations

Do they have a plan B if SCS doesn’t work?

State vs. Trait factors Potential for clinicians to: overstate dispositional factors (neuroticism) and underplay situational factors Watch for psychopathologising a miserable situation Poor outcome could be reflection of poor management – not the patient’s fault !

Potential for clinicians to:

overstate dispositional factors (neuroticism) and

underplay situational factors

Watch for psychopathologising a miserable situation

Poor outcome could be reflection of poor management – not the patient’s fault !

Facilitate patient risk assessment Anxious people may lousy statisticians Do they understand the odds? How is the information framed ? Get them to contemplate their own possible response to various outcomes black & white or graded ?

Anxious people may lousy statisticians

Do they understand the odds?

How is the information framed ?

Get them to contemplate their own possible response to various outcomes

black & white or graded ?

Informed consent Agreeing or compliance? demand characteristics/ social desirability ( May account for discrepancy between trial and permanent )‏ Dissenting for the right reasons? How much do they understand?

Agreeing or compliance?

demand characteristics/ social desirability

( May account for discrepancy between trial and permanent )‏

Dissenting for the right reasons?

How much do they understand?

Manage distress Work on their distress related or unrelated to pain, which if left untreated could interfere with SCS outcome Look for strengths in the patient as well as risk but watch out for Excessive stoicism

Work on their distress related or unrelated to pain, which if left untreated could interfere with SCS outcome

Look for strengths in the patient as well as risk

but watch out for Excessive stoicism

Facilitate behavioural change Breaking the habits of disability Goal setting and pacing Get them to internalise self-management rather than simply be compliant/ adherent

Breaking the habits of disability

Goal setting and pacing

Get them to internalise self-management rather than simply be compliant/ adherent

No Psychologist ? Psychometric screening & yellow flags reports pain being constant, no variability despite a range of interventions ‘ nothing eases it’ frequent visits to GP for pain or other issues >12 per year)‏ Multiple complaints

reports pain being constant, no variability despite a range of interventions ‘ nothing eases it’

frequent visits to GP for pain or other issues >12 per year)‏

Multiple complaints

Psychometric questionnaires Beck Depression Inventory-II Pain Anxiety Symptoms Scale Pain Catastrophising Scale Pain Self-Efficacy Questionnaire Roland & Morris Disability Questionnaire Visual Analogue Scale (pain)‏

Beck Depression Inventory-II

Pain Anxiety Symptoms Scale

Pain Catastrophising Scale

Pain Self-Efficacy Questionnaire

Roland & Morris Disability Questionnaire

Visual Analogue Scale (pain)‏

What to look for in the questionnaires Depression (BDI) – has 2 factors 1. Somatic factor - only high on this suggests primarily pain presentation 2. Cognitive-affective factor - high suggests depression If BDI >24 then possibly refer on If BDI >30 then always refer on

Depression (BDI) – has 2 factors

1. Somatic factor - only high on this suggests primarily pain presentation

2. Cognitive-affective factor - high suggests depression

If BDI >24 then possibly refer on

If BDI >30 then always refer on

Catastrophising Pain Catrastrophising Scale (Sullivan 2001)‏ Highly associated with ongoing and future disability Range 0-52 If >35 then possible refer on

Pain Catrastrophising Scale (Sullivan 2001)‏

Highly associated with ongoing and future disability

Range 0-52

If >35 then possible refer on

Pain Self Efficacy Questionnaire Assesses the patient’s view of their ability to manage their pain Range 0 –60 (Higher better)‏ If <20 then possible refer on to psychologist

Assesses the patient’s view of their ability to manage their pain

Range 0 –60 (Higher better)‏

If <20 then possible refer on to psychologist

Pain Anxiety Symptom Scale assesses Fear Avoidance behaviour High score can be associated with poor adherence to exercise/rehab in long term Range 0-200 If score >100 consider referring on

assesses Fear Avoidance behaviour

High score can be associated with poor adherence to exercise/rehab in long term

Range 0-200

If score >100 consider referring on

Refer to a clinical psychologist and/or PMP ? BDI (Depression) >24 Catastrophising >35 Pain Anxiety >100 Self-efficacy < 20 If 2 out of 4 then definite yes

BDI (Depression) >24

Catastrophising >35

Pain Anxiety >100

Self-efficacy < 20

If 2 out of 4 then definite yes

Case example 1 Pt extremely fearful of procedures, fears paralysis History of an operation (yrs earlier) going wrong Daughter his source of anxiety & guilt Involve family & educate

Pt extremely fearful of procedures, fears paralysis

History of an operation (yrs earlier) going wrong

Daughter his source of anxiety & guilt

Involve family & educate

Case example 2 Pt excellent trial response But high anxiety about op for permanent Turned out source of anxiety was: social and economic factors, child care & loss of income and ‘ playing her last card’

Pt excellent trial response

But high anxiety about op for permanent

Turned out source of anxiety was:

social and economic factors, child care & loss of income

and

‘ playing her last card’

Case example 3 Significant Psychiatric co-morbid presentation Don’t proceed to trial Liaise with psychiatric services review following CBT intervention

Significant Psychiatric co-morbid presentation

Don’t proceed to trial

Liaise with psychiatric services review following CBT intervention

Breakdown of all MDT Recommendations

Result of SCS Trial: MDT vs No MDT (success => 50% pain relief)‏

Permanent implants - 6 month follow-up 90% reported ≥ 50% pain relief for both MDA and No-MDA pts MDA greatest impact on trial selection and allowing more complex patients who may previously have been declined, to be considered for SCS Some non-MDA patients have required PMP etc later (observed trend)‏

90% reported ≥ 50% pain relief for both MDA and No-MDA pts

MDA greatest impact on trial selection

and allowing more complex patients who may previously have been declined, to be considered for SCS

Some non-MDA patients have required PMP etc later (observed trend)‏