Past studies have shown that surgical patients suffering from depression often have longer recuperation periods, more postsurgical complications and more difficulty complying with their medication schedules after leaving the hospital than surgical patients without symptoms of depression. Compounding this information, a recent study conducted by the Hopkins School of Medicine has found that most orthopedic surgeons do not screen well enough for depression and anxiety in patients prior to surgery.
The study was led by Richard Skolasky, director of the Hopkins Spine Outcomes Research Center and an associate professor of orthopedic surgery at the Hopkins School of Medicine. Skolasky’s team found that only 10 percent of orthopedic surgeons and neurosurgeons follow the guidelines for screening patients before surgery for back or leg pain. While this percentage seems small, it quickly adds up, as more than 600,00 spine surgeries are performed in the United States each year. In an interview with The News-Letter, Skolasky explained why he chose to study this subject. “I started to research what the recommendations were for screening for these factors,” he said. “I came to find that there were actual recommendations from the U.S. Preventive Services Task Force to screen patients using a pre-surgical psychological screening. So my question became how often are these recommendations followed and how often do surgeons use the full recommendation?”
The guidelines that surgeons are supposed to use are called the PPS, a two-part psychological test for use before surgery. The U.S. Preventive Services Task Force, a group of experts in clinical practices, strongly recommends the test. The questionnaire only takes 20 to 25 minutes to fill out, and, if necessary, a trained psychologist can follow up with the patient afterwards. “It’s important to note that the guidelines aren’t specific to spinal surgeries; it can be for any number of surgeries where mental health is a risk factor for surgical outcomes,” Skolasky said.
In their study, Skolasky and his team emailed a questionnaire to 340 licensed spinal surgeons in the U.S. from December 2010 to January 2011. 110 surgeons, most of whom were men, responded. The researchers found that surgeons with more than 15 years of experience were more likely to use the PPS. They also found that surgeons based in private practices or community hospitals were more likely to use the screening as opposed to surgeons at university-affiliated hospitals. Lastly, the study found that surgeons with a higher caseload of patients, more than 200 a year, were more likely to use the survey than surgeons that had fewer patients per year.
Skolasky believes that the results show that surgeons need to more fully appreciate how psychological health can impact recovery from surgical procedures. Sometimes, it is better for surgery to be delayed so the patient can be treated for mental health conditions. Skolasky believes that the results of his study should be used to promote psychological screenings for patients. Protocols should be established to ensure that these screenings are used. If a screening is not proposed, Skolasky thinks a patient should feel comfortable requesting one from a surgeon.
Skolasky was surprised that university-affiliated surgeons were less likely to use the psychological screening. He found such a result to be counter-intuitive because university-affiliated hospitals are more likely to have access to psychologists. While Skolasky believes this suggests the lack of understanding among surgeons of the importance of the screenings, he notes that it could also result from the a perception that the screenings might take up valuable time during which the patient’s condition could deteriorate.
Ultimately, Skolasky believes that it comes down to training, and that surgeons should be taught the importance of psychological tools like the PPs during their education. “We’re actually planning on developing a symposium at the North American Science Society. That symposium would be focused on reviewing and presenting the literature but then also describing what pre-surgical psychological screenings exist and how patients who get treatment could go on to have good outcomes after surgery,” Skolasky mentioned.
Patients should also be educated and know that such a test could be useful and they have the right to request it. In the future, Skolasky wants to study how treatment for depression and anxiety before back surgery speeds up or slows down recovery from surgery.
This study was funded by the Johns Hopkins’ Provost’s Undergraduate Research Award. The other researchers involved in the study were Arthur Young, Benjamin Young, and Lee Riley III.
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