Dr. David B. Adams – Psychological Blog

Psychology of Injury, Pain, Anxiety and Depression

SCS Trial

stimulator implant“In order to have a stimulator (SCS) implant trial, you must have psychological clearance…the psychologist says that the patient needs a two day evaluation, and always recommends 10 visits of psychological care *before* the implant trial. Is there any validity to that?”

Which part? The part where a three hour evaluation spans two days or where ten visits with a psychologist is needed to prep a patient for a stimulator trial?

This is, simply, a wallet biopsy.

Insurance companies, private and workers compensation, often see themselves as hostage to a costly procedure that may not alleviate pain. In turn, some psychologists hold patients hostage to mental health care before they will approve the patient for the procedure.

Here are some other wallet biopsy examples:

a. I prescribed you anti-depressants and need to see you every two weeks to see how you are doing. (Now, if the family physician had prescribed them, s/he would have simply said, “return to see me only if you have any questions, difficulty or if you feel it is not effective.”)

b. I have a pain management program and although it is a bit more difficult today, I can directly dispense narcotics as part of managing your pain. You will need to return every week for refills because I cannot phone in these prescriptions.

c. I am a mental health facility. You need an inpatient stay, followed by a day/inpatient program, then intensive out-patient care until your insurance no longer covers this essential treatment.

d. I actually may need to see you more than once a week (My private patients see me twice monthly, but I can see you this often since workers’ compensation will pay for it.)

A  stimulator implant trial (SCS) or a pain pump requires a very specific, but actually quite brief, evaluation.

Regarding care before the trial; that likely benefits the doctor more than the patient.

I was once referred a stimulator candidate who was floridly psychotic. She had been since adolescence. She was delusional. She had auditory hallucinations. Her back pain was due to evil spirits, and the stimulator implant was a means of the government sending radio waves to her as well as recording her thoughts.

I told the referring party that the patient was far too ill to consent to any procedure, that she needed hospitalization and stabilization and that we had no reassurance that her pain was not also part of her delusional system.

In return, the referral source asked (verbatim) “can you just patch her up enough that we can go on with the trial…make her un-schizophrenic?”

Over the past five years, I have seen many patients undergo successful stimulator trials and permanent implants, with marked reduction in narcotic intake and return to near-full functionality.

I have also seen patients who could not tolerate a trial for more than a day before turning off the stimulator and/or demanding it be removed. SCS trials are not for every patient, and there is good reason for requiring psychological clearance before embarking on this line of care.

Beware of evaluations that are excessive in length or cost, consistent recommendations for psychological care prior to an implant trial, and patients who do not fully comprehend the procedure, its benefits and its potential drawbacks.

American Psychosomatic Society

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