What Is a Pre-Surgical Psychological Evaluation?
A pre-surgical psychological evaluation is a focused assessment conducted by a licensed psychologist or other qualified mental health professional to determine a patient's psychological readiness for a specific medical procedure. While the bariatric evaluation is the best-known example, psychological evaluation is required or strongly recommended before a growing range of procedures — most prominently spinal cord stimulator (SCS) implantation and other implantable neuromodulation devices, and solid organ transplant candidacy.
The unifying logic across all of these evaluations is that surgical success depends on more than anatomy. An SCS only helps a patient whose expectations, mood, and pain beliefs allow them to perceive and use partial relief. A transplanted organ survives only in a patient who takes immunosuppressants every day for the rest of their life, attends frequent follow-up, and — in many cases — maintains sobriety. The psychologist's job is to assess the psychological and behavioral machinery the procedure depends on, identify modifiable risk factors, and give the surgical team a formulation and plan rather than a thumbs-up or thumbs-down.
These are specialty evaluations. Each procedure type has its own literature on psychological outcome predictors, its own screening conventions, and its own payer documentation requirements. Medicare and most commercial insurers require psychological screening before permanent SCS implantation, and transplant programs are required to perform psychosocial evaluation as part of candidate selection. An evaluator who applies a generic psychiatric intake to these referrals will miss the questions the surgical team actually needs answered.
When You Need It
- When a pain management physician refers a patient for psychological screening prior to a spinal cord stimulator trial or permanent implantation, or prior to an intrathecal drug delivery system
- When a transplant program requests a psychosocial evaluation as part of the candidate selection workup for kidney, liver, heart, or lung transplant listing
- When a patient is being evaluated as a living organ donor and the program requires independent psychological assessment
- When an insurance company mandates psychological evaluation as a condition of pre-authorization for an implantable device
- When a patient previously evaluated as not ready returns for re-evaluation after completing recommended treatment
- When a surgical team requests assessment of decision-making capacity, adherence risk, or psychiatric stability before any elective procedure
Key Components / Required Sections
The core skeleton is shared across procedure types; the emphasis shifts with the referral question. Sections below note SCS-specific and transplant-specific content where the two diverge.
Referral Information and Medical Context
Document the referring physician or program, the planned procedure, and the medical rationale. For SCS: the pain diagnosis (for example, persistent spinal pain syndrome after lumbar surgery, complex regional pain syndrome, painful diabetic neuropathy), pain duration, prior surgeries and interventions, current pain intensity and functional limitations, and whether the referral is for the trial phase or permanent implantation. For transplant: the organ, the disease process leading to organ failure, current disease severity indicators supplied by the medical team, and where the patient is in the listing process.
Condition and Treatment History
- Onset and course of the condition prompting surgery
- All prior treatments attempted and their outcomes (for pain: medications, injections, physical therapy, prior surgeries; for organ failure: medical management, dialysis, prior transplants)
- Current medication regimen, including opioid dose and duration for pain patients
- The patient's own narrative of the condition — how they explain it, what they believe will help, and how it has changed their identity and daily life
Psychiatric History and Current Functioning
- Current and lifetime psychiatric diagnoses, treatment history, hospitalizations
- Current psychotropic medications, prescribers, and adherence
- Depression and anxiety screening (PHQ-9 or BDI-II; GAD-7)
- Suicidal ideation and self-harm history — chronic pain and end-stage organ disease both elevate suicide risk, so screen explicitly
- Trauma history and its relationship to the medical condition
- Cognitive screening when disease processes (hepatic encephalopathy, uremia, cardiac insufficiency, long-term opioid use) may impair comprehension or memory
Pain-Specific Psychological Factors (SCS and Other Pain Procedures)
- Pain catastrophizing: rumination, magnification, and helplessness about pain — assess with the Pain Catastrophizing Scale (PCS)
- Fear-avoidance and kinesiophobia: avoidance of movement due to fear of pain or reinjury
- Somatic focus: the degree to which distress is expressed and experienced somatically
- Pain beliefs and locus of control: whether the patient sees any role for self-management or expects relief to come entirely from devices and procedures
- Functional goals: what specifically the patient wants to do again if pain improves — concrete goals predict engagement better than "less pain"
- Litigation and disability context: pending personal injury litigation or disability determinations do not preclude implantation, but they must be documented and considered in the formulation
Adherence and Regimen-Specific Factors (Transplant)
- Documented adherence history: missed appointments, medication adherence, dialysis attendance, dietary and fluid restrictions
- Understanding of the lifelong immunosuppression regimen and its side effects
- Identified primary caregiver and backup caregiver, with their own understanding of the commitment
- Substance use history in detail, including duration of sobriety, treatment history, relapse-prevention plan, and program-specific sobriety requirements
- Financial and logistical capacity for lifelong follow-up (transportation, insurance, medication costs)
- Consider a structured instrument such as the SIPAT or PACT to organize and quantify psychosocial risk
Substance Use Assessment
Screen every pre-surgical patient with validated measures (AUDIT, DAST-10). For pain patients, add opioid-specific risk assessment: current prescribed opioids and any aberrant use patterns, history of opioid use disorder, and family addiction history. For transplant candidates whose organ failure is substance-related, document the sobriety timeline, corroborating information, treatment engagement, and relapse-prevention plan in detail — this is frequently the decisive section for the selection committee.
Coping, Support, and Environment
- Current coping repertoire for the illness and for general stressors
- Household composition and the practical support available during recovery
- Family attitudes toward the procedure
- Occupational status and post-procedure plans
Knowledge, Motivation, and Expectations
Ask the patient to explain the procedure in their own words. For SCS, confirm the patient understands the two-stage pathway (a temporary trial of several days, with permanent implantation contingent on meaningful relief during the trial), the realistic goal of partial rather than complete pain reduction, device limitations and maintenance, and the continued need for self-management. For transplant, confirm understanding of waitlist realities, surgical risks, rejection, and the permanence of the immunosuppression regimen. Distinguish internal motivation from external pressure, and record what the patient expects will change in their life.
Mental Status Examination
Document a full mental status exam: appearance, behavior, speech, mood, affect, thought process and content, perception, cognition, insight, and judgment, including explicit suicidal and homicidal ideation status.
Clinical Formulation and Recommendation
Integrate findings into a formulation that answers the referral question, provide DSM-5-TR diagnoses if applicable, and issue a graded recommendation:
- No psychological contraindications identified — proceed as planned
- Proceed with recommendations — modifiable risk factors identified; specify concurrent interventions
- Delay recommended — specify the intervention, targets, timeline, and re-evaluation criteria
- Significant psychological contraindications at this time — rare; reserved for inability to consent, active psychosis, current suicidal intent, or active untreated substance use disorder where program policy requires stability
Pre-Surgical Psychological Evaluation — 51-Year-Old Spinal Cord Stimulator Trial Candidate
CONFIDENTIAL PSYCHOLOGICAL EVALUATION Pre-Surgical Assessment — Spinal Cord Stimulator Candidacy
Patient: Daniel Okafor Date of Birth: 09/14/1974 Age: 51 Date of Evaluation: 07/08/2026 Date of Report: 07/14/2026 Referring Physician: Priya Raman, M.D., Lakeside Pain Management Planned Procedure: Spinal cord stimulator trial, with permanent implantation contingent on trial response Evaluator: Marcus Bell, Psy.D., Licensed Psychologist
Referral Information
Mr. Okafor was referred by Dr. Raman for psychological evaluation as part of the standard pre-trial protocol for spinal cord stimulation. He carries a diagnosis of persistent spinal pain syndrome following two lumbar surgeries: an L4-L5 discectomy in 2019 and an L4-S1 fusion in 2022, neither of which produced lasting relief. He reports constant low back pain radiating into the left leg, currently rated 7/10 on average and 9/10 at worst. Prior conservative and interventional treatments include physical therapy (three courses), epidural steroid injections (four, with transient relief), radiofrequency ablation (minimal benefit), gabapentin 1,800mg daily (current), duloxetine 60mg daily (current), and tramadol 50mg up to twice daily as needed. He is not prescribed long-acting opioids. There is no pending litigation; he receives long-term disability benefits through his former employer, with no active dispute.
Pain and Treatment History
Mr. Okafor was a warehouse operations supervisor until a lifting injury in 2018. He describes a trajectory of escalating pain, two surgeries he now views as "mistakes I didn't know enough to avoid," and progressive loss of function: he can walk approximately 15 minutes before needing to sit, no longer drives more than 30 minutes, and has stopped coaching his son's soccer team, which he identifies as his most painful loss. He describes his pain as "the first thing I think about when I wake up." Despite this, he was able to articulate a differentiated view of his treatment history, identifying which interventions helped partially and which did not, and he did not present with global bitterness toward providers.
Psychiatric History and Current Functioning
Mr. Okafor developed depressive symptoms following the loss of his job in 2020. He was started on duloxetine by Dr. Raman in 2023, targeting both mood and neuropathic pain, with partial benefit. He describes his current mood as "flat but not hopeless." He denied current suicidal ideation, intent, or plan. He reported one period in late 2022, following his failed fusion, when he had passive thoughts that "my family might be better off without me having to be taken care of"; these thoughts resolved, never involved intent or planning, and he has had none in over three years. He has never attempted suicide and has never been psychiatrically hospitalized. He denied panic attacks, psychotic symptoms, manic episodes, and trauma history. He attended six sessions of counseling through his church in 2021, which he found supportive. He has never had pain-focused psychotherapy.
Screening Measure Results:
| Measure | Score | Interpretation |
|---|---|---|
| PHQ-9 | 12 | Moderate depressive symptoms |
| GAD-7 | 6 | Mild anxiety symptoms |
| PCS | 26 | Moderately elevated pain catastrophizing |
| AUDIT | 2 | Low-risk alcohol use |
| DAST-10 | 0 | No drug use concerns |
On the PCS, elevations were concentrated on the helplessness subscale ("There's nothing I can do to reduce the intensity of the pain") rather than magnification or rumination, consistent with his interview presentation of demoralization after repeated treatment failures rather than global catastrophic thinking.
Substance Use
Mr. Okafor drinks 1-2 beers on weekends. He denied any history of alcohol-related problems. He takes tramadol as prescribed, denies early refills or dose escalation, and his state prescription monitoring report (reviewed by Dr. Raman) is consistent with prescribed use. He denied illicit drug use and cannabis use. He smoked briefly in his twenties and has been tobacco-free for over 20 years.
Coping, Support, and Environment
Mr. Okafor lives with his wife Adaeze, a hospital pharmacy technician, and their 15-year-old son. He described his marriage as strong and his wife as actively supportive of the SCS trial; she attended part of the evaluation and asked well-informed questions about the trial process. His current coping strategies include pacing his activity, prayer, and woodworking in short sessions. He acknowledged a tendency to overdo activity on lower-pain days and "pay for it" afterward — a boom-bust pattern appropriate for targeting in pain-focused CBT.
Procedure Knowledge and Expectations
Mr. Okafor accurately described the two-stage process: a trial period of approximately one week with temporary leads, followed by a decision about permanent implantation based on his response. When asked what result would make the trial a success for him, he initially said, "getting my life back." On follow-up questioning, he identified concrete functional goals: walking 45 minutes, driving to his son's away games, and returning to part-time work "in some form." When asked directly whether he expected the stimulator to eliminate his pain, he said, "No — Dr. Raman told me 50 percent would be a win, and honestly I'd take 40." He understands the device does not treat the underlying spinal pathology, that stimulation patterns may need reprogramming, and that he will still need to manage activity and mood. His expectations are realistic and his motivation is internally driven and functionally framed.
Mental Status Examination
Mr. Okafor presented as a cooperative, well-groomed man who appeared his stated age, walking with a cane and shifting position frequently, consistent with reported pain. Speech was normal in rate and volume. He described his mood as "flat but hopeful about this"; affect was mildly constricted but reactive, with appropriate humor. Thought process was logical and goal-directed. He denied suicidal ideation, homicidal ideation, and perceptual disturbances. He was fully oriented; attention, memory, and comprehension were grossly intact. Insight and judgment were good.
Diagnostic Impressions
- Major Depressive Disorder, Single Episode, Moderate (F32.1) — onset following occupational loss and failed surgical treatment, partially responsive to duloxetine; PHQ-9 = 12.
- Chronic pain in the context of persistent spinal pain syndrome — documented by the referring physician; psychological factors (helplessness-weighted catastrophizing, boom-bust activity pattern) affect the condition.
Recommendation: NO PSYCHOLOGICAL CONTRAINDICATION TO SCS TRIAL — PROCEED WITH RECOMMENDATIONS
Mr. Okafor demonstrates realistic, functionally framed expectations; internally driven motivation; a strong support system; no substance use concerns; stable psychiatric functioning with moderate but treated depressive symptoms; and intact capacity to consent to and operate the device. His moderate depression and elevated helplessness-focused catastrophizing are modifiable risk factors that warrant concurrent treatment but do not justify delaying the trial.
Recommendations:
- Proceed with the SCS trial as planned.
- Begin pain-focused cognitive-behavioral therapy (CBT for chronic pain), targeting the helplessness component of catastrophizing, the boom-bust activity cycle (activity pacing), and behavioral activation for depressive symptoms. Recommend 8-10 sessions, beginning before or during the trial period.
- Define trial success criteria in functional terms with the patient before the trial begins (walking tolerance, sitting/driving tolerance, sleep), in addition to percentage pain reduction, so the implantation decision draws on concrete data.
- Prescriber to reassess duloxetine dosing given residual depressive symptoms (PHQ-9 = 12).
- If the trial is unsuccessful, brief psychological follow-up is recommended given his 2022 history of passive suicidal ideation after a failed intervention; a further treatment failure is a foreseeable stressor and a plan should be in place.
- Re-screen mood (PHQ-9) at the post-implantation follow-up visits during the first 6 months.
This is a sample for educational purposes only — not real patient data.
How to Write It Step by Step
Step 1: Pin Down the Referral Question and Payer Requirements
"Psych clearance for surgery" means different things to different programs. Ask the referring team exactly what decision your report will inform: an SCS trial, permanent implantation, transplant listing, or committee review. Ask whether the payer or program has required domains, required instruments, or a required format. Transplant programs in particular often have structured expectations and want SIPAT or PACT scores; pain programs may only need a narrative report with screening scores.
Step 2: Learn the Procedure Before You Evaluate for It
You cannot assess whether a patient's expectations are realistic if you do not know what the procedure realistically delivers. Before your first SCS evaluation, understand the trial-to-implant pathway, what "meaningful relief" means in that literature, and what living with an implanted device involves. Before your first transplant evaluation, understand immunosuppression, rejection, and the program's sobriety and caregiver policies. This is a competence issue, not a formality.
Step 3: Administer a Procedure-Appropriate Screening Battery
All pre-surgical evaluations should include depression (PHQ-9 or BDI-II), anxiety (GAD-7), and substance use (AUDIT, DAST-10) screening. Add pain-specific measures for neuromodulation candidates — the Pain Catastrophizing Scale at minimum, with fear-avoidance and functional measures as indicated — and a structured psychosocial instrument (SIPAT or PACT) for transplant candidates. Review scores before the interview and follow up on every elevation.
Step 4: Interview Around the Behavioral Demands of the Specific Procedure
Structure the interview around what the procedure will require of this patient. For SCS: can they tolerate the trial, operate the device, keep expectations calibrated to partial relief, and continue self-management? For transplant: can they take medication daily for life, attend follow-up, maintain sobriety, and mobilize a caregiver? Adherence history is the single best interview topic for predicting adherence future — ask about it concretely (refill gaps, missed dialysis, appointment no-shows) rather than hypothetically.
Step 5: Probe Expectations Until They Become Concrete
Nearly every candidate initially states an acceptable-sounding expectation. Push past it. Ask what specifically they will do again if the procedure works, what percentage of relief they expect, what they will do if it fails, and what they believe will not change. A patient who cannot describe life after a partially successful procedure — only after a cured one — needs psychoeducation before implantation, and your report should say so.
Step 6: Write a Graded, Conditional Recommendation
Avoid pass/fail language. Most candidates proceed with recommendations. When you recommend delay, make the path back explicit: the intervention, the targets, the timeline, and the re-evaluation criteria — the same discipline described in the bariatric evaluation guide. When risk factors exist but do not justify delay, say so directly and pair the go-ahead with concurrent-treatment recommendations, as in the example above.
Step 7: Write for the Surgical Team, Not for Another Psychologist
Your readers are surgeons, anesthesiologists, transplant coordinators, and utilization reviewers. Lead with the recommendation, present screening scores in a table, keep the formulation tight, and translate psychological constructs into operational consequences ("elevated helplessness-focused catastrophizing, which predicts poorer perceived benefit from partial relief and is an appropriate CBT target") rather than leaving them as jargon.
Common Mistakes
Treating every procedure like a bariatric evaluation. The domains overlap, but the decisive content differs. An SCS report that never addresses pain catastrophizing, expectations of partial versus complete relief, or the trial pathway — or a transplant report that never addresses adherence history and caregiver availability — has missed the referral question regardless of how thorough its psychiatric history is.
Framing the evaluation as gatekeeping. As with bariatric assessment, the purpose is outcome optimization, not exclusion. Most psychological risk factors identified in pre-surgical candidates are modifiable, and the defensible, clinically useful output is a plan: treat this, monitor that, re-evaluate then.
Accepting vague expectations. "I just want my life back" is a starting point, not an answer. Unexamined cure expectations are among the most consistently reported psychological predictors of dissatisfaction after SCS, and disappointed patients with implanted hardware are a difficult clinical situation to unwind. Concretize expectations during the evaluation and document them.
Under-assessing suicide risk in chronic pain and end-stage disease. Chronic pain is an established suicide risk factor, and a failed intervention is a foreseeable precipitant. Screen explicitly, document historical ideation and its context, and build contingency follow-up into your recommendations rather than treating a current denial of ideation as the end of the analysis.
Ignoring the medicolegal and incentive context. Pending litigation, disability determinations, and family pressure do not disqualify anyone, but omitting them from the report leaves the formulation incomplete. Document the context neutrally and address how it does or does not bear on motivation and expected outcomes.
Overstepping the role. The psychologist recommends; the surgical team and, for transplant, the selection committee decide. Reports that announce "cleared for surgery" as though the psychologist holds the scalpel overstate the evaluator's authority and understate the multidisciplinary nature of the decision. State your findings, your risk formulation, and your recommendation — precisely and within your lane.