Now that it has been well established that globally people with serious mental illness (SMI) experience significantly worse surgical outcomes compared to the general population, including more post-operative complications and longer stays in hospital [1], priority should be focused on determining what proactive steps can be undertaken to help this vulnerable population.

Currently there is little evidence describing or evaluating interventions designed to routinely and sensitively support this patient group pre-operatively. The main examples only exist within specialised surgical settings, such as for patients undergoing solid organ transplantation, bariatric surgery or gender confirmation surgery, where comprehensive psychosocial screening and assessments are undertaken [2]. Whilst the requirements for such extensive evaluations are apparent, and indeed often mandatory in these settings, the feasibility of it being implemented for all patients is not practical given the time taken and resources required to complete them, and arguably not warranted given the much lower prevalence rates of SMI in the general population[3].

So what other practical options might be considered then?

Despite the societal advancements that have been made in the overall perception and understanding of mental health, within the routine surgical setting, it arguably still remains one that is managed differently compared to other medical co-morbidities [4]. This includes surgeons infrequently asking patients about their mental health [5], and it being largely treated reactively rather than proactively [2,4]. In light of this, pre-operative mental health screening for all patients may be one mechanism to assist surgical teams in sensitively identifying those patients who would benefit from additional support. This approach is reinforced by evidence demonstrating that screening improves the accurate identification of people with mental illness [6], and is in keeping with the management of most other medical co-morbidities [7], which is important to patients with mental illness, in being treated like everyone else [8]. Accordingly, use of screening should only be undertaken with adequate systems in place to ensure that if a patient screens positive, additional support is put in place [6].

In reviewing the large range of mental health screening tools available, it was perhaps not unsurprising that only one; the Amsterdam Pre-operative Anxiety and Information Scale (APAIS) (9) could be found designed specifically for the pre-operative setting. The lack of surgery specific tools provides further insights into why pre-operative psychological screening is not often undertaken. Indeed with screening for other medical comorbidities routinely occurring with surgical patients, it suggests it is not the practice of screening itself that isn’t well embedded in surgery, but perhaps the availability of a suitable tool and the action to be taken when a positive screen is found.

Given this finding, determining what characteristics would ideally be present within a mental health screening tool is critical, including those that would enable it to be readily translated into pre-operative processes across the Australian public healthcare system. Keeping in mind the often busy, paperwork intensive and time limited environments in which pre-operative consultations take place, we have identified that an ideal screening tool for use in this unique setting would be self-reported by adult patients and broadly applicable across a range of mental disorders and symptoms to enable a wider net to be caste for capturing people who may require further mental health assistance. The tool would also need to be easy to score, brief to complete, free to use, previously used within surgical cohorts, and have adequate psychometric properties.

Using this criteria, we proceeded to complete a literature review and evaluation of 32 self-reported psychological screening tools with the aim to find a suitable tool for future use and assessment in the routine surgical setting [10]. Synthesizing this information, we identified three tools including the Kessler Psychological Distress Scale (K10 [11] and the short-form version (K6 )(11) and the Somatic and Psychological Health Report-12 (SPHERE-12 [12]. Although potentially suitable, we also found a number of key limitations with these tools. Most critically, and as previously highlighted, none of the tools included questions that were specifically designed for surgical patients. Furthermore, all of the tools included a focus on recent patient symptoms with no questions seeking information on overall mental health history, mental health service utilisation or current or previous treatments to provide some context to the screening. This presented an opportunity for us to consider how the screening tools might be strengthened and made fit-for-purpose through the addition of a small number of simple questions. Seeking the input of both surgical and mental health clinicians and consumers [13], we have been able to further evaluate the acceptability and validity of these amended tools, which are now ready for pilot testing.

Undoubtedly introducing any new system into surgery is challenging, with those relating to mental health perceived perhaps even more so. But pre-operative mental health screening for all patients does present as a worthwhile and relatively simple intervention to further investigate. The financial benefits alone for the health system in terms of the well-established increased length of stay for these patients [1], easily justifies the cost benefit. Indeed it may have the potential to not only normalize such considerations for everyone, but to most importantly improve the surgical experience for those particularly vulnerable patients who need it most.

1. McBride KE, Solomon MJ, Bannon PG, Glozier N, Steffens D. Surgical outcomes for people with serious mental illness are poorer than for other patients: a systematic review and meta-analysis. Med J Australia. 2021; 214: 379-385.
2. Zimbrean PC. The Role of the Psychiatrist in the Perioperative Setting. InPerioperative Psychiatr. 2019; 7-14.
3. Australian Institute of Health and Welfare (AIHW). Mental health services in Australia - In brief 2019.
4. Levenson JL. Psychiatric issues in surgical patients Part I: General issues. Primary Psychiatry. 2007. 14: 35.
5. McBride KE, Solomon MJ, Steffens D, Bannon PG, Glozier N. Mental illness and surgery: do we care?. ANZ J Surg. 2019; 89: 630-631.
6. Siu AL, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. Jama. 2016; 315: 380-387.
7. Bushnell BD, Horton KJ, McDonald MF, Robertson PG. Perioperative medical comorbidities in the orthopaedic patient. J Am Acad Orthop Surg. 2008; 16: 216-227.
8. McBride KE, Solomon MJ, Lambert T, O’Shannassy S, Yates C, Isbester J, et al. Surgical experience for patients with serious mental illness: a qualitative study. BMC psychiatr. 2021; 21: 1-9.
9. Moerman N, van Dam FS, Muller MJ, Oosting H. The Amsterdam preoperative anxiety and information scale (APAIS). Anesthesia & Analgesia. 1996; 82: 445-451.
10. McBride KE. Suitability of psychological screening tools for patients having routine surgery: a literature review. Surgical Outcomes for Patients with Serious Mental Illness. 2021; 88: 74.
11. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002; 32: 959-976.
12. Hickie IB, Davenport TA, Hadzi-Paviovic D, Koschera A, Naismith SL, Scott EM, Wilhelm KA. Development of a simple screening tool for common mental disorders in general practice. Med J Australia. 2001; 175: S10-17.
13. McBride KE, Steffens D, Lambert T, Glozier N, Roberts R, Solomon MJ. Acceptability and face validity of two mental health screening tools for use in the routine surgical setting. BMC Psychol. 2021; 9: 1-9.