Psychiatric screening and initial management in interventional pain practice: a narrative review and the Daradia Protocol

Abstract

Psychiatric comorbidities are common in chronic pain and can meaningfully influence safety, satisfaction, adherence, and durability of benefit after interventional pain procedures. Interventional pain physicians, typically trained in anesthesiology, often have limited time and limited access to liaison psychiatry, creating a gap between guideline intent and real-world feasibility. This narrative review summarizes clinically relevant psychiatric domains for interventional pain practice, highlights situations where procedures should proceed, be optimized in parallel, or be deferred, and outlines a pragmatic approach to screening and first-line management in busy clinics. The authors describe brief screening tools, including validated instruments where applicable, that can be implemented within routine workflow to identify depression, anxiety, suicidality, substance misuse risk, and maladaptive coping, and they propose the Daradia Protocol, a structured 10-minute stepped-care pathway that stratifies patients into Green, Amber, and Red risk categories to guide procedural decision-making and referral urgency. Clinic-initiated strategies emphasize psychoeducation, expectation alignment, graded activity, sleep support, and coordinated care with mental health professionals when indicated. Embedding rapid screening with clear action thresholds may strengthen informed consent, improve patient selection, and increase the likelihood of durable outcomes without materially extending consultation time.

INTRODUCTION

Interventional pain medicine has evolved from simple diagnostic and therapeutic nerve blocks to sophisticated neuromodulation techniques. Despite these technological advances, outcomes remain variable because procedure-level efficacy interacts with complex patient-level psychosocial factors [1]. The International Classification of Diseases, 11th Revision (ICD-11) framework defines chronic primary pain partly by the presence of emotional distress and functional interference, reinforcing that psychological assessment is intrinsic to comprehensive pain care rather than an optional adjunct [2]. Contemporary clinical practice guidelines on chronic pain management further emphasise biopsychosocial approaches and multidisciplinary care pathways [3].

Psychiatric comorbidity is highly prevalent in persistent pain conditions. Depression and anxiety frequently accompany neuropathic and nociplastic pain states; catastrophizing, fear-avoidance beliefs, and sleep disturbance are common [4]. A substantial body of evidence links pretreatment psychological variables—including bodily distress disorder (BDD), depression, anxiety, and poor coping strategies—to worse outcomes after lumbar spine surgery and spinal cord stimulation (SCS) [1]. While studies examining injections show mixed results, many demonstrate that patients with depression or high anxiety begin with worse baseline disability and quality of life; even when they improve by a similar relative magnitude, their absolute outcomes often remain poorer than those of patients without psychological distress [1,5]. In parallel, professional societies and best-practice statements advise formal psychological assessment prior to implantable therapies [6–8].

The challenge for the interventionalist is practical: clinic time is limited, access to liaison psychiatry (LP) services may be constrained, and many clinicians receive minimal training in psychiatric screening during their anesthesiology or pain fellowship training [9,10]. This review translates the available evidence into a clinic-ready protocol using ultra-brief screening instruments, consistent cut-off scores, specific “do not proceed” flags, and a basic treatment bundle that any interventional pain clinic can initiate on the same day as part of the overall assessment and treatment plan. The authors’ aim is to support safer patient selection, establish realistic expectations, and optimize long-term functional outcomes.

MAIN BODY

1. Literature search strategy

A narrative literature search was conducted using PubMed and Google Scholar for articles published up to January 2026. Search terms included “chronic pain,” “interventional pain,” “psychiatric comorbidity,” “depression screening,” “PHQ-9,” “HADS,” “suicide risk,” “substance use,” “spinal cord stimulation,” and “psychological assessment.” Relevant clinical guidelines, consensus statements, validation studies, systematic reviews, and clinically relevant narrative reviews were selected based on their relevance to psychiatric screening, risk stratification, and initial management in interventional pain practice.

2. Why psychiatric knowledge is critical for interventional practice

1) Prevalence and burden

Depression and anxiety disorders, often unrecognized, are common in the general population and are highly prevalent among patients presenting with chronic spine and musculoskeletal pain [11]. The ICD-11 emphasis on distress and disability reflects what clinicians observe daily: mood, sleep quality, and functional capacity co-evolve with pain intensity and coping strategies [2,3]. Failure to recognize and address these factors leaves a significant portion of the biopsychosocial model unaddressed.

2) Prediction of outcomes

Systematic reviews in spine surgery and SCS demonstrate that pretreatment psychological distress predicts poorer postoperative pain relief, greater disability, lower satisfaction, and reduced return to work [1,12]. Recent meta-analytic data indicate that patients with preoperative depression often show meaningful improvement after surgery but still demonstrate worse absolute severity at follow-up compared with non-depressed peers—information essential for candid counselling and expectation management [12].

For neuromodulation therapies, several analyses show lower trial success rates and reduced permanent implantation rates in patients with prominent psychological distress, sleep disturbance, and catastrophizing, although not all datasets agree [6,8,13–15]. This underlines the need for structured assessment and optimization rather than blanket exclusion of patients with psychological comorbidity.

3) Patient safety and informed consent

Active suicidality, psychosis, severe mania, or uncontrolled substance use disorders can compromise peri-procedural safety and the integrity of informed consent. Rapid identification and stabilization are strongly recommended before elective interventions. For opioid-involved peri-procedural care plans, brief tools such as the Opioid Risk Tool (ORT) or Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) aid risk stratification and provide documentation [16,17]. Similarly, Single Alcohol Screening Question (SASQ) or Single Drug Screening Question (SDSQ) are useful brief screening tools to identify alcohol or substance misuse disorders with sensitivity and specificity ranging from about 80% for SASQ and over 90% for SDSQ [18,19].

4) Therapeutic synergy

Psychological therapies (Cognitive Behavioral Therapy [CBT], Acceptance and Commitment Therapy [ACT] preferably with mindfulness-based or similar relaxation training), structured activity programs, and judicious use of first-line antidepressants (selective serotonin reuptake inhibitors [SSRIs] and serotonin-noradrenaline reuptake inhibitors [SNRIs], tricyclic antidepressants) align with chronic pain management guidelines and can be effectively integrated with procedural interventions. Coordinated care tends to improve functional outcomes and patient-reported measures while supporting realistic expectations and treatment adherence [3].

3. Brief screening tools for busy interventional clinics

The authors recommend a two-tier approach: an ultra-brief triage screening followed by a targeted severity assessment. The tools described below include validated instruments and are feasible for administration in clinic waiting rooms or during assessment.

1) Whooley two-question screen: during consultation

• Question 1: “During the past month, have you often been bothered by feeling down, depressed, or hopeless?”

• Question 2: “During the past month, have you often been bothered by little interest or pleasure in doing things?”

Action: Any “yes” response should prompt administration of the Patient Health Questionnaire-9 (PHQ-9), if it has not already been completed in the waiting area. Evidence demonstrates high sensitivity for detecting major depression in primary care settings; addition of a third “help” question improves specificity [20,21].

2) PHQ-9 for depression diagnosis and severity

The PHQ-9 is a 9-item scale (score range 0–27) with established cut-points of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively. A score ≥ 10 balances sensitivity and specificity for major depressive disorder. Item 9 screens for suicidal ideation and mandates formal suicide-risk assessment if scored > 0 [22]. The advantage of using this scale is that it is free of any licence fee.

In resource-limited settings, PHQ-9 may be preferred as the initial screening tool due to its free availability, ease of use, and extensive validation.

3) HADS

The Hospital Anxiety and Depression Scale (HADS) is a 14-item instrument with anxiety (HADS-A) and depression (HADS-D) subscales, designed specifically for medically ill outpatients to minimize somatic symptom confounding. Scores are interpreted as follows: 0–7, normal; 8–10, borderline; and ≥ 11, indicative of a probable case of either anxiety, depression, or both. This aids clinical decisions when physical symptoms could inflate scores on other depression scales [23]. Although a licence fee is required, this instrument minimizes confounding by somatic symptoms and may be particularly useful in medically ill populations. HADS may be used as an alternative where available, particularly when avoidance of somatic symptom overlap is desirable.

4) SASQ and SDSQ

Similar to the Whooley questions, these are single-sentence screening questions which can be used to screen for alcohol or other substance abuses. Their sensitivity and specificity data are accurate enough to be considered useful in a busy pain clinic setting to screen out cases of interest.

• SASQ: “How many times in the last 12 months have you had X or more drinks in a day” (where X is 5 for men and 4 for women) [24]?

• SDSQ: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons (such as to get high)?” The SDSQ has a reported sensitivity of over 91% and specificity of over 99% [19].

5) PRIME-5

This simple questionnaire is a screening tool for psychosis [25]. However, PRIME-5 (Prevention through Risk Identification, Management, and Education - 5) has primarily been validated in youth populations, and its validity in adult chronic pain outpatients has not been established. In the present protocol, it is used as a brief preliminary screen for psychosis-spectrum symptoms and should be interpreted cautiously, prompting further clinical assessment rather than serving as a standalone diagnostic or deferral criterion. Psychosis implies ongoing intermittent or continuous hallucinations in any sensory modality with or without delusions. Psychosis is a phenomenological or psychopathological term that can result from primary psychiatric disorders, most commonly schizophrenia, but can be seen in many psychiatric as well as medical disorders. For instance, delusional disorder patients present with delusion but no hallucination. In many serious medical conditions, transient hallucinations or delusions may occur as part of delirium, which is itself secondary to an underlying medical disorder.

Although some psychotic, manic or delirious patients manifest obvious psychopathology, in many cases phenomenological identification in busy pain practice can be tricky and challenging. One way these can be identified is asking one open ended question: “Can you tell me if you have recently experienced any unusual symptoms or experiences?” Another helpful tactic is to get collateral information from caretakers or family members accompanying the patient to the clinic. PRIME-5 may serve as a brief preliminary screening tool for psychosis-spectrum symptoms. Similarly, for delirium or confusion assessment, Confusion Assessment Method (CAM) or Brief Confusion Assessment Method (bCAM) assessment tools devised and tested by Inouye et al. [26] are validated and useful. There is another assessment tool, Single Question in Delirium (SQiD), which specifically asks caretakers or family members about any confusion or delirium present in the patient [27].

4. Adjunct tools (time permitting or for complex decisions)

• Pain Catastrophizing Scale (PCS): Identifies rumination, magnification, and helplessness associated with poorer outcomes in surgery and neuromodulation [28].

• Fear-Avoidance Beliefs Questionnaire (FABQ): Guides activity-based rehabilitation and pacing strategies [29].

• Columbia-Suicide Severity Rating Scale (C-SSRS): If suicidal ideation is suspected (e.g., PHQ-9 item 9 positive), use C-SSRS to stratify risk and determine urgency of referral [30]. Any reported suicidal ideation or positive PHQ-9 item 9 response requires further suicide-risk assessment. Absence of a reported plan or intent does not establish low risk or exclude the need for urgent evaluation.

• ORT or SOAPP-R: When opioids are considered peri-procedurally or for chronic regimens [16,17].

• Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar): Identifies risk of alcohol withdrawal and avoids missing patients at risk of delirium tremens [31].

5. Workflow integration

In new-patient clinics, provide PHQ-9 or HADS and PRIME-5 at registration; use Whooley questions verbally during consultation. Reception staff, nurse, or clinic assistant can score these instruments in < 3 minutes with minimal training and flag high-risk results for physician review.

6. When not to perform an interventional procedure

Within the Daradia Protocol, PHQ-9 ≥15 or HADS subscale ≥11 places the patient in the Red category and warrants elective procedure deferral. Clinical severity, functional impairment, and safety concerns determine the urgency of subsequent assessment and management.

1) Urgent deferral (stabilize first, then reconsider)

• Active suicidal ideation with plan or intent, a recent suicide attempt, or other immediate suicide-related safety concerns identified on clinical assessment.

• Psychosis, mania or hypomania, or delirium.

• Uncontrolled substance use disorder (including aberrant opioid behaviours) without a clear management pathway.

• Severe depressive or anxiety states with marked functional impairment (e.g., PHQ-9 ≥ 20 or HADS subscale ≥ 14) that compromise patient engagement, treatment adherence, or valid informed consent.

2) Strong reasons to defer and optimise before reconsidering the procedure

• PHQ-9 15–19 or HADS subscale 11–13 without immediate safety concerns: defer the procedure, initiate optimization, and arrange prompt LP assessment. Poor coping, catastrophizing, and sleep disturbance should also be addressed.

• Moderate to high dose ongoing use of benzodiazepines or Z drugs.

• Marked catastrophizing (high PCS) or fear-avoidance (high FABQ) that undermines rehabilitation potential and outcome durability.

• Inadequate social support or chaotic life circumstances likely to impede post-procedural care and follow-up.

7. Rationale

Psychological distress increases peri-procedural risk, undermines treatment adherence, and predicts worse pain and functional trajectories. For implantable therapies, professional guidance explicitly advises structured psychological assessment and, where indicated, treatment optimization prior to device implantation [6–8,13–15,30].

8. When and whom to refer

1) Urgent psychiatric assessment

Immediate safety concerns require immediate psychiatric/emergency assessment. For other presentations listed below, the timing and setting of assessment should be determined by clinical urgency. Suicidal ideation with intent or plan, recent suicide attempt, recent self-harm, history of repeated self-harm behaviors, disorientation/delirium, psychosis, bipolar disorder with hypomania or mania, severe agitation, or concerns about intoxication or withdrawal states.

2) Prompt referral (within 2–4 weeks)

• PHQ-9 ≥15 or HADS subscale ≥11 without immediate safety concerns: initiate optimization and arrange prompt LP assessment. Referral need not await symptom persistence for 2–4 weeks. Also consider prompt referral for PHQ-9 scores of 10–14 with substantial functional impairment.

• Obsessive-compulsive disorder, post-traumatic stress disorder, or personality disorder complicating pain management.

• Substance misuse affecting peri-procedural planning and safety, including moderate or high dose ongoing use of hypnotics.

• Any candidate for SCS or other implantables with psychosocial red flags, per neuromodulation guidance [6–8,13–15].

Psychology referral (CBT, ACT, or Pain Management Program) option should be available after initial LP input.

9. Basic treatment you can initiate in an interventional clinic

1) Psychoeducation and expectation setting

Explain that pain, mood, and functioning are interdependent, and that improving sleep, activity levels, and coping strategies enhances procedure outcomes even when the intervention successfully reduces nociceptive input. Use the ICD-11 chronic pain framework and collaboratively establish functional goals alongside numeric pain reduction targets [2,3].

2) Behavioural activation and graded activity

Develop a weekly activity plan emphasizing small, regular, meaningful activities with paced progression. Use time-based rather than pain-contingent movement schedules. Address fear-avoidance using graduated exposure informed by FABQ scores. Provide a pre-prepared brief sleep-hygiene handout and consider screening and psychological treatment for insomnia.

3) Pharmacotherapy (where within scope and local protocols)

For moderate-to-severe depression or anxiety and in the absence of bipolar or psychotic features, consider first-line SSRIs, SNRIs or tricyclic antidepressants (e.g., sertraline, escitalopram, duloxetine, amitriptyline) with appropriate safety checks, patient education, and a 4–6-week review using PHQ-9 or HADS to track response. Duloxetine or amitriptyline may offer additional benefit where neuropathic pain features coexist, though extra-caution is necessary when considering amitriptyline due to anticholinergic adverse effects as well as potential risk in overdose. Coordinate with psychiatry or primary care in complex cases or where polypharmacy is present.

4) Suicide risk management

If PHQ-9 item 9 is positive or suicidal ideation is suspected, undertake a prompt suicide-risk assessment, supported by the C-SSRS, to determine the appropriate response. Current suicidal thoughts require urgent assessment; a reported plan or intent is not a prerequisite for urgent evaluation. Where immediate safety concerns are identified, defer the elective procedure and arrange immediate psychiatric/emergency assessment according to local institutional policy. Implement safety planning, address access to lethal means, and involve family or support persons as appropriate [30].

5) Opioid risk management

Before initiating or continuing opioids around procedures, screen with SASQ + SDSQ, ORT or SOAPP-R, document risk-benefit analysis, prefer multimodal non-opioid analgesic strategies, and liaise with addiction or LP services if high risk is identified [16,17].

6) The Daradia Protocol: a structured 10-minute screening and stratification pathway

The Daradia Protocol is a streamlined approach to integrate psychiatric screening into routine interventional pain practice without extending clinic time.

(1) Step 1: screen (2–3 minutes)

At check-in, patients complete: PHQ-9 (preferred)/HADS (alternative), PRIME-5 with cautious interpretation due to limited adult validation, ORT/SASQ/SDSQ if opioid, alcohol, or substance use is suspected, and CIWA-Ar if alcohol withdrawal is suspected.

Staff score and flag high-risk results before physician encounter.

(2) Step 2: stratify (traffic light system)

Follow Table 1 for risk stratification. Patients are categorized as Green (low risk), Amber (intermediate risk), or Red (high risk) based on screening results and safety flags; management actions are linked to each category (Table 1). For major interventions, formal Psychiatric evaluation is strongly recommended for all Red and most Amber cases [6–8,13–15]. The Amber category is intentionally broad to preserve the simplicity and rapid usability of the protocol in busy clinical settings. It should be interpreted as a spectrum rather than a uniform risk state. Patients with lower Amber scores may proceed with psychoeducation, treatment-bundle initiation, and reassessment, whereas those with higher Amber scores, significant functional impairment, poor coping, or readily available LP support should be considered for earlier referral.

Table 1.

Traffic light system for risk stratification

Category	Criteria	Action
Green	PHQ-9: < 10 or HADS: ≤ 7 Low self-harm risk; PRIME-5 negative ORT/SASQ/SDSQ/CIWA-Ar: negative	Proceed with procedure and provide psychoeducation
Amber	PHQ-9: 10–14 or HADS: 8–10	Proceed with caution; initiate treatment bundle; consider LP referral; reassess in 4–6 weeks
Red	PHQ-9: ≥ 15 or HADS: ≥ 11 PRIME-5: positive ORT/SASQ/SDSQ/CIWA-Ar: significant Active suicidal ideation with plan or intent, a recent suicide attempt, or other immediate suicide-related safety concerns identified on clinical assessment	Defer procedure; initiate optimization and arrange LP assessment, with urgency determined by clinical severity and safety concerns

PHQ-9: Patient Health Questionnaire-9, HADS: Hospital Anxiety and Depression Scale, PRIME-5: Prevention through Risk Identification, Management, and Education - 5, ORT: Opioid Risk Tool, SASQ: Single Alcohol Screening Question, SDSQ: Single Drug Screening Question, CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, revised, LP: liaison psychiatry.

(3) Step 3: treat (same day)

• Green: Psychoeducation + functional goals

• Amber: Above + graded activity plan + sleep hygiene + consider SSRI/SNRI. If desired improvement is lacking, consider LP referral.

• Red: Defer the procedure; initiate optimization and arrange LP assessment, with urgency determined by clinical severity and safety concerns. Arrange urgent referral and stabilization when immediate safety concerns are present; include a safety plan where indicated.

(4) Step 4: document

Record scores, color category, decision rationale, treatment initiated, and referrals placed.

A flowchart representation of the Daradia Protocol is provided in Fig. 1.

Fig. 1.

The Daradia Protocol: a 10-minute clinical workflow for psychiatric screening and initial management in interventional pain practice. This figure presents a four-step workflow: screen, stratify, treat, and document. Screening uses PHQ-9 as the preferred tool, HADS as an alternative, and targeted instruments for substance use or alcohol withdrawal risk. PRIME-5 is included as a brief psychosis screen with limited adult validation. Patients are stratified into Green, Amber, or Red categories. Green indicates low risk and supports proceeding with psychoeducation. Amber indicates intermediate risk and requires treatment-bundle initiation, reassessment, and consideration of LP referral, especially with higher scores, functional impairment, or available psychiatric support. Red indicates high risk and warrants procedure deferral and LP assessment. Urgent psychiatric referral and stabilization are required when immediate safety concerns are present. Documentation includes screening scores, risk category, decision rationale, treatment initiated, and referrals placed. PHQ-9: Patient Health Questionnaire-9, HADS: Hospital Anxiety and Depression Scale, PRIME-5: Prevention through Risk Identification, Management, and Education - 5, ORT: Opioid Risk Tool, SASQ: Single Alcohol Screening Question, SDSQ: Single Drug Screening Question, CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, revised, LP: liaison psychiatry.

10. Practical application across common interventional scenarios

1) Epidural steroid injections and facet or sacroiliac joint interventions

Evidence regarding psychological moderators of injection outcomes is mixed, but patients with depression or anxiety often begin at worse functional baselines and may remain more disabled even when they improve proportionally. In Amber category cases, proceed with the injection while simultaneously initiating behavioral activation and LP referral; set clear expectations that procedures target specific pain generators but do not replace active self-management strategies.

2) RFA

Radiofrequency ablation (RFA) benefits from careful patient selection (confirmatory diagnostic blocks) and adherence to post-procedure activity plans [32,33]. High catastrophizing and fear-avoidance predict passive coping and poorer functional gains—address these proactively with graded exposure and written functional goals before and after RFA [28,34]. Depression has also been shown to adversely affect outcomes following genicular RFA, reinforcing the importance of identifying and addressing psychiatric comorbidity before undertaking interventions [35].

3) Advanced interventions (SCS, vertebral augmentation, intrathecal pump, etc.)

Most professional guidance recommends structured psychiatric assessment prior to trial implantation, with particular attention to mood disorders, catastrophizing, treatment expectations, social support, and adherence history [6–8,13–15]. Red category patients should be stabilized before proceeding. For Amber category patients, collaborative care with LP (skills-building, expectation calibration) often improves trial success rates and long-term patient satisfaction.

11. Counselling and shared decision-making

A simple communication framework helps align patient expectations:

• “Pain and mood travel together. Addressing sleep, activity, and mood improves the benefit you will experience from procedures.”

• “If your screening suggests we would achieve better and safer results after treating mood or anxiety first, we may postpone elective procedures temporarily.”

• “We will track your progress using short questionnaires (PHQ-9 and HADS) and adjust the treatment plan accordingly.”

Shared decision-making respects patient values and strengthens treatment adherence. Provide written handouts that explain the role of screening, the meaning of scores, and whom to contact for urgent concerns.

12. Implementation considerations in resource-constrained settings

• Task-Sharing: Train reception or nursing staff to administer and score PHQ-9 and HADS, and flag positive screens for physician review.

• Electronic Health Record Templates: Create “smart phrases” for documenting PHQ-9 and HADS scores, risk category (Green/Amber/Red), and action plans.

• Local Referral Network: Maintain an updated list of psychiatrists and psychologists (in-person and telepsychiatry options) and a crisis pathway for suicidality.

• Audit and Quality Improvement: Track percentage of patients screened, number of deferrals for safety reasons, referral uptake rates, and post-procedure outcomes; adjust cut-offs and workflow as needed based on local data.

13. Special note

ICD-11 reorganizes several previously separate “somatoform” categories into the broader construct of BDD, emphasizing persistent and disproportionate distress related to bodily symptoms rather than requiring medically unexplained pathology [36]. In clinical pain practice, such presentations may coexist with structural disease or occur in its absence, often complicating diagnostic formulation. Differentiating predominantly nociceptive or neuropathic mechanisms from symptom amplification driven by cognitive, affective, or behavioral processes requires systematic biopsychosocial assessment rather than reliance on structural findings alone. These cases frequently overlap with anxiety or depressive disorders and benefit from collaborative management involving LP and pain specialists. Importantly, malingering is separately classified in ICD-11 and is not considered a psychiatric disorder. Recognition of these distinctions supports accurate formulation, reduces unnecessary procedural escalation, and promotes appropriate multidisciplinary care.

14. Limitations of current evidence

The relationship between specific psychiatric features and specific injection-based outcomes remains inconsistent, with substantial heterogeneity in outcome measures and follow-up duration across studies. In the neuromodulation literature, most guidelines support pre-implant psychological assessment, but precise thresholds and mandatory exclusion criteria vary across settings and jurisdictions. Some recent analyses suggest nuanced effects of psychopathology on trial success rates [13–15].

The Daradia Protocol is a clinically derived framework that integrates established screening-tool thresholds, such as PHQ-9 and HADS severity cut-offs, with pragmatic clinical decision-making in interventional pain practice. It has not yet been prospectively validated or externally tested. Therefore, the proposed Green/Amber/Red categories should be interpreted as a practical risk-stratification framework rather than a validated prediction model. Future prospective studies should evaluate its feasibility, predictive validity, inter-rater consistency, and impact on procedural safety, referral patterns, and patient outcomes.

More implementation research is needed on screen-and-treat models embedded within interventional pathways and their impact on cost-effectiveness, safety events, and long-term functional outcomes. Future studies should also examine the optimal timing and intensity of psychological interventions relative to procedural interventions.

CONCLUSIONS

Psychiatric screening and stepped care are essential competencies for modern interventional pain physicians. Brief validated instruments (Whooley questions, PHQ-9, HADS) add only minutes to patient intake, yet identify individuals at risk of suboptimal outcomes or safety events. The Daradia Protocol provides a reproducible, evidence-aligned workflow that clarifies when to proceed, when to optimize, and when to defer and refer.

Embedding this pathway into routine practice supports better patient selection for injections and implantable devices, enhances peri-procedural safety, and promotes more durable functional gains—delivering the biopsychosocial care that contemporary pain medicine requires. Interventional pain physicians who integrate these principles into their clinical practice will be better positioned to optimize outcomes, manage risk, and provide truly comprehensive care to their patients with chronic pain.