What are the preoperative mental health evaluation and management recommendations for a 20-year-old male with a history of depression, currently experiencing low energy, low motivation, and fleeting thoughts of death or dying, scheduled for pectus excavatum repair surgery in a couple of weeks, and taking tramadol (opioid analgesic) daily for chest pain?

Preoperative Mental Health Management for Pectus Excavatum Surgery

Immediate Psychiatric Evaluation Required

This patient requires urgent psychiatric evaluation before surgery, but the surgery should not be delayed—instead, initiate treatment immediately and continue perioperatively. Depression with passive suicidal ideation ("fleeting thoughts of death/dying") in the preoperative period significantly increases postoperative mortality, heart failure hospitalization, MI, cardiac arrest, and need for repeat procedures 1. Preoperative anxiety independently increases mortality risk (HR: 1.88) more than depression itself in surgical patients 1.

Critical Medication Issue: Tramadol Must Be Addressed

Tramadol carries a 25% delirium risk and should be transitioned to a safer multimodal analgesic regimen before surgery 1. While tramadol does reduce postoperative opioid consumption by 25% 1, this patient's daily use creates significant perioperative delirium risk, particularly given his depression and young age (delirium risk compounds with psychiatric comorbidity) 1.

Recommended Analgesic Transition:

• Switch to acetaminophen 1g every 8 hours as first-line therapy 1
• Add pregabalin (600mg 1 hour preoperatively, continue 2 days postoperatively) or gabapentin (600mg 2 hours preoperatively) to reduce opioid requirements and improve pain scores 1
• Continue tramadol taper through surgery only if withdrawal risk exceeds delirium risk—but plan immediate postoperative discontinuation 2

Antidepressant Initiation Is Indicated and Safe

Start escitalopram 10mg daily immediately (2-3 weeks before surgery if possible), as treating depression preoperatively improves postoperative quality of life, reduces pain, and does not increase morbidity or mortality 2, 3. The American Heart Association specifically recommends treating depression before surgery to improve psychological outcomes 2. A randomized controlled trial of 361 surgical patients demonstrated that escitalopram initiated 2-3 weeks preoperatively resulted in better quality of life and less postoperative pain without affecting morbidity or mortality 2.

Key Points on Escitalopram:

• Do not delay necessary psychiatric treatment due to upcoming surgery—untreated depression poses greater risk than any theoretical perioperative drug interaction 2
• Continue escitalopram through surgery without interruption—the risk of withdrawal outweighs theoretical concerns about drug interactions 2
• Monitor for serotonin syndrome when combined with tramadol (which has serotonergic activity), though this risk is generally low in clinical practice 2

Medications to Strictly Avoid

Benzodiazepines must be avoided entirely—they precipitate delirium and worsen postoperative cognitive dysfunction, even when anxiety is prominent 2, 3. This is critical given this patient's age and psychiatric vulnerability.

Additional medications to avoid:

• Antihistamines (diphenhydramine, hydroxyzine, cyclizine) due to anticholinergic effects that increase delirium risk 2, 3
• Sedative-hypnotics and anticholinergic medications (tricyclic antidepressants, paroxetine, promethazine) 2, 3

Non-Pharmacological Treatment (Essential Component)

Initiate cognitive behavioral therapy or telephone-delivered collaborative care immediately—these are first-line interventions with the most durable effects 1, 3. Collaborative care for 8 months achieves 50% reduction in depression scores and improves quality of life and physical functioning, particularly effective in men 1, 3.

Body Image Considerations Specific to Pectus Excavatum

Patients with pectus deformities have significantly disturbed body image and reduced mental quality of life compared to controls, with body image distress being a major contributor to therapeutic decision-making 4. This patient's depression may be partially related to body image concerns, which typically improve after surgical correction but require specific psychological support 4.

Postoperative Delirium Prevention Strategy

This patient has multiple delirium risk factors (tramadol use, depression, male gender, surgical duration) 1:

• Implement systematic delirium screening at least once per nursing shift using CAM-ICU or ICU Delirium Screening Checklist 1
• Use multimodal opioid-sparing analgesia: acetaminophen, pregabalin/gabapentin, and consider dexmedetomidine intraoperatively 1
• Avoid all benzodiazepines and anticholinergic medications postoperatively 2, 3

Preoperative Risk Stratification

Higher educational level is protective against postoperative delirium—patients with college degrees have 55% lower risk (OR: 0.45) compared to those with less than high school education 1. Current smoking increases delirium risk by 37% (OR: 1.37) 1. Assess these factors to stratify this patient's individual risk.

Common Pitfalls to Avoid

• Do not substitute benzodiazepines for escitalopram even if anxiety seems more prominent than depression—benzodiazepines significantly worsen cognitive outcomes 2, 3
• Do not delay surgery for psychiatric treatment—initiate treatment now and continue perioperatively 2
• Do not continue tramadol postoperatively—transition to safer multimodal analgesia 1
• Do not underestimate passive suicidal ideation—"fleeting thoughts of death/dying" require formal psychiatric evaluation and treatment 1