Daradia Protocol for Psychiatric Screening Before Pain Interventions
A Practical 10-Minute Framework Published in the Korean Journal of Pain and Indexed in PubMed
Pain medicine has become increasingly sophisticated. Ultrasound guidance, fluoroscopy, radiofrequency procedures, neuromodulation and other advanced interventions allow pain physicians to target anatomical structures with remarkable precision.
But technical precision alone does not determine whether an intervention will succeed.
Depression, anxiety, psychological distress, maladaptive coping, substance misuse, sleep disturbance, catastrophizing, unrealistic expectations and other psychosocial factors can influence patient safety, treatment adherence, satisfaction and the durability of benefit after interventional pain procedures.
At the same time, many interventional pain physicians—often trained primarily in anaesthesiology—receive limited formal training in psychiatric screening, while access to liaison psychiatry may not always be readily available.
This practical gap was the background to the development of the Daradia Protocol.
The protocol has now been described in the peer-reviewed publication:
“Psychiatric screening and initial management in interventional pain practice: a narrative review and the Daradia Protocol”
Authors: Gautam Das, Ayanangshu Nayak, Anirudh Panemangalore Pai and Sushpa Das
Journal: The Korean Journal of Pain
Year: 2026
DOI: 10.3344/kjp.26097
PubMed PMID: 42754825
The article was published in September 2026 and is indexed in PubMed.
Importantly, publication in a peer-reviewed journal gives the Daradia Protocol a formal place in the scientific pain-medicine literature. It does not mean that the framework has been externally validated or endorsed as a universal guideline. That distinction is important.
Why Psychological and Psychiatric Screening Matters Before Pain Interventions
Chronic pain is not simply an anatomical phenomenon.
The contemporary understanding of pain is biopsychosocial. Biological pathology remains critically important, but mood, sleep, coping behaviour, expectations, social circumstances and psychological distress can interact with pain and disability.
The published review notes that psychological variables including depression, anxiety, bodily distress, catastrophizing and poor coping have been associated with poorer outcomes in several areas of spine surgery and neuromodulation. Evidence related to injection procedures is more heterogeneous, but psychological distress can still influence baseline disability, quality of life and treatment outcomes.
This raises an important question for every interventional pain physician:
Before asking “Can I perform this procedure?”, should we also ask “Is this patient ready for this procedure?”
Psychiatric screening does not mean assuming that pain is psychological.
It does not mean denying structural pathology.
And it certainly does not mean that every patient with depression or anxiety should be denied an intervention.
Instead, the purpose is to identify factors that may affect:
- Procedural safety
- Informed consent
- Expectations
- Treatment adherence
- Rehabilitation
- Functional recovery
- Substance-use risk
- Long-term procedural outcomes
- Need for psychiatric or psychological support
The goal is better patient selection and more complete pain care.
What Is the Daradia Protocol?
The Daradia Protocol is a structured clinical pathway proposed to help pain physicians incorporate psychiatric screening into routine interventional practice without making every consultation excessively long or complicated.
It is designed as an approximately 10-minute stepped-care pathway consisting of four components:
Screen → Stratify → Treat → Document
The protocol combines brief screening instruments with a simple Green–Amber–Red traffic-light system.
The intention is to help the pain physician determine whether an elective intervention may reasonably proceed, whether psychological factors should be addressed alongside treatment, or whether the procedure should be deferred while psychiatric assessment and optimisation take place.
Step 1: SCREEN
The first step is rapid screening.
Depending on the clinical situation, the published protocol discusses tools including:
PHQ-9
The Patient Health Questionnaire-9 is a widely used nine-item instrument for assessing depressive symptoms.
The paper uses PHQ-9 as the preferred depression screening instrument because it is brief, widely validated and freely available. A positive response to its suicide-related item requires further clinical suicide-risk assessment.
HADS
The Hospital Anxiety and Depression Scale may be used as an alternative, particularly where reducing overlap between physical symptoms and psychological symptoms is useful.
Whooley Questions
Two brief verbal questions regarding depressed mood and loss of interest may provide an initial depression screen. A positive response can prompt more detailed assessment using PHQ-9.
Substance-Use Screening
The paper also discusses brief tools such as the Single Alcohol Screening Question (SASQ) and Single Drug Screening Question (SDSQ) when alcohol or substance misuse is relevant.
Additional instruments may be used when clinically appropriate for opioid-related risk, alcohol withdrawal, catastrophizing, fear avoidance, delirium or suicide risk.
The purpose is screening—not psychiatric diagnosis by questionnaire alone.
Step 2: STRATIFY — The Traffic-Light System
One of the distinguishing features of the Daradia Protocol is its simple traffic-light approach.
🟢 GREEN — Lower Psychological Risk
The published framework identifies Green patients as those with relatively low screening scores and no major safety flags.
Suggested approach:
Proceed with the planned intervention when otherwise clinically appropriate, together with psychoeducation and appropriate functional goals.
Psychological screening does not replace the normal requirements for diagnosis, evidence-based patient selection, informed consent and procedural safety.
🟠 AMBER — Intermediate Risk
Amber represents an intermediate category.
These patients may have clinically relevant depression or anxiety symptoms without an immediate major safety concern.
The Amber category is intentionally broad. The paper specifically emphasizes that it should be considered a spectrum rather than a single uniform risk state.
Depending on the individual patient, management may include:
- Proceeding cautiously when clinically appropriate
- Psychoeducation
- Expectation alignment
- Graded activity
- Sleep optimisation
- Addressing poor coping or fear avoidance
- Reassessment
- Psychological or psychiatric referral when indicated
Patients at the higher end of the Amber spectrum, those with substantial functional impairment, poor coping, or those being considered for major interventions may warrant earlier specialist mental-health assessment.
🔴 RED — High Risk
The Red category identifies patients in whom elective procedural treatment may need to be deferred while psychological or psychiatric issues are assessed and optimised.
Examples discussed in the paper include severe depression or anxiety, significant substance-use concerns, psychosis-spectrum symptoms or major suicide-related safety concerns.
Where immediate safety concerns exist, urgent psychiatric or emergency assessment may be necessary.
The protocol therefore recommends:
Defer elective intervention → optimise the patient → arrange appropriate psychiatric assessment → reconsider the procedure after stabilisation when appropriate.
Importantly, “Red” should not be interpreted as permanent exclusion from interventional treatment.
The objective is safer sequencing of care.
Step 3: TREAT AND OPTIMISE
Screening is useful only when it changes clinical management.
The Daradia Protocol therefore moves beyond identifying psychological symptoms and encourages appropriate initial action.
For suitable patients, this may involve:
- Explaining the interaction between pain, mood, sleep and function
- Establishing realistic expectations from an intervention
- Setting functional rather than purely numerical pain goals
- Encouraging graded activity
- Addressing sleep
- Reducing fear-avoidance behaviour
- Coordinating care with psychiatrists or psychologists
- Using established mental-health treatments within the physician’s professional scope and local practice framework
The paper emphasizes that pain procedures and psychological care should not necessarily be viewed as competing approaches.
In many patients, they can be complementary components of multidisciplinary pain management.
Step 4: DOCUMENT
The final step is often overlooked.
The protocol recommends documenting:
- Screening instrument used
- Screening score
- Green/Amber/Red category
- Relevant clinical findings
- Rationale for proceeding or deferring
- Optimisation measures initiated
- Referrals arranged
- Follow-up plan
Documentation creates a transparent record of why a particular procedural decision was made.
It can also strengthen informed consent and encourage more systematic clinical decision-making.
When Should a Pain Procedure Be Deferred?
Psychological illness should not automatically exclude a patient from interventional treatment.
However, the publication identifies circumstances where proceeding with an elective intervention may be inappropriate until the patient has been further assessed or stabilised.
These include important safety concerns such as:
- Active suicidality or recent serious self-harm concerns
- Psychosis
- Mania or hypomania
- Delirium
- Uncontrolled substance-use disorder
- Severe depressive or anxiety states significantly interfering with engagement, adherence or informed consent
The paper distinguishes urgent safety situations from less acute psychological problems that may instead require optimisation and coordinated care.
This distinction is central to the protocol.
The question is not simply:
“Does the patient have depression or anxiety?”
The more clinically useful questions are:
How severe is it? Does it affect safety? Does it compromise consent, adherence or rehabilitation? Can treatment proceed while psychological care occurs simultaneously, or should elective intervention temporarily wait?
Application to Interventional Pain Procedures
The review discusses the relevance of psychiatric and psychological assessment across common areas of interventional pain practice.
Epidural, Facet and Sacroiliac Joint Interventions
Evidence regarding psychological predictors of injection outcomes is not completely consistent.
However, patients with depression or anxiety may begin with greater disability and poorer quality of life. In selected intermediate-risk patients, an intervention may still proceed while psychological optimisation and active rehabilitation occur simultaneously.
Radiofrequency Ablation
Successful radiofrequency treatment depends not only on technical execution but also on patient selection, appropriate diagnostic evaluation and post-procedural rehabilitation.
Catastrophizing, fear avoidance and depression may influence functional outcomes in some populations and therefore deserve consideration.
Neuromodulation and Other Major Interventions
Psychological assessment becomes particularly relevant when considering treatments such as spinal cord stimulation and other implantable therapies.
Professional guidance commonly recommends structured psychological assessment before neuromodulation, with attention to factors such as mood, expectations, coping, adherence and social support.
The Daradia Protocol provides a practical preliminary framework for identifying patients who may benefit from more formal assessment.
The Pain Physician Is Not Expected to Become a Psychiatrist
This is perhaps the most important practical message.
The purpose of the Daradia Protocol is not to convert interventional pain physicians into psychiatrists.
Pain physicians should, however, be able to recognise important psychological and psychiatric warning signs—just as they screen for infection, anticoagulation issues, neurological deficits and other factors that may affect procedural decision-making.
The role of the pain physician is to:
Recognise → Screen → Assess risk → Decide appropriately → Refer when necessary.
Complex psychiatric diagnosis and specialist treatment remain the domain of appropriately trained mental-health professionals.
Psychological Screening Does Not Mean the Pain Is “In the Mind”
Patients should never be made to feel that screening for anxiety, depression or coping implies that their pain is imaginary.
Pain can be biologically driven and psychologically influenced at the same time.
A patient may have genuine osteoarthritis, radiculopathy, neuropathic pain or another identifiable pain generator while also experiencing depression, poor sleep, fear avoidance or catastrophizing.
Recognising those factors does not invalidate the structural diagnosis.
It allows treatment to address the whole patient rather than only the anatomical target.
Why This Publication Is Important for Daradia
The publication represents an important academic milestone because the Daradia Protocol is now described within the peer-reviewed scientific literature and indexed in PubMed. The article itself lists Daradia: The Pain Clinic, New Town, Kolkata, India as the affiliation.
Rather than presenting psychiatric screening as an abstract recommendation, the protocol translates it into a workflow intended for the realities of a busy interventional pain clinic:
Screen → Stratify → Treat → Document
and:
🟢 Proceed
🟠 Proceed cautiously and optimise
🔴 Defer, assess and optimise when necessary
The larger objective is to encourage a transition from purely procedure-centred pain medicine toward patient-centred, biopsychosocial interventional pain care.
An Important Limitation: The Daradia Protocol Requires Further Validation
The Daradia Protocol should not currently be described as a validated prediction model, an international guideline or an internationally approved standard.
The authors explicitly acknowledge that the protocol is a clinically derived framework integrating established screening thresholds with pragmatic decision-making.
It has not yet undergone prospective validation or external testing.
Future research should evaluate:
- Feasibility
- Predictive validity
- Inter-rater consistency
- Impact on procedural safety
- Referral patterns
- Patient outcomes
This provides an important future research direction for Daradia and other pain centres interested in biopsychosocial patient selection.
Frequently Asked Questions About the Daradia Protocol
What is the Daradia Protocol?
The Daradia Protocol is a proposed approximately 10-minute clinical workflow for psychiatric screening and initial management in interventional pain practice. It uses brief screening tools followed by Green, Amber and Red risk stratification.
Is the Daradia Protocol published in a peer-reviewed journal?
Yes. It is described in a 2026 article in The Korean Journal of Pain and is indexed in PubMed.
Is the Daradia Protocol validated?
Not yet. The authors specifically state that prospective and external validation is required.
Does every chronic-pain patient need psychiatric referral?
No. The purpose of screening is to identify who may safely proceed, who may need psychological optimisation alongside treatment, and who requires psychiatric or psychological assessment before an elective intervention.
Does psychological screening replace psychiatric consultation?
No. Screening identifies possible concerns and supports clinical decision-making. It does not replace specialist psychiatric diagnosis or treatment.
Can a patient with depression still undergo a pain intervention?
Potentially, yes. Decisions depend on severity, functional impairment, safety concerns, ability to provide informed consent, treatment adherence and the nature of the proposed intervention. Psychological comorbidity should not automatically lead to exclusion.
Why screen before an intervention?
Because psychological and psychiatric factors can influence patient safety, expectations, adherence, rehabilitation and treatment outcomes. Screening can therefore form part of responsible patient selection.
Toward More Complete Interventional Pain Care
The future of interventional pain medicine is not simply about placing needles more accurately.
It is about selecting the correct patient, identifying the correct pain generator, understanding the patient’s broader biopsychosocial context, setting appropriate expectations and integrating procedures with rehabilitation and multidisciplinary care.
The Daradia Protocol is an attempt to make one important part of that process—psychiatric screening—more practical for everyday interventional pain practice.
Screen. Stratify. Treat. Document.
Sometimes the correct decision is to proceed.
Sometimes it is to proceed while simultaneously addressing psychological factors.
And sometimes the safest and most appropriate intervention is to wait, optimise and refer first.
That distinction can be as important as the procedure itself.
This article is written by Dr Sushpa Das & clinically reviewed by Dr Gautam Das
Publication
Das G, Nayak A, Pai AP, Das S.
Psychiatric screening and initial management in interventional pain practice: a narrative review and the Daradia Protocol.
The Korean Journal of Pain. 2026.
DOI: 10.3344/kjp.26097
PubMed PMID: 42754825
Medical disclaimer
The Daradia Protocol is a proposed clinical risk-stratification framework and does not replace comprehensive clinical assessment, formal psychiatric evaluation when indicated, local institutional protocols or professional clinical judgement. Patients with suicidal thoughts or other immediate psychiatric safety concerns require appropriate urgent assessment.
