Research Summary: Do GDPs have a role in identifying dental patients with mental health problems?
Background
Study
Results
Discussion and Recommendations:
Mental health conditions are becoming more prevalent in the general population.
Such conditions are known to have effects on a patient's oral health as well. Generally speaking, the low self-esteem, self-neglect, increased sugar intake, substance abuse and irregular dental attendance associated with many different mental health disorders can cause many different dental issues. More specifically for example, 57% of patients with a facial pain syndrome also suffer from a mental illness,
and one suggested aetiology of Burning Mouth Syndrome is a mental health disorder.
Therefore, whilst it is apparent these patients must be presenting themselves to dental clinics, their exact prevalence is unspecified, the GDP's ability to recognise such patients is unknown, and there appears to be a general lack of training and confidence when it then comes to the GDP attempting to assist such patients.
Hence, the three main aims of this study were:
- To what extent do general dental practitioners (GDPs) encounter dental patients with mental health problems?
- What procedure do GDPs currently adopt with such dental patients?
- Do GDPs regard themselves as having a role in identifying dental patients with mental health problems?
To answer these questions, in total 74 GDPs from the health authority lists within the Mersey region were contacted and answered questions relating to the main aims of this study. 54 of these GDPs responded via telephone interviews that allowed for further exploration of questions and answers, whilst the remaining 30 GDPs responded via semi-structured postal questionnaires. Demographic data showed most respondents had been practising GDPs for a minimum of 11 years.
All demographic and quantitive data was statistically analysed, whilst the qualitative data was examined by the core researches as well as a ‘dental project team’ consisting of 2 GDPs, 1 sociologist, 1 dental care specialist, 1 medical care specialist and 1 clinical psychologist, in order to ensure the data's validity and reliability.
Nearly half of all GDPs interviewed (46%) do not refer patients they suspect of having mental health problems. Even when GDPs do refer their patients to dental specialists, it tends to be regarding a physical manifestation as opposed to a psychological one. In circumstances where the GDPs do not refer dental patients with mental health problems, some suggested they allocate extra time to treat the patient
This suggests that the true aetiology of the patients’ problems may not always be addressed. At best, the procedure being adopted by the GDPs is an inefficient use of their time, and at worst, the patients are receiving inappropriate intervention.
All the GDPs who perceived the patient to have poor mental health focused on managing the physical symptoms of the dental condition. Although some GDPs (9%) indicated that they ‘talk’ to their patients about their problem, they stop short of addressing the underlying problems.
The majority of questionnaire responders (n = 14/17, 82%) indicated they would refer patients if suitable services were available.
The majority of interviewed GDPs (70%) felt the patient’s GMP was a good place for initial referral
However, collaboration between GDPs and GMPs was not currently prevalent, with 30% of GDPs commenting that there was definite need for improvement in the way GDPs and GMPs communicate
Only five GDPs (9%) stated that they referred dental patients with possible mental health problems to their general medical practitioner (GMP). In general, GDPs appeared cautious of GMPs’ reaction to the idea of identifying dental patients with possible mental health problems.
The reasons for GDPs expressing uncertainty or negativity towards identifying and referring dental patients with mental health problems was due to their scepticism of GMPs accepting them in this role and the reaction of dental patients.
a distinct lack of communication between themselves and GMPs. GDPs feel that they are regarded by GMPs as being only concerned with oral health.
It was thought that the stigma of mental health problems may cause reluctance to accept such a referral. A suggestion for overcoming this problem was to improve GDPs skills to broach the issue.
Concerns about the patient’s reaction to raising the issue of being referred for mental health problems were expressed by half of the GDPs (n=8/16, 50%).
the important factor is the manner adopted with the dental patient. It requires a degree of skill upon the part of the GDP and trust on the part of the patient
It was found that GDPs encounter dental patients with mental health problems. These encounters range from dental anxiety/fear to severe mental illness. In between these two points, there are patients with anxiety and depression due to life events, dental somatisation disorders (i.e. the patient presents with dental pain, but the GDP can find no physical cause), patients with behaviour suggesting a psychological disorder, and patients with diagnosed psychological problems.
Just over half of the questionnaire respondents (57%) claimed to have encountered patients with symptoms they suspected were caused by mental health problems. Their responses indicated that the majority of encounters were with patients who had a ‘dental somatisation disorder’ (53%)
The majority of GDPs interviewed (78%) stated they had encountered patients who had been diagnosed, or were possibly suffering from mental health problems (undiagnosed). Of the 12 GDPs who stated they were unaware of such patients, eight conceded this was due to a lack of knowledge/skills to identify such patients.
Seven GDPs (13%) stated that they did not encounter patients with mental health problems. However, the comments made by these GDPs indicate they do not look for, or necessarily recognise the symptoms and signs of psychological difficulties.
The results show that GDPs do encounter dental patients experiencing mental health conditions. These range from typical depression and dental anxiety/fear to severe diagnosable mental illness. More specifically, 57% of respondents reported seeing patients present with dental symptoms they suspected were caused by mental conditions - most commonly a form of dental somatisation disorder (i.e. when the patient presents with dental pain with no identifiable physical cause). Of those GDPs who stated they were unaware of encountering any patients with mental health conditions, their comments indicated they do not actively pay attention for or necessarily recognise the symptoms and signs of these conditions, and conceded this may be due to a lack of knowledge/skills on their part.
In terms of how such patients are addressed by GDPs, 46% of respondents did not make any sort of referral to a GMP or dental specialist, and even those that did tended to make said referrals based on the patient's physical manifestations as opposed to the underlying psychological issues. Of those GDPs who did not make any referrals, some did suggest they allocate extra time - presumably to facilitate further conversation - when treating the patient instead. However, unfortunately overall this suggests that the true aetiology of patients’ problems may not always be best addressed, if at all.
When discussing who they would like to refer patients to, 70% of those interviews stated they felt the GMP was best for an initial referral. However these respondents also noted there exists a distinct lack of communication between themselves and GMPs; GDPs also feel that GMPs view them being only interested in patients' oral health, and that GMPs may therefore be sceptical of accepting them in this role.
Furthermore, 50% of respondents were concerned how patients might react if the GDP were to address such a topic to them; it was thought that the stigma surrounding mental health conditions may cause reluctance to accept e.g. a referral.
This study suggests that: (1) GDPs are aware of encountering patients with conditions that may not require dental treatment, due to their psychosomatic origin. (2) The majority of GDPs are willing to help these patients, although currently their referral may be inappropriate due to not having the skills/guidelines to identify the best course of action.
It would appear that the majority of GDPs consider having a role in identifying patients with possible mental health problems. More specifically, the GDPs role might include: (1) being able to identify people whose mental health problems have so far been undiagnosed. (2) being aware of the dental conditions which may be caused by or associated with mental health problems.
Many GDPs are able to recall patients that have presented with symptoms which are either perceived as unsuitable for treatment or are suspected as being psychological in origin, but in the majority of cases GDPs do not refer. Although some GDPs attempt to adapt their approach and treatment according to the nature of the mental health problem with which they are presented, this appears to inadequately address the needs of these dental patients. They tend to treat the physical condition and ignore the underlying problem even though they admit that this may not be the best course of action. In many instances this was due to not knowing where to refer the patient or how to broach the subject of referral with the patient.
Surprisingly very little communication was reported between GDPs and GMPs considering that both professions are part of the ‘primary care team’. It was apparent from the interviews that GDPs currently refer dental patients to GMPs on an ‘ad hoc’ basis. Three issues emerge from this current practice. 1) There is no guarantee that the dental patient follows the GDP’s recommendation and goes to visit their GMP. 2) GDPs do not appear to inform GMPs of the reason for sending the dental patient to see them, therefore the GMP and ‘dental patient’ consultation may not relate to the problem suspected by the GDP. 3) The GDP does not receive any feedback from the GMP or make any follow up enquiries regarding the outcome of the consultation. Improving methods of information exchange between GDPs and GMPs requires further investigation, however the benefits of increased integration have been previously highlighted
In terms of the dental patient’s welfare, a referral to the GMP may be the most appropriate option. Based upon the premise that patients may initially be resistant to a referral, referral to the GMP would be the easier option of dealing with a patient presenting with mental health problems, as opposed to suggesting a referral to a psychiatrist. GDPs and GMPs are both part of ‘primary care provision’ therefore communication and collaboration should be easily developed and dental patients are more likely to accept a referral to their own GMP (i.e. they are likely to be acquainted with them) rather than an unknown health professional. A referral to a GMP would act as confirmation or refutation of the GDPs assessment. This would help to ensure that dental patients with mental health problems were not referred inappropriately (i.e. to mental health services). Although some GDPs refer patients to a dental specialist/GMP, currently no guidelines or agreed protocol exists which provides GDPs with the assurance that they are identifying and referring patients appropriately. GDPs do not appear to detail in their referral communication their suspicions concerning the possibility of a psychological as opposed to physical origin to the dental complaint.
Many GDPs appeared cautious about their ability to determine a patient’s psychological condition, this was especially so in the case of depression where it may just be short term (for example, a bad week at work). This caution may be due to a lack of training to identify such problems.
It has to be appreciated that a GDP’s workload places a limit upon the amount of time spent with each patient. However, the current procedures adopted for dealing with such patients are ineffective (that is referring for: ‘physical’ problems, administering unnecessary treatment, having them re-attend). By having set guidelines which outline what symptoms GDPs should be aware of, and when a patient should be referred to their GMP, will not only address the patient’s health needs, but also result in an efficient use of time and resources. Obviously, GDPs require a tool that will allow a relatively quick assessment. The hospital anxiety and depression scale22 and modified dental anxiety scale23 may be useful tools for this procedure.
This study overall suggests:
1) GDPs are aware of encountering patients with mental health problems, including those with dental conditions of related psychosomatic origin, an
2) Most GDPs are willing to help these patients, however their knowledge, skills and confidence when addressing and referring these patients are currently inadequate.
This study therefore recommends further research centring around improving methods of information exchange between GDPs and GMPs, and the creation of guidelines to help GDPs be aware of relevant symptoms and approaptie referall pathways, to give referring GDPs confidence in efficently and appropatiatley managing these patients.