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Service innovations: role of liaison psychiatrist in dental practice

Dr. Sanju George MRCPsych
Specialist Registrar in Psychiatry
Sandwell Outreach Team
The Cottage
6-6A Simpson Street
Oldbury, West Midlands
B69 4AL
Ph: 0121 5695704
E-mail: sanju.george@talk21.com

Femi Oyebode MBBS MD PhD FRCPsych
Professor and Head of Department of Psychiatry
Consultant Psychiatrist
Queen Elizabeth Psychiatric Hospital
Mindelsohn Way
Edgbaston
Birmingham
B15 2QZ
Ph: 0121 678 2526
E-mail: femi_oyebode@msn.com

Abstract

Objectives: Psychiatric disorders (overt/covert) are frequent in patients presenting to dentists, at least some of which go unrecognized and hence untreated. This study evaluates a unique consultation liaison psychiatric service for patients presenting with psychiatric disorders to a dental hospital in Birmingham.
Methods: All patients who were referred to and attended this service during the period December 2001-January 2002 were eligible for inclusion in the study. The relevant information were extracted from patients' psychiatric and dental case notes and analyzed using SPSS software.
Results: Thirty-seven of the thirty-nine patients referred, attended their initial appointment with the psychiatrist .The majority of this sample were female (n=29, 78%), aged 60 and above (n=21, 57%) and had symptoms of more than 10 years duration (n=11, 30%). The most common psychiatric diagnoses were Somatoform Disorders (n=23, 62%) and Depressive Disorders (n=10, 27%). Following psychiatric assessment, psychotropic medication was the only intervention recommended in 28 patients (76%), (with SSRIs being most commonly prescribed; n=20, 54%), while a combination of pharmacological and psychological approaches was used in four patients.
Conclusion: It has been possible to set up and effectively run a psychiatric consultation liaison service within a dental hospital, catering to patients who present with psychiatric disorders in dental practice. Most of these patients, once identified, readily engaged and responded well to simple and effective interventions. This specialist service helps to manage a patient subgroup, who otherwise remain resistant to conventional treatment, consume more resources and exact considerable economic burden on the health service and society. There is clearly a scope for similar services elsewhere in this country.

Introduction

Liaison psychiatry is fast emerging as a well-recognized subspecialty within psychiatry (1). The boundaries of this subspecialty are ill defined and extend into various branches of medicine. Though psychiatric consultation liaison in dental practice is still in its infancy in this country, the contribution of behavioral sciences in management of psychosomatic symptoms in patients presenting to dental specialists was recognized early elsewhere (2). In this context, we describe the setting up and running of a unique psychiatric liaison service in a dental hospital in Birmingham and also look at the socio-demographic and clinical characteristics of patients referred to this service over a one - year period (Dec 2001-Jan 2002).

Dentists spend a considerable amount of time treating patients who present with either psychiatric disorders like depression and anxiety or with physical manifestations of underlying emotional disturbances. Common manifestations of covert emotional disturbance in patients in dental practice include oral dysaesthesia, atypical facial pain and other atypical syndromes (3). Increasing attention needs to be given to identify and appropriately treat somatoform disorders, more so, as they constitute one-third to one-half of referrals to any liaison psychiatry service (4).

Somatoform disorders, apart from posing management problems, also cause significant functional impairment and overall disability for the patient (5). Bass et al (6) recognized somatoform disorders as severe psychiatric disorders and suggested that they be treated by psychiatrists or psychologists.

Recognizable psychopathology is seen in upto 30% of patients attending dental clinics (7) and this often goes undetected and hence untreated. Dental specialists, often come across patients, who present with complaints of pain, abnormalities of sensation, movement and salivation involving the mouth and face, which are a manifestation of underlying emotional disturbance and not due to a clearly identifiable physical cause. Early and appropriate recognition of such emotional distress would benefit both the individual and the health service (8).

Given the prevalence and impact of unrecognized and untreated psychiatric disorders in patients presenting in dental practice, there follows the need for a service to address this unmet need. This would directly provide a framework for psychiatric- dental liaison and indirectly lead to better understanding of psychiatric disorders by dental specialists, which in turn will lead to early identification and referral to such a service if one exists. It has been shown elsewhere (9) that availability of psychiatric liaison service will lead to an increase in rate of referrals.

The service

This psychiatric liaison clinic was set up in mid 1999 at the Birmingham Dental Hospital. There are two out patient clinics a month, run by a psychiatric team. These clinics run at the dental hospital and provide a context for the assessment of patients referred by dental specialists. The reasons for referral range from help with diagnostic clarification to advice regarding immediate and long-term management. Though the overall responsibility for running this service rests with the consultant psychiatrist, trainees (Senior House Officers and Specialist Registrars) too play an active role in running the clinics.

Methodology

This is a descriptive study of an innovative psychiatric consultation-liaison service operating at the Birmingham dental hospital. All patients who were referred to this service during the period Dec 2001- Jan 2002 were eligible for inclusion in the study. The relevant information (including clinical and socio demographic aspects) was extracted from their psychiatric and dental case notes, using a pre-designed data sheet, by a psychiatrist. (S.G) The data were analyzed using the Statistical Package for Social Sciences (SPSS) computer software. The results are discussed under the following headings: patient characteristics, dental diagnosis on referral, psychiatric diagnoses, and the treatments recommended after assessment.

Two methodological limitations of this study are: the relatively small sample size and the retrospective, case note-based method of data collection. Of course, a prospective study-design, with a larger sample, would have led to more reliable and valid findings.

Results

Patient characteristics

Over the one-year period (2001-2002), thirty-nine patients were referred for psychiatric assessment. Thirty-seven of the 39 patients attended their initial assessment. Majority of the sample were female (n=29, 78%) and the mean age of the sample was 63 years. Most of the patients were married (54%) and of Caucasian origin (73%). Nearly a third of these patients had had persistent symptoms for over 10 years. Eleven patients (n=11, 29.7%) had had symptoms for 10-15 years, five (13.5%) patients for 5-10 years, 12 (32.4%) patients for 2-5 years, and 8 (21.6%) patients for 1-2 years.

Reason for referral

In almost all cases, lack of response to conventional treatments (medical and surgical) was the reason for seeking a psychiatric opinion. These patients posed management problems and often dental specialists saw psychiatric referral as a last resort. Few patients (n=4) were referred for treatment of suspected co morbid depressive disorders.

Dental and Psychiatric diagnostic categories

More than three- quarters (n=29, 78%) of the patients were referred for psychiatric assessment with a diagnosis of oral dysaesthesia or burning mouth syndrome (these two terms were used interchangeably). Atypical facial pain syndromes constituted 14% (n=5) of cases, with leukoplakia (n=1) and temporomandibular joint (TMJ) dysfunction (n=2) making up the remaining diagnostic categories.

ICD-10 diagnostic categories were used for classification of psychiatric disorders (10). The most common psychiatric diagnoses in this group were somatoform disorders (n=23, 62%) and depressive disorders (n=10, 27%). A further break up of the ICD-10 diagnostic categories is given in Table I. Within the category of depressive disorders, moderate depressive disorders predominated, (6/10, 60%) and somatoform disorders-unspecified, within the diagnostic category of somatoform disorders (15/23, 68%).

Table- 1 ICD-10 (World Health Organization, 1992) psychiatric diagnoses of assessed patients

F 20-29. Schizophrenia, Schizotypal and delusional disorder
Delusional disorder	3
F 30-39. Mood Disorders
Mild depression	3
Moderate depression	6
Dysthymia	1
F 40-48. Neurotic, Somatoform and stress related disorders
Somatoform disorders, unspecified	15
Persistent somatoform pain disorder	5
Somatisation disorder	2
Hypochondriacal disorder	1
Mixed anxiety and depression	1

Treatments recommended

The range of treatments suggested, following the psychiatric assessment was: pharmacotherapy and psychotherapy, either alone or in combination. Twenty-eight patients (76%) were initiated on pharmacotherapy alone and selective serotonin reuptake inhibitors (SSRIs) predominated among the psychotropics used (71%). Other psychotropic medications used included tricyclic antidepressants (TCAs), serotonin noradrenalin reuptake inhibitors (SNRIs), newer antipsychotics, carbamazepine and gabapentin. A combined pharmacological and psychological approach was used in 4 patients (10%) and no specific intervention was suggested in 4 patients. All patients initiated on treatment were followed up in the clinic.

Discussion

This is a unique model of psychiatric - liaison service, which has been running smoothly for the last four years. Given the extent of psychiatric co- morbidity in patients presenting to dental specialists, it is surprising that there are very few such services available in the UK.

This study is unique in that these patients are a select subset of those attending dental clinics, who are suspected to have psychiatric disturbance, and hence referred for specialist assessment and management. There are no similar studies and hence direct comparison of findings is difficult. As the sample size is small, the generalizability of the findings is limited. The present study found that the most common reason for referral to the psychiatrist was non-response to

conventional treatment. Earlier studies, which have tried to identify factors leading to psychiatric referral among patients on medical wards, have pointed to non-compliance and disturbed behaviour as being of importance (11). We found the most common psychiatric diagnoses in this group to be somatoform disorders (n=23, 62%) and depressive disorders (n=10, 27%). These findings are broadly in keeping with those of previous studies which evaluated the psychiatric diagnoses of patients referred for evaluation of functional somatic symptoms, both of which found somatoform disorders and affective disorders to be the major diagnostic categories (4,12).

An interesting finding was the high prevalence (78%) of patients with a diagnosis of burning mouth syndrome (BMS) or oral dysaesthesia, which is an uncommon presentation in general psychiatry. BMS also referred to as Glossalgia, is characterized by a burning sensation in the oral
cavity with no observable abnormalities on local examination or investigations. The pain tends to be commonly bilateral and distal with non-conformity to typical sensory nerve distribution and has been reported to be more frequent in women (13). Within the context of psychiatric classificatory schema, this disorder would fall under the rubric of somatoform disorders. It has also been noted that patients with BMS have higher rates of co-morbid anxiety, depression and other psychological problems compared to controls (14).

Most of the patients in this study (78%) were treated only pharmacologically, though specific cognitive behavioural treatments like reattribution therapy have been shown to be effective in treatment of somatoform disorders (15). The infrequent use of such techniques (<10%) might suggest the limited availability of this resource or the lack of appropriate training and knowledge among psychiatrists.

This service arose out of a clinical need to identify patients presenting to dentists with somatic manifestations of underlying emotional distress. We have been able to show that such patients can be identified and engaged in treatment, provided there exists a specialist service. This should provide a useful psychiatric consultation - liaison model for further innovations and service developments in dental practice and so too in other branches of medicine. From a psychiatric trainee's perspective, the experience gained by working in such a service is invaluable and a key component of the desired overall training objectives.

References

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