Mental Health History and Review

The Mental Health
History and Interview Health history form Dental hygienists are accustomed to recording a medical history on each patient. It is helpful to have relevant mental health questions on the health history form along with the medical questions. These may include a question on psychiatric care and mental health status, an alcohol/ drug question, a question about dental fear and previous problems with oral health treatment, and specific questions about depression and panic attacks. Some suggestions are listed in Figure 2. The health history form should include a listing of prescription, over-the-counter (OTC) drugs, and alternative medications the patient has taken in the past 12 months; this information is also helpful for interviewing the patient. By taking a mental health history, important information can be obtained on conditions that affect oral health treatment, as later described.

Interview
The mental health questions elicit information in the patient interview that will help in treatment planning and working with the patient. When asking questions about mental health, use a nonjudgmental, matter- of-fact approach. “Stress” is a good word to use when discussing these issues with patients. One should listen carefully, but not pry, as patients will reveal what they feel comfortable discussing. Many patients with mental health conditions may not discuss their problem for various reasons, perhaps because of the stigma associated with such illnesses, from denial, or from lack of information. Their problems may become apparent later as they encounter stress in treatment or they may reveal them as they feel more comfortable with their providers.

If a patient says that he or she has a mental health condition, one should ask open-ended questions such as, “What can you tell me about this?” Doing so allows the patient to discuss the problem in his or her own way. If the patient is taking psychotropic medications, appropriate questions include:

What condition is the medication treating?
What are your symptoms?
How long have you been taking the medication and does it help?
Who is the physician treating the condition?
When was your mental illness diagnosed?
Are you receiving counseling or therapy, and how frequently do you see the physician or counselor?
Bear in mind that “psychotropic” medications may be used for multiple purposes, including some unrelated to mental illness. Bupropion hydrochloride (Wellbutrin®), for example, is indicated for depression and as an aid in smoking cessation. Diazepam (valium) may be used as a premedication prior to medical or dental treatment or to treat convulsive disorders, muscle spasms, spasticity, or anxiety disorders. Hydroxyzine hydrochloride (Atarax) is used to treat pruritis (itching) or anxiety.2

Sometimes the oral health care professional may wish to consult with a patient’s care provider about a medical or psychiatric condition. Patients with CMI, especially dementia, may be poor historians, so a consultation can be helpful. Patient consent for the consult must always be obtained.

For patients whose mental illness is a continuing and serious problem, questions about previous hospitalizations should be asked. For some patients, symptoms predictably wax and wane; these patients may need to schedule appointments when they are best able to cope with oral health care treatment.

It may be difficult to detect active substance abusers, but those in recovery will usually answer questions about their substance use.3 For alcohol abusers, these questions may include what they drink and how often. For any drug abuser, inquires should be made about what drugs are frequently or occasionally used and when the substances were last used. It is important to know that relapses (or “lapses”) are a common part of recovery. Many of those who successfully discontinue substance abuse have done so after several such lapses. Patients can be encouraged to move toward harm reduction at any stage of substance abuse.4

Ask patients about their previous experiences with oral health treatment. This can be a good indicator of their current level of comfort with treatment and can aid in recognizing dental anxiety when it is present.

Psychiatric referral
With the escalation of substance abuse, especially among younger people, and the prevalence of mental illness, referrals may sometimes be necessary.

Although oral health care professionals may feel this is out of their scope of practice and fear they may offend the patient, referral is consistent with the health care provider role. It also demonstrates willingness to help a patient with a problem. Caring for a patient’s total health can have a profoundly beneficial effect. It is helpful to identify respected mental health professionals in the community whose expertise matches the patient’s needs. Several professional associations provide information on qualified professionals in the community (Figure 3).

The role of dental hygienists is to alert the dentist to problems observed. The best time for a dentist to make the suggestion of a referral is in consultation with the patient in a nonintimidating setting, preferably away from the dental chair.