Journal of Orthodontics, Vol. 36, No. 2, 93-102, June 2009 doi:10.1179/14653120723004
© 2009 British Orthodontic Society
A qualitative study of orthognathic patients’ perceptions of referral to a mental health professional: Part 2—a questionnaire study
Fiona Siobhan Ryan,
Justin Shute and
Susan J Cunningham
Eastman Dental Hospital, London, UK
Address for correspondence: Fiona Siobhan Ryan, Eastman Dental Hospital, London, UK. Email: fionaryan25{at}hotmail.com
Received 16 December 2008;
accepted 26 January 2009
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Abstract
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Objectives: There is evidence to suggest that clinicians are reluctant to refer orthognathic patients for psychological evaluation due to fear of the patient reacting badly to the suggestion. The aim of this study was to assess orthognathic patients’ perceptions of referral to a psychiatrist/psychologist using a previously developed patient-centred questionnaire.
Methods: The study was divided into two parts. Stage 1 (presented previously) involved developing the questionnaire using qualitative methodology and stage 2 involved distribution of the questionnaire to 63 orthognathic patients. This paper describes the findings of stage 2.
Setting: UCLH Foundation Trust.
Results: The majority of patients viewed referral to a psychiatrist/psychologist positively (95.2%), the main benefits being having someone neutral to talk to who could explain and prepare them for treatment. Patients said they would prefer the referral to be made by the clinician they are most familiar with and to see the psychiatrist/psychologist on a one-to-one basis (79.4%) in an environment they are familiar with. The main perceived drawback of seeing a psychiatrist was the inconvenience of an additional visit.
Conclusions: Fear of the patient reacting badly to being referred to a mental health professional appears to be unfounded in this study of patients from a large teaching hospital and should not prevent clinicians referring patients whom they think would benefit from this.
Key words: Questionnaire, qualitative research, patients’ perceptions, mental health professional
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Introduction
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A recent study carried out in the United Kingdom revealed that orthodontists are often reluctant to refer orthognathic patients for psychological assessment, despite a large number of consultants believing that many patients would benefit from such a referral.1
Predictably, the most common reason for not referring patients was limited access to psychological services. More surprisingly, the second most common reason for clinicians’ reluctance to refer was fear of the patient reacting badly to the suggestion and a breakdown of trust in the professional relationship. There is no published literature regarding patients’ perceptions of referral to a mental health professional, so it was decided to investigate orthognathic patients’ perceptions of mental health services and their feelings towards being referred for psychological evaluation.
As there was no measure currently available to evaluate this it was necessary to develop a questionnaire de novo using qualitative methods. The first article in this series describes the questionnaire development process, which involved conducting interviews with orthognathic patients and clinicians. These were analysed qualitatively using thematic content analysis to yield topics of importance with respect to the research question. This article describes the results of a study using the questionnaire at the Eastman Dental Hospital, UCLH Foundation Trust.
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Subjects and methods
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Ethical considerations
The study was approved by the Joint Research and Ethics Committee of University College London Hospitals Foundation Trust (06/Q0505/17) and the Joint Research and Development Unit of UCL/UCLH. All participants were given written and verbal information. The inclusion criteria were that participants were 16 years of age or older and undergoing active orthognathic treatment. Cleft lip and palate and syndromic patients or those who were no longer in fixed appliances were excluded from the study.
Sample and setting
This study was conducted in a University Teaching Hospital. Patients were identified from the orthognathic waiting list and 63 consecutive patients were approached as they attended their routine orthodontic appointments and invited to participate in the study. Consent forms were signed and participants were given the option of completing the questionnaire (Appendix 1) immediately or at their convenience and returning it in the stamped addressed envelope provided.
The questionnaire consisted of 13 questions, the majority of which included multichotomous, close-ended responses for ease of completion and analysis. The final three questions related to personal details. Free text boxes were also included for each question. Responses were analysed using SPSS© (version 14) and the frequencies of responses expressed as percentages.
It was not possible to conduct a sample size calculation for this study as there were no similar studies in the published literature. In addition, the concepts under investigation were qualitative in nature, and thus statistical significance of the results was not of concern. Instead, it was decided to include as many participants as possible within the time constraints of the research project, so that the results would be as generalizable as possible.
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Results
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A total of 63 patients completed and returned the questionnaire (100% response rate) during the period October 2006 to March 2007. One third of respondents were male and two thirds were female. The mean age was 24.9 years and 74.6% of respondents were pre-surgery, whilst 25.4% were post-surgery (Table 1).
Question 1 (Table 2) asked patients what they thought the main reason orthognathic patients were referred to a psychiatrist/psychologist was. The most frequent responses were: to give patients methods of coping with the changes that occur following this treatment (39.7% of respondents) and to explain how facial changes will affect their life in general (28.6%).
Question 2 asked who they would prefer to make any referral to a mental health specialist, 38.1% said they would like it to come from their orthodontist, although 30.2% did not mind who made the referral.
Questions 3 and 4 enquired how patients would feel if they were referred to a psychiatrist and just over half (58.7%) said they would not mind at all. If referral were undertaken for all patients, 95.2% said they would be happy to attend and would still continue treatment.
Question 5 was a free-text question and asked patients to state in their own words what they thought a psychiatrist was. The responses could be divided into five categories, including: ‘someone who helps people’, ‘someone who offers coping strategies’, ‘someone who assesses the state of mind’, ‘someone to talk to’, and ‘someone who explains the changes’.
Questions 6 and 7 (Table 3) asked about the advantages and drawbacks of seeing a psychiatrist/ psychologist. The main benefits were perceived to be helping patients to focus on their goals (58.7%), having someone neutral to talk to (55.6%), and explaining how they would feel after the treatment (54%). The main drawbacks were seen as having to take time off work (42.9%) and the inconvenience of attending an additional appointment (34.9%). A third of those questioned felt there were no disadvantages at all to seeing a mental health professional.
Question 8 asked patients whether they would like to see the psychiatrist/psychologist alone or in a group with other patients, and the majority (79.4%) chose the former. However, a fifth (20.6%) said they would prefer to see the mental health professional in a group with other orthognathic patients present and this should be considered further in future planning of orthognathic services.
Questions 9 and 10 asked whether patients had been referred to a mental health professional as part of their orthognathic treatment or whether they had been seen by a psychiatrist or psychologist in the past for other reasons. Nineteen per cent of patients had been referred to see the orthognathic liaison psychiatrist as part of their orthognathic treatment and 9.5% had seen a psychiatrist in the past for other unrelated matters.
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Discussion
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Two thirds (66.7%) of respondents were female and one third was male (33.3%), this accurately reflects the current demographic of orthognathic patients, with females being twice as likely to seek treatment as males.2 Selection or respondent bias were unlikely to have affected these figures as all patients were approached as they attended clinics over a period of 6 months and only one person refused to participate. The mean age of patients was 24.9 years (range 17 to 54 years). This age range is perhaps wider than that of patients receiving treatment in other units, although no national statistics are available.
The limitations of this study must be borne in mind when interpreting the results of the data, and care should be taken when applying the results to other patient groups, however, every attempt was made to ensure this research is as generalizable as possible so that other units may benefit from the findings.
As many patients as possible were included in order to make the results as generalizable as possible although, it was decided not to include patients who had completed treatment as their perceptions may have changed once treatment finished and this may therefore introduce recall bias.3 The patients included in this study had all made a decision to proceed with treatment and they may differ in perceptions from those who decline treatment once offered. To this extent this limits how generalizable the results are, however, the current findings are still important in terms of management of patients during the orthognathic care pathway.
The majority of patients were pre-surgery (74.6%), although a quarter (25.4%) were in the post-operative stage of treatment but still wearing fixed appliances. Including patients at different stages of treatment may introduce different confounding factors and ideally the subgroups would have been analysed separately and the results compared. However, the relatively small numbers involved precluded such an approach.
Almost 10% (n = 6) of patients had been referred to see a mental health professional at some point in the past for unspecified reasons before they presented for orthognathic treatment. This number compares closely with the UK national average described in the National Service Framework for Mental Health, which estimates that 9% of patients attending their General Medical Practitioner with mental health problems are referred to specialist services for assessment, advice, or treatment.4 This also correlates well with previous studies which found that orthognathic patients displayed similar levels of depression to non-patients.5 Nineteen per cent of patients had been referred to see the psychiatrist at the Eastman Dental Hospital as part of their orthognathic treatment. It was decided to include patients who had previous experience of seeing a mental health professional in the analysis. The responses of these patients may well be affected by their previous experiences, however, it was thought important to include these viewpoints.
The findings from this study demonstrate that orthognathic patients in this unit saw referral to a psychiatrist, or a psychologist, as a generally positive experience and perhaps clinicians underestimate patients’ knowledge of, and attitudes towards, orthognathic treatment as a whole. An incidental finding was that the majority of patients acknowledged that moving their teeth and jaws was going to have an impact, not only on how they looked, but also on their lives in general and their overall well-being. This is a positive finding and suggests that many patients appreciate the psychosocial changes that accompany treatment.
More than half of respondents said that they would not mind if they were referred to see a psychiatrist/ psychologist, and a further quarter said they would be happy to be referred. This is important as many clinicians have previously assumed that patients would be unhappy at the prospect of seeing a mental health professional, and may have refrained from referring patients as a result,1 but this does not appear to be the case. In fact, no individual had any negative comments about mental health professionals or what they do. A third of patients said that there were no drawbacks to seeing a mental health professional and of those who did perceive one, the main issue was taking time off work and attending for an additional appointment, rather than being labelled or stigmatized in any way.
Only one person was concerned that they would be labelled as being ‘mad’ if they were referred to see the psychiatrist. This is interesting as it suggests that the stigma towards seeing a psychiatrist is not as prevalent among patients as clinicians think. This is in contrast to some recent studies which found that the presence, or even the suspicion, of mental illness had a negative impact on how clinicians responded to the patient and how they viewed themselves.6 However, in the unit where this study was undertaken there is a dedicated orthognathic liaison psychiatrist available to all patients, so this may have positively biased the patients.
It is not clear what makes some clinicians reluctant to refer patients to a psychiatrist where such a service exists. There appears to be a dichotomy between clinicians’ and patients’ attitudes towards mental health services and mental illness. Perhaps clinicians are right to be wary of sending patients to see a psychiatrist/ psychologist; indeed, the UK Department of Health figures confirm that fewer than 40% of employers would be prepared to employ someone with mental illness7 and over a third of people diagnosed with mental illness in the United Kingdom are unemployed.8 However, in the context of the orthognathic patient, they are not being referred due to mental illness but to support them through a physical treatment process and the benefits in this case are likely to outweigh the drawbacks.
In view of the findings of this research and the national guidelines set out by The Royal College of Psychiatrists, in collaboration with The Royal College of Surgeons of England,9 the psychological needs of all orthognathic patients must be met, and fear of the patient reacting badly should not prevent referral where it is felt to be appropriate.
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Conclusions
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The results of this study suggest that in the population studied.
- Orthognathic patients’ perceptions of referral to a mental health professional in the unit studied were generally positive.
- The majority of patients said they would prefer to see a psychiatrist/psychologist on a one-to-one basis.
- The major perceived drawback of seeing a mental health professional was the inconvenience of coming for an additional appointment.
- Fear of the patient reacting badly to being referred to a mental health professional appears to be unfounded and should not prevent clinicians referring patients who they think would benefit from such a referral.
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Contributors
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Fiona Ryan was responsible for patient recruitment, data collection, analysis, and drafting of the manuscript. Susan Cunningham was responsible for the study design, expert advice, critical revision, and final approval of the manuscript. Justin Shute was responsible for critical revision of the manuscript and expert advice. David Moles provided statistical support. Susan Cunningham is the guarantor.
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Acknowledgments
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We are very grateful to all the patients who took part in this study and to Dr D. Moles for his statistical support.
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References
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1 Juggins KJ, Feinmann C, Shute J, Cunningham SJ. Psychological support for orthognathic patients – what do orthodontists want? J Orthod 2006; 33: 107–15.[Abstract/Free Full Text]2 Bailey LJ, Haltiwanger LH, Blakey GH, Proffit WR. Who seeks surgical-orthodontic treatment: a current review. Int J Adult Orthod Orthognath Surg 2001; 16: 280–92.
3 de Oliveira CM, Sheiham A. Orthodontic treatment and its impact on oral health-related quality of life in Brazilian adolescents. J Orthod 2004; 1: 20–27.
4 Department of Health Publications. National Service Framework for Mental Health: modern standards and service models, 1999. Crown copyright, available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009598. Accessed on 5 April 2007.
5 Cunningham SJ, Gilthorpe MS, Hunt NP. Are orthognathic patients different? Eur J Orthod 2000; 22: 195–202.[Abstract/Free Full Text]
6 Liggins J, Hatcher S. Stigma toward the mentally ill in the general hospital: a qualitative study. Gen Hosp Psychiatry 2005; 27: 359–64.[CrossRef][Medline]
7 Manning C, White PD. Attitudes of employers to the mentally ill. Psychiatr Bull R Coll Psychiatr 1995; 19: 541–43.
8 Labour Force Survey, 2006. Office for National Statistics. Crown Copyright, available at: http://www.statistics.gov.uk/STATBASE/xsdataset.asp?More=Y&vlnk=1327&All=Y&B2.x=65&B2.y=1. Accessed on 20 April 2007.
9 Report of the working party on the psychological care of surgical patients. Council report 55. London: Royal College of Surgeons of England and Royal College of Psychiatrists, 1997.
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Abstract
Introduction
