Behavioral Health Within Primary Care Postgraduate Dental Curricula: A Mixed Methods Study

INTRODUCTION

Behavioral health (BH), according to the Substance Abuse and Mental Health Services Administration, is described as “the promotion of mental health, resilience and well-being; the treatment of mental and substance use disorders; and the support of those who experience and/or are in recovery from these conditions, along with their families and communities.”¹ BH disorders can have a severe impact on an individual’s physical, social, and financial well-being.² Based on the 2019 National Survey on Drug Use and Health, 61.2 million adults had a BH condition in that year. Some common disorders affecting the population were anxiety and depressive disorders.³ Additionally, substance use disorders, especially opioid use disorder (OUD), result in thousands of US deaths every year. Approximately 107,000 people died from drug overdoses in 2021, of whom almost 75% had deaths related to opioid use.⁴

The arrival of the COVID-19 pandemic has also increased the prevalence of several BH issues.⁵ Multiple environmental stressors for depressive disorders, anxiety disorder, and OUD such as emotional grief, interpersonal isolation, and financial constraints due to mass unemployment overwhelmed a burdened health care system and increased inequity across racial and socioeconomic lines.^6-8 Prolonged periods of lockdown and shelter-at-home orders posed a grave threat to those at risk for intimate partner violence (IPV), which 33% of Americans experience in their lifetime.⁹

The increase in mental health disorders requires diverse settings and care professionals to screen and refer patients for BH concerns. Several within the dental profession have long advocated for dentists taking greater responsibility for patients’ overall health, including mental health.^10,11 Dental settings provide a unique opportunity to integrate BH into their practice, particularly as many issues such as IPV and eating disorders present with oral findings. For example, 75% of the head and neck trauma associated with IPV manifests with oral injury.¹² Moreover, some mental health disorders may prevent patients from seeking dental care, further incentivizing screening, management, and referral for these conditions.^13,14

In light of the opioid epidemic, some dental schools undertook efforts to incorporate new competencies into their curricula to prevent opioid misuse and identify patients at risk for OUD.^15,16 Apart from inclusion of these competencies in some predoctoral programs, little is known about the current landscape of BH training in primary care dental programs and the preparedness of the dental workforce in this regard. Data from the American Dental Association suggest that more dental graduates choose Advanced Education in General Dentistry (AEGD) and General Practice Residency (GPR) compared with other specialties.¹⁷ Additionally, many of these programs are located within hospitals and primary care settings, ensuring an optimal opportunity to close gaps in access to care.

In this study, we examined the integration of training on BH topics into AEGD and GPR programs. We also explored the influences of facilitators of and barriers to integration.

METHODS

We used a mixed methods design with an explanatory sequential approach: an online survey followed by one-to-one interviews. The study was guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines¹⁸ and was reviewed, approved, and given an exempt determination by the Harvard Longwood Medical Area Office of Human Research and Administration Institutional Review Board (IRB 18-1935).

RESULTS

DISCUSSION

Dentists play an important role in the overall health of a patient and sometimes are the only point of contact with the larger health care system. The nature of dental care allows longer appointment times and follow-up visits, creating ample opportunity for screening and referral for BH conditions. This study, through a survey and interviews, evaluated the current state of integration of BH in primary care postgraduate dental training curricula, including barriers and facilitators. Most of the AEGD and GPR program directors agreed that it is important that residents be able to identify patients with BH disorders; however, less than one-half had trained their residents to identify anxiety, depressive and eating disorders, and IPV, leaving OUD as the exception. Understanding barriers cited by the programs may be the first step to comprehend this dichotomy. Programs that did not include BH in their curriculum listed lack of time, lack of accreditation standards in dental education, and lack of resources such as content experts. The interviews also highlighted the culture of the profession, which either considers BH as not within the purview of dental practice or speaks to the difficulty of navigating the stigma attached to BH conditions.

Lessons may also be learned from facilitators identified by programs that successfully include BH into their curricula. We found that although the program directors’ interest contributed to inclusion, external influences also played a major role. Programs that existed in a setting integrated with BH were found to give their residents more training on identifying depressive disorders compared with programs that were housed in settings with no to minimal collaboration. This finding highlights the important role organizations can play in creating a culture of integration for training emerging clinicians and removing the bias that BH is not under the purview of primary care dentists. There are other ways organizations can influence programs through mandates (eg, resident training for OUD), culture, and leadership. Even so, these facilitators for inclusion are largely unique to each program. Efforts such as mandates by the Commission on Dental Accreditation to incorporate BH into accreditation standards and changes in state policies, such as licensure requirements, may be more sustainable to ensure their inclusion in resident training. For example, several local, state, and national measures were instated recently because of the opioid epidemic, and our research indicates they have influenced OUD curricular inclusion.^16,31,32

Our interviews suggested that external funding by foundations and government agencies can also help to facilitate inclusion of BH into resident training. The Health Resources and Services Administration, for example, funded the National Network of Oral Health Access to conduct learning collaboratives that included depression screenings at community health centers.³³ Similar funding for residency programs can provide a strong incentive for integration. Finally, advocacy by key stakeholders within and outside the dental profession is critical to counter stigma, increase awareness, and provide momentum for curricular change.

Programs that included BH content in their curricula used various methods of content delivery. A considerable portion of the content, however, was delivered in a clinical setting through either direct patient care or observation. Incorporating the content into clinical delivery may make the material more meaningful/relevant to learners, as well as reduce the burden on the didactic portion of the curriculum. Although some of this training may take place during clinical rotations in medical and BH specialties, greater focus also needs to be placed on interprofessional education sessions with a dedicated BH focus. This may be easier to facilitate in residencies located in settings with integrated BH. Additionally, instruction through patient interactions without an explicit educational objective communicated to the resident may be difficult to standardize across residents, hindering evaluation of learners. A majority of the GPR and AEGD programs did not evaluate their residents on BH competence, and of those that did, a majority used clinical observation as the primary method. Rigorous evaluation of residents, and of the program, will help identify and disseminate best practices that other programs can successfully emulate.

Although it is imperative for dental primary care programs to integrate training on BH conditions, meaningful impact cannot be made without bridging the divide between training and practice. Future dental practitioners need to work in a collaborative environment with the larger health care system to ensure timely intervention and appropriate treatment of these conditions. Additionally, screening for BH conditions in the absence of referral and treatment can prove to be an ethical dilemma for practitioners. Health care organizations incorporating integrative practice models can help provide a template. For example, Asian Health Services in California provides holistic medical, dental, and mental health services to its patients, including depression screenings conducted during dental visits and appropriate referral pipelines for treatment of patients.³⁴ Concurrent strides within training and practice need to be made to support practitioners in integration of BH to help alleviate the burden of BH issues and promote whole-person care.

Our study is not without limitations. Survey responses, self-reported by the AEGD and GPR program directors, could not assess the residents’ perception of their training. Additionally, although our response rate was adequate for a health professions survey, the findings may not reflect the training of all GPR and AEGD residency programs. Moreover, this study assesses only the presence of BH education; further research is needed to evaluate its quality. Finally, the study examines the inclusion of BH only in postdoctoral dental programs. Additional studies are needed to understand its inclusion in predoctoral dental curriculum.

In conclusion, AEGD and GPR programs need to make greater efforts to include training on BH conditions, particularly anxiety disorder, depressive disorder, eating disorders, and IPV. The barriers and facilitators that we have identified may assist programs in integrating this important content in their curricula and better preparing their residents to deliver comprehensive patient care.