Julian Perez, Vice President of Risk Management & Compliance at dentalcorp; Michelle Budd, DDS, Patient Safety Consultant at dentalcorp
It’s been said that there is no health without mental health—the truth of this statement is difficult to refute. Mental illness presents a serious barrier to receiving good health care and dental care is no exception. The enormity of this public health concern becomes clear when you consider that, at any moment in Canada, mental health issues impact 1 in 5 people1; that’s 20% of dental professionals and 20% of patients in need of oral health care. Oral health and mental health issues cannot always be separated.
As we enter December and head towards the shortest day of the year (in the Northern Hemisphere), it’s worth remembering that loneliness increases during the holidays. At a time when many are celebrating, empty nesters, students, immigrants and others who live far from their social circles or family, are likely to feel alone. The elderly, who may not be able to ignore their isolation by focusing on work or hobbies, as well as those grieving the loss of loved ones are also vulnerable to these intense and unpredictable feelings.
At the same time, the holiday season often brings an increase in demands such as family issues, financial woes, and feeling unable to meet others’ expectations (real or perceived). These demands can lead to stress, anxiety, and depression—especially when the expectation is that everyone should be happy. Fear of stigma can cause people to avoid sharing their feelings of loneliness with others, thus exacerbating the situation.
Loneliness and suicide
Links between loneliness and different manifestations of suicidality (ideation, attempted suicide and suicide) have been reported; moreover, studies show that the prevalence of suicidal ideation and attempted suicide increase with the degree of loneliness2. Oral health care professionals might think suicidal conduct is not their domain; however, it can and does arise in the course of the dentist-patient relationship.
Oral health care professionals must realize that for patients who are depressed and deeply lonely, a dental appointment can be an intense experience. A caring touch and sustained eye contact could be all that it takes for someone in crisis to suddenly open up and share their emotional difficulties—including a desire to self-harm. Several dentists and hygienists have shared such experiences with me: a patient sits down for a routine exam, starts answering some questions from the medical history questionnaire, then without notice begins to divulge the details of their depression, trauma and suicidal thoughts.
What to do when confronted with suicidal behavior
Neither dental school nor dental hygiene school prepares a clinician for a patient experiencing a mental health crisis. For the dentist who plans to perform an oral exam or place a filling, it can be hard to shift gears when a patient suddenly shares their suicidal ideation. One can feel caught off guard or emotionally blindsided. Despite a lack of preparation, there are some important things to consider in such a situation.
Step 1: Listen without passing judgement
The first step is to listen without passing judgement. The Canadian Association for Suicide Prevention explains that “talking about suicide can provide tremendous relief and being a listener is the best intervention anyone can give.” Dentists and dental hygienists are health care providers; accordingly, the goal should be to find out whether the patient is in danger of acting on their suicidal feelings. Listening openly and patiently is the best way to do this.
Step 2: Ask direct questions
When the patient has finished sharing their thoughts, the Mayo Clinic advises that, as long as you do so in a sensitive manner, it’s beneficial to ask direct questions, such as:
1. Have you ever thought about suicide before, or tried to harm yourself before?
2. Have you thought about how or when you'd do it?
3. Do you have access to weapons or things that can be used to harm yourself?
4. Have you been diagnosed with depression, and if so, have you received a prescription for that condition?
One shouldn’t fear that asking such questions will cause the patient to act on their feelings. In fact, allowing a patient to get these feelings off their chest might even reduce the chance that they self harm. At this stage, it’s a good idea to tell the patient that there are hotlines that they can call. The Canadian Association for Suicide Prevention3 has a list of local numbers people can call and a number of other resources for people who are in crisis or are worried about someone else.
Step 3: Obtain patient consent to consult
The third step is to ask the patient for consent to discuss what they’ve shared with any family physician, therapist or mental health specialist whose care they may be receiving. Even in the worst-case scenario, i.e., the patient withholds consent, nothing is lost and nothing gained.
Step 4: Where consent is obtained, consult a trained professional
The fourth step depends on whether the patient provides consent to consult with their physician or mental health specialist. With consent, the oral health care provider can consult with them and explain the situation. Once this is done, the dentist or dental hygienist can leave the matter in the hands of someone trained to handle such crises knowing they did their best to improve the situation.
Without consent, all that the patient shared would be considered personal health information protected by provincial and territorial privacy legislation. The dental professional will need to determine whether, based on the patient’s disclosures, there appears to be “a significant risk of serious bodily harm.” When there is such a risk, a health care provider may be able to disclose personal health information; however, such disclosures are governed by statutes that vary from province to province. Before breaching a patient’s privacy by disclosing such information, consider consulting with a lawyer.
Step 5: Consider whether to call 911
Is it time to call 911? If the patient is merely exhibiting suicidal ideation—it is unlikely that they will actually attempt suicide. Meanwhile, calling 911 can have significant consequences for the patient. The police might arrive at the patient’s door with their sirens blaring. A crowd of inquisitive neighbors may gather. The street scene could be painfully embarrassing and humiliating. Fortunately, some cities, such as Toronto, have mobile crisis intervention teams that have an expertise in such situations and a mandate to “[p]rovide supportive counselling, as needed” and to “[a]rrange appropriate mental health treatment.” Even in situations where interventions are executed with greater discretion, a patient can end up being taken into custody against their will. Unless there is a serious risk of harm, these well intended actions can end up making things worse, not better.
It’s important to remember that one of the best ways for someone to cope with their own suicidal thoughts is to share them. If a patient is reported to 911 after sharing their troubles with a regulated health care professional, they may feel that nowhere is safe for them. Without an outlet, that sense of isolation and shame can be exacerbated. On the other hand, a patient who appears decided to take their own life and who has developed and articulated a plan, is at a significant risk of self harm. In such cases, if there is no family member, psychiatrist or therapist to intervene, a call to the police may be justifiable.
Step 6: Don’t blame yourself
No matter what happens, do not blame yourself if a patient does commit suicide. You can act in good faith to help someone, but you cannot prevent someone who is determined to commit suicide. If the worst happens, remember that sharing your feelings is the best medicine and don’t be afraid to seek professional help in processing your emotions. Health care workers so often try to cope with difficult situations on their own—however, the need for support during and after stressful situations should be recognized and satisfied.
Moving forward with compassion
Given the massive consequences of loneliness and depression on oral and overall health, oral health care teams should seek more training on mental health (e.g., depression, loneliness and the major diagnostic conditions) with an emphasis on their abilities to impact a patient’s oral health. These impacts include but are not limited to the pharmacological risks, side effects, and interactions of drugs used to treat mental and oral health conditions.
Dentists should also be cognisant that they have the ability and obligation to extend a helping hand to patients experiencing severe mental health crises. This may not be taught in dental school, but a lack of expertise must not be an impediment. Sometimes all that is required is listening. Other times, a more active role may be required; however, health care providers should be ready to help—especially their own patient—get to safety if the need arises. Many resources have been created to help people who want to help others.
One example is the Handbook on Sensitive Practice for Health Care Practitioners4, which was created to “help health care practitioners practise in a manner that is sensitive to the needs of adult survivors of childhood sexual abuse and other types of interpersonal violence … intended for health care practitioners and students of all health disciplines who have no specialized training in mental health.” There is also a mental health first aid course5 offered by Saint John’s Ambulance and others which “gives people the skills they need to provide that early help that is so important in recovery.”
It is important to remember that while you may have limited control over your patients’ mental health, your compassionate listening and response can make a significant impact on someone in crisis.
As originally published in Oral Health.
2 Stravynski A, Boyer R. (2001). Loneliness in relation to suicide ideation and parasuicide: a population-wide study. Suicide and Life-Threatening Behavior, 31(1),32-40. https://doi.org/10.1521/suli.184.108.40.20612
5 Handbook on Sensitive Practice for Health Care Practitioners
About the Authors
Julian Perez is the Vice President of Compliance & Risk Management at dentalcorp and is responsible for the development, implementation, and oversight of company-wide standards, programs, and systems to support practices in the delivery of optimal patient care. Julian has a robust legal background having worked for a Wall Street law firm in Manhattan as well as a professional liability program providing malpractice defense to over 10,000 dentists. Julian holds a bachelor’s degree from Yale University and a juris doctorate from Columbia University’s School of Law.
Dr. Michelle Budd works with dentalcorp’s Compliance & Risk Management team as a Patient Safety Consultant. She graduated from Western University with a Doctor of Dental Surgery degree. While running a busy dental practice, she also earned a Master of Public Health degree. Michelle has been a dental consultant for several insurance companies and government agencies and has travelled throughout Canada to help dental practices achieve and maintain professional compliance.