Addressing Suicide Risk in the Dental Setting

Death by suicide is a serious public health problem that affects millions of people worldwide. Each year, approximately 700,000 people die of suicide.^1–3 In 2019, it was the fourth leading cause of death among those ages 15 to 29 globally, with 77% of suicide deaths occurring in low- and middle-income countries.^1–3 In 2018 to 2019, suicide was the tenth leading cause of death in the United States and the second leading cause of death among young adults.^4–6 Death by suicide is not only devastating to the family involved, but it reverberates throughout the community and social circles.^1,4,6 Healthcare providers can be gatekeepers for the detection of patients at risk for suicide. More specifically, oral heath professionals are on the frontlines of preventive healthcare, with many patients seeking treatment biannually. This gives dental hygienists the opportunity to identify and address early warning signs of depression, self-harm, suicide ideation, and attempt. 

Categories Associated With Suicide 

Suicide ideation is the consideration of suicide along with the capability of suicide, but the individual has difficulty overcoming strong and natural fears of pain, injury, and death. Suicide attempt is defined as an unsuccessful effort to end one’s life. Successful suicide occurs when an individual inflicts methods of self-harm that ultimately result in death.^3–5 Suicide capability is the level of access to lethal means of executing death by suicide such as firearms, controlled substances, carbon monoxide poison, sharp objects for cutting, and/or ligatures for hanging.^5,7–9 The use of firearms is the most common means (51%) of suicide in the US, and the majority of deaths caused by firearms each year in the US are related to suicide.^7–9 

Demographic Information

Globally, suicide was the fourth leading cause of death among individuals between the ages of 15 and 19 in 2019, and, in the US, it was the second leading cause of death among those between the ages of 10 and 24. In the US, suicide rates have increased 57.7% between 2007 and 2018.^1,4,10,11 

Individuals who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual orientations not included in the acronym, LGBTQIA+, have significantly higher rates of depression, suicide ideation, and suicide attempts due to discrimination, stigma, loss of social supports, and /or internalized heterosexualism.^12–14 

Suicide is a leading cause of death among ethnic minorities (Asians, African Americans, American Indians, and Hispanics) in the United States.^4,15­–17 Discrimination is a chronic stressor for people of color, which may lead to mental health problems and high blood pressure.^15–17 

The suicide rate for US military veterans is 1.5 times higher than the general population.^4,18–20 In 2019, firearms were used in approximately 70% of all male veteran suicides and about 50% of all female veteran suicides.^18,20 Military veterans are at high risk for suicide due to substance abuse, acute psychosocial stressors, insomnia, and other mental health conditions, with post-traumatic stress disorder (PTSD) doubling the risk of suicidal attempt or ideation.^19,21,22

Impact of COVID-19

The COVID-19 pandemic brought significant challenges to mental health, and suicide ideation is thought to have increased over the past 2 years. The intersections of extreme social distancing, geographic isolation, rising unemployment, and disruption in routine contributed to financial strain, work-related stress, childcare challenges, and interpersonal struggles.^23–25 In the US, mental health-related emergency department visits for adolescents ages 12 to 17 years saw a 31% increase in 2020 as compared to 2019.^25,26 

Communities of color—specifically American Indian and Alaska Native women and men, Black/African-American women, and Hispanic women— experienced significantly increased risk of suicide—139%, 71%, 65%, and 37%, respectively— due to failure to receive adequate healthcare, job/business loss, and other economic consequences.^9,23,26 For racial and ethnic groups, the amalgamation of the aforementioned consequences and trying to survive amid the pandemic may result in an exacerbated risk of suicide ideation and attempt. 

Risk and Protective Factors

Most individuals who are depressed, attempt suicide, or have other risk factors do not necessarily die by suicide.^4,5,27 However, related risk factors include previous suicidal behavior; psychosocial trauma; family history of suicidal behavior; mental health diagnoses; misuse and abuse of alcohol or other drugs; exposure to violence (eg, child abuse and neglect, sexual violence, and intimate partner violence); recent loss of a loved one or job; hopelessness; severe insomnia; social isolation; chronic disease/pain; and access to lethal means.^{4,5,11,19,22,27–29} 

Protective factors encompass social connectedness (interpersonal or institutional); effective life coping and problem-solving skills; availability of quality and ongoing physical and mental healthcare; cultural, religious, or moral beliefs that prohibit suicide; and limited access to lethal means.^4,22,27–30 

Suicide prevention requires a multidisciplinary approach.^{4,25,27,29,30} Hospitals, schools, tribes, and branches of the military have expanded suicide prevention and screening efforts in an attempt to reduce suicide nationally and globally.

Prevention Strategies 

State and national programs are available to support suicide prevention. States, such as Tennessee, Massachusetts, and Texas, have made independent investments in suicide prevention by forging strong relationships with local healthcare systems and implementing the national Zero Suicide model.^8,9 In 2001, the Henry Ford Health System in Michigan improved its suicide prevention screening process, resulting in an 80% reduction in suicide rates between 2009 and 2010.^26,27,30,31 Parkland Hospital in Dallas implemented universal suicide risk screening in 2015.^26,32 The University of Pennsylvania evaluates all patients in its emergency department and outpatient setting on probability for suicide ideation, capability, and attempt.^26,33 The Billings Clinic serving Montana, Wyoming, and the western Dakotas screens all patients in its emergency department.^26,34 

School programs—such as the Universal Sources of Strength, Maine Youth Suicide Prevention Program, PROSPER project, University of Washington’s Communities That Care, 2004 Garrett Lee Smith Memorial Act, and the worldwide program Youth Aware of Mental Health—emphasize suicide screening, prevention, and training in the educational setting.^{4,8,9,27,30,35–39} 

For American Indian/Alaska Native populations, programs—such as the Native American Rehabilitative Association of the Northwest, 1991 Johns Hopkins Center for American Indian Health, 2001 White Mountain Apache Tribe Celebrating Life Prevention Team, and 2017 US Centers for Disease Control and Prevention Preventing Suicide: a Technical Package of Policy, Programs, and Practices—promote comprehensive suicide prevention efforts through decreasing harm and reducing risk.^4,8,9,30,40 

The 1996 US Air Force Suicide Prevention Program, 2007 Joshua Omvig Veterans Suicide Prevention Act, 2009 Army Service Suicide Prevention Program, 2012 Navy and Marine Corps Suicide Prevention Program, 2019 PREVENTS Program, 2019 Hannon Act, and 2020 the Veterans Combat Act were established to address suicide prevention efforts across multiple levels of the military.^9,20,27,41

Role of Oral Health Professionals

Oral health professionals may lack specific training to handle patients at risk for suicide. With additional education, dental providers can conduct routine screenings in a variety of settings to identify individuals at risk, create safeguards to protect patients from self-harm, and refer for follow-up care.^42–44 Dental hygienists are well positioned to screen for suicidal tendencies as they often treat patients twice annually. Biannual review of medical histories that incorporate suicide risk questionnaires may help prevent suicide ideation, capability, and attempt. 

Table 1 provides a list of tools clinicians may use to assess patients for suicide risk: the Patient Health Questionnaire (PQH-9), Ask Suicide Screening Questions (ASQ), and Columbia-Suicide Severity Rating Scale (C-SSRS).^22,28,43,45 These questionnaires are evidence-based, effective, and easily administered in the clinical setting. The PQH-9 is a brief assessment tool, incorporating nine questions that measure depression severity. The ASQ is a standardized screening tool for suicide risk using four yes/no questions that be administered in as little as 20 seconds. The C-SSRS assesses suicidal ideation and suicidal behavior via six yes/no questions.^22,28,43,45 Training is recommended for the administration of the C-SSRS and can be found online free-of-charge. 

Suicide risk screening should also include direct interventions that address suicidal thoughts and behaviors. Table 2 illustrates screening inquiries that dental professionals can deploy while engaging with patients in the dental setting. Incorporating such questions on the health history form can help identify the warning signs of suicidal thoughts. Actively listening, asking follow-up questions, and, when necessary, referring to medical or mental health professionals are key components for the succesful management of patients at risk for suicide.

Conclusion 

Several different levels of suicidal tendencies exist, ranging from self-harm, to ideation, to attempt, to ending one’s life. Suicide is a serious public health issue that has no single determining cause, but occurs in response to the intersections of multiple biological, psychological, interpersonal, environmental, and societal influences over time. Suicide ideation, risk, and attempt can be prevented by encompassing a comprehensive multidisciplinary approach on individual, relationship, societal, and community levels. 

Asking suicide screening questions is an effective intervention step because it may be the first encounter in which a patient verbalizes his or her troubling thoughts about suicide ideation. The entire healthcare team bears responsibility to increase gatekeeper training, improve knowledge of the warning signs for suicide ideation and attempt, and understand when and how to connect individuals in crisis to medical assistance and follow-up care. As dental hygiene providers on the frontlines of preventive healthcare, we need to incorporate inquiries and/or screening questionnaires on the medical history form assessing patients’ probability for suicide ideation, capability, and attempt. Those who are having thoughts of suicide ideation should be encouraged to call 800-273-8255, or text HOME to 741741 from anywhere in the US. 

References

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From Dimensions of Dental Hygiene. April 2022;20(4):34-37.