Suicide Screening in Dental Settings

Death by suicide is a serious public health problem that affects millions of people worldwide. Each year, approximately 700,000 people die by suicide.^1–3 In 2019, it was the fourth leading cause of death globally among those ages 15 to 29, with 77% of suicide deaths occurring in low- and middle-income countries.^1–3 In 2018 to 2019, suicide was the 10th 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, it also 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 health professionals are on the frontlines of preventive care, with many patients seeking treatment biannually. This gives dental teams the opportunity to identify and address early warning signs of depression, self-harm, suicide ideation and attempt.

Suicide ideation is the consideration of suicide, along with the capability of suicide — but the individual has difficulty overcoming 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 United States, and the majority of American deaths from firearms each year are related to suicide.^7–9

DEMOGRAPHICS

On a global level, suicide is the fourth leading cause of death among individuals between the ages of 15 and 19,¹ and, in this country, it is the second leading cause of death among those ages 10 to 24. In the United States, suicide rates 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 U.S. military veterans is 1.5 times higher than the general population.^4,18–20 In 2019, firearms were used in approximately 70% of male veteran suicides and about 50% of female veteran suicides.^18,20 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 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 since the outbreak began. 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 United States, mental health-related emergency department visits for adolescents ages 12 to 17 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 increased 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 drugs, exposure to violence (e.g., 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

National and state 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 settings 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 educational settings.^{4,8,9,27,30,35–39}

For American Indian/Alaska Native populations, programs — including 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 U.S. 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 U.S. 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 Veterans Combat Act were established to address suicide prevention efforts across multiple levels of the armed forces.^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 at-risk individuals, create safeguards to protect patients from self-harm, and offer referrals for follow-up care.^42–44 Dentists and 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 can use to assess patients for suicide risk; these include the Patient Health Questionnaire (PHQ-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 clinical settings. The PHQ-9 is a brief assessment tool that uses nine questions to measure depression severity. The ASQ is a standardized screening tool for suicide risk comprised of 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 before administering the C-SSRS and is available online at no charge.

Suicide risk screening should also include direct interventions that address suicidal thoughts and behaviors. Table 2 suggests screening inquiries that dental professionals can use while engaging with patients. 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 in the successful management of patients at risk for suicide.

CONCLUSION

Several levels of suicidal tendencies exist, ranging from self-harm to ideation, attempt, and successfully ending one’s life. This 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 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 encourage gatekeeper training, improve knowledge of the warning signs for suicide ideation and attempt, and increase clinical understanding of when and how to connect individuals in crisis with medical assistance and follow-up care.

As oral health professionals on the frontlines of preventive healthcare, dental teams should consider incorporating prompts and/or screening questionnaires on the medical history form in order to assess 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 United States.

REFERENCES

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From Decisions in Dentistry. September 2022;8(9)42-45.