Depression Screening: Not a Legal Obligation, but an Ethical One

In a perfect world, all patients would receive the care they need to improve their health. But too often patients hesitate to seek the care they need, especially when it comes to mental health. It is an unfortunate reality that there is still a stigma associated with mental illness, and those in need of treatment don’t always ask for help.

The Dentists Insurance Company’s Risk Management Advice Line has recently received calls from concerned practice owners who became aware of patients or employees suffering from depression or suicidal thoughts. In some cases, a patient mentioned feeling despondent or hopeless. In others, employees threatened suicide or self-harm. While mental health is out of a dental professional’s clinical scope of practice, they have an ethical obligation to help individuals who exhibit distress to access services or support.

Patients: A Cry for Help

TDIC Risk Management Analyst Trina Cervantes recalls a case in which a patient, whose depression and suicidal thoughts were noted in her medical history, came in for an appointment and mentioned to staff that she “just wanted to end it.” The dental staff asked her if she would accept a referral to an advice line, which she agreed to. They asked for permission to reach out to her family, which she declined. They chose not to report the situation to the authorities, but followed up with a phone call that evening to check on her and asked if there was anything they could do. She informed them that she planned to call her medical doctor.

Cervantes said the office staff did everything they could in this case, both legally and ethically, to help the patient, as her comment did not appear to be an immediate threat. Had she said “I’m going to end it all tonight” or “I’m going to kill myself today,” staff would have reconsidered contacting the authorities.

“It is crucial that every dental office take inventory of what they are presented with,” Cervantes said. “As much as we’d like to guarantee the perfect outcome, it simply isn’t possible. But it is possible to empower a dental office to analyze the facts of each situation and make an informed decision on what steps to take.”

According to the National Institute of Mental Health, an estimated 16.2 million people in the United States suffer from depression. Even more people are undiagnosed. Patients may talk about or display mental health issues in the dental practice. Some patients don’t know where else to turn or don’t have insurance coverage for mental health care. Others feel there is less stigma attached to seeking help in the dental setting than going to a designated mental health care practitioner.

Signs of depression include lack of concentration, poor appetite, weight changes, fatigue, insomnia, mood swings and lack of energy. But dental professionals should be wary of making comments that could be construed as making a diagnosis. For example, rather than saying, “It sounds like you are suffering from depression. I’ll refer you to an outside provider,” dentists could say, “You may benefit from talking to someone who can help you.”

If a patient has indicated a history of depression or suicidal thoughts on his or her intake form or if the patient’s record shows the use of antidepressants or other medications for mental illness, it’s a good idea to be alert for comments that may suggest their condition is not under control.

“Sometimes it’s just important to listen to your patient,” Cervantes said. “If they have a history of mental illness, keep your eyes and ears open for signs they may need help. If you are faced with a patient who mentions depression, suicidal thoughts, severe anxiety or any other conditions, ask if the patient will provide consent for you to reach out to their medical doctor or trusted family member on their behalf. View these cases no differently than if a patient exhibits any other type of medical concern, such as high blood pressure, which would warrant a referral to an outside provider.

Also, be sure the patient has signed a notice of privacy practices. If you provide a referral to a medical provider, it should be charted. If the patient is a minor, his or her parent or guardian must sign a notice of privacy practices and be informed of any referrals.

When patients decline consent, you can still offer information about community resources that they can access on their own. The National Suicide Prevention Lifeline is a good place to start: suicidepreventionlifeline.org or 800.273.TALK (8255).

Another beneficial resource is the Suicide Prevention Resource Center, online at sprc.org, which provides a suicide prevention toolkit designed for primary care providers that can also be used in the dental setting. The toolkit offers an office protocol to define roles and responsibilities, a learning module on risk assessment and intervention approaches according to the level of risk.

Implementing specific protocols and procedures is especially helpful in areas where the risk of depression or suicide is high and the likelihood of a patient seeking mental health care is low. Some community dental clinics have chosen to implement formal screening procedures and hire on-site mental health counselors to better serve the unique needs of their patient bases.

Employees

Should an employee inform you or a co-worker of thoughts of suicide, encourage him or her to seek professional help and enlist the help of a trusted family member. Provide the same resources you would provide to patients, such as referral to outreach programs and community services.

The first priority should be keeping your patients and employees safe, so if you hear second hand that an employee may be planning to take action at work, notify the authorities. It is your responsibility as an employer to keep the workplace safe and to act on any potential security risks.

Dental professionals often find themselves on the front lines with individuals suffering from mental health issues. While formal mental health screenings aren’t common in dental practices, taking a proactive approach when you do encounter at-risk patients can be the first step in helping them obtain the help they need. It is natural to be confused, concerned or anxious about what to do. A dentist can feel compelled to take some kind of action. Be confident that there are resources available to provide to others in their times of need. If you are ever in doubt about your options, TDIC’s Risk Management Advice Line can help you take inventory of the situation or give you guidance to shape your practice’s protocols.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 800.733.0633. For Risk Management guidance in Idaho, Oregon or Washington, call 800.452.0504.