Clare Yates and Vivek Furtado summarise what to do if a dental patient presents with a mental health crisis.

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©DrAfter123/DigitalVision Vectors/Getty Images Plus

Introduction

Mental health conditions are common among the general population, with common mental disorders affecting one in six adults at any given time.1 We are increasingly recognising mental health conditions and how this can lead to problems with employment and social dysfunction. Mental health conditions include depression and anxiety, bipolar disorder (which affects approximately 2% of the population) and schizophrenia (affecting 1% of the population). Suicidal thoughts and self-harm in the population have been increasing over recent years, possibly due to more reporting, in light of wider awareness. These have been reported in 6% of the population and one in four women, aged 16-24, have reported to have self-harmed at some point.1,2

Given that these conditions are common in the population, there is little literature available to support dental teams when managing patients with mental health conditions. Given these figures, we would expect that most dental health professionals will come into contact with patients with mental health conditions and should know of reasonable adjustments that would be needed. A recent service evaluation of a special care dental department showed 23% of patients seen were on medications for mental health conditions, again highlighting the prevalence of patients who may be at risk of experiencing such crises.3

A mental health crisis can be defined in several ways depending on the use. In a self-definition approach, a mental health crisis is when someone feels that their mental health is at breaking point and they need urgent help and support. This can include suicidal feelings, self-harm and panic attacks.2,4 It can also be defined in a risk-based approach, that is, the person is at risk of harming themselves or others.4 These definitions can be useful for the dental team to understand when they may need to support others through a mental health crisis. There are support services available for people in crisis and people with known existing mental health conditions may already know these. Dental practitioners are expected to engage in regular training, including for medical emergencies, but management of mental health emergencies is not part of routine training. This leaves dental practitioners ill-equipped during these potential emergency situations. Other primary care practitioners such as pharmacists have looked at how they can remove barriers to care for patients with mental health conditions and have emphasised the need for greater education on managing patients with these conditions.5

This paper aims to collate advice from the wider mental health sphere to provide dental practitioners with some basic tools to support their patients if they should present with such a crisis, including where to signpost for professional support when required. This includes the need for inclusion of questions around mental health disorders on all patients' medical history at routine appointments. Also, awareness of the importance of ascertaining a patient's community psychiatric nurse or psychiatric specialists as might be sought for other medical conditions.

This paper will use case discussions to highlight areas of learning relevant to dental professionals and a proposed pathway for managing mental health crises is proposed with signposting to appropriate training.

Literature search

There is a paucity of literature available on management of mental health crises in dental practice (Box 1). There is discussion about holistic management of patients with mental health conditions and the understanding that dental pain can affect patients' mental health;6 this is important in terms of provision of urgent dental care.

In an emergency, the Mental Health Act7 makes provision for detention of an individual in a place of safety if they are a risk to themselves or others.8

The lack of literature highlights the gap in knowledge, confidence and support in managing patients experiencing a mental health crisis in contrast with those experiencing a medical emergency. Community pharmacists have acknowledged this problem and by increasing their knowledge of mental health conditions and their acute management this has improved their confidence and patient feedback.5 Dental health professionals have been left to manage these urgent situations without support, which would be unthinkable in medical emergencies.

Within special care dentistry, we are likely to see a higher number of patients with severe mental health conditions and so it is to be expected that those working within special care dentistry may be more au fait with management of mental health crises. However, mental health conditions can affect anyone and it is important for all dental practitioners to be aware of the management of these.

This paper will not cover management of dental anxiety as this is covered well within other areas of dental literature (see resources).

Case reports

Patient A

History

This patient was a person with schizophrenia, living and managed within community psychiatric services. Patient A was living in supported accommodation, with support workers present in the morning, only when there is access to a landline. During the rest of the day, A had access to a mobile, but this rarely worked.

Dental need

A had recurrent pain from their teeth, they were not maintaining their dentition and A could not see this happening in the future. The long-term treatment plan for A was to transition to full dentures, but A was having partial dentures constructed.

Psychiatric presentation

A attended for their dental appointment and disclosed to the dental team that they had experienced an acute psychotic episode the previous night. They also disclosed that their psychotic voices remained loud that day. On further discussion, A disclosed that these voices were telling them to harm people and they were experiencing paranoia around people poisoning their drinks.

Action taken

The treating dentist abandoned treatment during this appointment. The dental team and A discussed seeking help. A has a community psychiatric nurse (CPN) who they have regular contact with, although they report they are currently unavailable and their phone is not working. A was happy for the dental team to seek help on their behalf.

A's CPN team were called and agreed for the on-call CPN to call A back at the dental clinic. The dentist asked A to wait in the waiting room. This was a secure area so that staff could maintain a safe distance while observing A.

While waiting for the return phone call, A's condition deteriorated and they became acutely distressed, pacing around the waiting room and talking to themself.

The dental team made further attempts to contact A's CPN and then sought advice from psychiatric colleagues on the best course of action. Because of A's deteriorating condition and no contact from the CPN, the dentist called emergency services to assist the transfer of A to a place of safety. Ambulance staff attended the dental clinic and the dental team handed over care of A.

Learning

This case shows the importance of having a thorough medical history for patients, including their mental health conditions, triggering factors and details of their CPN, similarly to how dental teams would ask for regarding other medical conditions. The next step, which wasn't taken in this instance but would have been useful, would be to request not only A's CPN contact details, but also A's emergency care or safety plan which would have contained details on what to do in an emergency.

This case also highlights the difficulties with accessing mental health emergency care for dental teams, knowing who to contact, how and when. Here, the dental team had already gained details of A's CPN and A could consent to the dental team contacting them on their behalf. When this access route was not available, the dental team were fortunate to have psychiatric colleagues on site to ensure that the dental team relayed the right message to the emergency services to get the support that they needed. A flow chart (Appendix 1) has been created to demonstrate a proposed pathway for management of mental health crises.

Another key learning from this case is that of assessing safety for team members as well as patients. This is the same first step as managing a medical emergency and as in this case, should be monitored throughout, as the relative safety may change as the situation develops. In this case, staff monitored A from behind a secure location and A was in a place where they could be monitored throughout in private. There may not always be as suitable a location, but consideration should be given to ensuring areas are as safe as possible for patient and staff alike. This may not always be within the dental surgery.

A remained lucid and consented to the dental team contacting support services on their behalf. If they had not consented and had presented a risk to themself or others, the dental team would have still contacted support services.

Patient B

History

This patient had a known history of problematic alcohol use and was due to attend a detox programme. They had no other stated medical or mental health issues. Patient B attended as part of a series of appointments to construct dentures and had developed a rapport with the dental team providing care. On examination of B's medications, they were on medications suggesting mental illness (mirtazapine, risperidone, zopiclone).

B had not provided details of any CPN, but they were supported by a charity for homeless people.

Dental needs

B was attending for a series of appointments for partial denture construction.

Psychiatric presentation

B appeared low in mood because of a recent setback in their detox programme. The dental team were concerned about B's mental health and their risk of harm to themself.

Action taken

The dentist discussed their concerns with B in a non-judgemental manner. B acknowledged their low mood and confirmed they did not feel at risk of harm to themself or others. B provided details of their keyworker to the dental team and consented to the dental team calling this keyworker. The keyworker was informed of the change in B's presentation from previous visits which they were already aware of.

Learning

This case shows the importance of an open and non-judgemental approach to management of patients with mental health conditions and how training can improve dental staff confidence in asking the right questions at the right time. Training is available from accredited sources and examples are at the end of this paper. This non-judgemental approach helps to improve access to the right support for these patients and shows the importance of patient rapport for discussing potentially sensitive issues with patients.

This case highlights the importance of knowledge of medications and their uses, as patients may not always be aware of all of their conditions or may not be willing to divulge. The clinician was familiar with these medications as being commonly used and this highlights the ongoing learning that dental professionals can undertake to ensure the best care for our patients.

Patient C

History

This patient was a person with schizophrenia, depression and anxiety, who was managed in the community with psychiatric support. Patient C had 24-hour care from support workers. C regularly reported hearing voices from teeth and these usually related to self-harm and suicide.

Dental needs

C is a long-standing patient who attends regularly. They attended on this day for routine examination, reporting a sore mouth.

Psychiatric presentation

C reported hearing voices from their teeth on this day. The dental team gently enquired about these voices to find out if they were specific and clear. The voices were telling C to go over the road and kill themself. C informed the dental team of this in front of their support workers who are in close liaison with their psychiatric team.

Action taken

The disclosure was documented in the clinical notes, the dental team ensured that the care team supporting C were aware and that measures were in place to support C, including psychiatric support should it be required. The sore mouth was addressed at this appointment.

Learning

C's case demonstrates a difficult management issue of how to manage a patient who discloses suicidal thoughts. While in C's case, they were well supported and little action was required from the dental team, this was known because of good documentation, including a question specifically relating to mental health conditions in a standard medical questionnaire (Box 2). This was then followed up with further, open, non-judgemental questions to assess how to manage this patient. Patients in this situation are not always in as fortunate position to have good support and it is important for the dental team to know how to manage these disclosures. A suggested pathway is outlined in Appendix 1.

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Appendix 1 Flowchart for managing mental health disclosures

C's case highlights the importance of training relevant to mental health crises, including mental health first aid and suicide awareness training. While not utilised in C's case as they were well supported, this situation could present in someone who does not have the same level of support.

Discussion

While challenging to manage, the common theme around the management of mental health crises includes specific questioning of a patient's mental health history, as clinicians would for any other aspect of a medical history. At times this can be perceived as challenging because of the associated stigma, but it is important, both for patient safety and reducing said stigma, to ensure that we feel comfortable asking these vital questions. These questions will vary depending on the mental health condition but can include: whether the patient is having thoughts of self-harm or suicide; whether they are currently experiencing hallucinations or delusions; and whether these are specific or generalised. This will help to form a risk assessment of the patient's risk of harm to themselves or those around them.

These patients also highlight the importance of risk assessment in the dental environment. Risk assessments can sometimes seem like a daunting process but they are something that we are well practiced at in dentistry, albeit informally. A medical history can be regarded as risk assessment and ensures the safety of the patient and the dental team and their preparedness for unexpected events. Indeed, the first step of managing medical emergencies is always to risk assess the situation for both responder and patient safety; mental health emergencies are no different. These should include, where appropriate, a patient's mental health and this will be of relevance to the safety, primarily of the patient, but also of the dental workforce and the public.

It is important to ensure that as a dental team, we are aware of when and how to seek help. This shouldn't only be at the point of crisis but signposting patients to early support can reduce ambulance call out, emergency department use and admission.9 There will be some geographical variation in crises teams available and how to contact them and this may change over time with commissioning, so it is advised that you seek to gain this information from an up-to-date and reliable source.

General places to seek support would include the patient's general medical practitioner, the patient's CPN or on-duty CPN, or calling (in the UK) 111, Samaritans (116-123) or the emergency services (999), depending on the urgency of need. Some patients with a known mental health condition will have a crisis (emergency or safety) plan and this could be shared with the dental team to enhance the support. This will rely on an open and trusting relationship with the dental team. Further training in mental health first aid is available and providers will vary depending on location (see resources).

Conclusion

Mental health conditions are becoming increasingly common and will be encountered by the general dental practitioner. With this, there will be a proportion of patients that will need urgent support because of a mental health crisis. It is important for the dental team to be aware of the support networks already in place for their patients and those that they can access when a patient presents with an urgent need. This will begin with an understanding of the patient's full medical history, including any diagnoses, medications and involvement of specialists involved in their care. For patients with mental health conditions, this can include CPNs and psychiatric specialists. Having a pathway for managing mental health emergencies (Appendix 1) as we do for medical emergencies can give dental teams more confidence in these high-pressure situations to ensure that the appropriate support is given for each patient. Mental health first aid courses and suicide awareness training can improve confidence in discussing such issues with patients and improve patient rapport. It is important to know that dentists may be the first person that someone has disclosed a mental health condition to and therefore providing non-judgemental initial support and clear onward support can help to reduce barriers to psychiatric care. It is also important to ensure that when patients disclose such things to a dental professional that it is not ignored, but is risk assessed and managed in the most appropriate manner. This may be to seek help without consent if the patient is a risk of harm to themselves or others.

Resources

Mental health support

Dental anxiety

  • Meecham J G, Robb N D, Seymour R A. Pain and anxiety control in the conscious dental patient. Oxford: Oxford University Press, 1998

  • Smith T A, Heaton L J. Fear of dental care: are we making any progress? J Am Dent Assoc 2003; 134: 1101-1108

  • Bare L C, Dundes L. Strategies for combating dental anxiety. J Dent Educ 2004; 68: 1172-1177

  • Rafique S, Fiske J, Banerjee A. Dental management of the petrified dental patient. Dent Update 2008; 35: 196-207

  • Armfield J M, Heaton L J. Management of the fear and anxiety in the dental clinic: A review. Aust Dent J 2013; 58: 390-407.

This article was originally published in the BDJ on 25 March 2022 in Volume 232 pages 375 to 378.