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 Table of Contents  
COMMENTARY
Year : 2012  |  Volume : 3  |  Issue : 4  |  Page : 164-168

Suicide rate in the dental profession: Fact or myth and coping strategies


Department of Oral Biology, University of Nebraska Medical Center, College of Dentistry, Lincoln, Nebraska 68583-0740, USA

Date of Web Publication5-Feb-2013

Correspondence Address:
Brian M Lange
Department of Oral Biology, University of Nebraska Medical Center, College of Dentistry, 40th and Holdrege Streets, Lincoln, Nebraska 68583-0740,
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2155-8213.106845

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  Abstract 

This article summarizes relevant scientific data on the alleged high suicide rate among dentists as compared to other health care professions. Potential contributing risk factors for the dental profession are identified. In addition, a brief review is provided for major depressive disorder, a contributor to increased suicide, along with its symptoms, underlying theory, drug treatment and coping skills to combat this disorder.

Keywords: Dental suicide rate, dentist, major depressive disorder, suicide


How to cite this article:
Lange BM, Fung EY, Dunning DG. Suicide rate in the dental profession: Fact or myth and coping strategies. Dent Hypotheses 2012;3:164-8

How to cite this URL:
Lange BM, Fung EY, Dunning DG. Suicide rate in the dental profession: Fact or myth and coping strategies. Dent Hypotheses [serial online] 2012 [cited 2017 Dec 11];3:164-8. Available from: http://www.dentalhypotheses.com/text.asp?2012/3/4/164/106845


  Introduction Top


Do dentists have the highest suicide rate among health care professionals? Are they at a higher risk of suicide? To more fully understand this topic, it is necessary to address several issues which include: the reporting of suicides, the statistics of suicide, the myth of suicide prone dentists and risk factors and symptoms.


  Suicide Rates in Dentists Top


Suicides tend to be under reported due to the stigma of shame and religious implications. [1] Further, suicide classified according to professions is complicated by suicides being reported as accidental death. Additionally, many states do not list the occupation of the deceased. From a statistical point of view, there is the problem of small numbers. Dentists represent only a small fraction of the total population and only a small portion die in a given year; of that number, only a small fraction die from suicide. Consequently, people draw conclusions on very limited samples. For example, one Midwestern state reported occupation on the death certificate-defined as the occupation the person did most of their life. In a 16 year period from 1989 to 2004, there were 244,628 total deaths. [2] There were 3002 suicides or 1.2% of the total deaths were suicides. Of the 244,628 deaths, 222 were dentists of which four committed suicide. Based on the above, about 1.8% of dentists who died had committed suicide. It would be disingenuous and misleading to conclude, therefore, that 50% more dentists committed suicide than the overall population. Statistically, this would be a sweeping and inaccurate generalization. The national suicide rate is 1.3% of total deaths. [3]

The myth surrounding the suicide rate of dentists can be traced back to studies that lack the correct scientific weighting for demographics. [4] Alexander, in a 2001 article, traces the beginnings of the myth to the 1920's when both the lay public and professional media repeatedly portrayed dentists as being suicide prone. In addition, over the years both the medical and dental professions have been referenced as groups of health care providers that are at a high risk of committing suicide. [1] These assertions have been repeated and apparently accepted without sufficient supporting data. In the 1960's claims based on statistical evidence that dentists committed suicide at a higher rate than other health care providers began to appear in the literature. [1] However, it was not until the mid-1970's that the earlier studies were scrutinized. A study conducted by the American Dental Association showed that data from 31 states did not support the conclusion that dentists committed suicide at higher rates than the general population. [5] Many studies on the suicide rate of health care providers and dentists have been published since the 1975 ADA study. [6],[7],[8],[9],[10] It is not the intent of this paper to provide an in-depth review of all those studies. Please consult Alexander's article for a thorough review. [1] Alexander does an excellent job of reviewing all studies that explore suicide rates within the dental profession. As Alexander concludes, there is no consistent statistical evidence available to prove that dentists are suicide prone; in fact, most reliable data suggest the opposite. [1]


  Risk Factors for Dentists Top


Some risk factors are general in nature and apply to the total population. Risk factors such as gender (males commit suicide at a rate four times that of females), age (people over age of 65 have suicide rates 50% higher than the normal population), race (whites are twice as likely to commit suicides as non-whites), marital status (married least likely to commit suicide), availability of lethal means, mental health, and adverse life events/major stressors apply to the general U.S. population. [3]


  Stressors for Dentists Top


There can be stressors unique to professions. Stressors in dentistry can include managing a solo practice, missed appointments, patient dissatisfaction with treatment, insurance problems, encroachment and regulations of governmental agencies and the lack of quiet time such as not having breaks from one's work. [1],[3],[11]

If we combine risk factors with stressors, we begin to build a profile that is useful to compare to symptoms that may be evidenced in an individual. [Table 1] highlights the most noteworthy symptoms for depression. [12],[13],[14] At high risk for suicide are people with multiple risk factors. However, depression is one risk factor that stands out. Psychological postmortem case studies reveal that more than 90% of suicides have depression or other diagnosable mental illness or substance abuse disorder. [3],[14],[15],[16] Most suicidal people are depressed. [3],[13],[15] Individuals are at a very high risk to harm themselves if they: displays symptoms of depression, have multiple risk factors, live in a stressful environment, and have weak social support systems (friends, family or activities) to assist in managing symptoms. [15],[16]
Table 1: Symptoms of depression (adapted from American Association of Suicidology)[12]

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As a group, dentists may also tend toward perfectionistic tendencies which make for precise restorations but lead to disappointments in life and practice when dealing with imperfect people.

Silverman identified physicians (male and female) at a high risk for suicide if they were white males 45 years or older. [10] Fifty years of older if females that were divorced, separated, single or having marital discord and have any or all of the following risk factors: depression, alcohol or drug abuse, workaholic, excessive risk taking, chronic pain or debilitating illness, change in professional status and access to legal medication and access to firearms.

Alexander identified the early signs of suicidal ideation including alcohol and or substance abuse or addiction, adverse changes in behavior, signs of depression, recent adverse life event, loss of confidence and working longer hours with decreased productivity, decrease interest in anything outside the office, postponing vacations, excess interest in prestige and power, atypical aggressiveness and hostility, vigorous denial and rationalization, new lack of organization and use of expressions like ending it all. [1] If someone you know fits the behaviors described talk to them, offer to listen and if need be offer to go with them to get help.


  Types of Depression Top


There are several different types of depression. [13],[14],[15],[16] Briefly, depression caused by external factors such as death of a loved one or unemployment, is known as exogenous or reactive depression. This type of depression is self-limiting. Usually, it does not require drug treatment and responds well to counseling. [17] The second major type of depression is known as primary, endogenous, unipolar or major depressive disorder (MDD), which is more serious and requires pharmacotherapy and/or psychotherapy. This type of disorder may not be associated with any specific cause and originates from within the individual. A serious consequence of MDD is an increased risk of suicide. [18]


  Symptoms of Depression Top


Symptoms of depression may not be limited to one episode and may return without an appropriate treatment plan. [14],[15] According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a major depressive episode consists of five or more of the symptoms presented in [Table 1], occurring most days for a period for at least two weeks. [18]


  Theory of Depression Top


Several theories have been proposed to explain the cause of endogenous depression, with major focus on putative neurotransmitters. It is not the intent of this article to review all the theories. However, the classic monoamine theory/biogenic amine hypothesis of affective disorders proposes that depression results from a deficit of the neurotransmitter serotonin, norepinephrine, or both at central synaptic sites. [19],[20],[21] Drugs that increase the level of serotonin or norepinephrine in the brain are effective in the treatment of mental depression. [14],[21]


  Drug Treatment Top


[Figure 1] illustrates the synthesis of the neurotransmitter, serotonin and its storage in vesicle to prevent metabolism by monoamine oxidase enzyme inside the neuron. Upon the arrival of an action potential, serotonin is released from the neuron and stimulates post-synaptic serotonergic receptors to mediate its pharmacological effects. Its action is mainly terminated by reuptake back to presynaptic neurons. [21],[22] Drugs employed in the treatment of endogenous depression are presented in [Table 2].
Figure 1: This figure illustrates the synthesis of the neurotransmitter, serotonin, the storage of serotonin in storage vesicles, its release from the neuron into the synaptic site and activation of postsynaptic receptors, its re-uptake back to nerve ending and the re-uptake blockade by specific serotonin re-uptake inhibitors (SSRIs), atypical SSRIs and tricyclic antidepressants

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Table 2: Representative antidepressant drugs[21]

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  Mechanism of Drug Action Top


Specific serotonin reuptake inhibitors (SSRIs) are a group of drugs that selectively block the reuptake of serotonin back into the serotonergic nerve endings, thus increasing its concentration at the synaptic cleft to stimulate the post-synaptic receptors. [20],[21],[22] The increased serotonergic activity in the cerebral cortical and limbic areas of the brain accounts for the antidepressant effects. The atypical SSRI antidepressant drugs inhibit the reuptake of serotonin similar to SSRI, but have additional action on other neurotransmitters, while the tricyclic antidepressants (TCA) block the re-uptake of both serotonin and norepinephrine into serotonergic and noradrenergic neuron nerve endings to alleviate the symptoms of depression. [22],[23],[24] By inhibiting the enzyme that metabolizes norepinephrine and serotonin, the monoamine oxidase inhibitors (MAO-I) increase the concentrations of both neurotransmitters in the brain. [21]

It is important to realize that the pharmacological actions of these drugs occur within a few hours, but the full improvement of antidepressant effect may take at least two weeks to develop. Therefore, antidepressants may exert other pharmacological actions that are not yet completely understood. Potential mechanisms of action may include down-regulation of presynaptic inhibitory receptors leading to increased release of neurotransmitter and/or enhanced sensitivity of postsynaptic receptors leading to increased therapeutic response. [20],[21],[22]


  Side Effects Top


The SSRIs have fewer and less severe adverse effects than the TCAs and MAO-Is. [21],[24] Thus, they are considered the first-line drugs in drug treatment. Side effects may include headache, dry mouth, bruxism, sweating, anxiety, agitation, gastrointestinal discomfort (nausea, vomiting, and diarrhea), fatigue, sleep disturbance, potential drug-drug interactions due to hepatic enzyme inhibition and sexual dysfunction. Due to blockade of muscarinic and alpha-adrenergic receptors, additional adverse effects include blurred vision, xerostomia, urinary retention, orthostatic hypotension, reflex tachycardia, sedation, weight gain and sexual dysfunction. [21],[22],[23],[24]


  Precaution Top


Antidepressants should be used cautiously in both children and teens. It has been reported pediatric patients may become more suicidal as a result of drug therapy. [20],[25] As mentioned earlier, suicidal tendencies are associated with depression. Therefore, all patients should be monitored for worsening depression and suicidal thinking during initiation of drug treatment or the drug dose is adjusted. Furthermore, patients are encouraged to engage in social and/or physical activities that can generate more emotional support.


  Other Treatment and Coping Skills Top


Other psychotherapies are available as sole treatment or adjunctive to drug treatment. Interpersonal psychotherapy, based on assumption that interpersonal factors may contribute to psychological problems like depression [26] and cognitive-behavioral therapy which is helping a person learn to reorganize negative patterns of thought, evaluate their validity and replace them with healthier ways of thinking therapy have been used and have been suggested to be as effective as pharmacotherapy in patients with mild to moderate depression. [26],[27] Medication is effective in eliminating symptoms of depression, while counseling provides coping skill in dealing with day-to-day problems and can also prevent release.


  Suicide is a Preventable Tragedy Top


We have discussed risk factors and some treatment options. While risk factors cannot be readily managed, awareness accompanied with prevention goes a long way in coping with stress which, in turn, can often be the trigger that leads to depression. [Table 3] lists a number of steps that can manage stress successfully. [3]
Table 3: Stress coping steps

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Learn the danger signs of a potential suicide. Most suicides occur with warning signs. Learn the warning signs [Table 1] of someone at risk and take the warning signs seriously. Be willing to listen and probe with questions. Do not be afraid to ask if someone is thinking about suicide. Be active in helping the individual get treatment. Most people thinking about suicide feel alone and do not think the pain will stop. Show interest in them and help them get help. The National Institute on Mental Health and the National Alliance on Mental Illness both have excellent and informative web sites for understanding mental illness and for helping those coping with it. [28],[29]

 
  References Top

1.
Alexander RE. Stress-related suicide by dentists and other health care workers. Fact or folklore? J Am Dent Assoc 2001;132:786-94.  Back to cited text no. 1
[PUBMED]    
2.
Unpublished data obtained from State of Nebraska, Department of Health. 2011.  Back to cited text no. 2
    
3.
Stein GM. Challenging the myth of the suicide-prone dentist. Northwest Dent 2004;83:35-8.  Back to cited text no. 3
    
4.
Sancho FM, Ruiz CN. Risk of suicide amongst dentists: Myth or reality? Int Dent J 2010;60:411-8.  Back to cited text no. 4
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5.
Mortality of dentists, 1968 to 1972. Bureau of Economic Research and Statistics. J Am Dent Assoc 1975;90:195-8.  Back to cited text no. 5
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Bers GS. Dentist suicide: A problem? J Okla Dent Assoc 1980;71:14, 21.  Back to cited text no. 6
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7.
Stack S. Suicide risk among dentists: A multivariate analysis. Deviant Behav 1996;17:107-118.  Back to cited text no. 7
    
8.
Hilliard-Lysen J, Reimer JW. Occupational stress and suicide among dentists. Deviant Behav 1988;9:333-46.  Back to cited text no. 8
    
9.
Rothman MA. Suicide: Not for dentists only. J Mo Dent Assoc 1981;61:26-7.  Back to cited text no. 9
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10.
Silverman M. Physicians and suicide. Goldman LS, Myers M, Dickstein LJ, editors. The Handbook of Physician Health: Essential Guide to Understanding the Health Care Needs of Physicians. Chicago Ill: American Medical Association; 2000.  Back to cited text no. 10
    
11.
Fung EY, Lange BM. Impact of drug abuse/dependence on dentists. Gen Dent 2011;59:356-9.  Back to cited text no. 11
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12.
American Association of Suicidology. Available from: http://www.suciidology.org/home. [Last assessed on 2012 Feb 15].  Back to cited text no. 12
    
13.
Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: Results from the World Health Surveys. Lancet 2007;370:851-8.  Back to cited text no. 13
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14.
Maletic V, Robinson M, Oakes T, Iyengar S, Ball SG, Russell J. Neurobiology of depression: An integrated view of key findings. Int J Clin Pract 2007;61:2030-40.  Back to cited text no. 14
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Belmaker RH, Agam G. Major depressive disorder. N Engl J Med 2008;358:55-68.  Back to cited text no. 15
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Paykel ES. Basic concepts of depression. Dialogues Clin Neurosci 2008;10:279-89.  Back to cited text no. 16
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17.
Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: A patient-level meta-analysis. JAMA 2010;303:47-53.  Back to cited text no. 17
    
18.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed (text revision)-DSM-IV-TR. Washington DC: American Psychiatric Association; 2000.  Back to cited text no. 18
    
19.
Smiga SM, Elliott GR. Psychopharmacology of depression in children and adolescents. Pediatr Clin North Am 2011;58:155-71.  Back to cited text no. 19
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20.
Hollon SD, Thase ME, Markowitz JC. Treatment and prevention of depression. Psychol Sci Public Interest 2002;3:39-77.  Back to cited text no. 20
    
21.
Katzung Bg, Masters SB, Trevor AJ. Basic and Clinical Pharmacolgoy. 12 th ed. NY: McGraw Hill Publisher; 2012.  Back to cited text no. 21
    
22.
Rakofsky JJ, Holtzheimer PE, Nemeroff CB. Emerging targets for antidepressant therapies. Curr Opin Chem Biol 2009;13:291-302.  Back to cited text no. 22
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23.
Hirschfeld RM. Antidepressants in long-term therapy: A review of tricyclic antidepressants and selective serotonin reuptake inhibitors. Acta Psychiatr Scand Suppl 2000;403:35-8.  Back to cited text no. 23
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24.
Gillman PK. Tricyclic antidepressant pharmacology and therapeutic drug interactions updated. Br J Pharmacol 2007;151:737-48.  Back to cited text no. 24
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25.
Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA 2004;292:338-43.  Back to cited text no. 25
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26.
Hirschfeld RM. Antidepressants in long-term therapy: A review of tricyclic antidepressants and selective serotonin reuptake inhibitors. Acta Psychiatr Scand Suppl 2000;403:35-8.  Back to cited text no. 26
[PUBMED]    
27.
Burns D. Feeling Good, the New Mood Therapy. New York: Avon Books; 1999.  Back to cited text no. 27
    
28.
National Institute of Mental Health. Available form: http://www.nimh.nih.gov. [Last accessed on 2012 Feb 15].  Back to cited text no. 28
    
29.
National Alliance of Mental Illness. Available from: http://www.nami.org. [Last accessed on 2012 Feb 10].  Back to cited text no. 29
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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Abstract
Introduction
Suicide Rates in...
Risk Factors for...
Stressors for De...
Types of Depression
Symptoms of Depr...
Theory of Depression
Drug Treatment
Mechanism of Dru...
Side Effects
Precaution
Other Treatment ...
Suicide is a Pre...
References
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