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Bipolar I disorder - Psychopathology, medical management and dental implications
Abstract
Background. The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental management of patients who have bipolar I disorder, or BD, previously known as manic-depressive disorder. Types of Studies Reviewed. The authors conducted a MEDLINE search for the period 1995 through 2001 using the key terms "bipolar disorder," "epidemiology," " pathophysiology," "treatment" and "dentistry." The articles they selected for further review included those published in English in peer-reviewed journals; they gave preference to articles reporting randomized, controlled trials. Results. BD is a psychiatric illness characterized by extreme mood swings. Mania is accompanied by euphoria, grandiosity, racing thoughts and lack of insight. Depression is characterized by marked sadness or loss of interest or pleasure in daily activities. The unpredictable mood swings can distress the person, can impair social function and quality of life and are associated with a significant increase in the risk for substance abuse and suicide. BD is common in the United States, with a lifetime prevalence rate of 1.6 percent and recurrence rate of more than 50 percent. Clinical Implications. The prevalence of dental disease usually is extensive because of poor oral hygiene and medication-induced xerostomia. Preventive dental education, saliva substitutes and anticaries agents are indicated. To avoid adverse drug interactions with the usually prescribed psychiatric medications, special precautions should be taken when administering certain antibiotics, analgesics and sedatives.
... Gün boyunca sık su içilmesi ve şekersiz sakız kullanımı tükürük akışını uyararak belirtilerin hafiflemesini sağlayabilir. [54,56,61] Bunun yanısıra, kserostominin şiddetine bağlı olarak hastaya randevular 3-4 aylık aralarla verilip, değerlendirmeler sıklaştırılabilir. ...
... ve Tablo.3). [54,56] Antipsikotik, duygudurum düzenleyici ve antidepresan ilaçlar tükrük bezi fonksiyonunu bozarak kserostomiye neden olurken lityum ile valproat sodyum kullanımı ve yoğun karbonhidrat alma isteğine sebep olabilir. [64,65] Hastalar kserostomi varlığında ve karbonhidrattan zengin beslenme biçiminde, sıklıkla şekerli içecek kullanımını artırırlar. ...
... [86][87][88] Psikiyatride Güncel Yaklaşımlar -Current Approaches in Psychiatry Tablo.3. Atipik Antipsikotikler, Benzodiazepinler, Duygudurum Düzenleyici ve Antidepresan İlaçların Orofasiyal Yan Etkileri [54,56] Kserostomi Klasik antipsikotik ilaçlar, TME dislokasyonu, bozulmuş öğürme refleksi ve obstrüktif disfajiye bağlı ölüm sıklığının artmasına sebep olabilen çene kasları spazmlarına da yol açabilirler. [52,55] Dislokasyon, artiküler disk boşluğunun kollapsıdır. ...
ABSTRACT
Although oral health is a major determinant of general health and quality of life, it has a low priority in the context of mental illness. Chronic mental illness and its treatment carry inherent risks for significant oral diseases. Both the disease itself and its various pharmacologic management modalities lead to a range of oral complications and side effects, with caries, periodontal disease and xerostomia being encountered most frequently. Older age, female gender, length of hospitalization, duration of mental illness and psychiatric diagnosis are the most discussed predictors for adverse dental outcomes in the reviewed studies. Poor oral hygiene, higher intake of carbonates, smoking, poor percep-tion of oral health self-needs, length of psychiatric disorder, length of psycho-tropic treatment, and less access to dental care pose at high risk for poor oral health among this population. This article emphasizes the importance of preventive dentistry programs to improve dental healthcare psychiatric chron-ic inpatients and the significance of bridging dental health education to psy-chiatric rehabilitation programs. In this review, general information concern-ing the oral manifestations of mental illness, effect of medication of mental illness on oral health, the factors affecting oral health among this special population have been provided.
Keywords: mental illness, oral health, xerostomia, psychotropic drugs
... Gün boyunca sık su içilmesi ve şekersiz sakız kullanımı tükürük akışını uyararak belirtilerin hafiflemesini sağlayabilir. [54,56,61] Bunun yanısıra, kserostominin şiddetine bağlı olarak hastaya randevular 3-4 aylık aralarla verilip, değerlendirmeler sıklaştırılabilir. ...
... ve Tablo.3). [54,56] Antipsikotik, duygudurum düzenleyici ve antidepresan ilaçlar tükrük bezi fonksiyonunu bozarak kserostomiye neden olurken lityum ile valproat sodyum kullanımı ve yoğun karbonhidrat alma isteğine sebep olabilir. [64,65] Hastalar kserostomi varlığında ve karbonhidrattan zengin beslenme biçiminde, sıklıkla şekerli içecek kullanımını artırırlar. ...
... [86][87][88] Psikiyatride Güncel Yaklaşımlar -Current Approaches in Psychiatry Tablo.3. Atipik Antipsikotikler, Benzodiazepinler, Duygudurum Düzenleyici ve Antidepresan İlaçların Orofasiyal Yan Etkileri [54,56] Kserostomi Klasik antipsikotik ilaçlar, TME dislokasyonu, bozulmuş öğürme refleksi ve obstrüktif disfajiye bağlı ölüm sıklığının artmasına sebep olabilen çene kasları spazmlarına da yol açabilirler. [52,55] Dislokasyon, artiküler disk boşluğunun kollapsıdır. ...
Although oral health is a major determinant of general health and quality of life, it has a low priority in the context of mental illness. Chronic mental illness and its treatment carry inherent risks for significant oral diseases. Both the disease itself and its various pharmacologic management modalities lead to a range of oral complications and side effects, with caries, periodontal disease and xerostomia being encountered most frequently. Older age, female gender, length of hospitalization, duration of mental illness, psychiatric diagnosis are the most discussed predictors for adverse dental outcomes in the reviewed studies. Poor oral hygiene, higher intake of carbonates, smoking, poor perception of oral health self-needs, length of psychiatric disorder, length of psychotropic treatment, and less access to dental care pose at high risk for poor oral health among this population. This article emphasizes the importance of preventive dentistry programs to improve dental healthcare psychiatric chronic inpatients and the signifance of bridging dental health education to psychiatric rehabilitation programs. In this review, general information concerning the oral manifestations of mental illness, effect of medication of mental illness on oral health, the factors affecting oral health among this special population have been provided.
... [12] It is not uncommon for patients to use sweets and sugary drinks to keep the oral mucosa moist and these also contribute to the progression of caries. [13,14] Hyposalivation reduces lubrication of the mucosa, which in turn has an adverse effect on the risk of injury to the oral mucosa and retention of removable dentures. Depressed people therefore often require dental treatment as a consequence of their underlying disease or the pharmacotherapeutic agents they are taking. ...
... [56] Aspirin can displace valproate from protein binding [51] and by inhibiting the metabolism. [14,55] lead to elevated serum levels of valproate. [51] The administration of aspirin or other NSAIDs in combination with valproate, carbamazepine and selective serotonin reuptake inhibitors (SSRIs) can cause excessive bleeding. ...
... [28,29,64] Erythromycin should be administered with caution, the patients should be closely monitored [29] and the dose of the drugs administered should be reduced. [14,48,65,66] It is advisable to replace erythromycin with dirithromycin or azithromycin because these antibiotics do not infl uence the hepatic metabolism of other drugs by inhibition of the CYP isoenzymes. [6,11] Tetracyclines and metronidazole ...
Depression is commonly associated with a high-carbohydrate diet, lack of interest in proper oral hygiene and xerostomia connected to the use of antidepressants. Patients often consult their dentists as a result of changes affecting the hard dental substance and the soft-tissues.
The aim of this study was to identify adverse drug interactions between the antidepressants and medications commonly administered in dentistry in order to give practicing dentists an overview of the scientific literature.
The objective is to identify the adverse drug interactions between antidepressants and medication commonly administered in dentistry.
The literature search was performed using PubMed, Cochrane and the specific search items. The review (1984-2009) focused on medicines used in dental practice (vasoconstrictors, non-opioid analgesics, non-steroidal anti-inflammatory drugs, antibiotics, antifungals and benzodiazepines).
There are various drug interactions between antidepressants and medicines used in dentistry. When two or more drugs are co-administered, a drug interaction must always be anticipated though many of the interactions are potential problems, but do not seem to be real clinical issues.
The probability of a drug interaction can be minimized by careful history-taking, skillful dose adjustment and safe administration of the therapeutic agent.
... Gedurende een manische episode poetsen en flossen patiënten soms dwangmatig frequent en bijzonder hevig waardoor cervicale abrasie en beschadiging van de orale mucosa ontstaan (Clark, 2003). Patiënten die 3 of meer keren waren gehospitaliseerd wegens manische episoden hadden vaker ernstige cervicale abrasie door tandenpoetsen en ook meer attritie door bruxisme ( Friedlander et al, 2002). ...
... Tijdens een depressieve periode vertonen veel patiën- ten een sterke daling in het niveau van mondhygiëne en dat resulteerde volgens een aantal onderzoeken in supra-en subgingivale plaqueaccumulatie, een toename van nieuwe carieuze laesies en ernstige vormen van parodontitis (Clark, 2003;Reebye et al, 2003;Little, 2004;Dougall en Fiske, 2008). Patiënten die 3 of meer keren waren opgenomen in een zorginstelling wegens een depressieve episode hadden een hogere DMFT-score en hevigere parodontitis dan min- der vaak opgenomen patiënten ( Friedlander et al, 2002). Gedurende een depressieve periode kan misbruik optreden van alcohol of drugs. ...
... De medicamenten die worden toegepast bij de behande- ling van bipolaire stoornissen hebben ook effect op de mond- gezondheid ( Friedlander et al, 2002;Little, 2004). Zo hadden patiënten die werden behandeld met tricyclische antidepres- siva vaker een slechte mondgezondheid dan patiënten die deze medicamenten niet kregen voorgeschreven. ...
De bipolaire stoornis is een stemmingsstoornis die wordt gekenmerkt door het recidiverende optreden van manische, depressieve en gemengde episoden met daartussen kortere of langere, relatief symptoomvrije perioden. In Nederland is de prevalentie 1,9%. Bij de behandeling wordt meestal een combinatie van psycho-educatie, zelfmanagement en farmacotherapie toegepast. Zowel de bipolaire stoornis als de toegepaste medicatie heeft negatieve effecten op de mondgezondheid. Patiënten hebben onder andere een groter risico op cariës, xerostomie, smaakafwijkingen en bruxisme. Uitgebreide instructie van de patiënt in mondverzorging, ondersteund door frequente professionele mondzorg, is daarom essentieel. Gezien de mogelijke interacties tussen geneesmiddelen dient de mondzorgverlener ‘non-steroid anti-inflammatory drugs’ alleen in overleg met de behandelende psychiater voor te schrijven.
... The CPITN revealed poor periodontal health of inpatients with schizophrenia, whereas the healthy periodontium was observed in only 4.7% of the subjects, which is even lower in comparison to the previous studies 10,15,[24][25][26] . Presence of calculi (46.8%) was the most common finding in the study group, in contrast to gingival bleeding (45.8%) which was observed in the control group. ...
... Presence of calculi (46.8%) was the most common finding in the study group, in contrast to gingival bleeding (45.8%) which was observed in the control group. Previous studies reported a significantly higher occurrence of calculi in psychiatric inpatients (range 71.8% to 94.2%) 24,25,27 . Presence of shallow pockets was observed in 24.2% in the study group, much more than in the control group (7.9%). ...
Background/Aim. Many studies on oral health of psychiatric inpatients reported schizophrenia as the most common psychiatric disorder among their sample population. The available evidence suggests the higher prevalence and severity of periodontal disease among the psychiatric inpatients. The aim of this study was to evaluate periodontal health among the inpatients with schizophrenia and to consider possible risk factors for their current periodontal diseases. Methods. This cross-sectional study comprised 190 inpatients with schizophrenia at the Clinic for Psychiatric Disorders “Dr Laza Lazarevic” in Belgrade, and 190 mentally healthy patients at the Clinic for Periodontology and Oral Medicine, Faculty of Dental Medicine, University in Belgrade. The Community Periodontal Index for Treatment Needs (CPITN) and sociodemographic characteristics were registered in both groups as well as the characteristics of the primary disease among the inpatients with schizophrenia. Results. The patients in the study group had significantly higher scores of the CPITN (2.24 ± 0.98) than the patients in the control group (1.21 ± 1.10). Most of the patients in the study group had supra- , or subgingival calculi (46.8%), in contrast to the control group patients, who had in most cases gingival bleeding (45.8%). The periodontal pockets where detected in 35.8% of schizophrenic inpatients. The linear regression analysis showed that the gender and age were statistically significant predictors of the CPITN value among the inpatients with schizophrenia. Conclusion. The results of this study generally indicate the need for continuous research of psychiatric patients’ oral health, in order to determine the modes of its improvement. Similar studies should elucidate significance of psychiatric patients’ periodontal health and sensitize psychiatrists and psychiatric nurses to the oral problems of their patients.
... Finally, the BAD without specific cause consists of partial syndromes such as recurrent hypomania without depression [12]. Although no age range of greater prevalence exists, the greatest onset of disease is between 15 and 24 years of life and if BAD is properly diagnosed and treated, may undergo remission for a period of five years [6]. The main medical findings are chronic fatigue, migraine, asthma, bronchitis, multiple chemical sensitiv it y, a nd hy pertension. ...
... RPD eliminates the need for additional niches, which further contribute to the accumulation of food residue. At the subsequent appointments, there was a distinct improvement in mood and selfesteem of the patient, important aspects from the psychotherapeutic point of view [6]. The patient was followed-up at every four months to monitor oral health. ...
This study, through a literature review, aimed to present the key aspects found in Bipolar Affective Disorder (BAD), as well as present a case report of a patient who received dental care in the Special Patient Course at the Pontifical Catholic University of Paraná (PUCPR). Case report: Female patient, 30 years of age, leukoderma, diagnosed by medical and psychological exams as suffering from BAD and slight mental retardation. The most evident characteristics inherent to the primary illness included swings in mood and affection as well as bipolar or manic depressions. The special school where she studied and worked referred her to receive dental care in the special patient course of PUCPR. Her main complaint was the lack of upper front teeth and the esthetic. The treatment plan included adequacy of oral environment through basic periodontal therapy and production of removable partial dentures. Conclusion: People with BAD requires extra care with regard to behavioral management.
... An increasing candidal carriage in saliva is seen in oral squamous cell carcinoma and their participation in oral cancer occurs primarily through the nitrosation of nitrosobenzene compounds [30]. ...
... Saliva serves as a tool in determination of protein polypeptide hormones and nonpeptide hormones [28]. Serum free hormone levels in case of several nonpeptide hormones like testosterone, estradiol, estriol, progesterone, aldosterone, androstenedione, dihidroandostendion, and insulin are calculated by salivary hormone level [30]. Salivary cortisol is proposed as the best screening methodology for detection of Cushing's syndrome [33]. ...
The ability to monitor the health and disease status of the patient through saliva is a highly desirable goal for the health professionals. Considering the microconcentration of salivary constituents, saliva is explored to be diagnostic tool as it also meets the demands for an inexpensive, noninvasive and easy to use screening method. The incorporation of salivary diagnostics into clinical practice is gaining reality and will be of diagnostic value in the prospective future. The investigative use of saliva is not being applied only in dental health but also in various other systemic disorders. The advent of molecular techniques is gaining attention and this has triggered its application as a specific and sensitive biomarker in proteomics, genomics, and transcriptomics. This review discusses the basics of salivary diagnostics, expectoration techniques, and its application in various local and systemic disorders.
... This situation causes periodontal disease and dental caries as a result of dry mouth. 39 Dry mouth also causes a decrease in the resistance of mucosal tissues to mechanical trauma. Lack of a normal amount of saliva causes difficulty in speaking, chewing and swallowing, especially in patients using removable prostheses and appliances. ...
... Poor self-care during mood episodes, high smoking rates, frequent alcohol abuse rates, psychotropic-induced side effects (e.g., xerostomia, dysgeusia, and stomatitis), and non-compliance with dental clinic visits have been suggested as potential causes for poor oral health and the development of periodontitis in patients with BD [33,34]. However, as previous studies on cardiovascular diseases and dementia suggested, the opposite causal relationship also should be considered. ...
Chronic low-grade inflammation plays a role in the pathophysiology of bipolar disorder. Recent studies have shown that periodontitis can affect the central nervous system by activating inflammatory mediators in the brain. However, only a few studies have examined the association between periodontitis and bipolar disorder. Here, we aimed to review the current evidence on the association between periodontal diseases and bipolar disorder, its potential mechanisms, and future research directions. Studies so far suggested that periodontal diseases were more common in patients with bipolar disorder than in the general population. Patients with bipolar disorder generally have poor oral hygiene owing to poor self-care, smoking, alcohol abuse, and the effects of psychotropic medications. Proposed mechanisms underlying this association include the effects of inflammatory mediators, direct invasion of oral microbiota, modulation of the neurotransmitter system, and impact on the vagus nerve and hypothalamus-pituitary- adrenal axis. Additional clinical studies examining the prevalence of periodontal diseases and their association with the clinical features of bipolar disorder are necessary. Clinical studies targeting the treatment of periodontal diseases for primary or secondary prevention of bipolar disorder are warranted.
... 15 Other work has assessed the risk of dry mouth in working-age adults but was restricted to a limited range of psychotropics and did not consider severity. [7][8][9][10][16][17][18][19][20] We therefore assessed the severity of both subjective and objective dry mouth secondary to psychotropic drugs in adults above 17 years old among eight drug classes and/or against placebo. ...
Background:
Poor oral health is increasingly recognised as an important comorbidity in people with psychiatric illness. One risk factor is psychotropic-induced dry mouth.
Aims:
To perform a systematic review of the severity of dry mouth due to psychotropic drugs in adults (CRD42021239725). Study quality was assessed using the Cochrane risk of bias tool.
Method:
We searched the following databases: PubMed, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science. We included randomised controlled trials (RCTs) measuring the severity of drug-induced hyposalivation and xerostomia.
Results:
Eighteen RCTs with 605 participants were included. Severity of drug-induced dry mouth was compared among eight drug classes and/or against placebo. All studies were published 20 to 40 years ago and included tricyclic antidepressants (TCAs), serotonin specific reuptake inhibitors (SSRIs) and other drug classes. Meta-analysis was not feasible owing to design heterogeneity. TCAs caused more severe dry mouth, both objectively and subjectively, than placebo or other drug classes. SSRIs were generally associated with less severe symptoms. However, there was no information on antipsychotics or more recently available antidepressants, and there was minimal information on mood stabilisers. Most studies were on healthy subjects, limiting the generalisability of findings. Only one study measured both objective and subjective dry mouth, which have different clinical implications.
Conclusions:
Psychotropic-induced dry mouth is a poorly researched area, and well-designed RCTs of newer psychotropic drugs using standardised objective and subjective measures are indicated. Given the ongoing use of TCAs for treatment-resistant depression, prescribers need to remain vigilant for xerostomia.
... Certain types of medications have been reported to cause changes in salivary composition examples of such medications include antihypertensive agents, muscle relaxants, anticholinergics, antidepressants, antipsychotics, diuretics, benzodiazepines, analgesics, and antihistamines have been reported to induce dry mouth, [97]. Phenytoin, valproate, and carbamazepine medications have also been reported to increase the concentration of amylase and total protein and decrease the concentration of cystatin S (but not the cystatin C). ...
... Prevalence of xerostomia among patients under antidepressants is being significantly more often reported in patients taking the conventional, tricyclic antidepressants (70 -85% of patients) compared to patients under novel drugs of selective serotonine reuptake inhibitors group (15 -35% of patients) [29][30][31][32]. Tricyclic antidepessants (TCAs), such as amitriptiline or imipramine, block the reuptake of both noradrenaline and serotonine into the nerve terminals and therefore enhance norepinephrine-and serotoninmediated transmission. ...
Keywords: Xerostomia; Psychotropic Drugs; Benzodiazepines; Antidepressants; Antipsychotics Xerostomia is the sense of dry mouth which may results from reduced salivary flow. Since saliva plays a key role in the oral homeostasis, major oral health issues and decreased quality of life reflect xerostomia in patients. Xerostomia represents significant burden among patients on pharmacotherapy. One of the frequently used drugs which induce xerostomia are psychotropic drugs. This article summarizes major pharmacodynamic interactions of psychotropic drugs with signalling mechanisms involved in salivary secretory
... [22] By contrast, when patients are in a manic period, they may overuse oral health aids, which has been correlated with the increased incidence and severity of cervical injuries and occasional mucosal or gingival wounds. [23] Furthermore, drug treatments, such as antidepressants and antipsychotics, have been demonstrated to cause moderate-tosevere xerostomia, which can exacerbate dental diseases. [24] Although the association between periodontitis and psychiatric conditions, such as major depressive disorders and cognitive decline, remains controversial, [25,26] periodontitis has been suggested as a risk factor for dementia. ...
Whether periodontitis is a risk factor for developing bipolar disorders (BD) has not been investigated. We aimed to determine whether periodontitis is associated with the subsequent development of BD and examine the risk factors for BD among patients with periodontitis.
Using ambulatory and inpatient claims data from the National Health Insurance Research Database (NHIRD), we identified 12,337 patients who were aged at least 20 years and newly diagnosed with periodontitis between 2000 and 2004. The date of the first claim with a periodontitis diagnosis was set as the index date. For each patient with periodontitis, 4 subjects without a history of periodontitis were randomly selected from the NHIRD and frequency-matched with the patients with periodontitis according to sex, age (in 5-year bands), and index year.
The periodontitis group had a mean age of 44.0 ± 13.7 years and slight predominance of men (51.3%). Compared with the subjects without periodontitis, the patients with periodontitis had higher prevalence of diabetes mellitus, hyperlipidemia, hypertension, ischemic heart disease, stroke, head injury, major depressive disorder, chronic obstructive pulmonary disease (COPD), and asthma (P < .001). The incidence rate of BD was higher in the periodontitis group than in the non-periodontitis group (2.74 vs 1.46 per 1000 person-year), with an adjusted hazard ratio of 1.82 (95% confidence interval = 1.59–2.08) after adjustment for sex, age, and comorbidities.
The patients with periodontitis exhibited a significantly higher risk of developing BD. Keep the better oral hygiene to reduce periodontitis might be a preventive strategy for BD.
... Depresif dönemde ise üzüntü, iştah kaybı, ilgisizlik, uykusuzluk ve azalmış enerji gibi bulgular izlenir. Yine bu rahatsızlık çerçevesinde intihar oranlarının arttığı bilinmelidir 31,32 . Dental açıdan bakıldığında hastanın kullandığı ilaçlar ve genel durumu hakkında doktoru ile temasa geçilmesinde yarar vardır. ...
It’s known that facing a psychiatric problem throughout the life is common. Dental treatments and applications are widely used in the majority of the society. Therefore such clinical problems may be encountered in dental clinics frequently. Drugs using in psychiatry clinic and/or accompanying clinical findings reveal the need for attention in dental treatment in psychiatric patients. People with chronic psychiatric disease have weaker oral health than the general population. Therefore it is necessary to enhance preventive dental care in this population.
The aim of this review is to reveal the characteristics of psychiatric patient groups that can be encountered often in the dental clinic and discuss the effect of possible dental treatment processes.
Balıkesir Sağlık Bilimleri Dergisi (Balıkesir Health Sciences Journal), 2019; 8(1), 33 - 40
Link:https://dergipark.org.tr/balikesirsbd/issue/44009/474899
... There are several explanations that may account for this phenomenon. First, patients with mood disorder were more likely to be irritable or uncooperative during dental visits and to have complaints related to dental care that were inconsistent with objective findings [35,36]. Second, the patients more commonly reported a high level of dental fear that would deter them from receiving dental care earlier [37,38]. ...
Background
The oral health of patients with severe mental illness is poor, in general, and this may be attributed, in part, to inadequate dental care. This study investigated dental care utilization among patients with severe mental illness using a national representative sample. Methods
This study used Taiwan’s National Health Insurance Research Dataset for 2009. Patients with the diagnosis of severe mental illness (ICD-9-CM: 290–298) were recruited as the study sample, and others comprised the control. Any visit to a dentist was defined as positive in terms of dental care utilization. Regression analyses were applied to determine the odds of dental care utilization for each diagnostic entity of severe mental illness, compared with the general population and controlling for potential covariates. ResultsOnly 40 % of 19,609 patients with severe mental illness visited the dentist within 12 months. This was significantly lower than the dental visit rate of 48.3 % for the control population (odds ratio [OR] = .72, 95 % confidence interval [CI] = .69–.74; P <0.0001). The odds of dental care utilization differed among the severe mental illness diagnostic categories; e.g., the odds were lowest among those with alcohol psychoses (OR = .54, CI = .43–.68), senile dementia (OR = .55, CI = .52–.59) and other organic psychoses (OR = .58, CI = .52–.65), and highest among those with mood disorder (OR = .89, CI = .85–.94), with schizophrenic patients occupying a mid-level position (OR = .63, CI = .59–.67). Conclusions
Patients with severe mental illness received less dental care than the general population. Health care providers and caregivers of patients with severe mental illness should encourage them to visit the dentist regularly, in order to improve the oral health of these vulnerable patient groups.
... But worse dental care among those in care homes. 67 , Tang (2014) 65 Less frequent visits linked to costs, living in an institution and drug abuse especially among men Neilsen (2011) 61 , Thomas (1996) 69 Tendency of dentists to treat patients with more extractions instead of complex preventative or restorative treatments Patients do not keep to appointments Friedlander and Birch (1990) 76 Less discrepancy between self-reported dental problems & dental professionals awareness of problems Tang (2014) 65 Importance of dental education Friedlander and Birch (1990) 76 Use of artificial salivary products (chewing gum) without sugar Friedlander and Birch (1990) 76 Need for greater collaboration between psychiatrists and dental professionals (especially dental hygienists) to be more aware of medication and the patient's current psychological situation & use of alcohol/drugs to exhibit supportive, non-judgemental attitude to patients & assure to patients info is confidential Clark (2003) 74 , Dicks (1995) 79 , Friedlander (2002) 77 85 ...
Background:
People with mental health illness are reported to have poorer access to dental services and poorer oral health outcomes. The aim of this review is to review the current literature regarding barriers and enablers for oral health outcomes and access to dental care for adults with mental health disorders which will be addressed from individual, organisational and systemic perspectives METHODS: A narrative review based on a search of the relevant literature regarding oral health for people with mental health disorders was undertaken using MEDline, Web of Science, ERIC and Psychlit. Any relevant systematic reviews were highlighted in this process along with primary studies and other relevant reviews.
Results:
The literature repeatedly verified poorer oral health and inadequate access to dental services in people with mental health disorders. The literature identified barriers at individual, organisational and systemic levels. Much of the literature focused on barriers with less being focused on enablers and interventions.
Conclusions:
Considerable investigation of barriers had not elucidated options to improve care or outcomes. This article is protected by copyright. All rights reserved.
... None of these genes/miRNAs have known functions that may impact dental caries. In the Mexican ancestry subsample, a few significant loci were observed, notably ANK3 (leading SNP rs116717469, P-value = 3.23E−8), a gene associated with bipolar disorder (37), which is in turn a risk factor for dental caries (38). Likewise, a region on chromosome 17 spanning several genes including CACNA1G was observed (leading SNP rs71381322, P-value = 3.72E−8). ...
Dental caries is the most common chronic disease worldwide, and exhibits profound disparities in the US with racial and ethnic minorities experiencing disproportionate disease burden. Though heritable, the specific genes influencing risk of dental caries remain largely unknown. Therefore, we performed genome-wide association scans (GWAS) for dental caries in a population-based cohort of 12,000 Hispanic/Latino participants aged 18-74 years from the HCHS/SOL. Intra-oral examinations were used to generate two common indices of dental caries experience which were tested for association with 27.7M genotyped or imputed single nucleotide polymorphisms (SNPs) separately in the six ancestry groups. A mixed-models approach was used, which adjusted for age, sex, recruitment site, five principal components of ancestry, and additional features of the sampling design. Meta-analyses were used to combine GWAS results across ancestry groups. Heritability estimates ranged from 20-53% in the six ancestry groups. The most significant association observed via meta-analysis for both phenotypes was in the region of the NAMPT gene (rs190395159; p-value=6×10(-10)), which is involved in many biological processes including periodontal healing. Another significant association was observed for rs72626594 (p-value=3×10(-8)) downstream of BMP7, a tooth development gene. Other associations were observed in genes lacking known or plausible roles in dental caries. In conclusion, this was the largest GWAS of dental caries, to date, and was the first to target Hispanic/Latino populations. Understanding the factors influencing dental caries susceptibility may lead to improvements in prediction, prevention, and disease management, which may ultimately reduce the disparities in oral health across racial, ethnic, and socioeconomic strata.
... Ainda com relação à dor, o grupo dos indivíduos com transtornos psiquiátricos foi o que necessitou maior número de tomadas radiográficas, devido à dificuldade de correlação entre a queixa de dor referida e o exame clínico intrabucal. Nas condições psiquiátricas os pacientes podem apresentar distorção da realidade e modulações no limiar de dor 16 . ...
... However, the research on older age groups though available, is beyond the scope of orthodontic therapy. [39][40][41][42] Studies have suggested that pre-surgical psychological assessment should not be used to predict the changes in mental state during postoperative orthodontic treatment as children transform rapidly in forms of health. 43,44 Hence, for the same reason, compliance with orthodontic treatment cannot be predicted by evaluating pretreatment personality traits of the patient. ...
Many diagnosable psychiatric disorders are noticed right from childhood years. However psychiatric disturbances are more common in adolescent patients as it is a period of physical and mental transformations. This makes the role of orthodontists all the more important as this is the age when majority of patients seek orthodontic treatment. Also, treatment duration of 12-24 months and frequent appointments puts the orthodontist in a better position than clinicians of other disciplines in noticing such disorders in patients and making appropriate referrals. It is a well known fact that many of the psychiatric disorders that develop during adolescence show high suicidal tendency. This article reviews the etiology, diagnosis and management of various psychiatric disorders that an orthodontist is likely to encounter in his clinical practice. Introduction: The psychological aspect of management is often ignored by orthodontists in their clinical practice. Considering the enormous physical and psychosocial changes that adolescents undergo, and the number of patients that belong to this age group seeking orthodontic treatment, the relevance of this aspect should be well understood by an orthodontist.
... However, 38.4% was diagnosed with hypersalivation. Friedlander et al. (15) reported a detailed study of the effects of psychotropic medications on the buccal mucosa. It relates the antipsychotic agents with the occurrence of dysgeusia, xerostomy, and stomatitis; benzodiazepines with xerostomy and sialorrhea; mood stabilizers and lithium with xerostomy, and dysgeusia, and carbamazepine with xerostomy and glossitis. ...
Oral diseases in psychiatric patients are usually a result of bad oral hygiene and psychopharmaceutical side-effects.
The aim of this study was to detect the most prevalent oral lesions in patients hospitalized in a psychiatric institution in Caracas, Venezuela with the confirmed diagnosis of psychiatric illness.
A transversal study consisted of 65 hospitalized patients with psychiatric disorders out of whom 50 were males and 15 females. Patients were aged from 19 to 80 years, mean age 50.2 years. Data on oral lesions were obtained within history and clinical examination of the oral cavity. Other medical data were collected from medical documentation. Statistical analysis was performed by SPSS version 17.0.
56.92% of patients had caries in at least one tooth, 29.23% presented gingivitis and 56.92% periodontal disease. In relation to Temporomandibular joint, 36.92% presented articular sounds and 10.76% muscular pain. Between the most prevalent parafunctional habits were found cigarette habit, bruxism, onychophagia and cheek bite.
Results imply that psychiatric patients are more frequently involved with oral lesions than healthy persons. It is necessary to organize specific preventive and educational oral health programmes with these patients, in a multidisciplinary group. Key words:Phychiatric patients, schizophrenia, medication, periodontal diseases.
... Psychiatric disorders affect behavior and lead to the occurrence and interplay of factors such as depression [6][7][8] , and loss of abilities and skills due to years of institutionalization 9,10 . Infrequent visits to the dentist, drugs that reduce the flow of saliva 11,12 and poor oral hygiene habits are considered determining factors for oral diseases in this population 13,14 . Facial attractiveness has been found to affect social attitudes and actions, and is important in employment situations 15 . ...
This cross-sectional descriptive study was performed at neuropsychiatric institutions in Buenos Aires Province. A randomized sample was selected of 384 20- to 65-year-old adults: 56 with mental disorders and undergoing a process of deinstitutionalization (DG), 220 institutionalized (IG) and 108 ambulatory adults with no diagnosis of mental disorder considered as the control group (CG). Inclusion criterion was receiving oral healthcare at the same dentistry facility. To estimate the endogenous variable (oral health) we used DMFT Löe y Silness plaque index and gingival index (PI - GI). Diagnosed mental conditions were classified according to DSM IV criteria. Mean DMFT was 18.75 +/- 6.19 for DG and 19.67 +/- 8.24 for IG. The difference between groups DG and IG was not significant (P = 0.7818). For CG the value was 14.54 +/- 5.96. The correlation analysis between DMFT and age showed significant association and the values were: DG r = 0.4423, IG r = 0.5056 and CG r = 0.3372. Missing teeth account for 80% in DG 81.12% in IG and 48.76% in CG. Mean PI-GI values were 1.66 +/- 0.72, 1.12 +/- 0.52 in GD; 2.13 +/- 0.55, 1.76 +/- 0.47 in IG and 1.51 +/- 0.52, 1.02 +/- 0.38 in CG. The discrepancy between IP means for DG and IG were not significant (P > 0.05), whereas the GI values for both groups differed significantly at 5% (P < 0.05). Data analysis describes the loss of teeth as a residual consequence of oral disease, and the need to include rehabilitation in a healthcare model for the deinstitutionalization process in psychiatric adults.
... 1,3 Oral healthcare providers (i.e., dentists and dental hygienists) are likely to encounter a number of sensitive oral/systemic health issues 4 while interacting with patients. Sensitive oral/systemic health issues may include: disordered eating behaviors [5][6][7][8][9][10][11][12][13][14][15] , tobacco use [16][17][18] , alcohol abuse [19][20][21] , methamphetamine use 22 , child/partner/elder abuse [23][24][25][26][27][28][29][30] , depression 31 , and other mental illness [32][33][34] . Successful treatment and/or management of the oral complications associated with these issues often depend upon the underlying causal factors being identified and addressed with the patient. ...
Oral healthcare providers are likely to encounter a number of sensitive oral/systemic health issues whilst interacting with patients. The purpose of the current study was to develop and evaluate a framework aimed at oral healthcare providers to engage in active secondary prevention of eating disorders (i.e. early detection of oral manifestations of disordered eating behaviours, patient approach and communication, patient-specific oral treatment, and referral to care) for patients presenting with signs of disordered eating behaviours. The EAT Framework was developed based on the Brief Motivational Interviewing (B-MI) conceptual framework and comprises three continuous steps: Evaluating, Assessing, and Treating. Using a group-randomized control design, 11 dental hygiene (DH) and seven dental (D) classes from eight institutions were randomized to either the intervention or control conditions. Both groups completed pre- and post-intervention assessments. Hierarchical linear models were conducted to measure the effects of the intervention whilst controlling for baseline levels. Statistically significant improvements from pre- to post-intervention were observed in the Intervention group compared with the Control group on knowledge of eating disorders and oral findings, skills-based knowledge, and self-efficacy (all P < 0.01). Effect sizes ranged from 0.57 to 0.95. No statistically significant differences in outcomes were observed by type of student. Although the EAT Framework was developed as part of a larger study on secondary prevention of eating disorders, the procedures and skills presented can be applied to other sensitive oral/systemic health issues. Because the EAT Framework was developed by translating B-MI principles and procedures, the framework can be easily adopted as a non-confrontational method for patient communication.
... Numerous kinds of medications such as anticholinergics, antidepressants, antipsychotics, diuretics, benzodiazepines, antihypertensive agents, muscle relaxants, analgesics, and antihistamines have been reported to induce xerostomia, although some (antipsychotics, benzodiazepines, and antihypertensive drugs) may also induce siallorhea (28). Antiepileptic drugs also induce sig-niÞcant changes in saliva; however, in this case the level of ßow rate and pH usually remains normal. ...
Saliva is a bodily fluid secreted by three pairs of major salivary glands (parotid submandibular and sublingual) and by many of minor salivary glands. Saliva is supplemented with several constituents that originate from blood serum, from intact or destroyed mucosal and immune cells, and from intact or destroyed oral microorganisms that result in a complex mixture of a variety of molecules. Saliva plays an important role in acquired pellicle formation on tooth surfaces, crystal growth homeostasis, bacterial adhesion, plaque formation, and—because of its lubricating effect—in maintaining mucosal integrity of the oral and upper gastrointestinal mucosal surfaces. It also plays an important role in physico-chemical defense, antimicrobial defense, and wound healing. Many saliva constituents including proteins, carbohydrates, lipids, and ions interact under fine regulation to fulfill these important tasks. Local and systemic disorders may disturb and interrupt these complex balanced functions, which can lead to mucosal and tooth damages. In other cases, systemic disorders induce salivary changes without any significant local effects. Many such changes are of high diagnostic interest because they can be rather specific to the causing conditions and can be used for screening and early diagnosis of several local and systemic disorders.
Masticatory function such as chewing is expected to modify human cognitive function, and/or the possibility of improving cognitive function is also predicted. This systematic review investigated whether masticatory function affects cognitive function for older/young adults. Full articles written in English from January 2000 to April 2022 were collected using PubMed and Cochrane Library. Target outcomes were cognitive function test scores, cognitive processing speed (reaction time), and masticatory function. For each research question, two independent reviewers conducted the search and screening, data extraction, quality assessment, and risk of bias assessment. The reviewers resolved any disagreements by discussion. From 226 articles retrieved, 20 were included in this review. Older adults with lower scores on the cognitive function test had lower masticatory performance, lower chewing ability, chewing difficulty, and decreased number of teeth. An increased risk of cognitive impairment was found in older adults with masticatory dysfunction. For young adults, gum chewing significantly reduced the processing speed of cognitive tasks compared to no gum chewing. Although most of the evidence included had a low level of evidence and a high risk of bias because of the research designs, the results still suggest that mastication may be a factor in improving cognitive function.
Background
An increasing number of observational studies have suggested an association between dental caries and Alzheimer’s disease (AD). The association between dental caries and Alzheimer’s disease may be mediated by confounders or reverse causality. In this study, we conducted bidirectional two-sample Mendelian randomization (MR) to estimate the bidirectional causality between dental caries and AD.
Materials and Methods
Genome-wide association study (GWAS) summary statistics of dental caries were extracted from a published meta-analysis which included a total of 487,823 participants. GWAS datasets of AD and AD onset age were obtained from the FinnGen bank. A bidirectional two-sample analysis was performed to explore the causality between dental caries and AD.
Results
For the dental caries-AD causality estimation, there was no significant association between dental caries and AD, neither with the AD GWASs from the FinnGen database (OR: 1.041, p = 0.874) nor with those from the International Genomics of Alzheimer’s Project (OR: 1.162, p = 0.409). In addition, the genetic susceptibility to dental caries was not related to the onset age of AD. No causality existed between dental caries and early-onset AD (OR: 0.515, p = 0.302) or late-onset AD (OR: 1.329, p = 0.347). For the AD-dental caries relationship, no causality was detected by the IVW method (OR: 1.000, p = 0.717). Findings from other MR methods were consistent. The pleiotropy test and sensitivity analysis confirmed the validity of these MR results.
Conclusions
In this bidirectional MR study, robust evidence to support a bidirectional causal effect between dental caries and AD from the GWAS results within large-scale European-descent populations was absent. Having dental caries would not alter the onset age of AD.
Although a growing number of studies have investigated the relationship between psychosocial factors and periodontitis, studies investigating the association between bipolar disorder (BD) and periodontitis are lacking. Using the Taiwan National Health Insurance Research Database, 4251 adolescents with BD and 17,004 age- and sex-matched controls were included. They were followed up from enrollment to the end of 2011 or death. Periodontitis was diagnosed during the follow-up. Cox regression analysis indicated that adolescents with BD had a higher risk of periodontitis (hazard ratio [HR]: 2.96, 95% confidence interval [CI] 2.77–3.17) than did controls. Subanalyses stratified by sex revealed a higher risk of periodontitis in male (HR: 2.83, 95% CI 2.56–3.14) and female (HR: 3.01, 95% CI 2.74–3.30) adolescents with BD than their respective controls. The long-term use of mood stabilizers was associated with a higher risk of periodontitis (HR: 1.19, 95% CI 1.06–1.35) in the BD cohort. Our study highlighted an increased risk of periodontitis in adolescents with BD compared with controls during the follow-up. We recommend that more attention should be paid to the prevention of periodontitis in adolescents with BD, especially those who are female or receiving mood stabilizers.
Alzheimer’s disease (AD) is the leading cause of cognitive impairment in the elderly. Recent evidence suggests that preventive interventional trials could significantly reduce the risk for development of dementia. Periodontitis is the most common dental disease characterized by chronic inflammation and loss of alveolar bone and perialveolar attachment of teeth. Growing number of studies propose a potential link between periodontitis and neurodegeneration. In the first part of the paper, we overview case-control studies analyzing the prevalence of periodontitis among AD patients and healthy controls. Second, we survey observational libraries and cross-sectional studies investigating the risk of cognitive decline in patients with periodontitis. Next, we describe the current view on the mechanism of periodontitis linked neural damage, highlighting bacterial invasion of neural tissue from dental plaques, and periodontitis induced systemic inflammation resulting in a neuroinflammatory process. Later, we summarize reports connecting the four most common periodontal pathogens to AD pathology. Finally, we provide a practical guide for further prevalence and interventional studies on the management of cognitively high-risk patients with and without periodontitis. In this section, we highlight strategies for risk control, patient information, dental evaluation, reporting protocol and dental procedures in the clinical management of patients with a risk for periodontitis and with diagnosed periodontitis. In conclusion, our review summarizes the current view on the association between AD and periodontitis and provides a research and intervention strategy for harmonized interventional trials and for further case-control or cross-sectional studies.
This chapter focuses on common neurologic diseases, especially those with greater impact on the orofacial region and/or dental treatment. With optimal medical monitoring and poststroke care, patients can safely undergo invasive dental treatment, with appropriate consideration for stress reduction, medication interactions, adverse effects, neurologic deficit management, and control of underlying cardio/cerebrovascular risk factors. Patients with multiple sclerosis often experience exacerbation of neurologic symptoms in response to an elevation of the body's core temperature. Therapy for MS can be divided into three categories: treatment of acute attacks; disease‐modifying therapies; and symptomatic therapy. The genetic basis of Alzheimer's disease has been studied extensively, and specific genetic mutations have been implicated in both the familial and sporadic forms of the disease. Genetic implies the existence of known or presumed genetic mutation(s) where seizures are a known complication of the genetic disorder that is the result of the mutation(s).
Objective:
To describe the socioeconomic, behavioral, clinical, and health-related characteristics of Brazilian older adults with Alzheimer's disease (AD).
Methods:
Baseline data from the Brazilian Longitudinal Study of Aging were analyzed. This nationwide survey interviewed 9,412 adults aged at least 50 years. Self-reported medical diagnosis of AD and exposure variables (sociodemographic, clinical, behavioral, and health-related) were assessed by face-to-face questionnaire-based interview. Multivariate analyses accounted for possible confounding factors, and values were reported in prevalence ratio (PR) and 95% confidence interval (95%CI).
Results:
Participants with AD have important demographic differences compared with older non-AD participants such as low education level and retirement. Clinically, these patients reported more medical appointments, falls, and higher frequency and duration of hospitalizations compared with non-AD participants. These characteristics may be related to worse physical and mental health observed in this population. Indeed, two out of five older adults with AD in Brazil reported always feeling lonely, while two out of three said they felt depressed or sad much of the time. Adjusted analyses showed that patients with AD were 95% (95%CI 1.08 – 3.50) more likely to be hospitalized in a year compared with non-AD older adults. People with AD in Brazil were more likely to be diagnosed with diabetes (PR = 1.83 [95%CI 1.08 – 3.12]), depression (PR = 3.07% [95%CI 1.63 – 5.79]), Parkinson's disease (PR = 17.63 [95%CI 6.99 – 44.51]), and stroke (PR = 3.55 [95%CI 1.90 – 6.67]) compared with non-AD participants.
Conclusion:
Older adults with AD in Brazil reported impaired physical and mental health compared with the non-AD population.
Objectives
To investigate the effects of a caregiver training program on the oral hygiene of caregivers and patients with Alzheimer's disease (AD) and to identify program components and parameters for accurate assessment of outcomes.
Design
Single-blinded prospective cohort study.
Setting and participants
Patients with AD and caregivers in nursing homes in the Greater Zhengzhou Area, China.
Methods
Initially 168 AD patient/caregiver pairs were recruited and randomly assigned to control, limited training, and comprehensive training groups. The mini-mental state examination, global deterioration scale, and Katz activities of daily living scale were conducted for patients with AD. Information on participants’ oral hygiene habits and general oral health was collected. The modified Quigley-Hein Plaque Index (PI) and Gingival Index (GI) were used to assess oral hygiene and gingival health. Intervention included (1) an educational video showing the role of dental plaque and the modified Bass technique; and (2) caregivers practicing toothbrushing on themselves and patients with AD under professional guidance. Changes in oral hygiene and correlations between patient PI/GI and caregiver PI/GI were analyzed.
Results
After 6 weeks, complete data for 146 AD patient/caregiver pairs were collected. Before enrollment, most patients with AD had very poor oral hygiene. Compared with controls and limited training, only comprehensive training was able to achieve steady reduction in PI and GI scores in patients with AD, which still fell short of desirable levels (PI: 2.46 ± 0.52, GI: 1.24 ± 0.24, week 6). PI and GI scores in caregivers saw steady improvement only through comprehensive training (PI: 1.41 ± 0.38, GI: 0.88 ± 0.19, week 6). Number of training sessions had the greatest influence on both patient PI and GI scores.
Conclusions and implications
Comprehensive caregiver training on toothbrushing skills is effective in improving the oral hygiene of caregivers and patients with AD in nursing homes. Additional evidence is needed to establish the optimal program structure.
People with a diagnosis of mental disorder have a life expectancy 20 to 30 years lower than the rest of the population, linked to significant morbidity, mainly cardiovascular. Through a clinical case analysis, we defined as the objective of this work to report on the articulation of the mechanisms underlying this poor physical health.
We reviewed the scientific literature, which shows that the lifestyle, but especially
psychotropic treatments and inequalities of access and treatment in the health care system seem to lead to an increase in risk factors. Solving this situation would require integrating health in its entirety and influencing the habits of users and professionals to promote positive health behaviours. Subsequently, we conducted a lexical analysis of the literature review in order to report on how scientific research addresses the articulation of the factors involved.
On the basis of this analysis, we present the mixed research protocol COPsyCAT co-
constructed with all stakeholders, users, carers, primary health and psychiatric professionals. This research is coordinated with the World Health Organization's Collaborating Centre, based on the European Mental Health Plan 2013-2020.
Finally, we illustrate how the elements identified in the literature review and the notions of
empowerment and participation, mobilized in the construction of the research protocol, can also inform daily clinical practice and contribute to the definition of the medical profession.
For the dentist whose practice focuses primarily on esthetic procedures, there are very particular considerations in the area of patient management. This is due to the fact that higher concentrations of certain patient types are more likely to seek esthetic dentistry. These include individuals going through normative life transitions when their physical appearance has greater than usual salience, such as early and middle adulthood, as well as patients with certain pathologies of mood, behavior, and personality, such as depression, eating disorders, and narcissistic personality disorder (NPD). Adjustment disorders are diagnosed when individuals lack adequate coping skills to handle specific life events, such as relationship breakups, poor grades, job loss, illness, and aging. A number of other psychiatric disorders commonly co‐occur with body dysmorphic disorder (BDD), including depression, obsessive‐compulsive disorder (OCD), social phobia, and eating disorders. The opportunity to enhance the self‐esteem and psychological well‐being of the patients can be satisfying for the esthetic dental team.
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Aging is a natural consequence of life and involves anatomical, biochemical, and physiological alterations in every system. This chapter addresses geriatric health and functional issues that are of particular importance to dentistry. It describes salient features of age-related vision changes, age-related hearing loss, mobility limitations, and cognitive impairment/dementias. Under each section, first a detailed background is given on the disease/disorder before focusing on medical and dental management. Under medical management, a set of key questions that have to be asked to the physician and another set that have to be asked to the patient, are also listed. Under dental management, risks of dental care, susceptibility to infection, drug actions/interactions, and the patient's ability to tolerate dental care, are described.
Neurodevelopmental and psychiatric disorders of particular importance to dentistry are discussed in this chapter. The neurodevelopmental disorders covered here include: intellectual disability (ID), Down syndrome (DS), Cerebral palsy (CP), autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD). The chapter explains the medical management and dental management of these disorders. The risks of dental care are also covered here. The psychiatric disorders discussed in the chapter include: generalized anxiety disorder (GAD), generalized anxiety disorder (GAD), Posttraumatic stress disorder (PTSD), Bipolar disorder (BPD), Major depressive disorder (MDD), Schizophrenia and Eating disorder (ED). Diagnosis of Major Depressive Disorder (MDD) is based on patient interview and a mental status evaluation. Cognitive behavior therapy (CBT) is often an effective treatment for OCD. Medications used to treat psychiatric disorders often have oral side effects, such as xerostomia, dysgeusia, stomatitis, glossitis, and even sialorrhea. Atypical antipsychotics can also cause orthostatic hypotension.
Purpose:
To compare perceptions on oral health-related quality of life (OHRQoL) between Alzheimer disease (AD) patients and their caregivers by using the Geriatric Oral Health Assessment Index (GOHAI). Correlation between GOHAI and prostheses quality was also performed.
Methods:
GOHAI was applied to 16 AD elders and their caregivers. GOHAI index was compared to objective measures of AD patients' prostheses quality, rated by a researcher. Data were submitted to Wilcoxon signed rank and McNemar tests (α = 5%). Kappa correlations verified the concordance for GOHAI scores between AD patients and caregivers. Spearman's correlation was used to explore concordance between GOHAI scores and prostheses quality indices.
Results:
Total GOHAI scores from AD patients and caregivers were similar (P = 0.262). Overall Kappa was good (0.62). There were no correlations between GOHAI scores and prostheses quality.
Conclusion:
AD patients assess and self-report their OHRQoL similarly to their main caregiver.
To test (a) the effects of an educational intervention about oral hygiene on the knowledge of mental health nurses, and (b) the effects of an oral care intervention on oral health in patients with severe mental illness (SMI).
We applied a pretest/posttest design to test improvements in nurses' knowledge and the oral health of SMI patients.
The nursing staff's knowledge increased significantly after the educational intervention. The oral health of the patients improved significantly after the oral health intervention.
Oral health of SMI patients can improve significantly with basic oral health interventions carried out by collaborating oral hygienists and mental health nurses.
© 2015 Wiley Periodicals, Inc.
Objective
To describe the orofacial pain, dental characteristics and associated factors in patients with Alzheimer's Disease that underwent dental treatment.
Method
29 patients with mild AD diagnosed by a neurologist were included. They fulfilled the Mini Mental State Exam and Pfeffer's questionnaire. A dentist performed a complete evaluation: clinical questionnaire; research diagnostic criteria for temporomandibular disorders; McGill pain questionnaire; oral health impact profile; decayed, missing and filled teeth index; and complete periodontal investigation. The protocol was applied before and after the dental treatment. Periodontal treatments (scaling), extractions and topic nystatin were the most frequent.
Results
There was a reduction in pain frequency (p=0.014), mandibular functional limitations (p=0.011) and periodontal indexes (p<0.05), and an improvement in quality of life (p=0.009) and functional impairment due to cognitive compromise (p<0.001) after the dental treatment. Orofacial complaints and intensity of pain also diminished.
Conclusion
The dental treatment contributed to reduce co-morbidities associated with AD and should be routinely included in the assessment of these patients.
ABSTRACT In the treatment of patients with dementia Alzheimer's type non-current and are facing tough situations. Treatment should be tailored to each stage of the disease and for each patient. In this type of disease is very important to involve families and caregivers to improve the quality of life of patients. The main goal with these patients is prevention. Patients should be all oral manifestations caused by the lack of inadequate oral hygiene, xerostomia and manifestations derived by taking drugs. The aim of this review is to describe the main oral manifestations that can result from this disease and the best treatment options taking into account the clinical stages in which patients are found. RESUMEN En el tratamiento a pacientes con demencias tipo Alzheimer se afrontan situaciones infrecuentes y comprometidas. El tratamiento debe personalizarse para cada estadio de la enfermedad y para cada paciente. En este tipo de enfermedades es muy importante involucrar a los familiares y cuidadores para mejorar la calidad de vida del enfermo. El principal objetivo con estos pacientes es la prevención. Se deben controlar todas las manifestaciones orales provocadas por la falta de una inadecuada higiene oral, la xerostomía y las manifestaciones derivadas por los fármacos que consumen. El objetivo de esta revisión es describir cuáles son las principales manifestaciones orales que pueden derivar de esta enfermedad y las mejores opciones de tratamiento teniendo en cuenta las etapas clínicas en las que se encuentran los pacientes.
/st> Mental illness (MI) affects approximately one in five U.S. adults, and it is associated with oral disease and poor dental treatment outcomes. Little is known about dental care utilization or unmet dental need in this population.
/st> The authors examined data regarding presence or absence of dental visits and unmet dental need in community-dwelling adults with MI from the 2007 Medical Expenditure Panel Survey. They tested differences between adults with and without MI by using multivariate logistic regression.
/st> Eighteen percent of adults (N = 19,368) had MI, and of these, 6.8 percent had unmet dental need. Although people with MI were not significantly more likely to have had a dental visit (46.3 percent) than were those without MI (42.2 percent; odds ratio [OR], 1.09; 95 percent confidence interval [CI], 0.97-1.23), they were significantly more likely to report unmet need (11.0 versus 5.3 percent; OR, 2.00; 95 percent CI, 1.67-2.41). Those with mood or anxiety disorders were most likely to report having an unmet dental need (P < .001 for all values).
/st> Although people with MI did not visit the dentist significantly more often than did adults without MI, their higher level of unmet need suggests that current use of dental services is not addressing their needs adequately. Practical Implications Dentists should be familiar with MI conditions as patients with MI may have greater unmet dental need.
A shifting pattern from communicable diseases to the chronic noncommunicable diseases and increased life expectancy are being sensed throughout the world. Aged populations with multiple chronic diseases come up with their unique needs and require specific attention to be challenged by the health systems. Neglected orodental facts among the elders and the dearth of specific designated undergraduate and postgraduate courses of geriatric dentistry in Iran inevitably adversely affect the delivery of appropriate dental care service to elders by untrained dentists. In this article, a proposal for academic geriatric dentistry courses in Iran is introduced and highlighted with regards to elders' special needs.
Background:
In this study, benzothiazole-piperazine compounds were synthesized by condensing the functional groups of donepezil (DNP), FK-960, and sabeluzole, which are known to have therapeutic potential against Alzheimer's disease, with the aim of obtaining new and potent anti-Alzheimer agents.
Methods:
Initially, acetylcholinesterase/butyrylcholinesterase enzyme inhibition activities of the synthesized test compounds were investigated by Ellman's method. Effects of the compounds on a streptozotocin (STZ) model of Alzheimer's disease (SMAD) were investigated in rats. SMAD was established by intracerebroventricular (icv) injection of STZ (3 mg/kg), bilaterally. The elevated plus maze, Morris water maze, and active avoidance tests were used to examine the effects of test compounds (1, 5, and 10 mg/kg) on learning and memory parameters of icv STZ-injected rats. Effects of the test compounds on spontaneous locomotor activities of rats were examined with the activity cage test.
Results:
The compounds B2-B5 and DNP exhibited significant selective inhibitory potencies against acetylcholinesterase. Compounds B2 and B3 at 10 mg/kg doses and compounds B4 and B5 at 5 and 10 mg/kg doses, as well as the reference drug DNP (1 and 3 mg/kg), significantly improved the learning and memory parameters of animals in all cognition tests. None of the test compounds changed spontaneous locomotor activities.
Conclusion:
Results of the present study revealed that compounds B2-B5 repaired the parameters related to the learning and memory deficits of icv STZ-injected rats. Potencies of these test compounds were comparable to the activity of DNP.
The objective of this study was to describe the oral health of elderly people diagnosed with Alzheimer's disease (AD).
Thirty elderly subjects with AD (mild, moderate, and severe) and 30 without AD (controls) were included in the study. Volunteer-reported oral health data were collected using the General Oral Health Assessment Index (GOHAI). Demographic and oral characteristics were assessed, including the number of natural teeth; number of decayed, missing, and filled teeth (DMTF); oral health index (OHI); removable prosthesis conditions; and oral pathologies.
GOHAI values were similar for both groups. Compared with the controls, the subjects with AD had a higher age, DMTF, OHI, and number of oral pathologies and a lower educational level and number of natural teeth.
Elderly subjects with AD had poorer oral health than those without the disease. Despite the positive self-perception of their oral health, the oral health of subjects with AD tended to decline as their disease progressed.
Aim:
The aim of this study was to investigate the prevalence of self-reported oral complaints in older hospitalized mentally ill patients and relate them to the primary psychiatric diagnosis.
Methods:
A total of 89 older hospitalized psychiatric patients consented to participate in the study, and were interviewed and clinically examined. The medical data were obtained from the hospital's medical records.
Results:
The mean age of the patients was 73 years (range 59-94 years). A total of 54% suffered from psychotic disorders, 26% from dementia and 20% from mood disorders. The most common oral complaint was xerostomia (45%), followed by dysgeusia (28%), oral malodor (26%), pain when chewing (25%), burning mouth (23%), chewing difficulties (12%) and sialorrhoea (2%). The prevalence of burning mouth, dysgeusia and oral malodor differed significantly among psychiatric diagnoses and was increased in patients with mood disorders. A close association was recorded between burning mouth, dysgeusia, xerostomia and oral malodor complaints. Stepwise logistic regression showed that the use of antidepressants and burning mouth complaints were significantly associated with mood disorders.
Conclusions:
An increased prevalence of oral complaints was recorded in the elderly psychiatric patients with mood disorders. Those patients should be systematically evaluated and managed for oral complaints, and particularly for burning mouth. The close association between burning mouth complaints and mood disorders requires further investigation to clarify the potential diagnostic value of the symptom for mood disorders.
To compile and evaluate all available data suggesting an association between selective serotonin-reuptake inhibitor (SSRI) administration and the occurrence of movement disorders, and to characterize these reactions in terms of onset, duration, treatment and outcome, and potential predisposing factors.
Reports of movement disorders were identified by conducting a comprehensive literature search that included tertiary adverse drug reaction resources, MEDLINE, EmBASE, Biological Abstracts, Current Contents, Reactions, ClinAlert, and International Pharmaceutical Abstracts. In addition, reports were solicited from the Canadian proprietary manufacturers of SSRIs, and from the Therapeutic Products Program of Health Canada. Each case was then classified according to the description of the movement disorder, based on predefined diagnostic criteria.
A total of 127 published reports of SSRI-induced movement disorders were identified involving akathisia (n = 30), dystonia (19), dyskinesia (12), tardive dyskinesia (6), parkinsonism (25), and 15 cases of mixed disorders. Ten isolated cases of bruxism were identified. Ten additional reports could not be classified. Manufacturers of SSRIs provided 49 reports of akathisia, 44 of dystonia, 208 of dyskinesia, 76 of tardive dyskinesia, 516 of parkinsonism, and 60 of bruxism. Treatment strategies included discontinuation of the SSRI; dosage reduction; or the addition of a benzodiazepine, beta-blocker, or anticholinergic agent.
SSRI use appears to be associated with the development of movement disorders, as either a direct result of the drug or exacerbation of an underlying condition. Predisposing factors may include the use of neuroleptics, existing neurologic diagnoses, or preexisting movement disorders. Clinicians should be cognizant of the potential for these reactions, as prompt recognition and management is essential in preventing potentially significant patient morbidity.
The Stanley Foundation Bipolar Network (SFBN) evaluates treatments, course and clinical and neurobiological markers of response in bipolar illness.
To give a preliminary summary of emerging findings in these areas.
Studies with established and potentially antimanic, antidepressant and mood-stabilising agents range from open case series to double-blind randomised clinical trials, and use the same core assessment methodology, thereby optimising the comparability of the outcomes. The National Institute of Mental Health Life Chart Method is the core instrument for retrospective and prospective longitudinal illness description.
The first groups of patients enrolled show a considerable degree of past and present symptomatology, psychiatric comorbidity and functional impairment. There are associations of both genetic and early environmental factors with more severe courses of illness. Open case series with add-on olanzapine, lamotrigine, gabapentin or topiramate show a differential spectrum of effectiveness in refractory patients.
The SFBN provides important new data for the understanding and treatment of bipolar disorder.
There is increasing support for the use of cognitive behaviour therapy as an adjunct to medication for patients with bipolar disorder.
To explore current psychological models of bipolar disorder, describing the clinical rationale for using cognitive therapy and providing a brief overview of the approach.
Results from outcome studies are discussed.
Preliminary findings indicate that cognitive therapy may be beneficial for patients with bipolar disorder. The collaborative, educational style of cognitive therapy, the use of a stepwise approach and of guided discovery is particularly suitable for patients who wish to take an equal and active role in their therapy.
Randomised, controlled trials of cognitive therapy in bipolar disorder are required to establish the short-term and long-term benefits of therapy, and whether any reported health gain exceeds that of treatment as usual.
Background. High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized. Methods: Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted. Results: Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations. Conclusions: Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.
Bipolar disorder (manic-depressive illness) is a common, recurrent, and severe psychiatric illness.20 Classified as a mood disorder, this illness also affects cognition and behavior and frequently is complicated by psychotic symptoms (e.g., delusions, hallucinations, disorganized thinking).47 Untreated, bipolar disorder is associated with substantial risks of morbidity and mortality. Bipolar disorder was the sixth leading cause of disability worldwide in 1990.49 Morbidity resulting from the illness is not limited to acute episodes of mania or depression. Full recovery of functioning often lags behind remission of symptoms.35 and 66 Recurrent episodes may cause progressive deterioration in functioning between episodes, and the number of episodes may have a negative impact on subsequent prognosis. Bipolar disorder can be a lethal illness. At least 25% of patients attempt suicide, and patients with mixed mania (cooccurring manic and depressive episodes) appear to be at greater risk for contemplating suicide.15, 20 and 69
Bipolar disorder is a highly heritable biologic illness. Concordance rates for bipolar disorder in monozygotic twins are approximately 65% to 70% and approximately 14% for dizygotic twins.22 In family studies, the lifetime prevalence rates of mood disorders (major depressive disorder and bipolar disorder) among first-degree relatives of bipolar probands are increased compared with the prevalence rates for these disorders in first-degree relatives of people without psychiatric illness.22 The mode of inheritance of bipolar disorder is unknown, however. The impact of life stresses, especially early in the course of illness, also remains uncertain.54 In clinical practice, a family history of a mood disorder, particularly bipolar disorder, is important corroborative evidence of the presence of a mood disorder in a patient presenting with psychotic symptoms.25
Background
Long-term outcomes are often poor in patients with bipolar disorder despite treatment; more effective treatments are needed to reduce recurrences and morbidity. This study compared the efficacy of divalproex, lithium, and placebo as prophylactic therapy.Methods
A randomized, double-blind, parallel-group multicenter study of treatment outcomes was conducted over a 52-week maintenance period. Patients who met the recovery criteria within 3 months of the onset of an index manic episode (n=372) were randomized to maintenance treatment with divalproex, lithium, or placebo in a 2:1:1 ratio. Psychotropic medications were discontinued before randomization, except for open-label divalproex or lithium, which were gradually tapered over the first 2 weeks of maintenance treatment. The primary outcome measure was time to recurrence of any mood episode. Secondary measures were time to a manic episode, time to a depressive episode, average change from baseline in Schedule for Affective Disorders and Schizophrenia–Change Version subscale scores for depression and mania, and Global Assessment of Function scores.Results
The divalproex group did not differ significantly from the placebo group in time to any mood episode. Divalproex was superior to placebo in terms of lower rates of discontinuation for either a recurrent mood episode or depressive episode. Divalproex was superior to lithium in longer duration of successful prophylaxis in the study and less deterioration in depressive symptoms and Global Assessment Scale scores.Conclusions
The treatments did not differ significantly on time to recurrence of any mood episode during maintenance therapy. Patients treated with divalproex had better outcomes than those treated with placebo or lithium on several secondary outcome measures.
There is sparse evidence for differences in response to electroconvulsive therapy (ECT) between patients with bipolar or unipolar major depression, with virtually no information on speed of response. We contrasted a large sample of bipolar (BP) and unipolar (UP) depressed patients in likelihood and rapidity of clinical improvement with ECT.
Over three double-blind treatment protocols, 228 patients met Research Diagnostic Criteria for UP (n = 162) or BP depression (n = 66). Other than lorazepam PRN (3 mg/day), patients were withdrawn from psychotropics prior to the ECT course and until after post-ECT assessments. Patients were randomized to ECT conditions that differed in electrode placement and stimulus intensity. Symptomatic change was evaluated at least twice weekly by a blinded evaluation team, which also determined treatment length.
Patients with BP and UP depression did not differ in rates of response or remission following the ECT course, or in response to unilateral or bilateral ECT. Degree of improvement in Hamilton Rating Scale for Depression scores following completion of ECT was also comparable. However, BP patients received significantly fewer ECT treatments than UP patients, and this effect was especially marked among bipolar ECT responders. Both BP I and BP II patients showed especially rapid response to ECT.
The BP/UP distinction had no predictive value in determining ECT outcome. In contrast, there was a large effect for BP patients to show more rapid clinical improvement and require fewer treatments than unipolar patients. The reasons for this difference are unknown, but could reflect a more rapid build up of anticonvulsant effects in BP patients.
There is accumulated evidence that the genes coding for the receptor of gamma aminobutyric acid (GABA), the most important inhibitory neurotransmitter in the CNS, may be involved in the pathogenesis of affective disorders. In a previous study, we have found a genetic association between the GABA-A receptor α5 subunit gene locus (GABRA5) on chromosome 15q11–of 13 and bipolar affective disorder. The aim of the present study was to examine the same subjects to see if there exists a genetic association between bipolar affective disorder and the GABA receptor β3 subunit gene (GABRB3), which is located within 100 kb from GABRA5. The sample consisted of 48 bipolar patients compared to 44 controls (blood donors). All subjects were Greek, unrelated, and personally interviewed. Diagnosis was based on DSM-IV and ICD-10 criteria. The marker used was a dinucleotide (CA) repeat polymorphism with 12 alleles 179 to 201 bp long; genotyping was successful in all patients and 43 controls. The distribution of GABRB3 genotypes among the controls did not deviate significantly from the Hardy-Weinberg equilibrium. No differences in allelic frequencies between bipolar patients and controls were found for GABRB3, while this locus and GABRA5 did not seem to be in significant linkage disequilibrium. In conclusion, the GABRB3 CA-repeat polymorphism we investigated does not present the observed association between bipolar affective illness and GABRA5. This could be due to higher mutation rate in the GABRB3 CA-repeat polymorphism, but it might also signify that GABRA5 is the gene actually associated with the disease. © 2001 Wiley-Liss, Inc.
Etiologic factors for incident periodontal attachment loss (ALOSS) have not been conclusively identified. The purpose of this study was to develop etiologic models for ALOSS in older adults. Data on 697 older blacks and whites were obtained from 5 sequential examinations over 7 years in the Piedmont 65+ dental study, a complex random sample of older adults in North Carolina. Multivariable Poisson regression models were fit for average number of ALOSS events per person or site month at risk. In models for whites, molar sites, sites with adjacent caries, sites in persons who had: Porphyromonas gingivalis (P.g.) at least 2% of total microbial count (TMC), never had a dental checkup, more depression symptoms, fewer than 12 years of education, higher BANA score, or smoked, had significantly higher rates of ALOSS. In a separate model for blacks, interproximal and molar sites, sites in blacks who had: P.g. at least 2% of TMC, higher BANA score, never had a dental checkup, lower socioeconomic status (SES), or smoked, had significantly higher rates of ALOSS. These results confirm a multifactorial etiology for ALOSS in older adults and indicate that interventions aimed at infection, smoking, and preventive dental care utilization, may be most useful.
The authors reviewed neuroimaging studies of bipolar disorder in order to evaluate how this literature contributes to the current understanding of the neurophysiology of the illness.
Papers were reviewed as identified, using the NIMH PubMed literature search systems that reported results of neuroimaging studies involving a minimum of five bipolar disorder patients compared with healthy comparison subjects.
Structural neuroimaging studies report mixed results for lateral and third ventriculomegaly. Recent studies suggest subcortical structural abnormalities in the striatum and amygdala, as well as the prefrontal cortex. Proton spectroscopic studies suggest that abnormalities in choline metabolism exist in bipolar disorder, particularly in the basal ganglia. Additionally, phosphorous MRS suggests that there may be abnormalities in frontal phospholipid metabolism in bipolar disorder. Functional studies have identified affective state-related changes in cerebral glucose metabolism and blood flow, particularly in the prefrontal cortex during depression, but no clear abnormalities specific to bipolar disorder have been consistently observed.
The current literature examining the neurophysiology of bipolar disorder using neuroimaging is limited. Nonetheless, abnormalities in specific frontal-subcortical brain circuits seem likely. Additional targeted studies are needed to capitalize on this burgeoning technology to advance our understanding of the neurophysiology of bipolar disorder.
Examined sucrose taste perception and odor identification in 2 experiments, using a total of 87 adult depressed (MDD) patients and 70 adult controls. Ss rated the perceived intensity and pleasantness of 7 concentrations of sucrose dissolved in deionized water or completed a forced-choice odor recognition test. Results show alterations of suprathreshold measures of sucrose taste intensity and pleasantness in some MDD Ss compared with controls. No significant differences were found between MDD Ss and controls in odor recognition. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Recent advances in molecular pharmacology have allowed the characterization of the specific isoforms that mediate the metabolism of various medications. This information can be integrated with older clinical observations to begin to develop specific mechanistic and predictive models of psychotropic drug interactions. The polymorphic cytochrome P450 2D6 has gained much attention, because competition for this isoform is responsible for serotonin reuptake inhibitor-induced increases in tricyclic antidepressant concentrations in plasma. However, the cytochrome P450 3A subfamily and the 3A3 and 3A4 isoforms (CYP3A3/4) in particular are becoming increasingly important in psychopharmacology as a result of their central involvement in the metabolism of a wide range of steroids and medications, including antidepressants, benzodiazepines, calcium channel blockers, and carbamazepine. The inhibition of CYP3A3/4 by medications such as certain newer antidepressants, calcium channel blockers, and antibiotics can increase the concentrations of CYP3A3/4 substrates, yielding toxicity. The induction of CYP3A3/4 by medications such as carbamazepine can decrease the concentrations of CYP3A3/4 substrates, yielding inefficiency. Thus, knowledge of the substrates, inhibitors, and inducers of CYP3A3/ and other cytochrome P450 isoforms may help clinicians to anticipate and avoid pharmacokinetic drug interactions and improve rational prescribing practices.
Although the chronic use of neuroleptic medications is generally discouraged in patients with bipolar disorder, data on the actual extent of this practice are relatively scarce.
All bipolar patients receiving treatment at the Connecticut Mental Health Center on September 1, 1994, were identified through a computerized administrative database; the medical record was then examined. Patients were included in the study if (1) the last two recorded diagnoses in the chart were concordant for bipolar disorder and (2) the patient had not been hospitalized in the past year.
Of 49 patients meeting review criteria, 33 (67%) met criteria for chronic neuroleptic exposure. The mean +/- SD continuous neuroleptic dosage for these 33 outpatients was 416 +/- 527 mg/day chlorpromazine (CPZ) equivalents. The dosage distribution was skewed, with 17 (52%) receiving < or = 200 mg/day CPZ [corrected] equivalents.
Chronic neuroleptic administration occurred frequently in our sample of nonhospitalized bipolar outpatients.
Remembering the myriad of psychotropic drug interactions is extremely difficult. Nevertheless, by applying a systematic approach, the clinician can often predict the occurrence and time course of such interactions. Several factors must be considered when assessing the potential consequences. Drug-related factors that increase the risk for clinically significant interactions include a low therapeutic index or narrow therapeutic window, a multiplicity of pharmacological actions, and inhibition or inducement of cytochrome P450 enzymes. Next, patient-related factors that can increase the risk for significant drug interactions should be considered. These include genetically based variations in drug-metabolizing capacity, as well as advanced age, underlying medical illness, and comorbid substance abuse. Finally, the literature should be carefully reviewed to as-certain the potential clinical relevance of available data. If a clinically significant drug interaction appears likely to occur, the patient's clinical status should be followed closely; therapeutic drug monitoring should be used if applicable and dosage adjustments made accordingly. Rational polypharmacy requires an understanding of the pharmacological principles governing drug interactions and a knowledge of the factors that increase the likelihood of clinically significant variations in drug action. This will allow the clinician to maximize beneficial effects while minimizing the risk of adverse events.
Bupropion has been previously shown to be particularly beneficial in bipolar and atypical depression. Previous research has supported a possible association of response to plasma levels and to changes in plasma homovanillic acid (HVA). These findings were here extended to bupropion slow-release (SR), a formulation with slower release kinetics.
Forty-one patients with major depressive disorder (DSM-III-R) completed 8 weeks of a fixed dose of 300 mg/day in two doses/day. Clinical outcome measures were the Hamilton Depression Rating Scale (HDRS) and Beck Depression Inventory (BDI). Biological parameters included plasma HVA and 3-methoxy-4-hydroxyphenyl-glycol (MHPG), as well as a final measurement of plasma bupropion and its metabolites.
Response to bupropion SR differed among the three groups: results for change in HDRS and in BDI were greater in the bipolar and atypical than in the "typical" depressed patients. Mean change in HDRS was, respectively, of 15.6, 17.1, and 7.6 (F = 5.57, p < .01); mean change in the BDI, 21.1, 16.9, and 7.3 (F = 3.32, p < .05). Threobupropion levels correlated with HDRS scores (r = .47, p = .02, n = 23); plasma HVA and MHPG increased significantly (t = 2.31, p = .03; t = 2.15, p = .04, n = 17). Bipolar depressed patients' improvement in HDRS was related to increases in MHPG (r = .87, p = .01) and in HVA (r = .70, p = .08).
This fixed-dose study indicates that there may be specific benefits for bupropion SR in atypical and bipolar depression, and that these benefits may be related also to plasma levels and biochemical changes in catecholamines. Due to the small sample size, replication is of key importance.
The selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) are extensively used in the treatment of depression, panic disorder and obsessive-compulsive disorder, and are now being evaluated in the treatment of a number of other psychiatric disorders. The aim of this study was to investigate the pattern of adverse reactions reported on SSRIs in Sweden and assess possible risk factors associated with the occurrence of adverse reactions to these agents.
A survey was made of 1202 reports describing 1861 adverse reactions to SSRIs submitted to the Swedish Adverse Drug Reactions Advisory Committee.
The most often reported adverse reactions were neurological symptoms (22.4%), psychiatric symptoms (19.5%) and gastrointestinal symptoms (18.0%); however, dermatological symptoms (11.4%) and general symptoms (9.8%) were also frequent. Compared with other drugs, gastrointestinal symptoms were more often reported for fluvoxamine, psychiatric symptoms were more often reported for sertraline and dermatological symptoms were more often reported for fluoxetine. In total, the diagnoses most frequently reported were nausea (n = 139), rash (n = 90), anxiety (n = 84), paraesthesias (n = 69), headache (n = 63) and diarrhoea (n = 63). Parkinsonism, confusion, hallucinations, euphoria, hyponatraemia, bradycardia and hypotension were more often reported in the elderly, whereas urticaria, akathisia, and haematological, endocrinological, sexual and some visual reactions were more often reported in individuals who were younger than average. Dermatological reactions, fatigue, hyponatraemia and cough were more common in women, whereas dyskinesias/akathisia and aggression more often were seen in men. The median SSRI dosages were above average in patients experiencing seizures, hypomania/mania, personality changes, malaise, bodyweight gain, gynaecomastia and hyperprolactinaemia/galactorrhoea. Severe symptoms, such as seizures, hyponatraemia and the serotonin syndrome, were rarely reported.
Although the design of the study makes it difficult to draw conclusions about causality, a variety of adverse reactions were reported. Therefore, the awareness that a particular symptom in a patient treated with an SSRI might be an adverse reaction should be high.
A meta-analysis of 20 short term comparative studies of 5 selective serotonin reuptake inhibitors (SSRIs; citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline) has shown no difference in efficacy between individual compounds but a slower onset of action of fluoxetine. There were suggestions that fluoxetine caused more agitation, weight loss and dermatological reactions than the other SSRIs. More patients discontinued fluvoxamine and fewer patients stopped sertraline because of adverse effects than their comparator SSRIs.
The most common adverse reactions to the SSRIs were gastrointestinal (especially nausea) and neuropsychiatric (particularly headache and tremor). Data from the Committee on Safety of Medicines showed more reports of suspected reactions (including discontinuation reactions) to paroxetine, and of gastrointestinal reactions to fluvoxamine and paroxetine, than the other SSRIs during their first 2 years of marketing.
Prescription-event monitoring revealed a higher incidence of adverse events related to fluvoxamine than its comparators. There were higher incidences of gastrointestinal symptoms, malaise, sedation and tremor during treatment with fluvoxamine and of sedation, tremor, sweating, sexual dysfunction and discontinuation reactions with paroxetine. Fluoxetine was not associated with a higher incidence of suicidal, aggressive and related events than the other SSRIs.
Patients have survived large overdoses of each of the compounds, but concern has been expressed over 6 fatalities following overdoses of citalopram.
Drug interactions mediated by cytochrome P450 enzymes are theoretically less likely to occur during treatment with citalopram and sertraline, but there is a sparsity of clinical data to support this.
Methodological difficulties and price changes do not allow choice for recommendations on the choice of SSRI based on pharmacoeconomic data.
Taking into account the strengths and weaknesses of the methods used to compare drugs, guidelines to the selection of individual SSRIs in clinical practice are proposed. Citalopram should be avoided in patients likely to take overdoses. Fluoxetine may not be the drug of first choice for patients in whom a rapid antidepressant effect is important or for those who are agitated, but it may have advantages over other SSRIs in patients who are poorly compliant with treatment and those who have previously had troublesome discontinuation symptoms. Fluvoxamine, and possibly paroxetine, should not be used as first choice in patients especially prone to SSRI-related adverse reactions, while paroxetine should be avoided if previous discontinuation of treatment was troublesome. When in doubt about the risks of drug interactions, citalopram or sertraline should be considered given the lower theoretical risk of interactions.
Recently, valproate has emerged as a drug of primary choice for the treatment of acute mania, especially mixed mania and, partially, rapid cycling. Because of its relative safety, it can be administered in high doses as an oral loading therapy, with approximately 60% to 70% of patients showing a favorable response. Here we report on seven bipolar I patients, two of which have euphoric mania, three have a mixed manic state (including one patient with ultra-rapid cycling and one with very prominent depressed features), and two have solely depressed mood. All but one of the manic patients showed a rapid and favorable response to intravenous valproate loading, which built up sufficient blood levels that were maintained by subsequent oral treatment. Of the two patients with solely depressed mood, however, one experienced only minor benefits and the other showed no change in the depressive symptomatology. Intravenous valproate was tolerated without problems and also led to a drastic reduction in and eventual withdrawal of benzodiazepine treatment in two cases. All of the patients showed a drastic remission of mania with valproate blood levels at or only slightly above 50 microg/mL (blood drawn 12 hours after last application). It is interesting to note that one patient who was previously nonresponsive to oral valproate loading responded well to intravenous valproate. Besides the obvious efficacy and safety of this treatment regimen, these findings may also imply that a difference in pharmacokinetics with intravenous loading may result in a quick saturation of plasma-binding proteins, and hence, peak concentrations of valproate may be reached rapidly, which could contribute to the beneficial action, even in patients previously nonresponsive to oral valproate.
Bupropion is increasingly used for nicotine withdrawal and in the treatment of major depression, especially in bipolar patients. We present the case of a 38-year-old female schizoaffective, rapid-cycling patient treated with bupropion for a depressive episode. After 4 weeks of successful treatment (300 mg/day), the patient developed a circumscribed unilateral impairment of sensory trigeminal nerve function. Symptoms completely recovered after discontinuation of bupropion. When re-exposed to bupropion, mild symptoms reappeared, leading to final discontinuation of bupropion. With this natural on-off-on-off design, a causative role of bupropion for trigeminal impairment in this patient can be assumed. To our knowledge, a similar side-effect of bupropion has not been described to date.
To compare the efficacy of sodium valproate administered as adjunct to neuroleptic medication for patients with acute mania with the efficacy of neuroleptics alone, the authors conducted a 21-day, randomized, double-blind, parallel-group, placebo-controlled trial. The study design closely reflected a clinical psychiatric setting in Europe where patients with acute mania commonly receive neuroleptic medication. In this trial, 136 hospitalized patients met the ICD-10 criteria for acute manic episodes; these patients received a fixed dose of 20 mg/kg of body weight of sodium valproate (Orfiril, Desitin Arzneimittel GmbH, Hamburg, Germany) orally, in addition to basic neuroleptic medication, preferably haloperidol and/or perazine. The primary outcome measure was the mean dose of neuroleptic medication (after conversion into haloperidol-equivalents) for the 21-day study period. Severity of symptoms was measured using the Young Mania Rating Scale (YMRS), the Global Assessment Scale, and the Clinical Global Impression Scale. Intent-to-treat analysis was based on 69 patients treated with valproate and 67 patients who received placebo. Groups were comparable with regard to demographic and clinical baseline data. Premature discontinuations occurred in only 13% of the patients. The mean neuroleptic dose declined continuously in the valproate group, whereas only slight variations were observed in the placebo group; the difference was statistically significant (p = 0.0007) for study weeks 2 and 3. The combination of neuroleptic and valproate proved superior to neuroleptics in attempts to alleviate manic symptoms. The proportion of responders (a 50% improvement rate shown on the YMRS) was higher for the combination with valproate than for the group receiving only neuroleptics (70% vs. 46%; p = 0.005). Adverse events consisted of those known for valproate or neuroleptics; the only adverse event was asthenia, which occurred more frequently with the combination therapy. Valproate represents a useful adjunct medication for the treatment of acute manic symptoms. Valproate is beneficial because it allows the administration of fewer neuroleptic medications and produces improved and quicker remission of manic symptoms.
Valproate, one of the major antiepileptic drugs used today, has besides its wide use in both generalized and partial epilepsies, several new approved indications including the treatment of bipolar disorders, neuropathic pain, and as a migraine prophylaxis. This wide spectrum of activities is reflected by several different mechanisms of action, which are discussed in this review. With regard to the antiepileptic effect of VPA, a special emphasis is put on the effect on the GABAergic system and the effect on enzymes like succinate semialdehyde dehydrogenase (SSA-DH), GABA transaminase (GABA-T), and alpha-ketoglutarate dehydrogenase, related to the tricarboxylic acid (TCA) cycle and thereby cerebral metabolism. In vitro studies have shown that VPA is a potent inhibitor of SSA-DH. In brain homogenates, GABA-T is inhibited at high concentrations only. Besides affecting the GABA-shunt, VPA might also inhibit the TCA cycle at the alpha-ketoglutarate dehydrogenase step. The effect of VPA on excitatory neurotransmission and on excitatory membranes are mechanisms likely to be responsible for the 'mood-stabilizing' effect as well as in the treatment of migraine. GABA-mediated responses may be involved in neuropathic pain. But still there are many aspects of the mechanisms of action of VPA that remain unknown.
Cost-effective psychotherapeutic interventions can enhance pharmacotherapy and improve outcomes in major depression and schizophrenia, but they are rarely studied in bipolar disorder, despite its often unsatisfactory response to medication alone. Following a literature search, we compiled and evaluated research reports on psychotherapeutic interventions in bipolar disorder patients. We found 32 peer-reviewed reports involving 1052 patients-14 studies on group therapy, 13 on couples or family therapy, and five on individual psychotherapy-all supplementing standard pharmacotherapy. Methodological limitations were common in these investigations. Nevertheless, important gains were often seen, as determined by objective measures of increased clinical stability and reduced rehospitalization, as well as other functional and psychosocial benefits. The results should further encourage rising international interest in testing the clinical and cost-effectiveness of psychosocial interventions in these common, often severe and disabling disorders.
Interpersonal and social rhythm therapy is an individual psychotherapy designed specifically for the treatment for bipolar disorder. Interpersonal and social rhythm therapy grew from a chronobiological model of bipolar disorder postulating that individuals with bipolar disorder have a genetic predisposition to circadian rhythm and sleep-wake cycle abnormalities that may be responsible, in part, for the symptomatic manifestations of the illness. In our model, life events (both negative and positive) may cause disruptions in patients' social rhythms that, in turn, perturb circadian rhythms and sleep-wake cycles and lead to the development of bipolar symptoms. Administered in concert with medications, interpersonal and social rhythm therapy combines the basic principles of interpersonal psychotherapy with behavioral techniques to help patients regularize their daily routines, diminish interpersonal problems, and adhere to medication regimens. It modulates both biological and psychosocial factors to mitigate patients' circadian and sleep-wake cycle vulnerabilities, improve overall functioning, and better manage the potential chaos of bipolar disorder symptomatology.
Although most of the care received by bipolar patients occurs during the maintenance phase, relatively little empirical data is available to guide long-term treatment decisions. We review literature pertaining to key questions related to use of pharmacotherapy in the maintenance phase of bipolar disorder. The few double-blind trials with a reasonable sample size are restricted to bipolar I patients and address a modest range of questions mostly related to use of lithium. One rigorous multicenter trial found valproate to have prophylactic benefit. Other studies with valproate alone and in combination suggest efficacy equivalent to lithium and perhaps greater than carbamazepine. Data available for combination treatment are sparse but moderately encouraging. Maintenance treatment with standard antidepressant medications appears destabilizing for some bipolar patients, particularly following a mixed episode. Although some bipolar patients may benefit from combined treatment with a mood stabilizer and a standard antidepressant medication, current knowledge does not allow confident selection of the bipolar patients who might benefit. Clozapine and perhaps other atypical antipsychotics are promising options for maintenance treatment but have not been evaluated in double-blind trials. The numerous other agents used in maintenance treatment are primarily adjuncts to lithium, valproate, or carbamazepine, and information about them is largely anecdotal and uncontrolled. Study design for maintenance trials remains an imperfect art. Conclusions must be drawn cautiously, given the limited generalizability of study designs that accession samples enriched with presumed treatment responders, randomize patients after brief periods of partial remission, abruptly taper prior treatment, make no attempt to distinguish relapse from recurrence, use no formal outcome assessments, or report hospitalization as the only outcome criterion.
There have been several reported incidents of iatrogenic bruxism (involuntary clenching or grinding of the teeth). These have involved diurnal bruxism ([Micheli et al , 1993][1]), felt to be associated with dopaminergic blockade, and nocturnal bruxism. Nocturnal bruxism has been reported with
Six monozygotic (MZ) twin pairs discordant for bipolar disorder were compared with normal MZ twins with magnetic resonance imaging (MRI) on volumes of basal ganglia (BG), amygdala-hippocampus (AH), and cerebral hemisphere. Caudate nuclei were larger in both affected and unaffected bipolar twins than in normal MZ twins. The right hippocampus was smaller in the sick vs. well bipolar twins. The hippocampus was also less asymmetric in the affected bipolar twins than in the well cotwins and the normal MZ twins. These anatomical structures continue to be of interest in bipolar disorder research.
The purpose of the study was to assess the efficacy and tolerance of risperidone in mania. Fourteen inpatients with a DSM-IV manic episode were treated with risperidone at a fixed daily dose of 6 mg for 4 weeks. Compliance was assured by weekly determinations of serum concentrations of risperidone. Ten out of the 14 patients completed all 4 weeks of treatment, and all of these achieved at least a 75% reduction on the Bech-Rafaelsen Mania Scale (MAS). On the other applied measures, a substantial improvement was also seen in most patients, and no worsening in any of the rating scales was observed in any patient. Five patients continued concomitant treatment with a mood stabilizer. When the results were compared with the results from a similar historic control group treated with the middle-potency typical antipsychotic zuclopenthixol at a daily dose of 20 mg under the same experimental conditions, a between group difference in mean percentage change (baseline versus endpoint) on the MAS was 34.7% (95% confidence interval = 7.9-61.6%) in favour of risperidone. Side-effect profiles were rather similar in the two treatment groups. Despite design limitations, these findings may justify the conduction of randomized controlled trials to investigate the use of risperidone in mania.
Combination treatment, rather than monotherapy, is prevalent in the treatment of subjects with bipolar disorder, probably due to the complex and phasic nature of the illness. In general, prescription patterns may be influenced by the demographic characteristics of patients as well. We evaluated prescription patterns and the influence of demographic variables on these patterns in a voluntary registry of subjects with bipolar disorder.
A subset of data from a larger voluntary registry was extracted for demographic variables and psychotropic medication use that had been reported in the month prior to registration by ambulatory, non-hospitalized subjects with bipolar I disorder in 1995/96 (n = 457).
Among the thymoleptic agents, lithium was prescribed in over 50% of subjects, valproate in approximately 40%, and carbamazepine in 11% of subjects. Eighteen percent of subjects had no prescription for thymoleptic agents. Nearly one-third of all subjects were receiving antipsychotic agents, of whom two-thirds were receiving the traditional neuroleptic agents. More than half of all subjects were receiving concomitant antidepressants, of whom nearly 50% received the SSRI antidepressants and nearly 25% received buproprion. Approximately 40% of subjects received benzodiazepines. Only 18% of subjects received monotherapy, and nearly 50% received three or more psychotropic agents. In general, no associations were noted between demographic parameters including age, gender, marital or educational status, and psychotropic prescriptions.
Consistent with the anecdotal reports, these data confirm that combination treatment is far more common than monotherapy. Demography appears to have a minimal impact on cross-sectional prescription patterns in subjects with bipolar disorder. Given that combination treatments are the rule rather than the exception, we should strive to achieve rational, yet pragmatic, treatment guidelines and algorithms to minimize the risks while maximizing the benefits of these combination treatments for patients with bipolar disorder.
Data from several studies suggest that medications, such as ketoconazole, which lower cortisol levels, may be effective for major depressive disorder (MDD). As with MDD, the manic, depressive, and mixed phases of bipolar disorder are frequently associated with elevated cortisol levels. The literature on the use of cortisol-lowering strategies in mood disorders is reviewed, and a case series illustrating the use of ketoconazole in bipolar depression is presented.
For the review, the MEDLINE and PSYCHINFO databases were searched, as were the bibliographies of pertinent articles to find papers on the use of cortisol-lowering agents in patients with mood disorders. In our open-label case series (n = 6), ketoconazole (up to 800 mg/day) as an add-on therapy was given to patients with treatment-resistant or intolerant bipolar I or II disorders with current symptoms of depression.
Several case reports and small open studies suggest that cortisol-lowering agents may be useful for patients with depression. Two recent placebo-controlled trials of ketoconazole on patients with MDD report conflicting results. In our case series, all three patients who received a dose of at least 400 mg/day had substantial reductions in depressive symptoms. None had significant increases in mania. However, cortisol levels were not lowered in any of the subjects.
The literature suggests that cortisol-lowering medications may be effective for a subset of depressed patients. Our preliminary findings suggest that ketoconazole may be useful in some patients with bipolar depression. Larger clinical trials are needed to confirm our observations.
To review studies of (A) whether lithium has a prophylactic action in bipolar disorder, (B) the efficacy of prophylactic lithium treatment in comparison with the efficacy of treatment with anticonvulsant drugs, and (C) the effect of lithium treatment on suicidal behavior.
Analysis of all relevant publications.
(A) The claim that a prophylactic action of lithium has never been satisfactorily demonstrated is based on wrong assumptions, biased selection of references, and unjustified generalizations. (B) In typical bipolar disorder lithium is significantly more efficacious than carbamazepine; in atypical bipolar disorder there is a non-significant trend for carbamazepine to be better than lithium. Valproate has not been proven prophylactically efficacious in typical bipolar disorder; in atypical bipolar disorder it may have an effect, but it has not been compared with that of lithium. (C) A significant association has been found between prophylactic lithium treatment, on the one hand, and reduced mortality and suicidal behavior, on the other. No such association has been reported for prophylactic treatment with other mood stabilizers.
In bipolar disorder the choice of prophylactic drug must be based on a weighing of efficacy against tolerability, interactions, ease of management, use during pregnancy and lactation, and expense. Lithium should be the preferred prophylactic drug in patients with typical bipolar disorder and in patients who are at high risk of committing suicide, that is, patients with severe depressions or depressions combined with persistent suicidal ideas or with suicide attempts in the past.
Stimulation of muscarinic cholinergic receptors on rat parotid acinar cells causes a rapid production of inositol phosphates, with the key metabolic event being the breakdown of phosphatidylinositol 4,5-bisphosphate into inositol 1,4,5-trisphosphate (Ins(1,4,5)P3) and diacylglycerol. Here a high-performance liquid chromatographic technique was used to measure the effects of intracellular lithium ions on the amount of various inositol phosphates produced. When acini were stimulated maximally with acetylcholine (ACh), the sum of all inositol phosphates produced followed a monoexponential function with a production rate constant for Ins(1,4,5)P3 of 0.07 +/- 0.01 solidus/sec. The presence of 23 mM LiCl intracellularly reduced the production rate constant of Ins(1,4,5)P3 induced by ACh to 0.03 +/- 0.01 solidus/sec, resulting in a decrease in the Ins(1,4,5)P3 production as well as in the magnitude of the rise in the intracellular free Ca2+ concentration. The lithium ion (Li+) did not affect the rate of conversion of Ins(1,4,5)P3 to either inositol 1,4-bisphosphate or inositol 1,3,4,5-tetrakisphosphate. The rate of the inositol phosphate production after the addition of the Ca2+ ionophore ionomycin was unaffected by intracellular Li+ (23 mM), which implies that the action of Li+ was at the muscarinic cholinergic receptor, on G-protein or on the interactions between G-proteins and phospholipase C. Thus, in the early events after receptor stimulation with ACh, Li+ causes a reduction in the concentration of the cellular messengers Ins(1,4,5)P3 and Ca2+.
The present investigation examined clinical features of periodontal disease and patterns of attachment loss in adult periodontitis subjects who were current, past or never smokers.
289 adult periodontitis subjects ranging in age from 20-86 years with at least 20 teeth and at least 4 sites with pocket depth and/or attachment level >4 mm were recruited. Smoking history was obtained using a questionnaire. Measures of plaque accumulation, overt gingivitis, bleeding on probing, suppuration, probing pocket depth and probing attachment level were taken at 6 sites per tooth at all teeth excluding 3rd molars at a baseline visit. Subjects were subset according to smoking history into never, past and current smokers and for certain analyses into age categories <41, 41-49, >49. Uni- and multi-variate analyses examined associations between smoking category, age and clinical parameters.
Current smokers had significantly more attachment loss, missing teeth, deeper pockets and fewer sites exhibiting bleeding on probing than past or never smokers. Current smokers had greater attachment loss than past or never smokers whether the subjects had mild, moderate or severe initial attachment loss. Increasing age and smoking status were independently significantly related to mean attachment level and the effect of these parameters was additive. Mean attachment level in non smokers <41 years and current smokers >49 years was 2.49 and 4.10 mm respectively. Stepwise multiple linear regression indicated that age, pack years and being a current smoker were strongly associated with mean attachment level. Full mouth attachment level profiles indicated that smokers had more attachment loss than never smokers particularly at maxillary lingual sites and at lower anterior teeth.
In accord with other studies, smokers had evidence of more severe periodontal disease than past or never smokers. At all levels of mean attachment loss, smokers exhibited more disease than never smokers. Difference in mean attachment level between smokers and never smokers at individual sites was not uniform. Significantly more loss was observed at maxillary lingual sites and lower anterior teeth suggesting the possibility of a local effect of cigarette smoking.
An association exists between smoking and schizophrenia, independent of other factors and related to psychotic symptomatology.
To determine whether smoking is associated with psychosis in bipolar affective disorder.
Smoking data were collected from 92 unrelated patients with bipolar affective disorder. An ordinal logistic regression analysis tested the relationship between smoking severity and psychotic symptomatology, allowing for potential confounders.
A significant relationship was detected between smoking/heavy smoking and history of psychosis (68.7%, n=44). Smoking was less prevalent in patients who were less symptomatic (56.5%, n=13) than in patients with a more severe psychosis (75.7, n=31). Prevalence and severity of smoking predicted severity of psychotic symptoms (P=0.001), a relationship independent of other variables (P=0.0272).
A link between smoking and psychosis exists in bipolar affective disorder and may be independent of categorical diagnosis.
Studies highlighting the difficulties associated with lithium suggest that the role of antipsychotic drugs and mood stabilizers in bipolar disorder should be reconsidered.
To review the efficacy and mode of action of antipsychotic drugs in mania, and to consider the differences between official guidelines and routine clinical practice in the use of these agents for mania.
Review of research, guideline- and practice-based literature.
Guidelines recommend lithium or valproate as first-line treatments for mania, and antipsychotic agents only as 'adjuncts' for agitation, dangerous behaviour or psychosis. However, in routine practice, antipsychotic drugs are often prescribed. The effectiveness of these agents in mania has been established by several studies; newer atypical compounds demonstrate antimanic efficacy with a reduced incidence of neurological side-effects.
Antipsychotic drugs are important in the treatment of bipolar disorder and mania. Future studies should evaluate the long-term efficacy and safety of newer atypical antipsychotic agents, and the place of anticonvulsants in combination with antipsychotics in bipolar disorder.
Atypical antipsychotics have revolutionized the treatment of schizophrenia, becoming the treatment of choice for patients not only during their first episode, but also throughout their life course. Of note, as of 1999 more than 70% of prescriptions for these drugs are being prescribed for conditions other than schizophrenia, such as bipolar disorder and geriatric agitation. While there have been very few controlled trials that have established the efficacy of the atypical antipsychotics for these "off-label" uses, there have been a large number of open trials and case reports. The few controlled trials suggest that the atypical antipsychotics may be useful for affective disorders (both mania and depression), geriatric conditions such as senile dementia and aggression, as well as a variety of other disorders. Atypical agents may be particularly helpful for elderly, child, or adolescent patients who are especially susceptible to the side effects of medications and whose risk of tardive dyskinesia is high but further controlled studies are necessary.
To develop a cost model that estimates the total and per case lifetime cost of bipolar disorder for 1998 incident cases in the US.
Lifetime cost simulation model.
Societal.
Age- and gender-specific incidence of bipolar disorder in 1998 was estimated by simulation based on existing prevalence data. The course of illness and mental health service cost of 6 clinically defined prognostic groups was estimated based on the research literature and the judgement of panels of experts. Excess cost of general medical care was estimated based on claims data from a large insurer. Indirect cost was projected including excess unemployment and reduced earnings reported in the National Comorbidity Survey. Comorbidity treatment and indirect cost related to alcohol (ethanol) and drug abuse was added based on a National Institute on Drug Abuse study.
The present value of the lifetime cost of persons with onset of bipolar disorder in 1998 was estimated at 24 billion US dollars ($US). Average cost per case ranged from $US11,720 for persons with a single manic episode to $US624,785 for persons with nonresponsive/chronic episodes.
The model indicates the potential cost savings of preventing a case of bipolar disorder and underscores the importance of achieving a stable outcome in new cases to limit the economic consequences of the disorder.
Selected groups of patients with bipolar and unipolar disorder have an increased mortality rate from suicide and natural causes of death. However, there has been no population-based study of mortality of patients followed up from the onset of the illness.
All patients with a hospital diagnosis of bipolar (n = 15 386) or unipolar (n = 39 182) disorder in Sweden from 1973 to 1995 were identified from the inpatient register and linked with the national cause-of-death register to determine the date and cause of death. Overall and cause-specific standardized mortality ratios (SMRs) and numbers of excess deaths were calculated by 5-year age classes and 5-year calendar periods.
The SMRs for suicide were 15.0 for males and 22.4 for females with bipolar disorder, and 20.9 and 27.0, respectively, for unipolar disorder. For all natural causes of death, SMRs were 1.9 for males and 2.1 for females with bipolar disorder, and 1.5 and 1.6, respectively, for unipolar disorder. For bipolar disorder, most excess deaths were from natural causes, whereas for unipolar disorder, most excess deaths were from unnatural causes. The SMR for suicide was especially high for younger patients during the first years after the first diagnosis. Increasing SMR for suicide during the period of study was found for female patients with unipolar disorder.
This population-based study of patients treated in the hospital documented increased SMRs for suicide in patients with bipolar and unipolar disorder. The SMR for all natural causes of death was also increased, causing about half the excess deaths.