Medical Management Considerations
Mood or affective disorders are characterized by mood symptoms. The two major affective disorders are Major Depressive Disorder/Dysthymia and Bipolar disorder. Individuals afflicted with only depressive episodes are considered to have Major Depressive Disorder or unipolar depression. Depressive symptoms in persons with developmental disabilities may include tearfulness, a sad appearance, loss of humor, loss of interest in friends or enjoyable activities, refusal to eat, increased pacing, running away, decreased vocalization, regression in skills, sleep disturbances, and increase in self injurious behaviors or level of agitation. Individuals with both manic and depressive episodes are considered to have bipolar disorder. Description of manic symptoms in persons with developmental disabilities may include a core episodic change in mood (euphoria or irritability) and/or increased level of agitation (ex: shouting, yelling, screaming), more silly behaviors, inflated self esteem, increased energy, staying up much of the night, non-stop talking, tendency to be distracted, increase in sexualized behavior (ex: frequent masturbation), and mood swings. The exact cause of mood disorders is not known. Relationships have been found in studies implicating biological, genetic, and psychological factors. In addition, some genetic disorders have a higher prevalence of mood disorders, (i.e., Down’s syndrome).
Mood disorders are very common. The lifetime prevalence of major depressive disorder is about 15 percent, perhaps as high as 25 percent for women. Bipolar disorder lifetime prevalence is estimated at about one percent in the general population. The exact prevalence of mood disorders in people with mental retardation is not known, but is felt to be quite common. Rates from clinic samples report up to 50 percent had a mood disorder. Therefore, familiarity and attention to mood symptoms is important for all health professionals who see people with mental retardation.
Condensed Diagnostic and Statistical Manual of Mental Disorders Ed. IV (DSM-IV) Criteria:
(3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) Fatigue or loss of energy nearly every day
(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
(4) Flight of ideas or subjective experience that thoughts are racing
(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
(7) Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
(5) Poor concentration or difficulty making decisions
(6) Feelings of hopelessness
Evaluation of a mood disorder in persons with developmental disabilities requires a special approach. The assessment must incorporate developmental level, communication skills, associated handicaps or medical problems, and family/sociocultural factors. The diagnostic criteria should be assessed over time through a patient interview, a comprehensive review of history from multiple informants, and medical review. Special consideration must be given to ruling out mood symptoms that are present primarily due to medication side effects, medical/neurologic reasons (i.e., thyroid abnormalities, dementia, delirium), bereavement process, and overlap of negative symptoms associated with psychotic symptoms. It is important to note that symptom presentation is similar throughout the age span. Irritability and agitation are more frequently noted than depressed mood or euphoria. Sleep and appetite changes are important clues to making a diagnosis of a mood disorder.
Once a mood disorder has been identified, a first consideration is safety, and a practitioner must assess the level of emergency of the identified symptoms. Potentially dangerous symptoms that may require immediate intervention include suicidal ideation, self-injurious behavior, aggression towards others, and severe anorexia. Immediate referral to a psychiatric treatment center or hospitalization must be considered for these individuals. For non-emergent and uncomplicated cases of major depressive disorder, the treatment requires a multimodel approach. Medical or neurological causes must be ruled out with appropriate physical exam and laboratory studies. Supportive intervention for the family and person with mental retardation need to be arranged. Educational or vocational modifications may need to be made to decrease stress. Arrangement for supportive psychotherapy should be considered when appropriate. The adage “start low, go slow” when starting and titrating medication is extremely important.
For non-emergent treatment of bipolar disorder, the treatment will most likely need to involve a referral to a mental health professional (e.g., psychiatrist) to provide a comprehensive evaluation and outline treatment approaches. Pharmacotherapy decisions can be complex and require midstream adjustments, depending on treatment response and side effects.
Once treatment has been initiated for mood disorders, special attention must be given to assessing effectiveness, side effects, adherence and costs. It is important to identify specific goals for target symptoms and follow-up on a regular and frequent basis until stabilization has been achieved. The prognosis for mood disorder is good but relapse must always be a consideration.
Selective Serotonin Reuptake Inhibitors (SSRI)
Potential side effects: headaches, increased anxiety, gastrointestinal effects, sleep difficulties, and mild weight gain
Note: Given side effect profile and concerns about overdose these agents are not first choice for treatment of depression. Also require laboratory tests to be performed such as CBC, electrolytes, liver function tests, and EKG in all children and adolescent, as well as adults at risk for heart disease.
Potential side effects: mania, anticholinergic effects, sedation, autonomic effects, cardiac effects, neurological effects, and allergic effects
It is very important to realize that antidepressant treatment may result in increased activation and or mania in some individuals. This may require discontinuation of medication or reduction in dosage.
Bipolar disorder typically involves treatment by a psychiatrist. Below are listed the most commonly prescribed medications and medical tests that may be done on a regular basis.
A thorough knowledge of the dental implications of mood disorders will aid a primary care provider and dental practitioner in preventing dental problems and providing the most appropriate treatment. In particular, care should be taken to prevent adverse drug interactions between the medications addressing the mood disorder and the medications used during dental treatment. Treatment options and limitations, as well as daily measures to take to prevent dental problems and maintain oral health, should be clearly explained to persons with developmental disabilities and their families/caregivers. Dental caries is an infectious and transmissible disease. Every person should be referred to an oral health professional for evaluation and have an oral health care plan by age 1 to prevent early childhood caries and later periodontal disease.
Managing the preventive, restorative, and surgical aspects of dental treatment involve an early (by age 1) and regular oral health evaluation and caries risk assessment, as well as the establishment of a customized oral health care plan.
Since patients may be receiving medications to treat the mood disorder, consider drug interactions prior to using additional medications, sedatives, or anesthetics. For patients on:
Monoamine Oxidase (MAO) inhibitors,
Patients undergoing electroconvulsive therapy (ECT) may receive drugs that compromise natural reflexes that guard against aspiration. These patients should be evaluated for
The dentist may create a mouth guard for patients undergoing ECT. Consider prescribing artificial saliva substitutes for patients with xerostomia.
[Return to the index for a full document on Dental Care]
Aman MG, Collier-Crespin A, Lindsay RL (2000). Pharmacotherapy of Disorders in Mental Retardation. European Child and Adolescent Psychiatry, 9(1), 98-107.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington DC: American Psychiatric Association.
Kaplan, H.I., Sadock, B.J. (1995). (Eds.) Comprehensive Textbook of Psychiatry/VI, Vol. 2, 6th edition. Baltimore: Williams & Wilkins.
Linna, S,L,, Moilanen, I., Ebeling, H., Piha, J., Kumpulainen, K., Tamminen, T,, Almqvist, F. (1999). Psychiatric Symptoms in Children with Intellectual Disability. European Child & Adolescent Psychiatry 8(4).
Marston, G.M., Perry, D.W., Roy, A. (1997). Manifestations of Depression in People with Intellectual Disability. Journal of Intellectual Disability Research, 41(6), 476-480.
Masi, G., Marcheschi, M., Pfanner, P. (1997). Paroxetine in Depressed Adolescents with Intellectual Disability: An Open Label Study. Journal of Intellectual Disability Research, 41(3), 268-272.
Masi, G,, Mucci, M., Favilla, L., Poli, P. (1999). Dysthymic Disorder in Adolescents with Intellectual Disability. Journal of Intellectual Disability Research, 43(2), 80-87.
Matson, J.L., Rush, K.S., Hamilton, M., Anderson, S.J., Bamburg, J.W., Baglio, C.S. (1999). Characteristics of Depression as Assessed by the Diagnostic Assessment for the Severely Handicapped-II (DASH-II). Research in Developmental Disabilities, 20(4), 305-313.
Reiss, S,, Aman, M.G. (1998). Psychotropic Medications and Developmental Disabilities: The International Consensus Handbook. Nisonger Center for Mental Retardation and Developmental Disabilities.
Rush, A,J., Frances, A. (2000). (Eds.),Treatment of Psychiatric and Behavioral Problems in Mental Retardation. American Journal of Mental Retardation, 105(3), 1-71.
Southern Association of Institutional Dentists. (2001)., Module 9: Clinical Concerns in Dental Care for Persons with Mental Illness. Modules. Retrieved on June 13, 2006 from http://saiddent.org/modules/17_module9.pdf
Szymanski, L., King, B.H. (1999). Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38(12), 5-31.
University of Florida, College of Dentistry, Department of Pediatric Dentistry. (2001). Major Depression and Bipolar Disorder. Oral Health Care for Persons with Disabilities. Retrieved on June 13, 2006 from http://www.dental.ufl.edu/Faculty/Pburtner/Disabilities/English/mndepres.htm and http://www.dental.ufl.edu/Faculty/Pburtner/Disabilities/English/mnbipola.htm.
Vanstraelen, M., Tyrer, S.P. (1999). Rapid Cycling Bipolar Affective Disorder in People with Intellectual Disability: A Systematic Review. Journal of Intellectual Disability Research, 43(5), 349-359.
American Academy of Child and Adolescent Psychiatry
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American Dental Association
Tips for People Who Have Special Needs
American Psychiatric Association
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The Arc (formally Association for Retarded Citizens)
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Association of University Centers on Disabilities
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California Alliance for the Mentally Ill
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California Regional Centers
The National Association for the Dually Diagnosed
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National Mental Health Association Information Center
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National Oral Health Information Clearinghouse
National Oral Health Information Clearinghouse
Oral Conditions in Children with Special Needs
A Guide for Health Care Providers
Project MED (Medical Education for Consumers)
Southern Association of Institutional Dentists
Special Care Dentistry
Special Olympics Special Smiles
A Guide to Good Oral Health for Persons with Special Needs
The Tarjan Center for Developmental Disabilities at UCLA
University of Florida
College of Dentistry
Department of Pediatric Dentistry
Oral Health Care for Persons with Disabilities
University of the Pacific
School of Dentistry
Center for Oral Health for People with Special Needs
Theodore A. Kastner, M.D., M.S.
Leonard Magnani, M.D., Ph.D.
Felice Weber Parisi, M.D., M.P.H.
Terrance D. Wardinsky, M.D.
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This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.