Mood Disorders (Depression and Bipolar Disorder)

BACKGROUND

Description

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).

Occurrence

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.

Characteristic Features

Condensed Diagnostic and Statistical Manual of Mental Disorders Ed. IV (DSM-IV) Criteria:

Major Depressive Episode

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(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
The symptoms do not meet criteria for a Mixed Episode (described in DSM-IV as including both manic and depressive episodes nearly daily for a week).
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:(1) Inflated self-esteem or grandiosity(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)(3) More talkative than usual or pressure to keep talking
(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)
The symptoms do not meet criteria for a Mixed Episode (described in DSM-IV as including both manic and depressive episodes nearly daily for a week).
The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Dysthymic Disorder

Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
Presence, while depressed, of two (or more) of the following:
(1) Poor appetite or overeating(2) Insomnia or hypersomnia(3) Low energy or fatigue(4) Low self-esteem

(5) Poor concentration or difficulty making decisions

(6) Feelings of hopelessness

Symptoms of mood disorder that are in response to a stressor and don’t meet criteria for Major Depressive Disorder or Bereavement may be related to an Adjustment Disorder.

Diagnostic Considerations

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.

MEDICAL MANAGEMENT CONSIDERATIONS

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.

Medication Management

Medical Considerations for Treating Depression

Start low and go slow when using medications (unless dangerous behavior exists; see above)
All assessments require collateral information from patient and caretakers
Assess on regular basis for side effects
Assess target symptoms for response
Check for potential drug-drug interactions before initiating medication

Antidepressant Medication (examples)

Selective Serotonin Reuptake Inhibitors (SSRI)

Fluoxetine (generic, Prozac, or Prozac weekly)
Sertraline (Zoloft)
Paroxetine (Paxil or Paxil CR)
Citalopram (Celexa) or escitalopram (Lexapro)
Fluvoxamine (Luvox)

Potential side effects: headaches, increased anxiety, gastrointestinal effects, sleep difficulties, and mild weight gain

Tricyclic Antidepressants

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.

Imipramine (Tofranil)
Desipramine (Norpramine)
Amitryptyline (Elavil)
Nortriptyline (Pamelor)

Potential side effects: mania, anticholinergic effects, sedation, autonomic effects, cardiac effects, neurological effects, and allergic effects

Other Antidepressants

Venlafaxine (Efexor XR): same side effects as SSRIs
Mirtazapine (Remeron): watch for sedation, weight gain
Nefazodone (Serzone): watch for sedation

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.

Antimanic Medication

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.

Lithium – often involves EKG, routine periodic blood tests: (check level, kidney function tests, electrolytes, TSH)
Valproic acid – often involves periodic blood tests: (check level, liver function tests, CBC with platelets)
Carbamazepine – often involves EKG, periodic blood tests: (check level, CBC with platelets, liver function tests)
Zyprexa – often involves weight monitoring and periodic blood tests (check triglycerides, glucose)
Trileptal – often involves periodic blood test (sodium)
Other newer anticonvulsants are under investigation include topiramate, lamotrigine, and gabapentin

ORAL HEALTH CONSIDERATIONS S

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.

Dental Conditions Associated with Major Depression

Poor oral hygiene
Poor nutrition, poor diet
Xerostomia (mouth dryness), associated with antidepressant medications
Dental decay due to poor oral hygiene, poor diet, and xerostomia
Periodontal disease due to poor oral hygiene, poor diet, and xerostomia
Oral-facial pain
Missing teeth due to dental extractions to treat caries and periodontal disease

Dental Conditions Associated with Bipolar Disorder

Abrasion of oral mucosa and teeth from vigorous brushing
Stomatitis (inflammation of the oral mucosa), associated with long-term lithium therapy
Xerostomia, associated with long-term lithium therapy
Dental decay due to xerostomia

Dental Management

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.

Clinical Considerations

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:

Tricyclic antidepressants,

Adverse drug interactions may occur between some tricyclic antidepressants and sedatives and general anesthetics, which could result in severe respiratory depression.
Do not use local anesthetics containing Neo-Cobefrin or Levophed.
Leuonordefrin is not recommended.
There is disagreement among practitioners regarding the use of local anesthetics containing epinephrine.

Monoamine Oxidase (MAO) inhibitors,

Do not use meperidine (Demerol).
Certain antihistamines such as phenylephrine should not be used.
Local anesthetics containing epinephrine must be used with caution; interactions may lead to a hypertensive crisis.
Do not use local anesthetics containing Neo-Cobefrin.

Lithium,

Using nonsteroidal anti-inflammatory drugs (NSAID) may affect renal flow and allow lithium buildup in the blood.
Use benzodiazepines with caution due to the chance of CNS depression.

Patients undergoing electroconvulsive therapy (ECT) may receive drugs that compromise natural reflexes that guard against aspiration. These patients should be evaluated for

Loose teeth
Gross calculus
Loose prostheses

The dentist may create a mouth guard for patients undergoing ECT. Consider prescribing artificial saliva substitutes for patients with xerostomia.

At-Home Care

Establish good daily oral hygiene procedures including plaque removal by brushing and flossing.
Encourage regular brushing/flossing.
Promote diet that does not increase the risk of dental decay.
Consider diet counseling for a patient with significant tooth decay.
Use fluoridated water and toothpaste.
Use gum, mints, or foods containing Xylitol as the primary sugar to reduce caries.
Use antimicrobial (Chlorhexidine) mouthwash or spray as an adjunct for some individuals with rampant caries and gingivitis.

[Return to the index for a full document on Dental Care]

REFERENCES

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, 4^th edition (DSM-IV). Washington DC: American Psychiatric Association.

Kaplan, H.I., Sadock, B.J. (1995). (Eds.) Comprehensive Textbook of Psychiatry/VI, Vol. 2, 6^th 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.

RESOURCES FOR FAMILIES

American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue N.W.

Washington, D.C. 20016-3007

202-966-7300

http://www.aacap.org

American Dental Association

312-440-2500

http://www.ada.org

Tips for People Who Have Special Needs

http://www.ada.org/public/topics/special_needs.asp

American Psychiatric Association

1400 K Street N.W.

Washington, DC 20005

888-337-7924

www.psych.org

The Arc (formally Association for Retarded Citizens)

500 East Border Street, Suite 300

Arlington, Texas 76010

617-261-6003

800-433-5225

Home

Association of University Centers on Disabilities

8630 Fenton Street, Suite 410

Silver Spring, MD 20910-3803

301-588-8252

http://www.aucd.org

California Alliance for the Mentally Ill

1111 Howe Avenue, Suite 475

Sacramento, CA 95825-8541

916-567-0163

800-950-NAMI

Fax: 916-567-1757

[email protected]

http://www.nami.org

http://namicalifornia.org

California Regional Centers

915-654-1958

http://www.dds.ca.gov/rc/RCInfo.cfm

The National Association for the Dually Diagnosed

132 Fair Street

Kingston, NY 12401

800-331-5362

http://www.thenadd.org

National Mental Health Association Information Center

2001 North Beauregard Street, 12^th floor

Alexandria, VA 22311

703-684-7722

800-969-6642

Fax: 703-684-5968

[email protected]

http://www.nmha.org

National Oral Health Information Clearinghouse

301-402-7364

TTY 301-656-7581

http://www.nohic.nidcr.nih.gov

National Oral Health Information Clearinghouse

Oral Conditions in Children with Special Needs

A Guide for Health Care Providers

http://www.nohic.nidcr.nih.gov/pubs/oral_conditions/index.htm

Project MED (Medical Education for Consumers)

www.projectmed.org

Southern Association of Institutional Dentists

http://saiddent.org/modules.asp

Special Care Dentistry

312-440-2660

http://www.scdonline.org

Special Olympics Special Smiles

http://www.specialsmiles.org

A Guide to Good Oral Health for Persons with Special Needs

http://www.specialsmiles.org/booklet.htm

The Tarjan Center for Developmental Disabilities at UCLA

http://www.tarjancenter.ucla.edu

University of Florida

College of Dentistry

Department of Pediatric Dentistry
Oral Health Care for Persons with Disabilities

http://www.dental.ufl.edu/Faculty/Pburtner/disabilities/Default.htm

University of the Pacific

School of Dentistry

Center for Oral Health for People with Special Needs

http://www.cfoh.org

Community Programs

http://dental.pacific.edu

ADVISORY COMMITTEE

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.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

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.