Working with Patients who have Severe or Chronic Mental Illness

Mood disorders
Both the patient with major depressive disorder and the depressed bipolar patient will frequently have difficulty maintaining oral hygiene or keeping appointments. Also, their recollection of instructions may be poor. These are symptoms of depression. Oral health care providers must avoid placing blame, and work to give the patient a sense of selfacceptance, worth, and of being in control. Their cognitive impairment may be temporary, but it is still important to keep instructions simple and to provide a copy for use at home as in the case of those with other cognitive impairments.

Bipolar patients in the manic phase of their illness may be highly distractible. Therefore, they also may benefit from simple, printed instructions.

Anxiety disorders
About 6 to 14% of the general population is estimated to have dental fear.28 The patient with an anxiety disorder is even more likely to fear dental treatment. (See case B for one example.) The principles listed in Figure 5 are helpful when managing patients who appear fearful or mistrusting. However, one should be prepared to refer such a patient to a mental health professional.

Psychotic disorders
Patients with psychotic disorders must live with thoughts and sensations that do not always accurately represent the world around them. As a result, their behaviors and beliefs may seem bizarre, but in context, they contain a certain logic. For example, people with auditory hallucinations hear apparently real voices with no evident source.1 Some may come to believe they have radio transmitters in their teeth. Their oral health care provider must accept that what they experience is real for them. Arguing is pointless and should be avoided. Instead, a supportive, predictable, non-stressful treatment atmosphere should be provided. With the patient’s permission, oral health care providers may keep in contact with the patient’s case manager or support person for help with oral hygiene and appointment reminders. This contact was very important for coordinating oral health appointments for the woman in case example A.

Dual diagnosis (mental illness and a history of substance abuse) A history of substance abuse is quite common among individuals with mental illness; they may try to use drugs or alcohol to self-medicate. In some cases, substance abuse may induce or amplify symptoms of mental illness.29 A history of drug use can create several problems in the oral health care setting, including cognitive impairment, abnormal bleeding problems, increased susceptibility to infections, and impaired liver detoxification of drugs.27 It is advisable to avoid the use of mood-altering drugs, such as nitrous oxide and IV sedation, and to use nonalcoholic mouthwashes. However, for patients with acute pain, “opiates remain central to therapy, including for addicted patients.”30 Clinical impressions and animal research suggest that patients with a substantial past history of substance abuse may be likely to need more local anesthesia than other patients, although this has not been experimentally verified in humans.31 As always, the patient must be the judge of when pain control is needed.