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Perspectives in Psychiatric Care
ISSN 0031-5990
Self-Reported and Interviewer-Rated Oral Health in Patients With Schizophrenia, Bipolar Disorder, and Major Depressive Disorder Li-Rong Tang, MD,* Wei Zheng, MD, MPhil Student,* Hui Zhu, MD,* Xin Ma, MD, Helen F. K. Chiu, FRCPsych, Christoph U. Correll, MD, Gabor S. Ungvari, MD, PhD, Ying-Qiang Xiang, MD, PhD, Kelly Y. C. Lai, MRCPsych, Xiao-Lan Cao, MD, Yan Li, MD, Bao-Liang Zhong, MD, Ka In Lok, MEd, MNs, and Yu-Tao Xiang, MD, PhD Li-Rong Tang, MD, is Attending Psychiatrist, Beijing Anding Hospital, Capital Medical University, Beijing, China; Wei Zheng, MD, MPhil, is Resident Psychiatrist, Beijing Anding Hospital, Capital Medical University, Beijing, China; Hui Zhu, MD, is Vice Consultant Psychiatrist, Beijing Anding Hospital, Capital Medical University, Beijing, China; Xin Ma, MD, is Professor, Beijing Anding Hospital, Capital Medical University, Beijing, China; Helen F. K. Chiu, FRCPsych, is Professor, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Christoph U. Correll, MD, is Professor, Division of Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York, USA; Gabor S. Ungvari, MD, PhD, is Professor, The University of Notre Dame, Fremantle, Western Australia, Australia, and Professor, Marian Centre, Perth, Western Australia, Australia; Ying-Qiang Xiang, MD, PhD, is Associate Professor, Beijing Anding Hospital, Capital Medical University, Beijing, China; Kelly Y. C. Lai, MRCPsych, is Associate Professor, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Xiao-Lan Cao, MD, is PhD student, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Yan Li, MD, is PhD student, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Bao-Liang Zhong, MD, is PhD student, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Ka In Lok, MEd, MNs, is Lecturer, Kiang Wu Nursing College of Macau, Macau, Macao SAR, China; and Yu-Tao Xiang, MD, PhD, is Associate Professor, Faculty of Health Sciences, University of Macau, Macau, Macao SAR, China
Search terms: Bipolar disorder, major depression, oral health, psychiatric inpatient, schizophrenia Author contact: [email protected]; [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement Dr. Correll has been a consultant and/or advisor to or has received honoraria from: Actelion, Alexza; Bristol-Myers Squibb, Cephalon, Eli Lilly, Genentech, Gerson Lehrman Group, IntraCellular Therapies, Janssen/J&J, Lundbeck, Medavante, Medscape, Merck, Otsuka, Pfizer, ProPhase, Roche, Sunovion, Takeda, Teva, and Vanda. He has received grant support from BMS, Janssen/J&J, Novo Nordisk A/S, and Otsuka. The other authors had no conflicts of interest related to the topic of the manuscript.
PURPOSE: To compare self-reported (SR) and interviewer-rated (IR) oral health between schizophrenia (SZ), bipolar disorder (BP), and major depressive disorder (MDD) patients. DESIGN AND METHODS: 356 patients with SZ, BP, or MDD underwent assessments of psychopathology, side effects, SR, and IR oral health status. FINDINGS: 118 patients (33.1%) reported poor oral health; the corresponding proportion was 36.4% in BP, 34.8% in SZ, and 25.5% in MD (p = .21). SR and IR oral health correlated only modestly (r = 0.17–0.36) in each group. PRACTICE IMPLICATIONS: Psychiatric patients need to be assessed for both SR and IR oral health.
*These authors equally contributed to this work. First Received July 20, 2014; Final Revision received October 27, 2014; Accepted for publication November 10, 2014. doi: 10.1111/ppc.12096
Perspectives in Psychiatric Care •• (2014) ••–•• © 2014 Wiley Periodicals, Inc.
1
Self-Reported and Interviewer-Rated Oral Health in Patients With Schizophrenia, Bipolar Disorder, and Major Depressive Disorder
Oral health is an important aspect of quality of life influencing speech, eating, appearance, physical health, and social activity (Nordenram, Ronnberg, & Winblad, 1994). Psychiatric patients often neglect their oral health due to either limited financial resources, or marked psychopathology, including depression and negative symptoms (Ramon, Grinshpoon, Zusman, & Weizman, 2003). For example, up to 50% of patients with schizophrenia (SZ) never brush their teeth (Sayegh, Dababneh, & Rodan, 2006). Psychiatric patients are less likely to attend regular dental checkup than the general population (Nielsen, Munk-Jorgensen, Skadhede, & Correll, 2011). Psychotropic medications frequently reduce salivary secretion, leading to dry mouth (xerostomia) via blocking muscarinic receptors (Persson, Axtelius, Soderfeldt, & Ostman, 2009). Xerostomia may lead to difficulties in speech and swallowing, could alter taste sensation, and increase staphylococcal parotitis and oral moniliasis, resulting in poor dental status, halitosis, oral infections, and social stigmatization (Chen, 2012). Up to 80% of patients with severe psychiatric disorders smoke, further worsening their dental status (Hughes, Hatsukami, Mitchell, & Dahlgren, 1986; Jones, 2000; Sjogren & Nordstrom, 2000). Poor oral health increases the risk of inflammation and systemic infections, such as endocarditis (Leucht, Burkard, Henderson, Maj, & Sartorius, 2007). Via these mechanisms, poor oral health negatively impacts social functioning and community living skills, accentuating the need for regular dental checkups and treatment for persons with severe psychiatric illness. SZ, major depressive disorder (MDD), and bipolar disorder (BP) are among the most common psychiatric disorders with different clinical presentations and prognoses. In the past decades, a number of studies have examined oral health in persons with severe psychiatric illness (Ramon et al., 2003; Sjogren & Nordstrom, 2000; Tang, Sun, Ungvari, & O’Donnell, 2004), but no study compared either selfreported (SR) and interviewer-rated (IR) oral health in psychiatric patients or oral health across different psychiatric disorders. Thus, the aims of this study were (a) to compare SR and IR oral health between SZ, MDD, and BP, (b) to examine the associations between SR and IR oral health in each of the three diagnostic categories, and (c) to explore their independent socio-demographic and clinical correlates in Chinese psychiatric inpatients. Method Study Design and Participants The study was conducted between July 1, 2013 and September 30, 2013 in Beijing Anding Hospital, a 700-bed universityaffiliated psychiatric center that serves approximately 19 million people. All consecutively admitted patients were screened and study criteria included (a) both genders, (b) age 2
of 18 years and above, (c) DSM-IV diagnosis of SZ, MDD, or BP being the diagnoses accounting for over 90% of inpatients in this hospital, and (d) being able and willing to give written informed consent for an interview and oral examination. The study protocol was approved by the Human Research and Ethics Committee of Beijing Anding Hospital. Instruments and Assessments Face-to-face interviews were conducted by two psychiatrists (LRT and WZ). Basic socio-demographic and clinical characteristics were collected using a data collection form designed for the study. Data on the current use of antipsychotics, mood stabilizers and antidepressants, psychiatric diagnoses, and major medical conditions were collected from the medical records and confirmed with patients and family members, if available. The severity of psychotic symptoms was measured with the Chinese version of the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962; Zhang et al., 1983). The Chinese version of the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (C-QIDS-16) total score measured the severity of depressive symptoms (total score = 0–27; higher scores indicate more severe depressive symptoms [Liu et al., 2013; Rush et al., 2003]). Extrapyramidal symptoms (EPS) were assessed with the Simpson-Angus Scale of Extrapyramidal Symptoms (SAS) (Simpson & Angus, 1970). Tardive dyskinesia (TD) was measured with the Abnormal Involuntary Movement Scale (AIMS) (National Institute of Mental Health, 1976). “Current smoking” referred to smoking at least one cigarette daily during the past month (Lasser et al., 2000). “Current alcohol use” was defined as having at least one alcoholic beverage per month during the past year (Xiang et al., 2009). IR oral health status was evaluated using the IR 12-item Oral Assessment Guide for Psychiatric Care (OAGPC) (Table 2) (Sjogren & Nordstrom, 2000) that was developed after Eilers’ OralAssessment Guide (Eilers, Berger, & Petersen, 1988).Each item of the OAGPC forms a subscale; its total score ranges from 12 to 32, with higher scores indicating poorer objective oral health. SR oral health was measured using the Chinese version of the short form of the Oral Health Impact Profile (OHIP-14) (Slade, 1997; Xin & Ling, 2006), which is a 14-item, selfadministered instrument of oral health perceived by the individual in the previous 4 weeks. The OHIP-14 scores were as follows: (a) total score by summing up all 14 items, and (b) seven subscales, including functional limitations, physical pain, psychological discomfort, physical disability, psychological disability,social disability,and handicap.A higher score indicates poorer SR oral health. There is no recommended cutoff value for the OHIP-14 to discriminate between good and poor oral health. The mean total score of the OHIP-14 was 11.8 in the Chinese general population (Xin & Ling, 2006), Perspectives in Psychiatric Care •• (2014) ••–•• © 2014 Wiley Periodicals, Inc.
Self-Reported and Interviewer-Rated Oral Health in Patients With Schizophrenia, Bipolar Disorder, and Major Depressive Disorder
Table 1. Comparison Between Patients With Schizophrenia, Major Depression, and Bipolar Disorders in Basic Demographic and Clinical Variables
Gender Female Male Married Urban Employed Having insurance High chronicity (> 5 years) On mood stabilizers On antidepressants On antipsychotics Having major medical conditions Current alcohol user Current smoker SR poor oral health
Age (years) Age of onset (years) Duration of illness (years) Education (years) BMI BPRS QIDS-SR-16 AIMS SAS
Total sample (n = 356)
Schizophrenia (n = 158)
Major depression (n = 80)
Bipolar disorders (n = 118)
Statistics
N
N
N
N
χ2
%
%
%
%
1.1 204 152 185 278 277 316 178 105 98 60 55 83 92 118
57.3 42.7 52.0 78.1 77.8 88.8 50.0 29.5 27.5 16.9 15.4 23.3 25.8 33.1
86 72 60 127 120 140 90 23 11 150 21 32 48 55
54.4 45.6 38.0 80.4 75.9 88.6 57.0 14.6 7.0 94.9 13.3 20.3 30.4 34.8
49 31 57 56 70 65 28 4 75 38 20 23 18 20
61.3 38.8 71.3 70.0 87.5 81.3 35.0 5.0 93.8 47.5 25.0 28.7 22.5 25.0
69 49 68 95 87 111 60 78 12 108 14 28 26 43
58.5 41.5 57.6 80.5 73.7 94.1 50.8 66.1 10.2 91.5 11.9 23.7 22.0 36.4
25.8 3.9 5.8 7.8 10.2 116.0 227.1 94.1 7.3 2.1 3.0 3.1
df 2
p .57
2
Perspectives in Psychiatric Care
ISSN 0031-5990
Self-Reported and Interviewer-Rated Oral Health in Patients With Schizophrenia, Bipolar Disorder, and Major Depressive Disorder Li-Rong Tang, MD,* Wei Zheng, MD, MPhil Student,* Hui Zhu, MD,* Xin Ma, MD, Helen F. K. Chiu, FRCPsych, Christoph U. Correll, MD, Gabor S. Ungvari, MD, PhD, Ying-Qiang Xiang, MD, PhD, Kelly Y. C. Lai, MRCPsych, Xiao-Lan Cao, MD, Yan Li, MD, Bao-Liang Zhong, MD, Ka In Lok, MEd, MNs, and Yu-Tao Xiang, MD, PhD Li-Rong Tang, MD, is Attending Psychiatrist, Beijing Anding Hospital, Capital Medical University, Beijing, China; Wei Zheng, MD, MPhil, is Resident Psychiatrist, Beijing Anding Hospital, Capital Medical University, Beijing, China; Hui Zhu, MD, is Vice Consultant Psychiatrist, Beijing Anding Hospital, Capital Medical University, Beijing, China; Xin Ma, MD, is Professor, Beijing Anding Hospital, Capital Medical University, Beijing, China; Helen F. K. Chiu, FRCPsych, is Professor, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Christoph U. Correll, MD, is Professor, Division of Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York, USA; Gabor S. Ungvari, MD, PhD, is Professor, The University of Notre Dame, Fremantle, Western Australia, Australia, and Professor, Marian Centre, Perth, Western Australia, Australia; Ying-Qiang Xiang, MD, PhD, is Associate Professor, Beijing Anding Hospital, Capital Medical University, Beijing, China; Kelly Y. C. Lai, MRCPsych, is Associate Professor, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Xiao-Lan Cao, MD, is PhD student, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Yan Li, MD, is PhD student, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Bao-Liang Zhong, MD, is PhD student, Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China; Ka In Lok, MEd, MNs, is Lecturer, Kiang Wu Nursing College of Macau, Macau, Macao SAR, China; and Yu-Tao Xiang, MD, PhD, is Associate Professor, Faculty of Health Sciences, University of Macau, Macau, Macao SAR, China
Search terms: Bipolar disorder, major depression, oral health, psychiatric inpatient, schizophrenia Author contact: [email protected]; [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement Dr. Correll has been a consultant and/or advisor to or has received honoraria from: Actelion, Alexza; Bristol-Myers Squibb, Cephalon, Eli Lilly, Genentech, Gerson Lehrman Group, IntraCellular Therapies, Janssen/J&J, Lundbeck, Medavante, Medscape, Merck, Otsuka, Pfizer, ProPhase, Roche, Sunovion, Takeda, Teva, and Vanda. He has received grant support from BMS, Janssen/J&J, Novo Nordisk A/S, and Otsuka. The other authors had no conflicts of interest related to the topic of the manuscript.
PURPOSE: To compare self-reported (SR) and interviewer-rated (IR) oral health between schizophrenia (SZ), bipolar disorder (BP), and major depressive disorder (MDD) patients. DESIGN AND METHODS: 356 patients with SZ, BP, or MDD underwent assessments of psychopathology, side effects, SR, and IR oral health status. FINDINGS: 118 patients (33.1%) reported poor oral health; the corresponding proportion was 36.4% in BP, 34.8% in SZ, and 25.5% in MD (p = .21). SR and IR oral health correlated only modestly (r = 0.17–0.36) in each group. PRACTICE IMPLICATIONS: Psychiatric patients need to be assessed for both SR and IR oral health.
*These authors equally contributed to this work. First Received July 20, 2014; Final Revision received October 27, 2014; Accepted for publication November 10, 2014. doi: 10.1111/ppc.12096
Perspectives in Psychiatric Care •• (2014) ••–•• © 2014 Wiley Periodicals, Inc.
1
Self-Reported and Interviewer-Rated Oral Health in Patients With Schizophrenia, Bipolar Disorder, and Major Depressive Disorder
Oral health is an important aspect of quality of life influencing speech, eating, appearance, physical health, and social activity (Nordenram, Ronnberg, & Winblad, 1994). Psychiatric patients often neglect their oral health due to either limited financial resources, or marked psychopathology, including depression and negative symptoms (Ramon, Grinshpoon, Zusman, & Weizman, 2003). For example, up to 50% of patients with schizophrenia (SZ) never brush their teeth (Sayegh, Dababneh, & Rodan, 2006). Psychiatric patients are less likely to attend regular dental checkup than the general population (Nielsen, Munk-Jorgensen, Skadhede, & Correll, 2011). Psychotropic medications frequently reduce salivary secretion, leading to dry mouth (xerostomia) via blocking muscarinic receptors (Persson, Axtelius, Soderfeldt, & Ostman, 2009). Xerostomia may lead to difficulties in speech and swallowing, could alter taste sensation, and increase staphylococcal parotitis and oral moniliasis, resulting in poor dental status, halitosis, oral infections, and social stigmatization (Chen, 2012). Up to 80% of patients with severe psychiatric disorders smoke, further worsening their dental status (Hughes, Hatsukami, Mitchell, & Dahlgren, 1986; Jones, 2000; Sjogren & Nordstrom, 2000). Poor oral health increases the risk of inflammation and systemic infections, such as endocarditis (Leucht, Burkard, Henderson, Maj, & Sartorius, 2007). Via these mechanisms, poor oral health negatively impacts social functioning and community living skills, accentuating the need for regular dental checkups and treatment for persons with severe psychiatric illness. SZ, major depressive disorder (MDD), and bipolar disorder (BP) are among the most common psychiatric disorders with different clinical presentations and prognoses. In the past decades, a number of studies have examined oral health in persons with severe psychiatric illness (Ramon et al., 2003; Sjogren & Nordstrom, 2000; Tang, Sun, Ungvari, & O’Donnell, 2004), but no study compared either selfreported (SR) and interviewer-rated (IR) oral health in psychiatric patients or oral health across different psychiatric disorders. Thus, the aims of this study were (a) to compare SR and IR oral health between SZ, MDD, and BP, (b) to examine the associations between SR and IR oral health in each of the three diagnostic categories, and (c) to explore their independent socio-demographic and clinical correlates in Chinese psychiatric inpatients. Method Study Design and Participants The study was conducted between July 1, 2013 and September 30, 2013 in Beijing Anding Hospital, a 700-bed universityaffiliated psychiatric center that serves approximately 19 million people. All consecutively admitted patients were screened and study criteria included (a) both genders, (b) age 2
of 18 years and above, (c) DSM-IV diagnosis of SZ, MDD, or BP being the diagnoses accounting for over 90% of inpatients in this hospital, and (d) being able and willing to give written informed consent for an interview and oral examination. The study protocol was approved by the Human Research and Ethics Committee of Beijing Anding Hospital. Instruments and Assessments Face-to-face interviews were conducted by two psychiatrists (LRT and WZ). Basic socio-demographic and clinical characteristics were collected using a data collection form designed for the study. Data on the current use of antipsychotics, mood stabilizers and antidepressants, psychiatric diagnoses, and major medical conditions were collected from the medical records and confirmed with patients and family members, if available. The severity of psychotic symptoms was measured with the Chinese version of the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962; Zhang et al., 1983). The Chinese version of the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (C-QIDS-16) total score measured the severity of depressive symptoms (total score = 0–27; higher scores indicate more severe depressive symptoms [Liu et al., 2013; Rush et al., 2003]). Extrapyramidal symptoms (EPS) were assessed with the Simpson-Angus Scale of Extrapyramidal Symptoms (SAS) (Simpson & Angus, 1970). Tardive dyskinesia (TD) was measured with the Abnormal Involuntary Movement Scale (AIMS) (National Institute of Mental Health, 1976). “Current smoking” referred to smoking at least one cigarette daily during the past month (Lasser et al., 2000). “Current alcohol use” was defined as having at least one alcoholic beverage per month during the past year (Xiang et al., 2009). IR oral health status was evaluated using the IR 12-item Oral Assessment Guide for Psychiatric Care (OAGPC) (Table 2) (Sjogren & Nordstrom, 2000) that was developed after Eilers’ OralAssessment Guide (Eilers, Berger, & Petersen, 1988).Each item of the OAGPC forms a subscale; its total score ranges from 12 to 32, with higher scores indicating poorer objective oral health. SR oral health was measured using the Chinese version of the short form of the Oral Health Impact Profile (OHIP-14) (Slade, 1997; Xin & Ling, 2006), which is a 14-item, selfadministered instrument of oral health perceived by the individual in the previous 4 weeks. The OHIP-14 scores were as follows: (a) total score by summing up all 14 items, and (b) seven subscales, including functional limitations, physical pain, psychological discomfort, physical disability, psychological disability,social disability,and handicap.A higher score indicates poorer SR oral health. There is no recommended cutoff value for the OHIP-14 to discriminate between good and poor oral health. The mean total score of the OHIP-14 was 11.8 in the Chinese general population (Xin & Ling, 2006), Perspectives in Psychiatric Care •• (2014) ••–•• © 2014 Wiley Periodicals, Inc.
Self-Reported and Interviewer-Rated Oral Health in Patients With Schizophrenia, Bipolar Disorder, and Major Depressive Disorder
Table 1. Comparison Between Patients With Schizophrenia, Major Depression, and Bipolar Disorders in Basic Demographic and Clinical Variables
Gender Female Male Married Urban Employed Having insurance High chronicity (> 5 years) On mood stabilizers On antidepressants On antipsychotics Having major medical conditions Current alcohol user Current smoker SR poor oral health
Age (years) Age of onset (years) Duration of illness (years) Education (years) BMI BPRS QIDS-SR-16 AIMS SAS
Total sample (n = 356)
Schizophrenia (n = 158)
Major depression (n = 80)
Bipolar disorders (n = 118)
Statistics
N
N
N
N
χ2
%
%
%
%
1.1 204 152 185 278 277 316 178 105 98 60 55 83 92 118
57.3 42.7 52.0 78.1 77.8 88.8 50.0 29.5 27.5 16.9 15.4 23.3 25.8 33.1
86 72 60 127 120 140 90 23 11 150 21 32 48 55
54.4 45.6 38.0 80.4 75.9 88.6 57.0 14.6 7.0 94.9 13.3 20.3 30.4 34.8
49 31 57 56 70 65 28 4 75 38 20 23 18 20
61.3 38.8 71.3 70.0 87.5 81.3 35.0 5.0 93.8 47.5 25.0 28.7 22.5 25.0
69 49 68 95 87 111 60 78 12 108 14 28 26 43
58.5 41.5 57.6 80.5 73.7 94.1 50.8 66.1 10.2 91.5 11.9 23.7 22.0 36.4
25.8 3.9 5.8 7.8 10.2 116.0 227.1 94.1 7.3 2.1 3.0 3.1
df 2
p .57
2
