Mental Health

Stressed? I Bet you’re Grinding…

01/22/2010 , 10:13 AM by Ryan Finnegan, DMD

Note to the Reader: This is the first in our celebrity blogger program on dentistry!

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So I guess I’ll start this blog with something I’m seeing more and more of at the office.  Do you ever wake up with headaches? neck pain? are your teeth sensitive to hot and cold?   You, like many of my patients, may be grinding your teeth.  Typically, when I ask a patient, “Do you grind your teeth?” they either tell me they have no idea whether they do or don’t or immediately say NO for fear I’m going to yell at them.  First things first, your dentist is not going to yell at you for grinding your teeth, but he wants to treat you properly.

So why do we grind our teeth?  STRESS.  It’s the body’s subconscious way of dealing with stress.  Perfect example of what we see: College student who has never had a cavity in their life comes in over christmas break complaining that they have had sensitive teeth a few weeks back.  They’ll report that it was very uncomfortable but has gotten better- can anyone say finals???  As we know stress has been increasing for a lot of us lately, worries about the economy, our job security, our mortgage, etc…  And we have seen many more patients who are clenching their teeth.  How does stress make your teeth hurt?  Basically there are 2 effects of grinding: tooth sensitivity or jaw pain/headaches.  The tooth sensitivity comes from the teeth being ground together, this will cause inflammation of the nerve inside the tooth and the patient will experience sensitivity.  The headaches / jaw pain are result of overuse of the muscles of the face, these muscles are contracted when we are grinding.  I tell people to imagine how their kness and legs would feel if they were jogging for 6 hours…

So what to do?  Diagnosis can be difficult because everyone’s symptoms are different and other factors can present the same way.  So step one is to see your dentist to rule out a tooth infection, cavity or other dental issue.  Treatment usually will consist of a nightguard, an anti-inflammatory [medication], possible a muscle relaxant in severe cases.  Other treatments that have proven effective for long term treatment of stress relief are therapeutic massage, acupuncture, and a few cases may need to be addressed surgically.

About Our Celebrity Blogger. Ryan Finnegan is a partner in a 35-year old private practice in Branford, Connecticut.  Completing his undergraduate work at Fairfield University, Dr. Finnegan attended the University of Connecticut School of Dental Medicine where he earned his DMD.  The good doctor continued his studies with a dental residency at SUNY Stony Brook. (Little interesting tid-bit: He eats lunch at the same time, in the same place, with the same person, every Sunday. No, it’s not his wife. And yes, more often than not, he orders the same dish!)

Exelon Follow-Up

11/01/2007 , 11:36 AM by Alex Sicre

October 23rd 2007 was the first day that the Exelon transdermal patch, the first and only skin patch for the symptomatic treatment of mild to moderately severe Alzheimer’s dementia, is available in the UK market. Here’s some info on it from ITNews.com, no author given:

A clinical study of 1,195 people with Alzheimer’s dementia demonstrated that the rivastigmine patch improves cognitive function (assessed using a tool that includes measures of orientation, memory and language), as well as a patient’s ability to perform everyday activities compared to placebo. The study also showed that the 9.5mg/24h patch is as effective as the maximum titrated dose of rivastigmine oral capsules.

Applied once a day (replaced every 24 hours), the rivastigmine patch provides smooth and continuous delivery of rivastigmine through the skin, which reduces nausea and vomiting caused by peaks in medication levels when the drug is taken orally.
Dr Peter Connelly, Consultant in Old Age Psychiatry, Perth, Scotland comments, “The Exelon patch represents a valuable advance in the treatment of Alzheimer’s disease. This formulation offers patients and their carers an effective, well-tolerated and convenient therapy option. I expect a significant proportion of carers will find the patch easier to use compared to the conventional formulation.”

Family cargivers are the backbone of long-term care to Alzheimer’s disease patients, frequently responsible for administering and managing patient medication. A survey conducted in over 1,000 caregivers showed that more than 70 per cent preferred the patch as a method of drug delivery compared to oral capsules(3). The most common reasons for preferring the patch were ease of following the schedule and ease of use.

The rivastigmine patch can be applied to the upper arm, chest or back(4). The patch may allow those caring for Alzheimer’s disease patients to monitor treatment compliance because it provides visual reassurance that the medication has been taken. Compliance with prescribed medication regimens represents a challenge for most patients but may be particularly difficult for older people due to: the extent to which drug regimens interfere with daily living; lack of understanding or misinterpretation of instructions; complex and complicated drug regimens; and forgetfulness(6). 75% of older people are believed to not comply with their treatment regimens.

“Caring for a relative with Alzheimer’s is very time-consuming and sometimes overwhelming. There’s a lot to think about and sufferers are often on a number of medications,” comments carer Lisa, who used to look after her sister at home. “People with the disease can find it difficult to take oral medication and to comply with a strict routine. A patch that provides 24 hour cover could help keep track of when medication has been taken.”

COMMENTS
I’m all for anything to improve patient medication adherence. Once again my hope is that patients remember they have the patch on and rmember to change them as well. To celebrate National Caregivers Month – here’s to Novartis!

EU Approval for Exelon

09/20/2007 , 10:44 AM by Alex Sicre

I have writen about patches in the past – both pro and con. With the EU approval of Exelon, caregivers and patients with Alzheimer’s have reason to cheer for better medication adherence. I can only imagine how difficult it must be to care for a parent or spouse with Alzheimer’s – not to mention their medication regime. Hopefully the Exelon patch will have a successful launch and adoption in the EU.

The Exelon patch was approved in the US in July and some expect sales to reach the $1B mark.

Here is a blurb from 9/24 Nursing In Practice website, no author provided:

The European Commission has on today approved the use of a transdermal patch to deliver medicine to patients with mild-to-moderately severe Alzheimer’s disease. The patch is the first type of transdermal treatment for Alzheimer’s disease and is applied once a day to the back, chest or upper arm of patients.

Experts say the patch improves compliance for Alzheimer’s patients and also reduces side-effects.

“All these benefits offer the potential for improved outcomes in patients,” said James Shannon, global head of development at Novartis Pharma.

“Exelon patch represents a therapeutic innovation that is designed specifically to meet the needs of patients, caregivers and physicians involved with this devastating disease.”

Bruno Dubois, Professor of Neurology in Paris, France, agrees that the patch provides vital reassurance that patients have “taken” their medicine, adding: “Just having to apply a patch can help reduce the burden of family life for people with Alzheimer’s disease and their families.”

In a survey of Alzheimer’s caregivers, 70% said they preferred the patch to oral medicines as it helped them follow their treatment schedules and was easier to use.

“People with Alzheimer’s disease and their caregivers welcome every new therapy for the disease,” said Mark Wortmann, executive director of Alzheimer’s Disease International. “I am pleased that the patch offers a new approach to treatment.”

Abstracts Are For Dummies -Psychiatry

09/14/2007 , 10:51 AM by Alex Sicre

I have found a lot of abstracts today dealing with psychiatric non-adherence to medication: factors and solutions. Here is one of them and the link to get the full paper itself. It is a pdf freebee from Science Direct at the bottom of the post. Once I read the paper I will have more comments.

Medication adherence is crucial in psychiatry, especially for chronic disorders. Both clinician and patient share responsibility for adherence, which is rarely an all-or-none phenomenon. For psychiatric drugs, non-adherence rates are approximately 40–60%. Such non-adherence explains much of the difference between drug efficacy and effectiveness, as demonstrated by higher relapse rates in non-adherent patient groups. Thus, non-adherence impacts profoundly on clinical and economic burdens for health services. During clinical assessment, predictive factors of non-adherence should be considered, including: a prior history of non-adherence; alcohol or substance misuse or where treatment is during an asymptomatic phase.

Similarly, drug dose and formulation polypharmacy, side effects and the therapeutic relationship also affect adherent behaviour.

Psychoeducational interventions aiming to enhance adherence focus primarily on imparting knowledge, rather than on attitudinal and behavioural change, and have proved largely ineffective. Individual psychological interventions are more effective as they specifically target the patient’s beliefs and attitudes concerning the illness and medication by utilizing cognitive–behavioural or motivational interviewing techniques.

Compliance therapy combines all of these. All clinicians should routinely use simple adherence-enhancing techniques, particularly as dedicated resources for specialist interventions remain rare. Moreover, in an attempt to further reduce the adverse clinical and economic impact of non-adherence, it is imperative that patients are given the opportunity to have their personal individual perspectives adequately heard.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B82Y7-4PN7KJV-4&_user=10&_coverDate=09%2F30%2F2007&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=849f29cf71a299db513642dc3ab73594#

Problems with Skin Patches

08/13/2007 , 10:36 AM by Alex Sicre

I have always been a big fan of medication patches from the begining for medication adherence. I remember first seeing “the patch” for smoking sensation and am glad that they are able to adapt this technology for Alzheimer’s and Parkinson’s. Although I do remember my father smoking and chewing Nicorette while using the patch, and getting incredibly sick.

I had heard about problems with the contraceptive patch, but had never heard of a narcotic patch. I can see how these problems can occur, especially for older patients who put a patch on Monday, then forget on Wednesday and put another one on. Although I would think they would solve this problem with packaging.

And discarded patches seem to be a problem as well. Here’s an article I found from the Toronto Star from 8/7/07. It only discusses Canadian problems, but I’m sure they are applicable in the US.

Skin Patches Have Their Downside by Nancy J. White.

Morag Dickie liked the convenience. She could just slap the nitroglycerin patch onto her body in the morning and not worry about popping pills.

“I could feel a consistent flow of energy,” says Toronto resident Dickie, 55, a heart patient.

That’s the idea behind a skin patch – an easy-to-use method with smooth, controlled drug release, not the peaks and valleys of ingested medicine. In the U.S. last month, the Food and Drug Administration approved the first skin patch to treat Alzheimer’s disease. In May, it gave the green light to a drug patch for Parkinson’s disease. Last year, medicinal patches were approved Attention Deficit Hyperactivity Disorder and depression.

Researchers are developing an insulin patch for diabetics.

But it’s also a system that can present problems from the occasional skin irritation – the reason Dickie, who has sensitive skin, had to eventually give up her patch – to unintended poisonings. Three people in this country have died from use of the narcotic fentanyl patch, according to the Institute for Safe Medication Practices Canada (ISMPC).

In June, a federal jury in the U.S. awarded $5.5 million to the father of a 28-year-old man who died in 2003 while wearing a fentanyl patch for chronic hip pain after a car accident.

In Canada, prescription patches are approved for a handful of uses, including contraception and hormone replacement therapy, pain relief, smoking cessation, prevention of motion sickness and control of angina.

As for new ones, Health Canada does not disclose drugs it is reviewing, according to a spokesman. The patch to treat the dementia of Alzheimer’s has been submitted to Health Canada and the manufacturer hopes for approval next year, says Jason Jacobs, a spokesman for Novartis Pharmaceuticals Canada. That patch delivers the drug Exelon or rivastigmine, which is currently sold in Canada for oral use.

Patches provide a smoother delivery of drugs than tablets, which send medication for absorption to the intestine, and may lessen the potential for side effects by avoiding a high peak.

They are longer-acting, some up to a week. “There’s better compliance when the patient doesn’t have to worry about taking a medicine three or four times a day,” says Bill Wilson, pharmacy director at Mount Sinai Hospital.

Patients may, however, forget they’re wearing a patch, especially since some are clear. “We’ve had reports of more than one patch of the same drug put on a person,” says Sylvia Hyland, vice president of the non-profit group ISMPC.

Youngsters have been poisoned by chewing ondiscarded patches or putting them on. “Children are fascinated by stickers and bandages,” says Hyland. “A thrown-away patch still has some drug in it.”

The ISMP has had reports from emergency room staff concerned by unlabelled patches. And the most dangerous are the patches delivering fentanyl, a narcotic. “They need to be prescribed appropriately for chronic severe pain, not acute pain,” explains Hyland. “Physicians need to be very knowledgeable about the patch.”

Two of the Canadian deaths from the fentanyl patch were adolescents. The deaths occurred in 2004. It’s supposed to be only for adults, says Hyland.

The birth-control patch, EVRA, has also raised concerns after a study indicated women using it in the U.S. had an increased risk of blood clots in the legs and lungs than women on an oral contraceptive. Another study, however, showed no difference in the risk.

More Information and Facts About the Friday Post from NCCBH

06/18/2007 , 1:53 PM by Alex Sicre

As I stated, I am a little behind the times, but this is the press release from the National Council for Community Behavioral Healthcare from June 13th addressing the “lawyer ads” about Zyprexa.

Survey results released today shed light on a new barrier to treatment affecting people with severe mental illness. The findings show fears raised by product liability litigation involving antipsychotic drugs may be putting patients with schizophrenia and bipolar disorder at risk for relapse. These fears add to the already heavy burden that patients face as they work to manage symptoms, stay on their medication and work with their treatment providers to improve their mental and physical health.

The survey, which was conducted among 402 psychiatrists who treat patients with schizophrenia and bipolar disorder, showed that, even when patients were responding well to their prescribed antipsychotic treatment, many requested a medication change because these drugs are featured in law firm advertisements. Other patients stopped taking their medication, often without telling their psychiatrist, for the same reason.

“Many of our patients already struggle with accepting their illness and staying on their prescribed treatment, and now they are experiencing new levels of fear due to the increasing incidence of these jarring advertisements,” said Dr. Ralph Aquila, assistant clinical professor of psychiatry, Columbia College of Physicians and Surgeons; director, residential community services, St Luke’s-Roosevelt Hospital Center, New York, NY. “This irresponsible advertising is hindering the progress of therapy for many of these patients and disrupting the important relationship between them and their healthcare providers. Plaintiffs attorneys need to consider the consequences that these advertisements may have on patients.”

The findings from this survey, which was commissioned by the National Council for Community Behavioral Healthcare and Eli Lilly and Company, are consistent with a Harris Interactive® poll of 250 physicians commissioned by the U.S. Chamber of Commerce in 2003 that examined how pharmaceutical litigation impacts prescribing decisions across disease states. However, this new survey went one step further by asking psychiatrists to examine the potential impact of this type of litigation on patient care. These new findings have implications for doctors who treat serious and persistent mental illnesses, and confirm trends in clinical practice that many people in the mental health community have observed, but have not been quantified until now.

Ninety-seven percent of surveyed psychiatrists had one or more patients who stopped taking medication or reduced their dosage. Of these psychiatrists, 52 percent believed patients took this action due to law firm advertisements about antipsychotic drugs, and reported the following:
• Ninety-three percent stated that one or more of their patients made medication changes without consulting them first, and the majority of these psychiatrists (94 percent) reported patient relapse as a result of discontinuing medication.
• The most frequent consequences of relapse were symptom recurrence (93 percent), hospitalization (75 percent), loss of an important relationship (40 percent) and suicide attempts (26 percent).

Even when patients were improving on their prescribed medication, they still approached their psychiatrists about stopping or changing. Ninety-seven percent of surveyed psychiatrists received one or more patient requests to stop or switch their medication. Of these psychiatrists, 59 percent felt patients made these requests based on concerns raised by law firm advertisements about antipsychotic drugs, and reported the following:
• The majority of these psychiatrists (93 percent) felt these patients were responding to treatment.
• Of the patients that were responding but requested a stop or switch, 71 percent of psychiatrists reported that one or more experienced a relapse, which also led to symptom recurrence, hospitalization, loss of an important relationship and suicide attempts.
• Half of the surveyed psychiatrists reported that patient caregivers also requested a medication switch or stop due to concerns generated by law firm advertisements, even if their loved one was responding to treatment.

“Doctors and patients need to discuss the risks and benefits of any medication in order to determine what is appropriate for each patient,” said Linda Rosenberg, MSW, president and CEO of the National Council. “That assessment becomes difficult in today’s atmosphere because so much of the advertising is alarmist and frightening. It’s especially crucial for patients to speak with their doctor before stopping their medication. Such discussions are an important part of the therapeutic relationship.”

The findings from the survey are especially pertinent given the number of barriers that already exist in helping patients adhere to their treatment. Among the many challenges psychiatrists noted they faced when selecting an antipsychotic medication to treat schizophrenia and bipolar disorder, the five most challenging issues identified were:
• Side effects (75%),
• Lack of adherence due to unwillingness to accept illness (73%),
• Medication costs (58%),
• Lack of adherence due to lack of support (50%), and
• Co-occurring mental illnesses (49%).

More than half (55%) of surveyed psychiatrists indicated that they had changed their prescribing practices over the last five years due to product liability cases involving antipsychotic medications – and reported frustration and concern that this type of litigation sometimes interferes with patient treatment. Furthermore, many psychiatrists (62%) reported that they know of colleagues who have made similar changes in their prescribing practices.