Managing Severe Depression: Addressing Oral Discomfort and Insomnia

Patients with severe depression may experience discomfort in the teeth and tongue, as well as issues with insomnia?

Hello Dr.
Lin, I am here to ask on behalf of my mother.
She has a history of severe depression for over twenty years (with a diagnosis) and has been on psychiatric medication for a long time.
Among these, she has been taking FM2, a very strong sedative, for over ten years, yet she has never experienced deep sleep and always wakes up within three hours.
She continues to have follow-up appointments with her psychiatrist, but her insomnia remains at a similar level.
Recently, she has been experiencing very unusual sensations in her teeth and tongue, which have caused her significant discomfort (she has had similar discomfort in the past, but it has worsened recently).
According to her, whenever her tongue touches her teeth, she feels as if her teeth are about to fall out or have softened, although upon touching her teeth, they feel fine, and she has no issues eating.
However, when she is not eating, it causes her great discomfort, leading her to feel overwhelmed.
She does nothing all day except for one meal, remaining in a state of panic, with no interest in reading, watching TV, or any activities; she can only sit or lie down, constantly expressing how uncomfortable her teeth and tongue feel.

We have taken her to see a dentist, but the dentist said it is not periodontal disease and could not find any issues during the examination.
They only provided her with a dental guard to try, but she cannot wear it for long periods.
Currently, she often bites down on the ends of cotton swabs to temporarily relieve her discomfort (they cannot touch; if they do, it becomes extremely uncomfortable), and she goes through dozens of cotton swab ends each day.
I suspect her dental and tongue issues may be symptoms related to long-term use of psychiatric medications affecting the trigeminal nerve or autonomic nervous system dysregulation.
I found online that carbamazepine might alleviate trigeminal discomfort, but carbamazepine is also a psychiatric medication, and I am concerned about the potential for a cycle of adverse effects.

I would like to ask what resources and support my mother can seek in her situation.
The doctor she is currently seeing has not provided clear recommendations, only suggesting to continue monitoring her condition.
However, her discomfort with her teeth and tongue has severely impacted her daily life, to the point where she cannot even go out for her follow-up appointments.
Therefore, I am inquiring here to find out about other possible solutions.
Thank you for your patience in reading this question!

Mr. Zheng, 20~29 year old female. Ask Date: 2016/07/02

Dr. Lin Niqi reply Psychiatry

The discomfort described by the patient's mother may not only be physical but could also be attributed to psychological symptoms, potentially indicating a psychosomatic disorder.
Emotional distress may lower the tolerance for physical discomfort, making it more challenging to endure bodily ailments.
It is recommended to seek a second opinion from a dental specialist and to consult a psychiatrist.
Collaboration between the dental and psychiatric professionals is advised.

Reply Date: 2016/07/02

More Info

Managing severe depression, particularly in cases like your mother's, can be incredibly challenging, especially when compounded by persistent insomnia and oral discomfort. It’s crucial to approach this situation holistically, considering both the psychological and physiological aspects of her condition.

Understanding the Symptoms
Your mother’s long-standing history of severe depression and her reliance on medications, including potent sedatives like FM2, suggest that her mental health has been significantly impacted over the years. The fact that she has not experienced deep sleep for over a decade is concerning. Chronic insomnia can exacerbate depressive symptoms, leading to a vicious cycle where poor sleep contributes to worsening mood and vice versa.

The oral discomfort she is experiencing—specifically the heightened sensitivity of her teeth and tongue—could be multifactorial. While it’s good that a dentist has ruled out periodontal disease, the sensations she describes could be related to several factors:
1. Medication Side Effects: Many psychiatric medications can cause dry mouth, altered taste, and other oral sensations. Long-term use of certain medications can lead to changes in oral health and sensitivity.

2. Anxiety and Depression: Psychological factors can manifest physically. Anxiety can lead to heightened sensitivity to sensations, including those in the mouth. This could explain why she feels discomfort when her tongue touches her teeth, even if there is no physical issue.

3. Neurological Factors: As you mentioned, there could be an impact on the trigeminal nerve or autonomic nervous system due to her medication regimen or underlying conditions. This could lead to abnormal sensations in the oral cavity.

Recommendations for Management
1. Consult a Psychiatrist: Given the complexity of her symptoms, it may be beneficial to consult a psychiatrist who specializes in medication management for patients with severe depression. They can evaluate her current medication regimen and consider alternatives or adjustments that might alleviate her insomnia and oral discomfort.

2. Psychotherapy: Engaging in therapy, particularly cognitive-behavioral therapy (CBT), can help address the psychological aspects of her condition. Therapy can provide coping strategies for managing anxiety and depression, which may, in turn, help with her insomnia and discomfort.

3. Oral Health Specialist: If her symptoms persist, consider consulting an oral medicine specialist or a neurologist who can evaluate her oral discomfort from a neurological perspective. They may provide insights into whether her symptoms are related to nerve issues or medication side effects.

4. Lifestyle Modifications: Encourage her to adopt a routine that promotes better sleep hygiene. This includes maintaining a consistent sleep schedule, creating a restful environment, and avoiding stimulants before bedtime. Gentle activities, such as light stretching or mindfulness exercises, may also help reduce anxiety and improve sleep quality.

5. Support Groups: Connecting with support groups for individuals with depression or chronic health issues can provide emotional support and practical advice. Sharing experiences with others who understand her struggles may help alleviate feelings of isolation.

6. Alternative Therapies: Some patients find relief through complementary therapies such as acupuncture, mindfulness meditation, or yoga. These approaches can help manage anxiety and improve overall well-being.

7. Medication Review: If her current medications are causing significant side effects, a review and possible adjustment of her medication regimen may be necessary. This should be done under the supervision of a qualified healthcare provider.

Conclusion
It’s essential to approach your mother’s situation with compassion and understanding. Encourage her to communicate openly with her healthcare providers about her symptoms and the impact they have on her daily life. A multidisciplinary approach that includes medical, psychological, and lifestyle interventions may provide the best chance for improvement. Remember, recovery from severe depression is often a gradual process, and it’s important to celebrate small victories along the way. Your support as a family member is invaluable in this journey.

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