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Nicotine and psychiatric disorder

Nicotine and psychiatric disorder. Robert West University College London. Outline. Tobacco/nicotine dependence as a psychiatric disorder Smoking patterns and psychiatric disorders Possible mechanisms linking smoking and psychiatric disorders Implications for diagnosis and treatment.

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Nicotine and psychiatric disorder

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  1. Nicotine and psychiatric disorder Robert West University College London

  2. Outline • Tobacco/nicotine dependence as a psychiatric disorder • Smoking patterns and psychiatric disorders • Possible mechanisms linking smoking and psychiatric disorders • Implications for diagnosis and treatment

  3. Tobacco/nicotine dependence as a psychiatric disorder

  4. WHO and American Psychiatric Association Definitions • WHO (ICD-10) • Tobacco dependence • Tobacco withdrawal syndrome • APA (DSM-IV) • Nicotine dependence • Nicotine withdrawal • Use same criteria as for other substance use disorders • Defining feature: Impaired control over behaviour

  5. Main diagnostic criteria • Failure of attempts to stop • Cravings or urges • Withdrawal syndrome • Continued use despite knowledge of harmful consequences ~80% of smokers fulfil DSM criteria for dependence

  6. Cigarette smoking and tobacco/ nicotine dependence • Cigarette smoking is most addictive form of nicotine use: • rapid nicotine delivery • palatable • convenient • readily accessible • few restrictions on use • Other forms of tobacco use are probably less addictive (West 2004) • Addiction to pure nicotine products is related to speed of nicotine delivery • Nasal spray • Transdermal patch Moderate Very low

  7. Smoking patterns and psychiatric diagnoses

  8. Smoking and schizophrenia • Widely believed that smoking is particularly high in schizophrenia • E.g. ‘Complex psychopathological, biochemical, and neuropharmacological interactions between smoking and schizophrenia are revealed’ McCloughen (2003) • But it is not specifically linked to this disorder ....

  9. Smoking and psychiatric diagnoses in the population Meltzer 1995)

  10. Smoking and psychiatric diagnosis in in institutions • Very high smoking prevalence in all institutionalised patient groups • Level is similar in the homeless

  11. Smoking and ADHD • Clear link with ADHD in adolescents • Children with ADHD more likely to smoke (Tercyak 2002) • Smokers with ADHD start smoking younger (Burke 2001)

  12. OPCS Psychiatric Morbidity Survey

  13. Smoking and deprivation • Need to rule out deprivation as an explanation • Strong link between nicotine dependence and deprivation From Jarvis et al:Deprivation indexed by: occupation, educational level, housing tenure, car ownership, unemployment, and living in crowded accommodation)

  14. Smoking and other addictive disorders • Strong links with other substance use disorders: • 80% of adults with alcohol dependence smoke cigarettes (see Enoch, 2003) • 80% of illicit drug users in treatment smoke (Farrell, 2001)

  15. CURRENT NEUROTIC DISORDER BY SMOKING HABIT OPCS PSYCHIATRIC MORBIDITY SURVEY 4 Odds adjusted for age, sex, deprivation, alcohol consumption & drug dependence 3 Odds of caseness 2 1 Odds ratio ñ 95% CI 30 min Less than More than 1 to 2 15-30 5-15 Never Ex- to 1 hr 5 minutes 2 hours hours minutes minutes smokers smokers N = 4395 2187 849 456 407 459 450 554 NON-SMOKERS TIME TO FIRST CIGARETTE OF THE DAY IN SMOKERS

  16. Substance use and psychiatric disorder in the general population OPCS Psychiatric Morbidity Survey: Meltzer et al 1995

  17. Focusing on depression

  18. Depression and smoking in smokers taking part in stop smoking trial • N=950 • Mean age 44 years • 61% female • Cigs per day=23 • Expired air CO=26ppm • Measured depression in postal questionnaire and at pre-quit session (R=0.38, p<.001) • 5-point rating scale (Not at all - Extremely)

  19. Correlates of depression

  20. Correlates of depression Depression does not exist in isolation and appears to be related more to functional aspects of smoking that amount smoked.

  21. Depression and smoking in adolescents • Smoking linked to depression in adolescents (Covey 1992; Tyas 1998R; Patten 1996; Escobedo 1996) • Attenuated but not removed by controlled for major common risk factors (Berard 2002; Fergusson 1996) • Intention to smoke linked to depression in young children (Coogan 1998)

  22. Depression as a predictor of smoking • Depression predicts uptake (Escobedo 1998; Brown 1996; Rohde 1994) possibly interacting with peer influence (Patton 1998) • Physical abuse predicts depression and smoking (Kaplan 1998)

  23. Smoking as a predictor of depression • Early onset smoking predicts depression and substance use later (Hanna 1999; Hanna 2001) • Adolescent smoking predicts major depressive episodes in later adolescence (Brown 1996) and adulthood (Cho 1998)

  24. Stopping smoking and depression • Acute studies show increase in depressed mood which resolves by about 4 weeks, more so in those with history of depression (Hughes 1994; Dalack 1995; Breslau 1992) • Numerous case reports of major depression following smoking cessation (Glassman 1990; Bock 1996) • Clinical depression found in 14% of those who stop smoking in trial but no more than those who did not (Tsoh 2000)

  25. Stopping smoking and depression • Major depressive episodes more likely in those with history of depression (Covey 1990; Covey 1997), those more depressed at baseline (Borrelli 1996) and those with ‘protracted withdrawal symptoms’ (Covey 1997) • But current smokers are more depressed than never or ex-smokers (e.g. Haukkala et al, 2000)

  26. Depression and stopping smoking • Population studies: Depressed smokers 40% less likely to have stopped after 9 years (Anda 1990) • Baseline depression and stopping - mixed findings: • No relationship (Vazquez 1999; ) • Significant relationship (Kinnunen 1996) • Increased depression during acute withdrawal sometimes predicts early relapse (Burgess 2002; Swan 1996; West 1989)

  27. Depression treatment and smoking cessation • Bupropion aids cessation and reduces depressed mood (Cochrane review) • MAO inhibitors may aid cessation (Cochrane review) • Works in patient with history of depression (Hayford 1999) • Nortriptyline aids cessation (Prochazka 1998)

  28. Depression treatment and smoking cessation • Nicotine gum may help particularly depressed patients (Kinnunen 1996) • Fluoxetine appears not to aid cessation (Cochrane review) and limited evidence for effect on depressed mood during withdrawal (Dalack 1995) • Mood-focused cognitive behavioural therapy - modest evidence for benefit over other treatments in aiding cessation (Patten 1998)

  29. Mechanisms

  30. Possible biological mechanisms • Smokers who smoke more for negative affect control are more depressed (Lerman 1996) • Cigarette smoke appears to have MAO inhibiting activity (Berlin 1995) • Smoking may increase brain 5HT and withdrawal may reduce it (Wurtman 1995)

  31. Possible genetic mechanisms • Analysis of twin data suggests link between major depression and smoking reflecting common underlying genetic vulnerability (Kendler 1993) • D1, DRD2 and D4 receptor genes may be implicated in increased susceptibility to nicotine dependence and to psychiatric conditions (Dagher 2001;Lerman 1998; Noble 2003)

  32. Psychiatric disorder increasing vulnerability to nicotine dependence • Increased need for nicotine reward • easy and reliable nicotine reward • self-medication (e.g. sensory gating) by nicotine • reduction in medication side-effects by nicotine • need to ‘fill time’ with smoking activity

  33. Evidence against self-medication hypothesis • Smoking cessation does not precipitate relapse to other disorders • depression (see earlier) • uncontrolled alcohol use (see Sullivan 2002) • Smoking cessation does not appear to lead to worsening of psychotic symptoms (Dalack 1999)

  34. Nicotine use and vulnerability to psychiatric disorder • Chronic nicotine intake may increase stress • reduced hippocampal 5-HT • chronic increase in sympathetic tone • Chronic nicotine intake may damage dopamine pathways in striatum

  35. Summary of the facts • About 80% of smokers suffer from the chronic, life-threatening psychiatric disorder: tobacco/nicotine dependence • Link with other psychiatric disorders is strong for all conditions, not just schizophrenia • The more severe the disorder the higher the smoking prevalence • There appear to be causal links in both directions

  36. Implications

  37. Implications for treatment • There is little need for concern that smoking cessation will provoke relapse in patients with history of psychiatric disorder • There is no good evidence that stopping smoking worsens psychotic symptoms; other symptoms may be improved

  38. Implications for diagnosis • One in five (22%) of UK smokers have current psychiatric disorder (Farrell et al, 2001) • Thus smoking may be a useful for screening prevalent, hidden disorders, particularly: • depression • anxiety • alcohol dependence

  39. Implications for treatment • Smoking cessation may be a useful intervention to improve minor psychiatric symptoms • Treating untreated minor psychiatric symptoms may improve smoking cessation outcomes • Smoking cessation treatment in psychiatric patients will need to be more intensive and prolonged and in some cases need to address other needs

  40. Latest news and views • Fagerstrom & Aubin Curr Med Res Opin. 2009 Feb;25(2):511-8 • Traditional programmes for smoking cessation may not always be suitable for psychiatric patients due to their neuropsychological profile. Preliminary evidence suggests that more flexible, open-ended, combination approaches of pharmacotherapy and counselling may be more successful • Alessi et al J Appl Behav Anal. 2008 Winter;41(4):617-22 • Prize contingency management reduced smoking compared with standard care in a pilot study

  41. Latest news and views • Solty et al Can J Psychiatry. 2009 Jan;54(1):36-45 • Self-reported motivation to quit is high in psychiatric inpatients • Kinnunen Int J Psychiatry Med. 2008;38(3):373-89 • NRT works in depressed and non-depressed smokers • Covey et al Nicotine Tob Res. 2008 Dec;10(12):1717-25 • Combined bupropion and nicotine patch treatment appears to be helpful for smokers with inattention but not smokers with hyperactivity/inattention symptoms

  42. Latest new and views • Zadonis et al Nicotine Tob Res. 2008 Dec;10(12):1691-715 • NIMH report. Historically, "self-medication" and "individual rights" have been concerns used to rationalize allowing ongoing tobacco use and limited smoking cessation efforts in many mental health treatment settings. Although research has shown that tobacco use can reduce or ameliorate certain psychiatric symptoms, overreliance on the self-medication hypothesis to explain the high rates of tobacco use in psychiatric populations may result in inadequate attention to other potential explanations for this addictive behavior among those with mental disorders.

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