Tobacco dependence in mental health disorders

Tobacco Dependence in Mental Health disorders

When is it Addiction?Three or more of the following:

Preoccupation with getting tobacco

Compulsive use

Difficulty with controlling intake

Persistent, even with health problems

Relapse

Tolerance

Withdrawal

How long does it take to become dependent?

Can be after the first cigarette!

References: World Health Organization Diagnostic and Statistical Manual - IV (DSM-IV)

What Initiates Tobacco Use?

Physiological Needs

Security & Safety Needs

Social Needs

Esteem Needs

SelfActualization Being Need

Deficit Needs

A. H. Maslow. A Theory of Human Motivation. Psychological Review, 50, 370-396. (1943)

Addiction via smoking

cigarettes have additives that cause addiction

sensory cues (heat, sight, and smell)

smokers have greater number of nicotinic receptors

inhalation from cigarettes causes nicotine to cross blood brain barrier more rapidly

Stages of Change Model

Prochaska, J. & DiClemente, C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.

Interventions

PharmacologicBehavioral

• Self-help materials• Brief Advice• Counseling• Exercise

• Nicotine-replacement therapy• Bupropion• Varenicline

Multi-Component Interventions Increase Long-Term Quit Rates

NoTherapy

Brief Advice

Behavioral Therapy

Placebo/No Medication

5% 10% 15%

First-Line Medication

10% 20% 30%

Source: Hughes JR. CA Cancer J Clin 2000;50:147.

The prevalence of tobacco use in people with MHA disorders is 2 to 4 times higher than in the general population (lesser et at, 2008).

The more important that many of them were unable to quit smoking.

Other studies have found that people with MHA disorders are at higher risk for developing many tobacco-related diseases, including cardiovascular and respiratory disease, and various cancers, compared with the general population (Hennekens et al, 2005).

Why?

Several explanations have been proposed for the high prevalence of smoking in people with MHA disorders (kalman et al,2005).

1.There may be intrinsic factors (for example, shared genes) that predispose people with MHA to initiation and maintenance of smoking behaviours.

2.Nicotine may be used by MHA patients to self medicate psychiatric symptoms and psychotropic drug side effects.

Cont...3.There may be common social and environmental determinants of this comorbidity (for example, easy access and availability, poverty, environmental stressor).

4. Nicotine administration through cigarette smoking may modulate several neurotransmitter systems (for example, DA, Glu, and GABA) thought to be involved in the pathogenes is of MHA disorders.

5. Psychological mechinsms: distress tolerance, negative affect and anxiety sensitivity and personality traits.

Treating Tobacco Use and Dependance in psychiatric patients.

Nicotine metabolism is mediated primarily by the cytochrome P450 1A2 (CYP1A2) and by CYP2A6. Since many psychiatric drugs, including diazepam, haloperidol, olanzapine, clozapine, fluphenazine, and mirtazapine, are also metabolized through CYP1A2 induction, smoking can lower their therapeutic blood levels and decrease their effectiveness.

Heavy smokers would require a 50–100% increase in olanzapine dose compared with nonsmokers to achieve the same therapeutic level (wu et al,2009).

Cont...

Smoking cessation leads to increased plasma concentrations with increased risks of adverse effects, creating a requirement for close drug dose monitoring in smokers during smoking cessation.

Conversely, antipsychotic medications may differentially impact an individual’s smoking status; for example, patients with schizophrenia were found to smoke more after initiation of haloperidol treatment and less when switched from haloperidol to clozapine.

Cont...

Other atypical antipsychotic medications, for example olanzapine and risperidone, can also reduce smoking rates and this effect may be attributable to increased cortical dopamine release, as well as enhanced prefrontal NMDA receptor-mediated transmission (Jardemark et al,2005).

It had been thought that smoking cessation may lead to an exacerbation of psychiatric symptomatology and an erroneous belief that smokers with comorbid psychiatric conditions are not motivated to quit smoking.

Cont...

Fortunately, the preponderance of evidence suggests that psychiatric symptoms typically do not worsen and, in fact, may even improve following abstinence from tobacco (hitsman et al, 2009).

1-Schizophrenia: Patients with schizophrenia are the group with the highest rates of tobacco use (70-85%), and for whom there has been considerable interest in identifying effective smoking cessations interventions .

Cont...

Between the recommended pharmacotherapies for treating nicotine dependence, bupropion has been demonstrated to have the greatest benefits for these patient population (banham et al, 2010).

The same meta-analysis found there was no evidence of benefit of NRT in smokers with schizophrenia.

Cont...

2-mood and anxiety disorders: About 45% of patients with major depressive disorder smoke. At present, the approach with the most empirical support, is the inclusion of cognitive behavioral therapy focusing on mood management as part of the cessation intervention.

With regard to pharmacotherapy, there is insufficient evidence to suggest that a particular type of medication is more effective for patients with comorbid depression.

Cont...

Despite the high rates of smoking among those with anxiety disorders, surprisingly little is known the best way to approach treatment for this patient population. Results for one small-scale study suggest that bupropion may increase cessation rates among patients with PTSD (Hertzberg et al,2001).

3-ADHD: Bupropion has shown efficacy in treating dults with ADHD and has also been approved by the Food and Drug Administration as an aid to smoking cessation (Wilens et al, 2006). Novel cholinergic agents have also shown promise in treating adults with ADHD (Vanable et al,2003).

Cont...

Non pharmacological approaches to treating ADHD might also be useful in facilitating smoking cessation. Emerging work shows promise for the use of ognitive-behavioral treatment of adults with ADHD.

It is not all or non?

Smoking cessation treatments in which treatment participation and smoking reduction have been targeted outcomes, with abstinence as the implicit end point, have tended to be more successful in achieving substantial smoking reduction and eventual abstinence in MHA smokers (Gallagher et al,2007).

Tobacco Policy for Inpatient Psychiatric Units

Smokers with MHA disorders often do not have access to supports that help to promote quitting and sustained smoking abstinence. The psychiatric treatment setting, especially inpatient units, can serve an important role in promoting smoking cessation.

Concern that restricting smoking may exacerbate clinical status has contributed to a reluctance to enforce smoking bans despite evidence that smokers, compared with nonsmokers, present with more severe symptomatology.

Most studies report positive outcomes following inpatient bans (Lawns et al, 2005).

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