depression and smoking: treatments lirio s. covey, ph.d. columbia university new york state...

Depression and smoking: Treatments

Lirio S. Covey, Ph.D.

Columbia University

New York State Psychiatric Institute

New York, NY, U.S.A.

Depression is a risk factor for:

Initiation of smoking

Progression to dependence

Failure to quit smoking

Intense withdrawal symptoms

Post-cessation depression

Initiation of smoking

Smokers with depression are more likely to become smokers

Progression from experimentation to

dependence

In data from young adults, there is a higher likelihood of smoking developing to dependence among those with MDD.

Failure to stop smoking

There has been some inconsistency in observations of effect of past MDD on smoking cessation.

Increased withdrawal symptoms

Smokers with past major depression experience higher levels of withdrawal symptoms.

Nicotine withdrawal symptoms: intensity at week 1 after quit day

0

0.5

1

1.5

2

2.5

3

3.5

4

MDD

No MDD

p<.05p<.01

Covey et al, Comp Psychiatry,1991

craving irritable anxious restless appetite concentr depressed

Smokers with pasts depression are at risk ofnew MDD following a smoking cessation attempt

The risk of a new episode may be independent of abstinence status.

Simply making the effort may provoke the new depressive episode.

Incidence of major depressive episodes in3-month follow-up of126 abstinent smokers

0

5

10

15

20

25

30

No MDD Single MDE Recurrent MDE

p=<.001,

Covey et al, Am J Psychiatry, 1997

Incidence of major depressive episodes in 12 month clinical trial of 304 smokers

0

5

10

15

20

25

Nonabstainers Abstainers

No MDD

MDD HX

Tsoh et al, Am J Psychiatry, 2000

Observations from an ongoing

Smoking cessation trial

2001 – 2005

“Maintenance treatment for prevention of smoking relapse”

Support:

NIDA RO1#13490Medication support from GSK

Study DesignAim: Efficacy of extended pharmacotherapy8-week Open Rx

16-wk D/Blind Maintenance Zyba

nNic patch

Counseling

Pbo + Pbo

Pbo + Nic Gum

Zyban + Pbo Gum

Zyban + Nic Gum

Rx-freeFollow-up

9th mo.

12th mo.

Phase I Phase II Phase III

Successes

Phase 1: 8-week Open Rx

Zyban-SR

Nicotine patch

Individual Counseling

STOP SMOKINGand STAY QUIT!

(212) 543-5905

Take part in research studiesat no cost to you.

Zyban, Nicotine Patch, Medical Exam, Counseling

The Smoking Cessation Clinic at Columbia University

Se requiere leer ingles.

COMO??Por medio de un estudio de investigación con tratamientos para

DEJAR de FUMAR Recibirás completamente gratis:

  Examén Médico  Concejería

    Zyban + Parches de Nicotina 

No lo dejes para más tarde!! Llama al: (212) 543-5905

 The SMOKING CESSATION CLINIC at COLUMBIA UNIVERSITY

 Se requiere leer inglés.

Le gustaría DEJAR de FUMAR?

Study Sample: n= 588

Mean age = 41 years (s.d.=11) 52% Males, 48% Females 62% Caucasian 21% African-American 12% Hispanic 5% Asian 39% Married/with mate

Socio-demographic characteristics

College - 51%, Graduate School – 28%

Professional/Executive – 34% Technical/Administrative/Clerical – 45% Blue-collar – 21%

< $29,000 – 23% $30,000-$50,000 – 37% $51,000 > - 40%

Smoking exposure at baseline

Cigarettes smoked per day 21.8 (14.1) Age first smoked 15.3( 3.7) Age smoked regularly 17.5 (3.9)

Carbon Monoxide 16.3 (8.5) Serum Cotinine 254.5 (121.1) Cotinine/cigarette ratio 13.2 (11.8)

Fagerstrom Test Nicotine Dependence 5.2 (2.0)

Psychiatric History

21% Past Major Depression 14% Single 7% Recurrent

14% Past Alcohol Dependence

Dependence, and tobacco intake according to frequency of MDD

No MDD S-MDD R-MDDMean (s.d.) Mean (s.d.) Mean (s.d.) p

Fagerstrom 5.2 (2.1) 5.2 (1.8) 5.6 (1.8) N.S.

Cigarettes/day 21.5 (11.1) 24.9 (26.2) 20.0 (7.1) 0.09

Cotinine 259 (124) 247 (110) 221 ( 89) N.S.

Times quit 3.5 (2.5) 3.9 (3.4) 4.3 (4.3) N.S.

Age began smoking 17.3 (4.1) 17.4 (6.9) 16.4 (5.8) N.S.

Smokers with depression are NOT so different from smokers without depression on smoking characteristics:

Psychological and Personality Variables by MDD history

0

10

20

30

40

50

Trait Anx POMS Neg Neuroticism HarmAvoidance

No MDD Single MDD Recurr MDD

All p values = 0.000

MDD history and age of MDD onset

S-MDD R-MDDMean (s.d.) Mean (s.d.) p

Age, years 33.4 (11.2) 23.0 ( 9.6) 0.000

Other reported differences according to presence or absence of MDD history

Less successful early quitting

Higher rate of relapse to smoking

Implications for treatment

Applying the 5 A’s. Ask

Advice Assess Assist

Arrange

ASK

Among patients who are smokers, probe for depressive symptoms or depressive disorder (past or present)

Among patients who present with depression, ask about smoking status

ADVISE

For smokers who present with depression, in clear, strong, and personalized manner, give advise regarding harmful consequences of tobacco and benefits of stopping smoking.

ASSESS

Depression Status

Level of nicotine dependence

Attitudes about stopping smoking

ASSESS

Depression Status Current or past Single or recurrent (index of severity) Level of negative affect

ASSESS

Level of nicotine dependence Fagerstrom Test for Nicotine Dependence DSM-IV nicotine dependence criteria

Number of cigarettes smoked daily Carbon monoxide level Cotinine level

ASSESS

Attitudes about stopping smoking Willing to stop? Motivation level? Confidence in ability to succeed

ASSIST

Clinical support

Knowledge and access to smoking cessation aids

Self-help materials

ASSIST

Clinical support Smokers with recurrent MDD are

responsive to intensive counseling E.g. Cognitive behavioral therapy

ASSIST

Nicotine gum (4 mg) reduced depressed mood during withdrawal

Nicotine gum (4 mg) increased abstinence rate among smokers with MD

ASSIST

Bupropion (Zyban) and Nortriptyline showed same short-term results regardless of MDD history

Smith et al, 2004 - Zyban helpful for female smokers and those with MD history

EOT (Week 9) abstinence rates for 4 treatment groups by history of depression

0

10

20

30

40

50

60

70

80

Placebo Bupropion Nicotine P Bup + NP

No HxHx MDD

ARRANGE Follow-up

Prevent relapse to smoking - negative affect increases risk of smoking relapse

Prevent relapse to depression - smokers with past MDD are at risk of experiencing a recurrence of depression

ARRANGE

Schedule followup contact, preferably within first week after the quit date.

Congratulate success View lapse as learning experience Anticipate challenges Assess medications Consider referral

Implications for cessation treatment

Smokers with depression will:

require more intensive interventions What works?

Higher Nicotine Replacement dose Bupropion or Nortriptyline Clonidine Greater intensity of clinical support/counseling Longer follow-up/monitoring to identify

psychiatric sequelae

Other Questions, no empirical evidence

How to help depressed smokers who are currently depressed.

How to help smokers with depression history being maintained on antidepressants.

Depression and smoking: Challenge to Psychiatry, General Medicine, and Public Health

Depression-prone smokers require intensive treatments. In addition to pharmacotherapy: Psychologically trained therapists More frequent contacts Longer duration of treatment

Are these costly treatments worthwhile?