Nicotine and psychiatric disorder

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Nicotine and psychiatric disorder
Robert West University College London
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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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Tobacco/nicotine dependence as a psychiatric
disorder
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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

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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
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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
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Smoking patterns and psychiatric diagnoses
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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 ....

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Smoking and psychiatric diagnoses in the
population
Meltzer 1995)
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Smoking and psychiatric diagnosis in in
institutions

• Very high smoking prevalence in all
  institutionalised patient groups
• Level is similar in the homeless

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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)

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OPCS Psychiatric Morbidity Survey
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Smoking and deprivation

• Need to rule out deprivation as an explanation
• Strong link between nicotine dependence and
  deprivation

From Jarvis et alDeprivation indexed by
occupation, educational level, housing
tenure, car ownership, unemployment, and living
in crowded accommodation)
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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)

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Substance use and psychiatric disorder in the
general population
OPCS Psychiatric Morbidity Survey Meltzer et al
1995
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Focusing on depression
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Depression and smoking in smokers taking part in
stop smoking trial

• N950
• Mean age 44 years
• 61 female
• Cigs per day23
• Expired air CO26ppm
• Measured depression in postal questionnaire and
  at pre-quit session (R0.38, plt.001)
• 5-point rating scale (Not at all - Extremely)

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

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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Mechanisms
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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)

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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
  2001Lerman 1998 Noble 2003)

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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

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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)

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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

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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

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Implications
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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

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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

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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

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Latest news and views

• Fagerstrom Aubin Curr Med Res Opin. 2009
  Feb25(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
  Winter41(4)617-22
• Prize contingency management reduced smoking
  compared with standard care in a pilot study

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Latest news and views

• Solty et al Can J Psychiatry. 2009
  Jan54(1)36-45
• Self-reported motivation to quit is high in
  psychiatric inpatients
• Kinnunen Int J Psychiatry Med. 200838(3)373-89
• NRT works in depressed and non-depressed smokers
• Covey et al Nicotine Tob Res. 2008
  Dec10(12)1717-25
• Combined bupropion and nicotine patch treatment
  appears to be helpful for smokers with
  inattention but not smokers with
  hyperactivity/inattention symptoms

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Latest new and views

• Zadonis et al Nicotine Tob Res. 2008
  Dec10(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.