Depression and smoking: Treatments Lirio S. Covey, Ph.D. Columbia University New York State...
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Depression and smoking: Treatments
Lirio S. Covey, Ph.D.
Columbia University
New York State Psychiatric Institute
New York, NY, U.S.A.
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Depression is a risk factor for:
Initiation of smoking
Progression to dependence
Failure to quit smoking
Intense withdrawal symptoms
Post-cessation depression
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Initiation of smoking
Smokers with depression are more likely to become smokers
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Progression from experimentation to
dependence
In data from young adults, there is a higher likelihood of smoking developing to dependence among those with MDD.
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Failure to stop smoking
There has been some inconsistency in observations of effect of past MDD on smoking cessation.
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Increased withdrawal symptoms
Smokers with past major depression experience higher levels of withdrawal symptoms.
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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
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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.
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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
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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
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Observations from an ongoing
Smoking cessation trial
2001 – 2005
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“Maintenance treatment for prevention of smoking relapse”
Support:
NIDA RO1#13490Medication support from GSK
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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
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Phase 1: 8-week Open Rx
Zyban-SR
Nicotine patch
Individual Counseling
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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.
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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?
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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
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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%
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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)
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Psychiatric History
21% Past Major Depression 14% Single 7% Recurrent
14% Past Alcohol Dependence
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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.
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Smokers with depression are NOT so different from smokers without depression on smoking characteristics:
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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
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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
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Other reported differences according to presence or absence of MDD history
Less successful early quitting
Higher rate of relapse to smoking
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Implications for treatment
Applying the 5 A’s. Ask
Advice Assess Assist
Arrange
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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
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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.
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ASSESS
Depression Status
Level of nicotine dependence
Attitudes about stopping smoking
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ASSESS
Depression Status Current or past Single or recurrent (index of severity) Level of negative affect
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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
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ASSESS
Attitudes about stopping smoking Willing to stop? Motivation level? Confidence in ability to succeed
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ASSIST
Clinical support
Knowledge and access to smoking cessation aids
Self-help materials
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ASSIST
Clinical support Smokers with recurrent MDD are
responsive to intensive counseling E.g. Cognitive behavioral therapy
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ASSIST
Nicotine gum (4 mg) reduced depressed mood during withdrawal
Nicotine gum (4 mg) increased abstinence rate among smokers with MD
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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
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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
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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
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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
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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
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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.
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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?