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