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Dr Kam Dhillon Head of Research. Taking a deep breath Smoking cessation and diagnosed mental health problems. Smoking and Mental Health. In the general population adult tobacco use is in decline, more so since the ban.
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Dr Kam Dhillon Head of Research Taking a deep breathSmoking cessation and diagnosed mental health problems
Smoking and Mental Health • In the general population adult tobacco use is in decline, more so since the ban. • However, cessation rates are 2 to 3 times lower for people with mental health problems. • No appreciable reduction in tobacco consumption among people with mental health problems. • People with diagnosed mental health problems have high rates of smoking.
Smoking and the brain • Within 10 seconds of inhaling tobacco smoke, nicotine reaches the brain and acts on specific neurons and releasing noradrenalin and dopamine that act as stimulants. This can lead to improved mood, concentration, decreased anxiety and stress. • This is more illusionary than real. Withdrawal symptoms kick in and are relieved by more smoking. Over time tolerance goes up and more nicotine is needed for ‘normal’ state. • Cravings feel stressful and smoking feels relaxing - self medication is established.
Stress and anxiety • 420,000 people reported stress at a level that was making them ill. • 47% of people with Generalised Anxiety Disorder smoke. • Self-medication hypothesis is a strong explanation, but sources of anxiety are also beyond the nicotine withdrawal symptoms. • People with eating disorders say that the strongest motivation for smoking was coping with stress and anxiety.
Depression • Many epidemiological studies link clinical depression with smoking. • Long term nicotine exposure may have a causal influence on depression Vs shared environmental or genetic factors predispose to both smoking and depression. • Previous smoking history increases the risk of depressive symptoms and depression. • For women, smoking increases the risk of major depression by 93% (Pasco et al, BJP, 2008). • 56% of people with depression diagnoses smoke and smoke earlier in the day, harder to quit and more likely to relapse.
Schizophrenia • People with schizophrenia diagnoses are more likely to smoke (88%) and smoke more heavily, particularly if staying in psychiatric settings. • They smoke early on in the day and find it harder to stop. • The are more likely to have smoking related illness – accounting for other relevant risk factors. • Reasons for high nicotine consumption may include – start younger, co-morbidity with other drug use, culture of inpatient wards and boredom. • Nicotine consumption reduces the negative symptoms of schizophrenia, due to increased dopamine – further self-medication. Dopamine pathways not absolutely clear.
Alzheimer’s disease • AD is the most common form of dementia. • 400,000 affected in UK. • Neuro-protective effect? – nicotine appears to alleviate the neurological impairment associated with the disease, may delay the onset. • Other research indicates that smoking increased the risk of AD. • An under-researched area.
Smoking cessation and mental health • Around 50% of smokers with mental health problems would like to quit. • However, cessation rates remain 2 to 3 times lower for people with mental health problems. • People with mental health problems get less support than other quitters. • They tend to be living in environments where smoking is a ‘norm.’ • They refuse voluntary psychiatric admission if forced to stop smoking. • They leave psychiatric settings earlier if stopped from smoking.
Psychological approaches to cessation • Psychological approaches widely available now. • Counselling is effective, both individual and group, with different intensity and duration (1,3, 6 session). • CBT shown to be effective for smokers with depression and schizophrenia. • The need to acknowledge and be mindful of mental health diagnoses in the therapeutic process is important – practitioners need to work with their professional accountability and ethics in mind.
Pharmacological approaches • Nicotine Replacement Therapy, anti-depressants and other medication has proved to be successful for cessation, but more applied research needed. • NRT has been effective in psychiatric in-patient settings but higher strength patches may be needed. • Smokers with depression have had positive outcomes with Buproprion (Zyban), but needed prescriptions beyond the usual 8 weeks.
Combined approaches • Combined psycho-pharmo interventions have been shown to be the most effective (i.e. NRT, CBT and MI). • Studies have shown positive results for smokers with depression, where 10 weeks of CBT addressed the depression too. • Sustained release Zyban, combined with CBT had significant positive cessation results for smokers with schizophrenia.
Smoking ban in England • Tobacco kills around 87,000 people annually in England alone (Smoke free England – One year on, DH, July 2008). • Compliance to the legislation has been high. • Local NHS Stop Smoking services have had a 20% increase in demand. • We do not know how people with mental health problems have fared since the smoking ban. • People are smoking outside psychiatric settings, like others in other clinical settings. • GPs now minded to record smoking prevalence and PCTs asked to increase prescribing of stop smoking products, encourage more smoke-free work places and target high risk groups (DH, 23rd September 2008).
Strategies for working with smokers with mental health problems • Recognise that the traditional approaches do not work as there appears a different and stronger relationship with nicotine. • Explore with people this relationship with nicotine – employ CBT oriented strategies with greater flexibility – combination approaches successful – keep mental health in the foreground, accounting for different vulnerabilities. • Confidence building and stress management activities are helpful. • Be aware of your capabilities and scope of work and refer to and work with other professionals.
