Transcript Psychological Interventions for Tobacco Dependence

University of Wisconsin School of Medicine and Public Health
Center for Tobacco Research and Intervention
Psychiatric Morbidity and
Smoking Cessation
Stevens S. Smith, Ph.D.
Assistant Professor / Licensed Psychologist
Department of Medicine
University of Wisconsin School of Medicine and Public Health
Center for Tobacco Research and Intervention
GIM Primary Care Conference Presentation
October 25, 2006
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Disclosure Statement
I have received research support (but no consulting or
speaking fees) from the following companies that market
smoking cessation medications:
• SmithKline Beecham
• GlaxoSmithKline
• Elan Corporation, plc
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Learning Objectives
•
Psychiatric morbidity and cessation in
two case studies
•
Influence of psychiatric morbidity on
smoking cessation
•
Evidence-based cessation treatment
for smokers with psychiatric disorders
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Case Studies
Patient A
Patient B
Psychiatric
Diagnosis
Dysthymia,
Tobacco Use Disorder
Adj Disorder w/Anxiety,
Tobacco Use Disorder
Age, Race, Sex
60 y.o., White, Female
25 y.o., White, Female
Social Worker
Autism Therapist
Never married; not in
relationship currently
Never married; in 7-yr
relationship
DM Type II, Hypothyroidism,
Hyperlipidemia,
Hypertension,
Atheroscler. Heart Dis.
None
Aspirin, Bupropion, XL,
Desloratadine, Enalapril,
Vytorin, Glyburide, Metformin,
Levothyroxine,
Rosigliatazone
Kariva
Occupation
Marital Status
General
Medical
Conditions
Medications
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Case Studies
Patient A
Patient B
Psychiatric
Diagnosis
Dysthymia,
Tobacco Use Disorder
Adj Disorder w/Anxiety,
Tobacco Use Disorder
Age, Race, Sex
60 y.o., White, Female
25 y.o., White, Female
Weight, Ht., BMI
151 lbs, 61”, BMI=28.5
(no signif change in years)
159 lbs, 64”, BMI=27.3
(181 lbs, 64”, BMI=31.1)
130/70
126/86
Lipids
Tot Chol=155, Triglyc=122,
HDL=57, LDL=74
Tot Chol=232, Triglyc=96,
HDL=67, LDL=146
TSH
3.71 (119 in Sept 2005)
1.40
Exercise / Diet
No exercise, no special
diet
Exercise 30 min 3x/wk,
Weight Watchers
HbA1c %
7.8% (10.2% in Sept 2005)
N/A
Other Hx
Hx of Alcoholism; no alc for
20+ years
None
BP
5
Case Studies: Smoking History
Patient A
Patient B
Psychiatric Diagnosis
Dysthymia,
Tobacco Use Disorder
Adj Disorder w/Anxiety,
Tobacco Use Disorder
Age, Race, Sex
60 y.o., White, Female
25 y.o., White, Female
Age 1st Cig
18 years old
13 years old
Daily smoking
23 years old
Started at age 15, 20 cpd
42 years
10 years
Most recent cigs/day
1 pack/day
10-15 cigs/day
# prior quit attempts
“Many” but no serious
quit attempts
6 (3 serious)
1 day
2 months (2005)
N/A
Bupropion SR, tapering
Work stress, caretaker
for Mom w/Alzheimer’s,
shaky social support
Partner smokes
# years smoking
Longest quit
Prior Cessation Tx
Other info
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Progress: Dramatic Decrease in Adult
Smoking Prevalence Over 40 Years
1965
Number
Current 50 million
Former 16 million
Never
52 million
Percent
42.4%
13.6%
44.0%
2005
Number
Percent
47 million
51 million
135 million
20.9%
21.5%
57.6%
(Source: National Health Interview Surveys, 1965-2005)
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42.4%
20.9%
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Remaining Challenges
• > 400,000 deaths per year nationally (8000 in WI)
• 2,000 children and adolescents become regular
smokers each day
• $75 billion in added healthcare costs
• $80 billion in lost productivity
• Low rates of clinical assistance with quitting
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2003 Wisconsin Tobacco Survey
Long-term success rate of “cold turkey” method is about 5%
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Disproportionate Smoking Rates
The highest rates of smoking are seen in individuals :
• living below the poverty level
• with the least education
• working in blue-collar and service jobs
• with psychiatric and substance use disorders
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Tobacco Dependence and Mental Illness
• Individuals with mental disorders typically smoke more
cigarettes per day and they have greater difficulty
quitting smoking
• Individuals with a current psychiatric disorder currently
make up about 30% of the population but consume 46%
percent of all cigarettes smoked in the U.S.
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Smoking Status and Mental Illness:
The National Comorbidity Survey
U.S. Population
Current
Smokers
Lifetime Ever
Smokers
No Mental Illness
50.7%
22.5%
39.1%
Mental Illness
During Lifetime
49.3%
34.8%
55.3%
Any Past Month
Mental Illness
28.3%
41.0%
59.0%
(Source: Lasser et al., JAMA. 2000;284:2606-2610)
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Smoking Status and Mental Illness:
The National Comorbidity Survey
Past 30 Days
% Current
Smoking Quit Rate, %
• No Mental Illness
• Major Depression
• Nonaffective Psychosis
• Gen. Anxiety Disorder
• Alcohol Abuse or Dependence
• Bipolar Disorder
• Drug Abuse or Dependence
23
45
45
55
56
61
68
43
26
0
29
17
26
22
(Source: Lasser et al., JAMA. 2000;284:2606-2610)
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Smoking Rate and Number of
Lifetime Psychiatric Diagnoses
60
50
40
% Who Are
30
Smokers
20
% Heavy Smokers
10
% Light-Moderate
Smokers
0
0
1
2
3
4
>4
No. of Lifetime Psychiatric
Diagnoses
(Adapted from Lasser et al., 2000)
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Tobacco Dependence and
Mental Illness
• Smokers with mental illnesses are aware of the
health risks of smoking
• However, nicotine may alleviate positive and
negative psychiatric symptoms as well as side
effects of psychiatric medications
• Effective smoking cessation treatments are
available for smokers with mental illness
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U.S. Public Health Service
Clinical Practice Guideline
Michael C. Fiore, MD, MPH
Panel Chair
Published June, 2000
Evidence-based
50 meta-analyses of
6000 articles (1975-1999)
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Putting the 5 A’s into PRACTICE:
ASK – ADVISE – ASSESS – ASSIST- ARRANGE
• Help develop a quit plan
• Provide practical counseling
• Provide intra-treatment social support
• Encourage the smoker to seek social support
• Recommend pharmacotherapy except in special
circumstances
• Provide supplementary materials
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ASK – ADVISE – ASSESS – ASSIST- ARRANGE
Pharmacotherapy
•The Guideline recommends the use of FDA-approved
pharmacotherapy, except when contraindicated
First-line medications:
Bupropion SR, nicotine patch,
nicotine gum, nicotine inhaler,
nicotine nasal spray
• Second-line medications: Clonidine, nortriptyline
(Although not available when the 2000 Guideline was
developed, consider OTC nicotine lozenge, varenicline)
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Who Should Receive Pharmacotherapy?
• The Guideline recommends that ALL smokers
trying to quit should be offered cessation
medication except for special circumstances:
- medical contraindications
- smoke < 10 cigarettes/day
- pregnant/breastfeeding
- adolescent smokers
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Guideline Recommendations for Smokers
With Psychiatric Comorbidities
• The antidepressants bupropion SR and nortriptyline
should be considered for smokers with current or past
history of depression
• Stopping smoking may affect the pharmacokinetics of
certain psychiatric medications: need to monitor
• No specific recommendations in the Guideline for
treating smokers with anxiety disorders
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General Recommendations for
Depressed Smokers
• Smoking cessation treatment can be initiated in
depressed smokers who are motivated to quit and
clinically stable
• Consider prescribing bupropion SR or nortriptyline (as
appropriate given other possible psychotropic meds)
• Consider nicotine replacement therapy (NRT) either as
a first-line pharmacotherapy or to augment bupropion
SR or nortriptyline
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General Recommendations for
Depressed Smokers
• Consider varenicline as another first-line
pharmacotherapy but do not combine with NRTs
• There are no clinical studies of varenicline in
combination with bupropion SR or nortriptyline (no
concern about drug interactions according to Michael
Fiore, M.D.)
• Consider referral to a mental health specialist
especially if the smoker’s depression is not responding
to antidepressant pharmacotherapy alone
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General Recommendations for
Smokers With an Anxiety Disorder
• Smoking cessation treatment can be initiated in anxious
smokers who are motivated to quit and clinically stable
• Neither bupropion SR nor nortriptyline are
recommended for patients with anxiety disorders
• SSRIs and benzodiazepines are commonly prescribed
for anxious patients; neither of these has shown
efficacy for smoking cessation
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General Recommendations for
Smokers With an Anxiety Disorder
• Consider nicotine replacement medication as the firstline pharmacotherapy
• Consider varenicline as another first-line
pharmacotherapy but do not combine with NRTs
• Consider referral to a mental health specialist
especially if the smoker’s anxiety is not responding to
pharmacotherapy alone
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Real-World Use of
Combination Pharmacotherapy
Source: University of Medicine & Dentistry of New Jersey – Tobacco Dependence Clinic – Annual Report 2004
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Case Studies
Patient A
Patient B
Psychiatric
Diagnosis
Dysthymia,
Tobacco Use Disorder
Adj Disorder w/Anxiety,
Tobacco Use Disorder
Age, Race, Sex
60 y.o., White, Female
25 y.o., White, Female
Date Tx Initiated
for Psychiatric
Condition
June 2002
(33 Tx sessions to date)
August 2006
(7 Tx sessions to date)
Status of Quit
Patient has been unable to
Attempts During
quit at all despite setting quit
Current Treatment dates (QDs) for:
With Dr. Smith
January 1, 2004
February 2004
June 2006
(Next: January 1, 2007;
wants to use varenicline)
Patient quit on Sept 10th
She elected to use the
14 mg nicotine patch 2
weeks, then 7 mg patch
for 2 weeks
Has been successfully
quit for 6 weeks
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Contact Information
Stevens S. Smith, Ph.D.
Phone: 608-262-7563
[email protected]
www.ctri.medicine.wisc.edu
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