1、1,GIM Primary Care Conference Presentation October 25, 2006,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,Psychiatric Morbidity and Smoking Cessation
2、,2,Disclosure Statement,I have received research support (but no consulting or speaking fees) from the following companies that market smoking cessation medications:,SmithKline BeechamGlaxoSmithKlineElan Corporation, plc,3,Learning Objectives,Psychiatric morbidity and cessation in two case studies I
3、nfluence of psychiatric morbidity on smoking cessation Evidence-based cessation treatment for smokers with psychiatric disorders,4,Case Studies,5,Case Studies,6,Case Studies: Smoking History,7,Progress: Dramatic Decrease in Adult Smoking Prevalence Over 40 Years,1965 2005Number Percent Number Percen
4、t Current 50 million 42.4% 47 million 20.9% Former 16 million 13.6% 51 million 21.5%Never 52 million 44.0% 135 million 57.6%,(Source: National Health Interview Surveys, 1965-2005),8,20.9%,42.4%,9, 400,000 deaths per year nationally (8000 in WI) 2,000 children and adolescents become regular smokers e
5、ach day $75 billion in added healthcare costs $80 billion in lost productivity Low rates of clinical assistance with quitting,Remaining Challenges,10,2003 Wisconsin Tobacco Survey,Long-term success rate of “cold turkey” method is about 5%,11,Disproportionate Smoking Rates,The highest rates of smokin
6、g are seen in individuals :living below the poverty levelwith the least educationworking in blue-collar and service jobs with psychiatric and substance use disorders,12,Tobacco Dependence and Mental Illness,Individuals with mental disorders typically smoke more cigarettes per day and they have great
7、er difficulty quitting smokingIndividuals 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.,13,(Source: Lasser et al., JAMA. 2000;284:2606-2610),Smoking Status and Mental Illness: The National Comorbidity Su
8、rvey,14,% CurrentPast 30 Days Smoking Quit Rate, %No Mental Illness 23 43Major Depression 45 26Nonaffective Psychosis 45 0Gen. Anxiety Disorder 55 29Alcohol Abuse or Dependence 56 17Bipolar Disorder 61 26Drug Abuse or Dependence 68 22,(Source: Lasser et al., JAMA. 2000;284:2606-2610),Smoking Status
9、and Mental Illness: The National Comorbidity Survey,15,(Adapted from Lasser et al., 2000),Smoking Rate and Number of Lifetime Psychiatric Diagnoses,16,Tobacco Dependence and Mental Illness,Smokers with mental illnesses are aware of the health risks of smoking However, nicotine may alleviate positive
10、 and negative psychiatric symptoms as well as side effects of psychiatric medications Effective smoking cessation treatments are available for smokers with mental illness,17,U.S. Public Health Service Clinical Practice GuidelineMichael C. Fiore, MD, MPH Panel ChairPublished June, 2000Evidence-based5
11、0 meta-analyses of 6000 articles (1975-1999),18,Putting the 5 As 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 circu
12、mstances Provide supplementary materials,19,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 spraySecond-line medications: Clonidine, nortriptyline(Althou
13、gh not available when the 2000 Guideline was developed, consider OTC nicotine lozenge, varenicline),ASK ADVISE ASSESS ASSIST- ARRANGE Pharmacotherapy,20,The Guideline recommends that ALL smokers trying to quit should be offered cessation medication except for special circumstances:- medical contrain
14、dications- smoke 10 cigarettes/day- pregnant/breastfeeding- adolescent smokers,Who Should Receive Pharmacotherapy?,21,Guideline Recommendations for Smokers With Psychiatric Comorbidities,The antidepressants bupropion SR and nortriptyline should be considered for smokers with current or past history
15、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,22,General Recommendations for Depressed Smokers,Smoking cessation treatment can be initiated in
16、 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
17、,23,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
18、.) Consider referral to a mental health specialist especially if the smokers depression is not responding to antidepressant pharmacotherapy alone,24,General Recommendations for Smokers With an Anxiety Disorder,Smoking cessation treatment can be initiated in anxious smokers who are motivated to quit
19、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,25,General Recommendations for Smokers With an Anxiety Di
20、sorder,Consider nicotine replacement medication as the first-line pharmacotherapy Consider varenicline as another first-line pharmacotherapy but do not combine with NRTs Consider referral to a mental health specialist especially if the smokers anxiety is not responding to pharmacotherapy alone,26,Real-World Use of Combination Pharmacotherapy,Source: University of Medicine & Dentistry of New Jersey Tobacco Dependence Clinic Annual Report 2004,27,Case Studies,28,Stevens S. Smith, Ph.D. Phone: 608-262-7563sssctri.medicine.wisc.eduwww.ctri.medicine.wisc.edu,Contact Information,
