Warsaw, ENQ meeting, May 2008 Regina M. van der Meer MPH, Marc C. Willemsen PhD,

1. Smoking cessation intervention for smokers with past major depression:arandomized controlled trial Warsaw, ENQ meeting, May 2008 Regina M. van der Meer MPH, Marc C. Willemsen PhD, Pim Cuijpers PhD, Filip Smit PhD, Gerard M. Schippers PhD

2. Major depression?

3. Major depression? • Having a very bad hair day

4. Major depression (DSM–IV) • Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; • At least one of the symptoms is: • Depressed mood or • Loss of interest or pleasure

5. Major depression (DSM–IV) • Significant weight loss or decrease or increase in appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or guilt • Diminished ability to think or concentrate, or indecisiveness • Recurrent thoughts of death

6. Pastmajor depression • Lifetime major depression, • but not • within the last month

7. Smoking & past major depression • Smoking and depression are strongly associated • Smokers are more likely to have past major depression than non-smokers • & • Persons with past major depression are more likely to be smokers than non-smokers • (Glassman, 1993; Kalman et al., 2005)

8. Smoking & past major depression • A recent study from Wiesbeck and colleagues in Neuropsychobiology support the evidence that smoking is linked to depression. • They found the highest rate of lifetime depression in current smokers (23,7%), the lowest rate in never smokers (6,2%) and the rate of those who had quit smoking was 14,6.

9. Smoking cessation & past major depression • Hughes (2007) found in a recent review that smokers with a past major depression clearly have an increased risk for a new depression after quit smoking when compared with smokers without a past major depression. • This might explain why it is more difficult for smokers with past major depression to quit.

10. Smoking cessation & past major depression • An often mentioned underlying mechanism is the self-medication assumption: • Smokers use cigarettes as a form of self-medication for coping with depressive symptoms • Smokers with past major depression may quit more easily if they have learned to better manage their mood without needing cigarettes.

11. Smoking cessation & past major depression • This self-medication assumption has resulted in several studies examining smoking cessation interventions that include strategies for managing depressive symptoms. (Hall et al., Brown et al) • But non of these interventions consisted out of telephonic counselling and most of these studies were very small.

12. I can handle the world, smokefree!

13. Aim of study • To assess whether the Mood Management intervention: • Produces higher abstinence rates compared to control intervention • 2. Helps to prevent and reduce depressive symptoms compared to control intervention

14. Control (C) • Telephone counselling • 8 sessions (1st: 30 minutes; • quitdate; 2nd – 8th: 12 min.) • by a trained coach of STIVORO • Content • Smoking cessation skills: • social support • increasing self-efficacy • self-rewarding • relapse prevention

15. Mood Management (MM) • Telephone counselling • 10 sessions (1st: 30 minutes; • 2nd – 3rd: 15 min; quit date; • 4th – 10th: 15 min) • by a trained coach of STIVORO • & • Quit smoking mood management manual • Self help manual with exercises • for reading and practicing • at home between the sessions

16. Mood Management (MM) • Content • Smoking cessation skills: • social support • increasing self-efficacy • self-rewarding • relapse prevention • Mood management skills: • Increasing pleasant events • Relaxation • Cognitive skills • Social skills • Based on cognitive behavioural therapy

17. Study design (RCT) • Recruitment – open population • advertisements, articles, website, flyers etc. • (n=4008 received information package) • Screening 1 & Informed consent • (n=1875 gave their informed consent) • (n=706 were invited for CIDI interview)

18. Study design(RCT) • 3. Screening 2 (CIDI) • Assessment of past major depression according to DSM-IV (exclusion of current depression, current alcohol disorder) • (n=531 met inclusion criteria) • Baseline measurement T0 • Randomisation • (n=485)

19. Study design (RCT) • 6. MM or C intervention • (MM: n=243; C: n=242) • 10 Counsellors gave MM and C intervention • Follow up T1 (6 months after T0) • Response (MM: 81.0%; C: 83.5%) • Follow up T2 (12 months after T0) • Response (MM: 77.0%; C: 76.4%)

20. Study design (RCT) • Participants • Past major depression • No current major depression • Preparator or contemplator • No current alcohol disorder • Outcomes • Prolonged abstinence • Point prevalence

25. Results - 6 months follow up OR Adjusted for self-efficacy and past depression * Significant

26. Results - 12 months follow up OR Adjusted for self-efficacy and past depression * Significant

27. Results – 6/12 months follow up a Adjusted for self-efficacy and past depression *Significant

28. Conclusion • Overall more smokers quit smoking with the Mood Management intervention when compared with the control intervention. • Although there are no significant differences on point prevalence abstinence. • Prolonged abstinence however does show significant differences.

29. Conclusion • It seems that the differences in smoking abstinence between Mood management intervention and control intervention can not be explained by differences in depressive symptoms • Mood Mangement intervention combined with telephone counselling seems to increase success rates for smokers with past major depression

30. How does the MM interventionworks in practice?Carl Simons

31. Many thanks for your attention! rvandermeer@stivoro.nl