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Tobacco and Depression: Bidirectional Association

Gain insight into the relationship between tobacco use and depression and anxiety, along with cessation interventions. Explore burden, associations, and treatment options.

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Tobacco and Depression: Bidirectional Association

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  1. TOBACCO AND DEPRESSIONAND ANXIETY Mini Lecture 2 Module: Tobacco and Mental Health

  2. Objectives of the Mini Lecture GOAL OF MINI LECTURE: Provide students with knowledge on the bidirectional association between tobacco use and depression, and tobacco use and anxiety LEARNING OBJECTIVES Students will be able to: • Describe the burden of smoking in patients with anxiety and depression • Explain the association between smoking and anxiety and depression • Discuss smoking cessation interventions for patients with anxiety and depression

  3. Contents Core Slides Optional Slides Factors Associated with Smoking in Patients with Depression Smoking and Anxiety Disorder Why Do Patients with Anxiety Disorder Smoke? • Anxiety and Depression: Burden • Anxiety and Depression and Smoking • Smoking and Depression: Association • Smoking and Anxiety: Association • Treatment for Anxiety and Depression and Smoking • Cessation Treatment: Depression and Anxiety • Clinical Consideration: Smoking Cessation in Anxiety and Depression

  4. CORE SLIDES Tobacco and Depression and Anxiety Mini Lecture 2 Module: Tobacco and Mental Health

  5. Anxiety and Depression: Burden • Unipolar depression • the 3rd leading cause of world wide burden of disease • the leading cause of disease burden for women aged 15–44 years worldwide.1 • The prevalence of anxiety and depression in Yogyakarta Province, Indonesia in 2007 was 3.9% and 4.3%, respectively (unpublished data). • Studies in high-income countries show a high prevalence of tobacco use in patients with anxiety and depression. • Studies need to be done in low- and middle-income countries on this topic.2 1. World Health Organization 2008; 2. Ziedonis et al. 2008

  6. Anxiety andDepression and Smoking • Patients with psychiatric disorders have higher prevalence of life-time and current smoking rates and lower smoking quitting rates than individuals without such disorders. • The US smoking prevalence: 23% in healthy people, 36% in patients with social phobia, 46% in persons with generalized anxiety disorder, 37% in persons with major depression and 69% in those with bipolar disorder. • Smoking quit rates: 43% in healthy people, 33% in social phobia and generalized anxiety disorder, 38% in major depression, 17% in bipolar disorder. Ziedonis et al. 2008

  7. Smoking and Depression:Association • A confounding association: Genetic vulnerability or environmental confounding factors increased risk of both depression and cigarette smoking.1, 3 • A bi-directional causal association among adolescents and elderly:2 • depression may cause smoking: young adults with depression are 3x more likely to smoke daily and 2x more likely to become nicotine dependent. • Smoking may cause depression: chronic smoking leads to neurophysiology compensation. 1. Lam et al. 2004; 2. Lam et al. 2005; 3. Ziedonis et al. 2008

  8. Smoking and Anxiety:Association • A study from the US showed that compared to non-smokers, panic disorder patients who smoke:1 • Experience more panic symptoms, which are more severe and intense. • Have more mental and social impairments • Reported higher levels of anxiety sensitivity, anxiety symptoms, and agoraphobic avoidance.2 • Data from low- and middle-income countries (LMICs) are scarce, more studies need to be done to observed if these phenomena also exist in LMICs. 1. Isensee et al. 2003; 2. Ziedonis et al. 2008

  9. Treatment for Anxiety andDepression and Smoking • Cigarette smoking influences the metabolism of drugs, including psychotropic drugs.1 • Polycyclic aromatic hydrocarbons (PAH) induces cytochrome P450 (CYP) enzymes which induce metabolism of many medications. • Psychiatric patients who attempt quitting might experience adverse effects even if the dose of their medication remains unchanged. • Most antipsychotics, antidepressants, anxiolytics, and mood stabilizer levels in blood will rise following initial smoking cessation.2 1. Kroon 2006; 2. Bjorson 2008

  10. Cessation Treatment: Depression and Anxiety • Cognitive behavioural therapy, with or without pharmacotherapy, is effective for smoking cessation in patients with depression. • Alternative: motivational feedback + NRT or buproprion.1 • Clinical trial evidence for anxiety patients is almost non-existent, except for post-traumatic stress disorder. • Assessment of smoking and cessation programs for patients with anxiety disorders is not currently integrated in the clinical management guidelines.2 1. Kisely and Campbell 2008; 2. Ziedonis et al. 2008

  11. Tobacco Cessation for Personswith Chronic Mental Illness • Recent studies in the U.S. show that persons with chronic mental illness die 25 years earlier than the general population. • Smoking is major contributor to this premature mortality. • People with chronic mental illness consume 44% of all cigarettes smoked in the US. • Reflects both high prevalence and heavy smoking by users. • Anxiety disorders: 46% prevalence • Depression: 37% prevalence Schroeder and Morris 2010

  12. Clinical Consideration: Smoking Cessation in Anxiety and Depression • In acute phases of cessation, some symptoms may be related to nicotine withdrawal, rather than related to the underlying psychiatric disorder. • Diagnosis of anxiety and depression cannot be made during this phase and the physician should wait up to 4 weeks to differentiate between withdrawal and psychiatric disorder symptoms. • Individuals suffering from a history of major depression should be carefully monitored during early stages of cessation as they are at risk to experiencing symptom relapse.

  13. OPTIONAL SLIDES Tobacco and Depression and Anxiety Mini Lecture 2 Module: Tobacco and Mental Health

  14. Factors Associated with Smoking in Patients with Depression • Biological factor: dopaminergic genes (the rate of smoking is positively associated with the number of DRD2-A1 alleles). • Psychological factors: positive reinforcing effect and reward value of smoking to activate dysfunctional brain reward system. • Social factor: depressive patients are more receptive to peer smoking and tobacco advertisements. Ziedonis et al. 2008

  15. Smoking and Anxiety Disorders • Daily tobacco consumption is related to the development of panic disorder and panic attacks, agoraphobia, and post-traumatic stress disorder (PSTD), but not generalized anxiety disorder. • Higher levels of tobacco consumption further increase the risk of agoraphobia, generalized anxiety disorder, and panic disorder . Ziedonis et al. 2008

  16. Why Do Patients withAnxiety Disorder Smoke? • Shared predisposition: similar predisposing factors related to anxiety disorder and nicotine addition (e.g., genetic predisposition, stress, trauma exposure, etc.). • Stress-coping mechanism: cigarettes used as self medication to regulate mood and mitigate effects of stress. Ziedonis et al. 2008

  17. The most important health message a doctor can give to patients is to quit smoking.

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