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Tobacco Dependence Treatment for Mental Health and Addiction Patients

This study examines the implementation and effectiveness of smoking cessation treatment in addiction/mental health care units in Brazil, Portugal, and France. It explores the reasons behind tobacco dependence in mental health patients, the approach to treating them, cost-effectiveness, potential adverse effects, and barriers to treatment.

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Tobacco Dependence Treatment for Mental Health and Addiction Patients

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  1. Tobacco Dependence Treatment for Mental Health and Addiction Patients João Mauricio Castaldelli-Maia, MD, TTS, PhD Clima Clinic (Brazil/France/Portugal)

  2. Conflict of Interest • Independent Grant: Pfizer Independent Grant for Learning and Change (IGLC) managed by Global Bridges (Healthcare Alliance for Tobacco Dependence Treatment) hosted at Mayo Clinic as the Principal Investigator • Aims: To support free smoking cessation treatment training in addiction/mental health care units in Brazil (grant IGLC 13513957), Portugal (grant IGLC 25629313) and France (grant IGLC 36893805)

  3. Where are we ? • Since 1964: decrease in smoking prevalence • Not the case for patients with Severe Mental Disorders (MD) • 53% versus 18% • 21-31% have any MD • Severe MD die 25 years earlier (vs Mild MD) Evins AE, Cather C, Laffer A. Treatment of Tobacco Use Disorders in Smokers with Serious Mental Illness: Toward Clinical Best Practices. Harvard Rev Psychiatry 2015; 23: 90-8. Aubin H-J, Rollema H, Svensson TH, Winterer G. Smoking, quitting, and psychiatric disease: A review. Neurosci Biobehav Rev 2012; 36: 271–84

  4. Morisano D, Bacher I, Audrain-McGovern J, George TP. Mechanisms underlying the comorbidity tobacco use in mental health and addiction disorders. Can J Psychiatry 2009; 54(6): 356-67.

  5. Which are the reasons ? • Shared vulnerability • Social determinants • Self-medication Gonzalez MO, Goudriaan AE, Périco CA, Waisman Campos M, de Andrade AG, Bhugra D, Castaldelli-Maia JM. Neural Correlates of Depressive Symptoms in Smokers - A Systematic Review of Imaging Studies. Subst Use Misuse. 2017; 52: 1809-1822. Sederer LI. The Social Determinants of Mental Health. Psychiatr Serv. 2016; 67(2): 234-5. Yokoyama N, Sasaki H, Mori Y, Ono M, Tsurumi K, Kawada R, Matsumoto Y, Yoshihara Y, Sugihara G, Miyata J, Murai T, Takahashi H. Additive Effect of Cigarette Smoking on Gray Matter Abnormalities in Schizophrenia. Schizophr Bull. 2018; 44: 535-541.

  6. How should we approach them ? • Smoking behavior detailed evaluation • Assess the perceived benefits of quitting • Assess the motivation to quit _____________________________________________________ • A few studies in this subpopulation • Evaluate the psychiatric comorbidity • Self-medication • Integrate with the MD care Ouellet-Plamondon C, Mohamed NS, Sharif-Razi M, Simpkin E, George TP. Treatment of Comorbid Tobacco Addiction in Substance Use and Psychiatric Disorders. CurrAddictRep 2014; 1: 61–68. Loreto AR, Carvalho CFC, Frallonardo FP, Ismael F, Andrade AG, Castaldelli-Maia JM. Smoking Cessation Treatment for Patients With Mental Disorders Using CBT and Combined Pharmacotherapy. J Dual Diagn. 2017; 13: 238-246.

  7. Is it cost-effective ? Does it work ?

  8. Can I cause adverse effects ? “The study did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo" Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, Ascher J, Russ C, Krishen A, Evins AE. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet 2016; 387: 2507-20. Anthenelli et al., Lancet 2016

  9. Should we take more care ? Tobacco Interaction Reduce medication concentration by inducing Isoenzime 1A2 (p450) Olanzapine*, Clozapine*, Fluvoxamine*, Caffeine* Smoking Cessation Medication Interaction Bupropion metabolization by Isoenzime 2B6 and 2D6 (p450) Interaction with several medications

  10. Which are the main barriers ?

  11. Retrospective cohort study (n = 349) • Smoking Cessation Service in Madrid • Patients with Psychiatric Disorders • Depression (60.2 %) • Schizophrenia (15.2 %) • Bipolar Disorder (11.2 %) • Medication (NRT or Varenicline) plus CBT

  12. Findings • 44.7 % achieved abstinence (39.0% in NRT / 53.7% in Varenicline) • Success associated with: • Men • Lower CO expired levels • Lower CPD • No cases of suicidal ideation or behavior were found • Adverse effects

  13. Retrospective cohort study • Smoking Cessation Service in São Paulo • Sample included: • Patients with Psychiatric/Addiction Disorders (n = 277) • Patients without Psychiatric/Addiction Disorders (n = 419) • Medication (NRT, Bupropion, Nortriptyline) plus CBT (mixed groups)

  14. Combined Pharmacotherapy • Stratified analysis by the presence mental disorder status • NRT patch alone versus NRT patch plus: • Bupropion • Nicotine gum • Nortriptyline

  15. Loreto AR, Carvalho CFC, Frallonardo FP, Ismael F, Andrade AG, Castaldelli-Maia JM. Smoking Cessation Treatment for Patients With Mental Disorders Using CBT and Combined Pharmacotherapy. J Dual Diagn. 2017 [Epub ahead of print]

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