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Cigarettes smoking and schizophrenia

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the high rates of smoking in schizophrenia is a problem that should be handled by the psychiatrists

the high rates of smoking in schizophrenia is a problem that should be handled by the psychiatrists

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    Cigarettes smoking and schizophrenia Cigarettes smoking and schizophrenia Presentation Transcript

    • WALID SARHAN F. R. C. Psych.
    •  Jordan 47%males 6%female  Tunisia 56%males 6.6% females  Saudi Arabia 22%males 2.2%females  Algeria 33.9% males2.4% females  Egypt 37.6% males 0.5 %females  22%of the world's population aged 15+ are smokers. WHO
    • The hookah (also known as the water pipe, shisha, nargileh, arghileh or hubble-bubble) poses a special tobacco problem in the Middle East. Epidemic in young females
    •  Reported prevalence rates of smoking range from 56% to 88% Schizophrenics tend to smoke high-tar cigarettes, inhale more deeply, and smoke for longer periods of time. (Kelly&McCreadie 2000) 4
    •  In the past cigarettes have been used in hospitals as rewards.??  High rates of unemployment , decreased amount of social activities and general boredom may contribute to smoking in schizophrenia.  Some patients may use smoking as a form of self medication to relieve negative symptoms or even EPS.
    •  People with schizophrenia who smoke require higher doses of neuroleptics than nonsmokers.  Nicotine may increase the plasma clearance for some antipsychotic medications.  It has also been demonstrated that smoking may reduce the effect of benzodiazepines.
    •  Psychiatric outpatients (n=271); Hughes, 1986  Smokers (%) ◦ Schizophrenia 88 ◦ Mania 70 ◦ Major depression 49 ◦ Anxiety disorder 47 ◦ personality disorder 46 ◦ Adjustment disorder 45 ◦ Controls (n=411) 30
    •  Increased propensity to dependence  Illness modulation effect  Side effect reduction  Immediate self-medicating effect  Social factors
    •  Aspects of the illness might lead more patients to smoke  Smoking might be an etiological factor in schizophrenia  Genetic and/or environmental factors might lead both to nicotine addiction and to schizophrenia
    •  Dopamine (DA) system  Mesolimbic Dopamine system ◦ Ventral Tegmental Area (VTA) ◦ Nucleus Accumbens (NAc) ◦ Projections to Medial Prefrontal Cortex
    •  Schizophrenia ◦ Hypoactivity of the Mesocortical tract- midbrain (VTA) to frontal and DLPFC causes negative symptoms  DA activation in reward pathways from drugs  More reinforcing  Negative symptom relief
    •  Heavy smoking common (>25 cpd)  Highly nicotine dependent ◦ Fagerstrom measures of nicotine dependence in the moderate to severe range (6-7)  Rapid smoking (2 or more cigarettes within 10-minute periods)  Smoking cigarettes completely to butts
    • It has been proposed that smokers with schizophrenia are more efficient smokers, who absorb more nicotine per cigarette than do smokers without this disorder.
    • ◦ Major nicotine metabolite ◦ Stable compound ◦ Half-life 16 hours ◦ Easy to measure in body fluids for 3- 5 days after nicotine exposure. ◦ Less dependent on the time to last cigarette than is nicotine.
    •  One objective of this study was to measure serum nicotine and cotinine levels in 100 smokers with schizophrenia and schizoaffective disorder and to compare these to control smokers without mental illness.
    •  Cotinine and nicotine levels of smokers with schizophrenia and schizoaffective disorder were 1.3 times higher than control smokers without major mental illness  3HC: Cotinine ratios were not different between groups  Diagnosis of schizophrenia predictor of higher cotinine level (Williams et al., in press, Schizophrenia Research)
    •  Cigarettes perhaps beneficial in performing simple, timed, repetitive, tasks  Reaction time  Attention ◦ (finger tapping, visual search) (Andersson, 1975, Stevens, 1976, Gonzales & Harris, 1980, Wesnes and Warburton, 1984)
    •  Smokers do worse on complex tasks ◦ tasks of manipulation of short term memory (working memory), ◦ long term memory ◦ comprehension  At heavy task demands and complex problem solving, performance deficit is most pronounced  Non-smokers outperform smokers in many tasks
    •  Abstinent schizophrenics worse visuospatial working memory (George 2002)  Improved verbal memory with high dose NNS (Smith 2002)  Improved working memory with nicotine patch and increased (fMRI) activation in anterior cingulate and bilateral thalamus (Jacobsen 2004)  Lack of improvement in verbal memory with nicotine gum/patch (Levin 1996; Harris 2004)
    •  Smokers with schizophrenia spent median $142.50 (range $57-319)/ month on cigarettes  Median public assistance benefit was $596  27.36% of monthly income on cigarettes (Steinberg, Williams and Ziedonis, Tobacco Control 2004)
    •  The life expectancy of patients with schizophrenia is approximately 20% shorter than that of the general population  Smoking-related fatal disease is more prominent than in the general population (Brown et al., 2000; Br J Psychiatry)
    •  Higher standardized mortality rates than the general population for ◦Cardiovascular disease 2.3x ◦Respiratory disease 3.2x  Both of which highly linked to smoking
    •  Smoking must be implicated in the increased mortality in schizophrenia  Smokers require higher doses of antipsychotic medication  A substantial proportion of the income of smokers with schizophrenia is spent on cigarettes  Patients with schizophrenia have to be offered treatment for their nicotine addiction
    •  Reframing our assumptions Don’t want to quit Low motivation Can’t quit Lack skills to quit It’s all they have Enabling It helps them Illness modulating They will become Ignorance and fear violent
    •  Biological Factors  Psychological Factors  Social Factors  Knowledge Deficit/ Cognitive Factors  Institutional Factors
    •  Motivational assessments and interventions  Slow pace, repetition  Alternative goals, eventual abstinence  Focused skill building, role plays  Relapse prevention skills  Strengthen self-efficacy  Psychoeducation  Support
    • - among a cohort of chronic institutionalized schizophrenic patients, smoking cessation and reduction outcomes were not correlated with NRT dose, and the cessation rate was much lower than rates in similar studies. - It indicates that long-term hospitalized schizophrenic patients have more difficulties with quitting smoking. More effective integrative moking cessation programs should be Hsing-Kang Chen et al European Archives of Psychiatry and Clinical Neuroscience February 2013, Volume 263, Issue 1, pp 75-82
    •  Bupropion and CBT (Evins et al)  12 weeks Bupropion 150mg QD and weekly group  N=19  Abstinence (CO<9)  Reduction in smoking ◦ >50% reduction in cpd ◦ >30% reduction in CO level
    •  18 (n=19) completed 6 months study  CBT attendance was 86%  One bupropion patient abstinent at 12 weeks  None placebo group  66% bupropion reduced smoking 11% placebo group reduced smoking No difference in positive symptoms between groups
    •  This evidence supports that currently recommended doses of nicotine replacement therapy are inadequate for many smokers  In heavy smokers, this under dosing may be one of the reasons for the limited efficacy of transdermal nicotine
    •  Rapid absorption  Rapid onset of action  More immediate craving relief  Dosed intermittently  Pulsatile delivery of nicotine that more closely mimics smoking a compared to the patch.  NNS effective in highly dependent smokers  ? More desirable for persons with schizophrenia
    • 78 Smokers with Schizophrenia / Schizoaffective Dx At least 10 cigarettes per day Not currently in tobacco dependence treatment Motivational Interviewing N=32 Psychoeducation N=34 Minimal Control N=12 One week and one month post-intervention follow-up by R.A. blind to treatment condition Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Motivational Interviewing With Personalized Feedback: A Brief Intervention for Motivating Smokers With Schizophrenia To Seek Treatment for Tobacco Dependence. Journal of Consulting & Clinical Psychology, in press.
    • 25.8% 32.3% 0.0% 11.4% 0.0% 0.0% 0% 5% 10% 15% 20% 25% 30% 35% Motivational (N=32) Psychoeducational (N=34) Control (N=12) Figure 1. Percentage of participants receiving each intervention following up on referral to tobacco dependence treatment at one-week and one-month post- intervention One-Week One-Month Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Motivational Interviewing With Personalized Feedback: A Brief Intervention for Motivating Smokers With Schizophrenia To Seek Treatment for Tobacco Dependence. Journal of Consulting & Clinical Psychology, in press.
    • Interventions for smoking cessation and reduction in individuals with schizophrenia Daniel T Tsoi,Mamta Porwal,Angela C Webster Cochrane Tobacco Addiction Group Published Online: 28 FEB 2013 Assessed as up-to-date: 10 JAN 2013 DOI: 10.1002/14651858.CD007253.pub3 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
    • Interventions for smoking cessation and reduction in individuals with schizophrenia Our review supports the effectiveness of bupropion for smoking cessation in patients with schizophrenia. The evidence is relatively weak with wide confidence intervals, especially for longer-term benefit, because of the low number of participants Daniel T Tsoi, Mamta Porwal, Angela C Published Online: 28 FEB 2013 Assessed as up-to-date: 10 JAN 2013 DOI: 10.1002/14651858.CD007253.pub3 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
    • Interventions for smoking cessation and reduction in individuals with schizophrenia We found no evidence of any significant deterioration of mental state secondary to use of bupropion in people with schizophrenia. Bupropion use in individuals with schizophrenia did not increase the risk of seizure. The evidence for bupropion as an aid to smoking reduction in people with schizophrenia is inconclusive. Daniel T Tsoi, Mamta Porwal, Angela C Published Online: 28 FEB 2013 Assessed as up-to-date: 10 JAN 2013 DOI: 10.1002/14651858.CD007253.pub3 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
    • Interventions for smoking cessation and reduction in individuals with schizophrenia • We also found some evidence in support of varenicline for smoking cessation among individuals with schizophrenia. • Compared with the bupropion trials, the number of participants is lower and the evidence weaker with wider confidence intervals. • There is no evidence at present to suggest that the varenicline's effectiveness will last in the longer term. Daniel T Tsoi, Mamta Porwal, Angela C Published Online: 28 FEB 2013 Assessed as up-to-date: 10 JAN 2013 DOI: 10.1002/14651858.CD007253.pub3 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
    • Interventions for smoking cessation and reduction in individuals with schizophrenia There is no evidence that varenicline worsens symptoms in schizophrenia, there is some concern about serious adverse events such as suicidal ideation or behaviour among schizophrenia patients on varenicline. Based on the current data, we do not think this possibility can be fully ruled out. Daniel T Tsoi, Mamta Porwal, Angela C Published Online: 28 FEB 2013 Assessed as up-to-date: 10 JAN 2013 DOI: 10.1002/14651858.CD007253.pub3 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
    • Interventions for smoking cessation and reduction in individuals with schizophrenia There is some evidence that rewards using money may increase smoking cessation and reduction rates among people with schizophrenia. However, we do not find any evidence for a sustained effect, after the rewards are withdrawn. For other drug treatments (including NRT) and psychosocial interventions, we did not find sufficient convincing evidence in to support their use in clinical practice.
    •  Advances in Psychiatric Treatment (2000) 6: 327-331 doi: 10.1192/apt.6.5.327  Effects of cigarette smoking on spatial working memory and attentional deficits in schizophrenia: involvement of nicotinic receptor mechanisms (June, 2005)  Nicotinic effects on cognitive function: behavioral characterization, pharmacological specification, and anatomic localization (October, 2005)  Nicotine improves delayed recognition in schizophrenic patients. (March, 2004)  Effects of nicotine on cognitive deficits in schizophrenia (2004)  Nicotinic treatment for cognitive dysfunction (2002)  Development of nicotinic drug therapy for cognitive disorders. (March, 2000)  Normalization of auditory physiology by cigarette smoking in schizophrenic patients (December, 1993)  Effects of smoking abstinence on visuospatial working memory function in schizophrenia (January, 2002)  Search on "Google Scholar" for "schizophrenia nicotine" research
    •  Kelly c.,McCreadie R. Cigarette smoking and schizophrenia, Advances in Psychiatric Treatment (2000) 6: 327- 331 doi:  Addington, J., el-Guebaly, N., Campbell, W., et al (1998) Smoking cessation treatment for patients with schizophrenia. American Journal of Psychiatry, 155, 974–976.  Hughes, J. R., Hatsukami, D. K., Mitchell, J. E., et al (1986) Prevalence of smoking among psychiatric outpatients. American Journal of Psychiatry, 143, 993–997.  Cullen K.R., et.al Cigarette smoking and white matter microstructure in schizophrenia Psychiatry Research: Neuroimaging, Volume 201, Issue 2, 28 February 2012, Pages 152–158.  Zhang X.Y.,Cigarette smoking, psychopathology and cognitive function in first-episode drug-naive patients with schizophrenia: a case-control studyPsychological Medicine, available on CJO2012. doi:10.1017/S0033291712002590.  Cooper J.,Tobacco smoking among people living with a psychotic illness: the second Australian survey of psychosis. Aust N Z J Psychiatry. 2012 Sep;46(9):851-63. doi: 10.1177/0004867412449876. Epub 2012 May 29.
    • Daniel T Tsoi, Mamta Porwal, Angela C Published Online: 28 FEB 2013 Assessed as up-to-date: 10 JAN 2013 DOI: 10.1002/14651858.CD007253.pub3 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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