What is the risk of psychiatric symptoms worsening as a result of quitting smoking? Little research on this topic is available because more often than not, smokers with psychiatric disorders are excluded from tobacco treatment studies. However, research examining psychiatric status changes among recent quitters with schizophrenia,20,21 depression,22,23 PTSD,17 and substance use disorders24 suggests smoking cessation does not worsen symptoms of these disorders, and may be associated with symptom improvement.17 Nonetheless, driven largely by anecdotal evidence, the misconception that smoking cessation worsens psychiatric symptoms remains a substantial barrier to treatment.
Mr. P’s case is an example of how not probing about the nature of psychiatric complaints can be problematic. Mr. P reported what on first glance appeared to be a worsening of psychiatric symptoms starting when he stopped smoking and resolved when he resumed smoking. However, without gathering additional information about these events, we cannot conclude stopping smoking caused his psychiatric symptoms to worsen. Other potential explanations include nicotine withdrawal symptoms, side effects of smoking cessation medications, an increase in levels of psychotropic medications for which metabolism is affected by tobacco smoke, or the natural course of his mood disorder. The timing of the onset and offset of symptoms seems to argue against Mr. P’s symptoms reflecting the natural course of his mood disorder, but the other 3 explanations remain plausible.
It is important to distinguish whether Mr. P’s worsening symptoms are consistent with a depressive episode or whether they are a manifestation of the transient dysphoria that accompanies nicotine withdrawal. Assessing the severity and persistence of the mood disturbance as well as the timing of onset could help make this determination. Nicotine withdrawal symptoms typically emerge within 24 hours of quitting or significantly reducing smoking and tend to peak within approximately 1 week. Thus, depressive symptoms that develop after weeks or months of abstinence would be less consistent with nicotine withdrawal. Additionally, the lethargy Mr. P reported may be a symptom of depression, or it may stem from a cessation-induced increase in antipsychotic serum levels. Because tobacco smoke increases the metabolism of several antipsychotics and antidepressants—including olanzapine, clozapine, haloperidol, and fluoxetine25—stopping smoking may increase medication levels and side effects. To rule out medication side effects as a cause of post-cessation mood changes, the psychiatrist should ask Mr. P about which smoking cessation pharmacotherapies (if any) he was using and which psychotropic medications he was taking. Unfortunately, such a detailed history is not always taken, and patient-generated theories of smoking cessation causing worsening psychiatric symptoms often are taken at face value.
When should smokers with psychiatric disorders be encouraged to quit? Are there times when smoking cessation should be discouraged? Tobacco treatment guidelines4 recommend advising users to quit at every clinical encounter, but there has been some debate about the timing of tobacco treatment for smokers with psychiatric disorders. There is minimal research to guide such treatment decisions. However, even if quit attempts are more successful during times of symptomatic stability—and there is no conclusive evidence to indicate they are—waiting for perfect mental health before initiating smoking cessation treatment is unnecessary and ill-advised. In some situations, such as when a patient has experienced an acute increase in psychiatric symptoms or when psychotropics are being titrated, a short-term postponement of quitting may be reasonable. However, discouraging smokers from trying to quit when they express readiness to try should be done sparingly, because it is uncertain how long that window of opportunity will be open, and the consequences of missed opportunities can be fatal.
- National Tobacco Quitline. 1-800-QUIT-NOW. www.smokefree.gov.
- University of California, San Francisco, Schools of Pharmacy and Medicine. Rx for Change (free online training program for clinicians). http://rxforchange.ucsf.edu.
- National Association of State Mental Health Program Directors. Tobacco-free living in psychiatric settings: a best-practices toolkit promoting wellness and recovery. www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf.
Drug Brand Names
- Bupropion • Wellbutrin, Zyban
- Clozapine • Clozaril
- Fluoxetine • Prozac
- Haloperidol • Haldol
- Nortriptyline • Aventyl, Pamelor
- Olanzapine • Zyprexa
- Varenicline • Chantix
Disclosures
Dr. Heffner was supported by National Institute on Drug Abuse grant#026517. She is a consultant to Pfizer Inc.
Dr. Anthenelli is supported by National Institute on Alcohol Abuse and Alcoholism grant#AA19720 and by the Department of Veterans Affairs. He is a consultant to GlaxoSmithKline and Pfizer Inc.
The Tri-State Tobacco and Alcohol Research Center receives research support from Eli Lilly and Company, Nabi Biopharmaceuticals, Pfizer Inc., and sanofi-aventis.