ABSTRACT: tobacco dependence, psychiatric comorbidity, outpatient psychiatry. Introduction:

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Last updated: August 25, 2019

 ABSTRACT:Introduction:Cigarette smoking remains prevalent among patients with psychiatric diagnosesand it is a major cause of morbidity and mortality in this group of patients.There have been few studies examining smoking cessation and treatments forthese patients in an outpatient psychiatric setting.Aims:To evaluate if smoking cessation is adequately addressed by residentpsychiatrists in an outpatient setting.

Methods:A retrospective chart review case series study consisting of fifty consecutivecharts of nicotine (tobacco) dependent psychiatric patients was conducted todetermine the number of visits patients had, number of times smoking cessation wasaddressed during these visits, if treatment was initiated and which type oftreatments patients received.Results:The average number of visits per patient was 45. Smoking cessation wasaddressed in 12% of patients and 4% of those patients were treated with prescribedmedication and psychotherapy for smoking cessation.Conclusions:Thecurrent study illustrates that resident psychiatrists are less readily assessingand treating tobacco dependence. The study results, combined withthe pressing health risks associated with smoking prevalence in the mentallyill population, suggests that more should be done to adequately address smokingcessation in patients with mental illnesses and to encourage treatments forthose patients who are open to them.

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 KeyWords: smoking cessation, nicotine dependence, tobaccodependence, psychiatric comorbidity, outpatient psychiatry.Introduction:Cigarette smokingremains a primary cause of preventable mortality and morbidity in the UnitedStates. Despite a great deal of research on smoking and greater awarenessregarding the adverse health effects of smoking, it is estimated to beresponsible for roughly five million deaths worldwide and 480,000 deaths peryear in the United States .iThe prevalence of smoking has been reduced from about 43% in 1965 to 18% as of2014 among adult populations in the United States.1 Despite this reduction, cigarette smokingcontinues to be a major contributor to lung cancer.iiCigarette smoking is also associated with other deleterious health effects,such as chronic obstructive pulmonary disease (COPD)iii,coronary heart disease,ivpeptic ulcer disease,vosteoporosis,vi,viiand reproductive disorders,viiiincluding increased risk of infertility,8 spontaneous abortions,8ectopic pregnancy,8,ixand premature menopause.8 Studies have shown thatquitting smoking at any age provides important health benefits and greater lifeexpectancy.

x,xiAccording to one study, treating smoking is considered one of the mostimportant activities a clinician can engage in, as it is beneficial in terms oflives saved, quality of life and cost effectiveness.xiiThe smoking prevalence among individuals with a current psychiatric illness isnearly double that of individuals without a mental illness (41% versus 23%)and, is even higher among severe mental disorders and substance use disorders.xiii,xivIt is estimated that 44% of the cigarettes sold in the United States areto those with psychiatric diagnoses.13 Studies have also shown highersmoking rates among patients with certain types of mental illnesses, such asschizophrenia, depression, bipolar disorder and panic disorder.xv,xvi,xvii,xviiiSchizophrenic patients have been shown to be heavily nicotine dependent, and theyoften have a very difficult time in quitting smoking cigarettes.17,xix,xx,xxiDepression is also an important factor associated with smoking and an increasedrisk of smoking cessation treatment failure.

xxii,xxiii,xxivOne  study showed that depressedindividuals are 27% more likely to smoke than those individuals with no historyof depression.15,xxv Pharmacologicaltreatments for smoking cessation include several U.S. Food and DrugAdministration (FDA) approved and off-label options. Nicotine replacement(polacrilex/gum, transdermal nicotine patch, nicotine nasal spray, and nicotineinhaler), bupropion (Zyban, Wellbutrin) and varenicline (Chantix) are all pharmacologictreatments to help patients with smoking cessation.  Social, psychological and behavioral supportsare generally effective as well, but require more time and motivation ofpatients and clinicians in order to be effective.24,xxviIt is difficult for a non-depressed patient to quit smoking, but when depressionis present with patients being sad, anhedonic, and lacking energy, quit rates arelikely to be even lower.

22 Though, more recent studies have shownthat there is not a significant difference in quit rates between depressed andnon depressed patients.xxviiThis suggests that clinicians may have a defeatist attitude when consideringtreating nicotine dependence in those seen as having greater psychiatriccomorbidity.  Given the higher rates ofsmoking and poor outcome for patients with psychiatric disorder, it isimportant for psychiatrists to adequately assess and treat cigarette smoking asboth a medical and psychiatric comorbidity in the outpatient setting.13,xxviii  An argument can be made for more aggressivepharmacological smoking cessation treatment in the mentally ill and couldideally be developed into the standard of care for psychiatric practice.xxix Residency is a timewhere young physicians are trained and adopt strategies for treatingpatients.

  Oftentimes, the skills learnedwill be used and repeated for decades while treating patients.  It is unclear if board certified or residentpsychiatrists are taught to uniformly address nicotine dependency in theirpatients or if they develop this skill set independently.  This paper sought to look at currentpractices in a psychiatry residency training program.  In particular, the investigators wished to determinehow often nicotine dependence was clinically addressed in session and how oftencessation strategies were suggested to the typical, highly comorbidoutpatient.   Methods:This study was aretrospective chart review case series of cases from 1/1/08 through 11/1/08. Itwas conducted after formal review board approval (October 29, 2008, IRB ExemptNo. 100-08).

 No patient contact wasestablished in order to collect study data. This study was not funded byexternal sources. Patients who were actively smoking were identified from acomputerized database.  The clinicgenerally operates with 10 residents who work 1.5 days per week, generallyconducting 50 minute sessions combining therapy and medication management.

  This is a small capacity training clinic.  As such, fifty consecutive charts werereviewed to determine the average number of days in treatment, the number ofvisits; the mode of treatment the patient received (either medications,psychotherapy or both), and primary psychiatric diagnoses covering both Axis Iand Axis II disorders. It was recorded whether smoking cessation was brought up,the number of times it was addressed, and if any treatment was prescribed.Raw numbers weretallied from independent chart reviews and the averages were calculated fromthese numbers. Results:Fifty charts ofpatients were studied at our clinic seen by approximately 20 mental healthclinicians (MD, NP, PhD, and CSW).

Particularly, the physicians in this studywere psychiatric residents (N=10) and the predominant mode of service deliverywas to provide therapy and medication management by the resident alone. Theclinic utilizes various mental health providers but these cases were restrictedto resident trainees’ cases.  Use ofanother mental health provider in a split therapy model was rare (15-20%).  Patient clinic enrollment ranged from 7 to1978 days with a mean of 725 days under care. The number of visits ranged from2 to 177 with an average of 45 visits as a follow-up for their primary diagnosis.Out of the fifty patients, only one (2%) received medication management alonefor their outpatient treatment, nine (18%) received psychotherapy alone, and 40(80%) received both medications and therapy simultaneously for their primarydiagnoses. All patients had 1 to3 diagnoses on Axis I and only one patient (2%)was diagnosed with a personalitydisorder comorbidity. The low prevalence of personality disorders may be aconsequence of selection bias and may not reflect the true prevalence ofpersonality disorder in the clinic.

 Surprisingly, the studyresults indicated that out of fifty patients, only six patients (12%) werecounseled regarding smoking cessation while they were in treatment for theirmain psychiatric diagnoses. After smoking cessation was addressed, only twopatients (4%) were prescribed varenicline and one patient (2%) was prescribedbupropion sustained-release (SR). The other three patients (6%) were notstarted on any treatment.

Finally, according to the chart review, when smokingcessation was addressed, one third of clinicians asked routinely at every visit,about smoking related issues, one third asked on several occasions, and onethird asked only two to three times throughout the patient’s enrollment in theclinic.  Discussion:As noted above, thereare a number of physician techniques available to address and enhance smokingcessation in outpatient mental health clinics. However, byreputation,  the mental health system hasbeen reluctant to identify and treat tobacco dependence despiteexhortations to diagnose and treat this often fatal disorder.18,29This phenomenon might be linked to the belief on the part of mentalhealth professionals that they do not have the skills to providesmoking treatment, the failure to understand that mental healthpatients may want to quit and can succeed in stopping, reimbursementconcerns, and fear of exacerbation of symptoms during nicotinewithdrawal.18,xxx,xxxiAlso, it is sometimes assumed that individuals with mental illnessare too distracted, demoralized, or disorganized to benefit fromsmoking treatment.31 Clearly, cessation treatments can work and itwould be useful to aid and encourage resident physicians, as well as moreveteran clinicians to start to actively address this problem.

xxxiiThis study utilized a simple retrospective chart review and found that patientswere followed up several times for the treatment for psychiatric diagnoses, butsmoking cessation intervention was infrequently included in any of the visits. There are datasupporting and encouraging the use of FDA approved medications for smokingcessation in the non-mentally ill, however, from our results it is clearlyevident that these agents have not been implemented effectively in our trainingclinic, commensurate with data suggesting low action rates at outpatient mentalhealth clinics in general.18,29,31 Smoking and mortality rates arehigher in the mentally ill, but there is not much data supporting the need for helpwith smoking cessation in this population group.

18,xxxiii  Mental health clinicians are well aware ofthe utility of bupropion SR in treating depression, but it is rarely used forsmoking cessation.xxxivThere are relative contraindications in using it in the bipolar smoker due torisk of mania activation, minimal risk using it in schizophrenia and minimal orno risk with depression or anxiety.xxxv  Its use in contraindicated in eatingdisorders.  Varenicline is an effectiveagent but has warnings that it may induce depression or suicidal behavior.xxxvi  It is not clear whether these risks areresults of the drug itself, or nicotine withdrawal. Federal warnings andcontradictory epidemiologic data regarding varenicline and suicidal events havelikely made clinicians concerned about using it.36,xxxviiRecent studies tend to show no risk of mental health exacerbation and haverecently led to the federal warnings being removed.37,xxxviiiSpecifically, there is still conflicting data regarding the relative safety ofvarenicline in patients with psychiatric illnesses.

One review articleconsisting of 25 case reports showed a high association between the use ofvarenicline and adverse psychiatric effects.xxxix Meanwhile, the Gibbons et al. review whichlooked at 17 randomized controlled trials showed very little adverse effects ofvarenicline compared to placebo in both psychiatric and non psychiatricpatients.37 There has also been a more recently published study showingno significant adverse effects of varenicline in the maintenance treatment ofsmoking cessation in patients with schizophrenia and bipolar disorder.xlHowever, despite these ongoing concerns, the mortality risk due to use of vareniclineis likely much lower than the risk associated with smoking.  Mental health clinicians are aware of theserisks and need to monitor for them during outpatient visits.

 Our findings in thisstudy suggest that there is a need to increase awareness among clinicians aboutaddressing and treating nicotine dependence with the agents noted above and ideally,conduct more safety studies regarding smoking cessation in mentally illpatients. In that arena, the recent study by Rogers, et al., also corroboratesour findings.xli Theyobserved 15 years of physician reported data from the National AmbulatoryMedical Care Survey completed by outpatient primary care providers and foundthat tobacco screening and counseling in psychiatric patients has been lowamong all physicians and particularly among psychiatrists. Despite this, smokingcessation counseling, though generally low, increased from 12% to 23% after theguidelines were implemented.

41The low numbers are similar to theresults of our study and show a trend of limited smoking cessation interventionsin psychiatric patients. Theoretically, the low counseling rates may occur dueto a lack of clinical skills yet achieved by trainees, or lack of familiarityand comfort with providing proper counseling.xliiRogers, et al. also found that psychiatrists, who were already counselingpatients on other issues like weight loss or alcohol or drug use, were morelikely to counsel patients on smoking cessation.

   The Rogers, et al.study observed how current practicing, board certified psychiatrists addresssmoking cessation psychiatric patients while our study specifically examined residentpsychiatrists in training. The results of our study along with the Rogers, etal. study again highlight that smoking cessation counseling and treatment iscurrently a lower prioritized treatment goal among psychiatrists.

Given theserious health impact of smoking, it will be important to further increaseawareness beyond the recommendations of guidelines and create impactfuleducational intervention to change clinical practice to include more aggressivescreening and treatment for psychiatric patients who are nicotine dependent.   If clinicians do nothave time to clinically assess nicotine dependence in session, patientcompleted screening questionnaires could be administered in the waiting roomand checked prior to the visit for all new admission patients.  Many hospitals routinely ask upon inpatientadmission and sometimes directly ask on these surveys if the patient desires toquit.  This approach then triggers theclinician to ask and provide treatment.  Simplescreening questions are generally printed on paper or computerized and dataentered at the initial visits.  Commonlyused language includes:-Have you used tobaccoin the past 6 months?-Do you currently usetobacco?-How often do you usetobacco?-Have you ever tried toquit or thought about quitting?-What strategies ormedications did you use? More formally,validated questionnaires like the Tobacco Daily Screener (TDS) could be used asa single worksheet dedicated to screening for nicotine dependence.  It is a 10 item scale that patients complete.

xliiiAlternatively,the Fagerström Tolerance Questionnaire is an 8 item scale that can be used.xliv In regard to trainingfor clinician administered approaches and the development of clinical smokingcessation skill sets, there are some tools available.  All are meant to encourage and guideclinicians in identifying and treating nicotine dependence. The updated 2014Surgeon General Report on Treatment for Tobacco Use and Dependence has somerecommendations that can guide clinicians, including resident psychiatrists,through the early processes of screening and treating patients.1 The5 R’s model for enhancing motivation to quit is a simple and direct guide towhat general clinicians should do in the screening process. It includes Relevance(encouraging patients to talk about specific reasons why quitting smoking isimportant and making suggestions), Risks (asking the patient toidentify acute and short term risks of smoking and making suggestions), Rewards(asking the patient to identify the benefits of stopping tobacco use and makingsuggestions), Roadblocks (asking the patient to identify potential barriersto successfully quitting smoking and in psychiatric patients, this could meanexploring the patient’s mental illness and other comorbidities) and Repetition(repeating the motivational intervention for unmotivated patients at everyvisit and encouraging those who have failed in trying to quit to continue torepeat the quit process).1 This can certainly be adopted and appliedin residency and other mental health clinics as well.  Once patients have beenidentified and agree to stop smoking, there is another proposed model calledthe 5 A’s model for treating tobacco use and dependence.

In this model,clinicians should Ask (identify anddocument patient smoking status at every visit), Advise to quit (urgepatients who are smokers to quit), Assess willingness to make a quit attempt (find out if patients arewilling to make an attempt to quit at this point in time), Assist in quit attempt(offer medication and/or counseling to those patients willing to quit andpropose interventions to help those who are unwilling to quit at this time to considerit in the future), and Arrange follow up (immediate followup within one week of patient’s quitting and follow up to reassess andencourage those who have not committed to quitting).1  Thismodel is proposed for treating all patients who are nicotine dependent and canbe applied in outpatient psychiatric clinics as well. This model has been shownto improve clinician assessment rates by 32% after clinicians have been simplytrained to use the 5 A’s.xlvThere are also many training modalities available to help clinicians becomemore adept and comfortable with these proposed models and in helping them toassess and treat their patients. There are online Continuing Medical Educationcourses, the Training Staff in Smoking Cessation Counseling courses from theTobacco Technical Assistance Consortium, the University of Wisconsin Center ForTobacco Research and Intervention training manuals, U.S.

Public Health Serviceclinician and patient materials online, Alliance for the Prevention andTreatment of Nicotine Addiction (APTNA) resources and services and many otherclinician tools and materials online.xlvi This study has thelimitations of being a sample of opportunity, naturalistic anduncontrolled.  The small sample size isrelated to the fact that the clinic utilized is mostly a psychotherapy trainingclinic that allows medication management within session with a small census andsmall number of psychiatric residents. The clinic utilizes other mental health providers but these cases wererestricted to resident trainees’ cases. A confound could exist if patients were counseled by other mental healthproviders or their primary care physicians in the community.            Conclusion:Cigarette smokingcontinues to be a major health burden in society.

It is especially a greaterchallenge for patients with psychiatric illnesses. It has been well documentedthat patients with mental health disorders are more predisposed to nicotinedependence. As such, it is important to identify and help these patients withsmoking cessation. In our study, 50 actively smoking patients’ charts werereviewed to determine if their resident psychiatrists addressed smokingcessation and whether any treatment plans were initiated.

In our study, wefound that three out of 10 physicians routinely addressed smoking cessationwith patients, suggesting that a large quantity of the patient population isnot being adequately assessed for help with quitting smoking. Only 12 percentof the patients in our study were counseled on smoking cessation and of thatgroup, only half ever received any treatment. These low intervention numbersare comparable to other studies that evaluate the clinical care of boardcertified physicians as well. The study results, combinedwith the pressing health risks associated with smoking prevalence in the mentallyill population, suggest that training in simple methodical approaches should beideally incorporated into clinical training programs so that young physiciansdevelop automatic screening and treatment provision habits in the area ofsmoking cessation.

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