1. Smoking Cessation Notes for Mental Health

2. The Myths Tobacco is a necessary form of self-medication People with MI are not interested in quitting Mentally ill people cannot quit smoking Quitting smoking interferes with recovery from MI Smoking is the lowest priority concern for those with acute psychiatric symptoms

3. Unit Nurse “Take your meds and I’ll give you a cigarette” Crisis Nurse “Once you come with us to the unit, you can have a smoke” Registrar “This person can have 5 minutes out of ICU to go up to the fence to have a cigarette”

4. In Mental Health & Addictions Higher rates of tobacco use: – schizophrenia60 – 85% – bipolar Disorder51 - 70% – major depression36 - 80% – anxiety disorders32 – 60% – PTSD45 – 60% – ADHD38 – 42% – Alcohol abuse34 – 80% – Other addictions49 – 98% See Te Pou (2014). The physical health of people with a serious mental illness and/or addiction: An evidence review. P 41.

5. DSM-1V – TR Quick Reference. APA 2,000. Substance Related Disorders: Substance Dependence: A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 3 (or more) of the following occurring at any time in the same 12 month period: 1: Tolerance – A need for markedly increased amounts to achieve desired effect. Markedly diminished effect with continued use of the same amount. 2: Withdrawal – The characteristic withdrawal syndrome for the substance. The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms. 3: - Substance is taken in larger amounts or over a longer period than was intended. 4: - Persistent desire or unsuccessful efforts to cut down or control use. 5: - Great deal of time spent in activities to obtain the substance, use the substance (chain-smoking eg) or recover from its effects. 6: - Important social, occupational or recreational activities are given up or reduced because of substance use. 7: - The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (alcohol – liver, ulcer eg).

6. Nicotine Related Disorders: 305.1 (Nicotine Dependence). Nicotine Withdrawal: A: Daily use of nicotine for at least several weeks. B: Abrupt cessation of nicotine use or reduction in the amount of nicotine used, – dysphoric or depressed mood – insomnia – irritability, frustration, anger – anxiety – difficulty concentrating – restlessness – reduced heart rate – increased appetite / weight gain C: Symptoms of withdrawal cause clinically significant distress or impairment in social, occupational or other important areas of functioning. D: Symptoms are not due to a general medical condition and are not better accounted for by any other mental disorder.

7. Mental health service users - More highly dependent on tobacco (nicotine) More likely to be heavy smokers – 20 to 30 daily More likely to experience severe withdrawal symptoms from cigarettes Can die up to 25 years earlier than the general population – mostly from tobacco related illness Account for approx. 1/3 of all the money spent on tobacco in New Zealand Are seldom included in clinical trials

8. Tobacco dependence is the most prevalent drug abuse disorder among adults with psychiatric diagnosis or illness. Though a number of neurobiological and psychosocial factors are believed to contribute to the high smoking rate among individuals with psychiatric disorders, systemic failures and failure to treat tobacco dependence in mental health and addiction treatment settings have been largely ignored. (Prochaska, 2010).

9. However … “Smoking cessation is associated with reduced depression, anxiety and stress and improved mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders.” Taylor et.al. (2014).

10. Recovery A process that encourages & support people to take responsibility and ownership of their illness & their lives. Recovery starts when a person requires a change in their lives Recovery is a process that takes people from a place of dependence to independence. Recovery as a process and as a way of life is owned, instigated and worked on by the person who is on the journey. Recovery empowers & enables people to be in charge of their lives. “Nothing about us without us”

11. The 6 Strengths Principles of Recovery People have the capacity to learn, grow and change The focus is on individual strengths rather than pathology The client is seen as the director of the helping relationship The relationship is primary and essential Assertive outreach is the preferred mode of intervention The community is an oasis of resources

12. Smoking withdrawal The symptoms of nicotine withdrawal can be confused with with symptoms of mental illness Offer/provide NRT to prevent this occuring

13. Antipsychotic Medications (And Smoking Cessation) The Background & Recommendations section of the NZ Guidelines for Helping People to Stop Smoking cover the effect of stopping smoking on metabolism of other drugs (inc. caffeine). Clozapine and olanzapine are 2 atypical antipsychotic medicines used in the treatment of schizophrenia that may need to be reduced when a person stops smoking. Reduced smoking does not require any adjustment. Adjustment may be required if smoking is resumed.

14. Remember It’s not nicotine or NRT that interacts with antipsychotic medications, it’s tobacco smoke. Stopping and/ or resuming smoking may require adjustment of some medicines. Prescribed medicines (Varenicline, Bupropion & Nortriptyline)require consideration of neuropsychiatric symptoms in the context of the benefits of stopping smoking.

15. Key MH Messages From the Hui People with MH problems who smoke want to quit and can quit Helping people to quit is our business NRT is safe to use by those with MH problems Smoking makes MH problems worse not better Stopping smoking improves morbidity and mortality outcomes NRT use to cut down is an effective evidence based approach to stopping altogether Smoking in the workforce needs to be reduced

16. What Can You Do? Have the conversation Know the benefits of quitting Make a recommendation and an offer of support Have information available Know about interactions between NRT and ant-psychotic medications Set up long term support

17. References American Psychiatric Association, (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text rev.). Washington, DC: Author. Matthews, A. M., Wilson, V. B. & Mitchell, S. H. (2011). The role of antipsychotics in smoking and smoking cessation. CNS Drugs 25 (4): 299-315. Mental Health Advocacy Coalition. (2008). Destination Recovery: Te Unga ki Oranga. Auckland: Mental Health Foundation of New Zealand. Ministry of Health. (2014).The New Zealand Guidelines for Helping People to Stop Smoking. Wellington: Ministry of Health. Prochaska, J. (2010). Failure to treat tobacco use in mental health and addiction treatment settings: A form of harm reduction? Drug and Aclohol Dependence; 110: 177-182.

18. References Cont. Prochaska, J. (2011). Smoking and mental illness – Breaking the link. New England Journal of Medicine; 365:196-198. Taylor, G., McNeill, A., Girling, A., Farley, A., Lindson-Hawley, N. & Aveyard, P. (2014). Changes in mental health after smoking cessation: Systematic review and meta-analysis. British Medical Journal: 348: g1151.