1. Smoking and Mental Health Problems in Treatment-Seeking University Students Eric Heiligenstein, M.D. University of Wisconsin-Madison Health Services Stevens S. Smith, Ph.D. University of Wisconsin Center for Tobacco Research and Intervention

2. Smoking Prevalence in the U.S. JAMA, 1989:261

3. Association of Smoking and Psychiatric Disorders  General population o 22-30%  Panic disorder o 35%  Alcohol abuse o 43%  Depression o 49%  Schizophrenia o 88%

4. Smoking Status According to Psychiatric Diagnosis US PopulationCurrent Smokers, % Lifetime Smokers, % Total 10028.547.1 No mental illness 50.722.539.1 Ever mental illness 49.334.855.3 Any mental illness in past month 28.341.059.0 Adapted from Lasser, 2000

5. Broad Complications of Smoking and Psychiatric Disorders Additive mortality risks from CV disease and cancer Associated with substance abuse and dependence Poorer HRQOL and functional status Income diversion  Boyd et al., 2001; Bruce et al., 1994; Degenhardt et al, 2001; Anda et al, 2003; Woolf et al, 1999

6. Specific Complications of Smoking and Psychiatric Disorders Higher risk for suicide and suicide attempts Smokers with PD have more severe symptoms than non-smokers with PD Smokers with schizophrenia have greater number of hospitalizations than non-smokers with schizophrenia  Miller et al., 2000; Zvolensky et al, 2003; Goff et al., 1992

7. Smoking Rates Compared to the Number of Lifetime Psychiatric Diagnoses Adapted from Lasser, 2000

8. Methods Data Sources  University of Wisconsin-Madison o 40,000 undergraduate, graduate, and professional students o Voluntarily presented for mental health treatment at Counseling Services (9/03-12/03)

9. Methods Assessment (retrospective chart review)  Basic demographic measures  Smoking status o Nonsmoker/occasional o Light smoker (at least weekly use) o Heavy smoker (daily smoking, >10 cigarettes per day)  PsyberCare-MH (Polaris Health Directions) o Standardized and validated computer assessment

10. PsyberCare-MH In Use Typical Clinical Setting Process Flow Real-Time Clinical Report Patient Self- Report Assessment (unassisted) Physician / Treatment Provider Patient Set Up At Computer (30 seconds) Master Database Aggregate Data Report

11. Question Presentation

12. Sample Report Page

13. Methods PsyberCare-MH Scales  Subjective well-being ( includes SF-12)  Psychiatric symptom severity (DSM IV)  Functional disability (SSI guidelines)

14. Results 1259 students presented for evaluation 1148 took PsyberCare-MH (91%) Reviewed random sample of ½ records (n=574) Smoking status identified in 503 (88%)

15. Demographic Characteristics According to Smoking Status VariableNonsmokers a (n=384) Light Smokers b (n=68) Heavy Smokers c (n=51) MeanSDMeanSDMeanSD Age22.44.322.64.022.75.0 N%N%N% Male12171.62615.42213.0 Female26378.74212.6298.7 White33075.56214.24510.3 Non- White d 5481.869.16 d Hispanic n=11, Black n=10, Asian n=16, International n=23, Other n=6

16. PsyberCare Scales By Smoking Status PsyberCare Scale Non-smokers with percentile scores < 50 a (n=384) Light smokers with percentile scores < 50 (n=68) Heavy smokers with percentile scores < 50 (n=51) Non-smokers vs Light Smokers Comparison Non-Smokers vs. Heavy Smokers Comparison Light Smokers vs. Heavy Smokers Comparison Depression32.3%41.2%80.4%  2 (1)=2.0, p=.15  2 (1)=44.2, p<.001  2 (1)=18.4, p<.001 Anxiety38.5%48.5%80.4%  2 (1)=2.4, p=.12  2 (1)=32.1, p<.001  2 (1)=12.6, p<.001 Subjective Well-being 54.7%61.8%96.1%  2 (1)=1.2, p=.28  2 (1)=32.0, p<.001  2 (1)=19.1, p<.001 Personal Functioning 25.0%35.3%82.4%  2 (1)=3.1, p=.08  2 (1)=63.4, p<.001  2 (1)=26.1, p<.001 Social Functioning 24.5%27.9%54.9%  2 (1)=0.4, p=.54  2 (1)=20.6, p<.001  2 (1)=8.9, p<.004 Vocational Functioning 27.1%32.4%68.6%  2 (1)=0.8, p=.37  2 (1)=35.7, p<.001  2 (1)=15.4, p<.001 a Percentile scores <50 indicate poorer functioning.

17. PsyberCare-MH Scales by Smoking Status

18. Discussion Heavy smokers compared to light and non- smokers  More severe depression and anxiety  Poorer overall well-being  Greater functional impairment  (all p<.008) No differences between light smokers and non-smokers

19. Discussion Results support existing research in general population and medical settings Smoking is severity of illness multiplier

20. Understanding the Results Neuropharmacologic effects of nicotine Shared genetic and psychosocial factors Cigarette smoke contains numerous other psychoactive compounds

21. Methodological Limitations Cross-sectional data Limited generalizability Tobacco use determine by self-report Psychiatric diagnoses not recorded

22. Clinical Implications Systematic identification processes that mesh with a non-medical practice style Integration of smoking cessation efforts within primary mental health treatments Evaluation of outcomes of standard mental health treatments in smokers Address the effects of psychiatric comorbidity on cessation efforts in primary care settings