Differential prevalence of cigarette smoking in patients with schizophrenic vs mood disorders
Introduction
The incidence of comorbid substance use among individuals with psychiatric disorders has consistently been found to be high in comparison to the general population (Mueser et al., 1990; Cohen and Henkin, 1993; Jeste et al., 1996). The Epidemiologic Catchment Area Study (ECAS; Regier et al., 1990) found that lifetime rates of substance abuse among those with major psychiatric disorders (schizophrenia, bipolar disorder, major depressive disorder) ranged from 32 to 56% and were markedly elevated compared to those of the general population. Other studies have separately corroborated these findings of extremely high levels of alcohol and drug use and abuse among persons with schizophrenia (Dixon et al., 1991; Selzer and Lieberman, 1993; Hamera et al., 1995; Jeste et al., 1996), bipolar disorder and major depressive disorder (Mueser et al., 1992). Some have suggested that there may be specificity to the relationship among types of substance abuse and psychiatric diagnosis (Richard et al., 1985; Schneier and Siris, 1987; Mueser et al., 1990; McPhillips et al., 1997). Others have found most types of substance abuse to be unrelated to psychiatric diagnosis (El-Guebaly and Hodgins, 1992; Mueser et al., 1992). Hence, the link between classes of drugs and diagnostic groups remains unclear.
Interestingly, cigarette smoking prevalence has not always been considered in studies examining substance-use disorders among psychiatric patients, despite the recognition that cigarette smoking is the most common substance-use disorder among the psychiatrically ill (Schneier and Siris, 1987; El-Guebaly and Hodgins, 1992). Smoking rates of 50% to as high as 93% have been reported (Goff et al., 1992; Ziedonis et al., 1994; de Leon et al., 1995), and remain elevated even when other contributing factors (gender, education, socio-economic status) are controlled (Hughes et al., 1986). More recently, efforts to understand the comorbidity of smoking with schizophrenia and with major depression have been undertaken (Lohr and Flynn, 1992; Glassman, 1993).
Across psychiatric diagnoses, smoking prevalence is highest among those with schizophrenia (Hughes et al., 1986; de Leon et al., 1995). Smokers with schizophrenia often report smoking in order to relax or calm themselves (Glynn and Sussman, 1990). Some studies have suggested that smoking may be an attempt to self-medicate positive as well as negative symptoms of schizophrenia (Sandyk and Kay, 1991; Lohr and Flynn, 1992). Other data have suggested that smokers with schizophrenia smoke to remediate attentional and cognitive processing deficits stemming from the psychiatric illness itself (Adler et al., 1993). The suggestion that smoking cessation might exacerbate psychiatric symptoms (Dalack and Meador-Woodruff, 1996) supports a more specific link between schizophrenia and smoking.
The relationship between smoking and major depressive disorder has been more extensively studied and has important implications for success in smoking cessation (Glassman et al., 1990Glassman et al., 1993), such that a history of major depressive disorder has been recognized as a poor prognostic sign for success in smoking cessation.
Beyond the original report of Hughes et al. (1986), however, little has been reported about the variations in smoking behaviors across psychiatric diagnostic groups. It remains unclear as to whether there exists any specificity of smoking in primary psychotic vs primary mood disorders in contrast to the lack of specificity of other drug-use disorders with these psychiatric syndromes.
This report summarizes patterns of smoking and drug use in patients with schizophrenic disorders (SCZ, schizophrenia+schizoaffective disorder) and mood disorders (AFF, major depressive disorder+bipolar disorder). We hypothesized that cigarette smoking, unlike other substance use, would be more highly prevalent among those with SCZ than AFF.
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Method
We developed a smoking questionnaire to be administered to psychiatric patients. This instrument was used to collect demographic information, individual and family smoking history, current smoking status, cessation attempts, and current and past caffeine, alcohol and other drug use. The strength of the questionnaire lies in its particularly detailed coverage of cigarette-smoking history. Clinical diagnoses, also reported in the questionnaire, were those made by the treating psychiatrist. The
Demographics, psychiatric status
Subjects with SCZ (n=63) were younger on average than those in the AFF group (n=20) (44±8 years vs 51±15 years; df=81; t=2.69; p=0.009). They were also more likely to be single. There were no differences in race, education, or mean income between the SCZ and AFF groups. At the time of assessment, psychotic symptoms were typically a more prominent feature of the schizophrenic disorders than the mood disorders. However, some of the mood-disorder patients did require chronic treatment with
Discussion
Our interest was in trying to examine links between smoking and other substance use and specific major psychiatric disorders. Our findings corroborate the elevated prevalence of current smoking among those with schizophrenia and schizoaffective disorders, but also indicate that the rate of ever-smoking is higher and smoking cessation much lower than among those with primary mood disorders. In this data set, among those with AFF, the majority of ever-smokers are former smokers, while the vast
Conclusion
This study attempts to discern patterns of smoking status among those with schizophrenic vs mood disorders, and to compare any patterns therein to use of marijuana, alcohol and cocaine in these groups. The results suggest that patterns of cigarette-smoking status are different from those of marijuana, alcohol and cocaine use. The implications of the greater specificity for smoking in SCZ vs AFF require further study. Indeed, the significantly higher prevalence of smoking among individuals with
Acknowledgements
Supported in part by an award from the Student Biomedical Research Program of the University of Michigan Medical School to A.D., by the Department of Veterans Affairs Research Advisory Group Award to G.W.D., and by the Mental Health Research Institute and Department of Psychiatry at the University of Michigan. The authors thank Lisa Becks, Elizabeth Abrams and Natasha Salij for their help in data collection.
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