Can quitting smoking trigger depression?
Saturday, June 16, 2007
Jonathan Foulds, MA, MAppSci, PhD
Depression is one of the most common and most unpleasant of all illnesses. It is characterized by feeling consistently sad, hopeless and pessimistic for more than 2 weeks (usually much longer), and often involves sleep disturbance, fatigue and changes in appetite. Perhaps most importantly, major depression is a risk factor for both attempted and completed suicide. So anyone who has ever suffered from major depression may understandably be very reluctant to do anything that may increase the risk of feeling that bad again. Remembering that low/depressed mood (which is not the same as full blown depression) is one of the symptoms of nicotine withdrawal, one can understand why someone with a history of depression would become concerned when they experience the onset of depressive symptoms after quitting smoking. Some studies find that people with a history of depression have a lower quit rate when they try to quit smoking, compared to those without such a history. One reason for this may be that onset of depressive symptoms raises the concern that a major depressive episode may return and triggers a return to smoking. However, a critical question is whether such fears are justified. Can quitting smoking increase the risks of onset of major depression?
Professor John Hughes, of the University of Vermont recently reviewed all the published studies providing evidence relevant to this question. The rate of major depression in the year after successfully quitting varied considerably across studies, from as low as 1% to as high as 31%. There was fairly consistent evidence that people with a history of major depression were more likely to have another episode after quitting, but this is not surprising as people with a prior history of depression are more likely to have another episode regardless of whether they quit smoking or not. Two studies by Professor Stan Glassman at Columbia University found that depression occurred more frequently in people with a history of depression who succeeded in quitting smoking compared with those who continued to smoke. In his review, Professor Hughes commented that none of the studies provided conclusive evidence and that there was a high risk of “publication bias”. This refers to the tendency for studies that don’t find a difference/effect to be less likely to be published. So what can we conclude from all this?
It looks likely that having a history of major depression is associated with slightly greater difficulty quitting smoking, and an increased risk of recurrence of depression in the months/years after quitting smoking. It remains uncertain whether quitting smoking can actually trigger an occurrence of depression, although it is clear that the majority (69-99%) of people who quit (even those with a history of depression) do NOT experience major depression within a year of quitting.
But how might this affect the choice of treatment, particularly for those with a history of depression? If I had a close relative who wanted to quit smoking but had a history of major depression, my advice would be as follows:
1. To ensure that you get the best advice and support, attend a treatment center with staff who have been trained to provide tobacco treatment, including access to medical staff with experience providing the range of tobacco treatment medications.
2. To increase the chances of successfully quitting AND preventing unpleasant withdrawal symptoms make sure you use an adequate dose of medication approved for smoking cessation. For the heavy smoker that should involve discussing with the doctor the potential advantages of combination therapy, such as Zyban (bupropion), plus the nicotine patch, plus one of the acute dosing nicotine replacement therapies (nicotine gum, lozenge, inhaler or nasal spray).
3. Make use of all the counseling support services available – ideally combining attendance at regular group or individual appointments, plus registering with a smoking cessation website (e.g. www.quitnet.com ), plus use of a telephone quitline.
4. Don’t start reducing the prescribed medication until you are feeling very confident about maintaining abstinence from tobacco and have discussed it with your prescriber. As a rule of thumb, don’t consider reducing your prescribed smoking cessation medications until you have had fourteen consecutive days with no cravings, withdrawal symptoms or near lapses.
5. Stay engaged in counseling for at least a few months (and ideally longer) after you have come off your smoking cessation medications. This could be as simple as scheduled monthly appointments or telephone calls, but even this relatively infrequent contact during months 4-12 after quitting smoking will help maintain focus on abstinence and will enable the counselors to monitor symptoms and treat as required.
Now all of this may sound like a great deal more work than people typically plan on when they try to quit smoking. It is. But I would remind my relative that this is a difficult but life-saving behavior change they are about to embark on. One likely to add ten healthy years to their life. Its well worth the effort both to successfully quit and to look after ones mental health in the process.
Labels: bupropion, cessation, depression, nicotine addiction cigarette smoking tobacco
11 Comments:
At Fri Sep 21, 04:12:00 PM 2007,
curious said…
i quit smoking 3 month ago
At Mon Sep 24, 05:44:00 PM 2007,
Jonathan Foulds, MA, MAppSci, PhD said…
Dear Curious,
Congratulations and well done!
How did you do it?
At Tue Nov 27, 09:43:00 AM 2007,
Anonymous said…
I quit smoking 4 months ago and have never felt worse in my life! My skin is terrible, my nails are brittle, I am as miserable as sin and haven't slept for months. Will I ever feel that quitting was actually a good move??
At Tue Nov 27, 12:53:00 PM 2007,
Jonathan Foulds, MA, MAppSci, PhD said…
Dear Anonymous of Nov 27,
Its unusual to remain so miserable 4 months after quitting. Those ffeling most commonly pass within the first month. Has anything else happened in your life other than quiting smoking?
Just not being able to sleep on its own can have a big impact on how one feels. I'd recommend talking with your doctor about this to get some help with feeling miserable and not sleeping. No-one should have to suffer that for too long. But don't assume its all the cigarettes fault (or lack of them). Going back to smoking would be bad for your general health and no guarantee you'd feel any better.
At Mon Feb 04, 02:46:00 PM 2008,
philosorappter said…
I quit smoking the first of the year. I have never been a very heavy smoker, mainly I smoked when I went to a bar. I didn't smoke at all in the morning or during working hours. I thought I had had a very easy time in quitting - but... I also have a history of severe depression. Last Wednesday I woke up in "the pit" and I feel horrible. I read your article and others because I wanted to know if the two were related. I'm going to see my doctor to ask if I should add or change medications. You recommend nicotine replacement AND psychoactives in your article. Would you still recommend that even though I haven't smoked in over a month?
At Sun Feb 10, 07:41:00 AM 2008,
Anonymous said…
I quit smiking last week, cold turkey. I really don't want to have to go through that agaian! However I am drinking like a fish, eating like a pig, and my mood and outlook is starting to deteriorate. Is there anything I should or can do? As far as drinking goes I have always drank, i've just noticed that I drink more now, (the same with eating). Any help or ideas would be greatly appreciated.
At Mon Feb 11, 12:35:00 PM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
Dear Anonymous of Feb 10th,
Sounds like you are experienceing the classic sugns ans symptoms of nicotine withdrawal syndrome. To learn more about it chack out:
What is nicotine withdrawal syndrome? 3/6/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/what-is-nicotine-withdrawal-syndrome.html
...and to cope with it check out...
Ten tips for coping with nicotine withdrawal. 3/7/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/ten-tips-on-coping-with-tobacco.html
At Sun Jun 29, 12:46:00 PM 2008,
Anonymous said…
I quit 28 Days ago. Same here, cant sleep, spotty skin, nails snapping, so depressed dont even want to get out of bed some days and the way im shouting at the people i love is a joke. But some how cant control myself. Had a relapse last wknd had one but it just made me cry with guilt !!
At Tue Jul 01, 12:24:00 PM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
Dear Anonymous of June 29,
Sounds like this could be mood disturbance related to nicotine withdrawal. Check out the links about nicotine withdrawal and how to handle it, provided in my previous response (above). If you are continuing to feel this way, worth talking to your doctor. The mood disturbance typically lessens over the first 4 weeks after quitting. Let us all know how you get on.
At Mon Jul 14, 09:48:00 AM 2008,
Anonymous said…
I quit smoking 4 weeks ago - this is my second attempt this year.
I quit in January for 8 weeks but started again after gaining 25 pounds.
I went back to my previous pack a day habit quickly and lost 22 of the 25 pounds I had gained and set a new quit date.
I quit again on June 15th and am realizing that with each passing week my depressive symptoms are becoming more pronounced. This weekend my major activities were sleeping and eating. I am also recognizing that, although I didn't clue into it in March, it was a return of the depressive symptoms (including the weight gain) that sent me back to smoking then.
It has been 15 years since my last major depressive episode and I thought I had it beat. I don't want to go back there.
At Tue Aug 05, 09:34:00 AM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
The bad mood that is caused by nicotine withdrawal typically peaks in the first week and is markedly improved by the 4th week after quitting. But if you find your mood still worsening and that it is interfering with with your everday life weeks after that, then you should talk to your doctor. If you find yourself having thoughts of being hopeless or worthless or thoughts of self-harm you should talk to your doctor immediately.Although the mood distrubance from nicotine withdrawal typically last up to 4 weeks, everyone is a little different, and of course other life circumstances have their effects. It would be helpful if those who experienced mood disturbance after quitting...but then recovered, could tell their story - including the symptoms/feelings and the time scale.
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