Elsevier

Addictive Behaviors

Volume 28, Issue 3, April 2003, Pages 461-470
Addictive Behaviors

Onset of major depression during treatment for nicotine dependence

https://doi.org/10.1016/S0306-4603(01)00266-0Get rights and content

Abstract

We monitored the emergence of major depression (MDD) during treatment for nicotine dependence among 224 smokers. MDD was assessed on three occasions during the course of treatment with the mood disorders portion of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID), fourth edition (DSM-IV). Out of 224 participants, 20% had suffered a past episode of MDD, 18% of males and 22% of females. Four percent (n=10) experienced onset of MDD during the course of the study, four males and six females. Only 2 of the 10 cases managed to achieve abstinence at end of treatment. Those who reported large increases in depression symptoms between baseline and end of treatment (Week 10) were less likely to be abstinent at 26-week follow-up. The evidence indicates that those who treat nicotine dependence must be prepared to monitor and respond to the emergence of depression associated with treatment.

Introduction

Do smokers develop diagnosable depression during cessation attempts? Surprisingly, little scientific evidence bears directly upon this question. We could find only three published trials that have used prospective designs and structured clinical interviews to examine the relationship between smoking cessation and development of major depression (MDD). Borrelli et al. (1996) assessed the development of MDD in 114 nondepressed participants in a trial investigating the effects of fluoxetine on smoking cessation. At posttreatment, 7% met DSM-III-R criteria for MDD. All had a previous history of MDD. However, the authors of the study noted that a high drop-out rate, only 69 participants completed a posttreatment SCID, might limit the generalizability of their findings.

Covey and colleagues examined onset of MDD in a subset of 126 smokers (total N=486) who successfully completed smoking cessation treatment, some with clonidine, and submitted to Structured Clinical Interviews (DSM-III-R) at both baseline and follow-up. Of this subgroup, about 7% (n=9) experienced a new episode of depression within 3 months of the conclusion of treatment (Covey, Glassman, & Stetner, 1997). A history of MDD predicted posttreatment MDD. Again, potential biases associated with attrition may limit the conclusions that can be drawn from this work.

Patten, Rummans, Croghan, Hurt, and Hays (1999) reported on the onset of depression in two trials that investigated the efficacy of bupropion for smoking cessation. In the first trial, <1% developed clinical depression during a 7-week treatment period. In Trial 2, none of the participants developed depression during the initial phase of treatment. However, almost 3% (2.7) assigned to a relapse prevention phase developed depression during the 45-week relapse prevention phase.

Finally, Tsoh et al. (2000), using a paper and pencil measure of depression, reported a 12-month incidence of depression of 14% in a sample of 304 smokers recruited from two cessation trials. Those who achieved abstinence were no more likely to develop depression than those who failed to quit smoking. The higher incidence of depression in this study may have resulted, in part, from the method of assessment. Paper and pencil self-report scales are useful for measuring psychological distress that may be relatively transient in nature. However, such scales may not reflect the enduring mood disturbance that is characteristic of clinical depression (Coyne, 1994).

Results from several studies suggest that depression may promote smoking relapse (Hall, Munoz, Reuss, & Sees, 1993). However, most of this research has been cross-sectional in nature, focused only on depressed mood, relied on retrospective reports Hall et al., 1993, Kozlowski, 1979, or examined highly selected samples (Covey, Glassman, Stetner, & Becker, 1993). In one of the few prospective investigations reported in which a structured clinical interview was used to index MDD, Hall, Munoz, and Reuss (1994) did not detect a significant relationship between a positive history and treatment outcome.

Recently, we examined the efficacy of a smoking cessation treatment combining nicotine replacement with the antidepressant medication paroxetine (Killen et al., 2000). In the study, 224 smokers received transdermal nicotine skin patches. Two-thirds of the sample also received paroxetine for prevention of depression symptoms that might otherwise contribute to smoking relapse. As part of that study, we conducted clinical interviews to monitor participants for onset of clinical depression during a 10-week treatment period. In the following pages, we report findings from a secondary analysis designed to answer the following questions: (a) do smokers attempting to quit smoking experience episodes of clinical depression during the quit attempt and (b) is a history of MDD prospectively associated with a poor response to treatment.

Section snippets

Design

The analyses presented in this report are based upon a randomized controlled trial examining the effects of nicotine patch therapy coupled with antidepressant medication (paroxetine) for the treatment of nicotine dependence. A total of 224 smokers (≥10 cigarettes/day) (males=121, females=103) were randomized to one of three treatment groups: (1) nicotine patch+placebo; (2) nicotine patch+paroxetine (20 mg); (3) nicotine patch+paroxetine (40 mg). Nicotine patch treatment was provided for 8

Smoking abstinence rate

The overall abstinence rate at end of treatment (Week 10) was 36% [NRT+placebo=36%; NRT+paroxetine (20 mg)=33%; NRT+paroxetine (40 mg)=39%]. The overall abstinence rate at 26-week follow-up was 24% [NRT+placebo=25%; NRT+paroxetine (20 mg)=21%; NRT+paroxetine (40 mg)=27%] (Killen et al., 2000).

History of MDD

Out of 224 study participants, 20% (45/224) suffered a past episode of MDD; 18% of males (22/121) and 22% (23/103) of females.

Baseline profile of participants

Using t tests, we compared those with and without a positive history of MDD on

Discussion

This study, along with those previously reviewed, is among the first to examine the emergence of major depression in the context of treatment of nicotine dependence using structured clinical interviews and prospective methodology. The findings are of interest given epidemiological research suggesting an apparent linkage between cigarette smoking and depression or negative affect (Anda et al., 1990; Breslau, Kilbey, & Andreski, 1991) and experimental evidence indicating that depression and drug

Acknowledgements

This research was funded by grant 6 RT-0041 from the University of California Tobacco-Related Disease Research Program.

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