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The mental health system has been reluctant to identify and treat tobacco dependence despite exhortations to diagnose and treat this often fatal disorder. This phenomenon can be linked to the belief on the part of mental health professionals that they do not have the skills to provide smoking treatment, the failure to understand that mental health patients can succeed in quitting smoking, reimbursement concerns, and fear of exacerbation of symptoms during nicotine withdrawal. Also, it is sometimes assumed that individuals with mental illness are too distracted, demoralized, or disorganized to benefit from smoking treatment
One large-scale recent study estimated that 44.3% of the cigarettes smoked in this country are smoked by individuals with a psychiatric disorder, such as substance abuse and dependence, schizophrenia, bipolar disorder, and major depressive disorder (MOD). Depressed smokers may be numerically the largest group of comorbid smokers, because of considerable co-occurrence, as well as the high incidence and prevalence of depression.
There are compelling arguments for the provision of smoking treatment in the psychiatric outpatient setting. The first such argument is the high prevalence of cigarette smoking in that setting. Second, if smoking cessation exacerbates psychiatric disorders, quitting smoking while in treatment would provide a safety net. Third, although mental health providers may view themselves as unable to skillfully provide nicotine-dependence treatment they already possess the basic tools needed to provide such treatment, including interviewing and behavior change methods and knowledge of psychopharmacology.
The Agency for Health Care Policy and Research guidelines and the American Psychiatric Association practice guidelines available at the time this study was initiated (in 1999) suggested that smokers with comorbid mental health conditions should be offered the same smoking cessation treatments that have been identified as effective for smokers in general: skill training, pharmacotherapy, and clinical support It is important to note that these recommendations are not currently implemented in mental health treatment settings.
The clinical trial described in our article tested the efficacy of a staged care intervention that was implemented in the mental health outpatient setting and was designed to change smoking behavior in all smokers, including those unmotivated to quit. The target population of interest was patients in outpatient treatment for depression. The staged care intervention was an appropriate intervention for smokers enrolled in depression treatment, because smoking cessation would not be a primary goal for these individuals. Yet, their presence in the mental health treatment setting provided an opportunity to intervene in their smoking behavior.
The staged care intervention operationalized the recommendations of the Agency for Health Care Policy and Research and the American Psychiatric Association practice guidelines. It integrated a computerized feedback system that was based on the Transtheoretical Model, which provided feedback about smoking with a provision for face-to-face individual psychological counseling and pharmacological treatment at the appropriate stage of readiness. The staged care intervention was compared with an educational materials and referral list control (brief contact control). The control condition was designed to model current practices in mental health clinics, although in practice it probably exceeded those usually provided.
Staged Care Intervention Model Components
The computerized system used in the present study is described in detail elsewhere. Participants met with their counselor and responded to questions on the computer about their cognitive and behavioral processes of change, their perceptions of the pros and cons of smoking, and about temptations to smoke. The system made normative and ipsative comparisons and produced a report that was designed to optimize movement into the next stage. The report described the participants' current stage, how their decisions and cognitive and behavioral processes compared with those of others and to their own earlier reports, and tempting situations and strategies for movement to the next stage of readiness. It also provided an individualized report of tempting situations and proposed strategies for moving to the next stage of readiness. The counselor and the participant reviewed the written report together. Treatment sessions based on the computerized feedback reports lasted about 15 minutes, They were held at baseline, and at months 3, 6, and 12.
Cessation treatment program. The second component of me staged care intervention model was a cessation treatment program for participants who had reached at least the contemplation stage on the basis of their computerized feedback report. The cessation treatment consisted of psychological counseling adapted from published interventions, nicotine patches, and possible use of sustained-release bupropion. Upon entrance into the study, each participant was assigned 1 of 2 counselors — one with a master's degree in psychology and a second with a doctorate in clinical psychology. Counselors provided the motivational counseling and cessation treatment to willing participants and were supervised weekly by either the project coordinator or by the first author. When participants reached the contemplation stage, they were offered cessation treatment. But, because of ethical concerns, any participant who requested cessation treatment, regardless of their stage, received it. During the study period, 34% (n= 53) of the staged care intervention participants entered cessation treatment.
Counseling was provided in 6 sessions of 30 minutes each, over the course of 8 weeks and focused on immediate and complete cessation at the agreed-upon quit date. The intervention included development of a commitment to abstinence and a quit plan that was iteratively revised during the quitting process, selection of a quit date, participation in a series of self-tests pertaining to reasons for smoking, discussion of information about the risks of smoking and the benefits of quitting, and discussion of information on nutrition and exercise. The intervention also included mood monitoring, discussions of ways to increase pleasant moods and decrease negative ones, use of behavioral skills to reduce relapse risk, and relaxation and social support skills. A manual is available from the senior author upon request.
Participants who smoked 10 or more cigarettes per day received 21-mg nicotine patches for the first 6 weeks, 14-mg patches for weeks 7 and 8, and 7-mg patches for the final 2 weeks. Participants who smoked fewer than 10 cigarettes per day started with 14-mg patches for 6 weeks and switched to 7-mg patches for the remainder of treatment
Brief Contact Control Intervention: The brief contact control intervention consisted of providing participants at the first visit with a folder containing a list of referrals to smoking cessation programs and a stop-smoking guide. There was no other therapeutic contact between these participants and study staff.
Conclusions: The current study tested a staged care intervention based on currently available interventions and therapies in outpatient mental health clinics. There are 2 important implications of this study: The first is that psychiatric patients will enter into smoking interventions while they are in mental health treatment although the study does not yield data on the proportion of eligible smokers who will do so. The second implication is that, when compared with a baseline treatment that exceeds those offered in most psychiatric clinics, these patients in the staged care intervention quit at higher rates than those in less intensive control conditions.
Reflection Exercise #8