Psychiatric Nursing

Introduction

It is one of the most heavily used  addictive in the United States and around the world. It causes lung cancer, emphysema and cardiovascular diseases .

Epidemiology

Age and gender

• The WHO estimates there are 1 billion smokers world wide and they smoke 6trillion cigarettes a year. The WHO also estimates that tobacco kills more than 3 million persons each year. The rate of quitting smoking has been highest among well-educated white men and lowest among women, blacks, teenagers and those with low levels of education.
• Tobacco is the most common form of nicotine. It is smoked most commonly in cigarettes, cigars , chewing tobacco and in pipes. About 3% of all persons in the United States currently use snuff or chewing tobacco and 6% of young adults ages 18 to 25 use those forms of tobacco.
• Currently about 25% of American smoke , 25% are former smokers and 50% have never smoked cigarettes. The mean age of onset of smoking is 16 years and few person start smoking after 20.
• More than 75% of smokers have tried to quit and about 40% try to quit each year. On a given attempt, only 30% remain abstinent for even 2 days,and only 5-10% stop permanently.
• According to DSM-IV-TR , around 85% of current daily smokers are nicotine dependent. Nicotine withdrawal occurs in about 50% smokers who try to quit.

Education: Of adults who had not completed high school ,37% smoked cigarette, whereas only 17% percent of college graduate smoked.

Psychiatric patients : Approximately 50% all psychiatric outpatients, 70% of outpatients with bipolar I disorder, almost 90% of outpatients with schizophrenia and 70% of substance use disorder patient smoke.

Patients with depressive disorder or anxiety disorder are less successful in their attempt to quit smoking than other persons.

Death : Tobacco use is associated with approximately 4000,000 premature deaths each year in the United States-255 of all deaths. Researchers have found that 30% of deaths in the United States are caused by tobacco smoke.

Cause of death : it include chronic bronchitis and emphysema (51,000 deaths), bronchogenic cancer (106,000 deaths) ,35% of MI(115,00deaths),cereberovascular disease ,cardiovascular disease and lung cancer. The increased use of chewing tobacco and snuff has been associated with the development of oropharyngial cancer. Smoking cause the cancer of the lung, upper respiratory tract, esophagus , bladder and pancreas and probably of the stomach .liver and kidney.

NEUROPHARMACOLOGY

The psychoactive component of tobacco is nicotine which affects the CNS. About 25% of the nicotine inhaled during smoking reaches blood stream, through which nicotine reaches the brain with in 15 seconds.  The half life of the nicotine is 2 hours. Nicotine is believed to produce its positive reinforcing and addictive properties by activating the dopaminergic pathway projecting from the ventral tegmental area to the cerebral cortex and limbic system. It also causes an increase in the concentration of norepinephrine and epinephrine and an increase in the release of vasopressin, beta endorphins,ACTH and cortisol. Theses hormones are thought to cause stimulatory effects of nicotine on the CNS.

DIAGNOSIS

The DSM IV TR lists three nicotine related disorders . theses are

• Nicotine dependence
• Nicotine withdrawal
• Nicotine related disorders not otherwise specified

Nicotine dependence

DSM IV TR diagnostic criteria

Same  as that of the criteria for substance dependence

Dependence on nicotine develops quickly because it activates the ventral tegmantal area of depaminergic system. Many studies proved  a genetical predisposition to nicotine dependence. Person are likely to smoke if their parents or siblings smoke and serve as role models.

Nicotine withdrawal

DSM IV TR diagnostic criteria

1. Daily use of nicotine for at least several weeks.
2. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four (or more) of the following signs:
   1. dysphoric or depressed mood
   2. insomnia
   3. irritability, frustration, or anger
   4. anxiety
   5. difficulty concentrating
   6. restlessness
   7. decreased heart rate
   8. increased appetite or weight gain
3. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Withdrawal symptoms can develop within 2 hours of smoking the last cigarette: they generally peak in the first 24 to 48 hours and and can last for weeks or months.

Symptoms : the common symptoms are an intense craving for nicotine ,tension, irritability, difficulty concentrating, drowsiness and paradoxical trouble sleeping, decreased heart rate and blood pressure, increased appetite and weight gain, decreased motor performance and increased muscle tensions.

Nicotine related disorders not otherwise specified

Nicotine related disorders not otherwise specified is a diagnostic category for nicotine-related disorders that do not fit into one of the categories discussed above. Such diagnoses may include nicotine intoxication, nicotine abuse, mood disorders and anxiety disorders associated with nicotine use.

CLINICAL FEATURES

Behaviorally it produces improved attention, learning, reaction time and problem solving ability. It also lifts their mood ,decreases tension and lessens depressive feelings. Studies proved that short term nicotine exposure increases the cerebral blood flow without changing cerebral oxygen metabolism but long term exposure decreases the cerebral blood flow. It also acts as a skeletal muscle relaxant.

ADVERSE EFFECTS

Nicotine is highly toxic alkaloid. Doses of 60mg in an adult are fatal secondary to respiratory paralysis. Doses of .5 mg are delivered by smoking an average cigarette.

Signs and symptoms:

In low doses the signs and symptoms include nausea ,vomiting, salivation ,pallor (due to peripheral vasoconstriction ) ,weakness, abdominal pain(caused by increased peristalsis),diarrhea, dizziness, headache ,increased blood pressure ,tachycardia, tremors and cold sweats.

Toxicity is also associated with an inability to concentrate , confusion and sensory disturbances.

Nicotine is also associated with a decrease in the user's amount of rapid eye movement sleep.

Tobacco use during pregnancy causes increased incidence of low birth weight babies and an increased incidence of newborns with persistent pulmonary hypertension.

Health benefits of smoking cessation

• It increases the life span compared to those continue to smoke
• Decreases the risk for lung cancer ,MI, cerebrovascular diseases and chronic lung disease.
• Women who stop smoking before or during the first trimester reduce their risk for having LBW babies.

TREATMENT

Psychiatrist should advise all patients to quit smoking. Gradual cessation is preferred over abrupt cessation .brief advice should focuses on the need for medication or group therapy, weight gain concern ,high risk situation ,making cigarettes unavailable and so forth.

PSYCHOSOCIAL THERAPIES :

Behavior therapy is the most widely accepted and well proved psychological therapy for smoking. Skill training and relapse prevention identify high risk situations and plan and practice behavioral or cognitive coping skills for those situations in which smoking occurs.

Stimulus control involves eliminating cues for smoking in the environment.

Aversive therapy has smokers smoke repeatedly and rapidly to the point of nausea that associates smoking with unpleasant rather than unpleasant sensation. To be effective it requires a good therapeutic alliance and patient compliance.

HYPNOSIS: Some patients benefits from a series of hypnotic sessions. Suggestions  about the benefits of not smoking are offered and assimilated into the patients cognitive framework as a result . posthypnotic suggestions that cause cigarettes to taste bad or to produce nausea when smoked are also used.

PSYCHOPHARMACOLOGICAL THERAPIES

Nicotine replacement therapies

All nicotine therapies double the cessation rates because they reduce the nicotine withdrawal. These therapies can also be used to reduce withdrawal in patients on smoke free ward.

Replacement therapies use a short period of maintenance of 6 to 12 weeks often followed by a gradual reduction period of another 6 to 12 weeks.

Nicotine polacrilex gum (Nicorette) is an OTC product that release nicotine via chewing and buccal absorption.

Dose: A 2mg variety for those who smoke fewer than 25 cigarettes and 4mg variety for those who smoke more than 25 cigarettes a day are available. Smokers are to use one to two pieces of gum per hour up to maximum 25 pieces per day after abrupt cessation. Acidic beverages(coffee, tea, soda and juice) should not be used before during or after gum use because they decrease absorption. Adverse effects are minor include bad taste and sore jaws. About 20% of the people who quit use the gum for long periods and 2%use it for longer than one year. Long tern use does not cause any harmful effects.

Nicotine lozenges (Commit)

Dose: available in 2mg and 4mg. Generally 9 to 12 lozenges a day are used during the first 6weeks with decrease in dosage there after

Use: They are useful for patients who smoke cigarette immediately on awakening. They  offer the highest level of nicotine of all nicotine replacement products.

Method of administration : users suck the lozenges until it dissolved and not swallow it.

Side effects : insomnia , nausea, heartburn, headache and hiccups.

Nicotine patches

Thses are also sold OTC, are available in a 16 hours no-taper preparation(Nicotrol) and a 24 or 16 hours tapering preparartion (Nicoderm CQ).

Method of administration: patches are administered each morning and produce blood concentration about half those of smoking.

Compliance is high and the only major adverse effect are rashes and with 24 hour wear , insomnia. After 6 to 12 weeks ,the patch is discontinued because it is no for long term use.

Nicotine nasal spray(Nicotrol) :available only by prescription ,produces nicotine concentrations in the blood that are more similar to those from smoking a cigarette and is helpful for heavily dependent smokers. The spray causes rhinitis, watering eyes and coughing more than 70 percent patients.

Nicotine inhaler : it designed to deliver nicotine to the lungs .it delivers 4mg per e and resultant nicotine levels are low. Major advantage is that it provides a behavioral substitute for smoking. It  doubles the quit rate. Theses devices requires frequent puffing -about 20 minutes to extract 4mg of nicotine. It has got minor adverse effects.

NON-NICOTINE MEDICATIONS : it is useful to those smokers who object philosophically to the notion of replacement therapy and smokers who fail replacement therapy. Bupropion which is an antidepressant is used as  non nicotine medication.

Dose: it is started at 150 mg per day for 3days and increased to 150 mg twice a day for 6 to 12 weeks. Daily dosage of 300 mg doubles the quit rates in smoker with or without a history of depression.

Adverse effects : insomnia, nausea

Second line of drug is Nortrypyline. It is found to be effective in smoking cessation.

Clonidine (Catapres) decreases sympathetic activity form the locus ceruleus and it decreases the withdrawal symptoms. Whether given as a patch or orally, .2 to .4 mg a day of clonidine appears to double the quit rates.  It is not much effective as other drugs. It causes drowsiness and hypotension.

Some patients benefit from benzodiazepine therapy (10 to 30 mg per day) for the first 2 to 3 weeks of abstinence.

A nicotine vaccine that produces nicotine specific antibodies in the brain is under investigation at the National Institute on Drug Abuse (NIDA)

Combined psychosocial and pharmacological therapy: increases quit rates over either therapy alone.

Smoke free environment

Secondhand smoke can contribute to lung cancer death and CAD in adult nonsmokers.  Two national health objectives for 2010 are to reduce cigarette smoking among adults to 12% and proportion of nonsmoker exposed to environment tobacco smoke to 45%.

Involuntary exposure to secondhand smoke is common public health hazard. Ban on smoking in publics reduces exposure to secondhand smoke and the number of cigarettes smoked by the smokers.

 

References :

1. Mary TC. Psychiatric Mental Health Nursing –Concept of Care 3^rd ed. Philadelphia :F.A. Davis Publishers ;2002
2. Ahuja N .A Short Text Book of Psychiatry 5^th ed.New Delhi: Jayee Medical Brothers Publishers .2002.
3. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry .9th ed.Hong Kong: William and Wilkinson Publishers ;1998.
4. Sadock BJ ,Sadock VA. Synopsis of psychiatry :Behavioral Sciences/ Clinical Psychiatry.10^th ed.Philadelphia: William and Wilkinson Publishers;2007.