Mental Health and/or Other
Addictions
CAN-ADAPTT Webinar Series
March 29, 2011, 12 pm (EST)
Presenter: Dr. Pamela Kaduri, MD, Mmed
Guideline Section Leads:
Charl Els, MBChB, FCPsych, MmedPsych (cum laude), ABAM, MROCC; and
Peter Selby, MBBS, CCFP, MHSc, FASAM
Bio & Disclosures
 Clinical Fellow, Addictions Program, Centre
for Addiction and Mental Health (CAMH)
 TEACH program psychiatrist
 No affiliation with pharmaceutical industry or
tobacco companies
Guideline Development Group
 Peter Selby, MBBS, CCFP, MHSc, FASAM;
 Gerry Brosky, MD, MSc, CCFP;
 Charl Els, MBChB, FCPsych, MMed Psych (cum
laude), Cert. ASAM, MRO;
 Rosa Dragonetti, MSc;
 Sheila Cote-Meek, BScN, MBA, PhD;
 Jennifer O’Loughlin, PhD;
 Paul McDonald, PhD, FRSPH;
 Alice Ordean, MD, CCFP, MHSc;
 Robert Reid, PhD, MBA
Guideline Section Status
 This guideline section, “Mental Health
and/or Other Addictions”, is currently under
review by the GDG lead (Dr. Peter Selby).
 This section will be launched shortly.
CAN-ADAPTT
 Guideline development, dissemination and
engagement project
 Integrates practice, policy and research in a
collaborative smoking cessation network
 Goal: To inform the development of a Pan-Canadian
clinical practice guideline (CPG) for smoking
cessation
Funded by the Drugs and Tobacco Initiative,
Health Canada
National Network
RESEARCH
Practice-informed
Research Agenda
Clinical Practice Guideline
Knowledge
Translation
Dissemination
& Engagement
PRACTICE
Guideline Development
Applied principles of
ADAPTE…
•
Review existing CPGs
•
Highest-scoring CPGs
included
•
Ongoing input from CANADAPTT network
•
GRADE framework used
Grade of
Recommendation
High
Strong
Level of
Evidence
Weak
Low
1A
2A
1B
2B
1C
2C
Pregnant and
Breastfeeding
Women/ Femmes
enceintes et qui
allaitent
Youth (Children
and Adolescents)/
Jeunes (enfants et
adolescents)
Mental Health and/or
Other Addictions/
Santé mentale et/ou
autres dépendances
Hospital-based
populations/
Populations des
hôpitaux
Aboriginal
Peoples/
Autochtones
Various doors for intervention
opportunities…
 Providing tobacco dependence treatment for mentally ill
and addicted clients can be more complex than for other
tobacco users
 Determinants of service depends on the seriousness of
the mental illness and or treatment for substance use
and the level of individuals functionality .
 Care can be through various doors
 Primary Health Care (PHC)
 Mental health treatment facility
 Substance use treatment facility
 Other community programs etc
Gaps in Practice & Barriers
 NRT reduce to quit and combination therapy although approved
for use in Canada has not been specifically studied in this
population.
 Complexity of mental health patients and need for access to
free pharmacotherapy.
 Monitoring for consequences of long-term use of medication.
Gaps in practice and Barriers #2
 Research targeted to address pharmacotherapy treatment
and management (i.e.: higher doses of longer duration)
for this population.
 Should approaches or interventions be tailored to different
levels of mental health services (e.g. Crisis, first
psychosis, etc.)?
Summary Statement #1
Health care providers should screen
persons with mental illness and/or
addictions for tobacco use.
GRADE: 1A
Summary Statement #2
Health care providers should offer counseling and
pharmacotherapy treatment to persons who smoke
and who have a mental illness and/or addiction to
other substances.
GRADE: 1A
Summary Statement #3
While reducing smoking or abstaining (quitting), health
care providers should monitor the patient’s/client’s
psychiatric condition(s) (mental health status and/or
other addiction(s)). Medication dosage should be
monitored and adjusted as necessary.
GRADE: 1A
Clinical Considerations
 Screen
 An equally accurate term for ‘screening’ may be ‘case finding’
given the prevalence of tobacco use among persons with
mental health diagnosis and/or addiction(s).
 The term ‘addictions’ refers to those other than tobacco.
 Due to the high prevalence of concurrent mental illness and
addiction, patients/clients should be screened for underlying,
non-debilitating, undiagnosed mental health challenges.
 Conducting regular, brief screenings for mood changes is
encouraged.
Clinical Considerations cont’d
 Offer pharmacotherapy/counselling
 It should be noted that no (cessation) pharmacotherapy has
been contraindicated in persons with mental illness unless
medically contraindicated.
 Recognize that involuntary abstinence from tobacco requires
management with an agonist at sufficient doses.
 The withdrawal/anxiety experienced by persons abstaining from
smoking should be recognized and addressed; especially in
acute care facilities.
Clinical Considerations cont’d
 Monitor
 Consider that persons with mental illness and/or
addiction(s) who smoke might need higher doses of NRT
or combination therapies and for a longer duration.
 Assess for interactions with medications used for co
morbid conditions.
 Caffeine should be considered a compound to be
monitored.
Clinical Considerations cont’d
 Follow-up
 Referral to appropriate healthcare services
(community, program referral, other team members)
for management/treatment and follow-up can be
considered.
 In-patient staff should be aware of community
resources to support cessation and address nicotine
dependence.
Clinical Considerations cont’d
Resources for healthcare providers
 Treatment facilities staff should increase their
understanding of mental health and nicotine
dependence to effectively offer cessation and
to address stigmas attached to mental illness.
Additional
Considerations
 Given the culture of mental health and addictions treatment facilities where
staff often smoked and thereby, clients’ smoking behaviour was sustained,
these facilities must address smoking in their policies. I.e. become
smoke-free grounds.
 Offer smoking cessation to all healthcare providers and staff who
smoke in a practice setting or treatment facility
 Financial resources for this “longer and stronger” counselling and/or
pharmacotherapy are necessary. Persons with mental illness and/or
addictions, due to a lower disposable income and proportionally higher
spending on tobacco, may especially benefit from subsidized
pharmacotherapy, in sufficient dose and duration.
 Limit out-of-pocket costs to smokers with mental illness and/or addictions to
improve outcomes.
Case #1
 64 year old widowed woman, retired; husband recently
died of heart disease . Smokes 20 cpd, on citalopram 30
mg daily for recurrent major depressive episodes, now in
partial remission
 Has been thinking more about her smoking, but does not
believe she can successfully quit because she quit
smoking for 5 days once and felt terrible. She tried the
nicotine lozenge but decided it didn’t help and says it’s
expensive.
 She reports worries about the impact of her smoking on
her grandchildren’s health, but fears gaining weight if she
were to try to quit. She was recently diagnosed with very
mild Type II Diabetes and encouraged to lose weight.
 She reports her morning routine is to make a pot of
coffee and smoke her cigarettes while reading the
newspaper.
Case #2
 34 year old married woman, employed in customer
service at a telephone company
 She presents for outpatient psychotherapy with mild
depressive symptoms .
 During the intake interview, the patient reports
smoking 10 cigarettes a day, wanting to quit, but
having just recently failed. She reports relapsing
after a fight with her boss.
 Patient reports a history of disordered eating and
concern about gaining weight when trying to quit
smoking.
Case scenario to think about!
 45 year old woman, diagnosed with Bipolar 1 disorder for many years
reports a history of daily smoking since age 17 , on ODSP and lives in a
boarding home .
 Smokes about 2 to 3 packs per day. She reports to be smoking within 5 min
of waking up and the morning cigarettes are hard to give up , she would
smoke even in places where smoking is forbidden and would smoke even
when physically ill. Her FTND was 9.
 Triggers include TV, waking up in the morning, stress, worsening of mental
illness, and after meals.
 She is recently diagnosed with COPD , denies any other substance use. She
has never tried to quit smoking before and is concerned what will happen
when she no longer smokes as smoking has been part of her life and a sole
friend.
 She however thinks that its about time she quits because of her COPD and
financial situation.
 She has been on remission from her mental health problems for the last 5
years. Her last episode was 7 years ago when she had a suicidal attempt due
to a depressive episode. Patient is now on Lithium 1200mg , Lamotrigine 60
mg, spiriva and ventolin puffers. She has a psychiatrist whom she sees on
monthly basis.
Tools/Resources
 Here to Help (BC Mental Health & Addiction Svcs)
 TEACH - specialized course on concurrent tobacco
dependence and mental health and/or addictive disorders
 Nicotine Dependence Clinic (CAMH)
Know of any others?
Share them on www.can-adaptt.net
Have additional feedback?
1. Join the network
2. Review the current version of the guideline
3. Provide your feedback online
• Clinical considerations; tools/resources
For more information
CAN-ADAPTT
Centre for Addiction and Mental Health
175 College St.
Toronto, ON M5T 1P7
T: 416-535-8501 ext. 7427
www.can-adaptt.net
Note: These presentation slides may be used or reproduced for
educational purposes only. Please acknowledge authorship of this
content to CAN-ADAPTT and CAMH.