Regina van der Meer

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					 Smoking cessation intervention for
smokers with past major depression:
      a randomized controlled trial




      Warsaw, ENQ meeting, May 2008
   Regina M. van der Meer MPH, Marc C. Willemsen PhD,
   Pim Cuijpers PhD, Filip Smit PhD, Gerard M. Schippers
                            PhD
Major depression?
Major depression?




               Having a very bad hair day
Major depression (DSM–IV)

Five or more of the following symptoms have been
present during the same 2-week period and
represent a change from previous functioning;

At least one of the symptoms is:

• Depressed mood or
• Loss of interest or pleasure
Major depression (DSM–IV)

• Significant weight loss or decrease or increase in
    appetite
•   Insomnia or hypersomnia
•   Psychomotor agitation or retardation
•   Fatigue or loss of energy
•   Feelings of worthlessness or guilt
•   Diminished ability to think or concentrate, or
    indecisiveness
•   Recurrent thoughts of death
Past major depression


Lifetime major depression,
but not
within the last month
Smoking & past major depression

Smoking and depression are strongly
associated

• Smokers are more likely to have past major
  depression than non-smokers
                         &
• Persons with past major depression are more
  likely to be smokers than non-smokers
  (Glassman, 1993; Kalman et al., 2005)
Smoking & past major depression

A recent study from Wiesbeck and colleagues in
Neuropsychobiology support the evidence that
smoking is linked to depression.

They found the highest rate of lifetime depression
in current smokers (23,7%), the lowest rate in
never smokers (6,2%) and the rate of those who
had quit smoking was 14,6.
Smoking cessation &
past major depression

Hughes (2007) found in a recent review that
smokers with a past major depression clearly have
an increased risk for a new depression after quit
smoking when compared with smokers without a
past major depression.

This might explain why it is more difficult for
smokers with past major depression to quit.
Smoking cessation &
past major depression

An often mentioned underlying mechanism is the
self-medication assumption:

Smokers use cigarettes as a form of self-
medication for coping with depressive symptoms

Smokers with past major depression may quit
more easily if they have learned to better manage
their mood without needing cigarettes.
Smoking cessation &
past major depression

This self-medication assumption has resulted in
several studies examining smoking cessation
interventions that include strategies for managing
depressive symptoms. (Hall et al., Brown et al)

But non of these interventions consisted out of
telephonic counselling and most of these studies
were very small.
I can handle the world, smokefree!
Aim of study

To assess whether the Mood Management
intervention:

1. Produces higher abstinence rates compared
   to control intervention

2. Helps to prevent and reduce depressive
   symptoms compared to control intervention
Control (C)

Telephone counselling
• 8 sessions (1st: 30 minutes;
  quitdate; 2nd – 8th: 12 min.)
• by a trained coach of STIVORO

Content
Smoking cessation skills:
• social support
• increasing self-efficacy
• self-rewarding
• relapse prevention
Mood Management (MM)
Telephone counselling
• 10 sessions (1st: 30 minutes;
  2nd – 3rd: 15 min; quit date;
  4th – 10th: 15 min)
• by a trained coach of STIVORO
             &
Quit smoking mood management manual
• Self help manual with exercises
  for reading and practicing
  at home between the sessions
Mood Management (MM)
Content
Smoking cessation skills:
• social support
• increasing self-efficacy
• self-rewarding
• relapse prevention
Mood management skills:
• Increasing pleasant events
• Relaxation
• Cognitive skills
• Social skills
Based on cognitive behavioural therapy
Study design (RCT)

1. Recruitment – open population
   advertisements, articles, website, flyers etc.
   (n=4008 received information package)

2. Screening 1 & Informed consent
   (n=1875 gave their informed consent)
   (n=706 were invited for CIDI interview)
Study design(RCT)

3. Screening 2 (CIDI)
   Assessment of past major depression
   according to DSM-IV (exclusion of current
   depression, current alcohol disorder)
   (n=531 met inclusion criteria)

4. Baseline measurement T0

5. Randomisation
   (n=485)
Study design (RCT)

6. MM or C intervention
   (MM: n=243; C: n=242)
   10 Counsellors gave MM and C intervention

7. Follow up T1 (6 months after T0)
   Response (MM: 81.0%; C: 83.5%)

8. Follow up T2 (12 months after T0)
   Response (MM: 77.0%; C: 76.4%)
Study design (RCT)

Participants
• Past major depression
• No current major depression
• Preparator or contemplator
• No current alcohol disorder

Outcomes
• Prolonged abstinence
• Point prevalence
Baseline              MM group     C group       Sign.
Characteristics       (n=243)      (n=242)


Male, %               23.0         24.0          NS


Age, mean SD          43.3  9.9   44.2  10.2   NS


Cigarettes, mean SD   21.4  8.9   21.8  9.7    NS


FTND, mean SD         5.1  2.2    5.1  2.4     NS


Stages of change, %                              NS
-Preparation          71.6         72.3
-Contemplation        28.4         27.7
Baseline                 MM group     C group      Sign.
Characteristics          (n=243)      (n=242)




Education %                                        NS
- Low                    12.0         11.2
- Medium                 37.3         42.6
- High                   50.6         46.3



Quit attempts, mean SD   6.2  11.5   5.8  10.2   NS




Self-efficacy, mean SD   3.0  10.6   5.1  10.6   .03
Baseline              MM group     C group       Sign.
Characteristics       (n=243)      (n=242)




Depressive symptoms
(CES-D), mean SD      18.1  7.6   17.8  8.0    NS




Alcohol-problem
drinkers, %           22.2         23.1          NS




Anxiety, mean SD      46.7  9.6   46.1  10.3   NS
Baseline                MM group   C group   Sign.
Characteristics         (n=243)    (n=242)


Past depression %                            NS


-   single, light       12.8       14.1
-   single, mild        10.7       13.7
-   single, severe      19.8       22.4
-   recurrent, light    24.8       18.7
-   recurrent, mild     15.3       19.1
-   recurrent, severe   16.5       12.0
    Results - 6 months follow up

Smoking      MM               C                     OR unadj.       OR adjust.
Cessation    (n=243)          (n=242)               95% CI          95% CI




Point        37.4 %           31.0 %                1.33            1.33
prevalence   n=91             n=75                  (0.9–1.9)       (0.9–2.0)




Prolonged    30.5 %           22.3 %                1.52*           1.48
abstinence   n=74             n=54                  (1.01- 2.3)     (0.98–2.2)



                OR Adjusted for self-efficacy and past depression
                * Significant
    Results - 12 months follow up

Smoking      MM               C                     OR unadj.       OR adjust.
Cessation    (n=243)          (n=242)               95% CI          95% CI




Point        27.6 %           24.0 %                1.21            1.17
prevalence   n=67             n=58                  (0.8–1.8)       (0.8–1.8)




Prolonged    23.9 %           14.0 %                1.92*           1.86*
abstinence   n=58             n=34                  (1.2–3.1)       (1.2–3.0)



                OR Adjusted for self-efficacy and past depression
                * Significant
    Results – 6/12 months follow up

Depressive   MM               C                     t-test        ANCOVAa
symptoms     (n=243)          (n=242)               (P-value)     (P-value)
(CES-D)      Mean             Mean
             (SD)             (SD)


6 months     15.4             14.7                  -.71          .09
             (10.5)           (10.4)                (.48)         (.77)




12 months    14.8             14.6                  -.21          .14
             (9.8)            (10.4)                (.84)         (.71)

                aAdjusted for self-efficacy and past depression
                *Significant
Conclusion

Overall more smokers quit smoking with the
Mood Management intervention when compared
with the control intervention.

Although there are no significant differences on
point prevalence abstinence.

Prolonged abstinence however does show
significant differences.
Conclusion

It seems that the differences in smoking
abstinence between Mood management
intervention and control intervention can not
be explained by differences in depressive
symptoms

Mood Mangement intervention combined with
telephone counselling seems to increase
success rates for smokers with past major
depression
How does the MM intervention
works in practice?

Carl Simons
Many thanks for your attention!




    rvandermeer@stivoro.nl

				
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