The Interaction of Depression and Smoking following ACS Andrew M. Busch, PhD

Transcription

1 The Interaction of Depression and Smoking following ACS Andrew M. Busch, PhD Senior Psychologist, Dept. of Medicine, HCMC Associate Professor, Dept. of Medicine, University of MN

2 Disclosures No conflicts of interest No industry funding Funding provided by NIH NHLBI NINR 2

3 Outline 1. Smoking Cessation Review/Update 2. Depression and ACS 3. Depression and smoking interaction 4. Practical resources

4 Smoking and Acute Coronary Syndrome (ACS) 37% smoking immediately prior to Acute Coronary Syndrome (ACS) hospital admission 400,000 per year Quitting smoking post-acs reduces 2 year mortality by 36% >50% are smoking by 6 months post-acs Khot et al 2003; Dawood et al 2008; Critchley & Capewell

5 First Line Treatments Behavioral counseling Individual, group, Quit-lines Nicotine Replacement Therapy (NRT) Nicotine Patch (OTC) Nicotine Gum (OTC) Nicotine Lozenge (OTC) Nicotine Inhaler (Rx) Nicotine Spray (Rx) Pill Medication (start 1-2 weeks before cessation) Bupropion SR (Wellbutrin, Zyban) Varenicline (Chantix)» Highest quit rates but more contraindications/monitoring Fiore et al., 2008

6 Combination Treatments Are Most Effective Any medication + counseling Nicotine patch + other NRT Any NRT + Bupropion Fiore et al., 2008

7 Smoking Cessation at Medical Visits: The 5As Ask about smoking status at every visit Advise to quit (clear, strong, personalized) Assess willingness to make a quit attempt Assist in development of a quit plan Arrange for follow-up (1 week is ideal) Fiore et al.,

8 Patients who are unmotivated to Quit: 5Rs Discuss with patients: personal Relevance of smoking, Risks of smoking Rewards of quitting Roadblocks to quitting for which the provider suggests possible solutions Repeat at subsequent visits Fiore et al.,

9 Smoking Cessation Update Changes to NRT FDA package labeling regarding dual use Allows for reduction goals Varenicline flexible and gradual quit plans EAGLES trial provides new CVD safety data for cessation medications E-Cigarettes

10 Evolution of e-cigarettes

11 E-Cigarettes Post-ACS study 49 participants drawn from randomized smoking cessation trial for ACS patients Completed questionnaire on e-cigarette use 24 weeks post-acs

12 E-Cigarettes Post-ACS E-Cigarette Use: 25 (51.0%) ever used an e-cigarette 14 (28.6%) first use before ACS 11 (22.4%) first use after ACS 13 (26.5%) used in 24 weeks post-acs Reasons for Trying E-Cigarette: 15 (60.0%) used to quit other tobacco

13 E-Cigarettes Post-ACS

14 E-Cigarettes Post-ACS Significant minority of patients use e- cigarettes post-acs. Patients believe e-cigarettes are less harmful than FDA-approved medications Providers should be prepared to discuss discrepancies between patient beliefs about safety of e-cigarettes and the current scientific understanding

15 Outline 1. Smoking Cessation Review/Update 2. Depression and ACS 3. Depression and smoking interaction 4. Practical resources

16 Major Depressive Disorder (MDD) Must have 5 of the 9 symptoms for at least 2 weeks. Must have at least one of first 2 symptoms: (1) depressed mood (2) markedly diminished interest or pleasure in all, or almost all, activities (i.e., anhedonia) (3) significant weight or appetite change (when not dieting) (4) insomnia or hypersomnia (5) psychomotor agitation or retardation (6) fatigue or loss of energy (7) feelings of worthlessness or excessive/inappropriate guilt (8) diminished ability to think or concentrate (9) recurrent thoughts of death/suicide

17 Post-ACS Depression Prevalence 20% post-acs patients have current major depression 3x more common than age matched general population 30-40% have clinically significant depression symptoms Post-ACS is a high risk period for development and recurrence of depression Thombs et al., 2006; Carney et al., 2008

18 Post-ACS Depression Predicts Subsequent Events and Mortality Meta-analytic evidence suggest that post-acs depression predicts a doubling of mortality risk 2 years later Holds up when controlling for multiple baseline confounders Lichtman et al 2008; Van Melle et al 2004; Davidson et al 2010

19 Post-ACS Depression Predicts Subsequent Events and Mortality Lespérance et al.,

20 Potential Behavioral Mechanisms of Post-ACS Depression Mortality Risk Post ACS depression is associated with: Failure to quit smoking Poor diet Lower rates of exercise Nonattendance at cardiac rehabilitation Lower adherence to medication regiment (Ziegelstein et al 2000; Glazer et al., 2002; Kendler et al., 1993; Gehi et al., 2005; May et al 2010)

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22 AHA Screening Recommendations

23 AHA Screening Recommendations

24 AHA Screening Recommendations 45%

25 AHA Screening Recommendations

26 AHA Screening Recommendations

27 AHA Screening Recommendations

28 No evidence that treating depression improves CVD outcomes Post- ACS Depression Treatment Depressed Mood (modest) Cardiac morbidity and mortality SADHART (n = 369) Sertraline vs. placebo CREATE (n = 284) Citalopram + Interpersonal Therapy ENRICHD (n = 2481) Cognitive-Behavioral Therapy vs. usual care 28

29 Outline 1. Smoking Cessation Review/Update 2. Depression and ACS 3. Depression and smoking interaction 4. Practical resources

30 Conceptual Model Those with depression are more likely to smoke Those who smoke are more likely to be depressed Smoking prospectively predicts later increases in depression Depression prospectively predicts failure to quit smoking Depressed Mood Negative CVD health behaviors CVD incidence and worsening e.g., Anda et al., 1990; Busch et al., 2012; Doyle et al., 2014; Niaura et al., 2001; 30

31 Why Treat Smoking and Mood Together in ACS patients? Depressed Mood Integrated mood and smoking tx Cardiac morbidity and mortality Smoking 31

32 Pilot RCT Design In hospital Screen (e-chart screened then approached for in person screen) Session 1 (50 mins; smoking cessation focused, based on clinical guidelines) Randomize at the end of session 1 BAT-CS Standard of Care (SoC) Hospital d/c Offered 8 weeks of nicotine patch Offered 8 weeks of nicotine patch 1 week post-d/c 3 weeks post-d/c 6 weeks post-d/c 9 weeks post-d/c 12 weeks post-d/c Session 2 (50 mins; in person, BA and Cessation) Session 3 (30 mins; Phone, BA and Cessation) Session 4 (30 mins; Phone, BA and Cessation) Session 5 (30 mins; Phone, BA and Cessation) Session 6 (30 mins; Phone, BA and Cessation) Written materials + check in call Written materials + check in call Written materials + check in call Written materials + check in call Written materials + check in call Busch et al.,

33 Depressed Mood Outcome (PHQ-9) η 2 partial=0.07, p=0.13 Busch et al.,

34 Survival Analysis: Time to Lapse (62.4 vs days, p=0.03; HR=0.38, 95% CI: , p=0.01). Busch et al.,

35 Outline 1. Smoking Cessation Review/Update 2. Depression and ACS 3. Depression and smoking interaction 4. Practical resources

36 Resources Clinical guidelines (includes dosing recommendations) Fiore et al 2008: Treating Tobacco Use and Dependence: 2008 Update acco_use08.pdf

37 Resources QuitNow nicotine-anonymous.org BeTobaccoFree.gov Smokefree.gov (also in Spanish) SmokefreeTXT 37

38 QUITPLAN launches enhanced helpline services Who qualifies: Minnesota Adults Underinsured or uninsured i.e., not covered through patient s health plan Report mental health conditions or substance disorders. 7 coaching calls to provide 12-weeks of combination nicotine replacement therapy

39 Questions? 39