ATTUD Journal Club Postings

Psychiatric co‐morbidity with smoking is increasing over time

Smokers with a history of a psychiatric disorder are less likely to stop smoking than those without this history. In addition, whenever a society stigmatizes a behavior and makes it more deviant, then those who, nevertheless, take up or continue the behavior are more likely to have psychiatric co­morbidity. As a result of these two phenomena, the association of smoking and psychiatric disorders should be increasing over time. Four articles have tested this notion. Two articles used scales of psychopathology in general and found no evidence of increasing association of psychopathology with smoking over time (Aust NZ J Publ Hlth 36:408; Aust NZ Psychiatry 44:1132). The two articles using structured psychiatric diagnosis interview did find an association (Drug Alcohol Depend 133:724; Talati et al, Molecular Psychiatry, in press). The most recent of these (Talati et al, in press) is probably the best test. This study examined 25,000 individuals and looked at drug abuse, alcohol abuse, depression, attention‐deficit, bipolar, and antisocial personality disorders. The association of all of these increased in later birth cohorts; i.e., among those born in the 1980s, the association of smoking with the disorder was greater than among those born in earlier times. The association was especially true for drug abuse and alcohol abuse. The increased association was somewhat due to increased dependence over time, but that did not explain all of the increasing association. This effect occurred in both men and women and in minorities. . Also, there is no reason to believe this association with comorbidity will not continue to increase over time. This is an issue that will increase, not decrease, over time.

In 1990, 41% of current smokers had a current mental disorder diagnosed via epidemiological survey (cf 28% in the general population)(JAMA 284:3606), now 26 years later, the incidence is probably over 50%.

The major implication of these findings is that they suggest TTSs need to be screening for the most common psychiatric disorder; especially drug and alcohol problems and determining whether they need treatment. Less 30% of those with a mental disorder who need treatment are currently in treatment, suggesting many will need treatment. On the other hand only half of those diagnosed via epidemiological surveys require treatment .

Studies of “dual diagnosis” patients (i.e. drug/alcohol disorder and non‐drug psychiatric disorder) find having “integrated treatment” where patients can “one‐stop shop” and receive treatment for both disorders at the same institution results in the best outcomes. This suggests TTSs need a reliable resource for treating psychiatric disorders.