A study by Glassman and colleagues examined 76 smokers with a past history of major depressive disorder, all euthymic and off of antidepressant medication at the start of smoking cessation treatment, in order to determine the rates of recurrent depression in abstainers versus nonabstainers. Subjects were enrolled in a 2-month smoking cessation trial, and recurrence of major depression was assessed by structured clinical interviews at three and six month intervals.
Thirteen of 42 successful abstainers had a recurrence of major depression; whereas two of 34 smokers had a recurrence of major depression. The findings demonstrate that depressed smokers who quit smoking are more likely to relapse to depression than depressed smokers who keep smoking; but only a minority of depressed smokers will get depressed.
The study did not include a comparison group of nondepressed smokers, and so does not address the question of whether depressed smokers are at higher risk for depression than nondepressed smokers during quitting.
Covey and colleagues compared the rates of occurrence of major depression with smoking cessation, among smokers with no prior diagnosis of depression, smokers with one prior major depressive episode, and smokers with recurrent major depressive disorder Covey et al Two of 91 subjects with no history, four of 24 subjects with past single major depression, and three of 10 subjects with past recurrent major depression, developed a major depressive episode by 3-month follow-up.
In the absence of a comparison between those who did and did not successfully quit smoking, the results of the study are difficult to interpret. Those who continued smoking might have relapsed to major depression at the 3-month follow-up at the same rates as those who quit, given the recurrent nature of depressive disorders, particular in the absence of treatment.
Nonetheless, the study does provide some preliminary evidence that those with prior depressive disorders, who quit smoking, are more likely to have a major depressive episode in the months following smoking cessation, than those with no prior depression history.
Even more remarkable is the apparent resiliency of smokers with depressive disorders in the face of smoking cessation, a significant physical and psychological stressor. The covey study found that 24 of 34 smokers, more than two-thirds the sample with a prior diagnosis of major depression, did not have a recurrence of major depression after quitting smoking, even without antidepressant medication or other apparent intervention. Two of the subjects who did have a recurrence of depression, experienced depressive symptoms for only two days before restarting effective antidepressant therapy.
Depressive symptoms were measured at weeks 8 and Changes in depressive symptoms were measured at these endpoints, and did not differ for those with and without a past history of depression Cox et al The clinical studies reviewed above have included depressed smokers who were euthymic ie, not depressed at the initiation of smoking cessation treatment, and not on antidepressant therapy.
Presumably, these individuals had a less severe form of depression, since they were able to be well without treatment for depression for some period of time. To our knowledge, smokers who are depressed at baseline, on or off medication, and smokers with more severe forms of depression, have not been included in smoking cessation studies comparing clinical outcomes with nondepressed smokers. Is there any evidence that stopping smoking actually improves depression? Thorsteinsson and colleagues used nicotine replacement therapy in smokers who were depressed at the initiation of smoking cessation treatment, independent of past history of depression, and examined both smoking and mood outcomes.
This study was limited by small sample size. A study by Kahler and colleagues looked prospectively at smokers with a history of major depression, and found that continuous abstinence was associated with short- and long-term reductions in depressive symptoms Kahler et al Although limited, these data suggest that abstinence may contribute to mood gains.
Improved mood with sustained abstinence from cigarettes may be related to brain serotonin levels. A study by Malone and colleagues showed an inverse relationship between amount of cigarettes smoked and serotonin function, as measured by fenfluramine challenge tests and cerebro-spinal fluid levels of 5-hydroxyindoleacetic acid. Another potential explanation for improved mood with smoking cessation is a decrease in hypercholinergic neurotransmission at the nicotinic acetylcholine receptors nAChR Shytle et al Based on the evidence reviewed above, if mood symptoms could be effectively targeted during smoking cessation treatment, then depressed smokers, or more accurately depressed quitters, would have a better chance at cessation.
Several studies have researched smoking cessation interventions designed specifically for depressed smokers. We examine these sparse data below. A study in African American smokers demonstrated benefit of bupropion on mood during smoking cessation treatment Ahluwalia et al ; and a follow-up study suggested that bupropion may facilitate smoking cessation in part by reducing depressive symptoms Catley et al In a group of sub-clinically depressed smokers, Lerman and colleagues found that highly nicotine dependent smokers score of six or more on the fagerstrom test for nicotine dependence receiving bupropion mg for smoking cessation, had a significant improvement in depressive symptoms compared to highly nicotine dependent smokers on placebo.
The effect of bupropion on mood held true only for the high dependence nicotine group, not the low dependence group. This study implies that highly dependent smokers are more likely to have a positive mood response to bupropion, and may need to continue bupropion longer than the usual 10—12 week recommended course. Whether the bupropion is directly mediating mood, or mediating some component of nicotine dependence affecting mood, is unclear.
Brown and colleagues found that for a subset of smokers with past recurrent major depression and high nicotine dependence, a cognitive behavioral therapy directed specifically for depressed mood led to higher abstinence rates than standard CBT for smoking cessation. A study by Haas and colleagues also supports the use of CBT over health education in smokers with a past history of major depression. Covey and colleagues designed a study looking at the use of sertraline, a serotonergic antidepressant, specificaly in the treatment of depressed smokers.
Sertraline proved to be more effective than placebo in ameliorating the acute withdrawal symptoms of irritability, anxiety, and craving, but no more effective than placebo in terms of abstinence rates.
The limited data suggest that smoking cessation treatments modified to target depressed mood, may improve abstinence rates for certain subpopulations of smokers. The interplay between mood and degree of nicotine dependence may be an important predictor of the progression of depression while quitting Pomerleau et al Most psychiatrists do not address or treat smoking in depressed patients, presumably because they anticipate that depressed smokers will be unwilling to quit, unable to quit, and that smoking cessation will cause or exacerbate depressive symptoms.
The evidence does not clearly support this bias. At least a quarter of nonhospitalized psychiatric patients with a diagnosis of a depressive disorder are willing to try and quit smoking. Past history of depression, and even depressive symptoms at the start of smoking cessation treatment, do not consistently negatively impact quit rates. Depressed smokers may be at higher risk to experience depression with smoking cessation than nondepressed smokers, but the data is equivocal. Abstinence from cigarettes for prolonged periods may be associated with a decrease in depressive symptomatology.
A minority of smokers will enter a major depressive episode during or shortly after quitting smoking. The trajectory of mood symptoms after quitting appears to be a sensitive predictor of relapse.
More research is needed to explore which individuals will become depressed after quitting; and what treatment methods should be used to target smoking cessation-induced depression.
More research on the impact of mood at baseline, including severity and specificity of depressive symptoms, would help clarify which types of smokers are most vulnerable to depression during smoking cessation.
Future studies should also try to elucidate what other variables besides mood contribute to poor mood trajectory and lower cessation rates. The data point toward nicotine dependence as an important contributing variable: highly nicotine dependent smokers are potentially at higher risk for depression and relapse, but also more responsive to bupropion.
Preliminary evidence supports the development of specific smoking cessation treatments tailored for depression, over standard smoking cessation therapies.
A review of the evidence highlights the resiliency of depressed smokers in the face of smoking cessation, contrary to common clinical wisdom. When one considers the potential gain in offering smoking cessation treatment to individuals with depressive disorders, including the potential for decreased morbidity and mortality from both nicotine dependence and depression; the risk of depression may well be worth taking, and certainly worth discussing with patients.
Start small and build up over time. But your efforts will pay off. Structure your day. Make a plan to stay busy. Get out of the house if you can. Be with other people. Many people who are depressed are cut off from other people.
Being in touch or talking with others every day can help your mood. Reward yourself. Do things you enjoy. Even small things add up and help you feel better. Quit Notes. To change or withdraw your consent choices for VerywellMind. At any time, you can update your settings through the "EU Privacy" link at the bottom of any page. These choices will be signaled globally to our partners and will not affect browsing data.
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Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Related Articles. An Overview of Nicotine Withdrawal. What to Know About the Nicotine Vaccine. Behavioral Barriers. Similarly to the social barriers, there are certain behavioral triggers that can enhance physical withdrawal symptoms and make it difficult not to give into cravings for smoking.
Whether it is a specific activity like driving or a feeling of stress you get at your job, there are certain events that challenge your ability to not go light up. For questions, partnership opportunities, or to get covered on this blog, click here.
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