Desktop Helper No.16 - Severe mental illness, tobacco dependence and chronic obstructive pulmonary disease (COPD) - online version

Severe mental illness (SMI) includes schizophrenia (SZ), bipolar disorder (BD) and affective disorder with psychosis.(2-5) SMI causes serious functional impairment that limits life activities and is related to worse health outcomes compared to those without SMI. The diagnosis is based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and is often made by secondary care psychiatrists. One of the major causes of COPD continues to be tobacco smoking.(6) There is a higher prevalence of tobacco smoking and regular exposure to other smoked drugs such as cannabis or heroin, which also may cause COPD/emphysema, in people living with SMI.

It is important for primary care physicians to recognize SMI in patients in order to identify potential related comorbidity, because approximately 1 in 4 people with SMI who smoke may have undiagnosed COPD.(2) Also, the prevalence of COPD is higher in patients with SMI and they may die up to 20 years earlier than the general population and are 3-9 times more likely to die from COPD.(7) Unfortunately, COPD is also often missed in this patient group due to a later age of diagnosis compared to concurrent SMI (their early twenties compared to early forties, respectively[1]) and underreporting or minimisation of symptoms. Regular lung function testing throughout life is therefore warranted in people with SMI who are tobacco dependent.

Therefore, there is a substantial opportunity to make measurable improvements in health outcomes and equity by diagnosing and treating COPD in people with SMI specifically by focusing on diagnosing and treating their tobacco dependence.

Diagnosis

1. Take a smoking history to understand the risk from cumulative exposure to tobacco and other drugs.
2. Identify symptoms suggestive of COPD using simple clinical scales such as the MRC breathlessness scale, combined with observation where necessary.(19)
3. Be aware that this patient group may be less likely to report and identify symptoms such as breathlessness and may be hypoxic without reporting breathlessness. This is why it is useful to use clinical measures of breathlessness.
4. Have a low threshold for performing a lung function test through an expiratory spirometry, or if a lung function test is not at hand, use a portable micro-spirometer which may be easier and indicate a diagnosis of COPD.(20)
5. Have and use a pulse oximeter because patients with SMI may report fewer symptoms / be less aware that they are unwell; take action on low readings. The COPD-phenotype in patients with significant smoked drug history may be more that of emphysema with relatively preserved spirometry and drop in blood oxygen saturations on exertion.(21)
6. The person may have other reasons for low blood oxygen saturation levels including obesity. Therefore, measure BMI because obesity is a common comorbidity of SMI.(22)

Intervention

1. Explain what COPD is ….’smoker’s lung’ and then use an evidence-based non-judgmental approach to offering treatment for tobacco dependence as the key treatment [see Helping people quit desktop helper and here for more detailed information on first-line pharmacotherapy for treating tobacco dependence.
2. If possible, measure CO-levels as this may also aid in motivating the smoker to quit.(23)
3. In people with COPD explain about and offer vaccinations. Recommended vaccines include flu, pneumococcal and COVID-19, as well as Tdap (pertussis, tetanus and diphtheria) if not vaccinated in adolescence, and shingles.(6)
4. Work with the mental health team who knows the patient on a shared agenda to ensure access to treatment for their tobacco dependence, vaccination and to enable those patients reporting breathlessness to attend pulmonary rehabilitation (see our desktop helper on PR to help explain it, as well as our video on how we breathe, and the Breathing Thinking Functioning model explained in our desktop helper).
5.  Cost is a significant factor that prevents patients from using these helpful interventions. Help improve access to these for free, either by signposting to a free service or advocating for your health service to provide this.
6. When collaborating with the mental health team on treating tobacco dependence, it may be helpful to address any potential myths about smoking within mental health services. Educating mental health professionals and addressing unhelpful views such as “smoking is the only pleasure our patients have”, “smoking helps to reduce patients’ agitation”, “we shouldn’t be telling patients what to do”, “banning smoking in inpatient settings is against patients’ human rights” is important because these views have all been demonstrated to be clinically and legally incorrect.
7. Do not start inhalers without a full respiratory assessment, or without a diagnosis – if new breathlessness is reported, order a chest X-ray as there could be other causes including lung cancer/heart failure.
8. Include deaths in people with serious mental illness under the age of 75 in reviews of adverse incidents to learn more as an integrated system about missed opportunities to preserve and extend life.

Behavioural support

Behavioural support through motivational interviewing and cognitive behavioural therapy (CBT) are commonly used in people with SMI. CBT combined with pharmacotherapy is more effective than just CBT. (5,28,30-33)

Drug interactions between tobacco and SMI medication

Tobacco use has an impact on the metabolism of other antipsychotic medications such as clozapine, olanzapine and risperidone, which may affect the doses needed to reach therapeutic blood levels and subsequently their effectiveness. However, while it is important to consider and address possible drug interactions the main message is to treat the tobacco dependence. People using some anti-psychotic medications who quit tobacco smoking may also able to reduce their dosage.(24) Modify the dosage of clozapine if the patient stops smoking.(34)

Nicotine Replacement Therapy (NRT)

Action

Reduce the need and craving for tobacco smoking by delivering nicotine without the harmful effects of combusting tobacco, which produces the smoke.

Evidence indicates:

• More than four weeks of use is more likely to result in successful cessation and eight weeks of use is considered to be equally  effective as longer durations of use, although patients experiencing withdrawal symptoms eight weeks after quitting may  benefit from longer durations.
• Current evidence does not support an association between long-term NRT exposure and serious adverse health effects. A longer period of NRT may help some people remain abstinent and it is far less harmful than tobacco smoking. This may especially be the case for people with serious mental illness.
• Higher dose and combination NRT are often required in people with severe mental illnesses who are often highly nicotine-dependent. 
• Continuing to smoke tobacco while using NRT may indicate the dose provided is too low, or NRT products are used incorrectly.
• Preloading with the use of NRT patches prior to reducing smoking, and not recommending tapering and longer-term use is recommended in heavy smokers.

Presentation form and posology

Comes in a variety of forms based on its system of delivery and onset of action. Patch: 7 mg, 14 mg, 21 mg.

24 hour patch:

• >20 cigarettes per day then use a 21mg patch for four weeks before moving to a lower strength patch.
• <20 cigarettes per day then start with a 14mg strength patch for up to eight weeks before moving to a lower strength patch.

16 hour patch:

• >20 cigarettes per day then use a 25mg patch for eight weeks before moving to a lower strength patch.
• < 20 cigarettes per day then start with a 15mg strength patch for up to eight weeks before moving to a lower strength patch.

Gum

• 2mg and 4 mg. Can be used every 2 hours alone to manage withdrawal symptoms, or can be used as needed for stronger cravings when used in combination with the nicotine patch
• Combing two forms of NRT (e.g., patch plus a faster-acting form, such as mouth spray, gum, inhalator, or lozenge) has been shown to be more efficacious than a single form of nicotine replacement. It is not appropriate for people with poor dentition.
• It is NOT like regular chewing gum. Slowly bite down on the gum (until tingling starts) and then keep the gum between cheek and gums for a minute without chewing to allow the nicotine to be absorbed. Repeat for around the next thirty minutes or until the tingling stops.

Spray

At first, 1 spray in each nostril (1 milligram (mg)). Total dose is usually not more than 40 mg per day (40 sprays in each nostril). Reducing before stopping treatment.

Nicotine oral inhaler

 6 cartridges per day for the first 3 to 6 weeks. (no more than 16 cartridges each day). Treatment period:10-12 weeks

Pregnant women

Offer to quit smoking with behavioural intervention alone, but clinicians may recommend NRT. Behavioural intervention and monitoring should also be provided.

Contraindications

• Children aged <12 years
• People with a known sensitivity to nicotine or any other component of the NRT product.
• People weighing less than 45kg, who can use NRT but may require the lower dose (e.g.,14 mg/24-hour patch).
• NRT should be used with caution for patients in hospital with acute cardiovascular events, but if the alternative is smoking, NRT can be still used under medical supervision.
• NRT is safe to use for patients with stable cardiovascular disease, but  should be used with caution in patients who have had a recent myocardial infarction, unstable angina, severe arrhythmias, or recent cerebrovascular events

Side effects

Minor side effects are common with NRT use and are often associated with the formulation:

• Patches: skin irritation, redness, itch, and rash, which are usually mild but can be treated with 1% hydrocortisone cream and rotating the site of application each day can reduce irritation.
• People may experience insomnia or vivid dreams, but these may also be associated with other pharmacotherapies and psychopathology. Decreasing caffeine intake by half and avoiding caffeine after 4pm can reduce sleep disturbance. However, if sleep disturbance is severe and there by disrupting daily activities, patients can remove the patch at bedtime or a couple of hours before and re-apply a new patch in the morning.
• Consider use of a faster-acting form of NRT in the morning, as it can take up to 3 hours for optimal nicotine levels to be reached after removal of a patch overnight. 
• For nicotine gum and lozenges: dyspepsia and nausea
• For nicotine inhalator or mouth spray: mouth and throat irritation can occur

Varenicline

Action

• Nicotinic receptor partial agonist drug for smoking cessation that relieves symptoms of craving and withdrawal. The use of varenicline can more than double the chances of long-term quitting.
• Can be safely used for people who smoke with mental health problems but must be monitored during quit attempts. Patients should be advised to report unusual mood changes, depression, behaviour disturbance and suicidal thoughts, and stop using the medicine if these occur.

Presentation form and posology

• Dosage: Start one week before quit date: 0.5 mg for 3 days, 0.5 mg for 4 days, then 1mg from quit date for 12 weeks

Contraindications

• For pregnant or breastfeeding women and adolescents.

Side effects

• Nausea which can be minimised if it is taken with food.
• Other side effects: sleep disturbance, drowsiness, headache, constipation, dizziness, and flatulence.
• Drink with full glass of water and meal to reduce nausea.

Bupoprion

Action

• Non-nicotine oral therapy,  approved for use as an antidepressant. Significantly increases cessation but  compared with placebo the rates has been shown to be less effective than varenicline and NRT for smoking cessation.

Presentation form and posology

• Dosage: 150mg (1 tablet) a day for 3 days, then on day 4 – 150mg (1 tablet) (at least 8 hours apart). Then regularly 150 mg for 7- 12 weeks and in some cases up to 6 months

Contraindications

• Patients with a history of seizures, eating disorders, and those taking monoamine oxidase inhibitors or pregnant/breastfeeding women.
• Should be used with caution in people taking medications that can lower seizure threshold (e.g., other antidepressants, antipsychotics, antimalarials, oral hypoglycaemic agents).

Side effects

• Seizure, insomnia, headache, dry mouth, dizziness, anxiety, taste disturbance.