I have a history of repeated episodes of depression and have taken antidepressant medication in the past, though I’m not taking any now. I’m also a heavy smoker (one to one-and-a-half packs a day.) I know smoking is bad for me, but stopping seems so overwhelmingly difficult. I feel like I can’t cope without my cigarettes. Any suggestions?
First of all, I want to congratulate you. I look at many, many questions — only a small fraction of which I’m able to respond to, unfortunately — and yours is the first that expresses a concern about smoking, a habit that is the biggest preventable cause of premature death, accounting for approximately 25 percent of all deaths.
Smoking tends to be lost in the smoke of denial and neglect, especially among those with mental disorders. Psychiatric hospitals are full of smokers, at least in those that permit smoking. Smoking is more common in people with a diagnosis of schizophrenia, bipolar disorder, and major depression than in others. Smoking and alcoholism also go together. Every psychiatrist, in the presence of his or her smoking patient, has at one time or another felt that smoking cessation may be more vital to the future well-being of that patient than some other question that the patient is engrossed with.
The relationship of smoking to mental illness is a rich and complicated one. Let’s just look at smoking and major depression for a moment. The same genes that underlie depression influence smoking. It’s not just that depressed people turn to smoking because they are depressed; they smoke in greater than expected numbers before they get depressed. It’s also true that when they try to stop, they have bigger problems and less success than others. And when they do stop — by quitting on their own or with the pre-nicotine-replacement methods — they have higher rates of common withdrawal symptoms, such as irritability, restlessness, anxiety, difficulty concentrating, craving, and weight gain. They also have an increased risk of major depression, the depression coming on weeks and months after stopping. In a year, practically all are smoking again.
A confirmed smoking habit can properly be looked upon as nicotine addiction, with features common to drug addictions: tolerance, craving, withdrawal, continuation despite knowledge of harmful effects, denial, and rationalization. Smoking is a very hard habit to break — harder than heroin, cocaine, or alcohol addiction, as measured by treatment success rates, and even harder, as discussed above, for those with a history of depression.
Some newer treatment for smoking may improve the situation for all smokers, including those with a history of depression. There are nicotine patches or nasal sprays that can be combined with various forms of support, education, and behavioral treatment. I suggest that people with current depression first seek treatment for their depression before trying to give up smoking. Those with a history of depression should consider taking an antidepressant that has helped them in the past — as part of their smoking cessation program.
Quitting smoking is a good idea, even if it ends in eventual relapse. The next attempt to quit may be for a more extended period or for good.
