Warsaw, ENQ meeting, May 2008 Regina M. van der Meer MPH, Marc C. Willemsen PhD,
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Transcript of Warsaw, ENQ meeting, May 2008 Regina M. van der Meer MPH, Marc C. Willemsen PhD,
Smoking cessation intervention for smokers with past major depression:
a randomized controlled trial
Warsaw, ENQ meeting, May 2008
Regina M. van der Meer MPH, Marc C. Willemsen PhD,
Pim Cuijpers PhD, Filip Smit PhD, Gerard M. Schippers
PhD
Major depression?
Major depression?
Having a very bad hair day
Major depression (DSM–IV)
Five or more of the following symptoms have been
present during the same 2-week period and
represent a change from previous functioning;
At least one of the symptoms is:
• Depressed mood or• Loss of interest or pleasure
Major depression (DSM–IV)
• Significant weight loss or decrease or increase in
appetite• Insomnia or hypersomnia• Psychomotor agitation or retardation• Fatigue or loss of energy• Feelings of worthlessness or guilt• Diminished ability to think or concentrate, or
indecisiveness• Recurrent thoughts of death
Past major depression
Lifetime major depression,
but not
within the last month
Smoking & past major depression
Smoking and depression are strongly associated
• Smokers are more likely to have past major
depression than non-smokers
&• Persons with past major depression are more
likely to be smokers than non-smokers (Glassman, 1993; Kalman et al., 2005)
Smoking & past major depression
A recent study from Wiesbeck and colleagues in
Neuropsychobiology support the evidence that
smoking is linked to depression.
They found the highest rate of lifetime depression
in current smokers (23,7%), the lowest rate in
never smokers (6,2%) and the rate of those who
had quit smoking was 14,6.
Smoking cessation & past major depression
Hughes (2007) found in a recent review that
smokers with a past major depression clearly have
an increased risk for a new depression after quit
smoking when compared with smokers without a
past major depression.
This might explain why it is more difficult for
smokers with past major depression to quit.
Smoking cessation & past major depression
An often mentioned underlying mechanism is the self-
medication assumption:
Smokers use cigarettes as a form of self-medication
for coping with depressive symptoms
Smokers with past major depression may quit more
easily if they have learned to better manage their
mood without needing cigarettes.
Smoking cessation & past major depression
This self-medication assumption has resulted in
several studies examining smoking cessation
interventions that include strategies for managing
depressive symptoms. (Hall et al., Brown et al)
But non of these interventions consisted out of
telephonic counselling and most of these studies
were very small.
I can handle the world, smokefree!
Aim of study
To assess whether the Mood Management intervention:
1. Produces higher abstinence rates compared to control intervention
2. Helps to prevent and reduce depressive symptoms compared to control intervention
Control (C)
Telephone counselling• 8 sessions (1st: 30 minutes;
quitdate; 2nd – 8th: 12 min.)• by a trained coach of STIVORO
Content Smoking cessation skills:• social support• increasing self-efficacy• self-rewarding• relapse prevention
Mood Management (MM)
Telephone counselling• 10 sessions (1st: 30 minutes;
2nd – 3rd: 15 min; quit date;4th – 10th: 15 min)
• by a trained coach of STIVORO&
Quit smoking mood management manual• Self help manual with exercises
for reading and practicing at home between the sessions
Mood Management (MM)
Content
Smoking cessation skills:• social support• increasing self-efficacy• self-rewarding• relapse prevention
Mood management skills:• Increasing pleasant events• Relaxation• Cognitive skills• Social skills
Based on cognitive behavioural therapy
Study design (RCT)
1. Recruitment – open population
advertisements, articles, website, flyers etc.
(n=4008 received information package)
2. Screening 1 & Informed consent
(n=1875 gave their informed consent)
(n=706 were invited for CIDI interview)
Study design(RCT)
3. Screening 2 (CIDI)
Assessment of past major depression
according to DSM-IV (exclusion of current
depression, current alcohol disorder)
(n=531 met inclusion criteria)
4. Baseline measurement T0
5. Randomisation
(n=485)
Study design (RCT)
6. MM or C intervention
(MM: n=243; C: n=242)
10 Counsellors gave MM and C intervention
7. Follow up T1 (6 months after T0)
Response (MM: 81.0%; C: 83.5%)
8. Follow up T2 (12 months after T0)
Response (MM: 77.0%; C: 76.4%)
Participants• Past major depression• No current major depression• Preparator or contemplator• No current alcohol disorder
Outcomes • Prolonged abstinence• Point prevalence
Study design (RCT)
BaselineCharacteristics
MM group(n=243)
C group(n=242)
Sign.
Male, % 23.0 24.0 NS
Age, mean SD 43.3 9.9 44.2 10.2
NS
Cigarettes, mean SD 21.4 8.9 21.8 9.7 NS
FTND, mean SD 5.1 2.2 5.1 2.4 NS
Stages of change, %-Preparation-Contemplation
71.628.4
72.327.7
NS
BaselineCharacteristics
MM group(n=243)
C group(n=242)
Sign.
Education %- Low- Medium- High
12.037.350.6
11.242.646.3
NS
Quit attempts, mean SD 6.2 11.5 5.8 10.2 NS
Self-efficacy, mean SD 3.0 10.6 5.1 10.6 .03
BaselineCharacteristics
MM group(n=243)
C group(n=242)
Sign.
Depressive symptoms (CES-D), mean SD 18.1 7.6 17.8 8.0 NS
Alcohol-problem drinkers, % 22.2 23.1 NS
Anxiety, mean SD 46.7 9.6 46.1 10.3
NS
BaselineCharacteristics
MM group(n=243)
C group(n=242)
Sign.
Past depression %
- single, light- single, mild- single, severe- recurrent, light- recurrent, mild- recurrent, severe
12.8
10.7
19.8
24.8
15.3
16.5
14.1
13.7
22.4
18.7
19.1
12.0
NS
Results - 6 months follow up
OR Adjusted for self-efficacy and past depression
* Significant
Smoking Cessation
MM(n=243)
C(n=242)
OR unadj.95% CI
OR adjust.95% CI
Point prevalence
37.4 %n=91
31.0 %n=75
1.33(0.9–1.9)
1.33(0.9–2.0)
Prolongedabstinence
30.5 %n=74
22.3 %n=54
1.52*(1.01- 2.3)
1.48(0.98–2.2)
Results - 12 months follow up
OR Adjusted for self-efficacy and past depression
* Significant
Smoking Cessation
MM(n=243)
C(n=242)
OR unadj.95% CI
OR adjust.95% CI
Point prevalence
27.6 %n=67
24.0 %n=58
1.21(0.8–1.8)
1.17(0.8–1.8)
Prolongedabstinence
23.9 %n=58
14.0 %n=34
1.92*(1.2–3.1)
1.86*(1.2–3.0)
Results – 6/12 months follow up
a Adjusted for self-efficacy and past depression
*Significant
Depressive symptoms(CES-D)
MM(n=243)Mean(SD)
C(n=242)Mean (SD)
t-test(P-value)
ANCOVAa
(P-value)
6 months 15.4 (10.5)
14.7 (10.4)
-.71(.48)
.09(.77)
12 months 14.8(9.8)
14.6(10.4)
-.21(.84)
.14(.71)
Conclusion
Overall more smokers quit smoking with the
Mood Management intervention when
compared with the control intervention.
Although there are no significant differences on
point prevalence abstinence.
Prolonged abstinence however does show
significant differences.
Conclusion
It seems that the differences in smoking
abstinence between Mood management
intervention and control intervention can not be
explained by differences in depressive
symptoms
Mood Mangement intervention combined with
telephone counselling seems to increase success
rates for smokers with past major depression
How does the MM interventionworks in practice?
Carl Simons
Many thanks for your attention!