Can I have a drag?

July 20, 2009

Many items have converged on the topic for this article. Brainblogger, The Frontal Cortex, my observations at work, and two articles I read recently (see below) made me think about the association between cigarettes and schizophrenia. More precisely nicotine and schizophrenia.

About 80% of the residents at Andrew smoke. The point prevalence of smokers in the United States in 2006: 20.6%. So if Andrew Residence is a somewhat representative sample of the people with mental illness in the U.S., then we would expect people with serious and persistent mental illness (S&PMI) to smoke at four times the rate of the “well” population. This rate difference is exactly what was reported in both the articles I read, as well as the facts that people with schizophrenia smoke much more per day, smoke lung darts with high tar contents, and smoke their cigarettes to the very end (Lyon said this was because that’s where the highest nicotine content is, I think it is probably just because they don’t want to waste what little tobacco they get and I think this is more parsimonious, more on this below). The latter tends to end in burnt and yellow fingers. The burning then makes the residents drop the butt on themselves and burn holes in their clothes. Andrew has gotten in trouble with state boards in the past for “not caring for our residents” because of some of these issues. We try to balance the residents freedoms, watching their budgets (always buying new clothes), and keeping hawk eyes on them while they’re rockin’ a grant.

Digression: Speaking of grants: cigarettes are a currency at Andrew. So many of our residents are vulnerable to just giving up their smokes when people ask for one (after all, it is kind of the smokers unwritten code to give a smoke out when someone needs one – we understand the craving). And since we are helping so many people with their budgets, and this disallows many of them from smoking more than a pack a day of Remington’s, we tend to control how many cigarettes a person can have per hour. It sounds cruel, but so many times the other option is that their coffin nails are chain smoked, bummed, and borrowed so quickly that by the 10th of the month they won’t have any left until the 1st of the next. /end digression

Off the culture of Andrew and back onto the science of nicotine and schizophrenia. I need to mention some of the symptoms of schizophrenia, brain chemistry, and antipsychotic medications, for the interaction of nicotine and all these to make sense.

First of all, the “negative symptoms” of schizophrenia involve avolition, flat affect, anhedonia, alogia (comes with a good example of the kind of conversation I have at work every day), and general seclusion from social life.

The brain chemistry ties in with the above negative symptoms: hypofontality. This is a pretty common characteristic associated with people with schizophrenia. It means that the frontal portions of the brain (the frontal and prefrontal cortices) are not seeing nearly the amount of activation that people without schizophrenia experience. Most of this is associated with dopamine, but also involved are acetylcholine, serotonin, glutamate, and norepinephrine. So what? The frontal lobe conducts the “executive functions” of the brain. It controls many of your social responses, for example: your roommate keeps leaving his shoes right in front of the door so upon entering you are consistently tripping over them.

Do you
(A) Ask him politely to move his shoes two feet to the right explaining why?
(B) Throw a hissy fit and his shoes at the door of his room while he is sleeping?
(C) Not say anything because it might cause conflict and you hate conflict?
(D) Note he continues to do this despite asking him to move them and develop a paranoid delusion regarding his intentions to harm you?

Though the latter is not a choice, all of these are reactions I could see happening from one or more of the residents at Andrew. The frontal cortex allows us to appropriately choose option (A) if the region is sufficiently stimulated. It allows us a level of social functioning. So the explanation that is offered by both Lyon and McGloughen in their literature reviews are that nicotine increases dopaminergic activity in this frontal area of the brain thus reducing the negative symptoms of the disease. Once this happens, people also realize they are being more social active and this can be reinforcing of the habit (like when you smoke while drinking but then it slowly seeps into the rest of your life).

There is something called prepulse inhibition (or sensory gating) that I learned about when I was working in the Cuthbert Lab at the University of Minnesota. In the lab the lab techs will put an EEG on you and play two tones: first a quieter more pleasant tone, then a loud white noise like static on T.V. about 20 milliseconds later. In healthy people the first tone reduces our brain’s reaction to the second tone because our attention cannot switch that fast. But we see a deficit of this in people with schizophrenia and it actually looks more like their reactions are stacked or added to one another. Nicotine has been found to reduce this deficit for people with schizophrenia. I think this is really interesting because the essential problem is filtering of extraneous noise. What effect does this have on their auditory hallucinations then? Can they better focus them out and their conversations with their fellow smokers in? Overall though the explanation of nicotine use due to positive symptomatology is less clear, but nicotine could help increase attention and memory (as it does for everyone), which are both in deficit in people with schizophrenia.

So far all the above has been pretty positive, no? Well the negative aspect of smoking for people with schizophrenia that does not apply to the well population is the dose of antipsychotics they have to take. A few studies have found that the amount of antipsychotics that people have to take if they smoke is about 50% higher. Though, others found that haloperidol and risperidal increased the amount a person smokes while clozapine decreased the amount a person smoked (as well as decreasing alcohol, cocaine and heroin use). Lyon states this is because “polycyclic hydrocarbons in cigarette smoke stimulate the hepatic microsomal system, inducing liver enzymes to increase the metabolism of antipsychotic medications.”

Both articles I read assumed that smoking was still evil. I’m not so sure. Nicotine does do the above is it really something to take away from our residents? There are options of course: patches, gums, lozenges and nicotine inhalers. But I cannot help but think that if smoking is something a resident enjoys, and the nicotine is helping reduce some of their symptoms, why are we trying to take it away from them? Some psych wards have instituted full smoking bans and have only seen increases in pro re nata medications for a short while afterward, then a return to normal. They also did not find an increase in security calls or agitation. They article says nothing of an increase in seclusive behavior or the other negative symptoms I mentioned above though.

Lyon, E.R. (1999). A review of the effects of nicotine on schizophrenia and antipsychotic medications. Psychiatric Services, 50, 1346-1350.

McGloughen, A. (2003). The association between schizophrenia and cigarette smoking: a review of the literature and implications for mental health nursing practice. International Journal of Mental Health Nursing, 12, 119-129.

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