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July 2009 – Tips & Topics

Volume 7, No.4
July 2009

In this issue
— Until Next Time

Welcome to the July edition of TIPS and TOPICS. Thanks for joining us.


If you are interested in co-occurring disorders, you might want to subscribe to Co-Occurring Dialogues. It is an Electronic Discussion List which is free and unrestricted.  You can subscribe simply by sending an e-mail to The Center for Substance Abuse Treatment (CSAT) that sponsors the listserv assumes no responsibility for the opinions and information posted by users.

The Listserv introduced an article recently that appeared on another site- the Brain Blogger. This covers topics from multidimensional biopsychosocial perspectives. When I hear “multidimensional biopsychosocial perspectives”, my ears perk up because that is what we have been trying to do for years with the ASAM Patient Placement Criteria (ASAM PPC).

This is what Brain Blogger writes about themselves: We review “the latest news and research related to neuroscience/neurology, psychology/psychiatry, and health/healthcare.  Our blog serves as a focal point for attracting new minds beyond the basic sciences of the mind-and-brain and into the biopsychosocial model.” I don’t know enough about the site and the organization to endorse it, but there are some thought-provoking
articles there. One of those I am excerpting and commenting on here. You can read the full blog -see the References section below.

Topic: Why Do Schizophrenics Smoke Cigarettes? and Editorial Comments

Excerpt from BrainBlog/Psychiatry & Psychology/July 03, 2009 by Dirk Hanson, MA

About: Dirk Hanson is a freelance science writer and the author of “The Chemical Carousel: What Science Tells Us About Beating Addiction.” He is also the author of ”The New Alchemists: Silicon Valley and the Microelectronics Revolution.” He has worked as a business and technology reporter for numerous magazines and trade publications.

For health care workers in psychiatric hospitals, it is no secret: one of the major issues confronting psychiatric facilities seeking to institute blanket no-smoking policies concerns chronic inpatients with schizophrenia. Patients with schizophrenia are almost always heavy cigarette smokers, given a choice. As Edward Lyon wrote  in an analysis of studies and surveys performed throughout the 1990s: “Many patients
in psychiatric hospitals would smoke two, three, or even four packs of cigarettes a day if an unlimited supply of cigarettes were available.”

Generally, the rate of inpatient smoking among schizophrenics is three to four times higher than the general smoking population. In one British study of 100 institutionalized schizophrenics cited by Lyon, 92% of the men and 82% of the women were smokers.  Moreover, schizophrenics smoke more cigarettes per day than other smokers do, and they commonly smoke high-tar, unfiltered cigarettes – niche brands for heavy smokers used by only 1% of the total smoking population.

Australian research performed in 2001 found that because of high rates of smoking, “people with mental illness have 30% more heart disease and 30% more respiratory disorders,” according to Ann Crocker, now a professor of Clinical Psychiatry at McGill University.

DML comment:

These statistics remind us that recovery involves a holistic, biopsychosocial multidimensional assessment and service plan, not just a focus on psychiatric signs and symptom stabilization.

Not only do an estimated 80% of schizophrenics smoke, compared to roughly 25% of the total adult population, psychiatric facilities report that depressives and  those with anxiety disorders also smoke in great numbers.


The review of studies through 1999, undertaken by Lyon and published in Psychiatric Services, shows unequivocally that schizophrenic smokers are self-medicating to improve processing of auditory stimuli and to reduce many of the cognitive symptoms of the disease. “Neurobiological factors provide the strongest explanation for the link between smoking and schizophrenia,” Lyons writes, “because a direct neurochemical interaction can be demonstrated.”

Of particular interest is the interaction between nicotine and dopamine in the nucleus accumbens and prefrontal cortex. Several of the symptoms of schizophrenia appear to be associated with dopamine release in these brain areas. A 2005 German study concluded that nicotine improved cognitive functions related to attention and memory.  “There is substantial evidence that nicotine could be used by patients with schizophrenia as a ‘self-medication’ to improve deficits in attention, cognition, and information processing and to reduce side effects of antipsychotic medication,” the German researchers concluded.

DML comment:

It is popular these days to view everything as a “brain disease” fixed by the magic bullet of a pharmaceutical miracle drug, medical device or procedure. We have” restless legs syndrome” and on Saturday Night Live, they even spoofed an explanation for extramarital affairs as “restless penis syndrome”. I am not denigrating the advances of neurochemistry, but a biopsychosocial, multidimensional perspective is important to take.

In addition, the process known as “sensory gating,” which lowers response levels to repeated auditory stimuli, so that a schizophrenic’s response to a second stimulus is greater than a normal person’s, is also impacted by cigarettes. Sensory gating may be involved in the auditory hallucinations common to schizophrenics. Receptors for nicotine are involved in sensory gating, and several studies have shown that sensory gating among schizophrenics is markedly improved after smoking.

There is an additional reason why smoking is an issue of importance for health professionals.  According to Lyon, “Several studies have reported that smokers require higher levels of antipsychotics than nonsmokers. Smoking can lower the blood levels of some antipsychotics by as much as 50%…. For example, Ziedonis and associates found that the average antipsychotic dosage for smokers in their sample was 590 mg in chlorpromazine equivalents compared with 375 mg for nonsmokers.”

Smoking among inpatient psychiatric patients is not trivial. Neither is the decision to institute smoking bans in psychiatric hospitals, a move that is understandably unpopular with patients.

DML comment:

Your facility recently may have become smoke-free. Perhaps it plans to soon. You might start thinking you should hold off given the neurochemical explanations of self-medication with nicotine. But there are psychosocial causes, consequences and solutions for what to do about smoking. Public health principles tell us the more available and less expensive a drug is, the greater the prevalence of use (and also the health and social consequences). If we are interested in advancing full recovery for all our clients and patients (medical, addiction and co-occurring disorders), then this is not the time to reverse moves to smoke-free health care facilities.


Hanson, D (2009). Why Do Schizophrenics Smoke Cigarettes?

Adler, L., Hoffer, L. Wiser, A. (1993). Normalization of auditory physiology by cigarette smoking in schizophrenic patients. American Journal of Psychiatry, 150, 1856-1861.

Cattapan-Ludewig, K. (2005). Why do schizophrenic patients smoke? Nervenarzt, 76 (3), 287-294.

Lyon, E. (1999). A Review of the Effects of Nicotine on Schizophrenia and Antipsychotic Medications. Psychiatric Services, 50, 1346-1350.

Mueser, K., Crocker, A., Frisman, L., Drake, R., Covell, N., & Essock, S. (2005).
Conduct Disorder and Antisocial Personality Disorder in Persons With Severe Psychiatric and Substance Use Disorders Schizophrenia Bulletin, 32 (4), 626-636 DOI: 10.1093/schbul/sbj068


Sometimes it seems researchers spend lots of time, effort and resources to prove what seems to be the obvious. That is not to diminish the need for such research because at times, “conventional wisdom” is exposed by research and found to be actually wrong. (Think “flat earth” conventional wisdom; and “smoking is not a health hazard” research) Recently I read a research paper on medication adherence and severe mental disorders. This seemed to be another example of “well that’s obvious”.


  • Increase your client’s adherence to taking their medication. How? Ask them their personal beliefs about their treatment and medications.

Non-adherence to taking medication is a major problem in patients with severe mental disorders. It is associated with poor clinical outcomes and high resource utilization.  Let me refer to a recent study on this issue- see reference below.

Jane Clatworthy and associates studied bipolar disordered patients, and attempted to understand their attitudes towards medications. They concluded that, indeed, “attitudes toward medication among bipolar disorder patients” may “have a significant impact on adherence.”

In the study, University of London researchers “administered the Medication Adherence Report Scale and the Beliefs About Medication Questionnaire to 2,223 patients prescribed bipolar disorder medication.” Results showed that patients who adhered less to their medication felt a significantly lower need for treatment and had greater concerns about treatment than patients who did take their medication more faithfully.

This doesn’t seem like rocket science. But how many times have I examined mental
health charts where the first goal of the so-called collaborative treatment plan
is: “Medication compliance”.

Then you turn to the client and ask further. Your dialogue might go something like this.

Therapist: “Do you even think you have Schizophrenic Disorder and want to take this medication?” and they say:

Client:  “No, it’s a plot and they are trying to poison me.”

Comment: Amazingly, the client is non-compliant with medication and does not adhere to their treatment plan!

Or you turn to the Bipolar Disordered person and your dialogue might go like this:

Therapist: “You look quite stable and calm. When you take your medication and are not manic and up all night, do you feel much better on the medication?” and they say:

Client: “Actually, I think people are exaggerating about how out of control I get; and when I take the medication, I kinda miss all the energy I had and feel a bit depressed.”

Therapist might counter with:
“Well, no, actually you were quite manic and agitated and the medication has really worked well to stabilize your Bipolar Disorder. So you better stay on your medication and make sure you don’t stop.”

Or the Therapist might say:

“Well let’s explore more what you mean about people exaggerating how out of control you get. Also, if you feel you miss the energy and that the medication makes you feel a bit depressed, I really want to understand that and see what we can do.”

Comment: Coming back to the study, the authors concluded, “Prescribing is unlikely to be associated with adherence unless it incorporates a process of eliciting and responding to individuals’ personal beliefs about the treatment.”

Clatworthy J, Bowskill R, Parham R et al (2009): Understanding medication non-adherence in bipolar disorders using a Necessity-Concerns Framework. J Affective Disorders Volume 116 Issue 1, Pages 51-55


I am continually blown away by how much information there is so readily available because of the internet. Often it seems too much information in fact. Now that I just got my new 3G S iPhone I have even easier access at all times. I remember when I was wowed by a fax machine sending grainy documents via phone lines.

No doubt many of you are overwhelmed by all the information you get too. You are reading this, but even people who signed up for TIPS and TOPICS themselves don’t always open and read it. I’m grateful that you do, and that some of you even forward it to your colleagues.

How to cope with the information explosion?

There are so many great websites chocked full of fascinating information. Ignorance was bliss. Now I have no excuse for not being informed about all sides of a political or scientific debate. But with emails, newsletters, blogs and journal articles flooding into my inbox, what to do?

On top of that, industry experts who advise about business development extol the virtues of having a presence on Facebook, Twitter and LinkedIn. I have trouble keeping up with my snail mail let alone tweeting what I think about Michael Jackson’s prescription drug use.

I know this sounds like the current version of our parents’ alarm at Elvis Presley’s suggestive gyrations; or their complaints about boys’ hair length- “you can’t tell who is a girl or a boy anymore!” And maybe it is. The 20 somethings have no trouble reading their news on the internet when I still enjoy leafing through the newspaper.

But I am quite warmed up to listening on my iPod to podcasts of “Talk of the Nation” from National Public Radio. And I am absolutely stoked about the time- saving Digital Video Recorder (DVR) feature of my cable TV system. Now, I can listen or watch what and when I want and can. Zip through TV commercials (sorry advertisers) and be more efficient with my time. Get information on my schedule, not the radio or TV’s. Researching a topic for scientific or casual purposes is so easy now. You can even search 6 years of TIPS and TOPICS and tap into lots of information on my website rather than leafing through back issues if you even bothered to print them out. Finding an address or phone number, directions and what hours a store is open are now so easy.

Come to think about it, I wouldn’t trade the information access and technology of yesterday for anything.

Until Next Time

Thanks for reading. See you in late August.

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