Many smokers desire counseling to help them quit, but only few are receiving it

Among American adults who have a serious mental illness such as schizophrenia, bipolar disorder or clinical depression, 57 percent are smokers. In contrast, only 15 percent of U.S. adults overall smoke.

Many with such psychiatric problems want to quit smoking, but their psychiatrists and caseworkers typically don't prescribe medications to help them or refer them to services aimed at smoking cessation, researchers at Washington University School of Medicine and BJC Behavioral Health in St. Louis have found.

The findings are published online in the Community Mental Health Journal.

"Patients with serious mental illness die an average of 25 years younger than people who don't have these problems, and smoking is a big factor," said Li-Shiun Chen, MD, an assistant professor of psychiatry and the study's first author. "Smoking is a common and serious problem for our patients, and although smoking rates have been decreasing in the general population, the rates remain very high in this vulnerable population."

Traditionally, psychiatric wards were among the few places in hospitals where smoking was allowed. Psychiatrists used to feel it was acceptable to allow seriously ill patients to smoke since the key focus in treatment was psychosis or depression.

"But in the past few years, research has shown that smoking cessation is beneficial to the mental health of psychiatric patients," said Laura Jean Bierut, MD, the Alumni Endowed Professor of Psychiatry and the study's senior author. "When they stop smoking, it decreases the risk of recurrent depressive episodes that can lead to hospitalization. It also decreases the amount of medication they need. Our understanding has evolved. Twenty years ago, doctors might have thought that continuing to smoke didn't have mental health repercussions, but now we know better."

The researchers surveyed 213 patients with psychiatric illnesses who were treated at one of four BJC Behavioral Health clinics in and near St. Louis. Surveying patients they believed to be fairly representative of those seen in community health centers around the country, the researchers found that 82 percent of the patients who smoked were interested in trying to quit. Forty-four percent said they would like to take medication to help them quit, but only 13 percent were receiving such treatment. Meanwhile, 25 percent said they desired counseling to help them quit, but only 5 percent were receiving it.

Along with those patient surveys, an anonymous survey of mental health providers found that 91 percent of psychiatrists and 84 percent of caseworkers had the impression that their patients had no interest in quitting or reducing the amount they smoked.

"There is quite a disconnect between the two groups," said Chen, who also is a staff psychiatrist at BJC Behavioral Health. "Our goal is to realign the desires of patients and the perspectives of the physicians who treat them."

One example of the disconnect involved use of electronic cigarettes. Chen said that about half of the surveyed patients who were smokers expressed an interest in using electronic cigarettes as a step toward quitting and that 22 percent reported that they already were using electronic cigarettes to kick the habit.

"The high use of electronic cigarettes is a sign that many of these patients are trying to change their smoking behavior," Chen said.

A potential problem, however, is that it's not clear whether electronic cigarettes help people quit. And some researchers believe that use of electronic cigarettes could lead patients with serious mental illness to smoke electronic cigarettes while continuing to use traditional cigarettes.

"It would be better to use proven therapies with patients who want to quit than to keep our fingers crossed that their use of electronic cigarettes might help them stop smoking," Bierut said.

To determine whether patients smoke and whether they want help kicking the habit, the clinics at BJC Behavioral Health now ask patients to fill out surveys about smoking every time they come in for appointments. The questionnaires then are given to physicians and caseworkers before the appointments begin.

"We want the providers to be aware of patient-reported treatment needs and smoking behaviors," Chen said. "We want the psychiatrists and caseworkers to know whether their patients have expressed a wish to stop smoking so that they can refer them to counseling or provide them with prescriptions for nicotine lozenges, patches or other medications that may help these patients quit smoking. We think those fairly simple changes really could pay off in a big way."

As the new approach is implemented, Chen, Bierut and their colleagues plan to track smoking rates in such patients to see whether more individuals with serious mental illnesses are able to quit successfully and, eventually, whether quitting smoking helps them live longer, healthier lives.