Efficacy and safety of bupropion for smoking cessation and reduction in schizophrenia: systematic review and meta-analysis.

Academic Clinical Psychiatry, University of Sheffield, Sheffield, UK.
The British journal of psychiatry: the journal of mental science (Impact Factor: 7.34). 05/2010; 196(5):346-53. DOI: 10.1192/bjp.bp.109.066019
Source: PubMed

ABSTRACT The benefits and harms of bupropion as an aid for smoking cessation in schizophrenia remain uncertain.
To summarise the current evidence for efficacy and safety of bupropion as treatment for nicotine dependence in schizophrenia.
Systematic review and random-effects meta-analysis of randomised controlled trials (RCTs) comparing bupropion with placebo or alternative therapeutic control in adult smokers with schizophrenia.
Twenty-one reports from seven RCTs were included. Biochemically verified self-reported smoking cessation rates after bupropion were significantly higher than placebo at the end of treatment (risk ratio (RR) = 2.57, P = 0.004) and at 6 months (RR = 2.78, P = 0.05). Expired carbon monoxide level was significantly lower with bupropion at the end of therapy (P = 0.002) but not at 6 months (P = 0.37). There was no significant difference in positive (P = 0.28) or negative symptoms (P = 0.49) between the bupropion and the placebo group.
Bupropion increases the rates of smoking abstinence in smokers with schizophrenia, without jeopardising their mental state.

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    ABSTRACT: Background Prevalence rates of smoking in people with mental illness are high and premature mortality attributed to tobacco related physical comorbidity is a major concern. We conducted a meta-analysis comparing rates of receipt of smoking cessation advice among people with and without mental illness. Method Major electronic databases were searched from inception till August 2014 for studies comparing rates of receipt of smoking cessation advice of people with and without a mental illness. Two independent authors completed methodological appraisal and extracted data. A random effects meta-analysis was utilized. Results Seven studies of satisfactory methodological quality (n mental illness = 68,811, n control = 652,847) were included. Overall there was no significant difference in smoking cessation advice rates between those with and without a mental illness (RR = 1.02, 95% CI: 0.94 – 1.11-, n = 721,658, Q = 1421, p < 0.001). Subgroup analyses demonstrated people with severe mental illness (SMI) received comparable rates of smoking cessation advice to those without SMI (RR = 1.09, 95% CI 0.98-1.2, n = 559,122). This remained true for people with schizophrenia (RR = 1.09, 95% CI 0.68-1.70) and bipolar disorder (RR = 1.14, 95% CI 0.85-1.5). People with non-severe mental illnesses were slightly more likely to receive smoking cessation advice (RR = 1.16, 95% CI = 1.04-1.30, Q = 1364, p < 0.001, n = 580,206). Conclusions People with SMI receive similar smoking cessation advice rates as people without mental illness, whilst those with non-severe mental illness are slightly more likely to receive smoking cessation advice. Whilst progress has been made, offering smoking cessation advice should receive a higher priority in everyday clinical practice for patients with a mental health diagnosis.
    General Hospital Psychiatry 12/2014; 37(1). DOI:10.1016/j.genhosppsych.2014.11.006 · 2.90 Impact Factor
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    ABSTRACT: Objectives The comorbidity between psychosis and substance use has attracted wide attention over the years, and a vast literature is now available for meta-analytic treatment. In the field, a majority of authors assume that cannabis smoking is a risk factor for psychosis, that substance abuse is highly prevalent in schizophrenia, that substance abuse worsens the prognosis of schizophrenia, and that integrated treatments have greater efficacy than treatment-as-usual for this complex population. The objective of the current article is to review the meta-analyses that have been published in the comorbidity field in order to determine if the above-mentioned assumptions are substantiated by evidence or not. Methods A search of the literature was performed using PubMed, PsycINFO and EMBASE. The literature search retrieved a total of 25 systematic quantitative reviews, addressing the following issues: etiology, age at onset, prevalence rates, cognition, treatment, as well as psychiatric, neurologic and functional outcomes. Results Evidence shows that the prevalence of tobacco smoking, cannabis smoking and alcohol use is elevated in psychosis. However, this prevalence is likely to be over-estimated since studies have been performed in clinical settings rather than the general population. Reliable evidence also suggests that cannabis smoking is a risk factor for psychosis outcomes. However, the association is rather small and it remains difficult to draw an unequivocal public health message from this literature. In the same vein, evidence suggests that cannabis smoking is associated with an earlier age at onset of psychosis. However, this observation is derived from cross-sectional studies, not longitudinal ones; thus, no undisputable claims on causality can be made from them. On clinical grounds, some evidence also suggests that substance use is associated with self-harm, increased positive and depressive symptoms in psychosis patients, but this evidence is derived from cross-sectional studies, not longitudinal ones. Cocaine may exacerbate antipsychotic-induced extrapyramidal symptoms in schizophrenia, but this observation is based on a small number of studies. In the case of violence, the aggregation of studies involving very large samples of patients has shown a strong association with substance abuse in psychosis patients. However, this association is based on statistics that are not adjusted for potential confounds, and the role of cluster-B personality disorders in the substance abuse-violence association has yet to be determined from an evidence-based perspective. The effects of psychoactive substances on cognition in psychosis patients are inconsistent and contradictory. In terms of treatment, evidence shows that bupropion and varenicline increase tobacco smoking cessation rates in psychosis. However, this observation is based on a small number of studies. Finally, there is no evidence that integrated psychosocial interventions are superior to treatment as usual in this population. This lack of efficacy may due to a real lack of efficacy or to methodological problems making the comparison of intervention studies difficult. Discussion The evidence supporting the main assumptions of the comorbidity field is not as strong as it may seem. Moreover, important gaps in our understanding of the psychosis-addiction comorbidity remain. Due to lack of interest or lack of data, no meta-analysis has been performed, in the dual-diagnosis population, on injectable antipsychotics, subjective reasons for use, treatment compliance, medical comorbidities, the social context of use, the neurobiological links between substance use and psychosis, as well as the comparative efficacy of nicotine replacement therapy.
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    ABSTRACT: A common remark among laypeople, and notably also among mental health workers, is that individuals with mental illnesses use drugs as self-medication to allay clinical symptoms and the side effects of drug treatments. Roots of the self-medication concept in psychiatry date back at least to the 1980s. Observations that rates of smokers in schizophrenic patients are multiple times the rates for regular smoking in the general population, as well as those with other disorders, proved particularly tempting for a self-medication explanation. Additional evidence came from experiments with animal models exposed to nicotine and the identification of neurobiological mechanisms suggesting self-medication with smoking is a plausible idea. More recently, results from studies comparing smoking and non-smoking schizophrenic patients have led to the questioning of the self-medication hypothesis. Closer examination of the literature points to the possibility that smoking is less beneficial on schizophrenic symptomology than generally assumed while clearly increasing the risk of cancer and other smoking-related diseases responsible for early mortality. It is a good time to examine the evidence for the self-medication concept as it relates to smoking. Our approach is to focus on data addressing direct or implied predictions of the hypothesis in schizophrenic smokers.
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