Abstract
Psychiatrists’ views of the helpfulness of reducing cigarette use for young people with mental disorders
Rates of cigarette smoking among psychiatric patients tend to be two to threefold higher than the general population, ranging from around 40–50% in patients with depressive disorders to 70–90% in patients with chronic schizophrenia [1]. This pattern is particularly concerning because smoking is one of the leading causes of preventable morbidity and mortality in Australia, and places a heavy financial burden on our patients, who spend a sizeable proportion of their income on cigarettes [2]. In addition, smokers who begin in adolescence have a lower probability of quitting as adults, and maintain higher levels of tobacco intake [3]. It is therefore not surprising that a number of professional bodies recommend that psychiatrists should assess the smoking status of all patients, including their level of nicotine dependence and readiness to quit.
Between September 2006 and January 2007, a survey examining beliefs regarding appropriate interventions for mental disorder in youth was sent to 1710 psychiatrists and 2000 general practitioners (GPs) in Australia, with response rates of 35% and 24%, respectively. The survey was based on a vignette of a young person with a mental disorder. Participants within each professional group were randomly given one of four vignettes: depression, psychosis (schizophrenia), social phobia or depression with alcohol misuse. The age of the person in the vignette was also randomly varied to be either 15 years or 21 years [4]. Respondents were asked a wide range of questions, including ‘Do you think the following are likely to be helpful, harmful or neither for John's problem …. Cutting down on smoking cigarettes?’. For simplicity, here we report data only from the psychosis and depression vignettes (Table 1).
Beliefs of GPs and psychiatrists in the helpfulness of cutting down on smoking cigarettes for young people with mental disorders
CI, confidence interval; GP, general practitioner.
†n for each disorder was 72, 67, 48 and 57, respectively.
‡n for each disorder was 73, 85, 77 and 78, respectively.
Compared with GPs, psychiatrists consistently endorsed less belief in the helpfulness of reducing smoking for young people with either psychosis or depression. Interestingly, the majority of GPs reported that decreasing smoking would be helpful, suggesting that many may take a more holistic approach to care. Indeed, it was surprising that psychiatrists did not place greater emphasis on cigarette use among the 15-year-olds, despite evidence that teenagers who smoke tobacco regularly appear to be more likely to have mental health problems in older adolescence [5]. It may be that the questions were interpreted differently by individual practitioners, such that psychiatrists did not endorse the question if they felt that smoking reduction would not directly improve the mental disorder. Nevertheless, the data are in keeping with previous research, in which psychiatrists appear to seldom discuss smoking with their patients, despite the majority of individuals with mental health disorders admitting that smoking is an issue [1]. Indeed, interventions are not routinely offered within psychiatric practice, even though patients’ motivation to quit has been found to be similar to that of the general population [1]. The data presented here support the notion that psychiatrists need to take a more proactive role in addressing smoking within mental health settings.
Olanzapine exposure during pregnancy
Reports about the course of pregnancy in women treated with atypical antipsychotics are rare [1, 2]. Only 4 cases of malformations were reported with olanzapine during pregnancy [1, 2]. There was no recurrent pattern found in these reported malformations [2]. We report the case of a woman who took an olanzapine overdose during pregnancy, without any suicidal intent.
Ms A. was a 21-year-old Caucasian woman with a 3 year history of schizophrenia, according to the DSM-IV criteria, without other psychiatric problems. She was effectively treated with olanzapine, 7.5 mg day−1, for 2 years before the onset of pregnancy. She did not smoke or drink alcohol. She had no other psychiatric problems. She became pregnant when stabilized with 7.5 mg day−1 olanzapine. Because haloperidol treatment may be considered safe during pregnancy [2, 3], her olanzapine was changed to haloperidol 10 mg day−1, at week 2 of gestation. However, she experienced extrapyramidal symptoms and stopped haloperidol after 15 days. Moreover, she refused to take any other medication. After stopping her antipsychotic treatment, her symptoms increased, particularly irritability, anxiety, attention disorders and disorganized behaviour. At week 16 of gestation, she took 112.5 mg olanzapine by herself, because of her psychological distress, although she did not show any suicidal intent. She was admitted to the Psychiatric Department at Orsay General Hospital, France. Because she had previously responded well to olanzapine, it was started again at 7.5 mg day−1. Ms A. and her husband gave their informed consent, after they had been given information about the risks and benefits of the treatment. She showed significant symptomatic improvement, and received olanzapine from week 16 of gestation until delivery, with oxazepam 50 mg day−1 for anxiety. She had no side-effects from olanzapine. Because olanzapine has been associated with weight gain and insulin resistance, particularly during pregnancy [2], and gestational diabetes, blood sugar levels were monitored. Blood sugar was normal, from 4.6 mmol L−1 to 5.4 mmol L−1. Her weight was 60 kg (body mass index = 20) before the onset of pregnancy, 72 kg at the delivery. At week 37, a healthy baby girl was delivered. The baby weighed 3.415 kg. Her height was 52 cm. Her Apgar scores were 7 at 1 min and 7 at 5 min. The baby's neurocognitive development was normal.
To our knowledge, this is the first report of an olanzapine overdose during pregnancy. No complication occurred, either due to olanzapine overdose or to olanzapine treatment from week 16 of gestation to delivery. However, more experience is needed to rule out any possible side-effects of olanzapine during pregnancy.