From the Guidelines
For smoking cessation in a 36-year-old with depression, Varenicline (Chantix) is the most effective option, as it works by both reducing nicotine cravings and blocking the pleasurable effects of smoking, with a recommended target dose of 1 mg twice daily 1.
Key Considerations
- The patient's depression should be closely monitored during smoking cessation, as quitting can temporarily worsen depression symptoms.
- Combining medication with behavioral counseling significantly improves success rates.
- Bupropion (Zyban, Wellbutrin) is another excellent choice, as it treats both depression and nicotine dependence simultaneously, usually prescribed at 150mg daily for 3 days, then 150mg twice daily for 7-12 weeks 1.
- Nicotine replacement therapy (patches, gum, lozenges) can also be effective and can be used alongside these medications.
Treatment Approach
- The selection of a pharmacotherapeutic aid to smoking cessation should be guided by the patient’s medical history, the presence of contraindications, the preferences of the patient and clinician, and the cost of therapy 1.
- In case of relapse to smoking or simply failure to achieve abstinence with appropriate medication, trying a first-line medication not previously used, using combination therapy, or recommending a longer course of treatment may be effective 1.
Important Notes
- Always consult with a healthcare provider before starting any smoking cessation medication to ensure it's appropriate for your specific health situation and to discuss potential side effects.
- Combining counseling with effective medications is superior to either treatment approach alone, as stated in the 2008 US Department of Health and Human Services clinical practice guideline 1.
From the FDA Drug Label
5 WARNINGS AND PRECAUTIONS
5.1 Neuropsychiatric Adverse Events including Suicidality Serious neuropsychiatric adverse events have been reported in patients being treated with varenicline [see Adverse Reactions (6. 2)]. These postmarketing reports have included changes in mood (including depression and mania), psychosis, hallucinations, paranoia, delusions, homicidal ideation, aggression, hostility, agitation, anxiety, and panic, as well as suicidal ideation, suicide attempt, and completed suicide Some patients who stopped smoking may have been experiencing symptoms of nicotine withdrawal, including depressed mood. Depression, rarely including suicidal ideation, has been reported in smokers undergoing a smoking cessation attempt without medication. However, some of these adverse events occurred in patients taking varenicline who continued to smoke Neuropsychiatric adverse events occurred in patients without and with pre-existing psychiatric disease; some patients experienced worsening of their psychiatric illnesses.
- Varenicline may not be the best option for a 36-year-old with depression due to the increased risk of neuropsychiatric adverse events, including depression and suicidal ideation.
- The FDA label warns that varenicline can worsen psychiatric illnesses, including depression.
- Given the patient's history of depression, it is essential to consider alternative treatments and closely monitor the patient's mental health if varenicline is prescribed 2.
From the Research
Medication Options for Smoking Cessation in Individuals with Depression
The following medications have been studied for their effectiveness in smoking cessation, particularly in individuals with depression:
- Varenicline: This medication has been shown to be effective in smoking cessation and may have a favorable effect on symptoms of depression 3.
- Bupropion: This medication is a clinically-effective antidepressant that has been marketed for smoking cessation and has been found to be effective in this population 4, 5.
- Nicotine replacement therapy: This therapy has been found to be effective in smoking cessation, but may not be as effective as varenicline or bupropion in individuals with depression 4, 6.
Considerations for Individuals with Depression
Individuals with depression may experience more severe negative moods and are at increased risk of major depression after quitting smoking 4. Therefore, it is essential to monitor mood changes after quitting and consider additional support and longer courses of treatment 4. Preventive antidepressants may have a role in high-risk cases, especially for those with recurrent depression 4.
Comparison of Medications
Studies have compared the effectiveness of varenicline, bupropion, and nicotine replacement therapy in smoking cessation. One study found that varenicline was associated with a generalized suppression of depression and reduced smoking reward compared to the other treatments 3. Another study found that there was no evidence of an increased risk of suicidal behavior in patients prescribed varenicline or bupropion compared to those prescribed nicotine replacement therapy 7.