International Journal of Psychiatry in Clinical Practice, 2005; 9(2): 145 /148
SHORT REPORT
Cigarette smoking and psychiatric disorders in Hungary
´ CS2, Z. TELEKI1 & ¨ ME1, Z. RIHMER1, X. GONDA1, P. PESTALITY1, G. KOVA P. DO P. MANDL1,3 1
National Institute for Psychiatry and Neurology, Budapest, Hungary, 2National Kora´nyi Institute for Tuberculosis and Pulmonology, Budapest, Hungary, and 3Department of Pharmacology, Institute of Experimental Medicine, Hungarian Academy of Sciences, Budapest, Hungary
Abstract Data from the United States and from several European countries show that patients with major mood disorders, schizophrenia and social phobia smoke at significantly higher rates than the general population. However, there are no published results on this field from Central Europe, including Hungary. In the present study, the rate of current and lifetime smoking of the consecutively screened outpatients with DSM-IV unipolar major depression (n /92), bipolar disorder (n /60), schizophrenia (n /80), schizoaffective disorder (n /42) and panic disorder without major depression (n /60) were assessed and the data were compared to the controls (n /5503), representative for the general population of Hungary. The results showed that, compared to controls, the rates of current and lifetime smoking were significantly higher among patients with unipolar major depression, bipolar disorder, schizophrenia and schizoaffective disorder, but not among patients with panic disorder without major depression. The findings support previous findings from other countries on the strong relationship between cigarette smoking and major mood and schizophrenic spectrum disorders.
Key Words: Bipolar disorder, Hungary, major depression, panic disorder, schizoaffective disorder, schizophrenia, smoking
Introduction It is well documented that major depression [1,2], bipolar I disorder [3 /6], schizophrenia [1,7,8] and schizoaffective disorder [9] is associated with higher rate of cigarette smoking than that of the normal population. As for anxiety disorders, it has recently been reported that patients with social phobia smoke significantly more, even after controlling for comorbid depression [10], and patients with obsessive / compulsive disorder smoke significantly less than the general population [11]. The present study was designed to examine the relationship between smoking and different psychiatric disorders such as affective, schizoaffective disorder, schizophrenia and panic disorder in Hungary. Methods To minimize the social influence of hospitalization on current smoking, only outpatients were studied. More than 360 outpatients, with the diagnosis of unipolar major depression, bipolar disorder, schizo-
phrenia, schizoaffective disorder and pure panic disorder, who received treatment in three different outpatient departments at the National Institute for Psychiatry and Neurology, Budapest, were interviewed regarding their smoking habits. Only panic disorder patients without current and/or past major depression were included. Patients with comorbid substance-use/dependence disorders were also exluded. More than two-thirds of the unipolar, bipolar, schizoaffective and schizophrenic patients, but less than 5% of panic disorder patients, were previously treated as inpatients at the same institute. All patients were diagnosed by experienced clinical psychiatrists according to the DSM-IV criteria [12]. The frequency of current and lifetime smoking was compared with data of 5503 adults, representative for the whole Hungarian population [13]. Associations between categorical variables were calculated by the chi-square test. Results The final sample (N /334) consisted of 92 unipolar major depressive, 60 bipolar (32 bipolar I and 28
Correspondence: Zolta´n Rihmer, National Institute for Psychiatry and Neurology, Pf. 1, Budapest 27, 1281, Hungary. Tel: /36 1 391 5353. Fax: /36 1 200 0770. E-mail: [email protected]
(Received 10 November 2004; accepted 3 February 2005) ISSN 1365-1501 print/ISSN 1471-1788 online # 2005 Taylor & Francis DOI: 10.1080/13651500510028977
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Table I. Frequency of current and lifetime smoking in different patient-groups and in controls. Smokers
Diagnosis Unipolar major depression
Bipolar I/II disorder
Schizoaffective disorder
Schizophrenia
Panic disorder
Controls
N Total Males Females Total Males Females Total Males Females Total Males Females Total Males Females Total Males Females
92 32 60 60 26 34 42 19 23 80 43 37 60 16 44 5503 2467 3036
Current n (%) 49 18 31 36 17 19 29 13 16 43 25 18 20 6 14 1933 1135 798
(53) (56) (52) (60) (65) (56) (69) (68) (69) (54) (58) (49) (33) (37) (32) (35) (41) (26)
Lifetime n (%) 64 24 40 42 20 22 35 15 20 56 31 25 29 11 18 2900 1655 1245
(70) (75) (67) (70) (77) (65) (83) (79) (87) (70) (72) (68) (48) (69) (41) (53) (67) (41)
Unipolars vs. controls. Current: x2 /13.01, df /1, P /0.0003; Lifetime: x2 /10.33, df /1, P /0.0013. Bipolar I/II vs. controls: Current: x2 /16.06, df /1, P /0.0001; Lifetime: x2 /7.13, df /1, P /0.0076. Schizoaffectives vs. controls: Current: x2 /20.98, df /1, P /0.0000; Lifetime: x2 /15.7, df /1, p / 0.0001. Schizophrenics vs. controls. Current: x2 /11.96 df /1, p /0,0005 Lifetime: x2 /9,47, df /1, P /0.0021. Panic disorder patients vs. controls. Current: x2 /0.08, df /1, P /0.772; Lifetime: x2 /0.45, df /1, P /0.5. Male controls vs. female controls: Current: x2 /316.88, df /1, P /0.00000; Lifetime: x2 /371.31, df /1, P /0.0000.
bipolar II), 42 schizoaffective, 80 schizophrenic and 60 pure panic disorder patients (Table I). Because of the small number of bipolar I and bipolar II patients, these subgroups were not analysed separately. All patients who were classified as regular (everyday) smokers smoked cigarettes (of these, six patients also smoked a pipe and/or cigar occasionally), and, interestingly, no patient smoked only a pipe or cigar on a regular basis. None of these patients reported a smokeless use of tobacco (i.e. tobacco chewing, snuff, etc.) in this sample. The rates of current and lifetime smokers in different diagnostic groups as well as in the control sample are shown in Table I. Compared to controls, the rate of current and lifetime smoking is significantly higher among unipolar, bipolar, schizoaffective and schizophrenic patients, but panic disorder patients show similar rates of current and lifetime smoking as members of the control group. Of the four diagnostic groups with a high frequency of smoking (major depressives, bipolars, schizophrenics and schizoaffectives), schizoaffective patients show the highest rate of current and lifetime smoking; but, compared to unipolars, bipolars and schizophrenics, this difference is not significant. Statistical comparison between the different diagnostic groups and the control group by gender was not performed due to the relatively small number of cases. However, the inspection of these figures show that (except for the schizoaffective group) the
rate of current and lifetime smoking is numerically lower among females in the remaining four patient groups, but this difference is smaller than in the control group, where the frequency of current and lifetime smokers is significantly higher among males (Table I). Discussion Our findings support the strong relationship between cigarette smoking and unipolar major depressive disorder [1,2], bipolar disorder [3 /6], schizophrenia [1,7,8] and schizoaffective disorder [9], demonstrating that this association is present not only in the United States [1,2,7], Spain [3], Scotland [8], Ireland [5] and Israel [4], but also in Hungary. The underlying biological mechanisms that could explain the strong association between smoking and major mood disorders, schizophrenia and schizoaffective disorder are not exactly established at present, but they seem to be different in mood disorders [14,15] and in schizophrenia [16 /18]. On the other hand, however, it seems that not only genetical/ biological, but also cultural, economical and social backgrounds of the given country influence the smoking habits of psychiatric patients and of normal population too; e.g. in Japan, smoking frequency is the same among schizophrenics as in the normal population [19]. Another study from India showed similar data, suggesting that smoking and heavy
Smoking and psychiatric disorders in Hungary smoking rates among schizophrenics were no different from the same rates of the non-psychiatric control group [20]. Considering these facts it is important to examine the above-mentioned relationship between smoking rates and psychiatric diagnoses in countries with different economical, cultural and social backgrounds. We found that the frequency of current and lifetime cigarette smoking among schizoaffective patients highly exceeded the rates of patients with schizophrenia or major mood disoders. The underlying biological mechanisms that predispose for smoking in patients with mood disorder and schizophrenia seem to be different: low central serotonin function in mood disorder patients [14,15], while abnormalities in central nicotine receptors in schizophrenics [15/17] might predispose for smoking. Schizoaffective disorder shares several genetical/ biological and clinical characteristics of both schizophrenia and mood disorders [18]. Therefore, the simultaneous presence of these two different underlying biological abnormalities in schizoaffective disorder may explain why the smoking rate is much higher in schizoaffective illness, as compared to both schizophrenia and major mood disorders. The relationship between anxiety disorders and smoking seems to be more complex. While patients with social phobia smoke significantly more [10] and obsessive /compulsive patients smoke significantly less than their control persons [11], our results show that patients with panic disorder without current or past major depression have the same smoking habits as the general population. This finding is consistent with the results of a recent epidemiological study, showing that people suffering from panic attacks, lifetime smokers have had much higher rate of comorbid major depression (50%) than nonsmokers (39%) [21]. On the other hand, however, it should be noted that panic disorder (either with, or without major depression) is not representative of all anxiety disorders, therefore our findings have limited value in this respect. However, the fact that age, social class, and alcohol/coffeine consumption was not controlled in our patients, coupled with the fact that dependent versus nondependent smokers were not distinguished, should be considered as limiting factors. Key points . The present Hungarian study shows that, in agreement with previous reports from United States and some Western European countries, patients with major mood and schizophrenic spectrum disorders smoke at siginificantly higher rate than the general population
147
. Panic disorder patients without current and past major depression do not show increased rate of smoking . Since the relationship between smoking and major psychiatric disorders is quite complex, this connection needs further investigations
Statement of interest Dr Rihmer is consultant at AstraZeneca, Eli Lilly, GlaxoSmithKline, Lundbeck, Organon, Pfizer, Servier-EGIS, and Wyeth. He is also a member of Speaker’s Bureau at AstraZeneca, Eli Lilly, GlaxoSmithKline, Jannsen-Cilag, Lundbeck, Organon, Pfizer, Richter, Roche, Sanofi-Synthe´labo, ServierEGIS and Wyeth.
References [1] Hughes JR, Hatsukami DK, Mitchell JE, Dahlgren LA. Prevalence of smoking among psychiatric outpatients. Am J Psychiatry 1986;143:993 /7. [2] Glassman AH. Cigarette smoking: Implications for psychiatric illness. Am J Psychiatry 1993;150:546 /53. [3] Gonzalez-Pinto A, Gutierrez M, Ezcurra J, et al. Tobacco smoking and bipolar disorder. J Clin Psychiatry 1998; 59:225 /8. [4] Itkin O, Nemets B, Einat H. Smoking habits in bipolar and schizophrenic outpatients in Southern Israel. J Clin Psychiatry 2001;62:269 /72. [5] Corvin A, O’Mahony E, O’Regan M, et al. Cigarette smoking and psychotic symptoms in bipolar affective disorder. Br J Psychiatry 2001;179:35 /8. [6] Cassidy F, McEvoy JP, Yang YK, Wilson WH. Smoking and psychosis in patients with bipolar I disorder. Comp Psychiatry 2002;43:63 /4. [7] DeLeon J, Gadvand M, Cannso C, et al. Schizophrenia and smoking: an epidemiological study in a state hospital. Am J Psychiatry 1995;152:453 /5. [8] McCreadie RG, On behalf of the Scottish Comorbidity Study Group. Use of drugs, alcohol and tabacco by people with schizophrenia: Case-control study. Br J Psychiatry 2002;181:321 /5. [9] Vanable PA, Carey MP, Carey KB, Maisto SA. Smoking among psychiatric outpatients: Relationship to substance use, diagnosis and illness severity. Psychol Addict Behav 2003;4:259 /65. [10] Sontag H, Wittchen H-U, Ho¨fler M, et al. Are social fears and DSM-IV social anxiety disorder associated with smoking and nicotine dependence in adolescents and young adults? Eur Psychiatry 2000;15:67 /74. [11] Bejerot S, Humble M. Low prevalence of smoking among patients with obsessive-compulsive disorder. Comp Psychiatry 1999;40:268 /72. [12] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association Press; 1994. [13] Boros J. Dohanyzas. In: Boros J, Nemeth R, Vitrai J, editors. Orsza´gos Lakossagi Egeszsegfelmeres. Budapest: Orszagos Epidemiologiai Kozpont; 2000, pp. 143 /144 (in Hungarian). [14] Kendler KS, Neale MC, MacLean CJ, et al. Smoking and major depression. A causal analysis. Arch Gen Psychiatry 1993;50:36 /43. [15] Malone KM, Waternaux C, Haas GL. Cigarette smoking, suicidal behavior, and serotonin function in major psychiatric disorders. Am J Psychiatry 2003;160:773 /9.
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[16] Adler LE, Olincy A, Waldo M, et al. Schizophrenia, sensory gating, and nicotinic receptors. Schizophr Bull 1998; 24:189 /202. [17] Leonard S, Adams C, Breese CR, et al. Nicotine receptor function in schizophrenia. Schizophr Bull 1996;22:431 /45. [18] Marneros A, Tsuang MT, editors. Affective and Schizoaffective Disorders: Similarities and Differences. New York: Springer; 1990.
[19] Mori T, Sasaki T, Iwanami A, et al. Smoking habits in Japanese patients with schizophrenia. Psychiatry Res 2003;120:207 /9. [20] Srinivasan TN, Thara R. Smoking in schizophrenia / All is not biological. Schizophr Res 2002;56:67 /74. [21] Goodwin R, Hamilton SP. Cigarette smoking and panic: The role of neuroticism. Am J Psychiatry 2002;159:1208 / 13.
SHORT REPORT
Cigarette smoking and psychiatric disorders in Hungary
´ CS2, Z. TELEKI1 & ¨ ME1, Z. RIHMER1, X. GONDA1, P. PESTALITY1, G. KOVA P. DO P. MANDL1,3 1
National Institute for Psychiatry and Neurology, Budapest, Hungary, 2National Kora´nyi Institute for Tuberculosis and Pulmonology, Budapest, Hungary, and 3Department of Pharmacology, Institute of Experimental Medicine, Hungarian Academy of Sciences, Budapest, Hungary
Abstract Data from the United States and from several European countries show that patients with major mood disorders, schizophrenia and social phobia smoke at significantly higher rates than the general population. However, there are no published results on this field from Central Europe, including Hungary. In the present study, the rate of current and lifetime smoking of the consecutively screened outpatients with DSM-IV unipolar major depression (n /92), bipolar disorder (n /60), schizophrenia (n /80), schizoaffective disorder (n /42) and panic disorder without major depression (n /60) were assessed and the data were compared to the controls (n /5503), representative for the general population of Hungary. The results showed that, compared to controls, the rates of current and lifetime smoking were significantly higher among patients with unipolar major depression, bipolar disorder, schizophrenia and schizoaffective disorder, but not among patients with panic disorder without major depression. The findings support previous findings from other countries on the strong relationship between cigarette smoking and major mood and schizophrenic spectrum disorders.
Key Words: Bipolar disorder, Hungary, major depression, panic disorder, schizoaffective disorder, schizophrenia, smoking
Introduction It is well documented that major depression [1,2], bipolar I disorder [3 /6], schizophrenia [1,7,8] and schizoaffective disorder [9] is associated with higher rate of cigarette smoking than that of the normal population. As for anxiety disorders, it has recently been reported that patients with social phobia smoke significantly more, even after controlling for comorbid depression [10], and patients with obsessive / compulsive disorder smoke significantly less than the general population [11]. The present study was designed to examine the relationship between smoking and different psychiatric disorders such as affective, schizoaffective disorder, schizophrenia and panic disorder in Hungary. Methods To minimize the social influence of hospitalization on current smoking, only outpatients were studied. More than 360 outpatients, with the diagnosis of unipolar major depression, bipolar disorder, schizo-
phrenia, schizoaffective disorder and pure panic disorder, who received treatment in three different outpatient departments at the National Institute for Psychiatry and Neurology, Budapest, were interviewed regarding their smoking habits. Only panic disorder patients without current and/or past major depression were included. Patients with comorbid substance-use/dependence disorders were also exluded. More than two-thirds of the unipolar, bipolar, schizoaffective and schizophrenic patients, but less than 5% of panic disorder patients, were previously treated as inpatients at the same institute. All patients were diagnosed by experienced clinical psychiatrists according to the DSM-IV criteria [12]. The frequency of current and lifetime smoking was compared with data of 5503 adults, representative for the whole Hungarian population [13]. Associations between categorical variables were calculated by the chi-square test. Results The final sample (N /334) consisted of 92 unipolar major depressive, 60 bipolar (32 bipolar I and 28
Correspondence: Zolta´n Rihmer, National Institute for Psychiatry and Neurology, Pf. 1, Budapest 27, 1281, Hungary. Tel: /36 1 391 5353. Fax: /36 1 200 0770. E-mail: [email protected]
(Received 10 November 2004; accepted 3 February 2005) ISSN 1365-1501 print/ISSN 1471-1788 online # 2005 Taylor & Francis DOI: 10.1080/13651500510028977
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P. Do¨me et al.
Table I. Frequency of current and lifetime smoking in different patient-groups and in controls. Smokers
Diagnosis Unipolar major depression
Bipolar I/II disorder
Schizoaffective disorder
Schizophrenia
Panic disorder
Controls
N Total Males Females Total Males Females Total Males Females Total Males Females Total Males Females Total Males Females
92 32 60 60 26 34 42 19 23 80 43 37 60 16 44 5503 2467 3036
Current n (%) 49 18 31 36 17 19 29 13 16 43 25 18 20 6 14 1933 1135 798
(53) (56) (52) (60) (65) (56) (69) (68) (69) (54) (58) (49) (33) (37) (32) (35) (41) (26)
Lifetime n (%) 64 24 40 42 20 22 35 15 20 56 31 25 29 11 18 2900 1655 1245
(70) (75) (67) (70) (77) (65) (83) (79) (87) (70) (72) (68) (48) (69) (41) (53) (67) (41)
Unipolars vs. controls. Current: x2 /13.01, df /1, P /0.0003; Lifetime: x2 /10.33, df /1, P /0.0013. Bipolar I/II vs. controls: Current: x2 /16.06, df /1, P /0.0001; Lifetime: x2 /7.13, df /1, P /0.0076. Schizoaffectives vs. controls: Current: x2 /20.98, df /1, P /0.0000; Lifetime: x2 /15.7, df /1, p / 0.0001. Schizophrenics vs. controls. Current: x2 /11.96 df /1, p /0,0005 Lifetime: x2 /9,47, df /1, P /0.0021. Panic disorder patients vs. controls. Current: x2 /0.08, df /1, P /0.772; Lifetime: x2 /0.45, df /1, P /0.5. Male controls vs. female controls: Current: x2 /316.88, df /1, P /0.00000; Lifetime: x2 /371.31, df /1, P /0.0000.
bipolar II), 42 schizoaffective, 80 schizophrenic and 60 pure panic disorder patients (Table I). Because of the small number of bipolar I and bipolar II patients, these subgroups were not analysed separately. All patients who were classified as regular (everyday) smokers smoked cigarettes (of these, six patients also smoked a pipe and/or cigar occasionally), and, interestingly, no patient smoked only a pipe or cigar on a regular basis. None of these patients reported a smokeless use of tobacco (i.e. tobacco chewing, snuff, etc.) in this sample. The rates of current and lifetime smokers in different diagnostic groups as well as in the control sample are shown in Table I. Compared to controls, the rate of current and lifetime smoking is significantly higher among unipolar, bipolar, schizoaffective and schizophrenic patients, but panic disorder patients show similar rates of current and lifetime smoking as members of the control group. Of the four diagnostic groups with a high frequency of smoking (major depressives, bipolars, schizophrenics and schizoaffectives), schizoaffective patients show the highest rate of current and lifetime smoking; but, compared to unipolars, bipolars and schizophrenics, this difference is not significant. Statistical comparison between the different diagnostic groups and the control group by gender was not performed due to the relatively small number of cases. However, the inspection of these figures show that (except for the schizoaffective group) the
rate of current and lifetime smoking is numerically lower among females in the remaining four patient groups, but this difference is smaller than in the control group, where the frequency of current and lifetime smokers is significantly higher among males (Table I). Discussion Our findings support the strong relationship between cigarette smoking and unipolar major depressive disorder [1,2], bipolar disorder [3 /6], schizophrenia [1,7,8] and schizoaffective disorder [9], demonstrating that this association is present not only in the United States [1,2,7], Spain [3], Scotland [8], Ireland [5] and Israel [4], but also in Hungary. The underlying biological mechanisms that could explain the strong association between smoking and major mood disorders, schizophrenia and schizoaffective disorder are not exactly established at present, but they seem to be different in mood disorders [14,15] and in schizophrenia [16 /18]. On the other hand, however, it seems that not only genetical/ biological, but also cultural, economical and social backgrounds of the given country influence the smoking habits of psychiatric patients and of normal population too; e.g. in Japan, smoking frequency is the same among schizophrenics as in the normal population [19]. Another study from India showed similar data, suggesting that smoking and heavy
Smoking and psychiatric disorders in Hungary smoking rates among schizophrenics were no different from the same rates of the non-psychiatric control group [20]. Considering these facts it is important to examine the above-mentioned relationship between smoking rates and psychiatric diagnoses in countries with different economical, cultural and social backgrounds. We found that the frequency of current and lifetime cigarette smoking among schizoaffective patients highly exceeded the rates of patients with schizophrenia or major mood disoders. The underlying biological mechanisms that predispose for smoking in patients with mood disorder and schizophrenia seem to be different: low central serotonin function in mood disorder patients [14,15], while abnormalities in central nicotine receptors in schizophrenics [15/17] might predispose for smoking. Schizoaffective disorder shares several genetical/ biological and clinical characteristics of both schizophrenia and mood disorders [18]. Therefore, the simultaneous presence of these two different underlying biological abnormalities in schizoaffective disorder may explain why the smoking rate is much higher in schizoaffective illness, as compared to both schizophrenia and major mood disorders. The relationship between anxiety disorders and smoking seems to be more complex. While patients with social phobia smoke significantly more [10] and obsessive /compulsive patients smoke significantly less than their control persons [11], our results show that patients with panic disorder without current or past major depression have the same smoking habits as the general population. This finding is consistent with the results of a recent epidemiological study, showing that people suffering from panic attacks, lifetime smokers have had much higher rate of comorbid major depression (50%) than nonsmokers (39%) [21]. On the other hand, however, it should be noted that panic disorder (either with, or without major depression) is not representative of all anxiety disorders, therefore our findings have limited value in this respect. However, the fact that age, social class, and alcohol/coffeine consumption was not controlled in our patients, coupled with the fact that dependent versus nondependent smokers were not distinguished, should be considered as limiting factors. Key points . The present Hungarian study shows that, in agreement with previous reports from United States and some Western European countries, patients with major mood and schizophrenic spectrum disorders smoke at siginificantly higher rate than the general population
147
. Panic disorder patients without current and past major depression do not show increased rate of smoking . Since the relationship between smoking and major psychiatric disorders is quite complex, this connection needs further investigations
Statement of interest Dr Rihmer is consultant at AstraZeneca, Eli Lilly, GlaxoSmithKline, Lundbeck, Organon, Pfizer, Servier-EGIS, and Wyeth. He is also a member of Speaker’s Bureau at AstraZeneca, Eli Lilly, GlaxoSmithKline, Jannsen-Cilag, Lundbeck, Organon, Pfizer, Richter, Roche, Sanofi-Synthe´labo, ServierEGIS and Wyeth.
References [1] Hughes JR, Hatsukami DK, Mitchell JE, Dahlgren LA. Prevalence of smoking among psychiatric outpatients. Am J Psychiatry 1986;143:993 /7. [2] Glassman AH. Cigarette smoking: Implications for psychiatric illness. Am J Psychiatry 1993;150:546 /53. [3] Gonzalez-Pinto A, Gutierrez M, Ezcurra J, et al. Tobacco smoking and bipolar disorder. J Clin Psychiatry 1998; 59:225 /8. [4] Itkin O, Nemets B, Einat H. Smoking habits in bipolar and schizophrenic outpatients in Southern Israel. J Clin Psychiatry 2001;62:269 /72. [5] Corvin A, O’Mahony E, O’Regan M, et al. Cigarette smoking and psychotic symptoms in bipolar affective disorder. Br J Psychiatry 2001;179:35 /8. [6] Cassidy F, McEvoy JP, Yang YK, Wilson WH. Smoking and psychosis in patients with bipolar I disorder. Comp Psychiatry 2002;43:63 /4. [7] DeLeon J, Gadvand M, Cannso C, et al. Schizophrenia and smoking: an epidemiological study in a state hospital. Am J Psychiatry 1995;152:453 /5. [8] McCreadie RG, On behalf of the Scottish Comorbidity Study Group. Use of drugs, alcohol and tabacco by people with schizophrenia: Case-control study. Br J Psychiatry 2002;181:321 /5. [9] Vanable PA, Carey MP, Carey KB, Maisto SA. Smoking among psychiatric outpatients: Relationship to substance use, diagnosis and illness severity. Psychol Addict Behav 2003;4:259 /65. [10] Sontag H, Wittchen H-U, Ho¨fler M, et al. Are social fears and DSM-IV social anxiety disorder associated with smoking and nicotine dependence in adolescents and young adults? Eur Psychiatry 2000;15:67 /74. [11] Bejerot S, Humble M. Low prevalence of smoking among patients with obsessive-compulsive disorder. Comp Psychiatry 1999;40:268 /72. [12] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association Press; 1994. [13] Boros J. Dohanyzas. In: Boros J, Nemeth R, Vitrai J, editors. Orsza´gos Lakossagi Egeszsegfelmeres. Budapest: Orszagos Epidemiologiai Kozpont; 2000, pp. 143 /144 (in Hungarian). [14] Kendler KS, Neale MC, MacLean CJ, et al. Smoking and major depression. A causal analysis. Arch Gen Psychiatry 1993;50:36 /43. [15] Malone KM, Waternaux C, Haas GL. Cigarette smoking, suicidal behavior, and serotonin function in major psychiatric disorders. Am J Psychiatry 2003;160:773 /9.
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P. Do¨me et al.
[16] Adler LE, Olincy A, Waldo M, et al. Schizophrenia, sensory gating, and nicotinic receptors. Schizophr Bull 1998; 24:189 /202. [17] Leonard S, Adams C, Breese CR, et al. Nicotine receptor function in schizophrenia. Schizophr Bull 1996;22:431 /45. [18] Marneros A, Tsuang MT, editors. Affective and Schizoaffective Disorders: Similarities and Differences. New York: Springer; 1990.
[19] Mori T, Sasaki T, Iwanami A, et al. Smoking habits in Japanese patients with schizophrenia. Psychiatry Res 2003;120:207 /9. [20] Srinivasan TN, Thara R. Smoking in schizophrenia / All is not biological. Schizophr Res 2002;56:67 /74. [21] Goodwin R, Hamilton SP. Cigarette smoking and panic: The role of neuroticism. Am J Psychiatry 2002;159:1208 / 13.
